1. Infection Prevention Risk Assessment: A How-to Exercise Carla Parker MSN RN NE BC CIC Infection Preventionist Cabell Huntington Hospital

2. What is a risk assessment?  Risk Assessment – An assessment that examines a process in detail including sequencing of events and actual and potential risks, failure or points of vulnerability; and that, through a logical process, prioritizes areas for improvement based on the actual or potential impact (that is, criticality) of care, treatment, or services (TJC, 2010).

3. Risk-Based Planning – What TJC expects  Risk Assessment Infection risk assessment  Goal Reduce or eliminate infection  Implementation Based on guidelines and organization- specific risk  Evaluation Rates reduced? Best practices followed? Implementation complete? IC.01.03.01 Risks IC.01.04.01 Goals IC.03.01.01 Evaluation IC.02.01.01 Implementation

4. Joint Commission Standards  Standard IC.01.03.01 The hospital identifies risks for acquiring and transmitting infections based on the following: Its geographic location, community, and population served. EP1. The hospital identifies risks for acquiring and transmitting infections based on the following: The care, treatment, and services it provides. EP2. The hospital identifies risks for acquiring and transmitting infections based on the following: The analysis of surveillance activities and other infection control data.

5. Joint Commission Standards  Standard IC.01.03.01 EP3. The hospital reviews and identifies its risks at least annually and whenever significant changes occur with input from, at a minimum, infection control personnel, medical staff, nursing, and leadership. EP4. The hospital prioritizes the identified risks for acquiring and transmitting infections. These prioritized risks are documented. EP5. Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections.

6. Joint Commission Standards  Standard IC.01.04.01 Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections. EP1. The hospital's written infection prevention and control goals include the following: Addressing its prioritized risks.

7. Joint Commission Standards  NPSG.07.03.01 Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals. EP2. Based on the results of the risk assessment, educate staff and licensed independent practitioners about health care–associated infections, multidrug- resistant organisms, and prevention strategies at hire and annually thereafter.

8. Joint Commission Standards  NPSG.07.04.01 Implement evidence- based practices to prevent central line– associated bloodstream infections. Note: This requirement covers short- and long- term central venous catheters and peripherally inserted central catheter (PICC) lines. EP4. Conduct periodic risk assessments for central line–associated bloodstream infections, monitor compliance with evidence-based practices, and evaluate the effectiveness of prevention efforts. The risk assessments are conducted in time frames defined by the hospital, and this infection surveillance activity is hospital-wide, not targeted.

9. Joint Commission Standards  NPSG.07.05.01 Implement evidence- based practices for preventing surgical site infections EP 4 As part of the effort to reduce surgical site infections:  - Conduct periodic risk assessments for surgical site infections in a time frame determined by the hospital.  - Select surgical site infection measures using best practices or evidence-based guidelines.  - Monitor compliance with best practices or evidence-based guidelines.  - Evaluate the effectiveness of prevention efforts.

10. Risk Assessment Tools  Joint Commission is not prescriptive about any type of tool that you use.  Joint Commission is not prescriptive about how you get input from others.  Joint Commission is not prescriptive about who the risk assessment should be reported to You make those decisions

11. Risk Assessment Tools  Joint Commission will expect That the risk assessment process is well designed That the risk assessment process is credible That the risk assessment process is used to develop you Infection Control Plan That the risk assessment includes all of the required elements That the risk assessment is used – not just a paper exercise

12. Sample Risk Assessment Tools

13. LikelihoodImpactPreparedness Risk 1=None 2=Rare 3=Occasional 4=Frequent Event 1=No Impact 2=Limited 3=Substantial 4=Major Impact 1=highly prepared 2= moderate prepared 3=limited prepared 4=not prepared Risk Score Community MRSA 44116 College town 3113 Diabetic patients 43112 Environmental cleaning 2418

18. HOW TO Conduct a Risk Assessment  Choose your tool / process  Review your tool and assure it meets your needs locally  Review your tool and assure it meets regulatory requirements  Determine the process that you are going to use for completing your risk assessment  Complete your risk assessment

19. Wrapping up the Risk Assessment  Put the bow on the package Develop a cover sheet that explains the process, how you did it, who helped to do it and keep it with the risk assessment. This will allow the document to stand by itself.