Getting Started or so you are the new Infection Preventionist – what now? Karen Hoover Russ Olmsted Ruth Anne Rye
Support New Hire Orientation All personnel Personnel specific Ongoing Regulatory mandate Task-specific Facility-determined Pre-placement evaluation Routine screening Work restrictions Occupational exposure management Personal hygiene Blood Stream - Eyes, Ears & Throat Gastrointestinal, Genitourinary Tract - Skin Respiratory Tract – Central Nervous System -- - Dental Service Dietary Services Equipment: Cleaning Disinfection/Sterilization Environmental Cleaning Emergency preparedness Facility operations; air, water construction/renovation Laboratory/Pathology Waste management Employee Health Prevention Body System Review Leadership Education Clinical Practice Support Services Surveillance/ Performance Measurement MI MODEL: INFECTION PREVENTION PROGRAM MSIPC Reviewed 2013 Scope: Processes & outcomes Patient: Community & Healthcare- Associated Infection Personnel: Health & Injury Prevention Environment of Care (EOC) Outbreak and Sentinel Events Philosophy-Authority-Responsibility I.P. Program Elements Patient & Personnel Safety Culture Oversight: Function and Committees Performance Improvement Regulatory Compliance Community Standards of Care Antimicrobial use Asepsis Continuum of care Hand Hygiene Immunization Isolation Precautions Patient Care Plan
IC :The [organization] has an infection prevention and control plan. Evidence-based national guidelines or, in the absence of such guidelines, expert consensus. The hospital’s infection prevention and control plan includes: a written description of the activities, including surveillance, etc. process to evaluate the infection prevention and control plan. The hospital describes, in writing, the process for investigating outbreaks of infectious disease. All hospital components and functions are integrated into infection prevention and control activities. Communicating responsibilities about prevention to licensed independent practitioners (LIPs), staff, visitors, patients, and families. Methods for reporting infection surveillance and control information to external organizations. Accreditation Standards, 2015
IC :The [organization] identifies risks for acquiring and transmitting infections EPs: Identify risks- acquiring and transmitting infections, based on: geographic location, community, and population served. Care, treatment, and services it provides. Analysis of surveillance activities and other infection control data. Review risks at least annually and whenever significant changes occur Prioritizes the identified risks Accreditation Standards, 2015
Is there a facility-specific Infection Prevention & Control Plan? Infection Prevention & Control Program Plan Risk Assessment: Assessment of services provided Assessment of populations served Prioritized strategies for risk reduction Surveillance plan including data analysis Plan is reviewed annually or as often as needed
Evaluation of potential risk for infections, contamination and exposures among population served by the facility; 1)Sources of information: known risks, historical data, local public health, publically reportable data, reports in literature, etc. – Do you have any surveillance data available? 2)Evaluation of preventable harms [HAIs, falls, pressure ulcers, inter-facility transfers] 3)Evaluation of organization’s preparedness to eliminate or mitigate the harm or risk of preventable harm
Setting Services & Care Delivery Descriptive analysis – Geographic area served – Environmental factors – Populations served – Breakdown of major payors – CMS survey requirements – Local public agency: county population assessment Care, Treatment & Services Provided Skilled care, Rehab, Long Term Acute Care, Home care/Hospice, Critical access hospital Surgery, medicine, both Critical care? Obstetrics? Combination of acute + LTC?
Multidisciplinary team – Employee health, environmental services, lab, pharmacy, nursing, administration etc. Perform at least annually – Remember to update if new services are added Review & approval by IPC and/or Patient Safety/Quality Committee Organization/committee consensus for priorities
Priority Level = 1 (top) Topic: Catheter Associated UTI (CAUTI) Goal- Achieve zero CAUTIs in medical surgical patients by December 2012 Objectives - 1. Provide CAUTI prevention education for 95% of clinical staff by June 2012 2. Implement Nurse protocol for Foley catheter removal by June 2012 Strategies/Tactics - 1. Develop educational program 2. Schedule in-services for med surg nursing 3. Develop nurse driven Foley catheter removal criteria Evaluation Progress/Analysis/Reporting
Let’s Practice shall we?