best practices for infection control - performance

Best Practices for Infection

Control - Performance

Improvements and Standards

Compliance

Sylvia Garcia-Houchins, RN, MBA, CIC

Director, Infection Prevention and Control

Mike Dye, Senior Business Development Specialist

September 18, 2019

2

© 2018 The Joint Commission. All Rights Reserved.

⎻ These slides are current as of (09/01/2019). The Joint Commission

reserves the right to change the content of the information, as

appropriate.

⎻ These slides are only meant to be cue points, which were expounded

upon verbally by the original presenter and are not meant to be

comprehensive statements of standards interpretation or represent all

the content of the presentation. Thus, care should be exercised in

interpreting Joint Commission requirements based solely on the content

of these slides.

⎻ These slides are copyrighted and may not be further used, shared or

distributed without permission of presenter or The Joint Commission.

Distribution of the speaker’s presentation other than in PDF format is

expressly prohibited.

The Joint Commission Disclaimer

3


Committing to Zero Patient Harm

– Deploy highly effective process

improvement models

– Establish a culture of safety and

collaboration

– Make a personal commitment

4


Hierarchical Approach to IC Standards

5


Most Frequently Cited Infection Control (IC) StandardsJan. 1, 2019-June 30, 2019

6


Disinfection and Sterilization

7


8


Regulations: Disinfection and Sterilization

Requirements

Must know your state requirements

For Example: Alabama

Sterilization…procedures must include…

2. Length of time to accomplish sterilization.

3. A prohibition against reuse of one-time-use

(disposable) items, unless the items have been

reprocessed in accordance with federal law.

4. Temperature, time and pressure for steam

sterilization.

5. Proper methods of preparation of items for

sterilization (cleaning, wrapping and dating).

6. Shelf storage time for sterile time.

7. Use of sterilizer indicators.

https://www.alabamapublichealth.gov/providerstandards/assets/ASCRules.pdf

9


CMS Sources of Disinfection and

Sterilization Requirements

– Survey and Certification Letters

– Quality Safety & Oversight Memoranda

https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

10


Cause of Immediate Threats in Ambulatory Settings: Failure to Follow Spaulding Classification

11


Manufacturer Instructions

READ CAREFULLY; must identify minimum level of reprocessing required based on Spaulding classification

Touches eye (mucous membrane) – requires high level disinfection

Does not mean all are high

level disinfectants - must

choose a high level

disinfectant

12


How to Find a High Level Disinfectant

FDA Website https://www.fda.gov/medicaldevices/deviceregulationandguidance/reproc

essingofreusablemedicaldevices/ucm437347.htm

https://www.fda.gov/medicaldevices/deviceregulationandguidance/reprocessingofreusablemedicaldevices/ucm437347.htm

13



Only FDA approved

High Level

Disinfectants in this

list


14



Instructions from another product listed as compatible

but not a high level disinfectant

This product is not to be used as a

terminal sterilant/high-level disinfectant on

any surface or instrument that (1) is

introduced directly into the human body

either into or in contact with the

bloodstream or normally sterile areas of

the body, or (2) contacts intact mucous

membranes but which does not ordinarily

penetrate the blood barrier or otherwise

enter normally sterile areas of he body.

This product may be used to preclean or

decontaminate critical or semi-critical

medical devices prior to sterilization/high-

level disinfection

15


Standard Precautions

IC.02.01.01 EP2

16


⎻ Refer to Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee states Standard Precautions include:

• Hand hygiene

• Environmental cleaning and disinfection

• Injection and medication safety

• Risk assessment with use of appropriate personal protective equipment (e.g., gloves, gowns, face masks) based on activities being performed

• Minimizing Potential Exposures (e.g. respiratory hygiene and cough etiquette)

• Reprocessing of reusable medical equipment between each patient and when soiled

IC.02.01.01 EP2 Standard Precautions

17


Frequent Findings:

⎻ Lack of hand hygiene

⎻ Use of a hand hygiene sink for disposal or cleaning of

equipment

⎻ Use of single dose medication vials on multiple patients or

availability for use after opening

⎻ Taking a multi-dose vial into a patient room and then using it

for a subsequent patient

⎻ Failure to scrub the hub of an IV line or medication vial


18


Frequent Findings:

⎻ Not following state regulation, evidence based guideline

and/or facility policy regarding dress code in restricted areas

⎻ Failure to provide PPE at point of use

⎻ Failure to use or incorrect/inappropriate use of PPE

⎻ Failure to follow aseptic technique


19


Cleaning and Low Level

DisinfectionIC.02.02.01 EP1

20


Facilities must follow evidence based guidelines

21


⎻ Disinfectant not being used in accordance with manufacturer IFU (e.g., dilution, type of surface, contraindicated, expired)

⎻ Use of an antiseptic to clean environmental surfaces

⎻ Failure to clean thermometer, blood pressure cuff, stethoscope or pulse oximeter, etc. after each patient

⎻ Lack of environmental cleaning between patients in exam rooms, procedure rooms, operating rooms etc.

⎻ Employees did not know….

IC.02.02.01 EP1 Low Level Disinfection

Frequent Findings:

22


Implementation of Infection

Prevention and Control

ProgramIC.02.01.01 EP1

23


Examples of Frequent Findings

⎻ Failure to separate clean and dirty

⎻ No surveillance over the cleaning, disinfection, or sterilization

process by IC

⎻ Not following facility policy related to infection control

⎻ Not following manufacturer instructions, including performing

routine maintenance

⎻ Presence of surfaces that are not cleanable (e.g., foam, torn,

delaminated,)

IC.02.01.01 EP1 Implementation of Infection Prevention and Control Program

24


Identify and Prioritize Risks

IC.01.03.01 EP1

25


The organization identifies risks for acquiring and

transmitting infections

1. The organization identifies infection risks based on the

following:

• Its geographic location, community, and population

served

• The care, treatment, or services it provides

• The analysis of its infection surveillance and control data

Standard IC.01.03.01

26


Proactive Cycle to Prevent Infections

Identify Organizational Components

Evaluate Risks

Prioritize Risks

Determine Goals

Develop IC Plan

Implement IC Plan

Evaluate the Plan

27


Example:

• Ambulatory Clinic in El Paso, Tx

• 82% Hispanic

• Large immigrant population

• Tuberculosis rates are higher along the Texas-Mexico border.

• Provides

• Primary Care (vaccination)

• Women’s Care (speculums, ultrasound)

• Wound Care (instruments, sterile supplies)

• Vision Care (medications, tonometers)

• Dental Services (instruments, medications)

28




Evaluate Risks

Prioritize Risks

Determine Goals

Develop IC Plan

Implement IC Plan

Evaluate the Plan

29


Example (cont.):

• Patient Risks

• Coughing patient could have tuberculosis

• Communication – only speak Spanish

• Environmental Risks

• Cleaning, disinfection, and sterilization

• Refrigerators for vaccine storage

• Medication storage

• Employee Related Risks

• Personal health (bloodborne pathogens, tuberculosis)

• Degree of compliance with IC practices

• Training, competency and supervision

• Other

• Clinic Manager, Infection Preventionist, 2 Medical Assistants are new

30




Evaluate Risks

Prioritize Risks

Determine Goals

Develop IC Plan

Implement IC Plan

Evaluate the Plan

31


Example (continued)

• Priorities

• Prevent transmission of TB to other patients and staff

• Need to Implement Standard Precautions for all

coughing patients

• Following manufacturer instructions for cleaning and

sterilizing instruments

• Need to implement rigorous disinfection and sterilization

procedures

• Training and competency of new staff

• Need to ensure staff are able to implement infection

control practices

32




Evaluate Risks

Prioritize Risks

Determine Goals

Develop IC Plan

Implement IC Plan

Evaluate the Plan

33


Getting toGold

34


Tools and Resources

Survey Activity & Review Process

Guides

Document List or “Ready-to-Go List” helps

your organization and survey/review team

prepare

Perspectives

Joint Commission’s official monthly

e-periodical

E-dition

Free access to electronic version of standards

Getting to Gold

35


Joint Commission ConnectTM (Extranet)

Leading Practice Library

Real-life solutions from customers

Targeted Solutions ToolTM

Helps identify customized solutions

regarding safe surgery and other

persistent issues

BoosterPakTM

Searchable document intended to

provide detailed information about a

single standard topic

Getting to Gold

36


Industry/Joint Commission News

Industry Resources

−AmBuzz: Bi-Monthly Blog

−Ambulatory Care LinkedIn

Showcase Page

−Ambulatory Care Twitter Feed

−Enterprise Content Library Index -

contains links to current Joint

Commission content, organized

into typical topic areas in a

searchable PDF

Getting to Gold

https://www.jointcommission.org/daily_update/joint_commission_daily_update.aspx?t=2&k=3001,3229&b=1

https://www.linkedin.com/company/joint-commission-ambulatory-accreditation?trk=biz-companies-cym

https://twitter.com/Mkulcz

https://www.jointcommission.org/enterprise_content_library_index/

37


Joint Commission Resources (JCR)

−Publishes standards manuals

−Hosts webinars and conferences

−Range of publications & e-books,

for example, mock tracer

workbooks, patient safety

Getting to Gold

38


Ambulatory Care HAI Portal

Getting to Gold

https://www.jointcommission.org/topics/hai_ambulatory_health_care.aspx

39


Quick Safety Issue 33

Getting to Gold

40


AmBuzz Blog April 18, 2018

Getting to Gold

https://www.jointcommission.org/ambulatory_buzz/following_manufacturers_inst

ructions_helps_prevent_surgical_infections/

https://www.jointcommission.org/ambulatory_buzz/following_manufacturers_instructions_

https://www.jointcommission.org/ambulatory_buzz/following_manufacturers_instructions_helps_prevent_surgical_infections/

41


Don’t miss our next webinar!

Why A Joint Commission Surveyor is

Your Organization’s Greatest Ally

October 30, 2019 - Noon CST

Getting to Gold

Register/Access past webinars:

www.jointcommission.org/AHCWeb

42


Contact our Ambulatory Care Team

Phone: 630.792.5286

Email: [email protected]

Website: www.jointcommission.org/AHCProgram

Next Steps

best practices for infection control - performance

Documents