1. 1

2. Infection Control Risk Assessment Terrie B. Lee, RN, MS, MPH, CIC Director, Infection Prevention & Employee Health Charleston Area Medical Center Charleston, WV 2

3. Organizational Infection Risk Assessment Part of infection prevention and control planning process Serves as starting point of well-developed plan Together with plan, form foundation of program Assists in focusing surveillance and other program activities Meets regulatory requirements 3

4. Infection Risk Assessment Regulatory Influence Identify risks for acquiring and transmitting infections based on: –Geographic location, community, and population served –Care, treatment, and services provided –Analysis of surveillance activities and other infection data Risks identified annually and when significant changes occur 4

5. Infection Risk Assessment Regulatory Influence Risk assessment occurs with interdisciplinary input: –Infection prevention personnel –Medical staff –Nursing –Leadership –Others Prioritize and document risks 5

6. Risk Assessment Process Homework and Planning –Forms Preliminary completion of organization evaluation form Preparation of risk assessment form –Standards –Reports: Surveillance data –Knowledge of current issues 6

7. Risk Assessment Process Team Recruitment –Invitation –Solicit information in advance What are the most important infection prevention and control problems? What are our most frequent reasons for visit, admission, procedures performed, etc.? 7

8. Risk Assessment Team IP Staff Employee Health Medical Staff Laboratory Pharmacy Nursing Surgery Ambulatory Services Environmental Services Engineering Administration Central Processing Quality/Performance Improvement JC Coordinator 8

9. Risk Assessment Meeting Commitment for attendance/ participation Time for thoughtful discussion Prioritizing risks Determining IP Plan 9

10. Organization Evaluation Factors to Include: –Geographic and environmental –Population characteristics –Area endemic infections –Other area-related risks –Medical care characteristics –Services provided 10

11. Organization Evaluation Description of factors Characteristics that increase risk for infection Characteristics that decrease risk for infection Get input at meeting for final completion of form Include findings in risk assessment 11

12. Risk Assessment The group work begins! 12

13. Risk Groups Antibiotic-resistant organisms Failure of prevention activities Isolation activities Policy & procedure Preparedness HAIs Environment Employee Health Other 13

14. Assigning Three Values to Each Risk Probability of event occurring Impact/severity Current systems 14

15. Probability Considerations Known risks Historical data Reports in literature 15

16. Impact Considerations Threat to life and/or health Disruption of services Loss of function Loss of community trust Financial impact Legal issues Regulatory impact Standards/requirements 16

17. Current Systems Considerations Current policy & procedure Implementation of plans Training status Measures of outcome or process Availability of backup systems Community/public health resources 17

18. How to Assign Values There are no right or wrong answers! Allow discussion Push group for consensus Keep group focused, on target Important to be consistent Go through entire list of risks Assign someone to calculate risk scores 18

19. Risk Score Derived from multiplication of three component numbers Group consensus vs. mathematical averaging or summation 19

20. Prioritization Rank order risks using risk scores Each organization’s priorities will be different 20

21. Risk Assessment Exercise Determine fictitious setting Discuss each potential risk Come to group consensus on assignment of number for each component Multiply component numbers to calculate risk score Occasionally compare risk scores to validate with group 21

22. Infection Prevention Plan Regulatory Influence Written infection prevention plan –Goals –Measureable objectives –Strategies for implementation 22

23. Infection Prevention Plan Regulatory Influence Goals based on prioritized risks and include: –Limiting unprotected exposure to pathogens (isolation precautions and use of PPE) –Limiting transmission related to procedures –Limiting transmission related to medical equipment, devices, supplies –Improving hand hygiene 23

24. Infection Prevention Progress Report Priority Goal Objectives Strategies Evaluation method Current status/ Evaluation/ Next Steps 24

25. Infection Prevention Progress Report Rank-ordered prioritiesFrom risk assessment Goals (broad statements)To address each priority Objectives (measureable)To achieve each goal StrategiesSteps to achieve each objective Evaluation methodFor each objective (how to measure success) Progress and AnalysisHow are we doing? Next steps defined 25

26. Sample Goal & Objectives Assessment: Personnel wash hands or use alcohol hand rub during direct patient care activities. Goal: Increase use of hand hygiene Objective: Increase use of hand hygiene by direct care providers on 3 North by 40% in the next 6 months 26

27. Infection Prevention Progress Report Exercise For top three scored risks, complete the following: –Goal –At least one objective –Strategies to reach objective –Method of evaluation 27

28. Benefits of Risk Assessment Meeting Spreading the knowledge of what you “do” Getting buy-in and support from key organizational stakeholders No individuals to blame for priorities – organizational decisions Many people able to articulate how IP plan was created Meets regulatory requirements 28

29. Infection Prevention Progress Report Tracks most important aspects of IP program Reporting mechanism Demonstrates program results/ improvement 29

30. Summary Each organization must conduct an infection risk assessment that is unique to itself. This risk assessment is used to set priorities for the infection prevention program. Once priorities are identified, goals, objectives, and strategies help to create the organizational infection prevention plan. 30

31. Summary, cont. The risk assessment process is ongoing, with a focused revision taking place annually. A progress report can be used to track and report priorities and accomplishments of the infection prevention program. 31

32. Questions 32

33. 33