infection prevention program overview

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

Leading infection prevention education and training across the Rocky Mountain Region

LTC IP Program Checklist


✓ 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


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


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


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


➢ 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


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


© 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


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


Resources

Additional Activities


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


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


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


Long-term care specific IPCP


This policy pulls in the Quality

Assurance Committee

Surveillance


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


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:


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


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


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

http://www.pathwayhealsth.com/

Hand Hygiene


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


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


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)


Guideline for Hand Hygiene in Health-care settings. MMWR 2002; vol. 51, no. RR-16.

Hand hygiene audit tool


Schweon, SJ, et al Infection Preventionist’s Guide to Long-Term Care APIC 2013

Joint Commission and Hand Hygiene


Hand Hygiene Programs


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


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.


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


https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf

Transmission


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)


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


Equipment cleaningHand Hygiene Compliance with Precautions

Three basic routes of transmission


❑ 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


Elements of transmission-based precautions


• Hand Hygiene

• Gown

• Gloves

Contact Precautions

• Hand Hygiene

• MaskDroplet Precautions

• Hand Hygiene

• Negative pressure room

• PAPR/N-95 Respirator mask

Airborne Precautions


Contact Precautions


“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


PPE Donning


Ensure staff safety by having sufficient

supplies and by being properly trained

with those supplies. Inconsistency was

witnessed during the Ebola response


PPE Doffing


file:///C:/Users/mhule/AppData/Local/Microsoft/Windows/INetCache/IE/E9B9P01K/PPE-Sequence.pdf

Wearing PPE


Transmission-based precaution audits


✓ Compliance with transmission-based

precautions should be audited

✓ Auditing offers opportunity for real-time

education

✓ 100% compliance required

Droplet Precautions


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


http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf


Airborne Precautions


“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




So what’s missing in this discussion ?


➢ 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


Standard Precautions


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


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


The IP must be knowledgeable about available laboratory services

Are you familiar with PCR testing?

Schweon, SJ , et al 2013


Environment of Care


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.


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


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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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


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


✓ 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


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


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



https://health.gov/hcq/prevent-hai-action-plan.asp

https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf


https://www.epa.gov/pesticide-registration/list-k-epas-registered-antimicrobial-products-effective-against-clostridium

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


https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants

https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051

https://www.osha.gov/SLTC/bloodbornepathogens/index.html

https://www.cdc.gov/hai/pdfs/toolkits/environ-cleaning-eval-toolkit12-2-2010.pdf

https://www.cdc.gov/infectioncontrol/tools/index.html

https://www.cdc.gov/infectioncontrol/

https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

Thank you


infection prevention program overview

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