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Hospital Patient Safety Initiatives: Infection Control

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Title: Hospital Patient Safety Initiatives: Infection Control


1

Hospital Patient Safety Initiatives Infection
Control
Michele Kala, MS,RN

2
October 2011-Developed by CMS
  • Related to three Conditions of Participation
    (CoPs)
  • 482.21 Quality Assessment and Performance
    Improvement (HFAP Hospital Chapter 12)
  • 482.42 Infection Control (HFAP Hospital Chapter
    7)
  • 482.43 Discharge Planning (HFAP Hospital Chapter
    15)

3
Worksheet Purpose
  • Reduce hospital acquired conditions (HAC)
    including hospital acquired infections (HAI) and
    preventable readmissions.
  • Designed to assist surveyors and hospital staff
    to identify when and where compliance is an issue.

4
CMS Worksheet Development
  • In draft format
  • Currently in use by state surveyors, accredited
    facilities and accrediting agencies.

5
CMS Worksheets
  • Facilitate recording of observations by
    surveyors
  • Are a self-assessment tool

6
Findings
  • Hospitals with higher readmission rates may be at
    greater risk for noncompliance with all three
    CoPs.
  • The tools assist facilities in focusing on key
    issues that impact positive patient outcomes and
    thereby compliance.

7
Verification Methods
  • Interview
  • Observation
  • Topic Specific Document Review
  • Medical Record Review
  • Other Document Review

8
Hospital Patient Safety Initiatives
  • Quality Assessment and Performance Improvement
  • Infection Control
  • Discharge Planning

9
Infection Control Worksheet
  • Five Sections
  • Infection Prevention
  • General Elements
  • Equipment Reprocessing
  • Tracer Patient
  • Special Care Environment

10
1. Infection Prevention
  • Prevention Program
  • Infection Control Quality Systems
  • Multiple Drug Resistant Organism Prevention
    (MDRP) and Antibiotic Stewardship

11
a. Prevention Program Resources
  • A designated Infection Control Officer (ICO)
  • Qualifications of ICO
  • Practice and policies based on nationally
    recognized standards and state law
  • Infection Control Risk Assessment related to
    construction
  • (Above scored at 07.01.01)
  • 5. Air exchange rates (07.01.02)

12
Construction Risk Assessment
  • www.ashe.org
  • ICRA Matrix

13
Air exchange rates
  • Airborne Infection Isolation Room (AIIR)
  • Existing construction- 6 air exchanges per
    hour, OR
  • New construction or renovation 12 exchanges
    per hour, OR
  • Per state licensure rules, if more stringent.

14
Air exchange rates (contd)
  • Direct exhaust to the outside, or recycled
    through a HEPA filter
  • Daily monitoring of pressure with visual
    indicators.
  • Door is closed
  • (Scored at 07.01.02)

15
b. Hospital Quality Systems Related to Infection
Prevention and Control
  • IC Problems are Identified and Addressed
  • (07.01.04)
  • Non-punitive Approach to Reporting
  • (12.00.21)
  • Leadership Support
  • (07.01.04)
  • Infection Control Risk Assessment
  • (NOT SCORED)

16
Infection Control Risk Assessment References
  • Infection Control Risk Assessment APIC
    2011-Baltimore (Web search)
  • http//oregonpatientsafety.org/healthcare-professi
    onals/infection-prevention-toolkit/section-1-infec
    tion-prevention-programdevelopment/473/oregonpatie
    ntsafety.org/healthcare.../infection...toolkit/...
    infection.../473/

17
c. Prevent MDROs and Promote Antibiotic
Stewardship, Surveillance
  • 1. Policies to minimize transmission of Multiple
    Drug Resistant Organism (MDROs)
  • Facility MDRO policy effectiveness
    identification process preventing development
    and transmission of MDROs
  • (1 2 NOT SCORED)

18
c. Prevent MDROs and Promote Antibiotic
Stewardship, Surveillance (contd)
  • Antibiotic Stewardship
  • Process to review Antibiotic Utilization,
    Susceptibility and Availability
  • Appropriate antibiotic selection
  • Indications for Use Documented
  • 72-hour review
  • Timely IV to oral switch
  • Resistance Pattern Notification
  • (NOT SCORED)

19
c. Prevent MDROs and Promote Antibiotic
Stewardship, Surveillance (contd)
  • Colonized or Infected Patients on Admission and
    HEALTHCARE PERSONNEL are Identified and Isolated
    (07.01.02)
  • List of Current Reportable Diseases (not scored)
  • Reportable Diseases are Reported to local and
    State Health Departments (07.01.02

20
d. Infection Control Training
  • Job Specific IC Training on Hire and ANNUALLY
    (04.00.11 also)
  • Bloodborne Pathogen Training as Appropriate
  • Policies on Sharps Injuries and Exposurespatient
    and staff
  • Treatment and Prophylaxis following exposure
  • TB Conversion Follow-up
  • (all scored at 07.01.02)

21
d. Infection Control Training (contd)
  • Respiratory Protection System (N95 disposable
    respirator system) with polices and procedures
    regarding use
  • Annual fit testing
  • Employee health policies
  • Reporting of illness without penalty
  • Staff education regarding prompt reporting of
    illness
  • Annual calculation of TB conversion rates
  • (these questions not scored)

22
d. Infection Control Training (contd)
  • Staff annual (at a minimum) IC training and
    competency validation and also following
    identification of IC issues. (also 04.00.12)
  • Corrective action and causal analysis following
    employee exposures
  • (both scored at 07.01.04)

23
d. Infection Control Training (contd)
  • Hep B Vaccinations Offered (not scored)
  • TB Testing Done Upon Hire (two step process)
    follow-up based on the facility risk
    classification and state requirements (07.01.23)
  • Annual Flu Immunizations Offered to all Staff.
  • (scored at 07.01.25)

24
2. General Infection Control Elements
  • Applicable in all locations where patients are
    treated
  • a. Hand Hygiene (07.01.01 07.01.21 )
  • b. Injection Practices and Sharps Safety
    (07.01.02)
  • c. Personal Protective Equipment (PPE)
    (07.01.02)
  • d. Environmental Services (07.01.02)

25
a. Hand Hygiene
  • Availability of hand-washing areas
  • Availability of alcohol-based hand rub solution
  • Hand hygiene is performed (even though gloves are
    worn)
  • before patient care
  • prior to leaving a patient environment
  • prior to an aseptic task
  • following contact with blood, body fluids
  • or contaminated surfaces

26
a. Hand Hygiene (contd)
  • Soap and water cleansing occurs when hands are
    visibly soiled
  • Artificial nails are prohibited in high risk
    areas

27
b. Injection Practices and Sharps Safety
  • Injection preparation areas clean and free of
    contaminates
  • Single use needles
  • Syringes are used for only one patient, including
    insulin pens
  • Rubber stopper disinfection
  • Medication vial access with a clean needle ONLY
  • Medication vial access with a clean
  • syringe ONLY

28
b. Injection Practices and Sharps Safety (contd)
  • Single Patient Use Items
  • Single dose vials
  • IV bags
  • Medication tubing and connectors
  • Multidose vials are dated for 28-day expiration
  • Multidose vial use for multiple patients are not
    kept in treatment areas
  • Use of sharps containers for disposal
  • Sharps container replacement

29
c. Personal Protective Equipment
  • PPE availability at point of use
  • Staff glove when in contact with blood, body
    fluids, mucous membranes or non-intact skin
  • A glove change and hand hygiene prior to moving
    from a contaminated to a clean body site
  • Gown use
  • Mouth, nose, and eye protection
  • Surgical mask use when entering an epidural or
    subdural space

30
d. Environmental Services
  • Environmental service worker PPE use (also
    07.03.08)
  • Patient care area cleaning processeshigh touch
    areas are cleaned daily
  • Terminal Cleaning and removal of linen
  • Use of cleaners and disinfectants reflect
    manufacturers guidelines for use
  • Clean cloths for each patient room/corridor (also
    07.03.06)

31
d. Environmental Services (contd)
  • Mop head and cloth cleaning daily (also 07.03.06)
  • Blood and body fluid cleaning process--spills
  • Equipment cleaning schedules (HVAC, eyewash
    stations, ice machines, refrigerators, scrub
    sinks and aerators on faucets)

32
d. Environmental Services (contd)
  • Handling of clean and dirty laundry with no
    potential for cross contamination
  • Bagging and storage of dirty linen
  • Segregation of clean from dirty in laundry
    processing area
  • (also 07.04.01 for all three)

33
d. Environmental Services (contd)
  • Disinfection of non-critical reusable patient
    care items, using manufacturers instructions if
    applicable is specifically assigned by policy and
    staff can articulate the process
  • Cleaning of hydrotherapy equipment

34
3. Equipment Reprocessing
  • Reprocessing of Semi-Critical Equipment(Scored
    at 07.01.02)
  • Reprocessing of Critical Equipment (Scored at
    07.01.02)
  • Single Use Devices
  • (Scored at 07.01.01)

35
a. Processing of Semi-Critical Equipment
  • High Level Disinfection Policymake sure the
    policy is consistent for Ultrasound, TEE probes
    and outpatient areas (also 07.02.08)
  • Flexible endoscope inspection and testing
  • Pre-cleaning processes
  • Use of enzymatic cleaners
  • Cleaning brush maintenance

36
a. Processing of Semi-Critical Equipment (contd)
  • Chemicals used in high level disinfection
  • Automated equipment processing
  • Appropriate processing length of time and
    temperature recorded
  • Rinsing process following disinfection

37
a. Processing of Semi-Critical Equipment (contd)
  • Drying of equipment following disinfection
  • Maintenance records for disinfection equipment
  • Equipment storage following disinfection
  • Logs regarding equipment use

38
b. Reprocessing of Critical Equipment
  • Pre-cleaning process
  • Use of enzymatic cleaners
  • Cleaning brush maintenance
  • Wrapping/packaging process

39
b. Reprocessing of Critical Equipment (contd)
  • Use of chemical indicators in all packs in every
    load
  • Use of biological indicators at least weekly and
    with all implants
  • Bowie-Dick testing in pre-vacuum steam
    sterilization
  • gravity displacement vs. pre-vacuum
    steam
  • sterilizers
  • (also 07.02.05)
  • Labeling of sterile packssterilizer, load number
    and date (also 07.02.09)

40
b. Reprocessing of Critical Equipment (contd)
  • Sterilizer logs are kept for all loads (also
    07.02.06)
  • Maintenance of sterilizers is per manufacturers
    recommendations
  • Storage of sterilized items prevents
    contamination (also 07.02.04)

41
b. Reprocessing of Critical Equipment (contd)
  • Inspection of processed items prior to use
  • Immediate Use Steam Sterilization (IUSS)
    previously know as flash sterilization
  • Item must be thoroughly cleaned
  • Sterilizer cycle is appropriate for the
    instrument
  • All appropriate chemical and biological
    indicators are used
  • The facility has adequate instrumentation to meet
    the needs defined by surgical volume.

42
b. Reprocessing of Critical Equipment (contd)
  • Immediate use of flashed equipment
  • (also 07.02.01 for flash sterilization process)
  • Recall of sterilized equipment (also 07.02.10)

43
c. Single-Use Devices
  • Disposal after use or opening
  • OR
  • FDA-registered vendors used for reprocessing
  • (also 07.02.03)

44
Patient Tracers
  • Policies and procedures to identify and prevent
    infections for the following
  • Urinary Catheter
  • Central Venous Catheter
  • Ventilator/Respiratory Care
  • Spinal Injection Procedures
  • Point of Care Devices
  • Isolation Precautions
  • Surgical Procedures

45
Patient Tracers, Cont.
  • Issues identified during the survey which
    indicate the processes in place are not
    controlling and preventing infections would be
    scored at 07.01.01
  • Protocols are not required but policies and
    procedures and staff compliance must demonstrate
    effectiveness in controlling and preventing
    infections

46
Urinary Catheter Tracer
  • Use of urinary catheters in a manner to minimize
    infection
  • Hospital maintains guidelines for appropriate use
    of urinary catheters
  • Hand hygiene
  • Before and after insertion
  • Placement of catheter using aseptic technique
  • Catheter properly secured after insertion
  • (scored at 07.01.02)

47
Urinary Catheter Tracer
  • Catheter insertion and indication are documented
    (10.01.04)
  • Hand hygiene before and after manipulation of
    catheter
  • Avoid irrigation
  • Collection bag emptied using aseptic technique
  • Aseptic collection of urine samples
  • Small amounts through needleless port
  • Keep urine collection bag below level of bladder
    at all times
  • Catheter tubing unobstructed with no kinking
  • (07.01.02)

48
Urinary Catheter Tracer
  • Need for catheter reviewed daily
  • Prompt removal when deemed unnecessary
  • No convenience
  • (Not scored)

49
Central Venous Catheter Tracer
  • Central venous catheters are inserted, assessed
    and maintained in a manner to minimize infection
  • Hand Hygiene performed before and after insertion
  • Maximal barrier precautions used for insertion
  • Surgical protection including full patient body
    drape
  • Use of gt0.5 chlorhexidine with alcohol used for
    skin antisepsis prior to insertion
  • Can use tincture of iodine, iodophor or 70
    alcohol alternatively
  • Dressing to cover catheter insertion site
  • Sterile gauze
  • Sterile transparent, semi-permeable dressing
  • Well healed and tunneled catheters may not need
    to be covered
  • (07.01.02)

50
Central Venous Catheter Tracer
  • Central line insertion and indication documented
    (10.01.04)
  • Hand hygiene performed before and after
    manipulating catheter
  • Gloves
  • Soiled dressings are changed promptly
  • All dressings changed using aseptic technique
  • Gloves
  • Access port is scrubbed with an appropriate
    antiseptic prior to accessing
  • Chlorhexidine, Povidone iodine, an iodophor, or
    70 alcohol
  • Catheter accessed with sterile devices
  • (07.01.02 07.01.19)

51
Central Venous Catheter Tracer
  • Need to central venous catheters reviewed daily
    with prompt removal when not necessary (Not
    scored)

52
Ventilator/Respiratory Therapy Tracer
  • General Respiratory Therapy Practices for all
    Patients
  • Hand hygiene
  • Gloves
  • Sterile water for nebulization
  • Single dose vials for aerosolized medications
  • Using manufacturers instructions for handling,
    storing and dispensing of medications

53
Ventilator/Respiratory Therapy Tracer
  • If multi-dose vials for aerosolized medications
    are used for more than one patient
  • Restricted to a centralized medication location
  • They do not enter the immediate patient treatment
    area
  • (07.01.02 17.00.04)
  • Comprehensive oral hygiene program for all at
    risk patients
  • Elevated HOB for all at risk patients (ventilator
    or enteral tube placement)
  • (not scored)

54
Ventilator/Respiratory Therapy Tracer
  • Ventilator Care
  • Ventilator circuit is changed if visibly soiled
    or mechanically malfunctioning
  • Sterile water is used to fill bubbling
    humidifiers
  • Condensate in tubing is periodically drained and
    discarded
  • Condensate should not drain toward the patient
  • Use of sterile single-use suction catheter
  • Multi-use closed system catheter
  • Only sterile fluid is used to remove secretions
  • (07.01.02 17.00.04)

55
Ventilator/Respiratory Therapy Tracer
  • Sedation is lightened daily in eligible patients
  • Spontaneous breathing trials are performed daily
    in eligible patients
  • Weaning
  • (not scored)

56
Spinal Injection Procedures
  • Spinal injection procedures
  • Hand hygiene
  • Spinal injection
  • Aseptic technique
  • Surgical masks are used when placing a catheter
    or injecting materials into the epidural or
    subdural space
  • (07.01.02)

57
Point of Care Devices
  • Blood Glucose Meter
  • INR Monitor

58
Point of Care Devices
  • Hand hygiene
  • Gloves
  • Used for finger-stick procedures
  • Removed after the procedure, followed by hand
    hygiene
  • Finger stick devices are used for one patient
  • Lancet
  • Lancet holding device

59
Point of Care Devices
  • Point of Care device is cleaned and disinfected
    after every use according to manufacturers
    instructions
  • Single use only if no manufacturers instructions
    for cleaning and disinfection
  • (07.01.02)

60
Isolation Contact Precautions
  • Gloves are available and located near point of
    use
  • Signs indicating that the patient is in contact
    isolation
  • Patients in contact isolation are in single rooms
  • Can be cohorted based on clinical risk assessment

61
Isolation Contact Precautions
  • Soap and water must be used when bare hands are
    visibly soiled (e.g., blood, body fluids) or
    after caring for a patient with known or
    suspected C. difficile or norovirus during an
    outbreak. In all other situations, ABHR is
    preferred.

62
Isolation Contact Precautions
  • Gloves and gowns
  • Before entering patient care environment
  • Removed and discarded hand hygiene is performed
    before leaving the patient care environment

63
Isolation Contact Precautions
  • Dedicated or disposable noncritical patient- care
    equipment (e.g., blood pressure cuffs) is used or
    if not available, then equipment is cleaned and
    disinfected prior to use on another patient
    according to manufacturer's instructions.

64
Isolation Contact Precautions
  • Traffic control
  • Into patients room
  • Patient moving out of the room to other parts of
    the hospital
  • Contact precautions outside the patients room
  • Cleaning of objects and patient care areas that
    are touched in patients isolation room
  • When visibly soiled
  • At least once a day
  • Terminal cleaning
  • All surfaces thoroughly cleaned and disinfected
    and all textiles are replaced with clean textiles
  • Cleaners and disinfectants are labeled and used
    in accordance with hospital policy and procedure
    and manufacturers instructions
  • (07.01.02)

65
Isolation Droplet Precautions
  • Masks
  • On entering
  • Discarded when leaving
  • Signs
  • Patient on droplet precautions are housed in a
    single room or cohorted based on clinical risk
    assessment
  • Hand hygiene
  • Limited patient movement for droplet isolation
    patients
  • Medically necessary procedures
  • Patient wears surgical mask when transported
  • Communication of patients status

66
Isolation Droplet Precautions
  • Cleaning
  • Once a day per policy and manufacturers
    instruction while patient is admitted
  • Terminal cleaning after discharge including
    wiping and disinfection of all hard surfaces
  • Changing all textiles in the isolation room
  • All cleaners are used in accordance with hospital
    policy and procedure and manufacturers
    instructions (dilution, storage, shelf-life,
    contact time)
  • (07.01.02)

67
Isolation Airborne precautions
  • Use of N-95 or higher particulate respirators
  • Available and near point of use
  • Signs indicating patient is on airborne
    precautions
  • Clear and visible
  • Patients on airborne isolation are housed in
    airborne isolation rooms
  • Hand hygiene before entering
  • And leaving
  • N-95 or higher particulate respirator to be worn
    when entering patient room for confirmed or
    suspected TB

68
Isolation Airborne precautions
  • Facility limits movement of patients on airborne
    isolation to medically necessary purposes
  • Patient wears surgical mask per hospital policy
  • Hospital has means to communicate patients
    status
  • (07.01.02)

69
Surgical procedure tracer
  • Surgical scrub before donning of sterile gloves
    for a surgical procedure in the OR
  • Use of either
  • Antimicrobial surgical scrub
  • FDA-approved alcohol-based antiseptic surgical
    hand rub
  • Visibly soiled hands should be washed with soap
    and water prior to the above procedures
  • After surgical scrub hands and arms are dried
    with a sterile towel and sterile surgical gown
    and gloves are donned in the OR

70
Surgical procedure tracer
  • Surgical attire
  • Scrubs
  • Surgical caps/hoods covering all head and facial
    hair
  • Worn by all personnel in semi restricted and
    restricted areas
  • Restricted areas include
  • OR
  • Procedure rooms
  • Clean core
  • Semi restricted areas include
  • Peripheral support areas of the surgical suite

71
Surgical procedure tracer
  • Masks
  • Properly tied and fully covering mouth and nose
    are worn by all personnel in restricted areas
    where open sterile supplies or scrubbed persons
    are located
  • Sterile drapes are used to establish the sterile
    field
  • Sterile field
  • Items in sterile field are sterile
  • Items introduced to the sterile field are opened,
    dispensed and transferred in a manner to maintain
    sterility
  • Established in a location where it will be used
    and as close as possible to the time of use
  • Movement around the sterile field is done in a
    manner to maintain sterility

72
Surgical procedure tracer
  • Traffic in and out of the OR is kept to a minimum
    and is limited to essential staff
  • Traffic Control Policies and Procedures
  • Surgical masks are removed when leaving the
    sterile areas and are not reused when returning

73
Surgical procedure tracer
  • Cleaners and disinfectants
  • Used according to hospital policy and procedure
    and manufacturers instructions

74
Surgical procedure tracer
  • Cleaningstart of the day
  • Horizontal surfaces
  • Damp dusted with a lint-free cloth and
    EPA-registered hospital detergent/disinfectant
  • High touch surfaces cleaned and disinfected
    between patients
  • Anesthesia equipment is cleaned and disinfected
    between patients
  • Reusable noncritical items (BP cuffs, etc.) are
    cleaned and disinfected between patients

75
Surgical procedure tracer
  • Terminal cleaning of Operating Rooms
  • After the last procedure of the day
  • Including weekends!
  • Includes
  • Wet-vacuuming or moping the floor with an
    EPA-registered disinfectant
  • All surfaces
  • Internal components of anesthesia machine
    breathing circuit are cleaned according to
    manufacturers instructions

76
Surgical procedure tracer
  • Ventilation requirements
  • Positive pressure, 15 air exchanges per hourat
    least 3 of which are fresh air
  • 90 filtration
  • HEPA optional
  • Air filters are checked regularly and replaced
    according to hospital policies and procedures
  • Temperature and relative humidity are maintained
    at required levels
  • Doors are self-closing
  • Air vents and grill work are clean and dry
  • (07.01.02 07.01.20)

77
A Protective Environment (e.g. Bone Marrow
patients)
  • Positive pressureair flow out to the corridor
    from the room
  • 12 air exchanges per hour
  • Supply air is HEPA filtered
  • Well sealed rooms so that there are no
    penetration spaces in the walls, ceilings or
    windows
  • Self closing door that fully closes on all room
    exits
  • Failures are addressed and documented
  • (07.01.02)

78
A Protective Environment (e.g. Bone Marrow
patients)
  • Ventilation requirements are monitored using
    visual methods
  • Kleenex test flutter strips, etc. (07.01.04)

79
QUESTIONS?
Please submit questions to info_at_hfap.org
80
POST TEST
  • This presentation has been awarded 1.5 hours of
    AOA Category 2-B CME credit. To receive your CME
    certificate, please complete the post test at the
    following link
  • https//testmoz.com/359881
  • This should bring up PSI Infection Control
    Test.
  • Type in your name and the passcode PSIIC.
  • (those are upper case is, not lower case Ls)
  • Your certificate will be submitted
    electronically.
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