1. Conducting Infection Control Risk Assessments
Maureen Spencer, RN, BSN, M.Ed, CIC, FAPIC
Infection Prevention Consultant

2. Objectives
Discuss three strategies to ensure a successful risk assessment;
Develop an infection control plan from risk assessment results
Create a progress report to track accomplishments of the infection control plan
Using Quality Tools for presenting plans and data

3. Joint Commission
IC standards have made risk assessment and infection prevention goal setting more structured, formal process to enhance a well designed and thoughtful approach to infection prevention activities.
The Joint Commission Standard:
– IC – the hospital identifies risks for acquiring and transmitting infections

4. Definition of a Risk Assessment
Thoughtful examination of what could cause harm to patients, staff, families and visitors, or facility
The important issues are:
whether a known or potential risk is likely to occur
if it will be significant should it occur
whether the organization is adequately prepared to handle it so that the negative effects are eliminated or minimized

5. Risk Assessment Components
• The Risk Assessment should contain the following elements: – Demographics – Geographic location – Community and Population served – Care, treatment and services provided – Analysis of surveillance activities and rates – Annual review (preferably no later than March if on calendar year) – Prioritization of risks for following year

6. IC
The hospital identifies risks for acquiring and transmitting infections

7. Risks
Reviews, identifies risks at least annually and with significant changes
Require input from IP, medical staff, nursing, and leadership
Prioritized and documented

8. IC
Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections

9. Goals Include Limiting unprotected exposure to pathogens
Limiting transmission of infections associated with procedures
Limiting transmission of infections associated with use of medical equipment, devices, and supplies

10. Goals Include
Improving compliance with hand hygiene guidelines

11. IC
The hospital has an infection
prevention and control plan

12. IC.02.01.01 The hospital implements its infection
prevention and control plan

13. Implementation Includes
Activities including surveillance to minimize, reduce, or eliminate risk of infection
Transmission-Transmission
Standard precautions based precautions
Outbreak investigation

14. Implementation Includes
Methods for storing and disposing of infectious waste
Methods of communicating responsibilities for
prevention and control to LIPs LIPs, staff, visitors,
patients, and families
Reporting information to staff and to local, state, and
federal public health

15. Implementation Includes
Reporting infection information to transferring
and receiving organizations
Reduction of risk associated with medical
equipment, devices and supplies
Cleaning, disinfection, sterilization, disposal, storage
Issues related to reprocessing of SUDs

17. Implementation Includes
Employee health-related issues
Screening
Handling of infections Exposures
Influenza vaccination program for staff and LIPs

18. NPSG.07 Prevention of Infection
– Hand Hygiene
– Sentinel Events – Root Cause Analysis
– MDROs (13 EPs)
– Central Line Associated Bloodstream Infections (17 EPs)
– Surgical Site Infections

19. NPSG
Surgical Site Infections (12 EPs) in requirements in 2009
All implemented by 1/1/2010

25. NPSG.13 Requirements for patient education (and documentation) (2009)
Hand Hygiene
Contact Precautions
Respiratory Hygiene
Surgical Site Infection Prevention

26. IC
The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change.

27. Evaluation Includes Prioritized risks IPC plan plan’s goals
Implementation of IPC plan’s activities
Communication to patient safety program
Use of findings when revising plan

28. Risk Assessment Process
Homework & Planning
Forms
Standards
Data
Current issues

29. Risk Assessment Process
Team Recruitment
Solicit information in advance
Invitation What are the most important infection prevention & control problems?
What are our most frequent reasons for admission, procedures performed, etc.

30. Risk Assessment Team IP Staff EH Medical Staff Laboratory Pharmacy
Nursing
Surgery
Housekeeping
Maintenance
Administration
Central Processing
Quality Department
Joint Commission
Coordinator

31. Risk Assessment Meeting
Commitment for attendance/participation
Time for thought and discussion
Prioritizing risks
Determine IPC Plan

32. Organization Evaluation
Factors to include
Geographic and environmental
Population characteristics
Area endemic infections
Other area related risks
Factors to include:
Area endemic infections related risks
Medical care characteristics
Services provided

33. Organization Evaluation
Description of factors
Characteristics that increase risk for infection
Include findings in risk assessment tool

34. Risk Assessment Form Components
Probability of event occurring
Impact/severity
Health
Financial
Legal Regulatory, accrediting
Current systems

35. Risk Score Derived from multiplication of three component numbers
Group consensus vs. mathematical averaging or summation

36. Prioritization Rank order risks using risk scores
Each organization's priorities will be different

38. Infection Prevention and Control Plan
Develop a plan for each strategy with persons, resources, timelines, etc.
Get ICC and administrative support
Develop partnership with key staff
Don’t take on too many at one time
Build in objectives, measurements and evaluation

39. The IPC Progress Report
Objectives (specific & measureable)
Rank ordered priorities
Goals (broad statements - support the goal)
Strategies (steps to take to achieve the objective)
Evaluation (how you will measure your success)
Progress and analysis (current status and next steps)

40. Risk Assessment/Planning
Documentation of processes
Group involvement/organizational support
Process/forms for reporting
Tracking of results
Program improvement

41. Infection Control Helpful Tips
Stay in a constant state of readiness
Rounding on the inpatient units
Rounding on the outpatient areas
May combine IC rounds with EOC rounds
Keep up with the PPR
Utilize “teachable moments” with the staff
Lunch & Learn staff meetings including housekeeping

42. The Joint Commission is focusing on Cleaning, Disinfection and Sterilization of equipment
Key Points:
Follow manufacturer’s directions
Standardize process for cleaning the same types of equipment
Orientation and training of the staff that mix solutions for disinfection
Make sure they are not following someone else’s bad habits
Sterilization logs and Quality checks must be kept up
Assure Endoscopy reprocessing is not a problem – big area of focus for both TJC and CMS

43. Joint Commission Resources - Tracers

44. Examples of a Risk Assessment

45. Example of a Risk Assessment on Medication Safety
1) There is clear evidence that injections are prepared using
aseptic technique in a clean area free from contamination or
contact with blood, body fluids, or contaminated equipment.

46. Medication Safety
2) There is clear evidence that needles and syringes are used for only on patient (this includes manufactured prefilled syringes and cartridge devices as insulin pens)

47. Medication Safety
3) There is clear evidence that aseptic technique is used by care providers when preparing and administering injections (i.e. evidence that the rubber septum on a medication vial is disinfected with alcohol prior to piercing)

48. Medication Safety
4) There is clear evidence that medication vials are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient.

49. Medication Safety
5) There is clear evidence that Single dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution are used for only one patient.

50. Medication Safety
6) There is clear evidence that Medication administration tubing and connectors are used for only one patient.

51. Medication Safety
7. There is clear evidence that Multi-dose vials are dated by HCP when they are first opened and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

52. Medication Safety
8. There is clear evidence that Multi-dose vials are dedicated to individual patients whenever possible.

53. Medication Safety
9. There is clear evidence that Multi-dose vials to be used for more than one patient are kept in a centralized medication area and do not enter the immediate patient treatment area (e.g. operating room, patient room/cubicle).

54. Use of Quality Tools

55. Mind Mapping

58. Fishbone Diagram

59. Fishbone Diagram Elements
Patient Factors
Condition (complexity and seriousness)
Language and communication
Personality and social factors
Individual (staff) factors
Knowledge and skills
Competence
Physical and mental health
Work Environmental Factors
Staffing levels and skills mix
Workload and shift patterns
Design, availability and maintenance of equipment
Administrative and managerial support
Environment
Physical
Task Factors
Task design and clarity of structure
Availability and use of protocols
Availability and accuracy of test results
Decision-making
aids
Team Factors
Verbal communication
Written communication
Supervision and seeking help
Team structure (congruence, consistency, leadership, etc)
Organizational and Management Factors
Financial resources and constraints
Organizational structure
Policy, standards and goals
Safety culture and priorities
Care Delivery problems (CDPs)
Care deviated beyond safe limits of practice
The deviation had at least a potential direct or indirect effect for an adverse outcome for the patient, staff or general public
Examples: Failure to monitor, observe or act
Incorrect (with hindsight) decision
Not seeking help when necessary
The fishbone is often used in root cause analysis and provides a systematic frame work to work through all the potential factors that may have contributed to the situation. If you have been to the Dept of Pediatrics M&M you have seen this used

60. Peri-operative Team Factors Care Delivery problems (CDPs)
SSI Fishbone Diagram
Patient Factors
Surgeon Technique
Work Environmental Factors
Pre-operative Factors
Peri-operative Team Factors
Organizational and Management Factors
Care Delivery problems (CDPs)
Lack of traffic control – too many in room
Contaminated environment
Lack of hand hygiene
Financial constraints
Improper surgical hand antisepsis
Patient body colonization
Poor communication among team
Inadequate surgical prophylaxis
Poor leadership
Improper surgical attire
Lack of pre-op shower
Increase hospitalization days
Surgical irrigation
Unsterile instruments
Non-coated sutures
Use of Staples or steri-strips
MRSA or MSSA nasal colonization
Obese
Poor staffing levels
Lack of discontinuation of antibiotics at 24 hrs
Use of Drains
The fishbone is often used in root cause analysis and provides a systematic frame work to work through all the potential factors that may have contributed to the situation. If you have been to the Dept of Pediatrics M&M you have seen this used
Infection at another site
Diabetic
Poor surgical technique
Workload and shift patterns
Smoker
Contamination of incision post-op
Lack of re-dosing of antibiotic
Contaminated environment
Immunosuppressive agents
Design, availability and maintenance of equipment
Environment and physical plant problems (air handling system)
Inadequate staffing for post-op care
Lack of hand hygiene
Lack of foley catheter removal within 48 hrs

62. Process Pathways

65. Algorithms

66. Review printout of cultures if receiving hard copies
Surveillance of HAIs
Denominators – patient days, admissions, surgical file, central line days, foley days, vent days
Review printout of cultures if receiving hard copies
Cerner – Check IC Alert
Cerner – Check IC Alert
Review Patient’s History and Physical
If surgical wound culture – review operative notes, ID consults
If urine culture, review urinalysis, presence of catheter
If sputum culture, review reason culture obtained, method (bronchoscopy)
If blood culture, review progress notes, why obtained, where obtained, is there a central line or PICC
Complete SSI algorithm
Complete CAUTI algorithm
Complete VAE calculator and algorithm
Complete CLABSI algorithm

72. Gap Analysis

74. The End