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LEADERSHIP • Philosophy -Reflect facility mission & vision

• Administrative accountability Whom responsible for employee compliance to policy/protocol, standards of care?

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• Authority to take action - Designate person/position to act when indicated

Responsibility * Designate scope of responsibility and program management * Infection Control position description * IC professional development plan * Competency measurement/performance evaluation * Time allocation for program functions

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Responsibility, continued

• Policy, procedure, protocol development* Determine need/title* Research* Prepare* Seek approval* Education employees affected* Implement* Assess

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• Oversight: Function/committee Infection Control Committee? Quality Committee?

* Multi-disciplinary membership* Reporting structure* Goals and objectives* Program evaluation

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Performance Improvement

* Performance measures consistent with goals/objectives * Process/methods for data collection, data analysis description, reporting formats, improvements/recommendations, intervention/follow-up

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Regulatory compliance and/or Community standards of care Reflect in policy, procedure, protocols

• Bloodborne pathogens• Clinical laboratory improvement amendments (CLIA) - waived testing• Communicable disease reporting• Construction and renovation standards• Dietary practices• Employee health and safety

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Regulatory Compliance and/orCommunity Standards of Care (continued)

• First responder notification• Hand hygiene• Housekeeping and building maintenance• HIV: resident or employee• Vaccinations: resident, employee• Isolation/precautions

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Surveillance of Nosocomial Infections: Long Term Care

Gail Bennett, RN, MSN, CIC

www.icpasssociates.com

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Surveillance: The Method

“The ongoing, systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know.”CDC Definition

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Reasons for Surveillance Activities

Establish baseline endemic nosocomial infection rates

Facilitate early awareness of epidemics or clusters of nosocomial infections

Identify problems for which there is action that may decrease rates and actions that may lead to prevention of future infections

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Types of Surveillance

Traditional, total house surveillance– Finding ALL nosocomial infections ALL of

the time Useful to establish endemic rates Time consuming

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Types of Surveillance Targeted Surveillance

Geographic locations or types of nosocomial infections may be targeted for review May consider: High risk High volumeProblem prone

Be alert to your state surveyors’ expectations re: type of surveillance

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Methods of Finding Infections/Data Sources

Microbiology (culture) reports Unit generated report forms 24 hour report Antibiotic monitoring Unit rounds/communication forms/verbal reports Medical record review Review should be concurrent, not retrospective

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Data to Collect What is essential to your analysis?

Some facilities collect:

Resident name Record number Physician Admission date Symptoms & onset

Site Culture

date/pathogen Risk factors Other

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Making an Infection Determination

Is infection present?– Definitions of infection

If yes, is it nosocomial?– Based on time (48 hour rule)

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Definitions of Infections for LTC

McGeer definitions

American Journal of Infection Control, 1991; 19;1-7.

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Methods of Presentation of Data

Line listing Monthly summary of

infections Tables, graphs,

charts

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Data Interpretation

Clusters of infections (closely grouped series of infections)

Outbreak (excess cases over normal) Sentinel events (single occurrence

which requires action) Trend (increase in specific infections

over time) Seasonal occurrence

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Outbreaks

Require quick identification and action 10 published steps for outbreak

investigation (see outbreak investigation form)

You may need to seek assistance Report to the health department as

required by your state law

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Numerators New cases of infection for the period of

review

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Denominators

Census

Patient days

Device days

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Nosocomial Infection Rates

New cases of infection

___________________X 100 =___%

Census

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Nosocomial Infection Rates

New cases of infection

________________X 1000=

Total resident days

# infections/1000 resident days

[This has become the preferred method of calculation if you choose to do an overall rate.]

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Nosocomial Infection Rates using Device Days

New cases of UTI

________________ X 1000=

Total urinary device days

# UTIs per 1000 urinary device days

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Forms

Example forms provided:

Monthly summary Summary of device

related infections Line listing Outbreak investigation

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Surveillance resources

Bennett, G. Infection control manual for long term care. 2004 edition. HCPro, Marblehead, MA. $199.00

Lee TB, Baker OG, Lee JT, Scheckler WE, Steele L, Laxton CE, APIC Surveillance Initiative Working Group. Recommended Practices for Surveillance. American Journal of Infection Control 1998;26:277-288.

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Surveillance resources

McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, Peppler C, Rivera A, Schollenberger DG, Simor AE, Smith PW, Wang E. Definitions of Infection for Surveillance in Long Term Care Facilities. American Journal of Infection Control 1991;19(1):1-7.

Nicolle, L. Preventing infections in non-hospital settings: long term care. EID, vol. 7, no. 2, Mar/Apr, 2001. www.cdc.gov/ncidid/eid/vol7no2/nicolle.htm

Smith, P. and Rusnak, P. Infection prevention and control in the long term care facility. AJIC, 1997; 25; 488-512.

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EDUCATION

• New-hire orientation: All employees * Hand hygiene * Infectious Disease model * Exposure Control Plan: Bloodborne * Tuberculosis * Work restriction policy * Immunization program

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EDUCATION, continued

• New-hire: certain employees * Information specific to responsibility• Annual * Bloodborne Pathogen * Others, as/if required by regulationOn-going * Change in policy/procedure/protocol * IC/ID information, if indicated

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Employee Health: Bloodborne Pathogens and TB

Gail Bennett, RN, MSN, CIC

www.icpassociates.com

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Health assessments

Pre-placement evaluation

Annual assessment

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Assess:

General health History of communicable diseases Immunization status

– Hepatitis B– Measles, mumps, rubella– Varicella– Tetanus– Influenza if hired during flu season

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Employee Health: Bloodborne Pathogens and TB

Governed by OSHA regulations

Potential for OSHA fines for non-compliance

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Exposure Control Plans

Bloodborne pathogens

Tuberculosis

Must be written and accessible.

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Hepatitis B (HBV)Hepatitis C (HCV)

Human Immunodeficiency Virus (HIV)Hepatitis Immunization

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Hepatitis Immunization

Training must occur – prior to offering immunization– Prior to obtaining consent or declination

Training must include a qualified person available to answer questions if video is used

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Hepatitis Immunization 10 working days from hire

to offer and administer Schedule of immunization:

0,1,6 months Deltoid muscle Post testing – antibody

– Can be fined by OSHA if not done – not following PHS recommendations

If 3 immunizations with negative titer, repeat series

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Form

A sample consent/declination form is included in handouts

Form includes up to six immunizations and antibody screens

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Still…

No vaccine for Hepatitis C or HIV

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BBP Exposures

OSHA requires detailed actions and documentation of BBP exposures.

Handout: Comprehensive form for documenting exposures.

Must maintain exposure records the length of employment plus 30 years! Mark those files - “may destroy 2033” (example).

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BBP Exposures

If we have documented + antibody to Hepatitis B, do not have to test associate for Hepatitis B. Still test for Hepatitis C and HIV.

If Hepatitis B status not documented, test. Test resident for Hepatitis B, C, HIV unless

positive status is already known Follow state regulations regarding obtaining

consent Follow CDC guidelines for subsequent testing

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HIV exposure

Exposure to a known positive resident with HIV, follow the CDC guidelines

Timeliness of follow-up is critical Many LTCFs have a relationship with a

hospital to assess HIV exposures and intitiate appropriate prophylaxis

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Tuberculosis

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PPD Skin Testing

Employees:– 2 step on hire (unless tested in last

12 months and documented)– Requirement for annual PPDs (or

more often based on annual facility TB risk assessment)

– Test after exposure (immediately then in 10-12 weeks)

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PPD Skin Testing

Employees:– If positive prior to hire - have them

bring x-ray results and documentation of no active disease

– If they do not have an evaluation, we must get one.

– If positive, assessment for symptoms on hire and annually.

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PPD Skin Testing

Employees:

– If convert during employment, have an evaluation done (PHD should do this and give free INH as indicated)

– Report on OSHA 300 log

– Start annual assessment for symptoms

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Training of all Associates

All associates should receive orientation and annual training on bloodborne pathogens and TB

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TB Risk Assessment

Must be done every each year

Determines if we can continue annual PPDs on associates vs. more frequently

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Employee Illnesses

Maintain a log of associates with infections.

Requires all department heads to assist.

Many facilities have the logs turned in to IC/EH.

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Work Restrictions

Policy on work restrictions – CDC occupational health guidelines have a work restrictions table.

Adopt a policy for your facility.

Enforce it.

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Associate Immunizations

Hepatitis B Influenza

annually MMR Varicella Tetanus

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Resident Immunizations

National recommendations: Pneumonia vaccine on admission if has

not had it since age 65– If prior to age 65, give a dose once every 5

years until 65 - then lifetime immunity.

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Resident Immunizations

Influenza vaccine: give each fall when vaccine arrives

Continue to vaccinate through March 31 Many LTCFs now vaccinate under

standing orders – refusal of care form signed if refuse vaccine

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Resident Immunizations

Documentation of immunizations on medical record – preferably not thinned

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Remember the rules!

Consequences can be great!– Transmission of

infections

– Fines from OSHA

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References Bolyard, EA, et al. Guideline for infection control in

health care personnel, 1998. CDC/ HICPAC. AJIC, 26(3):289-354, 1998.

CDC. Updated public health service guidelines for the management of occupational exposures to HBV, HCV, HIV and recommendations for post-exposure prophylaxis. MMWR, 6/29/01/Vol.50/No.RR-11.

CDC. Guidelines for preventing transmission of Mycobacterium tuberculosis in healthcare facilities, 1994. MMWR 43(RR13); 1-132.

Core curriculum on tuberculosis: what the clinician should know. CDC, 3rd edition, 1994.

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Web sites:– www.cdc.gov– www.osha.gov– www.niosh.gov– www.apic.org– www.icpassociates.com

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HAND HYGIENE

Antiseptic handwash

Antiseptic handrub

Handwashing

Surgical hand antisepsis

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HAND HYGIENE, WHY?

Reduce risk of morbidity, mortality, and cost associated with healthcare associated infections

Eliminate transient organisms andreduce resident hand flora

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INDICATIONS FOR HANDWASHING

1. Between patient contacts 2. After contact with blood, body fluids, excretions, secretions, contaminated equipment, mucous membrane, non-intact skin. 3. After glove or any PPE removal 4. Between task/procedures on same patient 5. When visibly soiled/dirty 6. Before and after eating or handling food 7. After coughing or sneezing After using a handkerchief / tissue 8. After using the toilet and helping others in the bathroom 9. Before and after smoking

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HOW TO WASH HANDS

Turn on faucet

Wet hands

Apply cleanser

Friction, at least 15 seconds

Rinse well

Pat dry

Use towel to turn off faucet

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Involves use of waterless alcohol-based agent

Purpose: reduction of bacterial counts on hands when handsare not visibly soiled

Available when sink not available or water supply disruption

HAND RUB

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HAND HYGIENE WITH ALCOHOL-BASED HAND RUB

Apply product to one hand

Rub hands together

Cover all surfaces of hands and fingers

Rub until the hands are dry

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DISPENSER PLACEMENT AND STORAGE (1)

Michigan CIS Office of Fire Safety

Dispensers containing this product are prohibited from being located in a required corridor or exit, or any area open to a required corridor or exit

This product must be isolated from high temperature and possible ignition sources such as , but not limited to, open flame, electrical equipment, switches or receptacles.

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DISPENSER PLACEMENT AND STORAGE (2)

The storage of quantities (10 gallons or more), and

dispensing of this product shall comply with the requirements of NFPA BASE 30, FLAMMABLE AND COMBUSTIBLE LIQUIDS, Chapter 4, and or the Michigan flammable and combustible rules and NFPS Base 99, N-7.2.2.

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SURGICAL HAND ANTISEPSIS

Remove watches rings braclets

Use nail cleaner and running water to remove debris under fingernails

Antimicrobial soap-scrub 2 to 6 minutes, or manufacturer’s directions

Alcohol based surgical hand scrub, prewash hands and forearms with plain soap.

Dry completely, apply product, allow to dry, don sterile gloves

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ADDITIONAL CONSIDERATION

Hand creams

Nails

Jewelry

Glove Use

Compliance

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BARRIERS

Lack of knowledge that guidelines for hand hygiene exist

Not recognizing opportunities during the performance of ones duties

Lack of awareness for the risk of cross contamination of organisms

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BEST PRACTICE

Facility decision regarding hand hygiene

Evaluate products

Develop and implement system for measuring improvement