Infection Prevention and Control Handbook for Hospitals

The Joint Commission Infection Prevention and Control Handbook for Hospitals Technical Editor: Susan M. Slavish, B.S.N., M.P.H., C.I.C. The Joint C...
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The Joint Commission

Infection Prevention and Control Handbook for Hospitals Technical Editor: Susan M. Slavish, B.S.N., M.P.H., C.I.C.

The Joint Commission Infection Prevention and Control Handbook for Hospitals

Technical Editor: Susan M. Slavish, B.S.N., M.P.H., C.I.C. Senior Editor: Maria R. Aviles, M.A. Project Manager: Meghan Anderson Manager, Publications: Paul Reis Associate Director, Production: Johanna Harris Executive Director: Catherine Chopp Hinckley, Ph.D. Joint Commission/JCR Reviewers: Nanne Finis, Kelly Fugate, Catherine Hinckley, Nancy Kupka, Carol Mooney, Rick Morrow, Deborah Nadzam, Paul Reis Joint Commission Resources Mission

The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject to change. Please also note that some of the examples in this publication are specific to the laws and regulations of the locality of the facility. The information and examples in this publication are provided with the understanding that the publisher is not engaged in providing medical, legal, or other professional advice. If any such assistance is desired, the services of a competent professional person should be sought. © 2010 The Joint Commission Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A. 5 4 3 2 1 Requests for permission to make copies of any part of this work should be mailed to Permissions Editor Department of Publications Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 [email protected] ISBN: 978-1-59940-383-0 ISSN: OR Library of Congress Control Number: 2010933762 For more information about Joint Commission Resources, please visit http://www.jcrinc.com. ii

Table of Contents

Foreword ...........................................................................................................................................................................v Introduction ...................................................................................................................................................................vii Part 1 – Hospitalwide Infection Prevention and Control Practices

Chapter 1: Surveillance for Infection Prevention and Control .............................................................................3 Chapter 2: Reducing the Risk of Infections Through Environmental Mitigation...............................................19 Chapter 3: Reducing the Risk of Infections Through Occupational Health Programs .......................................39 Chapter 4: Preventing Health Care–Associated Infections..................................................................................53 Part 2 – Infection Prevention and Control Practices for Specific Hospital Departments

Departments with High-Patient Volume

Chapter 5: The Emergency Department ............................................................................................................77 Departments That Provide Support Services

Chapter 6: Environmental Services ....................................................................................................................83 Chapter 7: Central Services Department............................................................................................................93 Chapter 8: Linen and Laundry Service.............................................................................................................105 Chapter 9: Medical Waste Management ..........................................................................................................111 Chapter 10: Food and Nutrition Services.........................................................................................................117 Chapter 11: Pharmacy .....................................................................................................................................123 Departments That Provide Diagnostic and Therapeutic Services

Chapter 12: Laboratory....................................................................................................................................129 Chapter 13: Pathology .....................................................................................................................................137 Chapter 14: Radiology.....................................................................................................................................141 Chapter 15: Cardiac Catheterization Laboratory..............................................................................................147 Chapter 16: Respiratory Care Services .............................................................................................................153 continued on next page

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The Joint Commission Infection Prevention and Control Handbook for Hospitals

Part 2 – Infection Prevention and Control Practices for Specific Hospital Departments

Departments with High-Risk Populations

Chapter 17: Intensive Care Unit ......................................................................................................................161 Chapter 18: Immunocompromised Patients.....................................................................................................165 Chapter 19: Geriatric Patients..........................................................................................................................173 Chapter 20: Pediatric and Neonatal Patients ....................................................................................................181 Chapter 21: Obstetrics.....................................................................................................................................191 Chapter 22: Dialysis ........................................................................................................................................197 Departments That Provide Surgical Services

Chapter 23: Surgery and Anesthesia.................................................................................................................203 Index ...............................................................................................................................................................219

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Foreword

There is an ever-increasing emphasis on preventing health care–associated infections (HAIs) across the continuum of care, and The Joint Commission has joined this effort by assisting health care professionals engaged in these prevention efforts. Numerous government and professional organizations, including the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the World Health Organization (WHO), and the Association for Professionals in Infection Control and Epidemiology (APIC), have created resources to assist infection preventionists to reduce the rate of HAIs. During the past several years, The Joint Commission has collaborated with all these groups to develop state-of-the-science HAI prevention resources. In spite of this work, information and resource gaps in the clinical and administrative areas of preventing HAIs continue to exist. To help fill these gaps, The Joint Commission has developed The Joint Commission Infection Prevention and Control Handbook for Hospitals. Although the handbook can serve as a resource for the infection preventionist, we believe that it will also provide valuable information for hospital administrators, department heads, nurse managers, and direct care providers. Themes found in the handbook are both general and specific. Chapters 1 through 4 focus on understanding strategies to prevent infections in all parts of the hospital. Chapter 1 explains surveillance for infection prevention and control. The central role of the environment in infection prevention is the focus of Chapter 2. Because the health of those providing patient care and support services is key to infection prevention, Chapter 3 covers the important role of occupational health programs. And best practices for preventing six of the most problematic HAIs are covered in Chapter 4.

Chapters 5 through 23 discuss infection prevention and control strategies for various hospital departments. Unique infection risks are present when large numbers of patients move through a hospital department. The emergency department is probably the best example of a department serving a high volume of patients, and Chapter 5 provides practical methods to reduce the risk of infection transmission associated with caring for numerous potentially infectious patients. In addition to covering a variety of patient-care settings, infection prevention and control strategies associated with departments that provide support and diagnostic services are addressed. Support services addressed in the handbook are Environmental Services (Chapter 6), Central Services (Chapter 7), Linen and Laundry (Chapter 8), Medical Waste Management (Chapter 9), Food and Nutritional Services (Chapter 10), and the Pharmacy (Chapter 11). Diagnostic services covered in the handbook are the Laboratory (Chapter 12), Pathology (Chapter 13), Radiology (Chapter 14), the Cardiac Laboratory (Chapter 15), and Respiratory Care Services (Chapter 16). Each of these chapters contain information specific to the role of the department and associated infection prevention and control strategies. Six chapters are devoted to patient populations considered to be at high risk for acquiring HAIs. These populations include: intensive care patients (Chapter 17), immune compromised patients (Chapter 18), the elderly (Chapter 19), pediatric and neonatal patients (Chapter 20), the pregnant patient (Chapter 21), and those on dialysis (Chapter 22). Chapter 23 looks at the surgical environment, including risks associated with anesthesia. Some of the topics covered v

The Joint Commission Infection Prevention and Control Handbook for Hospitals

in this chapter are: properly maintaining the air quality in the surgical suite; preparing the surgical patient from preoperative showering to surgical site preparation; and infection prevention strategies related to the surgical team, including surgical scrub and attire, traffic control, and sharps safety. Throughout the population- and service-specific chapters, basic infection prevention themes, including hand hygiene, health care provider education, medical equipment cleaning and disinfection, and environmental cleaning, are repeated to reinforce the important roles these play in the prevention of HAIs.

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Everyone involved with developing this handbook is committed to infection prevention and to providing you and your colleagues with an invaluable resource to help in your ongoing efforts to prevent HAIs in the patients you care for each day. It is our hope that you will use the handbook often and share the tips and other information in the book with all members of your healthcare team as you strive toward zero HAIs.

Susan M. Slavish, B.S.N., M.P.H., C.I.C. Infection Prevention and Control Consultant Joint Commission Resources

Introduction

In every hospital around the world, patients contract infections, health care workers (HCWs) are exposed to dangerous pathogens, and members of the community seek treatment for infectious diseases, such as pneumonia, hepatitis, and human immunodeficiency virus (HIV). These events are not isolated incidents—they are regular occurrences that hospitals must know how to manage. Infection prevention and control (IPC) in a hospital affects every single department every single day of the year. To ensure the safety of patients, HCWs, families, visitors, and others who come into contact with a hospital, IPC must be a top priority.

Setting the Stage Because of the size and scope of IPC in hospitals, work in this area cannot be left to one or two individuals, such as the infection preventionist or a clinician in charge of a particular unit. Similarly, IPC cannot involve only one or two targeted interventions implemented in specific departments. It must instead involve a hospitalwide focus that includes all individuals who work, receive care, or visit the hospital. This focus must stress the importance of incorporating IPC into daily operations and routines so it becomes part of the culture and fabric of the hospital. To achieve such a multidisciplinary, multifaceted approach, hospitals must have the following three elements in place: 1. A comprehensive and systematic IPC program 2. Strong leadership and support for the IPC program 3. Comprehensive education and training about IPC for every member of the health care team as well as patients and their families

The Infection Prevention and Control Program An IPC program specifies a hospital’s approach to IPC. Such a program should be based on the specific infection risks a hospital faces, the services it provides, and the populations it serves. It should stress communication and collaboration and be based on accepted best practices regarding IPC. It should continually be monitored and updated to reflect the ever-changing landscape of pathogens, infection risks, and mitigation strategies. Everyone involved in the daily operation of a hospital— including physicians, nurses, therapists, pharmacists, administrative staff, environmental services professionals, housekeeping staff, building engineers, and so on—should play a role in developing, implementing, and sustaining the IPC program. Leadership Support Without leadership support and buy-in, IPC efforts in a hospital may slip down the priority list. Leadership has a direct impact on patient safety and quality of care. In most hospitals, programs that receive the visible support and buy-in of leadership are the ones that HCWs take the most seriously; therefore, these programs are usually the ones that are the most successful. Leadership can actively support an IPC program through the following actions: • Allocating the necessary HCW time and resources. Leadership should appropriate financial and resource support for programs to reduce and prevent the acquisition and spread of infections—especially health care–associated infections (HAIs). This may involve hiring more staff or reallocating staff to areas, such as neonatal intensive care units, in which high staff-topatient ratios help drive down infection rates. vii

The Joint Commission Infection Prevention and Control Handbook for Hospitals

• Allowing access to information. To truly analyze and report infection rates, possible outbreaks, and other critical data points, infection preventionists must have access to detailed information, such as patient records. • Providing appropriate IPC equipment. IPC equipment can include personal protective equipment (PPE), such as masks, gloves, and gowns; accessible sinks; alcoholbased hand rub; sharps disposal boxes; and other safety equipment. Leaders should encourage HCWs to weigh in on the types of equipment that can make their jobs safer and easier and can prevent and control infections. • Actively supporting a multidisciplinary approach to IPC. This collaboration may involve attending IPC committee meetings, encouraging the use of multidisciplinary teams to examine and respond to particular IPC issues, and allowing time for different disciplines to participate in multidisciplinary teams. • Serving as a role model. People imitate what they see. For example, if leaders are practicing good hand hygiene, HCWs throughout the hospital will be more likely to practice good hand hygiene as well. Conversely, if leaders skip this critical activity, HCWs will see it is not a priority and skip it themselves. Leadership should also communicate about specific goals and initiatives and share results of performance improvement projects related to IPC. HCWs benefit from knowing their roles in preventing the transmission of infection and are motivated when they see results. When a particular initiative reduces infection rates, for example, HCWs are more likely to pay attention to the initiative, and compliance rates may go up. Education and Training It is critical for all HCWs to realize the importance of their individual roles in preventing and controlling infections in hospitals. One of the ways this can be accomplished is through HCW education and training. Comprehensive education programs should focus on the following topics: • What individuals can do to prevent or control infections. This topic can include general preventive strategies, such as hand hygiene and the use of PPE, as well as more department-specific topics, such as how to correctly prepare a patient for surgery or how to effectively clean a dialysis machine. • How to identify problems or potential problems related to IPC. This topic can include processes for reporting identified problems, what to report, and to whom to report these. viii

• How individuals can preserve their health to help preserve the safety of their patients. These practices can include staying home when ill, using appropriate PPE, and getting immunized for such infectious diseases as influenza and hepatitis B. Effective education and training programs apply not only to patient care providers but to everyone in the hospital who has the potential to come in contact with patients, such as biomedical technicians, waste and garbage handlers, plumbers, electricians, delivery personnel, personal aides, and housekeepers. All these individuals can be exposed to and act as carriers of infection and must be familiar with how to ensure their safety as well as the safety of others in the hospital. HCWs who work with high-risk patients, such as the elderly, neonates, or the immunosuppressed, should know how to identify risk factors for infection in these specific populations. Training HCWs to be aware of populationspecific risk factors and how to prevent and control infections in those populations can go a long way in decreasing infections in the hospital.

About This Book The Joint Commission Infection Prevention and Control Handbook for Hospitals is designed to assist hospitals to identify problem areas and barriers related to IPC (the infection risks) and to provide evidence-based best practices and solutions to address these problem areas and eliminate these barriers. This book takes a multipronged approach and communicates information in two parts. A note about the term infection preventionist that is used throughout this book: This term was recently adopted by the Association for Professionals in Infection Control and Epidemiology (APIC) to refer to IPC professionals who work in a variety of health care settings and who have the scientific knowledge and clinical expertise to prevent infections. According to APIC, “An infection preventionist is typically a registered nurse, physician, epidemiologist or medical technologist who: Helps to prevent nosocomial infections [HAIs] in healthcare facilities by isolating sources of infections and limiting their spread; systematically collects, analyzes and interprets health data in order to plan, implement, evaluate and disseminate appropriate public health practices; and trains healthcare staff through instruction and dissemination of information on infection prevention and control practices.”1 Many hospitals employ infection preventionists on a full-time basis and others a

INTRODUCTION

part-time basis. Many hospitals, however, do not have an infection preventionist for a variety of reasons. This does not mean that they do not have individuals who are in charge of the IPC program and of preventing infections in their institution. There are many HCWs who have specialized training, knowledge, and clinical experience in preventing and controlling infections, yet they do not carry the label of infection preventionist. Therefore, the term infection preventionist, as used in this publication, refers to these individuals. As indicated previously, IPC in a hospital should be a multidisciplinary effort that involves many individuals and teams with a variety of talents, roles, and expertise, all of whom work together to prevent infections in hospitals from threatening the lives and safety of patients and the staff who work in its confines. Part 1: Hospitalwide Infection Prevention and Control Practices Because hospitals must attack infections using organizationwide approaches and because many preventive strategies are practiced throughout a hospital, the first part of the book provides a comprehensive look at addressing IPC issues enterprisewide. Chapters within this portion of the book (Chapters 1 to 4) focus on practices that need to be followed by all hospital departments. These strategies include surveillance; hand hygiene; PPE; staff screenings, physicals, and immunizations; protection against common pathogens; sharps injuries; and postexposure prophylaxis. This part of the book also discusses best practices to prevent six of the most common HAIs: catheter-associated urinary tract infections, ventilator-associated pneumonia, surgical site infections, multidrug-resistant organisms, Clostridium difficile infections, and central line–associated bloodstream infections. Because HAIs are the most pervasive type of infection that hospitals face, this part of the book focuses on preventing and eliminating some of the most difficult and widespread HAIs. Part 2: Infection Prevention and Control Practices for Specific Hospital Departments Because hospital departments have unique IPC issues, the second part of the book presents strategies for preventing infections that are tailored to meet the IPC needs and unique circumstances of some of these departments. Although there are numerous departments in hospitals and different hospitals have various types of departments, the departments covered in this book were chosen because they are among the most common, see the most patients, and present the most difficult or prevalent infection risks.

Chapters 5 to 23 are designed to teach staff on the front lines how to identify and prevent infections in their particular departments as well as other departments they have contact with. The audience for these chapters includes direct care providers (such as physicians, licensed independent practitioners, and nurses) as well as clinical support staff (including housekeeping, pharmacists, and radiologists) and other hospital staff (such as human resources and building maintenance). All these individuals play key roles in preventing hospital infections in patients and among HCWs. But the road to prevention does not begin and end with these individuals. It is their responsibility to educate patients, family members, visitors, and others who come to the hospital about their responsibilities to prevent infections. The 19 chapters in Part 2 are organized into discrete groups based on the primary function the department performs in a hospital. Chapter Five: The Emergency Department is placed in the “Departments with High-Patient Volume” group, because the large number of patients seen in this department and the conditions they present with often pose infection risks. The next group, “Departments That Provide Support Services” contains Chapter 6: Environmental Services, Chapter 7: Central Services Department, Chapter 8: Linen and Laundry Service, Chapter 9: Medical Waste Management, Chapter 10: Food and Nutrition Services, and Chapter 11: Pharmacy. Although these departments do not provide direct patient care or are not involved with care at the bedside, they nevertheless play pivotal roles in infection prevention and have direct impacts on the health and well-being of patients. The “Departments That Provide Diagnostic and Therapeutic Services” group encompasses departments that perform a wide variety of procedures and use a vast array of equipment to diagnose, cure, care for, and treat patients. These include Chapter 12: Laboratory, Chapter 13: Pathology, Chapter 14: Radiology, Chapter 15: Cardiac Catheterization Laboratory, and Chapter 16: Respiratory Care Services. There are certain patient populations in hospitals that face greater infection threats than other patients. These threats and the strategies to mitigate them are covered in the next group, “Departments with High-Risk Populations.” Chapter 17: Intensive Care Unit, Chapter 18: Immunocompromised Patients, Chapter 19: Geriatric Patients, Chapter 20: Pediatric and Neonatal Patients, ix

The Joint Commission Infection Prevention and Control Handbook for Hospitals

Chapter 21: Obstetrics, and Chapter 22: Dialysis all discuss hospital patients who are particularly vulnerable to developing infections. The last group, “Departments That Provide Surgical Services,” presents infection risks and preventive strategies for patients who will undergo surgery (Chapter 23: Surgery and Anesthesia). The information in each chapter in Part 2 is supplemented with a wide variety of figures, posters, brochures, forms, tips, and sidebars. HCWs can use these materials to implement the best practices presented in each chapter to prevent infections and improve compliance. Additionally, each chapter in Part 2 begins with a snapshot of the chapter contents. The most important IPC risks that the department faces are indicated with the symbol, and the most effective best practices and preventive strategies are highlighted with the icon. When considered together, the two parts of the book provide a complete roadmap for IPC in a hospital and can help serve as a guide for a hospital’s efforts in this area. By using this guide, infection preventionists and others who work in the hospital, such as leaders, occupational health professionals, environment of care professionals, physicians, nurses, and other HCWs, can work together to develop, implement, and manage a comprehensive IPC program and preserve the safety of patients and workers while reducing the introduction and transmission of infectious diseases within the hospital.

Acknowledgments This book has greatly benefited from the knowledge, expertise, and experience of a great number of individuals, and Joint Commission Resources (JCR) would like to extend a hand of thanks to them.

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First and foremost, sincere thanks go to Susan M. Slavish, B.S.N., M.P.H., C.I.C., who served as the technical editor for this project. At the forefront of Susan’s mind was making sure that the IPC information in the chapters was accurate, useful, and timely and that it would truly have a positive impact on saving lives, preventing needless suffering, and helping HCWs better serve their patients and protect themselves from harm. Susan worked tirelessly to realize these goals by reviewing numerous drafts of this publication, suggesting references to include, and providing overall guidance. Thanks to her for her patience and support. JCR would also like to thank and acknowledge the contributions made by the many reviewers. These individuals helped develop the content and reviewed the clinical and IPC information for accuracy and completeness. Kelly Fugate, Carol Mooney, and Rick Morrow from The Joint Commission and Nanne Finis, Catherine Hinckley, Deb Nadzam, and Paul Reis from JCR provided invaluable comments, edits, guidance, and assistance. Last, this book would not have been possible without the writing talents of Kathy Vega. As indicated by the breadth and scope of this book, a large amount of information, knowledge, detail, and expertise was required to create the content. Kathy deserves special recognition for being able to quickly master complex IPC data and information and should be named an honorary “infection preventionist.”

Reference 1.

Association for Professionals in Infection Control and Epidemiology (APIC): About the Profession. http://www.apic.org/Content/NavigationMenu/AboutAPIC/ AbouttheProfession/About_the_Profession.htm (accessed May 15, 2010).