the road to an effective infection prevention program

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PIN QI Showcase 2011. Linda Matranga, R.N. QI Director Infection Preventionist Safety Officer Asst. Dir. Public Health Clinical Information Systems Project Manager. The Road to an effective infection Prevention program. Federal LTC Survey on 2/25/2010 F441. F441. - PowerPoint PPT Presentation


The Road to a better infection control program

The Road to an effective infection Prevention programLinda Matranga, R.N. QI DirectorInfection PreventionistSafety OfficerAsst. Dir. Public HealthClinical Information Systems Project ManagerPIN QI Showcase 2011

Federal LTC Survey on 2/25/2010


F441483.65 Infection Control The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. 483.65(a) Infection Control Program The facility must establish an Infection Control Program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. F441483.65(b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

483.65(c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. What they citedThe facility failed to implement an infection control program through which all infections were tracked and preventative measures implemented. Additionally the facility failed to ensure that staff techniques during cares minimized the potential for cross contamination and the spread of infections.

What they citedSurveillance retrospective not concurrentCurrent tracking of infections did not show follow up or resolutionSurveillance data inaccurateSurveillance data collection processes not dependableSurveillance data was incomplete

What they citedInterventions not implemented appropriately Staff dressing change techniquesIncorrect linen handling by CNA and Laundry staffIncorrect hand hygiene during feeding of residentsIncorrect management of applesauce/pudding during med pass

What we HadNo coordinated IC programPerson responsible did not have the proper trainingOther departments not involved, dietary, clinic, housekeeping, etc.No IC CommitteeNo provider involvementOnly about 3 hours a month dedicated to IC specifically

What we hadInfections not followed up with appropriate interventions in a timely mannerAll staff did not understand isolationIsolation equipment and supplies not readily available

What did we need to do?Develop processes and policies for concurrent surveillance of infectionsExam our policies and practice for infection prevention, isolation, dressing changes, pericare and others.Educate staff

What did we need to do?Involve all departments in ICAppreciate the need to invest more hoursExamine the IC/IP role in our facilityInfection Control CommitteeProvide education for IP

Our biggest ChallengesWho would be the IP/IC? Divided the duties between the D.O.N. and the QI DirectorDeveloped processes and forms so that the DON could track infections on the floorThe QI Dir. would get the education, manage the program and do the data.Work as a team.

Our biggest ChallengesInfection Preventionist EducationJoined APIC- $185, MT. APIC Chapter Dues $30-awesome price for what you get.Utilized the APIC website- huge resource for information and educationAttended MT APIC ConferenceAttended the EPI 101 course in S.F.MT APIC Listserv- excellent networking with IPs around the state

Our biggest ChallengesHow can the IP know what infections are in the facility?Worked with lab staff to develop process to receive C&S and other reports.Worked with unit secretary to develop a process to get all antibiotic orders.Worked with nurses to notify IP of infections.

Our biggest ChallengesStaff Education and InvolvementNew policiesBasic IC education for all nursing staffIncreased teaching momentsEmphasized importance and involvement

80% of PMC staff were immunized.

Key ImprovementsAn infection control program was implemented for all patients and residents which; investigates, controls, and prevents infections; decides what procedures, such as isolation should be applied to an individual resident; and maintains a record of incidents and corrective actions related to infections. Redefined the IP role and expanded hours for infection control and preventionInvolved all departments in the IC Program

Key ImprovementsProvided IP with educational opportunities and supportImplemented new processes with lab for notification of resultsImplemented improved Public Health Communication processesInvolved medical staff via the IC committee and at Med Staff MeetingsUpdated all policies

Other ImprovementsProvided staff with resources, guidelines, books, reference materialsImproved Sharps Injury processes, policy, manager and staff education, forms and documentationInitiated process changes R/T Single use tourniquets Improved endoscopy cleaning procedures

Other ImprovementsInitiated process changes R/T specimen transportInitiated process changes R/T how housekeepers refill disinfectant bottlesWorked with providers to establish criteria for urine C&S orders

Other ImprovementsImplemented new policy for Blood and Body Fluids Exposure and Follow UpProvided info, forms and process guidance for providers, managers and staff in the ER for any exposures.Implemented an aggressive but fun immunization program for staffImplemented employee illness tracking, new process and forms

The Bottom LineEducationStaff InvolvementTeamworkAdministrative Support

March 2011 LTC SurveyComplimentary of the work we had done.

Cited two issues, use of Definitions of Infection for Surveillance and Antibiotic Use Review.

McGeer Definitions of Infection for LTC

McGeer Definitions of Infection for LTCAntibiotic ReviewImplement processes for antibiotic use reviewOpportunity for medical staff involvementAnother learning moment

The Road aheadGrowing emphasis nationally on the importance of infection prevention.PPS hospitals currently required to report certain infections.Trend toward mandatory reporting in other states.Will this be the future for CAH too?The Right Thing To Do.

MTDPHHSMHAMPQHSurveillanceStandardization of surveillance activities through use of NHSN and existing information systemsEncourage use of NHSN for surveillanceEnrolled all IPPS facilities into NHSNEvidence-Based PracticesStandardization of isolation practicesCUSPCAH MRSA ProjectSurgical Care Improvement ProjectMRSACoachingAll infection prevention and control activitiesCUSPSurgical Care Improvement ProjectMRSACommunication & EducationWeb SiteIP TrainingHCW TrainingIP Listserv MgmtPINLiaison to CEO/CFOAdvocacyIP TrainingSharepoint siteIP Listserv HostingCollaboration Between AgenciesAlthough the Montana Department of Health and Human Services received federal dollars and the responsibility for establishing a statewide HAI prevention program, they are by no means the primary organization in the prevention and control of HAIs in Montana.

MHA has taken the lead in improvement through the implementation of the CUSP project to decrease urinary tract infections in selected facilities.

MPQH has been involved in improving surgical care process measures for >5 years. In addition, they have been responsible for enrolling NINE facilities into the use of the NHSN data system since May 2010!

35Thank You Questions?

Attachment A, Infection Control Program Policy

Quarterly summary reports are given to Board of Directors, Medical Staff, QIC/QAA Committees, Clinical Managers and Directors.

The Infection Control Committee oversees the surveillance, investigation, reporting, control and prevention of infections; occupational exposures to blood, body fluids, or other potentially infectious materials; and monitoring for proper implementation of and adherence to infection control policies and procedures.

Infection Control Program Data Sources and Surveillance Activities

Data is collected on healthcare-associated cases, as is appropriate depending on the type of infection identified

Data is collected, trended, analyzed and reported for each specific area (LTC, CAH) using surveillance tools.

Staff nurses, clinical managers, employees & providers report residents and patients and employees of concern. Concurrent tracking and interventions documentation is maintained using the worksheet tool.

Lab provides copies of positive

cultures, unusual organisms, reportable diseases & other isolates of clinical significance.

Patients are placed in appropriate isolation and education provided to health care workers

Reportable Diseases as defined by MT State law are

reported to Public Health in compliance with state law and HIPAA regulations (LTC, CAH, Hospice, ALF & Clinic staff report diseases within their department)

During surveillance rounds the ICP reviews each chart to determine whether the infection is healthcare associated or was acquired in the community using standard CDC/NHSN case definitions.

Infection Control Preventionist (ICP) uses referred patient data to identify chart review needed to achieve surveillance strategies.

Staff nurses, clinical managers, employees & providers report employee illness of concern.

Infection Control ProgramPage 5 of 5

Infection Con


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