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Infection Risk Assessment The Base Of Your Infection Prevention Plan
CAH IP Workshop April 18, 2018 Lisa Higley, RN MBA CIC Cassia Regional Hospital Infection Prevention
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Objectives Use a risk assessment tool to evaluate for infection potential Discuss three strategies to ensure a successful risk assessment process Develop an infection prevention plan from risk assessment results Create a progress report to track successes of your infection prevention program
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Infection Risk Assessment
What is it??? Part of infection prevention and control planning process Serves as the starting point of a well-developed plan Together with the IP plan, form the foundation of the IP program Assists in focusing surveillance and other program activities Sets the priorities of the infection prevention program Meet regulatory requirements (CMS, IDAPA, Accrediting agencies)
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Centers for Medicare & Medicaid Services
Regulatory Influence Identify risks for acquiring and transmitting infections Risks are identified annually and when significant changes happen Interdisciplinary input Prioritize and documents risk Centers for Medicare & Medicaid Services The standards include requirements to maintain a sanitary environment, designate an infection control officer, and develop, implement, and maintain an active infection prevention program.
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Process Preparation of risk assessment form Review your data
Current issues Define your multi-disciplinary team
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Preparation of risk assessment form
Risk Groups Prevention Activities High Level Disinfection HH Isolation Policy/Procedure Exposure plans Hospital Acquired Infection (HAI) Multi-drug Resistant Organisms (MDRO) Emergency Management Environment of Care Employee Health
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Assign Three Values to Each Risk
Probability of event occurring Impact/severity Current systems
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Probability of Risk Occurrence
Things to consider Known risks Historical Data Reports in literature
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Impact/Severity Things to consider: Threat to life and/or health
Disruption of services Loss of function Loss of community trust Financial impact Legal issues Regulatory impact Standards/requirements
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Current Systems/Preparedness
Things to consider: Current policy & procedure Implementation of plans Training status Measures of outcome or process Availability of backup systems Community/public health resources
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INFECTION CONTROL RISK ASSESSMENT
The Infection Control Risk Assessment [ICRA] grid is a visual tool to develop IC program priorities and stratify infection control risks based on our community, patient population and review of previous IC data analysis. The annual IC Plan is developed based upon identified risks. The ICRA is an ongoing, continual process. A more focused review is done on an annual basis after reviewing quarterly and annual reports with the Infection Control Committee. 1 of 3 Program Components PROBABILITY RISK/IMPACT (Health, Financial, Legal, Regulatory) CURRENT SYSTEMS SCORE Expect Likely Maybe Rare Never Loss of life/ limb/ function Temp loss of function ↑ length of stay Moderate clinical/ financial Minimal None Poor Fair Good Solid PxRxS (> 10 is goal level) Weight 4 3 2 1 5 Failure of Prevention Activities Lack of Hand Hygiene Lack of Respiratory Hygiene Lack of sinks or hand sanitizer Isolation Activities Lack of Standard Precautions/ PPE usage Lack of Airborne Precautions Lack of Droplet Precautions Lack of Contact Precautions Lack of Isolation Precaution Document-ation Failure of negative pressure Failure of positive pressure
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Identify your interdisciplinary team
Who??? IP Employee Health Medical Staff Lab Pharmacy Nursing Surgery Housekeeping Maintenance Ambulatory Services Quality Administration Solicit information in advance -What are the most important infection prevention and control problems in your area?
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Risk Assessment Meeting
Assign Values There are no right or wrong answers Discuss each potential risk Push group for consensus on assignment of number of each component Keep group on target Important to be consistent Go through entire list of risks Benefits Spreads the knowledge of what the IP does Increases understanding of the IP Plan Buy-in from key stakeholders No individual to blame for priorities – group decision
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Risk Score Derived from multiplication of three component numbers
Determine a value below which no action is necessary. Acceptance of risk is at the discretion of the organization.
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Prioritization Goals Rank order risks using risk scores
Each organizations priorities will be different
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Infection Surveillance, Prevention and Control Plan
Developed based upon identified priorities and needs from the risk assessment. Sets goals and objectives with strategies to meet identified goals. Serves as foundation for progress reports and your annual program evaluation.
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Background Section Identify risks for acquiring and transmitting infections based on: Organization Evaluation Geographical and environmental Population served Area endemic infections Other area-related risks (Construction, Legionella, MDRO, TB) Care, treatment, and services provided Population risks include immunization preventable communicable diseases due to low immunization rate (≈75%) of children; enteric diseases related to drinking raw milk; and immunocompromised states associated with advanced age; and co-morbidities of obesity, cancer, and diabetes
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Action Section Goals are based on the prioritized risks identified during the completion of facility risk assessments. The purpose of the program goals and plan are to focus on limiting unprotected exposures to pathogens as well as minimizing the risks associated with medical procedures, medical equipment and invasive devices.
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Tips for Developing Written Plan
Develop outline of Infection Prevention & Control Program Draft Table of Contents Network with others Include the essential elements Authority & Scope Surveillance & Prevention Activities Reporting & Accountabilities Program Evaluation Distribute your plan widely Review and approve through your Infection Control Committee (IDAPA )
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Table of Contents II. Assessments I. Infection Prevention Program
Objectives Authority & Scope Surveillance & Prevention Activities Infection Prevention Collaboration Teams Reporting and Accountabilities Program Evaluation II. Assessments Community Facility Construction Multi-Drug Resistant Organisms Cardboard Box Storage Tuberculosis Legionella
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III. Infection Prevention Goals & Plan IV. Appendices
Hand Hygiene Compliance Isolation Precautions/PPE Usage Compliance Surgical Site Infections Clostridium difficile High Level Disinfection Compliance IV. Appendices Facility Risk Assessment Tuberculosis Risk Assessment
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Annual Review Risk Assessment and Infection Prevention Plan are reviewed and updated at least annually or when every any significant change happens.
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Sample Goals & Objectives
Assessment: 40% of personnel received flu vaccine last year. Goal: Increase influenza immunization rate in personnel next flu season. Objective: Increase influenza immunization rate in personnel in patient care departments next year by 80% (80% of 40 is 32; increase to 72%)
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Hand Hygiene Compliance
b Hand Hygiene Compliance Goal Measurements Action Plan or Method Hand Hygiene Compliance rates will be maintained at, or exceed, the following: Entry: 95% Target: 96.5% Stretch: 98% Hand Hygiene compliance will be reported as a percentage (total # of times HH performed/total # of HH opportunities x 100) Overall compliance rates will be provided for the following: Physicians, Nursing, Ancillary, and Outpatient departments as well as a combined total Staff will follow the Hand Hygiene Policy, which is based on recommendations from the CDC’s Hand Hygiene Guideline Acute care areas will report at least 20 nursing opportunities, 10 ancillary opportunities, and 10 physician opportunities each month Selected ancillary and outpatient areas will report at least 20 opportunities each month from any employee within that department Department rates will be reported monthly on Manager Scorecards Results will be reported monthly to corporate leadership Hospital-wide results will be reported quarterly in Infection Prevention reports Patient Care Directors and Managers will be responsible to share HH compliance findings routinely with their staff and are responsible to implement improvement measures for less than optimal performance Infection Prevention will assist with hand hygiene education and awareness efforts on an as-needed basis. Evaluation 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr. Physician 97.8% 97.6% Nursing 96.9% 97.3% 97.4% Ancillary 97.9% 98.0% Outpatient 95.3% 97.1% 97.5% Overall 96.8% Goal Met Met
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Resources Joint Commission Resources: Chapter Three: Using the Risk Assessment to Set Goals and Develop the Infection Prevention and Control Plan 10 Elements to Consider When Conducting an Infection Risk Assessment APIC EPI 101: The Fundamentals of Infection Surveillance, Prevention and Control. Risk Assessment
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