NEW YORK HOSPITAL QUEENS FLUSHING, NEW YORK 11355 INFECTION CONTROL PROGRAM 2014 Mission The New York Hospital Queens (NYHQ) Infection Control Program (ICP) is to promote safe and quality care to our patients, healthcare workers, and visitors through prevention and control of infections. This is to be achieved through the use of sound epidemiological principles and scientific based decision-making in addition to our commitment of excellence and, respectful patient care. The goals of program are: 1.
2.
3.
Protect the patient by minimizing the risk of transmission of infections associated with the use of procedures, medical equipment, and medical devices thus reducing Healthcare Associated Infections (HAIs) in an effort to reduce morbidity and mortality and shorten periods of illness and hospitalization. Protect healthcare workers, visitors and others in the healthcare environment. This is accomplished by limiting unprotected exposure to pathogens by using administrative controls, engineering controls, isolation, hand hygiene, barrier precautions including personal protective equipment, case investigation, education, immunization, and employee health programs that protect employees from job-related exposures. Provide budget proposals and information resource requests that facilitate general infection prevention and control program activities defined by program components and specific activities that support disease prevention, data collection, and reporting. Accomplish the previous two goals in a cost effective manner by preventing costs to the healthcare payer associated with the treatment of complications due to HAIs and avoiding costs to the organization resulting from infection-related absenteeism and liability.
Infection Control Authority and Responsibility The Infectious Disease Chair or his designee has the authority to institute any surveillance, prevention, control measure, or study when there is reason to believe that any patient, personnel, or visitor may be in danger. This authority and responsibility includes, but may not be limited to: Develop and implement a preventive and corrective program designed to minimize infection hazards Develop a system for identifying, reporting, and analyzing the incidence and causes of HAI Review and approve all policies and procedures related to infection surveillance, prevention, and control activities in all departments/services
Determine when isolation precautions, barrier precautions, or environmental cultures are required, and implement these processes Collaborate with the organization leadership to institute emergency measures such as closure of units, transfer of patients, halting constructions and other measures to prevent infections Participate with pharmacy in regard to antibiotic utilization practice patterns, or with other medical or hospital committees deemed essential to infection prevention and control activities Promote application of organizational and departmental policies relating to infection control involving but not limited to, isolation procedures and techniques, disinfection and sterilization procedures, the safe disposal of infectious or contaminated wastes, and prevention of infection due to contaminated equipment Implement a system for surveillance of community and health care associated infections and to identify, report, and analyze clusters of infections, outbreaks, sentinel events, and emerging pathogens and spread of HAI Coordinate with the public health department and other appropriate government and regulatory agencies for the reporting, investigation and prevention of infections Risk Assessment and Prioritization of Goals The ICP is a multidisciplinary collaborative plan designed to control the spread of infection based upon the clinical needs and demographics of our patients and employees. The Centers for Disease Control (CDC) National Healthcare Safety Network (NHSN) is used to define infections. Consideration will be given to issues, which present high risk, occur with increased frequency, or are problem prone. An annual risk assessment is developed and may also be expanded or altered to meet facility needs. Changes in the plan will be at the approval of the Infection Control Chairperson and/or the Infection Control Committee (ICC). These may include new techniques, emerging or reemerging trends and other issues. The factors that are addressed in the risk assessment include at a minimum: Geographic Location and Community Environment: The threat of mass casualty, terrorism in all its forms, and other human events are taken into consideration. o New York Hospital Queens (NYHQ) is a 519 bed, voluntary, non-profit, teaching medical center. It serves the Queens county population of 2 million. o It is also a trauma center located near two major airports (LaGuardia and Kennedy), three major highways (Long Island Expressway, Grand Central Parkway; and Van Wyck Expressway), and three major bridges (Robert F. Kennedy, Whitestone, and Throgs Neck).
Characteristics of the Population Served o NYHQ serves a diverse community in which half of the borough’s population is foreign born. o NYHQ is a New York State AIDS Designated Center o NYHQ is located within the geographic service area that serves patients with high prevalence of confirmed tuberculosis. o The age range of our patients varies from newborns, to children and adolescents, to adults, and senior adults. Each age group has unique risk factor for developing community and HAI. Results of Analysis of NYHQ’s Infection, Prevention, and Control Data o The surveillance results from surgical procedures, device related infections, communicable disease exposure events, and environmental incidents are reviewed for variances o The surveillance results from antibiotic usage are reviewed for variances Care, Treatment and Services Provided o Services provided: Surgical services including: Cardiothoracic, General, OB/GYN, Urology, Neurology, Orthopedic Surgeries etc; hemo and peritoneal Dialysis Treatments; 3rd level NICU; Medical ICU, Surgical ICU, Coronary Care Unit, Oncology Care Unit; Cardiovascular Recovery Unit; Transitional Care Unit (TCU) o Infectious Disease consultations -housewide Performance Improvement Methodology The ICC utilizes the Deming Cycle of PDSA as employed hospital-wide Plan: Recognize an opportunity and plan a change Do: Carry out a small scale study to test the change Study: Review the test. Analyze the results and identify what was learned Act: Take action based on what was learned. If the change did not work, go through the cycle again with a different plan. If it did, incorporate what was learned into broader change. The findings of Infection Control data may be used for: Departmental level for education and evaluation of PDSA processes related to infection prevention.
Committee reports for communication with multi disciplinary groups and administration External benchmarking with CDC/NNIS/NHSN, New York State Partnership for Patient (NYSPFP) data and internal unit based historic trend data Hospital wide PI projects with Infection Control components. 2014 Program Activity List 1. Targeted Surveillance a) Multi-drug resistant organisms (MDROs) b) Clostridium difficile (C-diff) c) Central Line Associated Bloodstream Infections (CLABSI) d) Ventilator Associated Events (VAE) e) Catheter Associated Urinary Tract Infections (CAUTI) f) Blood Culture Contamination g) HIV Testing 2. Precautions Management 3. Hand Hygiene/Patient Safety 4. Administrative Activities 5. Education 6. Employee Health Support 7. Department of Environment & Safety 8. Surgical Site Infections 1. Targeted Surveillance Multi-drug Resistance Organism (MDRO) Prevention- We continue surveillance and initiation of barrier precautions for MDROs including select GNRs and MRSA. The definition of MDROs was expanded as it pertained to increasing resistance and the limited antibiotics, which continue to be effective. In addition, the Extensively Drug-Resistant organisms (XDROs) including Pseudomonas, Acinetobacter, and Klebsiella were identified for a more focused surveillance. Methicillin-Resistant Staphylococcus aureus (MRSA)- We will continue to report into the NHSN system all MRSA Bacteremia Lab ID Event Clostridium difficile Infection (CDI)- A comprehensive program involving Building Services, Infection Control, Antibiotic Stewardship, and staff education continues to address the problem of CDI. NYSDOH requires the reporting of Laboratory Identification Events. . Central Line Associated Bloodstream Infections (CLABSI): Adult and neonatal ICUs CLABSI became state mandate reportable in 2008. This surveillance was expanded house wide in 2010. We will continue to monitor
CLABSI in 2014 with a goal of ≤ 0.75 per 1,000 line days. NYHQ follows the evidenced-based central line bundle for catheter insertion. Ventilator-Associated Event (VAE): In 2014, NYHQ will continue to follow the surveillance definition algorithm for ventilator-associated events (VAE). It is to be used for surveillance purposes only. It is not a clinical definition algorithm and is not to be used for clinical management of patients. The VAE surveillance will be monitored for patients who are 18 years and older in the four adult ICUs, PICU and 5 North Vent Unit. The standards of care (VAP Bundle) for ventilator patients will continue on the medical and surgical units in 2014. Catheter Associated Urinary Tract Infection (CAUTI)- Continue to monitor CAUTI rates in 2014. Report in the NHSN all ICU CAUTIs, NDNQI housewide and NYSPFP unit specific CAUTI rates. NYHQ will follow the CAUTI Bundle: ARMIE Blood Cultures Contamination-A positive blood culture provides the clinician a definitive diagnosis and enables the targeting of therapy for the patient. However, false positive results delay treatment to the patients and costly to the medical center. In 2014, we will continue to focus on the Emergency Department’s blood culture contamination rates. HIV Testing-A positive blood culture provides the clinician a definitive diagnosis and enables the targeting of therapy for the patient. However, false positive results delay treatment to the patients and costly to the medical center. In 2014, we will continue to focus on the Emergency Department’s blood culture contamination rates. 2. Precaution Program The Precaution Program provides a framework for limiting the potential for staff, patient, and/or visitor exposures to pathogens throughout the hospital. Precaution Policy and required practices are based on state and federal mandates, CDC Guidelines/ Recommendations, and professional practice guidelines from various professional disciplines. Practices may also be based on supportive scientific evidence-based data from professional journals and research. There are three levels to the Precaution program: 1. Standard precautions as required under OSHA regulations 2. Transmission-Based Precautions based on CDC guidelines 3. Special isolation management as required for seasonal illnesses, outbreaks or an unusual influx of patients with a known or suspected
infectious disease process (as may be associated with emerging pathogens or agents of bioterrorism). 3. Hand Hygiene Program/Patient Safety Good hand hygiene is recognized as a critical practice for the control of healthcare associated infections. Infection Control / Patient Safety and Quality Improvement collaborate on the Hand Hygiene Program based on National Patient Safety Goals and CDC Recommendations.
Program Components for 2014 include: 1. Educational Activities a. Hand Hygiene program at orientation and re- orientation for all employees. b. Additional Education efforts including skills fair demonstration, posters, newsletter bulletins, and live programs. 2. Monitoring Activities a. Anonymous compliance monitoring with monthly feedback reports to departments/supervisors. 4. Administrative Activities The Infection Preventionist (IP) provides consultation and support to hospital administration through the following functions: 1. Facilitates review of departmental policies and procedures related to infection control. 2. Participates in compliance monitoring activities as required by state, federal, and other governing agencies. 3. Provides reports and surveillance findings to appropriate committees and departments, or individuals. 4. Assists with facility decision making and problem solving activities related to infection control. 5. Serves as a consultant to Facilities Planning to assure patient and employee safety as related to infection risks during construction projects. 6. Serves as a consultant to Risk Management and Legal Counsel on infection control related issues. 7. Participates as appropriate with professional organizations in educational and policy-making efforts. 8. Provides infection control expertise house wide when any new service or sites of care are being considered for implementation. 9. Serves on hospital committees requiring consultation/expertise on infection control related issues.
5. Educational Activities: The Infection Control Education program includes education for staff, patients, families, visitors, community groups, physician offices and others as needed. Staff education: Infection Control is responsible for offering or assisting with educational programs via: a. New Employee orientation programs (includes students, volunteers). b. Re-orientation of new employee and volunteers. c. Live programs as needed to address specific issues. d. One-on-one staff education during isolation rounds/during problem solving activities utilizing verbal and printed materials. Department Heads, directors, and/or supervisors are responsible for ensuring all personnel receive annual Infection Control Education via net learning. Select Infection Control programs may be offered throughout the year based on staff needs. These programs may be classified as mandatory, required and optional. It is the responsibility of the Department Director or supervisor to ensure all appropriate personnel attend these programs. Patient/Visitor education: Infection control supports patient, family and visitor education via: Individual consultation with patients and family. Various printed information on infection control related issues. 6. Employee Health Liaison Activities: The IPs collaborate with the Employee Health Services to address the following employee health/infection control related issues: Blood Exposures/Sharps Injuries Management a. Assist employees with exposure management issues as appropriate. b. Assist with exposure monitoring for employee compliance with follow-up protocol and source testing c. Provide Blood Exposure Report Data to various departments and committees as appropriate d. Utilize data in educational and prevention activities Flu Vaccine Program for Hospital Employees a. Coordinate education and vaccine administration for the flu season b. Collaborate with the Wellness Program Committee on the endeavor c. Comply with the NYS mandate for vaccination of personnel
Employee communicable disease exposure and prophylaxis issues a. Investigate/identify employees with potential on the job exposure to communicable diseases. d. Facilitate the provision of appropriate management and prophylaxis, if indicated. 7. Department of Environment and Safety Liaison Activities: The Infection Control Program is integrated with the Department of Environment and Safety through the following activities: IPs along with the Environmental of Care (EOC) and Materials Management Committee serve to address and assure compliance with state and Federal sharps safety legislation. a. Assist with the selection and implementation of new sharps safety products. b. Assist in complaint investigations and problem resolutions related to sharps devices when appropriate. c. Review database on sharps related injuries as provided by Employee Health and provide reports to appropriate committees and departments. Assists with investigation of employee illness related to work place complaints. Assists with bioterrorism preparedness and response issues. Assists with pandemic influenza preparedness and response issues. Assists with emerging pathogens, quarantine and patient management issues. 8. Surgical Site Infection Program The 2014 SSI Surveillance Program includes: 1. 2. 3. 4.
CBGB-Chest and Donor site Total Hip Colon surgeries, Hysterectomy,
The IP will review culture reports for SSI association and notification from staff if any identification made throughout any healthcare facility. Surgical wound infection surveillance data will be collected and collated to allow utilization both internally and externally for patient care improvement activities.
Reference: 2014 Hospital Accreditation Standards, The Joint Commission Accreditation Hospital, http://www.jointcommission.org 2013 New York State DOH, Prevention of Influenza Transmission by Healthcare and Residential Facility and Agency Personnel, Public Health Law Sections 225, 2800, 2803, 3612 and 4010, Association for Professionals in Infection Control and Epidemiology, Inc.www.apic.org Association for the Advancement of Medical Instrumentation-www.aami.org Association of periOperativeRegistered Nurses-www.aorn.org Centers for Disease Control and Prevention-www.cdc.gov Infectious Diseases Society of America-www.idsociety.org Occupational Safety and Health Administration-www.osha.gov Society for Healthcare Epidemiology of America-www.shea-online.org A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, www.journals.uchicago.edu/toc/iche/2008/29/sl
Approvals:
Sorana Segal-Maurer, MD Chair of Infection Control Committee
Mimi Lim, MPA, MSN, RN, CIC, NEA-BC, CNL Director of Infection Control
Stephen Rimar, MD Executive Vice President, Chief Medical Officer
William Wolff, MD Chairman of the Medical Board
Michaelle Williams, MA, RN, NEA-BC Senior VP of Patient Care Services
Stephen S. Mills Chief Executive Officer
NYHQ INFECTION CONTROL RISK ASSESSMENT 2014 Evaluate every potential event in each of the three categories of probability, risk, and preparedness. Add additional events as necessary. H= High, M=Medium, L=Low Issues to consider for Probability include, but are not limited to: Known risk Historical data Manufacturer/vendor statistics The intensity for Organizational Response, but are not limited to: Threat to life and/or health Disruption of services Damage/failure possibilities Loss of community trust Financial impact Legal issues Issues to consider for Potential Change in Care, Treatment, Services, but are not limited to: Threat to life and/or health Disruption of services Damage/failure possibilities Loss of community trust Financial impact Legal issues Issues to consider for Preparedness include, but are not limited to: Status of current plans Training status Insurance Availability of back-up systems Community resources Add the ratings for each event in the area of probability, risk and preparedness. The total value of 10 or greater will represent the events most in need of organization focus and resources for emergency planning. Acceptance of risk is at the discretion of NYHQ Infection Control Committee
NEW YORK HOSPITAL QUEENS
INFECTION CONTROL RISK ASSESSMENT-2014 EVENT
Probability H
SCORE
M 3
2
Required Organizational Response L
NONE 1
0
LIFE THREAT 3
Perm Harm 2
Temp Harm 1
None 0
Potential Change in Care, Treatment, Services H M L NONE 3
2
1
0
Preparedness Poor
Fair
3
2
Risk Level Good 1
GEOGRAPHY AND COMMUNITY Hospital Acquired Infection (HAI) Reporting Influx of infectious patients ie: Pandemic Avian Flu Outbreak, Bioterrorism Patient Education regarding their role in infection prevention
3
2
2
1
3
2
2
2
9
3
2
2
2
9
3
2
2
2
3
2 2
2 2
8
POTENTIAL INFECTION Central Line Associated Bloodstream Infections Ventilator Associated Event (VAE) Surgical Site Infections Catheter Associated Urinary Tract Infection (CAUTI) Outbreak of multi-drug Resistant Organisms (including, C-diff, Gram negative MDRO) Contamination Rates of Blood Cultures
2 3 3 3
3
3
1
2
3
2
9
2
9 10
2
11
3
3
8
3
11
COMMUNICATON Lack of notification of presence of Hospital Acquired Infection (internal or external)
2
2
2
2
2 2
3 3
2
2 2
3
2
8
2 2
9 10
EMPLOYEES Poor Hand Hygiene Compliance Influenza vaccine compliance rates Sharps Injury Employees’ lack of understanding and compliance with disease transmission and prevention-with a focus on TB
3
3
2
1 2
7 10
2
8
ENVIROMENT Ineffective preconstruction IC Planning (meeting & risk assessment) Improper cleaning/disinfection of environment
2
3
2
2
2
2
3
10
SUPPLIES /EQUIPMENT Improper cleaning/disinfection of supplies/equipment Education regarding proper cleaning/disinfection of equipment
3
3
3
3
2 3
2
10
2
11
RISK PRIORITY GEOGRAPHY AND COMMUNITY Hospital Acquired Infection (HAI) Reporting
Goals
To maintain a program capable of identifying and tracking HAI for the purpose of public reporting on the CDC’s National Healthcare Safety Network (NHSN).
INFECTION PREVENTION AND CONTROL PLAN 2014 Measurable Strategies Evaluation Objective
Electronic Reporting of HAI-100%
Infection Preventionists will enter all baseline demographics and data
Responsibility
Periodical validation by DOH
Infection Preventionists
Report Compliance with Hospital Emergency Incident Command System plan regarding Infection Control to Environment of Care, Infection Control Committee, Emergency management, leadership and other appropriate committees or groups
Infection Preventionists
Monthly review of the medical records for compliance
Departmental managers/ supervisors
To report on all CLABIs events in MICU, CCU, SICU, CVRU, and NICU. Report HAI for the following procedures: Surgical site infections (SSI) associated with coronary artery bypass graft, colon procedures-, hip replacements and hysterectomies Report on all lab events for CDI and MRA Bacteremia
Adequate response to an influx or risk of influx of infectious patients ie: pandemic Avian Influenza, agents of Bioterrorism, etc
Prepare for the response to an influx or risk of influx infectious patients
Patients/ significant others are
Increase patient/ significant
Meet equal to or greater than 90% of Hospital Emergency Incident Command System plan requirements as related to infectious patients
Be part of and attend all meetings of the Emergency Management Committee Provide expert Infection Control input on infection control issues during emergencies Review and revise if needed the policies and procedures for influx of patients, outbreaks, emerging infections and Bioterrorism,
75 % compliance of documented education of infectious diseases
Provide the patient with information regarding infection control measures for hand hygiene practices, respiratory
Emergency Management Officer
Updates
RISK PRIORITY
Goals
knowledgeable regarding their infectious diseases transmission and prevention
others’ understanding and compliance with disease transmission and prevention.
Measurable Objective transmission and prevention of medical records reviewed.
The patient/ significant others are able to verbalize the disease process, transmission and prevention to the staff. POTENTIAL INFECTION Catheter Related Bloodstream Infections CLABSI
Prevent central line associated bloodstream infections and deaths by implementing the “Central Line Bundle”
Strategies
Evaluation
hygiene practice and contact precautions according to the patient’s condition
Infection Preventionists
Multi language FAQs available on the Intranet
Staff
Information is discussed with the patient and his or her family members’ on the day the patient enters the hospital or as soon as possible.
Reduce Central Line Associated Bloodstream Infections (CLABIs) to zero house wide Compliance Rates are to be 90% or greater
Responsibility
Use evidence based bundle for CLABIs: Hand Hygiene Maximal Barrier Precautions on Insertion Chlorhexidine Skin antisepsis Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for nontunneled catheters Daily review of line necessity with prompt removal of unnecessary lines Monitor central line days Daily review of microbiology isolates Concurrent and/or retrospective chart review Provide feedback to staff if the infection control practices are not adhered to for the reduction of CLABIs
Medical Staff
Others as appropriate
Monthly review of CLABIs data
Infection Preventionists ICU directors and managers Medical staff Infection Control Committee PI committee
Updates
RISK PRIORITY
Goals
Measurable Objective
Strategies
Evaluation
Responsibility
Reports findings to Infection Control Committee, ICU managers, Critical Care Committee, Hospital Wide PI committee
Ventilator Associated Event (VAE)
Prevent VAE by implementing the Vent Bundle
VAE infection rate to be 1 per 1,000 ventilator days
Use evidence based bundle for VAEs:
Monthly review of VAE data
Elevation of the Head of the Bed (HOB) to 30 degrees Daily “Sedation Vacations” and assessment of readiness to extubate Peptic Ulcer disease prophylaxis DVT prophylaxis Daily oral chlorhexidine rinses
Infection Preventionists ICU directors and managers Medical staff Infection Control Committee PI committee
Monitor ventilator days Daily review of microbiology isolates Review of changes in oxygenation Concurrent and /or retrospective chart review Provide feedback to staff if the infection control practices are not adhered to for the reduction of VAE Reports findings to Infection Control Committee, ICU managers, Critical Care Committee, Hospital Wide PI committee Surgical Site Infections (SSI)
To prevent surgical site infections
SSI rates are within the 2011 NHSN or better
Use evidence based practices for prevention of SSI such as: IV antibiotics within one hour before incision
Monthly review of all targeted surgery specific medical records
Surgical staff Infection Preventionists
Updates
RISK PRIORITY
Goals
Measurable Objective
Strategies
Evaluation
Discontinue prophylactic antibiotic within 24 hours after surgery Cardiac surgery – glucose < 200 at 6 am POD #1 and 2 Surgery patient with perioperative temperature management When hair removal is needed only clipping or use of depilatories-no shaving
Responsibility
Infection Control Committee PI committee
The Infection Preventionists will attend monthly QA meetings of various surgical departments for updates of SSIs
Catheterassociated Urinary Tract Infection
To prevent CAUTI
CAUTI to be 2.4 per 1,000 foley days or less
Reports findings to Infection Control Committee, ICU managers, Critical Care Committee, Hospital Wide QA committee Use evidence based practices for prevention of CAUTI such as: Avoid unnecessary use of foley catheter Review catheter use daily. Assess for removal Maintain catheter properly Insert using aseptic technique Education of staff in insertion and Foley care
Monthly review of CAUTI and foley use per patient days
Nursing and medical staff Infection Preventionists Infection Control Committee PI committee
Reports findings to Infection Control Committee, ICU managers, Critical Care Committee, Hospital Wide PI committee annually Surveillance and control of multiresistant organisms including but not
To prevent an outbreak of CDI and/or other multidrug-
To decrease the hospital acquired infection CDI rate to ≤ 15 per 10,000 patient days
Daily review of microbiology isolates Infectious Disease Pharmacist reviews daily antibiotic usage
Monthly reports of findings to the Infection Control Committee
Infection Preventionists Unit Managers
Updates
RISK PRIORITY limited to: Clostridium difficile Infection (CDI), Vancomycinresistant enterococci (VRE), Mulitdrugresistant organism (MDRO) and Methicillinresistant staphylococcus aureus (MRSA)
Goals
Measurable Objective
resistant organisms (including MRSA)
Strategies
Evaluation
Responsibility
Daily communication with the PCUs regarding which patients will need to be placed on precautions-via fax and on the Allscripts™ documentation system
Medical staff
Provide feedback to staff if the infection control practices are not adhered to for the reduction of resistant organisms in the medical center
Infection Control Committee
Building Services managers and staff
PI committee
Multidrug-resistant organisms/CDiff Daily communicate with Building Service supervisors to ensure cleaning with appropriate agents. Institute private rooms or cohorting of patients with CDI Continue antibiotic restriction policy Report to the NHSN system all CDI lab event Multidrug-resistant organisms/MRSA Report to the NHSN system all positive bactermia MRSA Lab Event
Blood Culture Contamination in ED
Decrease the percentage of blood culture contamination rates from the ED
ED blood culture contamination rate to ≤ 3%
Education of ED staff members proper technique of drawing blood cultures Report findings to ED staff, PI Committee and others as needed.
Monthly monitoring of ED’s rate of blood culture contamination rates
Departmental managers/supervisors Infection Preventionists Staff Medical Staff
Updates
RISK PRIORITY
Goals
Measurable Objective
Strategies
Evaluation
Responsibility Others as appropriate
COMMUNICATON
Employees are knowledgeable regarding infectious diseases transmission and prevention as it relates to TB
EMPLOYEES Hand hygiene compliance
Increase employees’ understanding and compliance with disease transmission and prevention as it relates to TB.
Increase hand hygiene compliance through individual unit supervision of Healthcare Workers
The number of TB exposures to be limited to 5 or below
Achieve 92% (overall medical center) compliance with hand hygiene policy
Daily review of all patients on TB isolation
Monthly monitoring of TB exposures
Departmental managers/supervisors
Continue the Annual Mandatory SelfLearning Module.
Infection Preventionists
Daily conversations with direct care givers of specific patients on respiratory isolation as it relates to TB
Staff
Staff in-service in “real” time of targeted TB and other HAIs
Others as appropriate
Continuing education-including staff meetings etc Monitor compliance and provide feedback of rates to staff and committees Visual reminders and written materials for staff, visitors, patients and LIPs Utilize “Patient Safety Mondays” team to monitor hand hygiene observations Letters to department heads informing staff who fail to comply with hand hygiene standards.
Medical Staff
Receive the Hand Hygiene Monitoring Logs of the Patient Care Units on a monthly basis
Departmental managers/ supervisors
Report findings to Infection Control Committee, PI Committee, Environment of Care, staff, Leadership and other appropriate committees
Staff
Report rates to staff and appropriate committees
Infection Preventionists
Medical Staff Others as appropriate
Updates
RISK PRIORITY Employee Influenza vaccine compliance
Goals Increase the employee influenza vaccines rates
Measurable Objective Increase employee Influenza vaccines rates to 60% 20132014 and 70% 20142015
Strategies Influenza vaccine offer to staff in the Fall 2014 Education regarding influenza, transmission and prevention
Evaluation Evaluate 20132014 program in May 2014 in preparation for 2014-2015 season
Responsibility Employee Health Services Departmental managers/ supervisors
Declination in all employees’ assessment form Infection Preventionists
Utilizing the Nursing Management Team to give out the flu vaccines to staff.
Staff
ENVIRONMENT
Cleanliness of the environment and/or equipment
Maintain a clean and safe environment for our patients and employees
The environment and/or equipment that come in contact with the patients are cleaned and properly disinfected prior to use.
Monitor number of flashes in the Main OR and ASU. Review biological indicators. Review hemodialysis bacteriological R/O water and dialysate cultures Establish with Building Service a routine schedule for cleaning of equipment
Review on a monthly basis biological, flashes and bacteriological reports from the respective areas. Building Services to provide monthly reports to the Infection Control Committee
Infection Preventionists Director of Building Services Director of Materials Management Director of Central Processing
A standardized cleaning process for multiuse of general patient care equipment using the Bleach wipes or solutions
Unit Managers and staff
Equipment is cleaned between patientsto include exam tables, med carts, fans, X-ray machines, Ultrasound equipments etc.
Others as appropriate
All equipment in precautions/isolation rooms is properly cleaned prior to going in and out of the patients’ rooms Building Services to monitor high touch areas including patients’
Safety Officer
Updates
RISK PRIORITY
Goals
Measurable Objective
Strategies
Evaluation
Responsibility
bathrooms
Staff educated on contact time of cleaning solutions Infection Control to be notified of any construction, renovation or alteration in facility prior to start of project.
Infection Control will be notified of any construction, renovation or alteration in facility prior to work beginning Infection Control Clinicians inclusion in preconstruction/ renovation planning
Equal to or grater than 95% inclusion of Infection Preventionists n the design and planning phases of construction, renovation, or alteration
Attend Facilities Planning meetings Jointly develop policy with appropriate staff to assure inclusion of Infection Prevetionists in the process Provide education to planning, engineers, maintenance and telecommunication staff about Infection Control Risk Assessment (ICRA)
Compare the number of construction permits and ICRAs with number of construction projects
Infection Preventionists Director of Engineering Director of Planning Contractors Unit Managers
Provide immediate feedback when lack of compliance
Safety Officer Others as appropriate
Updates
