Accreditation and Infection Control

1. Accreditation and Infection Control Marcia R Patrick, MSN, RN, CIC Tacoma, WA November 7, 2013

2. I have nothing to declare • No off-label use of medications will be discussed • Use of brand names and images is for illustration only, no endorsement is implied

3. Objectives • Be familiar with the salient points of the CMS Infection Control Worksheet • Discuss three critical injection practices to prevent transmission of bloodborne pathogens in the ASC • Describe at least three critical elements in safely and adequately performing high-level disinfection in the ASC

4. Centers for Medicare and Medicaid Services- CMS • Requires all ASCs that accept money from CMS meet specific Infection Control requirements • Result of disease outbreaks in ambulatory pts. • IC requirements included in all accreditation surveys • Accreditation Association for Ambulatory Health Care (AAAHC) • American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) • American Osteopathic Association (AOA) • The Joint Commission (TJC) • A good idea regardless of accreditation surveys! • It’s all about patient safety

5. CMS, con’t. Requires: • Licensed, qualified IC person • Written Infection Control Plan • Which IC standards are being followed- CDC (various), AORN, specialty, etc. • Surveillance plan for infections • Method of notifying DOH of reportable dz • Education of staff in infection control

6. CMS, con’t. • Hand hygiene- wash or alcohol-based hand sanitizer, appropriate times • Use of gloves, other personal protective equip. • Needle and medication safety: One needle, one syringe, one patient, one time • Single dose vials are single patient use • Proper placement & use of sharps containers • Sterilization & disinfection • Environmental cleaning • Point of care testing devices (blood glucose)

7. Goals of an Infection Prevention and Control Program Protect patients Protect workers Ensure compliance with infection prevention and control regulations and other requirements, guidelines and recommendations Promote “zero tolerance” for infections

8. Elements of the Infection Surveillance, Prevention & Control Program Risk Assessment based on services provided, locale, population Written Infection Prevention and Control Plan Authority Statement Infection ControlService description Surveillance Plan

9. Elements, continued 6.Goals and Measurable Objectives 7. Prevention & Control Strategies 8. Communication and Reporting 9. Emergency Management & Planning 10. Education 11. Evaluation of Program Effectiveness

10. Facility Risk Assessment • Provides a basis for infection prevention activities and annual surveillance plan • Identify at-risk populations in your facility- high volume, high risk, or problem-prone procedures • Assist in focusing surveillance efforts • Meet regulatory and otherrequirements

11. Facility Risk Assessment Epidemiologic principles to address Volumes Populations served General and specialty services Staff Surveillance data Geographic location and size Epidemiologically important organisms

12. Assessment Summary Who is at risk for infection What types of infections Recommendations to reduce risks Facility Risk Assessment

13. Surveillance Plan Surveillance methodology – how Surveillance indicators/events - what Risk assessment - why Reasons for selecting indicators Committee/leadership recommendations New services, procedures, treatments Comparative databases used Outbreak identification and response

14. Authority Statement Example:The Board of Directors (Medical Director/Quality Committee) authorizes and supports the Director (Manager/etc.) of Infection Prevention to institute appropriate infection control measures within the facility. This includes authority to employ whatever methods necessary when, in their judgment, there is a reasonable possibility of immediate danger to any patient(s), personnel or others in the facility.

15. Infection Prevention & Control Service Composition Based on organization size, type, services, needs, regulations & requirements Personnel: number, qualifications, core competencies, (office) location, hours Medical Director/Epidemiologist/ID consultant Leadership support Authority Reporting structure, other responsibilities

16. Goals & Objectives • Identify & prioritize goals • Based on risk assessment • Team effort & leadership approval • Goals should address at least: • Limiting acquisition & transmission of pathogens • Limiting unprotected exposure to pathogens • Enhancing hand hygiene • Minimizing risk associated with procedures, devices & equipment • Develop measurable objective(s)

17. Program Goals Provide cost-effective program Healthcare Associated Infections = increased cost Infection Control programs = decreased cost Limited reimbursement from CMS for preventable harm, also other payers

18. Prevention & Control Strategies Identify prevention & control strategies Base on risk for transmission, care setting, diseases in community Hand hygiene program Minimize risk associated with procedures, devices, equipment

19. Communication & Reporting Communication systems Internal External Reports What is reported How it is reported (written, verbal) Who receives the information How often

20. Education Education & training for Health care providers, ancillary staff New employee orientation, competency evaluations Annual and as needed infection control education Leaders Infection Prevention and Control personnel List offerings for the year – Plan a calendar

21. Emergency Management & Planning Must involve collaboration Internal External (local emergency mgmt, health dept.) Plan for Recognition Response (including influx of infectious pts.) Containment Communication (internal & external)

22. Evaluation of Program Effectiveness Evaluate goals & program, ability to meet Measure success or failure, why Rate reduction- highlight accomplishments! Processes improved/Compliance improved Infection Control Program resources Personnel Non-personnel (computers, clerical support) Collaborate Establish new goals and objectives

23. IC Program vs. Written IC Plan • The written Plan documents the existence of your IC Program • The Plan should incorporate all the elements required or included in your program • Reviewed and updated as things change, at least annually

24. Tips for Developing Written Plan Identify regulations & requirements Identify guidelines you will use Develop outline of Infection Prevention and Control program Can use the examples given Network with others Consider incorporating your plan into your annual report

25. Tips,con’t. • Demonstrate collaboration throughout plan • Leaders, managers, caregivers & others • Collaborate in program development, implementation, evaluation, and assessment of resources • Assign responsibility for annual review • Include the essential elements • Distribute your plan widely

26. Single most important procedure for preventing healthcare-associated (nosocomial) infections Underwood MA. APIC Text 2005 Hand Hygiene CDC Guideline for Hand Hygiene in Healthcare Settings, 2002 http://www.cdc.gov/handhygiene/

27. Definitions Antiseptic – antimicrobial substances (e.g. alcohol, CHG, triclosan) applied to the skin to reduce microbial flora Alcohol-based hand rub – alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms Antimicrobial soap – detergent containing antiseptic agent Waterless antiseptic agent – an antiseptic agent that does not require use of exogenous water

28. Why we use hand sanitizers A 24-year-old man who had quadriplegia due to a traumatic spinal cord injury was found on routine surveillance cultures to have methicillin-resistant Staphylococcus aureus (MRSA) colonization of his anterior nares. He had no history of MRSA infection or colonization. To assess the potential implications of the patient's MRSA carriage for infection control, an imprint of a health care worker's ungloved hand was obtained for culture after the worker had performed an abdominal examination of the patient. The MRSA colonies grown from this handprint on the plate (CHROMagar Staph aureus), which contained 6 µg of cefoxitin per milliliter to inhibit methicillin-susceptible S. aureus, are pink and show the outline of the worker's fingers and thumb (Panel A). With the use of a polymerase-chain-reaction assay, the mecA gene, which confers methicillin resistance, was amplified from nares and imprint isolates. After the worker's hand had been cleaned with alcohol foam, another hand imprint was obtained, and the resulting culture was negative for MRSA (Panel B). These images illustrate the critical importance of hand hygiene in caring for patients, including those not known to carry antibiotic-resistant pathogens. New England Journal of Medicine

29. Opportunities for Hand Hygiene • Before entering patient room • Before touching patient • Before donning gloves • Before handling meds, linen, clean supplies • Between dirty and clean tasks • After touching patient or their environment • After handling soiled linen, dressings, etc. • On removing gloves • On leaving the room

30. State of the science: waterless surgical scrub solutions Alcohol-based surgical hand-scrub Prewash hands and forearms with non-antimicrobial soap, dry, then apply per manufacturer's instructions Antiseptic surgical hand-scrub Chlorhexidine (CHG) & Povidone Iodine (PVI) most common Surgical Hand Antisepsis

31. Artificial Nails HCWs more likely to harbor gram negative pathogens on their fingertips Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails Artificial fingernails epidemiologically implicated in several other outbreaks Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms) (IA)

32. Jewelry • Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings • Study: 40% of nurses harbored gram-negative bacilli (e.g., E. cloacae, Klebsiella, and Acinetobacter) on skin under rings & certain nurses carried the same organism under their rings for several months • In a more recent study involving >60 intensive care unit nurses, multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S. aureus and that the concentration of organisms recovered correlated with the number of rings worn • Rings are not appropriate in the OR • Earrings/necklaces must be covered in OR CDC Guideline for Hand Hygiene in Healthcare Settings, 2002

33. Safe Injection, Infusion and Medication Vial Practices in Healthcare

34. Maintaining Sterility • Perform hand hygiene before accessing and preparing medications • Disinfect (scrub) all vial tops & IV ports/hubs, locks with alcohol for 15 seconds before accessing (includes needleless systems) • Let dry 15 seconds • A needle should never be left inserted into a medication vial septum for multiple uses • This provides a direct route for microorganisms to enter the vial and contaminate the fluid • Use 5 micron filter needle for ampule

35. Maintaining Sterility • A new sterile needle and syringe used for each injection and each entry into vial • Do not use bags or bottles of intravenous solution as a common source of supply for more than one patient • Leftover parenteral medications should never be pooled for later administration • Single-use medication vials (e.g., propofol) should never be used for more than one patient • Assign multi-dose vials to a single patient whenever possible

36. IV Solutions • Sanitize hands before any contact with IV tubing or bag handling or change • Keep IV bags in plastic overwrap until ready for use (if out, date & discard in 30 days) • Begin administration within one hour of spiking IV bag/bottle (USP 797) or a soon as possible (APIC)-otherwise discard bag

37. IV Solution & Syringe Labeling • NEVER set an unlabeled syringe down or leave it unattended • NEVER administer a medication from an unlabeled syringe that you did not draw up & have control of from time drawn up to time given • NEVER draw up an oral or topical liquid into an injection syringe

38. Expiration • Discard medications upon expiration or any time there are concerns regarding the sterility • Date multidose vials when first entered & discard at 28 days or manufacturer’s expiration date, whichever is first • Discard unopened vials at manufacturer’s expiration date • Discard opened single dose vial/ampule discarded immediately after use on patient • Discard prepared syringes at end of procedure-do not save for next case http://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html

39. Irrigating Solutions • Best if irrigation solutions are discarded between patients • Warming irrigation solutions: • T max <113°F, lower (104°) if IV fluids included (record temp daily) • NEVER warm in microwave (any pt care item!) • Medication containing irrigations: obtain from Pharmacy - single patient use

40. Eye Drops, Ointments, Ear Drops • Hand hygiene before & after • Glove if contact with mucous membranes anticipated • Administer all eye & ear products using “no touch” technique to prevent contamination • If break in technique discard the container ASAP • Prefer single patient use

41. Topicals • Sanitize hands • Prevent contamination of bulk containers; use smallest available • Small size can be dedicated to single patient and then discarded • Remove desired amount with a sterile applicator or tongue blade (no double-dipping) or squeeze onto a sterile gauze in a clean area

42. Cleaning, Disinfection, Sterilization

43. Risks in Invasive Procedures Both Inside and Outside the Traditional OR Improper environment Inadequate cleaning, disinfection, and sterilization Staff not trained adequately Antiquated equipment Borrowed equipment Improper use of equipment Compromised cleaning procedures

44. Definitions Cleaning: removal of all soil from objects/surfaces Decontamination: removal of all pathogenic microorganisms from objects to ensure they are safe to handle Disinfection: elimination of many or all pathogenic organisms with the exception of bacterial spores Sterilization: complete elimination, destruction of all microbial life CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

45. CLEANING

46. Cleaning Defined as the physical removal of all visible soil, dust, and other foreign materials Effective cleaning will reduce microbial contamination on environmental surfaces & equipment Cleaning is the first and most important step before disinfection or sterilization can occur CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

47. Presoaking Prevents soils & proteins from drying on the instruments Softens soils and assists with removal Prevents biofilm development Presoaking the instruments should ideally occur immediately following the surgical procedure Sprays, foams, available AAMI ST79 2010; 7.4.1 p. 53

48. Enzymatic Detergents Detergents are defined as substances capable of dislodging, removing and dispersing solid or liquid soils from a surface being cleaned Enzymatic detergents usually consist of a detergent base with a neutral pH to which one or more enzymes and a surfactant is added AAMI ST79, 2010, 7.5.2, p.55

49. Manual Cleaning Follows presoaking Instruments washed submerged under water to prevent potential exposure to microorganisms through aerosolization Use a basket to lift out sharp items Staff must wear PPE including eye and face protection Some endoscope washers may allow you to eliminate manual cleaning AAMI ST 79, 2010, 2.17, p.8

50. Ultrasonics for Delicate Instruments(e.g. eye instruments) Effectiveness is based on cavitation: sonic waves generate minute bubbles on instrument surface Bubbles then expand, become unstable, then collapse or implode Implosion generates very localized vacuum areas that literally dislodges/sucks off the soil Must clean machine per instructions AAMI ST79, 2010, 7.5.3.3, p. 57