infection prevention and control handbook for hospitals - joint

Technical Editor: Susan M. Slavish, B.S.N., M.P.H., C.I.C.

The Joint Commission

Infection Prevention and ControlHandbook for Hospitals

The Joint Commission Infection Prevention and Control Handbook for Hospitals

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Technical Editor: Susan M. Slavish, B.S.N., M.P.H., C.I.C.Senior Editor: Maria R. Aviles, M.A.Project Manager: Meghan AndersonManager, Publications: Paul ReisAssociate Director, Production: Johanna HarrisExecutive Director: Catherine Chopp Hinckley, Ph.D.Joint Commission/JCR Reviewers: Nanne Finis, Kelly Fugate, Catherine Hinckley, Nancy Kupka, Carol Mooney,Rick Morrow, Deborah Nadzam, Paul Reis

Joint Commission Resources MissionThe mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in theUnited States and in the international community through the provision of education, publications, consultation, andevaluation services.

Joint Commission Resources educational programs and publications support, but are separate from, the accreditationactivities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers ofJoint Commission Resources publications receive no special consideration or treatment in, or confidential informationabout, the accreditation process.

The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not beconstrued as an endorsement of such organization, product, or service, nor is failure to include an organization name,product, or service to be construed as disapproval.

This publication is designed to provide accurate and authoritative information in regard to the subject matter covered.Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations,and standards are subject to change. Please also note that some of the examples in this publication are specific to the lawsand regulations of the locality of the facility. The information and examples in this publication are provided with theunderstanding that the publisher is not engaged in providing medical, legal, or other professional advice. If any suchassistance is desired, the services of a competent professional person should be sought.

© 2010 The Joint Commission

Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated byThe Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materialsunder license from The Joint Commission.

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ISBN: 978-1-59940-383-0ISSN: OR Library of Congress Control Number: 2010933762

For more information about Joint Commission Resources, please visit http://www.jcrinc.com.

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Foreword ...........................................................................................................................................................................v

Introduction ...................................................................................................................................................................vii

Chapter 1: Surveillance for Infection Prevention and Control .............................................................................3

Chapter 2: Reducing the Risk of Infections Through Environmental Mitigation...............................................19

Chapter 3: Reducing the Risk of Infections Through Occupational Health Programs .......................................39

Chapter 4: Preventing Health Care–Associated Infections..................................................................................53

Departments with High-Patient Volume

Chapter 5: The Emergency Department ............................................................................................................77

Departments That Provide Support Services

Chapter 6: Environmental Services ....................................................................................................................83

Chapter 7: Central Services Department............................................................................................................93

Chapter 8: Linen and Laundry Service.............................................................................................................105

Chapter 9: Medical Waste Management ..........................................................................................................111

Chapter 10: Food and Nutrition Services.........................................................................................................117

Chapter 11: Pharmacy .....................................................................................................................................123

Departments That Provide Diagnostic and Therapeutic Services

Chapter 12: Laboratory....................................................................................................................................129

Chapter 13: Pathology .....................................................................................................................................137

Chapter 14: Radiology.....................................................................................................................................141

Chapter 15: Cardiac Catheterization Laboratory..............................................................................................147

Chapter 16: Respiratory Care Services .............................................................................................................153

continued on next page

Table of Contents

Part 2 – Infection Prevention and Control Practices for Specific Hospital Departments

Part 1 – Hospitalwide Infection Prevention and Control Practices


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Departments with High-Risk PopulationsChapter 17: Intensive Care Unit ......................................................................................................................161Chapter 18: Immunocompromised Patients.....................................................................................................165Chapter 19: Geriatric Patients..........................................................................................................................173Chapter 20: Pediatric and Neonatal Patients ....................................................................................................181Chapter 21: Obstetrics.....................................................................................................................................191Chapter 22: Dialysis ........................................................................................................................................197

Departments That Provide Surgical ServicesChapter 23: Surgery and Anesthesia.................................................................................................................203

Index ...............................................................................................................................................................219

Part 2 – Infection Prevention and Control Practices for Specific Hospital Departments

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Foreword

There is an ever-increasing emphasis on preventing healthcare–associated infections (HAIs) across the continuum ofcare, and The Joint Commission has joined this effort byassisting health care professionals engaged in theseprevention efforts. Numerous government and professionalorganizations, including the Centers for Disease Controland Prevention (CDC), the Society for HealthcareEpidemiology of America (SHEA), the World HealthOrganization (WHO), and the Association for Professionalsin Infection Control and Epidemiology (APIC), havecreated resources to assist infection preventionists to reducethe rate of HAIs. During the past several years, The JointCommission has collaborated with all these groups to developstate-of-the-science HAI prevention resources. In spite ofthis work, information and resource gaps in the clinical andadministrative areas of preventing HAIs continue to exist.

To help fill these gaps, The Joint Commission hasdeveloped The Joint Commission Infection Prevention andControl Handbook for Hospitals. Although the handbook canserve as a resource for the infection preventionist, webelieve that it will also provide valuable information forhospital administrators, department heads, nurse managers,and direct care providers.

Themes found in the handbook are both general andspecific. Chapters 1 through 4 focus on understandingstrategies to prevent infections in all parts of the hospital.Chapter 1 explains surveillance for infection prevention andcontrol. The central role of the environment in infectionprevention is the focus of Chapter 2. Because the health ofthose providing patient care and support services is key toinfection prevention, Chapter 3 covers the important roleof occupational health programs. And best practices forpreventing six of the most problematic HAIs are covered inChapter 4.

Chapters 5 through 23 discuss infection prevention andcontrol strategies for various hospital departments. Uniqueinfection risks are present when large numbers of patientsmove through a hospital department. The emergencydepartment is probably the best example of a departmentserving a high volume of patients, and Chapter 5 providespractical methods to reduce the risk of infectiontransmission associated with caring for numerouspotentially infectious patients.

In addition to covering a variety of patient-care settings,infection prevention and control strategies associated withdepartments that provide support and diagnostic servicesare addressed. Support services addressed in the handbookare Environmental Services (Chapter 6), Central Services(Chapter 7), Linen and Laundry (Chapter 8), MedicalWaste Management (Chapter 9), Food and NutritionalServices (Chapter 10), and the Pharmacy (Chapter 11).Diagnostic services covered in the handbook are theLaboratory (Chapter 12), Pathology (Chapter 13),Radiology (Chapter 14), the Cardiac Laboratory (Chapter15), and Respiratory Care Services (Chapter 16). Each ofthese chapters contain information specific to the role ofthe department and associated infection prevention andcontrol strategies.

Six chapters are devoted to patient populations consideredto be at high risk for acquiring HAIs. These populationsinclude: intensive care patients (Chapter 17), immunecompromised patients (Chapter 18), the elderly (Chapter19), pediatric and neonatal patients (Chapter 20), thepregnant patient (Chapter 21), and those on dialysis(Chapter 22).

Chapter 23 looks at the surgical environment, includingrisks associated with anesthesia. Some of the topics covered


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in this chapter are: properly maintaining the air quality inthe surgical suite; preparing the surgical patient frompreoperative showering to surgical site preparation; andinfection prevention strategies related to the surgical team,including surgical scrub and attire, traffic control, andsharps safety.

Throughout the population- and service-specific chapters,basic infection prevention themes, including hand hygiene,health care provider education, medical equipment cleaningand disinfection, and environmental cleaning, are repeatedto reinforce the important roles these play in the preventionof HAIs.

Everyone involved with developing this handbook iscommitted to infection prevention and to providing youand your colleagues with an invaluable resource to help inyour ongoing efforts to prevent HAIs in the patients youcare for each day. It is our hope that you will use thehandbook often and share the tips and other information inthe book with all members of your healthcare team as youstrive toward zero HAIs.

Susan M. Slavish, B.S.N., M.P.H., C.I.C.Infection Prevention and Control ConsultantJoint Commission Resources

Introduction

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In every hospital around the world, patients contractinfections, health care workers (HCWs) are exposed todangerous pathogens, and members of the communityseek treatment for infectious diseases, such as pneumonia,hepatitis, and human immunodeficiency virus (HIV).These events are not isolated incidents—they are regularoccurrences that hospitals must know how to manage.

Infection prevention and control (IPC) in a hospital affectsevery single department every single day of the year. Toensure the safety of patients, HCWs, families, visitors, andothers who come into contact with a hospital, IPC must bea top priority.

Setting the StageBecause of the size and scope of IPC in hospitals, work inthis area cannot be left to one or two individuals, such asthe infection preventionist or a clinician in charge of aparticular unit. Similarly, IPC cannot involve only one ortwo targeted interventions implemented in specificdepartments. It must instead involve a hospitalwide focusthat includes all individuals who work, receive care, or visitthe hospital. This focus must stress the importance ofincorporating IPC into daily operations and routines so itbecomes part of the culture and fabric of the hospital.

To achieve such a multidisciplinary, multifaceted approach,hospitals must have the following three elements in place:

1. A comprehensive and systematic IPC program

2. Strong leadership and support for the IPC program

3. Comprehensive education and training about IPC forevery member of the health care team as well as patientsand their families

The Infection Prevention and Control ProgramAn IPC program specifies a hospital’s approach to IPC.Such a program should be based on the specific infectionrisks a hospital faces, the services it provides, and thepopulations it serves. It should stress communication andcollaboration and be based on accepted best practicesregarding IPC. It should continually be monitored andupdated to reflect the ever-changing landscape ofpathogens, infection risks, and mitigation strategies.Everyone involved in the daily operation of a hospital—including physicians, nurses, therapists, pharmacists,administrative staff, environmental services professionals,housekeeping staff, building engineers, and so on—shouldplay a role in developing, implementing, and sustainingthe IPC program.

Leadership SupportWithout leadership support and buy-in, IPC efforts in ahospital may slip down the priority list. Leadership has adirect impact on patient safety and quality of care. In mosthospitals, programs that receive the visible support andbuy-in of leadership are the ones that HCWs take the mostseriously; therefore, these programs are usually the ones thatare the most successful.

Leadership can actively support an IPC program throughthe following actions:

• Allocating the necessary HCW time and resources.Leadership should appropriate financial and resourcesupport for programs to reduce and prevent theacquisition and spread of infections—especially healthcare–associated infections (HAIs). This may involvehiring more staff or reallocating staff to areas, such asneonatal intensive care units, in which high staff-to-patient ratios help drive down infection rates.


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• Allowing access to information. To truly analyze andreport infection rates, possible outbreaks, and othercritical data points, infection preventionists must haveaccess to detailed information, such as patient records.

• Providing appropriate IPC equipment. IPC equipmentcan include personal protective equipment (PPE), suchas masks, gloves, and gowns; accessible sinks; alcohol-based hand rub; sharps disposal boxes; and other safetyequipment. Leaders should encourage HCWs to weighin on the types of equipment that can make their jobssafer and easier and can prevent and control infections.

• Actively supporting a multidisciplinary approach to IPC.This collaboration may involve attending IPCcommittee meetings, encouraging the use ofmultidisciplinary teams to examine and respond toparticular IPC issues, and allowing time for differentdisciplines to participate in multidisciplinary teams.

• Serving as a role model. People imitate what they see. Forexample, if leaders are practicing good hand hygiene,HCWs throughout the hospital will be more likely topractice good hand hygiene as well. Conversely, if leadersskip this critical activity, HCWs will see it is not apriority and skip it themselves.

Leadership should also communicate about specific goalsand initiatives and share results of performance improvementprojects related to IPC. HCWs benefit from knowing theirroles in preventing the transmission of infection and aremotivated when they see results. When a particularinitiative reduces infection rates, for example, HCWs aremore likely to pay attention to the initiative, andcompliance rates may go up.

Education and TrainingIt is critical for all HCWs to realize the importance of theirindividual roles in preventing and controlling infections inhospitals. One of the ways this can be accomplished isthrough HCW education and training. Comprehensiveeducation programs should focus on the following topics:

• What individuals can do to prevent or control infections.This topic can include general preventive strategies, suchas hand hygiene and the use of PPE, as well as moredepartment-specific topics, such as how to correctlyprepare a patient for surgery or how to effectively clean adialysis machine.

• How to identify problems or potential problems related toIPC. This topic can include processes for reportingidentified problems, what to report, and to whom toreport these.

• How individuals can preserve their health to help preservethe safety of their patients. These practices can includestaying home when ill, using appropriate PPE, andgetting immunized for such infectious diseases asinfluenza and hepatitis B.

Effective education and training programs apply not onlyto patient care providers but to everyone in the hospitalwho has the potential to come in contact with patients,such as biomedical technicians, waste and garbage handlers,plumbers, electricians, delivery personnel, personal aides,and housekeepers. All these individuals can be exposed toand act as carriers of infection and must be familiar withhow to ensure their safety as well as the safety of others inthe hospital.

HCWs who work with high-risk patients, such as theelderly, neonates, or the immunosuppressed, should knowhow to identify risk factors for infection in these specificpopulations. Training HCWs to be aware of population-specific risk factors and how to prevent and controlinfections in those populations can go a long way indecreasing infections in the hospital.

About This BookThe Joint Commission Infection Prevention and ControlHandbook for Hospitals is designed to assist hospitals toidentify problem areas and barriers related to IPC (theinfection risks) and to provide evidence-based best practicesand solutions to address these problem areas and eliminatethese barriers. This book takes a multipronged approachand communicates information in two parts.

A note about the term infection preventionist that is usedthroughout this book: This term was recently adopted bythe Association for Professionals in Infection Control andEpidemiology (APIC) to refer to IPC professionals whowork in a variety of health care settings and who have thescientific knowledge and clinical expertise to preventinfections. According to APIC, “An infection preventionistis typically a registered nurse, physician, epidemiologist ormedical technologist who: Helps to prevent nosocomialinfections [HAIs] in healthcare facilities by isolating sourcesof infections and limiting their spread; systematicallycollects, analyzes and interprets health data in order toplan, implement, evaluate and disseminate appropriatepublic health practices; and trains healthcare staff throughinstruction and dissemination of information on infectionprevention and control practices.”1 Many hospitals employinfection preventionists on a full-time basis and others a

INTRODUCTION

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part-time basis. Many hospitals, however, do not have aninfection preventionist for a variety of reasons. This doesnot mean that they do not have individuals who are incharge of the IPC program and of preventing infections intheir institution. There are many HCWs who havespecialized training, knowledge, and clinical experience inpreventing and controlling infections, yet they do not carrythe label of infection preventionist. Therefore, the terminfection preventionist, as used in this publication, refers tothese individuals. As indicated previously, IPC in a hospitalshould be a multidisciplinary effort that involves manyindividuals and teams with a variety of talents, roles, andexpertise, all of whom work together to prevent infectionsin hospitals from threatening the lives and safety of patientsand the staff who work inits confines.

Part 1: Hospitalwide Infection Preventionand Control PracticesBecause hospitals must attack infections usingorganizationwide approaches and because many preventivestrategies are practiced throughout a hospital, the first part ofthe book provides a comprehensive look at addressing IPCissues enterprisewide. Chapters within this portion of thebook (Chapters 1 to 4) focus on practices that need to befollowed by all hospital departments. These strategies includesurveillance; hand hygiene; PPE; staff screenings, physicals,and immunizations; protection against common pathogens;sharps injuries; and postexposure prophylaxis. This part ofthe book also discusses best practices to prevent six of themost common HAIs: catheter-associated urinary tractinfections, ventilator-associated pneumonia, surgical siteinfections, multidrug-resistant organisms, Clostridiumdifficile infections, and central line–associated bloodstreaminfections. Because HAIs are the most pervasive type ofinfection that hospitals face, this part of the book focuseson preventing and eliminating some of the most difficultand widespread HAIs.

Part 2: Infection Prevention and ControlPractices for Specific Hospital DepartmentsBecause hospital departments have unique IPC issues, thesecond part of the book presents strategies for preventinginfections that are tailored to meet the IPC needs andunique circumstances of some of these departments.Although there are numerous departments in hospitals anddifferent hospitals have various types of departments, thedepartments covered in this book were chosen because theyare among the most common, see the most patients, andpresent the most difficult or prevalent infection risks.

Chapters 5 to 23 are designed to teach staff on the front lineshow to identify and prevent infections in their particulardepartments as well as other departments they have contactwith. The audience for these chapters includes direct careproviders (such as physicians, licensed independentpractitioners, and nurses) as well as clinical support staff(including housekeeping, pharmacists, and radiologists) andother hospital staff (such as human resources and buildingmaintenance). All these individuals play key roles inpreventing hospital infections in patients and amongHCWs. But the road to prevention does not begin and endwith these individuals. It is their responsibility to educatepatients, family members, visitors, and others who come tothe hospital about their responsibilities to prevent infections.

The 19 chapters in Part 2 are organized into discrete groupsbased on the primary function the department performs ina hospital. Chapter Five: The Emergency Department isplaced in the “Departments with High-Patient Volume”group, because the large number of patients seen in thisdepartment and the conditions they present with often poseinfection risks.

The next group, “Departments That Provide SupportServices” contains Chapter 6: Environmental Services,Chapter 7: Central Services Department, Chapter 8: Linenand Laundry Service, Chapter 9: Medical WasteManagement, Chapter 10: Food and Nutrition Services,and Chapter 11: Pharmacy. Although these departments donot provide direct patient care or are not involved with careat the bedside, they nevertheless play pivotal roles ininfection prevention and have direct impacts on the healthand well-being of patients.

The “Departments That Provide Diagnostic andTherapeutic Services” group encompasses departments thatperform a wide variety of procedures and use a vast array ofequipment to diagnose, cure, care for, and treat patients.These include Chapter 12: Laboratory, Chapter 13:Pathology, Chapter 14: Radiology, Chapter 15: CardiacCatheterization Laboratory, and Chapter 16: RespiratoryCare Services.

There are certain patient populations in hospitals that facegreater infection threats than other patients. These threatsand the strategies to mitigate them are covered in the nextgroup, “Departments with High-Risk Populations.”Chapter 17: Intensive Care Unit, Chapter 18:Immunocompromised Patients, Chapter 19: GeriatricPatients, Chapter 20: Pediatric and Neonatal Patients,


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Chapter 21: Obstetrics, and Chapter 22: Dialysis all discusshospital patients who are particularly vulnerable todeveloping infections.

The last group, “Departments That Provide SurgicalServices,” presents infection risks and preventive strategiesfor patients who will undergo surgery (Chapter 23: Surgeryand Anesthesia).

The information in each chapter in Part 2 is supplementedwith a wide variety of figures, posters, brochures, forms,tips, and sidebars. HCWs can use these materials toimplement the best practices presented in each chapter toprevent infections and improve compliance. Additionally,each chapter in Part 2 begins with a snapshot of the chaptercontents. The most important IPC risks that thedepartment faces are indicated with the symbol, andthe most effective best practices and preventive strategiesare highlighted with the icon.

When considered together, the two parts of the bookprovide a complete roadmap for IPC in a hospital and canhelp serve as a guide for a hospital’s efforts in this area. Byusing this guide, infection preventionists and others whowork in the hospital, such as leaders, occupational healthprofessionals, environment of care professionals, physicians,nurses, and other HCWs, can work together to develop,implement, and manage a comprehensive IPC program andpreserve the safety of patients and workers while reducingthe introduction and transmission of infectious diseaseswithin the hospital.

AcknowledgmentsThis book has greatly benefited from the knowledge,expertise, and experience of a great number of individuals,and Joint Commission Resources (JCR) would like toextend a hand of thanks to them.

First and foremost, sincere thanks go to Susan M. Slavish,B.S.N., M.P.H., C.I.C., who served as the technical editorfor this project. At the forefront of Susan’s mind was makingsure that the IPC information in the chapters was accurate,useful, and timely and that it would truly have a positiveimpact on saving lives, preventing needless suffering, andhelping HCWs better serve their patients and protectthemselves from harm. Susan worked tirelessly to realizethese goals by reviewing numerous drafts of this publication,suggesting references to include, and providing overallguidance. Thanks to her for her patience and support.

JCR would also like to thank and acknowledge thecontributions made by the many reviewers. Theseindividuals helped develop the content and reviewed theclinical and IPC information for accuracy and completeness.Kelly Fugate, Carol Mooney, and Rick Morrow from TheJoint Commission and Nanne Finis, Catherine Hinckley,Deb Nadzam, and Paul Reis from JCR provided invaluablecomments, edits, guidance, and assistance.

Last, this book would not have been possible without thewriting talents of Kathy Vega. As indicated by the breadthand scope of this book, a large amount of information,knowledge, detail, and expertise was required to create thecontent. Kathy deserves special recognition for being ableto quickly master complex IPC data and information andshould be named an honorary “infection preventionist.”

Reference1. Association for Professionals in Infection Control and

Epidemiology (APIC): About the Profession.http://www.apic.org/Content/NavigationMenu/AboutAPIC/AbouttheProfession/About_the_Profession.htm(accessed May 15, 2010).

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