Basics of anInfection Prevention Program

Cheryl Richardson, RN, BSN, CICSenior Consultant, Clinical OperationspCareFusion MedMined Services Division

Rosie Bartel StoryRosie Bartel Story

One Is Too Many: Viewing Infection Data fromOne Is Too Many: Viewing Infection Data from the Patient's Perspective

Link:  h // ihi /k l d /P /A dihttp://www.ihi.org/knowledge/Pages/AudioandVideo/OneIsTooManyViewingInfectionDataf

P i P iromPatientsPerspective.aspx

ObjectivesObjectives

• Explain Goals of Infection Prevention ProgramExplain Goals of Infection Prevention Program• Describe Scope of the Infection Prevention ProgramProgram 

• Outline Responsibilities for Infection P i A i i iPrevention Activities

• Discuss Reporting Mechanisms for Infection Prevention 

§482.42 Condition of ParticipationI f i C l PInfection Control Program

• The hospital must provide a sanitary environment to avoid p p ysources and transmission of infections and communicable diseases. There must be an active program for the prevention control and investigation of infections andprevention, control, and investigation of infections and communicable diseases. 

§482.42(a) Standard: Organization d land Policies

• A person or persons must be designated asA person or persons must be designated as infection control officer or officers to develop and implement policies governing control ofand implement policies governing control of infections and communicable diseases. 

• §482.42(a)(1) ‐ The infection control officer§482.42(a)(1)  The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. 

• §482.42(a)(2) ‐ The infection control officer or officers must maintain a log of incidents l d i f i d i blrelated to infections and communicable 

diseases. 

Goals of thefInfection Prevention Program

• Decrease risk of infection to patient andDecrease risk of infection to patient and healthcare workers

• Monitor occurrence of infection and i l limplement control measures

• Identify and correct problems relating to infection prevention practicesp p

Goals of thef ( )Infection Prevention Program (cont.)

• Limit unprotected exposure to pathogensLimit unprotected exposure to pathogens throughout facility 

• Minimize risk associated with procedures, di l d i d di l imedical devices, and medical equipment

• Maintain compliance with state and federal regulations relating to infection preventiong g p

Scope of the Program

Scope of IP ProgramScope of IP Program

• ComprehensiveComprehensive• Addresses detection, prevention, and control of infectionsof infections

• Scope of services depends on patient l i f i d i li d d fpopulation, function, and specialized needs of 

the facility

Major Activities of the ProgramMajor Activities of the Program

OutbreakOutbreakEducationEducation

OutbreakOutbreak

InvestigationInvestigation

SurveillanceSurveillance

Policy and ProcedurePolicy and Procedure Quality/PerformanceQuality/Performance

Review and RevisionReview and RevisionImprovementImprovement

ConsultationConsultation

Surveillance(With Implementation of Control and Prevention Measures)

• Ongoing Monitoring forOngoing Monitoring for Infections

• Prevention of Spread

• Staff and Patient Education Focuses on Risk of Infection and Practices to Decrease

Outbreak Investigationg

Systems are in place to facilitate recognition ofincreases in infections as well as

clusters and outbreaks.

Policy and Procedurey

• Policies and proceduresPolicies and procedures for infection prevention are reviewed on a regular schedule and updated as needed.

• Policy and procedure review includes house wide and departmentwide and department specific policies and procedures.procedures.

Staff Education

Training of staff in infection prevention begins with 

orientation of new hires andorientation of new hires and occurs at least annually.

Quality Assurance/Performance ImprovementQuality Assurance/Performance Improvement

• Infection Prevention is aInfection Prevention is a component of the facility’s quality assurance and improvement program.

• Infection Prevention reports are made to the QA/PI Committee.

d d• IP rounds are made to assess level of quality provided and actions for improvementactions for improvement.

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Consultation

Infection preventionists serve as a resource for all staff and all departments relating to prevention of infections.

Division of Responsibilities forDivision of Responsibilities for Infection Prevention Activities

The administrator/CEO is ltimatel responsibleThe administrator/CEO is ultimately responsible for the infection prevention program.

Infection PreventionistInfection Preventionist

• Responsibility delegated to IP to carry out theResponsibility delegated to IP to carry out the daily functions of the infection prevention programprogram.

• Functions described in job description.IP h k l d d i i• IP has knowledge, competence, and interest in infection prevention.

Infection Prevention Addressed at lCommittee Level

• Committee meets on a regular gbasis.

• Committee provides input on d f h fdirection for the infection prevention program.

• Policies and procedures relating• Policies and procedures relating to infection prevention are approved by the committee.

• Infection reports are presented to committee which recommends actions and controlrecommends actions and control measures.

R ti M h i fReporting Mechanisms for Infection Prevention

Patient Monitoring & ReportingPatient Monitoring & Reporting

• Patient infections arePatient infections are monitored.

• IP completes summary p yand reports to:– Committee– IP Supervisor and others as directedStaff in the form of– Staff in the form of feedback as needed

– Medical Staff

Employee Monitoring & ReportingEmployee Monitoring & Reporting

• Employee infections areEmployee infections are reported by the employee to supervisor, EH/OH or IP

• IP/EH/OH completes employee infection report and reports to:

C i– Committee– IP/EH/OH Supervisor and others as directedothers as directed

Compliance with IP Practicesd d d bMonitored and Documented by:

• Staff EvaluationStaff Evaluation• Observation of Practices

– The IP, infectionThe IP, infection prevention department supervisor, and appropriate departmentappropriate department managers review the compliance monitoring and initiate appropriate actions.

Infection Prevention Plan

Performing An IP Risk Assessment

Select Categories to Assess

RiskIdentify Risks in Each

Category

Establish Priorities

•TJC / CMS / Other RiskAssessment

Cycle

g y

•Local Community•Organizational•Societal

Perform

•Limit Number

Cycle •Societal

Involve OthersDevelop Methods

Assessment

•Include Others

•ICC•Leadership•Key Staff

Develop Methods•Quantitative•QualitativeSWOT

•Establish Timelines

Key Staff•Health Dept

•SWOT•Gap Analysis•Research

QuestionsQuestions