CIP CONSULTING LLCBASIC AND INTERMEDIATE

INFECTION PREVENTIONMichele Barr, RN, BSN, CIC

Jennifer Perry, RN, BSN, CIC, CPHRM

COMMON SURVEY QUESTIONS

MICROBIOLOGY REVIEW

Basic Infection Prevention Training

STAIN…. WILL IDENTIFY To visualize microbes the lab can stain

them using two common staining methods.

1. Gram stain Gram + Purple Gram – Red

Gram Stain – allows identification of four basic groups of bacteria, and provide early suggestion of empiric antibiotics to use and possible initiation of isolation precautions.

2. Acid-fast stain

STAINS…. Acid-fast stain – The cells of some

bacteria and parasites are impervious to crystal violet and other dyes, so heat or detergents are used to force dye into this type of cell.

If smear +, look closely at the patient to determine if airborne isolation is needed.

1. S/S of TB?2. Look at most recent chest x-ray.

HOW ARE MICROBES CULTURED?

• Nutrient – type of plate• Optimal temperature - 35 – 37 degrees

C.• Atmosphere – does the microbe need

oxygen or carbon dioxide?• Collection – (Do you have a specimen

collection policy? Check with lab, and educate your people)

• Tissue culture – Some viral pathogens are more difficult to grow than bacteria, so non culture methods are used for their identification.

MIC STUDIES (MINIMUM INHIBITORY CONCENTRATION STUDIES)

MIC studies help determine antimicrobial susceptibility to antibiotics.

The lowest concentration of an antimicrobial that will inhibit the visible growth of a microorganism after incubation.

(examples of disk diffusion)

Other methods to determine MIC are broth dilution, E-test, and automated systems.

MIC The zone sites are looked up on a

standardized chart to give a result of 1. Sensitive2. Intermediate3. Resistant

The charts have a corresponding column which gives the minimum inhibitory concentration for that drug.

(Example of E-test)

R, I, S, DESIGNATIONS

For instance this culture report – the Ampicillin zone of inhibition was > 32, according to the CLSI guidelines that the lab uses, that zone of inhibition should be reported as “R”

ANTIBIOGRAM

Done annually by the Microbiology lab. Helps guide antibiotic usage, very

specific to the facility. See example in packet – let’s review!

DIRECT ANTIGEN TESTING• In addition to traditional culturing

methods, there are non-culture methods to detect microbes.

• EIA (Enzyme immunoassay) This procedure uses known specific antibodies which are reacted with a patient specimen. If the unknown patient antigen reacts with the antibody, a visible result can be observed by an enzymatic reaction. (i.e., Influenza A virus antibody, HIV, Strep kit)

• Advantage – rapid testing, agents that are difficult to grow, very specific identification.

DNA PROBES – ANOTHER NON-CULTURING METHOD

Matches DNA from an unknown agent, with nucleic acid segments from a known agent.

Lab frequently uses this method for genital specimens to detect Neisseria gonorrhea and Chlamydia.

PCR – POLYMERASE CHAIN REACTION - ANOTHER NON-CULTURE DETECTION METHOD.

PCR enzymatically enhances the number of nucleic acid molecules to the point that they can be detected.

Used to detect Toxoplasmosis, Enteroviruses, RSV, Pneumocystic carinii, and MTB.

Disadvantage – does not allow the testing of antimicrobial susceptibility testing.

PULSE FIELD GEL ELECTROPHORESIS PFGE technique can be used with

remarkable precision to determine relatedness of isolates from an outbreak…

ENVIRONMENTAL TESTING• “Can we culture the ice machine, I don’t

think they clean them, and I see some black sludge on the dispenser”

• Microbiological environmental testing is not generally recommended. In most cases no standards for comparison exist, so what are you going to do with the information?

• Just clean the ice machine and make sure that there is a scheduled cleaning procedure.

FUNGI

Some are well adapted human pathogens, but most are accidental pathogens that we acquire through decaying organic matter or airborne spores.• Two groups1. Yeasts – i.e. Candida species, Cryptococcus 2. Molds – i.e. Aspergillus species, histoplasma

capsulatum

What type of host plays an important part!Construction on an oncology ward higher risk

than construction on a medical surgical unit.

VIRUSES –

Cannot multiply on their own, need living cells to live and grow

Multiplication occurs in 5 steps1. Attachment2. Penetration3. Replication4. Maturation5. Release

PARASITES Vary in size and complexity, i.e. may be

single celled microscopic protozoa or complex worms over 10 feet in length!

Flukes, tapeworms, roundworms, and ectoparasites such as lice and scabies.

STAPHYLOCOCCUS AUREUS – MOST FREQUENTLY SEEN MICROBE IN HUMAN INFECTIONS.

Gram positive cocci, easily grown in the micro-lab.

Normal flora on skin. Common pathogen – possesses

numerous invasive enzymes which aid its pathogenicity.

Frequently resistant to the penicillin group of antibiotics, including the oxacillin-like agents (methicillin)

STAPHYLOCOCCUS AUREUS – MOST FREQUENTLY SEEN MICROBE IN HUMAN INFECTIONS Commonly seen as “R” to Oxacillin on the culture

report. MRSA – cannot be taken lightly!

MRSA was first isolated in the United States in 1968. By the early 1990s, MRSA accounted for 20%-25% of Staphylococcus aureus isolates from hospitalized patients.

1999, MRSA accounted for >50% of S. aureus isolates from patients in ICUs in the (NNIS) system.

in 2003, 59.5% of S. aureus isolates in NNIS ICUs were MRSA.

PSEUDOMONAS AERUGINOSA• Gram negative bacilli.• Most commonly associated with water.• Frequently a colonizing organism in

patients.• “Opportunistic pathogen”, takes

advantage of lowered defense systems of the host.

• Can be commonly resistant to multiple antimicrobial agents.

• Associated with outbreaks on healthcare systems.

MYCOBACTERIUM TUBERCULOSIS Referred to as an acid fast bacillus. Slow growing (can take 4-6 weeks to

grow) Spread by the airborne route – so if +

acid fast smear +, consider negative airflow.

If smear +, reportable to Oklahoma State health department.

HERPES SIMPLEX VIRUS Not seen by gram staining – it is a virus. Requires tissue culture to grow. Can a Healthcare worker (HCW) with a

herpes lesion on their lip work? What if they work in the NICU or

oncology? What if the HCW has a herpetic whitlow? How do you find the answers? (CDC

healthcare worker guidelines)

BASIC INFECTION PREVENTION TERMINOLOGY

INFECTION VS COLONIZATION WITH NORMAL FLORA• Colonization – presence of

microorganisms with multiplication but without tissue invasion or damage. (urine culture E-coli < 20,000 cfu, patient with no symptoms)

• Infection – entry and multiplication of an infectious agent in the tissues of a host. (urine culture E-coli >100,000 cfu, patient has fever, frequency, dysuria)

EXOGENOUS VS ENDOGENOUS Exogenous organisms are those that

come from outside the host.

Endogenous organisms are those that come from the host’s own flora.

AEROBIC VS ANAEROBIC Aerobic

needs oxygen, Containing oxygen; referring to an organism, environment, or cellular process that requires oxygen.

AnaerobicLacking oxygen; referring to an organism,

environment, or cellular process that lacks oxygen and may be poisoned by it.

OTHER TERMS

ASEPSISFreedom from infection or infectious material.

BACTERIOSTATIC Arresting the growth or multiplication of bacteria. An antibiotic may be classified as a bacteriostatic medication.

WBC COUNT AND DIFFERENTIAL• Normal WBC count is 5,000 – 10,000 • White blood cells originate in the bone

marrow.• Types of WBC1. Phagocytic – ingest and destroy

bacteria, protozoa, cells and cellular debris. (neutrophils, eosinophils, basophils, monocytes, and macrophages)

2. Non-phagocytic – important to immune function and produce antibody. (T and B lymphocytes)

HAND HYGIENE

2003 HAND HYGIENE GUIDELINES

This gentleman insisted his students clean their hands with a chlorine solution between each patient. He practiced in the 1800. Who is he?

A. Oliver Wendell HolmesB. Jack the RipperC. Ignaz SemmelweisD. Joseph Lister

HANDWASHING

• The most important measure you can use to prevent the spread the spread of infection.  

2003 HAND HYGIENE GUIDELINES When washing hands with soap and

water, hands should be rub together vigorously for:

A. 6 secondsB. 15 secondsC. 20 secondsD. 3 minutes

2003 HAND HYGIENE GUIDELINES When hands are visibly dirty or

contaminated with proteinaceous material, hands should be wash with:

A. Antimicrobial soapB. Non-antimicrobial soapC. A chlorine solutionD. Both A and B

2003 HAND HYGIENE GUIDELINES It is not necessary to decontaminate

your hands if you are only touching intact skin.

A. TrueB. False

2003 HAND HYGIENE GUIDELINES Soap dispensers should be refilled:A. When 2/3 fullB. When ¾ fullC. NeverD. Only when completely empty

2003 HAND HYGIENE GUIDELINES Natural nail tip length should be:A. Less than ¼ inchB. Less than ½ inchC. Bitten to nubsD. Nails can be any length as long as they

are natural

2003 HAND HYGIENE GUIDELINES It is not the responsibility of the facility

to provide lotion to the HCW, but the facility should encourage the use of lotion to minimize the occurrence of dermatitis.

A. TrueB. False

2003 HAND HYGIENE GUIDELINES When performing surgical hand

antisepsis one should:A. Remove rings, watches and bracelets

before beginning the hand scrubB. Leave all jewelry on during hand scrub

so you can clean the jewelry and hands at the same time.

C. Remove only items that will be damaged by the water.

HAND WASHING

Wash hands to prevent transfer of microorganisms :

Before & after patient contact After gloves are removedBetween task on the same patient to prevent cross-contamination of different body sites

2003 HAND HYGIENE GUIDELINES If your hands have been exposed to

Bacillus anthracis, you should:A. Wash your hands with antimicrobial

soap B. Wash your hands with non-

antimicrobial soapC. Wash your hands with an iodophorD. A and BE. Cry

CLEAN HANDS ARE HAPPY, HEALTHY HANDS!!!!!

“FOAM IN FOAM OUT”

IT IS DECEMBER!GIVE THE GIFT OF GOOD HEALTH

TO OUR PATIENTS AND YOURSELF!“FOAM IN FOAM OUT”

If visibly soiled, wash with soap, water and friction

HAND HYGIENE COMPLIANCE Who collects the data at your facility? Audit tool (review sample tools) Calculation of Hand hygiene compliance

rates # of “yes” observations/Total # of

observations X 100

Communicate the data to the HCW’s.

HAND HYGIENE COMPLIANCE RATES

Jan-11 Feb-11 Mar-11 Apr-110

10

20

30

40

50

60

70

80

90

100

Monthly hand hygiene rate

Facility Goal

% C

om

pli

an

t w

ith

ha

nd

h

yg

ien

e

Analysis – The April rate increasedTo 92% from 82% due to increasedHand hygiene awareness and Discussion by administration at Facility “Town Hall meeting”.

Action Plan – Continue hand hygienediscussions by administration attown hall meetings andimplement administrative hand Hygiene rounds with IC dept. for increasedawareness.

DR. _______ SAYS…. GOT FOAM???? USE IT! BEFORE AND AFTER PATIENT CARE OR CONTACT WITH THE PATIENT ENVIRONMENT.

Hand hygiene matters!!!!!

Thank you Dr. ____

DR. ___________ IS SENDING SUBLIMINAL MESSAGES DURING ROUNDS….

Infection prevention dept. loves it!Thank you Dr. ______

HAND HYGIENE - KEEP IT FUN!Ideas to keep the ball rolling….• “Glow Germ” at staff meetings• Hand hygiene “huddles”• Hand hygiene videos to show at staff

meetings, orientation, advocate meetings, patient videos.

• Pictures of staff washing hands!http://www.cdc.gov/handhygiene/Patient_materials.html

http://www.hhs.gov/ash/initiatives/hai/training/partneringtoheal.html

http://web.me.com/danielwlieu/Hands/Infection_Prevention_and_Control.html

HAND HYGIENE - KEEP IT FUN!• Mandatory annual hand hygiene

educationhttp://www.cdc.gov/handhygiene/training/interactiveeducation/

• Small prizes or tickets for free food when you catch a HCW performing hand hygiene. (OFMQ – “thank you pocket card, be a life saver pocket card”

HAND HYGIENE - KEEP IT FUN!• Wear Hand hygiene apron when out on IC rounds,

make some for hospital managers.

• iScrub - iScrub Lite is available free from the iTunes App Store. Search for iScrub in the App Store

• Face book/Twitter

• Web page buttons –

DISEASE TRANSMISSION AND

ISOLATION

Basic Infection Prevention Training

INFECTIOUS DISEASE PROCESS Exposure

Incubation Period (time from exposure to onset of symptoms)

Onset of symptoms/clinical disease

Recovery, disability or death

CHAIN OF INFECTION Infectious agent Reservoir Portal of Exit Means of Transmission Portal of entry Susceptible Host

STANDARD PRECAUTIONS

Apply standard precautions to all:PatientsContaminated equipment, surfaces & materials

Use judgment to determine when personal protective equipment is necessary

STANDARD PRECAUTIONS

Wear face mask with eye shield

or mask & eye protection during

patient care activities that may

generate splashes or sprays of

blood or body fluids

STANDARD PRECAUTIONS

Prevent injury when using & disposing of needles or other contaminated sharp instruments

Immediately dispose of used sharps in puncture-resistant container

Do not recap using two-handed technique

STANDARD PRECAUTIONS

Keep work area clean

Minimize the splashing or spraying of blood or body fluids while performing procedures

Clean up spills of blood or body fluids promptly using gloves & approved disinfectant

STANDARD PRECAUTIONS

Remove gloves, gown, mask, eye protection before leaving work area

Gloves, gown, mask are not worn in halls, elevators, cafeteria, or gift shop

STANDARD PRECAUTIONS

Clean re-useable equipment

between patients to prevent

transfer of microorganisms to

other patients, staff

or environment

STANDARD PRECAUTIONS

Use:MouthpiecesResuscitation bagsVentilatory device

As an alternative to mouth-to-mouth resuscitation methods

CONTACT ISOLATION STANDARD PRECAUTIONS

Patients infected or colonized with:Epidemiologically important microorganisms

Transmitted by direct contact with the patient

Indirect contact with room surfaces or patient care items

CONTACT ISOLATION STANDARD PRECAUTIONS

Patient may have:IncontinenceDiarrheaIleostomyColostomyWound drainage not contained by dressings

CONTACT ISOLATIONSTANDARD PRECAUTIONS

Wear gloves and gown before entering room

Change gloves after contact with infective material

Remove gloves before leaving room & wash hands

Avoid contact with contaminated surfaces while leaving room

CONTACT ISOLATIONSTANDARD PRECAUTIONS

Limit transport to essential purposes

Communicate precautions to appropriate departments

Maintain Contact Isolation

CONTACT ISOLATIONSTANDARD PRECAUTIONS

Dedicate non-critical equipment to Contact Isolation patient

Clean & disinfect equipment between patients to avoid spread of microorganisms to other patients, staff, or environment.

Upcoming slide – when should contact isolation be discontinued????

DROPLET ISOLATION STANDARD PRECAUTIONS

Patients infected or colonizedwith

Microorganisms Transmitted by droplet from coughing, sneezing, talking, or performing procedures

DROPLET ISOLATION STANDARD PRECAUTIONS

Wear mask when working within three feet of patient

Limit transport to essential purposes

Minimize dispersal of droplets by masking patient if possible during transport

AIRBORNE ISOLATION STANDARD PRECAUTIONS

Patients infected with:

Pulmonary tuberculosis (TB)

Rubeola (measles)

Varicella (chicken pox)

AIRBORNE ISOLATION STANDARD PRECAUTIONS

Place patient in a negative air-flow isolation room

Keep room doors closed & patient in room

Limit transport to essential purposes & minimize dispersal of droplets by masking patient

AIRBORNE ISOLATION STANDARD PRECAUTIONS

Tuberculosis - wear particulate respirator to enter room

Varicella & Rubeola - susceptible care givers not to enter room if immune caregivers are availableSusceptible = maskImmune persons = no mask

CDC - MANAGEMENT OF MULTIDRUG-RESISTANT ORGANISMS INHEALTHCARE SETTINGS, 2006

General recommendations for all healthcare settings independent of the prevalence of multidrug resistant organism (MDRO) infections or the population served.

Administrative measuresMake MDRO prevention and control an

organizational patient safety priority.

CDC - MANAGEMENT OF MULTIDRUG-RESISTANT ORGANISMS (MDRO’S) IN HEALTHCARE SETTINGS, 2006

In healthcare organizations that outsource microbiology laboratory services (e.g., ambulatory care, home care, LTCFs, smaller acute care hospitals), specify by contract that the laboratory provide either facility-specific susceptibility data or local or regional aggregate susceptibility data in order to identify prevalent MDROs and trends in the geographic area served.(363) Category II

MDRO’S In ambulatory settings, use Standard

Precautions for patients known to be

infected or colonized with target MDROs, making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes and bags. Category II

MDRO’S

Discontinuation of Contact Precautions. No recommendation can be made regarding when to discontinue Contact Precautions. Unresolved issue

Discussion

MDRO’S Intensified interventions to prevent

MDRO transmission. List combinations of control elements

that were selected and have been shown to reduced MDRO transmission rates in a variety of healthcare settings.

Active surveillance cultures Decolonization

APPENDIX A, ISOLATION GUIDELINE In packet, it is an A-Z reference that

details what type of isolation is needed for specific diseases and conditions.

Scabies Lice Influenza C-diff TB

C- DIFFICILE A spore forming anaerobic gram positive

bacilli which are particularly virulent because of the toxins they produce.

On April 11, 2005 at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA) infectious disease experts presented information concerning a new highly toxic strain of C- Diff. (NAP 1 strain_

C – DIFF PREVENTION Hand Hygiene – soap, water, and

friction. Alcohol hand foam is not effective in

killing the spores of C – Diff. CDC states in outbreak settings or settings with higher rates of c-diff, use hand washing only.

Contact Isolation – gloves and gowns when entering the room of patient with c-diff. The spores can be transmitted from person to person, as well as by persons touching objects (side rails, nurse call light) contaminated with the spores.

C – DIFF PREVENTION Use of hypochlorite disinfectant (bleach)

has been found to be more effective in killing the C-diff spores upon patient discharge.

Educate Health Care Workers

Prudent Antibiotic use.

TUBERCULOSIS Infectious disease caused by bacteria. Usually affects lungs. Other body parts can be affected.

TRANSMISSION Spread through air (droplet nuclei). Sneezing, coughing, speaking, singing

by individual with TB disease. Sharing the same air space with persons

with infectious TB disease.

SYMPTOMS OF TB Weak Weight loss Fever Night sweats Cough Chest pain Coughing up blood

TB INFECTION VS. TB DISEASE Have the

organism in their body.

No symptom.

Bacteria is inactive.

Have symptoms.

Are sick.

Bacteria is active and multiplying.

MULTI DRUG RESISTANT TB (MDR TB) One or more drugs can no longer kill TB

bacteria. High risk persons for MDR TB:

Persons who did not take their TB meds. Immunocompromised persons, i.e. cancer,

HIV infection.Persons previously treated for TB with an

ineffective regimen of drugs.

TREATMENT FOR TB

TB drugs for TB disease.

If infected may need to take TB drugs to prevent TB disease.

TB drugs are taken for 6-12 months.

REPORTABLE DISEASES IN OKLAHOMA Discuss Oklahoma Reportable Diseases Review PHIDDO system (open OSDH

website to review with the group) How do I get access to the system to

report?

http://www.ok.gov/health/Disease,_Prevention,_Preparedness/Acute_Disease_Service/Disease_Reporting/What_to_Report/index.html

INFECTION CONTROL RISK ASSESSMENTS

Basic Infection Prevention Training

ICRA’S

Annual Multi-disciplinary Risk Assessment – done prior to your annual IC surveillance plan review. Also review Example IC surveillance plan.

Construction Risk Assessment (review form)

TB Risk assessment (review form)

Multi-drug resistant Risk Assessment (Annual Antibiogram, historical date, data from SSI organisms, C-diff lab ID event)

Surveillance Methods1. Facility wide2. Periodic (Quarterly)3. Targeted (unit specific)4. Outbreak Thresholds

Collecting Relevant Data Managing Data Analyzing and Interpreting Data Communicating Results

COMPONENTS OF SURVEILLANCE

IN GOD WE TRUST, ALL

OTHERS BRING DATA

Using Definitions for data collectionDetermine the population or event to studyWrite your definition or use an established

one e.g. CDC NHSNApply the definition consistentlyWrite or find a data collection tool

Concurrent or retrospective data collection

COLLECTING RELEVANT DATA

Review your data collection for accuracy and effectiveness Check for flaws in the dataCheck your data sources (patient based, lab

based, post discharge surveillance letters, post op calls)

Validate if you make changes

COLLECTING RELEVANT DATA

Record data systematicallyBe consistent (data collection tool)Flow sheet or line listCan others look at the data and understand

it Think about how you may want to

manipulate or analyze the data laterComputer systemSoftware for analysis (Excel)

MANAGING DATA

Analyzing is the reason we do surveillanceAnalyze promptly to identify needs for

intervention Compare Data

Same definitionsSame patient population, risk group

Proper denominatorDevice DaysPatient DaysSurgical Cases

ANALYZING DATA

Compare or BenchmarkHistorically against your own ratesAgainst other hospitals of similar sizeNational Rates (Review NHSN report as a

group) Interpretation and Significance

Use of statisticsData interpretation pit fallsReporting Data

ANALYZING DATA

STATISTICSStatistics can summarize and simplify large

amounts of numerical data.Using statistics one can draw conclusions

about data.Statistics can help communicate findings

clearly and meaningfully to others.Statistics can not prove anything- estimates

are normally presented in probabilistic terms (e.g. we are 95% sure ...)

Statistics can not make bad data better - "garbage in, garbage out"

STATISTICS Statistics may reveal underlying

patterns in data not normally observable.

If used correctly, statistics can separate the probable from the possible

STATISTICS Infection Preventionists routinely use

statistical methods to:Prepare reports for committee Identify problems or outbreaksMonitor the impact of interventions Identify areas for improvement

STATISTICS Some commonly used statistical

methods in health care are:Measure of central tendency

Mean Median Mode

Measures of Dispersion Standard Deviation Range Variance

STATISTICSMeasures of frequency

Incidence rate Prevalence rate Ratio Proportion

Statistical process control Control Charts

P-VALUE What is "Statistical Significance" (p-

value)?The statistical significance of a result is the

probability that the observed relationship or a difference in a sample occurred by pure chance ("luck of the draw"), and that in the population from which the sample was drawn, no such relationship or differences exist. Using less technical terms, we could say that the statistical significance of a result tells us something about the degree to which the result is "true" (in the sense of being "representative of the population").

P-VALUE Typically, in many sciences, results that

yield p .05 are considered borderline statistically significant, but remember that this level of significance still involves a pretty high probability of error (5%). Results that are significant at the p  .01 level are commonly considered statistically significant, and p  .005 or p  .001 levels are often called "highly" significant.

This is what adjusts for severity of illness. Should be procedure-specific. (Review NHSN SSI Data submission form)

Based on 3 factors collected on all surgical patients:Length of surgeryAmerican Society of Anesthesiology (ASA)

ScoreSurgical wound classification

SURGICAL SITE RISK ADJUSTMENT

STANDARD INFECTION RATIO (SIR) What is a standardized infection ratio (SIR)? The standardized infection ratio (SIR) is a summary measure used to

track HAIs at a national, state, or local level over time.  The SIR adjusts for the fact that each healthcare facility treats different types of patients.  For example, the experience with HAIs at a hospital with a large burn unit (a location where patients are more at risk of acquiring infections) cannot be directly compared to a facility without a burn unit. 

The method of calculating an SIR is similar to the method used to calculate the Standardized Mortality Ratio (SMR), a summary statistic widely used in public health to analyze mortality data. In HAI data analysis, the SIR compares the actual number of HAIs in a facility or state with the baseline U.S. experience (i.e., standard population), adjusting for several risk factors that have been found to be most associated with differences in infection rates.

In other words, an SIR significantly greater than 1.0 indicates that more HAIs were observed than predicted, accounting for differences in the types of patients followed; conversely, an SIR of significantly less than 1.0 indicates that fewer HAIs were observed than predicted.  Reference -

http://www.cdc.gov/hai/QA_stateSummary.html#6

FIRST STATE-SPECIFICHEALTHCARE-ASSOCIATED INFECTIONS SUMMARY DATA REPORT

January – June, 2009

SIRSIR = Observed (O) HAIs

Expected (predicted) (E) HAIs

To calculate O, sum the number of HAIs among a reporting entity

To calculate E, requires the use of the appropriate aggregate data from a standard population (NHSN)

Communicate/Report Data

Look for trends (Analysis)

Implement Changes (Action plan)

Monitor, Track and report Effect of Interventions

WHAT DO YOU DO WITH THE DATA?

How to reportChart

Pie Chart Bar Charts

Graph Line Graph Control Chart

COMMUNICATING DATA

Title Time Period Location Values Unit Labels Definitions

MAKE THINGS SELF-EXPLANATORY

ANTERIOR INTERBODY (22554) INFECTION RATE 2013

• Analysis:– No SSI

identified since July case

• Action Plan: Continue to

do surveillance and discuss prevention measures

ROLES , CONCEPTS, AND ACTIVITIES VITAL TO A

SUCCESSFUL PROGRAM

ROLES VITAL TO PROGRAM SUCCESS• The Infection Preventionist has several

roles that are vital to the success of the program:– IP expert during surveys

• Be familiar with survey process• Stay prepared• Keep up-to-date on survey hot topics• Know your policy and procedures• If you don’t know, DON’T make it up!!!

ROLES VITAL TO PROGRAM SUCCESS• Collaborator with diverse departments– Maintenance

• ICRA• Water/Mold remediation

– Housekeeping• Cleanliness issues• Proper Chemical use and selection• In-services

– Employee Health• Work Restrictions• Education on Communicable Diseases

ROLE OF THE ICP Infection Prevention and control expert Mentor staff Role model for Infection Prevention and

Control Resource for the staff Design and implement effective

programs

ROLE OF THE ICP Liaison to public health Liaison in emergency preparedness Promote zero tolerance for HAIs Collect and analyze infection data Develop and review policies Consult on infection risk assessments,

prevention and control strategies

ROLE OF THE ICP Educate and direct interventions to

reduce infection risk Implement change mandated by

regulatory bodies Evaluate Product changes Evaluate Chemical changes Development of IC Surveillance plan and

annual evaluation Read and interpret guidelines

COMMITTEEAnnouncements that need to be recorded in

the minutesNews related to Infection PreventionUpdates from any construction projectsReports from regular surveillanceReports from Employee HealthReports from Dialysis water culturesReports from IC Rounding

ROUNDS One of the most important activities for

an IP is Rounding. Through rounding the IP:Develops relationships with staff Identifies educational opportunities Identifies breaches in practice Identifies cleaning and disinfection issues Identifies opportunities for improvement

Review rounding tool(s)

ESSENTIALS Join EPIC

Dues $25 annually Text books

APIC ManualControl of Communicable Diseases ManualThe Pink Book

Websites

FEDERAL AND STATE REGULATIONS

Basic Infection Prevention Training

STATE HEALTH REGULATIONS FOR HOSPITALS CHAPTER 667 Employee and/or worker Health

examinations chapter 667-5-4Pre employment exams for

Each employee full or part-time with or without patient care responsibilities

Physicians Emergency medical personnel Students Lab and pharmacy workers Volunteers and administrative staff Food service workers

CHAPTER 667

The pre employment health exam will include but not be limited to:

Immunization History Born before 1957 Born in 1957 or later Serologic screening

Tb Skin Testing2-step TestingBCG

Hepatitis B

CHAPTER 667 (e) Annual influenza vaccination program. Each hospital shall have an annual

influenza vaccination program consistent with the recommendations of the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices that shall include at least the following:

(1) The offer of influenza vaccination onsite, at no charge to all employees and/or workers in the hospital or acceptance of documented

evidence of current season vaccination from another vaccine source or hospital; (2) Documentation of vaccination for each employee and/or worker or a signed declination

statement on record from each individual who refuses the influenza vaccination for other than medical contraindications; and (3) Education of all employees and/or workers about the following:

(A) Influenza vaccination; (B) Non-vaccine influenza control measures; and (C) The symptoms, transmission, and potential impact of influenza.

(4) Each hospital influenza vaccination program shall conduct an annual evaluation of the program including the reasons for nonparticipation.

(5) The requirements to complete vaccinations or declination statements for each employee and/or worker may be suspended by the

hospital's medical staff executive in the event of a shortage of vaccine as recognized by the Commissioner of Health.

CHAPTER 667 TB Skin Test

Based on annual TB risk assessment

Communicable Diseases

CHAPTER 667

A file shall be maintained for each employee containing the results of the evaluations and examinations and the dates of illness related to employment.

CHAPTER 667

These are for Credentialed non-employees (physicians/mid-level providers)Such workers provide evidence of

immunization history and TB skin test consistent with the TB Control Program. It is in the form of a signed attestation statement.

CHAPTER 667

667-13-1 Infection Control ProgramProvide a sanitary environmentAvoid sources and transmission of infectionProvide written policies and procedures for:

identifying, reporting, evaluating, and maintaining records of infection among patients and personnel.

Ongoing review and evaluation of all aseptic, isolation and sanitation techniques employed in the hospital

Development and coordination of training programs in infection control for all hospital personnel.

CHAPTER 667

667-13-2 Infection Control CommitteeShall meet at least quarterlyAttendees – at least one person with

appropriate background who can speak for the relevant department(s) attends the meeting or is consulted.

CHAPTER 667

667-13-3 Policies and ProceduresThe infection control committee shall

evaluate, revise, and approve the type and scope of surveillance activities at least annually

Policies and Procedures shall be reviewed periodically and revised as necessary

CHAPTER 667

667-13-4 Policy and Procedure contentRecord of all reported infections generated

by surveillance activitiesHandling and disposal of biomedical wasteRelated to admixture and drug

reconstitution Indications for and type of isolation for each

specific diseaseA definition for nosocomial infectionDesignation of an Infection Control officer

CHAPTER 667

A program of orientation of new employees and other workers including physicians

A program of continuing education concerning infection control

CMS REGULATIONS (STATE OPERATIONS MANUAL)

482.42 Infection ControlProvide Sanitary environment to avoid

sources and transmissions of infections and communicable diseases.

Must have active program for the prevention and control and investigation of infections and diseases.

A person or persons must be designated as the Infection Control officer

CMS REGULATIONS• Log of incidents related to infections and

communicable diseases (review sample log)

• The CEO, medical staff and director of nursing MUST ensure that there are hospital programs and training related to infection control and they are responsible for the implementation of successful corrective action in problem areas

• Review the 16 page CMS IC surveyor audit tool.

MRSA BACTEREMIA & C- DIFF LAB ID EVENT

WHAT ABOUT HCW INFLUENZA?

CMS Mandatory Reporting

OSHA

Requires Bloodborne Pathogens Exposure Control Plan that must include the following: PurposeScopeDefinitionsExposure determination

OSHAControl Measures

Engineering Controls Work Practice Controls PPE (personal protective equipment)

Hepatitis B vaccinationPost exposure evaluation and follow-upSharps Injury logTraining and EducationRecordkeeping

OSHA Bloodborne pathogens 1910.1030 29CFR www.osha.gov/pls/oshaweb/owadisp.show_documen

t?p_table=STANDARDS&p_id=10051

1910.1030(c)(1)(iv)(B) Document annually consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure.

1910.1030(c)(1)(v) An employer, who is required to establish an Exposure Control Plan shall solicit input from non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls and shall document the solicitation in the Exposure Control Plan.

OSHA• TB Control plan and Risk Assessment• http://www.cdc.gov/tb/pubs/mmwr/

Maj_guide/Control_Elim.htm• Risk Assessment Appendix B must be

done annually.– Low– Medium– High

• Contact Investigation

THE IP IN THE OR

Intermediate Infection Prevention Training

Collaboration = key to success!!!

INFECTION PREVENTION IN THE OR

Use an audit tool to document the rounds.

How often should rounds be done? Who should do the rounds? Communicate the findings found during

OR rounds. Learn from OR co-workers!!! Thank

them Consider implementing an “OR best

practices” campaign, using AORN standards and recommended practices.

ROUNDS IN THE OR

Ensure that the patient gets appropriate pre-op antibiotic within an hour of “cut time.”

Keep patients warm, must be ≥ 96⁰ F

Apply skin prep according to manufacturer instructions, allow to dry before draping.

Hand hygiene before and after patient care.

Limit “traffic” in and out of room during surgical procedures.

“BEST PRACTICES” TO HELP PREVENT SURGICAL SITE INFECTIONS”

Be sure that the central line “insertion bundle” is used when central lines are placed. (Evidence based practice)

1. Hand hygiene prior to line insertion

2. Use Chlorhexadine skin prep and allow to dry.

3. Avoid the femoral site (it is associated with more bacteria)

4. Those inserting the line and any personnel assisting must wear sterile hat, mask, gown and large drape used to cover the patient during placement.

5. Assess the line every shift to ensure it is still needed, if not get an order to remove.

Use alcohol to “scrub the hub” before accessing the line for medications or blood draws.

BEST PRACTICES TO PREVENT CENTRAL LINE ASSOCIATED BACTEREMIA

2011 AORN recommended practices for preoperative patient skin antisepsis, pages 361-377.

Pre-op shower? What are your facilities policies? Is there a place to document?

Pre-op antibiotic given by anesthesia personnel within 60 minutes prior to incision

What are your SCIP #’s on this measure? How often are the surgery staff and

physicians informed of their SCIP data?

PRE-OP ROUNDS…TAKE A LOOK

OR appears clean – 2011 AORN recommended practices “Environmental cleaning”, pages 237-249.

OR facility in good repair Sub-sterile area appears clean Scrub sink area appears clean Interim (between cases) cleaning

performed Terminal cleaning

AUDIT TOOL, “OR ENVIRONMENT”

Ventilation requirements: 2011 AORN recommended practices, “Safe environment of care”, pages 218 – 220.

Positive pressure how often is this checked?

Doors closed during the case? Temperature between 68 and 73

degrees F Humidity monitored? ACH monitored? (OR, PACU, Sterile

storage)

“OR ENVIRONMENT”

During rounds, how are you seeing hands being cleaned before and after patient care?

1. Soap and water? 2. Is an alcohol product used if hands are

not visibly dirty?3. Who collects hand hygiene data for

your surgical area?4. How often are the results

communicated?5. Hand lotion, what is the staff using?

HAND HYGIENE

It is all about the hands!!!!!Keep them healthy

1. Short natural nails2. Remove fingernail polish if chipped3. Use hospital approved lotion4. Use soap water and friction for at least

15 seconds when washing

OR INFECTION PREVENTION “BEST PRACTICES”

Is the traditional surgical hand scrub being used?

If so, how long is the scrub? 3 or 5 minutes?

If your facility has moved to an alcohol based antiseptic surgical hand rub, are they following the manufacturers instructions for use?

Consider annual competency…

SURGICAL HAND SCRUB

OR “BEST PRACTICE” ARE YOU APPLYING THE AVAGUARD CORRECTLY?THE 3M MANUFACTURE INSTRUCTIONS SAY……

Apply to clean dry hands, use nail pick to clean under nails with first hand wash of the day.

Pump # 1

Dispense one pump (2 ml) into the palm of one hand. Dip fingertips of the

opposite hand into the hand prep and work under fingernails. Spread

remaining hand prep over the hand and up to just above the elbow.

Pump # 2

Dispense one pump (2 ml) and repeat procedure with opposite hand.

Pump # 3

Dispense final pump (2 ml) of hand prep into either hand and reapply to all aspects of both hands up to the wrists.

Allow to dry. Do not use towels!Applying correctly matters.

2011 AORN recommended practices, “Hand Hygiene”, pages 73-85.

Artificial nails should not be worn by healthcare personnel in the operative environment, any fingernail enhancement or resin bonding product is considered artificial.

Rings Watches and bracelets

NAILS AND JEWELRY…..

Remind co-workers and physicians of following opportunities for hand hygiene!!!!

Decontaminate hands after –

Contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient)

If moving from a contaminated-body site to a clean-body site during patient care.

After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

MARCH INFECTION PREVENTION “BEST PRACTICES”

Sterile items left open no > than 30 minutes prior to patient entering room

Scrubbed persons maintain sterility of sterile gown, gloves, supplies

Hands remain above waist Sterile field constantly monitored Items introduced into sterile field

opened, dispensed, transferred by methods to maintain sterility/integrity

Items/devices dropped below level of the OR table are considered contaminated

STERILE FIELD – 2011 AORN RECOMMENDED PRACTICES FOR MAINTAINING A STERILE FIELD, PAGES 87-93

All personnel moving in/around sterile field do so in manner to maintain sterility

Adjacent sterile fields not at disparate heights

Separation of sterile team from non-sterile team maintained

Staff do not turn back to sterile field Traffic in and out of room kept to

minimum

STERILE FIELD

Safe injection practices used for IV tubing, fluids, medication vials?

CMS surveyor tool – “Injection Practices”

“Observations are to be made of staff who prepare and administer medications and perform injections (e.g., anesthesiologists, certified registered nurse anesthetists, nurses).”

Link to the 16 page surveyor tool - http://totalsol.vo.llnwd.net/o29/data/1080/infection_control_surveyor_worksheet.pdf

ANESTHESIOLOGY:

Aseptic practice used for all invasive procedures: (epidurals, blocks, IV insertion)

Anesthesia cart appears clean, who cleans after each case?

Cleans shared equipment (e.g., stethoscope) between cases

ANESTHESIOLOGY:

Keep patients warm during surgery – the recommendation is to keep patients ≥ 36.0 C (96.8 F) Remind anesthesia to monitor during surgery.

Date all multi-dose vials when you open, they are only good for 28 days after opening and maybe sooner if manufacturer recommends…

JANUARY INFECTION PREVENTION “BEST PRACTICES”

Appropriate eye protection used Sharps containers not overfull Shoe covers/boots if indicated Surgeons/first assistants double gloved

(recommended) Circulators wear gloves for handling

contaminated items. Performs hand hygiene after glove removal

Sharps are passed in a basin or by using neutral zone rather than by hand

Sharps safety devices

OSHA/BLOOD BORNE PATHOGENS

OR “BEST PRACTICES”

A fresh surgical mask should be worn for every procedure. Literature shows that after 4 hours surgical masks had decreased efficacy.

Surgical masks should be discarded after each procedure.

Surgical masks should not be worn hanging down from the neck.

(AORN 2011 perioperative standards and recommendations)

Patients with communicable disease handled appropriately

Sterile team removes gloves and performs hand hygiene at end of case

Policies regarding “Immediate Use Sterilization” are followed

Personnel appear free from communicable disease (no open skin lesions on hands/face)

Observers comply with “Observers Protocol” for Surgical Services

Surgical attire (AORN, CDC, SHEA) Clean, sterile, and soiled items are kept separate Instruments are kept moist during cases.

GENERAL INFECTION CONTROL:

INFECTION PREVENTION “BEST PRACTICES” FOR THE OR*INSTRUMENTS SHOULD BE KEPT FREE OF GROSS SOIL DURING SURGICAL PROCEDURES.*REMOVING GROSS SOIL AND MOISTENING SOIL AT THE POINT OF USE IMPROVES THE EFFICIENCY AND EFFECTIVENESS OF DECONTAMINATION.

1. Wipe instruments as needed with sterile surgical sponges moistened with sterile saline during the procedure to remove gross soil.

2. Instruments with lumens should be irrigated with sterile water as needed through the surgical procedure.

2011 AORN Standards and recommended practice, “Care of instruments”, pg 431

Yes!!!!!And there are audit tools for that too….

http://www.infectionpreventiontools.com/

http://www.ofmq.com/hai

http://www.ascquality.org/Library/sterilizationhighleveldisinfectiontoolkit/Sterilization%20Audit%20Checklist%20SPSmedical.pdf

http://www.ascquality.org/SterilizationHighLevelDisinfectionToolkit.cfm

www.cipconsultingllc.com

DO I NEED TO GO INTO THE INSTRUMENT PROCESSING AREA?

SEE YOU TOMORROW

THANK YOU!!