infection prevention program overview
TRANSCRIPT
Infection Prevention Program Overview
Infection Prevention Essentials in Long-Term Care
Spring 2019
Teri Hulett, RN, BSN, CIC, FAPIC
Leading infection prevention education across the Rocky Mountain Region
Infection Prevention Program
The infection preventionist
Policy and Procedure
Infection Control Risk Assessment
Infection Control Plan
Surveillance
Outbreak Investigation
Education
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LTC IP Program Checklist
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✓ 3-page document
✓ Great resource
✓ Good cross check to ensure all
required elements are in place
Schweon, SJ, et al Infection Preventionist’sGuide to Long-Term Care APIC 2013
The Infection Preventionist
Leader, manager, change agent, investigator/detective, educator
Infection prevention and control is a priority for patient safety in healthcare facilities
Managing the effects of regulatory scrutiny on HAIs; preventing and controlling HAIs in a variety of settings
Globalization presents new challenges; people and manufactured goods and products
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Scope: the infection preventionists scope encompasses a broad range of
practice settings, including, but not limited to:
• Acute care • Behavioral Health• Long-term Care • Outpatient settings
• Rehab centers • Public Health centers
• Dialysis centers • Infusion centers
Bubb TN, et al; APIC professional and practice standards, American Journal of Infection Control: AJIC 2016; 44:745-749
The IP serves as coordinator of the IPCP
Policy and Procedure
Facilitate adherence with recognized professional practices
Promote compliance with regulations, statutes, and accreditation
requirements (HIPPA, CMS, CoP, DNV, Joint Commission)
Reduce practice variation
Standardize practices across multiple entities within a single health
system
Serve as a resource for staff, particularly for new staff
Reduce reliance on memory, which, when overtaxed, has been shown
to be a major source of human errors and oversight
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Formalized, written policies and procedures fulfill a number of important purposes:
https://www.psqh.com/analysis/policies-and-procedures-for-healthcare-organizations-a-risk-management-perspective/
Policy, Standard, Procedure, and Guideline
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Guidelineprovides additional, recommended
guidance
Procedure establishes proper steps to take
Standardassigns quantifiable measures
Policy identifies issue and scope
How do I do it?
What is required?
Why do I need to do this?
Elements of a policy
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➢ Consolidate when able and appropriate
➢ Keep broad➢ Gowns must be impervious and fluid
resistant
➢ N95 (P2) respirators (duckbill masks) are
recommended to protect the wearer from airborne pathogens such as tuberculosis
➢ Impervious linen bags with red strip are to
be utilized
1. Purpose
2. Scope
3. Definitions
4. Policy
5. Procedures for Standard & TBP
6. Table 1 – Type of Precautions and
Requirements (including Transport)
7. Appendices - CDC
Infection Prevention Risk Assessment
An assessment performed to identify key internal and external infection
vulnerabilities that can inhibit efforts to prevent and control infections
High risk, high volume, high-cost, problem-prone
It evaluates risks specific to your facility and your community
It establishes infection prevention priorities
It sets goals and objectives
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What is the Risk Assessment?
The Infection Preventionist and the Infection Prevention Medical Director
with input from the Infection Prevention Committee members assess
risks on an ongoing basis and the risk assessment document is re-
evaluated annually and as needed due to changing factors. Chapter1 pg. 4
Luebbert, PP(2010). Infection Prevention Policy and Procedure Manual for Hospitals. Marblehead, MA: HCPro
Risk Assessment
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© 2013 APIC. Adapted from original work by Terrie B. Lee, RN, MS, MPH, CIC. May be used and/or modified for individual use in a work and/or educational setting. Duplication,
distribution, publication, or other use for profit or other commercial purposes without prior written permission from APIC.
Schweon, SJ. et al; Infection Preventionists Guide to Long-term Care APIC(2013)
LTC Infection Prevention and Control Plan
Defines the oversight and management of the Infection Prevention and Control Program
Identifies the authority and guidance statements
Identifies goals, objectives, and metrics that will be used to evaluate program effectiveness
Addresses infection prevention collaboration and support
Address education needs of staff, residents, and visitors
Identifies prioritized prevention goals
Addresses surveillance and reporting requirements
Identifies infection prevention challenges – i.e. transitions in care, resident safety
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The infection prevention and control program is described in a
written plan. The plan is developed to address needs identified
in the risk assessment, as well as:
Schweon, SJ, et al; Infection Preventionists Guide to Long-term Care 2013; 26-27
Elements of an Infection Prevention and Control Plan
Policy: states the what and the who
Scope:
Structure and Authority:
Members
IP Professional requirements
Medical Director
Authority
Risk Assessment
Evaluation of Effectiveness
Reporting Structure
Goals and Functions:
Prevention
Education and Training
Policy and Procedure Development and Review
Surveillance – whole house or targeted
Control
Outbreak Investigation
Resources
Additional Activities
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Scope of the LTC IPCP
Surveillance
Data analysis
Implementation of prevention and control interventions
Education of staff, residents, families, and visitors
Environment and equipment cleaning and disinfecting
Product evaluation
Immunization
Policy and Procedure evaluation and review
Outbreak investigation
Committee coordination and communications
Consultation
Antibiotic Stewardship
Disaster Preparedness
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Scope describes what activities will be conducted and to what extent
they will be implemented. The scope will vary based on risk
assessment, size, resident population, community needs, and
available resources.
Schweon, SJ. et al; Infection Preventionists Guide to Long-term Care 2013; 26-27
Sample Infection Prevention Plan
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Collaborate with the organization
leadership to institute emergency
measures to prevent infections such as
closure of units, transfer of patients,
halting construction, etc.
Luebbert, PP. (2010)
Sample authority statement
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Long-term care specific IPCP
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This policy pulls in the Quality
Assurance Committee
Surveillance
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Surveillance
Infection/Syndromic Surveillance; analysis of patient data
Hand Hygiene; process and outcome data
Transmission Based Precautions; process and outcome data
Labs; patient-level data
Point-of-Care Testing
Environment of Care (EOC); process and outcome data
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Surveillance is the comprehensive method of measuring process and
outcome data; data collection, analysis, and dissemination of patient-
level and environmental information as a process to HAI prevention.
So….surveillance is a cornerstone to prevent or reduce HAIs leading
to improved outcomes and resident safety
According to the final rule:
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Surveillance should be established based on the facility risk assessment and include:
✓ Routine
✓ Ongoing
✓ Systematic collection
✓ Analysis
✓ Interpretation and dissemination
✓ Infection risks
✓ Outbreaks
Facilities must establish a system for surveillance based upon national
standards of practice, the facility assessment, the resident
population, and services and care provided.
Surveillance must include a
data collection tracking tool
and the use of nationally
recognized surveillance
criteria…….such as NHSN or
McGeer’s
Infection Surveillance in LTC
Urinary tract infections; the most commonly treated infection reported
Lower respiratory tract infection; Sepsis
GI Tract - Clostridioides difficile; #1 cause of diarrhea in NHs and SNFs:
>50% of all GE in PA NHs
One of the most common and costly HAIs
Skin and soft tissue infections; epidermis thinner and protective SQ fat declines
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Syndromic surveillance is the analysis of patient-level data to detect or
anticipate disease outbreaks.
Long-term care residents are requiring more complex medical care as a
result of transitions between healthcare settings
https://health.gov/hcq/pdfs/hai-action-plan-ltcf.pdf
Surveillance process
Select surveillance criteria: population, process, or infection type
Define criteria for measurement (standardized case definitions, numerator, and denominator)
Decide what method you will use for your surveillance:
Concurrent Surveillance:
Regular rounds on resident units
Verbal or written reports from nursing staff
Retrospective Surveillance:
Culture data (lab reports)
Pharmacy reports of antibiotic use
Radiology reports
Chart review
Develop line lists for tracking purposes (Infection Control Log)
Produce reports to share with units, providers, and at ICC and QAPI meetings
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Work with your in-house or reference lab to develop lab reports containing
the lab metrics you will need to perform surveillance
Pathway Health Services, Inc. Infection Prevention and Control Manual 2017 www.pathwayhealsth.com
Hand Hygiene
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Hand Hygiene; Foundation of IP
National data shows <50% compliance
Semmelweis demonstrated effectiveness of hand hygiene in the 1800s
CDC and WHO Guidelines
Educate; JC requirement
Product; choice, location
Track and report compliance
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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol 55, no. RR-16.
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
“Hand Hygiene (HH) has frequently been cited as the single most important
practice to reduce the transmission of infectious agents in healthcare
settings and is an essential element of Standard Precautions.”
Time spent on hand hygiene
Hand washing with soap and water: 56 minutes
Based on seven 60-second handrub events per hour
Alcohol-based handrub: 18 minutes
Based on seven 20-second handrub events per hour
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Alcohol-based handrubs reduce time required for
compliant hand disinfection
Voss A, Widmer AF, Infection Control Hospital Epidemiology 1997:18;205-208
Skin care and your hand hygiene program
Provide healthcare workers (HCWs) with hand lotions or
creams
Obtain product information from manufacturers regarding
interactions between soaps and lotions to prevent negative
product interactions (inactivation)
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Guideline for Hand Hygiene in Health-care settings. MMWR 2002; vol. 51, no. RR-16.
Hand hygiene audit tool
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Schweon, SJ, et al Infection Preventionist’s Guide to Long-Term Care APIC 2013
Joint Commission and Hand Hygiene
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Hand Hygiene Programs
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1. Before touching resident
2. Before clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a resident
5. After touching resident
surroundings
Transmission-Based Precautions
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Transmission-Based Precautions
Transmission-Based Precautions are interventions
designed to supplement standard precautions in
patients/residents with documented or suspected
infection/colonization of highly transmissible or
epidemiologically important pathogens.
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http://www.mass.edu/mcncps/orientation/m2Transmission.asp
What exactly are transmission-based precautions?
Isolation should be the least restrictive possible for the
resident based on current national guidelines
Appendix A
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https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf
Transmission
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Transmission of infectious agents within a healthcare
setting requires 3 elements
1. A source (or reservoir) of infectious agents
2. A susceptible host with a portal of entry receptive to the agent
3. A mode of transmission for the agent
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
The Chain of Infection (transmission)
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Infectious Agent
Bacteria
Virus
Fungi
Reservoir
People
Environment
Equipment & Water
Portal of Exit
Excretion, secretions, skin, and droplets
Means of Transmission
Direct & Indirect Contact
Inhalation
Airborne
Portal of Entry
Mucous Membranes
Respiratory & GI Tract
Broken Skin
Susceptible HostPatient
Staff
Visitor
Recognition of high risk patients
Treatment of underlying disease Immunizations
Hand Hygiene
Personal HygieneTransmission Based Precautions Aseptic Technique
Wound/catheter care
Hand Hygiene
Transmission based precautions Environmental Hygiene
Hand Hygiene,
Control of Excretions & secretions Proper attire
Education
Environmental Hygiene Disinfection and Sterilization
HCW
Breaking the chain of transmission
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Equipment cleaningHand Hygiene Compliance with Precautions
Three basic routes of transmission
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❑ Contact❑ Direct
❑ Indirect
❑ Droplet❑ Larger; don’t travel long distances, not infective over time
❑ Spatial separation (≥ 3 feet)
❑ Airborne❑ Smaller; infective over time and distance
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Elements of transmission-based precautions
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• Hand Hygiene
• Gown
• Gloves
Contact Precautions
• Hand Hygiene
• MaskDroplet Precautions
• Hand Hygiene
• Negative pressure room
• PAPR/N-95 Respirator mask
Airborne Precautions
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Contact Precautions
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“Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are
spread by direct or indirect contact with the patient or the patient’s environment.”
Healthcare personnel caring for patients on contact precautions MUST wear an isolation gown and gloves/personal protective equipment (PPE) for all interactions (that may involve contact with the patient or potentially contaminated areas in the patients environment)
Donning (putting on) of PPE must occur immediately prior to entry
Doffing (removing) PPE must occur immediately prior to exiting
ANYONE ENTERING THE ROOM MUST COMPLY WITH PRECAUTIONS
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
PPE Donning
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Ensure staff safety by having sufficient
supplies and by being properly trained
with those supplies. Inconsistency was
witnessed during the Ebola response
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
PPE Doffing
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file:///C:/Users/mhule/AppData/Local/Microsoft/Windows/INetCache/IE/E9B9P01K/PPE-Sequence.pdf
Wearing PPE
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Transmission-based precaution audits
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✓ Compliance with transmission-based
precautions should be audited
✓ Auditing offers opportunity for real-time
education
✓ 100% compliance required
Droplet Precautions
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Droplet Precautions are intended to prevent transmission of
pathogens spread through close respiratory or mucous membrane
contact with respiratory secretions.”
“Pathogens requiring droplet precaution do not remain infectious over long
distances in a healthcare facility and so do not require special air handling and
ventilation to prevent droplet transmission.”
• Don face mask (NOT N-95 respirator) prior to entering patient room
• Spacial separation ≥ 3 feet
• Place face mask on patient for transport outside of room
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
Airborne Precautions
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“Airborne Precautions prevent transmission of infectious agents that
remain infectious over long distances when suspended in the air
(measles, chicken pox, TB)”
Patient must be placed in an airborne isolation infection room (AIIR): this
is a single-patient room equipped with special air handling and ventilation
capacity that complies with specific regulatory guidelines:
• monitored negative pressure relative to the surrounding area
• 6 or 12 air exchanges/hour
• Air exhausted directly to the outside or recirculated through a
HEPA filtration system before return
• Door MUST remain closed
• Staff must wear N-95 respirator mask or PAPR
• Visitors entering must wear surgical mask
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
So what’s missing in this discussion ?
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➢ Apply to all patients receiving care in healthcare facilities, regardless of their diagnosis or presumed infection status
➢ Designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infections
➢ Under standard precautions, blood and body fluids of all patients are considered potentially infectious
Standard Precautions
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Standard Precautions
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Standard Precautions combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous
membranes may contain transmissible infectious agents. 2007 HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
“Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status.”
• Hand Hygiene
• Use of gowns, gloves, face shields, eye protection
• Safe injection practices
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Laboratory Services
Tests available and normal ranges of available tests
Turnaround time
Reporting of results
Specimen collection, holding, and transport: high quality specimen
required to produce high quality results
Urine
Stool
Wound
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The IP must be knowledgeable about available laboratory services
Are you familiar with PCR testing?
Schweon, SJ , et al 2013
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Environment of Care
Outbreak Investigation
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Outbreak Investigation
An outbreak should be suspected any time the number of cases of an infection
exceeds the normal baseline
Any time a single case of an unusual or highly contagious infection presents (TB,
E. Coli 0157, Salmonella, Influenza)
Three or more cases of clinically significant, facility acquired infections caused
by the same organisms occurring in the same general area within a 7-day
period.
Twice the average number of the clinically significant, facility acquired
infections caused by the same organism per month observed for 3 consecutive
months.
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Outbreak surveillance is a high priority in the LTC setting.
What is considered an outbreak?
Pathway Health Services Infection Prevention and Control Resource Manual 2017
Outbreak investigation process
Establish that an outbreak exists
Monitor ill residents
Prevent transmission (control and contain)
Notify appropriate stakeholders (Staff, administration, local and state HDs)
Work with state and local health departments
Educate (staff, residents, visitors)
Monitor compliance with contain and control interventions (HH, TBPs)
Analyze data, disseminate findings, institute practice changes for identified gaps
Report outbreak and findings to the Quality Assurance Committee
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This is a situation in which you may need to invoke your authority
Pathway Healthcare Infection Prevention and Control Resource Manual 2017
Fingerprinting……..
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https://www.bing.com/images/search?view=detailV2&ccid=RoBI7s2V&id=7867A761D7C2EE7B5CA8AF29E4F4103FC3891FBE&thid=OIP.RoBI7s2Vs h0hZZn11rTWTgHaFM&mediaurl=
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Education
Hand Hygiene: no exceptions
Transmission-Based Precautions: build knowledge
Environment of Care: the environment’s role in resident/staff safety
Employee Health: individual role/responsibility in infection prevention
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Proper education and training of staff is critical in the work of
preventing healthcare-acquired infections.
Staff education must occur:
• Upon hire
• Annually
• As needed throughout the year
Everyone’s Responsibility
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✓ Infection prevention is everyone’s responsibility
✓ One of the primary roles of an IP is to educate
on the role of the HCW and best-practice
CDC Infection Control Resources
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https://www.cdc.gov/infectioncontrol/
References and Resources
1. Bubb, TN, Billings, C, et al (2016). APIC professional and practice standards, American Journal of Infection Control,
44, 745-749
2. Policies and Procedures for Healthcare Organizations: A Risk Management Perspective
https://www.psqh.com/analysis/policies-and-procedures-for-healthcare-organizations-a-risk-management-perspective/
3. Luebbert, PP (2010); Infection Prevention Policy and Procedure Manual for Hospitals. Marblehead, MA: HCPro
4. Schweon, SJ, Burdsall, DP, et al. (2013); Infection Preventionist’s Guide to Long-Term Care. Upper Marlboro, MD: Linemark
5. Lee, TB, Montgomery, OG, et al (2007). Recommended practices for surveillance: Association for Professionals in Infection Control and Epidemiology (APIC), Inc., American Journal of Infection Control, 35(7), 427-440
6. National Action Plan to Prevent Health Care-Associated Infections: Road Map To Elimination April 2013 https://health.gov/hcq/prevent-hai-action-plan.asp
7. Report Guideline for Hand Hygiene in Health-Care Settings MMWR 2002 Vol 51, No. RR-16. https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
8. Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
9. List K: EPA’s Registered Antimicrobial Products Effective against Clostridium difficile Spores
https://www.epa.gov/pesticide-registration/list-k-epas-registered-antimicrobial-products-effective-against-clostridium
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References and Resources
1. Selected EPA-registered Disinfectants
https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants
2. Guidelines for Environmental Infection Control in Health-Care Facilities
https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf
3. U.S. Department of Labor Occupational Safety and Health Administration Regulation (Standards – 29 CFR) Bloodborne
Pathogens -1910-1030 https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051
4. U.S Department of Labor Occupational Safety and Health Administration Bloodborne and Needlestick Prevention https://www.osha.gov/SLTC/bloodbornepathogens/index.html
5. Options for Evaluating Environmental Cleaning https://www.cdc.gov/hai/pdfs/toolkits/environ-cleaning-eval-toolkit12-2-2010.pdf
6. CDC Environmental Checklist for Monitoring Terminal Cleaning https://www.cdc.gov/infectioncontrol/tools/index.html
7. CDC Infection Control resources https://www.cdc.gov/infectioncontrol/
8. CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)
https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html Accessed online June 8, 2018
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Thank you
Leading infection prevention education and training across the Rocky Mountain Region