1. Hospital Patient Safety Initiatives: Infection Control
Michele Kala, MS,RN

2. October 2011-Developed by CMS
Related to three Conditions of Participation (CoPs)
Quality Assessment and Performance Improvement (HFAP Hospital Chapter 12)
Infection Control (HFAP Hospital Chapter 7)
Discharge Planning (HFAP Hospital Chapter 15)

3. Worksheet Purpose
Reduce hospital acquired conditions (HAC) including hospital acquired infections (HAI) and preventable readmissions.
Designed to assist surveyors and hospital staff to identify when and where compliance is an issue.

4. CMS Worksheet Development
In draft format
Currently in use by state surveyors, accredited facilities and accrediting agencies.

5. CMS Worksheets: Facilitate recording of observations by surveyors
Are a self-assessment tool

6. Findings
Hospitals with higher readmission rates may be at greater risk for noncompliance with all three CoPs.
The tools assist facilities in focusing on key issues that impact positive patient outcomes and thereby compliance.

7. Verification Methods Interview Observation
Topic Specific Document Review
Medical Record Review
Other Document Review

8. Hospital Patient Safety Initiatives
Quality Assessment and Performance Improvement
Infection Control
Discharge Planning

9. Infection Control Worksheet
Five Sections
Infection Prevention
General Elements
Equipment Reprocessing
Tracer Patient
Special Care Environment

10. 1. Infection Prevention Prevention Program
Infection Control Quality Systems
Multiple Drug Resistant Organism Prevention (MDRP) and Antibiotic Stewardship

11. a. Prevention Program & Resources
A designated Infection Control Officer (ICO)
Qualifications of ICO
Practice and policies based on nationally recognized standards and state law
Infection Control Risk Assessment related to construction
(Above scored at )
5. Air exchange rates ( )

12. Construction Risk Assessment
ICRA Matrix

13. Air exchange rates Airborne Infection Isolation Room (AIIR)
Existing construction- 6 air exchanges per hour, OR
New construction or renovation – 12 exchanges per hour, OR
Per state licensure rules, if more stringent.

14. Air exchange rates (cont’d)
Direct exhaust to the outside, or recycled through a HEPA filter
Daily monitoring of pressure with visual indicators.
Door is closed
(Scored at )

15. b. Hospital Quality Systems Related to Infection Prevention and Control
IC Problems are Identified and Addressed
( )
Non-punitive Approach to Reporting
( )
Leadership Support
Infection Control Risk Assessment
(NOT SCORED)

16. Infection Control Risk Assessment: References
Infection Control Risk Assessment APIC 2011-Baltimore (Web search)

17. c. Prevent MDROs and Promote Antibiotic Stewardship, Surveillance
1. Policies to minimize transmission of Multiple Drug Resistant Organism (MDROs)
Facility MDRO policy effectiveness: identification process preventing development and transmission of MDROs
(1 & 2 NOT SCORED)

18. c. Prevent MDROs and Promote Antibiotic Stewardship, Surveillance (cont’d)
Process to review Antibiotic Utilization, Susceptibility and Availability
Appropriate antibiotic selection
Indications for Use Documented
72-hour review
Timely IV to oral switch
Resistance Pattern Notification
(NOT SCORED)

19. c. Prevent MDROs and Promote Antibiotic Stewardship, Surveillance (cont’d)
Colonized or Infected Patients on Admission and HEALTHCARE PERSONNEL are Identified and Isolated ( )
List of Current Reportable Diseases (not scored)
Reportable Diseases are Reported to local and State Health Departments (

20. d. Infection Control Training
Job Specific IC Training on Hire and ANNUALLY ( also)
Bloodborne Pathogen Training as Appropriate
Policies on Sharps Injuries and Exposures—patient and staff
Treatment and Prophylaxis following exposure
TB Conversion Follow-up
(all scored at )

21. d. Infection Control Training (cont’d)
Respiratory Protection System (N95 disposable respirator system) with polices and procedures regarding use
Annual fit testing
Employee health policies:
Reporting of illness without penalty
Staff education regarding prompt reporting of illness
Annual calculation of TB conversion rates
(these questions not scored)

22. d. Infection Control Training (cont’d)
Staff annual (at a minimum) IC training and competency validation and also following identification of IC issues. (also )
Corrective action and causal analysis following employee exposures
(both scored at )

23. d. Infection Control Training (cont’d)
Hep B Vaccinations Offered (not scored)
TB Testing Done Upon Hire (two step process) & follow-up based on the facility risk classification and state requirements ( )
Annual Flu Immunizations Offered to all Staff.
(scored at )

24. 2. General Infection Control Elements
Applicable in all locations where patients are treated
a. Hand Hygiene ( & )
b. Injection Practices and Sharps Safety ( )
c. Personal Protective Equipment (PPE) ( )
d. Environmental Services ( )

25. a. Hand Hygiene Availability of hand-washing areas
Availability of alcohol-based hand rub solution
Hand hygiene is performed (even though gloves are worn):
before patient care
prior to leaving a patient environment
prior to an aseptic task
following contact with blood, body fluids
or contaminated surfaces

26. a. Hand Hygiene (cont’d)
Soap and water cleansing occurs when hands are visibly soiled
Artificial nails are prohibited in high risk areas

27. b. Injection Practices and Sharps Safety
Injection preparation areas clean and free of contaminates
Single use needles
Syringes are used for only one patient, including insulin pens
Rubber stopper disinfection
Medication vial access with a clean needle ONLY
Medication vial access with a clean
syringe ONLY

28. b. Injection Practices and Sharps Safety (cont’d)
Single Patient Use Items:
Single dose vials
IV bags
Medication tubing and connectors
Multidose vials are dated for 28-day expiration
Multidose vial use for multiple patients are not kept in treatment areas
Use of sharps containers for disposal
Sharps container replacement

29. c. Personal Protective Equipment
PPE availability at point of use
Staff glove when in contact with blood, body fluids, mucous membranes or non-intact skin
A glove change and hand hygiene prior to moving from a contaminated to a clean body site
Gown use
Mouth, nose, and eye protection
Surgical mask use when entering an epidural or subdural space

30. d. Environmental Services
Environmental service worker PPE use (also )
Patient care area cleaning processes—high touch areas are cleaned daily
Terminal Cleaning and removal of linen
Use of cleaners and disinfectants reflect manufacturers guidelines for use
Clean cloths for each patient room/corridor (also )

31. d. Environmental Services (cont’d)
Mop head and cloth cleaning daily (also )
Blood and body fluid cleaning process--spills
Equipment cleaning schedules (HVAC, eyewash stations, ice machines, refrigerators, scrub sinks and aerators on faucets)

32. d. Environmental Services (cont’d)
Handling of clean and dirty laundry with no potential for cross contamination
Bagging and storage of dirty linen
Segregation of clean from dirty in laundry processing area
(also for all three)

33. d. Environmental Services (cont’d)
Disinfection of non-critical reusable patient care items, using manufacturers instructions if applicable is specifically assigned by policy and staff can articulate the process
Cleaning of hydrotherapy equipment

34. 3. Equipment Reprocessing
Reprocessing of Semi-Critical Equipment (Scored at )
Reprocessing of Critical Equipment (Scored at )
Single Use Devices
(Scored at )

35. a. Processing of Semi-Critical Equipment
High Level Disinfection Policy—make sure the policy is consistent for Ultrasound, TEE probes and outpatient areas (also )
Flexible endoscope inspection and testing
Pre-cleaning processes
Use of enzymatic cleaners
Cleaning brush maintenance

36. a. Processing of Semi-Critical Equipment (cont’d)
Chemicals used in high level disinfection
Automated equipment processing
Appropriate processing length of time and temperature recorded
Rinsing process following disinfection

37. a. Processing of Semi-Critical Equipment (cont’d)
Drying of equipment following disinfection
Maintenance records for disinfection equipment
Equipment storage following disinfection
Logs regarding equipment use

38. b. Reprocessing of Critical Equipment
Pre-cleaning process
Use of enzymatic cleaners
Cleaning brush maintenance
Wrapping/packaging process

39. b. Reprocessing of Critical Equipment (cont’d)
Use of chemical indicators in all packs in every load
Use of biological indicators at least weekly and with all implants
Bowie-Dick testing in pre-vacuum steam sterilization
gravity displacement vs. pre-vacuum steam
sterilizers
(also )
Labeling of sterile packs—sterilizer, load number and date (also )

40. b. Reprocessing of Critical Equipment (cont’d)
Sterilizer logs are kept for all loads (also )
Maintenance of sterilizers is per manufacturers recommendations
Storage of sterilized items prevents contamination (also )

41. b. Reprocessing of Critical Equipment (cont’d)
Inspection of processed items prior to use
Immediate Use Steam Sterilization (IUSS) previously know as flash sterilization:
Item must be thoroughly cleaned
Sterilizer cycle is appropriate for the instrument
All appropriate chemical and biological indicators are used
The facility has adequate instrumentation to meet the needs defined by surgical volume.

42. b. Reprocessing of Critical Equipment (cont’d)
Immediate use of flashed equipment
(also for flash sterilization process)
Recall of sterilized equipment (also )

43. c. Single-Use Devices Disposal after use or opening OR
FDA-registered vendors used for reprocessing
(also )

44. Patient Tracers
Policies and procedures to identify and prevent infections for the following:
Urinary Catheter
Central Venous Catheter
Ventilator/Respiratory Care
Spinal Injection Procedures
Point of Care Devices
Isolation Precautions
Surgical Procedures

45. Patient Tracers, Cont.
Issues identified during the survey which indicate the processes in place are not controlling and preventing infections would be scored at
Protocols are not required but policies and procedures and staff compliance must demonstrate effectiveness in controlling and preventing infections

46. Urinary Catheter Tracer
Use of urinary catheters in a manner to minimize infection
Hospital maintains guidelines for appropriate use of urinary catheters
Hand hygiene
Before and after insertion
Placement of catheter using aseptic technique
Catheter properly secured after insertion
(scored at )

47. Urinary Catheter Tracer
Catheter insertion and indication are documented ( )
Hand hygiene before and after manipulation of catheter
Avoid irrigation
Collection bag emptied using aseptic technique
Aseptic collection of urine samples
Small amounts through needleless port
Keep urine collection bag below level of bladder at all times
Catheter tubing unobstructed with no kinking
( )

48. Urinary Catheter Tracer
Need for catheter reviewed daily
Prompt removal when deemed unnecessary
No “convenience”
(Not scored)

49. Central Venous Catheter Tracer
Central venous catheters are inserted, assessed and maintained in a manner to minimize infection
Hand Hygiene performed before and after insertion
Maximal barrier precautions used for insertion
Surgical protection including full patient body drape
Use of >0.5% chlorhexidine with alcohol used for skin antisepsis prior to insertion
Can use tincture of iodine, iodophor or 70% alcohol alternatively
Dressing to cover catheter insertion site
Sterile gauze
Sterile transparent, semi-permeable dressing
Well healed and tunneled catheters may not need to be covered
( )

50. Central Venous Catheter Tracer
Central line insertion and indication documented ( )
Hand hygiene performed before and after manipulating catheter
Gloves
Soiled dressings are changed promptly
All dressings changed using aseptic technique
Access port is scrubbed with an appropriate antiseptic prior to accessing
Chlorhexidine, Povidone iodine, an iodophor, or 70% alcohol
Catheter accessed with sterile devices
( & )

51. Central Venous Catheter Tracer
Need to central venous catheters reviewed daily with prompt removal when not necessary (Not scored)

52. Ventilator/Respiratory Therapy Tracer
General Respiratory Therapy Practices for all Patients:
Hand hygiene
Gloves
Sterile water for nebulization
Single dose vials for aerosolized medications
Using manufacturer’s instructions for handling, storing and dispensing of medications

53. Ventilator/Respiratory Therapy Tracer
If multi-dose vials for aerosolized medications are used for more than one patient—
Restricted to a centralized medication location
They do not enter the immediate patient treatment area
( & )
Comprehensive oral hygiene program for all at risk patients
Elevated HOB for all at risk patients (ventilator or enteral tube placement)
(not scored)

54. Ventilator/Respiratory Therapy Tracer
Ventilator Care:
Ventilator circuit is changed if visibly soiled or mechanically malfunctioning
Sterile water is used to fill bubbling humidifiers
Condensate in tubing is periodically drained and discarded
Condensate should not drain toward the patient
Use of sterile single-use suction catheter
Multi-use closed system catheter
Only sterile fluid is used to remove secretions
( & )

55. Ventilator/Respiratory Therapy Tracer
Sedation is lightened daily in eligible patients
Spontaneous breathing trials are performed daily in eligible patients
“Weaning”
(not scored)

56. Spinal Injection Procedures
Hand hygiene
Spinal injection
Aseptic technique
Surgical masks are used when placing a catheter or injecting materials into the epidural or subdural space
( )

57. Point of Care Devices
Blood Glucose Meter
INR Monitor

58. Point of Care Devices Hand hygiene Gloves
Used for “finger-stick” procedures
Removed after the procedure, followed by hand hygiene
Finger stick devices are used for one patient
Lancet
Lancet holding device

59. Point of Care Devices
Point of Care device is cleaned and disinfected after every use according to manufacturer’s instructions
Single use only if no manufacturer’s instructions for cleaning and disinfection
( )

60. Isolation: Contact Precautions
Gloves are available and located near point of use
Signs indicating that the patient is in contact isolation
Patients in contact isolation are in single rooms
Can be cohorted based on clinical risk assessment

61. Isolation: Contact Precautions
Soap and water must be used when bare hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus during an outbreak. In all other situations, ABHR is preferred.

62. Isolation: Contact Precautions
Gloves and gowns
Before entering patient care environment
Removed and discarded; hand hygiene is performed before leaving the patient care environment

63. Isolation: Contact Precautions
Dedicated or disposable noncritical patient- care equipment (e.g., blood pressure cuffs) is used or if not available, then equipment is cleaned and disinfected prior to use on another patient according to manufacturer's instructions.

64. Isolation: Contact Precautions
Traffic control
Into patient’s room
Patient moving out of the room to other parts of the hospital
Contact precautions outside the patient’s room
Cleaning of objects and patient care areas that are touched in patient’s isolation room
When visibly soiled
At least once a day
Terminal cleaning
All surfaces thoroughly cleaned and disinfected and all textiles are replaced with clean textiles
Cleaners and disinfectants are labeled and used in accordance with hospital policy and procedure and manufacturer’s instructions
( )

65. Isolation: Droplet Precautions
Masks
On entering
Discarded when leaving
Signs
Patient on droplet precautions are housed in a single room or cohorted based on clinical risk assessment
Hand hygiene
Limited patient movement for droplet isolation patients
Medically necessary procedures
Patient wears surgical mask when transported
Communication of patient’s status

66. Isolation: Droplet Precautions
Cleaning
Once a day per policy and manufacturer’s instruction while patient is admitted
Terminal cleaning after discharge including wiping and disinfection of all hard surfaces
Changing all textiles in the isolation room
All cleaners are used in accordance with hospital policy and procedure and manufacturer’s instructions (dilution, storage, shelf-life, contact time)
( )

67. Isolation: Airborne precautions
Use of N-95 or higher particulate respirators
Available and near point of use
Signs indicating patient is on airborne precautions
Clear and visible
Patients on airborne isolation are housed in airborne isolation rooms
Hand hygiene before entering
And leaving
N-95 or higher particulate respirator to be worn when entering patient room for confirmed or suspected TB

68. Isolation: Airborne precautions
Facility limits movement of patients on airborne isolation to medically necessary purposes
Patient wears surgical mask per hospital policy
Hospital has means to communicate patient’s status
( )

69. Surgical procedure tracer
Surgical scrub before donning of sterile gloves for a surgical procedure in the OR
Use of either
Antimicrobial surgical scrub
FDA-approved alcohol-based antiseptic surgical hand rub
Visibly soiled hands should be washed with soap and water prior to the above procedures
After surgical scrub hands and arms are dried with a sterile towel and sterile surgical gown and gloves are donned in the OR

70. Surgical procedure tracer
Surgical attire
Scrubs
Surgical caps/hoods covering all head and facial hair
Worn by all personnel in semi restricted and restricted areas
Restricted areas include OR
Procedure rooms
Clean core
Semi restricted areas include
Peripheral support areas of the surgical suite

71. Surgical procedure tracer
Masks
Properly tied and fully covering mouth and nose are worn by all personnel in restricted areas where open sterile supplies or scrubbed persons are located
Sterile drapes are used to establish the sterile field
Sterile field
Items in sterile field are sterile
Items introduced to the sterile field are opened, dispensed and transferred in a manner to maintain sterility
Established in a location where it will be used and as close as possible to the time of use
Movement around the sterile field is done in a manner to maintain sterility

72. Surgical procedure tracer
Traffic in and out of the OR is kept to a minimum and is limited to essential staff
Traffic Control Policies and Procedures
Surgical masks are removed when leaving the sterile areas and are not reused when returning

73. Surgical procedure tracer
Cleaners and disinfectants
Used according to hospital policy and procedure and manufacturer’s instructions

74. Surgical procedure tracer
Cleaning—start of the day
Horizontal surfaces
Damp dusted with a lint-free cloth and EPA-registered hospital detergent/disinfectant
High touch surfaces cleaned and disinfected between patients
Anesthesia equipment is cleaned and disinfected between patients
Reusable noncritical items (BP cuffs, etc.) are cleaned and disinfected between patients

75. Surgical procedure tracer
Terminal cleaning of Operating Rooms
After the last procedure of the day
Including weekends!
Includes
Wet-vacuuming or moping the floor with an EPA-registered disinfectant
All surfaces
Internal components of anesthesia machine breathing circuit are cleaned according to manufacturer’s instructions

76. Surgical procedure tracer
Ventilation requirements
Positive pressure, 15 air exchanges per hour—at least 3 of which are fresh air
90% filtration
HEPA optional
Air filters are checked regularly and replaced according to hospital policies and procedures
Temperature and relative humidity are maintained at required levels
Doors are self-closing
Air vents and grill work are clean and dry
( & )

77. A Protective Environment (e.g. Bone Marrow patients)
Positive pressure—air flow out to the corridor from the room
12 air exchanges per hour
Supply air is HEPA filtered
Well sealed rooms so that there are no penetration spaces in the walls, ceilings or windows
Self closing door that fully closes on all room exits
Failures are addressed and documented
( )

78. A Protective Environment (e.g. Bone Marrow patients)
Ventilation requirements are monitored using visual methods
“Kleenex test”; flutter strips, etc. ( )

79. Please submit questions to:

80. POST TEST
This presentation has been awarded 1.5 hours of AOA Category 2-B CME credit. To receive your CME certificate, please complete the post test at the following link:
This should bring up “PSI Infection Control Test”.
Type in your name and the passcode “PSIIC”.
(those are upper case i’s, not lower case L’s)
Your certificate will be submitted electronically.