CMS Infection Control StandardsAppendix

What Hospitals Need to Know. Hospitals Need to Know About the

Infection Control Interpretive

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Speaker

Sue Dill Calloway RN, Esq. CPHRM

AD, BA, BSN, MSN, JD

President

Patient Safety and Education

5447 Fawnbrook Lane

Dublin, Ohio 43017

614 791-1468

sdill1@columbus.rr.com

Appendix with additional resources

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Injection Safety CDC

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Advancing ASC Quality

ASC Quality Collaboration has ASC tool kit for infection prevention

Includes one on hand hygiene and safe injection practices

Includes a basic and expanded version of the toolkit

These are available at http://www.ascquality.org/advancing_asc_quality.cfm

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Resources

TJC has Speak Up Initiatives including five things you can do to prevent infections at www.jointcommission.org/GeneralPublic/Speak+Up/about_speakup.htm

Options to Increase Isolation Surge Capacity, Slides at www.jcrinc.com/common/PDFs/document_collection/resources/collections/00032482/00032984-0001.pdf

Preparing for a Pandemic, EM Case Study, How the Health First Hosptial Developed a Pandemic Influenza Plan at www.jcrinc.com/common/pdfs/qualityandsafety/preparing_for_a_pandemic_brevard_county_FL.pdf

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Spice www.unc.edu/depts/spice/

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www.apic.org

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CDC has Dialysis Resources also

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www.apic.org/Content/NavigationMenu/PracticeGuidance/APICEliminationGuides/Hemodialysis_Resourc.htm

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Institute for Healthcare Improvement

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Source: www.shea-online.org

www.who.int/en/

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http://www.his.org.uk/

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www.theific.org/

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Source: www.idsociety.org

www.idsociety.org/

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PA Patient Safety Authority

Source: http://www.patientsafetyauthority.org/Pages/Default.aspx

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IHI ICU Improvements VHA united with IHI to improve ICU care

Better control of blood sugars with glucose monitoring protocols1

Aggressive treatment of sepsis/blood stream infections (see central line bundle)

Prevention of ventilator associated pneumonia (see VAP bundle), surgical infections

Developed toolkits (order sets, protocols, daily goal sheets), report templates for monthly reporting of change

1www.ihi.org

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Head of bed (HOB) elevation > 30 degrees

Deep venous thrombosis (DVT) prophylaxis

Peptic ulcer disease (PUD) prophylaxis

Daily sedation vacations

Assessment of readiness of wean

Oral care

Use a checklist and document each!

Ventilator Bundle

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Hand hygiene

Maximal barrier precautions upon insertion

Chlorhexidine skin antisepsis

Optimal catheter site selection with subclavian vein as the preferred site for non-tunneled catheters

Daily review of line necessity with prompt removal of unnecessary lines

Central Line Bundle

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Over 750,000 patients a year develop sepsis or septic shock in the US

Severe sepsis will kill 30% of infected patients and another 20% will die within six months

Surviving sepsis campaign

Can listen to presentations

Sepsis bundle lists seven tasks to be done during first six hours

Sepsis Bundle

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If hypotension, give serum lactate >4 mmol/L (deliver initial minimum of 20 mL/kg of crystalloid and vasopressors for arterial pressure less 65 mm Hg)

Bundle 5 is for persistent hypotension achieve central venous pressure > 8mm Hg and venous oxygen sat of > 70%

Sepsis Resuscitation Bundle

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Administer low dose steroids with standardized ICU policy

Administer recombinant human activated protein C (rhAPC) in accordance with a standardized ICU policy. If not administered, document why the patient did not qualify for rhAPC.       

Maintain glucose control >70, but <150 mg/dL.

Sepsis Management Bundle

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Surviving Sepsis Campaign website1

Sepsis bundle website2

Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Critical Care Medicine. 2004;32(3):858-873.

See IHI, Defeating Sepsis; 25% by 20093

1http://www.survivingsepsis.org/ 2http://www.survivingsepsis.org/implement/bundles

3http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/ImprovementStories/

FSDefeatingSepsis25Percentby2009.htm

Sepsis Bundle

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Do not put in unless absolutely necessary

Make sure meticulous care is followed in inserting

Remove ASAP

Document everyday considerations as to whether foley can come out

Follow evidence based literature and CDC guidelines on preventing catheter associated UTI

Many UTIs can be prevented with proper management of the indwelling urethral catheter

Maintain sterile closed system CDC 2009 guidelines at www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html

Preventing UTI from Catheters

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Recent cases of improperly sterilized equipment.

PA Safety Authority reports number of reported cases of contaminated equipment from prior surgery

Portland VA sent out 2,270 letters of TRUS guided prostate biopsy equipment

FDA alert July 2006 and 2009 on prostate biopsy equipment

Called bioburden

Old dried blood and tissue came out of tissue protector on drill, triple trocar full of dried blood, suture remained on tunneler, and particles of tissue found on cannulated instruments

Sterilized Equipment Issue

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Sterilized Equipment Issue (continued)

Adequate cleaning is required to remove all residual that remains, if not prevents sterilization

Many wipe instruments with wet lap or gauze sponge with sterile water during or after procedure

CMS and TJC issue information on flash sterilization so make sure you pay attention to this issue

Soaking instrument in enzymatic solution after procedure and follow manufacturers instructions Immediately soak all instruments

May need to use brushes to remove material

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Cleaning of Medical Equipment

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Many are on infection control

Implement best practices to prevent multiple drug resistant organisms MDROs

Educate staff and patients about MDRO and necessity for prevention

Measure MRSA and CDAD (C-diff associated disease)

Clean and disinfect equipment and patient care environment

TJC NPSGs

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MRDOs Resources

CDC MRSA resources at http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Includes fact sheet on MRSA, MRSA in healthcare setting 2007, educational material, data, lab testing and practices, etc.

Isolation precaution 2007 at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

VRE resources at http://www.cdc.gov/ncidod/dhqp/ ar_vre.html

Guidelines for Prevention of Surgical Site Infections

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Resources APIC resources at www.apic.org and see

standards and guidelines

Guidelines for Environmental Infection Control in Health Care Facilities

Guidelines for Prevention of Surgical Site Infections

Recommendations for Preventing the Spread of VRE

Guidelines to Prevent Intravascular Catheter Related Infections

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2010 NPSG Chapter Outline

Accreditation Connection, June 28, 2010

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2010 NPSG Chapter Outline

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Goal 7: Hand Hygiene NPSG.07.01.01

Reduce the risk of HAI,

4 of 5 sections remain in 2010,

Deleted 7 B on HAI as SE,

Retained hand hygiene, MDRO, reducing central line associated blood steam infections, and preventing surgical site infections,

Infection control important in 2010 with CMS getting 40 million grant to enforce standards,

CMS Hospital CoP 2010 has12 pages of standards and TJC IC chapter is 8 pages,

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Hand Hygiene NPSG.07.01.01

Comply with current CDC or WHO hand hygiene guidelines and has 3 EPs,

EP1 Implement a program that follows categories 1A, 1B, and 1C on one of the above,

EP2 Set goals for improving compliance with hand hygiene guidelines,

EP3 Improve compliance with hand hygiene guidelines based on established goals,

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CDC Hand Hygiene Recommendations

CDC published guidelines Oct 25, 2002 at www.cdc.gov/handhygiene/

In CDC MMWR Recommendations and Reports,

Report available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm or go to www.cdc.gov,

TJC published document in 2009 on Measuring Hand Hygiene Adherence: Overcoming the Challenges and this is an important document,

Monitored during infection control tracer,

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Hand Hygiene IHI CDC

IHI publishes 2006 “How-to Guide: Improving Hand Hygiene. A Guide for Improving Practices among Health Care Workers”

Project with CDC, APIC and Society of Healthcare Epidemiology of America (SHEA) and available at www.ihi.org,

Hand hygiene one of most important IC measures,

2 million health-care associated infections (HAIs) and 98,000 deaths per year,

CDC has free posters on hand washing at www.cdc.gov,

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Hand Hygiene

WHO Guidelines on Hand Hygiene in Health Care; Clean Hands are Safer Hands at www.who.int/patientsafety/events/05/HH_en.pdf

Good website for children on importance of washing hands.

Colorful posters, puzzles, and quiz.

http://www.microbe.org/washup/Wash_Up.asp

Henry the Hand at henrythehand.com,

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CDC Hand Hygiene

Category 1A-strongly recommended for implementation and strongly supported by research,

1B- strongly recommended and supported by certain experimental, clinical research,

1C-required for implementation, as mandated by state or federal law,

Hospitals must comply with all three above.

Category II- are suggested for implementation and supported by suggestive clinical studies,

No recommendation-unresolved issues,

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Infection Control

TJC requires all facilities to comply with ALL category 1 recommendations,

Category II recommendations should be considered,

Artificial nails is a category IA recommendation so it is required for those who provide direct care to high risk patients,

However, ¼ inch nail tips is category II so it should be considered,

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Hand Hygiene

Facility must provide alcohol based hand rub product (ABHR),

However, staff doesn’t have to use it,May be used instead of soap and water, remember to use soap and water for patients with C-diff),

LSC allows for installation of ABHR gel dispensers in egress corridors, with some limitations (6 ft corridor, at least 4 ft apart, not over plug, no more 1.2 liters for dispensers in room and corridor, foam with same rules, et. al.)But suggest hand hygiene in presence of patient,

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CDC Hand Hygiene

If hands not visible soiled, use alcohol based hand rub in all settings,

If hand visibly soiled or contaminated with protein material, blood or other body fluids then soap and water,

Monitor volume of ABHR used per 1000 patient days,

Periodically monitor and record adherence to hand hygiene compliance and provide feedback,

This direct observation is necessary for corrective action,

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CDC Hand Hygiene

1B - decontaminate hands before having direct contact with patients,

1B - decontaminate hands before putting on sterile gloves when inserting central line,

Decontaminate hands before inserting Foley, peripheral vascular lines and other invasive devices,

Wash hands with soap and water before eating and after using bathroom

Must comply with 1A, 1B, and 1C CDC recommendations,

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Hand hygiene technique

Apply alcohol based hand rub to palm of one hand and rub together , covering all surfaces of hands and fingers, until hands are dry,

When using soap and water, wet hands first , apply soap and rub hands vigorously for at least 15 seconds, covering all surfaces of hands and fingers, rinse and dry with disposable towel,

Use towel to turn off faucet

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Implement Evidenced Based Practices

Implement evidenced based practices to prevent HAI due to multi-drug resistant organisms (MDROs),

7C or 07.03.01,

9 EPs (12 but no EP 1-4 since these were EPs related to phase in and suppose to be in full compliance January 1, 2010,

Applies to, but not limited to, MRSA, VRE, C-Diff, and MDRO gram negative bacteria,

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Evidenced Based HAI Prevention

5. Conduct periodic risk assessment (in time frame set by hospital) for MDROs acquisition and transmission

See IC.01.03.01, EPs 1-5

Slides for these five are attached for reference but will not be discussed

TJC infection control chapter very important and dove tails with these infection control NPSGs

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Identify Risks for Transmitting Infections

IC.01.03.01 The hospital identifies risks for acquiring and transmitting infections EP1 Hospital identifies risks based on geographic

location, community, and population served– NPSG.07.03.01 EP1 Conduct periodic risk assessments in time

frames set by hospital for multidrug-resistent organisms (MDRO) acquisitions and transmission

– MDRO includes methicillin-resistant Staphylococcus Aureus (MRSA), Vancomycin-resistant Enterococcus (VRE), Klebsiella , and Acinetobacter

– CDC has free MDRO infection (and CDAD) surveillance and training on the National Healthcare Safety Network (NISN) 1

– 1 http://www.cdc.gov/nhsn/wc_MDRO_CDAD.html

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Identify Risks for Transmitting Infections IC.01.03.01

EP2 Hospital identifies risk for acquiring and transmitting infections based on the care and treatment it provides (on MDRO)

EP3 Look at risk for acquiring or transmitting an infection by doing an analysis of surveillance activities and other infection control data (including MRDO and adverse tissue reactions)

EP4 Review and identify risks annually and when there is a significant change and get input from IP, MS, nursing, and leadership including MRDO

EP5 Prioritize these risks

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Evidenced Based HAI Prevention

6. Educate staff and LIPS about HAI, MDROs, and preventive strategies in orientation (at hire) and annually

Use information from your risk assessment,

7. Educate patient and their families about HAI strategies who are infected or colonized with MRDO,

8. Implement a MDRO surveillance program based on your risk assessment,

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Evidenced Based HAI Prevention

9. Measure and monitor MDRO prevention processes and outcomes including; MDRO infection rates using evidence based metrics, compliance with evidenced based practice, and evaluate education provided,

10.Provide MRDO process and outcome data to key stakeholders, nurses, doctors, LIPs and other clinicians,

11. Implement P&Ps to reduce transmission of MRDOs which meet CDC and other professional organization standards (APIC,SHEA,OSHA),

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Evidenced Based Practices

12. Implement a laboratory based alert system that identifies new patients with MDRO when indicated by the risk assessment,

The alert system can be manual or electronic and can use faxes, pages, telephones etc.,

13. Implement an alert system that identifies readmitted or transferred MRDO positive patient when indicated by risk assessment,

Alert system can be in a separate database or integrated and can manual or electronic.

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Central Lines 7D or 07.04.01

Implement best practices to prevent central line associated bloodstream infections,

17 EPs with no 1-4 EP since phase in EPs as previously discussed,

IHI has how to guide and other resources at www.ihi.org (Keystone project),

EP5 Educate staff involved in procedures about HAI, central line infection and importance of prevention,

Must do education in orientation and annually and if procedure added to your job,

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Central Lines

6. Educate patients and families before inserting central line about central line associated bloodstream infection prevention (BSI), as needed,

7. Implement P&Ps to reduce risk of BSI that meet regulatory and evidenced based standards,

8. Conduct periodic risk assessments for surgical site infection, measure BSI rate, and monitor compliance with best practices and how effective the prevention efforts are,

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Central Lines

9. Provide CSI rate data and prevention outcome measurement to staff and LIPs and clinicians,

10. Use a catheter checklist and standard protocol for central line insertion,

11. Perform hand hygiene before catheter insertion or manipulation,

12. Do not put in femoral vein unless last resort for adult patients,

13. Use standardized supply care or kit for central lines,

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Central Lines

14. Use standardized protocol for maximum sterile barrier precautions during insertion,

15. Use chlorahexidine for skin prep in patients over two months,

16. Use standardized protocol to disinfect catheter hubs and injection ports before accessing,

17. Evaluate all central lines routinely and remove none essential catheters,

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Surgical Site Infections

Implement best practices to prevent surgical site infections,

There are 8 EPs, No EP 1-4 as was implementation phase,

5. Educate hospital staff involved in procedures about HAI, surgical site, and importance of prevention,

Educate during orientation, annually, and if added to your job,

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Surgical Site Infections

6. Educate patients and families, who are undergoing surgical procedures, about preventing surgical site infections (SSI),

7. Implement P&P to reduce SSI that meet regulations and evidenced based practice (such as the CDC and other professional organizations),

8. Conduct periodic risk assessments for SSI, select measures using best practices or evidence based guidelines and monitor compliance with them and how effective they are,

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Surgical Site Infections

EP9 Measure surgical site infection rates for the first 30 days following a procedure that do not involve inserting implantable devices

Measure for the first year procedures involving implantable devices

Need to follow evidence based guidelines

Surveillance may to targeted to certain procedures based on hospital risk assessment

10.Provide process and outcome data on SSI to stakeholders etc,

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Surgical Site Infections

11. Antimicrobial agents for prophylaxis are administered according to standards and guidelines,

IV antibiotics 1 hour before surgery except for 2 hrs for vancomycin and fluoroquinolones,

D/C antibiotics within 24 hours after surgery except 48 for some cardiothoracic patients,

12. Clippers or depilatories for hair removal,

www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html

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www.cdc.gov/hicpac/CAUTI_fastFacts.html

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www.cdc.gov/hicpac/Disinfection_Sterilization/acknowledg.html

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http://www.cdc.gov/hicpac/pubs.html

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