1. Hospital Patient Safety Initiatives: Infection Control Michele Kala, 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 form until midyear 2013 There may be additional adjustments to the worksheets Currently in use by state surveyors 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 1.Infection Prevention 2.General Elements 3.Equipment Reprocessing 4.Tracer Patient 5.Special Care Environment

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

11. a. Prevention Program & Resources 1.A designated Infection Control Officer (ICO) 2.Qualifications of ICO 3.Practice and policies based on nationally recognized standards 4.Infection Control Risk Assessment related to construction 5.Air exchange rates

12. Construction Risk Assessment www.premierinc.com/quality – Tools and Resources – ICRA Matrix – Matrix of Precautions for Construction and Renovation 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 (cont’d) Direct exhaust to the outside, or recycled through a HEPA filter Daily monitoring of pressure with visual indicators. Door is closed

15. b. Hospital Quality Systems Related to Infection Prevention and Control 1.IC Problems are Identified and Addressed 2.Non-punitive Approach to Reporting 3.Leadership Support 4.Infection Control Risk Assessment

16. Infection Control Risk Assessment: References Infection Control Risk Assessment APIC 2011-Baltimore (Web search) www.infectionpreventiontools.com SPMH Risk Assessment

17. c. Prevent MDROs and Promote Antibiotic Stewardship, Surveillance 1. Policies to minimize transmission of Multiple Drug Resistant Organism (MDROs) 2. Facility MDRO policy effectiveness: identification process preventing development and transmission of MDROs

18. c. Prevent MDROs and Promote Antibiotic Stewardship, Surveillance (cont’d) 3.Antibiotic Stewardship Process to review Antibiotic Utilization, Susceptibility and Availability Appropriate antibiotic selection Indications for Use Documented 72 hour review

19. c. Prevent MDROs and Promote Antibiotic Stewardship, Surveillance (cont’d) Timely IV to oral switch Resistance Pattern Notification Colonized or Infected Patients on Admission and HEALTHCARE PERSONNEL are Identified and Isolated List of Current Reportable Diseases Reportable Diseases are Reported to local and State Health Departments

20. d. Infection Control Training Job Specific IC Training on Hire and ANNUALLY Blood Born Pathogen Training as Appropriate Policies on Sharps Injuries and Exposures—patient and staff Treatment and Prophylaxis following exposure TB Conversion Follow-up

21. d. Infection Control Training (cont’d) Respiratory Protection System (N95 disposable respirator system) Annual fit testing Employee health policies: Reporting of illness without penalty Staff education regarding prompt reporting of illness

22. d. Infection Control Training (cont’d) Annual calculation of TB conversion rates Staff annual (at a minimum) IC training and competency validation. Corrective action analysis following employee exposures

23. d. Infection Control Training (cont’d) Hep B Vaccinations Offered TB Testing Done Upon Hire (two step process) & follow-up based on the facility risk classification Annual Flu Immunizations Offered to all Staff.

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

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 (cont’d) 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 Single use needles Syringes are used for only one patient, including insulin pens Rubber stopper disinfection Medication vial access with a sterile needle ONLY Medication vial access with a sterile syringe ONLY

28. b. Injection Practices and Sharps Safety (cont’d) 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 Use of sharps containers for disposal Sharps container replacement

29. c. Personal Protective Equipment PPE availability 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

30. d. Environmental Services Environmental service worker PPE use Patient care area cleaning processes Terminal Cleaning Use of cleaners and disinfectants Clean cloths for each patient room/corridor

31. d. Environmental Services (cont’d) Mop head and cloth cleaning daily Blood and body fluid cleaning process Equipment cleaning schedules (HVAC, eyewash stations, ice machines, refrigerators, scrub sinks and aerators on faucets)

32. d. Environmental Services (cont’d) Handling of clean and dirty laundry Bagging and storage of dirty linen Segregation of clean from dirty in laundry processing area

33. d. Environmental Services (cont’d) Disinfection of non-critical reusable patient care items, using manufacturers instructions if applicable Cleaning of hydrotherapy equipment

34. 3. Equipment Reprocessing a.Reprocessing of Semi-Critical Equipment b.Reprocessing of Critical Equipment c.Single Use Devices

35. a. Processing of Semi-Critical Equipment High Level Disinfection Policy Flexible endoscope inspection and testing Pre-cleaning processes Use of enzymatic cleaners Cleaning brush maintenance

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

37. a. Processing of Semi-Critical Equipment (cont’d) 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 (cont’d) Use of chemical indicators Use of biological indicators Bowie-Dick testing gravity displacement vs pre-vacuum steam sterilizers Labeling of sterile packs

40. b. Reprocessing of Critical Equipment (cont’d) Sterilizer logs Maintenance of sterilizers Storage of sterilized items

41. b. Reprocessing of Critical Equipment (cont’d) Inspection of processed items prior to use Flash sterilization Immediate use of flashed equipment Recall of sterilized equipment

42. c. Single-Use Devices Disposal after use or opening OR FDA-registered vendors used for reprocessing

43. QUESTIONS? Please submit questions to: info@hfap.org