1. Getting Started or so you are the new Infection Preventionist – what now? Karen Hoover Russ Olmsted Ruth Anne Rye

2. Support New Hire Orientation All personnel Personnel specific Ongoing Regulatory mandate Task-specific Facility-determined Pre-placement evaluation Routine screening Work restrictions Occupational exposure management Personal hygiene Blood Stream - Eyes, Ears & Throat Gastrointestinal, Genitourinary Tract - Skin Respiratory Tract – Central Nervous System -- - Dental Service Dietary Services Equipment: Cleaning Disinfection/Sterilization Environmental Cleaning Emergency preparedness Facility operations; air, water construction/renovation Laboratory/Pathology Waste management Employee Health Prevention Body System Review Leadership Education Clinical Practice Support Services Surveillance/ Performance Measurement MI MODEL: INFECTION PREVENTION PROGRAM  MSIPC Reviewed 2013 Scope: Processes & outcomes Patient: Community & Healthcare- Associated Infection Personnel: Health & Injury Prevention Environment of Care (EOC) Outbreak and Sentinel Events Philosophy-Authority-Responsibility I.P. Program Elements Patient & Personnel Safety Culture Oversight: Function and Committees Performance Improvement Regulatory Compliance Community Standards of Care Antimicrobial use Asepsis Continuum of care Hand Hygiene Immunization Isolation Precautions Patient Care Plan

3.  IC.01.05.01:The [organization] has an infection prevention and control plan.  Evidence-based national guidelines or, in the absence of such guidelines, expert consensus.  The hospital’s infection prevention and control plan includes:  a written description of the activities, including surveillance, etc.  process to evaluate the infection prevention and control plan.  The hospital describes, in writing, the process for investigating outbreaks of infectious disease.  All hospital components and functions are integrated into infection prevention and control activities.  Communicating responsibilities about prevention to licensed independent practitioners (LIPs), staff, visitors, patients, and families.  Methods for reporting infection surveillance and control information to external organizations. Accreditation Standards, 2015

4.  IC.01.03.01:The [organization] identifies risks for acquiring and transmitting infections  EPs:  Identify risks- acquiring and transmitting infections, based on: geographic location, community, and population served.  Care, treatment, and services it provides.  Analysis of surveillance activities and other infection control data.  Review risks at least annually and whenever significant changes occur  Prioritizes the identified risks Accreditation Standards, 2015

5.  Is there a facility-specific Infection Prevention & Control Plan? Infection Prevention & Control Program Plan  Risk Assessment:  Assessment of services provided  Assessment of populations served  Prioritized strategies for risk reduction  Surveillance plan including data analysis  Plan is reviewed annually or as often as needed

6. Evaluation of potential risk for infections, contamination and exposures among population served by the facility; 1)Sources of information: known risks, historical data, local public health, publically reportable data, reports in literature, etc. – Do you have any surveillance data available? 2)Evaluation of preventable harms [HAIs, falls, pressure ulcers, inter-facility transfers] 3)Evaluation of organization’s preparedness to eliminate or mitigate the harm or risk of preventable harm

7. Setting Services & Care Delivery  Descriptive analysis – Geographic area served – Environmental factors – Populations served – Breakdown of major payors – CMS survey requirements – Local public agency: county population assessment  Care, Treatment & Services Provided  Skilled care, Rehab, Long Term Acute Care, Home care/Hospice, Critical access hospital  Surgery, medicine, both  Critical care?  Obstetrics?  Combination of acute + LTC?

9.  Multidisciplinary team – Employee health, environmental services, lab, pharmacy, nursing, administration etc.  Perform at least annually – Remember to update if new services are added  Review & approval by IPC and/or Patient Safety/Quality Committee  Organization/committee consensus for priorities

11. Priority Level = 1 (top)  Topic: Catheter Associated UTI (CAUTI)  Goal- Achieve zero CAUTIs in medical surgical patients by  December 2012  Objectives -  1. Provide CAUTI prevention education for 95% of clinical staff by June 2012  2. Implement Nurse protocol for Foley catheter removal by June 2012  Strategies/Tactics -  1. Develop educational program  2. Schedule in-services for med surg nursing  3. Develop nurse driven Foley catheter removal criteria  Evaluation  Progress/Analysis/Reporting

12. Let’s Practice shall we?