infection prevention and control breakfast for hospitals ... · infection prevention and control...

© J

oint

Com

mis

sion

Res

ourc

es

Infection Prevention and Control Breakfast for Hospitals

September 14, 2017

Karen Martin RN, MPH, CICConsultant, Infection Prevention Services

Joint Commission Resources

© J

oint

Com

mis

sion

Res

ourc

es

Disclosure Statement

Disclosure StatementThe following staff and speakers have disclosed that they do not

have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity:• Karen Martin• Leslie LaBelle• George Riccio• Steve Chinn

The listed staff and speakers have verbally disclosed their arrangements and affiliations: Not Applicable to this presentation

Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products.

2

© J

oint

Com

mis

sion

Res

ourc

es

Publications and Record Restrictions

The program may be electronically recorded by JCR and is subject to the protection of the copyright laws of the US. No individual or entity other than JCR may electronically record any portion of these programs for any purpose without the written permission of JCR. Any and all reproduction or publication of these proceedings and programs for commercial purposes by anyone other than JCR is prohibited.

3

© J

oint

Com

mis

sion

Res

ourc

es

Publications and Record Restrictions

Copyright © 2017 by Joint Commission Resources, Inc. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Request for permission to make copies of any part of this work should be mailed to: Publication and Education Resources, Joint Commission Resources, 1515 West 22nd StreetSuite 1300W, Oak Brook, Illinois 60523.

4

© J

oint

Com

mis

sion

Res

ourc

es

Objectives for Hospital Briefings: The Participant will be able to:

• Discuss most cited Standards IPC challenges and solutions.

• Discuss changes to the 2018 standards as it relates to NPSG.07.03.01

• Discuss changes to the 2018 standards as it relates to NPSG.07.04.01

5

© J

oint

Com

mis

sion

Res

ourc

es

Most Frequent Non-Compliant Standards For 2016

6

© J

oint

Com

mis

sion

Res

ourc

es

What’s Wrong With This Picture

7

© J

oint

Com

mis

sion

Res

ourc

es

It’s Headed In The Wrong DirectionIC.02.02.01

From 60%

To 70%

© J

oint

Com

mis

sion

Res

ourc

es

CDC Progress Report For HAI’s

9

© J

oint

Com

mis

sion

Res

ourc

es

CDC Progress Report 2016

Among national acute care hospitals, the report found:

50 percent decrease in CLABSI between 2008 and 2014

No change in overall CAUTI between 2009 and 2014 • However, there was progress in non-ICU

settings between 2009 and 2014, progress in all settings between 2013 and 2014, and even more progress in all settings towards the end of 2014

17 percent decrease in SSI related to the

10

© J

oint

Com

mis

sion

Res

ourc

es

10 select procedures tracked in previous reports • 17 percent decrease in abdominal hysterectomy

SSI between 2008 and 2014• 2 percent decrease in colon surgery SSI

between 2008 and 2014 8 percent decrease in C. difficile infections

between 2011 and 2014 13 percent decrease in MRSA bacteremia

between 2011 and 2014

11

© J

oint

Com

mis

sion

Res

ourc

es

HAI Prevalence Survey

HAI Estimates Occurring in US Acute Care Hospitals, 2011

Major Site of Infection Estimated No.

Pneumonia 157,500

Gastrointestinal Illness 123,100

Urinary Tract Infections 93,300

Primary Bloodstream Infections 71,900

Surgical site infections from any inpatient surgery 157,500

Other types of infections 118,500

Estimated total number of infections in hospitals 721,800

12

© J

oint

Com

mis

sion

Res

ourc

es

What Does This Mean For Us

13

This Photo by Unknown Author is licensed under CC BY-NC-SA

© J

oint

Com

mis

sion

Res

ourc

es

14

Effective Infection Prevention and Control (IPC) Program

Goal: Reduce the risk of acquisition and transmission of healthcare associated infections (HAI)• Input and support of hospital leadership• Communication and collaboration• Everyone involved in the daily operations of the

facility knows their role in preventing infection• Culture of patient and staff safety

© J

oint

Com

mis

sion

Res

ourc

es

Joint Commission Infection Prevention and Control Standards

l. PlanningA. Responsibility (IC.01.01.01)B. Resources (IC.01.02.01)C. Risks (IC.01.03.01)D. Goals (IC.01.04.01)E. Activities – Plan (IC.01.05.01)F. Influx (IC.01.06.01)

ll. ImplementationA. Activities (IC.02.01.01)B. Medical Equipment, Devices and Supplies (IC .02.02.01)C. Transmission of Infections (IC.20.03.01)D. Influenza Vaccinations (IC.02.04.01)

III. Evaluation (IC.03.01.01)

15

© J

oint

Com

mis

sion

Res

ourc

es

IPC Standards Are Supported By Other Chapter’s Standards

• Leadership• Management of the Environment of Care• Management of Human Resources• Improving Organization Performance• Emergency Preparedness

See Examples in Slides at the end of the presentation

16

© J

oint

Com

mis

sion

Res

ourc

es

2017 IC Standards Non Compliance

17

© J

oint

Com

mis

sion

Res

ourc

es

What are the Most Challenging Infection Prevention and Control Standards for Hospitals?

18

© J

oint

Com

mis

sion

Res

ourc

es

Top Cited Standards From 4/17 –8/17

19

© J

oint

Com

mis

sion

Res

ourc

es

IC.02.01.01 Non-Compliance

EP 1 - Implements infection control activities (407/1445)

EP 2 – The hospital uses standard precautions ( 93/ 1445)

EP 3 – The hospital uses transmission based precautions ( 20/1445)

EP 6 – The hospital minimizes risk of infectious waste (10/1445)

© J

oint

Com

mis

sion

Res

ourc

es

The Hospital Implements It’s Infection Prevention Activities

· Soiled ceiling tiles in central sterile department (CSD) · Patient care items stored within three feet of sinks · Unclear processes for separation of clean/dirty · Lack of solid surfaces on storage shelves · Drink found in patient care areas· Commingling of clean and dirty supplies

21

© J

oint

Com

mis

sion

Res

ourc

es

The Hospital Implements Standard Precautions

22

© J

oint

Com

mis

sion

Res

ourc

es

Hospital Implements Transmission Based Precautions

23

© J

oint

Com

mis

sion

Res

ourc

es

Minimizes the Risk of Infection When Storing and Disposing of Medical Waste

24

© J

oint

Com

mis

sion

Res

ourc

es

25

© J

oint

Com

mis

sion

Res

ourc

es

IC.02.02.01The hospital reduces the risk of infections associated with medical equipment, devices and supplies

26

© J

oint

Com

mis

sion

Res

ourc

es

Noncompliance Findings Sterilization

Quality monitoring parameters (physical, chemical, and biological) not being consistently conducted or documented per manufacturer’s instructions, or use of evidence based guidelines

Approximating use of cleaning products not measuring per manufacturer’s instructions

No documentation of routine cleaning or preventative maintenance of the sterilizer

27

© J

oint

Com

mis

sion

Res

ourc

es

Non compliance Continued

Not following sterilization evidence-based guidelines

28

© J

oint

Com

mis

sion

Res

ourc

es

Non compliance High Level Disinfection

Use of a low-level disinfectant wipe instead of a high level disinfectant to reprocess a vaginal ultrasound probe between patient use

Lack of quality monitoring documentation( temperature, time. Minimal effective concentration of high-level disinfectant per manufacturers’ instructions or evidence based guidelines

29

© J

oint

Com

mis

sion

Res

ourc

es

Noncompliance Continued

Reusable brushes to clean endoscopes not being cleaned or disinfected between each use or at the end of the day per evidence –based guidelines or manufactures’ instructions

Not following device manufacturer instructions for use or high level disinfection evidence-based guidelines for endoscopes or probes (vaginal,rectal)

30

© J

oint

Com

mis

sion

Res

ourc

es

IC.02.02.01 Medical equipment, devices and supplies. Surveyors have found:

Failure to properly:• Clean• Disinfect• Sterilize• Use • Store

Medical equipment, devices, and supplies

31

© J

oint

Com

mis

sion

Res

ourc

es

What Needs TO Be Done TO Improve

Training

Clear concise policies

Standardization of process

Follow manufacturers’ direction for use

32

© J

oint

Com

mis

sion

Res

ourc

es

IC.02.02.01 Medical equipment, devices and supplies

Orientation, training, and competency of health care workers who are processing medical equipment, devices, and supplies

Levels of staffing and supervision of the health care workers who are processing medical equipment, devices, and supplies

33

© J

oint

Com

mis

sion

Res

ourc

es

IC.02.02.01 Medical equipment, devices and supplies

Standardization of process regardless of whether it is centralized or decentralized

Reinforcing the process

Ongoing quality monitoring

34

© J

oint

Com

mis

sion

Res

ourc

es

Training and Competency

Training and Competency• Upon hire• At least annually• Whenever new item or equipment

– borrowed – leased– purchased

• Whenever new policies and procedures are implemented

35

© J

oint

Com

mis

sion

Res

ourc

es


Training should include*• Principles of cleaning, disinfection and sterilization• Inspection, preparation, and packaging of

instruments• Worker safety and use of personal protective

equipment (PPE)• Manufacturer’s instructions for use• Quality control of processes• Endoscope model specific cleaning and

disinfection, if applicable

* Abbreviated list for presentation purposes

36

© J

oint

Com

mis

sion

Res

ourc

es


Training is NOT equivalent to demonstrated competency

Competency is ability of the individual to perform specific tasks in accordance to the standards that are required

37

© J

oint

Com

mis

sion

Res

ourc

es

Policies and Procedures

Clear – no room for interpretation (creativity and work-a-rounds not appropriate)

Based on• scientifically based standards• manufacturer’s instructions for use• infection control and prevention practices

Apply to all locations and staff Readily accessible to staff

38

© J

oint

Com

mis

sion

Res

ourc

es

IC.02.02.01

39

© J

oint

Com

mis

sion

Res

ourc

es

Low Level Disinfection

40

Slideshare.net

© J

oint

Com

mis

sion

Res

ourc

es

Findings of Noncompliance

Lack of clear policy

Separation of Clean /Dirty

Identifying what is clean

Proper wet contact time

Not following policy

41

© J

oint

Com

mis

sion

Res

ourc

es

Use of Supplies

42

© Sylvia Garcia-Houchins

Must be able to clearly differentiate clean from dirty

© J

oint

Com

mis

sion

Res

ourc

es

Performing Intermediate and High Level Disinfection and Sterilization

43

© J

oint

Com

mis

sion

Res

ourc

es

Personal Protective Equipment

Donned by all persons entering decontamination areas

• fluid-resistant gown or jump suit

• hair and shoe covering Individuals performing

decontamination of instruments or equipment

• heavy duty gloves• fluid-resistant mask • eye protection


44

© J

oint

Com

mis

sion

Res

ourc

es

Endoscopy: Processing Room

Pre-cleaning must be done at bedside Endoscope processing may not occur in a

room that is used for any other purpose, and it should never occur in the procedure room• area physically separated from locations where

clean items are handled and patient care activities are performed.

10 air changes (local regulations or manufacturers recommendations may require more)

45Source: Perspectives March 2012

© J

oint

Com

mis

sion

Res

ourc

es

Pre-Cleaning

Should start as soon as possible after use to prevent drying• Flush lumens with sterile water • Wipe instruments with a moistened sponge

Immediately after the procedure, cover with • A compatible enzymatic spray, gel or foam, • Compatible detergent • Cloth moistened with water

Transport as soon as possible Some endoscopes require reprocessing within 1

hour

Ref: AORN and AAMI

46

© J

oint

Com

mis

sion

Res

ourc

es

Decontamination

Follow manufacturer’s instructions May require

• Manual• Mechanical• Combination of both

Ensure entire instrument is disassembled, cleaned and rinsed including valves, channels, connectors and all detachable parts in accordance with manufacturer’s instructions


47

© J

oint

Com

mis

sion

Res

ourc

es

Decontamination

Follow recommended dilution of cleaning chemicals and soak times

Rinse according to cleaning agent manufacturer’s instructions

Brushes • may be labeled as single or

multiple use• reusable brushes should be

disinfected• In accordance with device

instructions

51

© J

oint

Com

mis

sion

Res

ourc

es

Equipment

Use in accordance to manufacturer’s instructions

Test at installation and at least weekly, if applicable © Sylvia Garcia-Houchins

52



© J

oint

Com

mis

sion

Res

ourc

es

Monitoring and Documentation

If the device includes a printout, staff should verify that all sterilization parameters were met by initialing the printout

If no recording device is part of the device, the operator should verify in writing that sterilization parameters as indicated by the manufacturer were met


53

© J

oint

Com

mis

sion

Res

ourc

es

Packaging and Labeling

Sterile Items• Compatible with process• Used according to

manufacturer’s instruction High Level

Disinfection• Identify the date

reprocessed, person reprocessing, date reprocessing expired

Clean Items• Clearly able to differentiate

from sterile

54

© J

oint

Com

mis

sion

Res

ourc

es

Labeling Sterile Products

Label should • Not compromise

the barrier Include

• Contents• Date sterilized• Identifier that

allows the item to be tracked back to the sterilization load





55

© J

oint

Com

mis

sion

Res

ourc

es

Storage of Sterile Devices

AAMI: sterile items be stored • at least 8 inches of the floor• 18 inches below ceiling or sprinkler• 2 inches from outside wall• away from any location where they

could become wet Dust covers may be used to

protect sterilized items that could be subjected to environmental challenges or excessive handling before use

No corrugated boxes (external shipping boxes)

Does not damage packaging


56

© J

oint

Com

mis

sion

Res

ourc

es

Storage of Sterile Devices

If open shelves are used, traffic control, ventilation, and housekeeping should be monitored

• Bottom shelves should be solid to prevent soiling when floors are cleaned

• Covered or closed cabinets limit dust and are preferred for seldom used items


57

© J

oint

Com

mis

sion

Res

ourc

es

Essential References for Endoscopy

Society of Gastroenterology Nurses and Associates (SGNA)

American Society for Gastrointestinal Endoscopy (ASGE)

Gastrointestinal Society of Australia (GESA)

58

© J

oint

Com

mis

sion

Res

ourc

es

Essential References

AAMI AORN CDC Guidelines OSHA Bloodborne

Pathogens Standard State Regulations

59

© J

oint

Com

mis

sion

Res

ourc

es

What’s On The Horizon 2018

No changes for IC standards

Modifications to National Patient Safety Goal 7

NPSG.07.03.01

NPSG.07.04.01

62

© J

oint

Com

mis

sion

Res

ourc

es

NPSG.07.03.01 MDRO’s

Although this goal already exists for hospitals, Carbapenem-resistant enterobacteriaceae (CRE) as one of the organisms covered by the goal

Organizations can determine timeframe for education to staff

Surveillance may be targeted rather than house wide

63

© J

oint

Com

mis

sion

Res

ourc

es

NPSG.07.04.01 Central Lines

Organizations can determine time-lines for education

Maximum sterile barrier no more protocol for

Chlorhexidine antiseptic for skin preparation

64

infection prevention and control breakfast for hospitals ... · infection prevention and control...

Documents