1. August 2011 Department of Quality and Safety Mount Auburn Hospital Infection Prevention JC Readiness

2. Environment of Care: Areas of Focus SEPARATION OF CLEAN AND DIRTY Only clean/sterile items stored in clean utility space Clean items stored outside of designated clean utility or clean storage space must be clearly labeled as clean Only dirty items stored in dirty utility room PPE (gloves, fluid resistant gowns, and faceshields) should be routinely available in dirty utility areas No clean supplies stored under sinks

3. Environment of Care: Areas of Focus PATIENT EQUIPMENT Every non-disposable patient equipment must have a routine cleaning/disinfection schedule Non-critical items (contact only with intact skin of patients - e.g. BP cuffs, pulse oximetry, etc.) Define frequency/schedule i.e. between every patient, daily, weekly AND whenever soiling occurs Precaution Patients – equipment is designated to that patient only or must be cleaned/disinfected after each use.

4. Environment of Care: Areas of Focus PATIENT EQUIPMENT Semi-critical (contact with mucous membranes of patients e.g. thermometers, laryngoscopes, vaginal probes, TEEs, flexible endoscopes) 1.Pre-cleaning process (using enzymatic detergent) 2.Timed immersion in liquid chemical (Cidex OPA/Meticide) 3.Triple rinse 4.Dried and stored in clean draw/cabinet (not open to air) Intense scrutiny on quality control documentation (logs on test strips and solution) and personnel training/competency.

5. Environment of Care: Areas of Focus PATIENT EQUIPMENT Critical Items (contact with normally sterile body cavities e.g. biopsy forceps, bronchoscopes) 1.Decontamination and sterilization must be controlled/centralized (i.e. SPD) 2.If sterilization performed outside SPD (e.g. OR – Immediate Use Steam Sterilization) process must meet same standards as SPD Intense scrutiny on quality control documentation (e.g. cycle contents and parameters, biological indicators) and personnel training/competency.

6. 6 NPSGs: Focus on Processes of Care NPSG.07.01 Hand Hygiene - Elements of Performance 1.Implement CDC or WHO hand hygiene guidelines MAH policy revised in 2011 to incorporate CDC specific indications for hand hygiene (not just In and Out) 2.Set Goals for Performance 3.Improve Performance

7. CDC Indications Decontaminate hands before having direct contact with patients Decontaminate hands before donning sterile gloves Decontaminate hands before inserting invasive devices (non surgical procedure) Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) Decontaminate hands after contact with body fluids or excretions, mucous membranes, non- intact skin, and wound dressings Decontaminate hands if moving from a contaminated-body site to a clean- body site during patient care Decontaminate hands after contact with objects (including medical equipment) in the immediate vicinity of the patient Decontaminate hands after removing gloves Before eating and after using a restroom wash hands with soap and water

8. “Five Moments” WHO 5 Moments for Hand Hygiene – Critical times when hand hygiene should be performed

9. 9 Performance Goals

10. Medical Safety Steering Committee June Meeting – 20 minutes of observations per month from all areas

11. 11 NPSGs: Focus on Processes of Care NPSG.07.03.01 Implement Best Practices to prevent MDRO (MRSA, CDI, VRE, ESBL) - Elements of Performance 1.Measure and monitor MDRO prevention processes and outcomes 2.Educate patients, and their families as needed, who are infected or colonized with MDRO about prevention

12. Measure and Monitor MDRO Prevention PROCESS OUTCOME

13. Measure and Monitor MDRO Prevention PROCESS OUTCOME

14. 14 NPSGs: Focus on Processes of Care NPSG.07.04.01 Implement Best Practices to prevent central line associated bloodstream infection (CLABSI) - Elements of Performance 1.Educate patients and, as needed, their families about CLABSI Prevention 2.Perform hand hygiene prior to catheter insertion OR MANIPULATION 3.Do not insert catheters into femoral vein unless other sites are unavailable 4.Use supply/procedure cart that contains all necessary components for insertion

15. 15 NPSGs: Focus on Processes of Care NPSG.07.04.01 Implement Best Practices to prevent central line associated bloodstream infection (CLABSI) - Elements of Performance 6.Full barrier precautions (includes full body patient drape) 7.Standardized protocol to disinfect catheter hubs and injection ports 8.Standardized protocol to disinfect catheter hubs and injection ports 9.Daily evaluate all central venous catheters and remove nonessential catheters

16. Process Measure: CL checklist Implemented in ED and OR early 2011 Value stems from empowered assistant/observer to monitor and attest to standards of asepsis Monitoring of checklist usage ongoing

17. Outcome Measure (rate)

18. 18 Newest NPSG: Full implementation 2012 NPSG.07.06.01 Implement Best Practices to prevent indwelling catheter-associated urinary tract infections (CAUTI) - Elements of Performance 1.Insert according to evidence based guidelines addressing aseptic technique, equipment, and supplies 2.Appropriate management including: –Securing catheters for unobstructed flow –Maintain sterility of collection systems –Aseptic collection of urine samples/replacing collection system when required –Maintain drainage bag below level of bladder –Daily assessment of medical necessity and prompt removal of unnecessary catheters 3.Monitor compliance with best practices – i.e. auditing

19. Outcome Measure (rate)

20. SSI and VAP NPSG.07.05.01 relates to prevention of surgical site infections (SSI) – Elements of Performance are essentially SCIP measures No NPSG related to VAP but MDPH requires monitoring of VAP process measures and rates (also tied to reimbursement)