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Basic Infection Prevention Training. CIP Consulting LLC. Basic Infection Prevention Training. Role of the ICP. Father of Hand Hygiene: Dr. Ignaz Semmelweis. Role of the ICP. Infection Prevention and control expert Mentor staff Role model for Infection Prevention and Control

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Father of hand hygiene dr ignaz semmelweis
Father of Hand Hygiene:Dr. Ignaz Semmelweis

Role of the icp1
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 icp2
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 icp3
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 (review and discuss a sample infection control surveillance plan with the group)

Stain will identify
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


  • 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.

  • S/S of TB?

  • Look at most recent chest x-ray.

How are microbes cultured
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.


  • The zone sites are looked up on a standardized chart to give a result of

  • Sensitive

  • Intermediate

  • Resistant

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

Mic studies minimum inhibitory concentration studies
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.

R i s designations
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”


  • Done annually by the Microbiology lab.

  • Helps guide antibiotic usage, very specific to the facility.

Multi drug resistant organisms mdro
Multi-drug resistant organisms - MDRO

  • CDC MDRO definition

    Bacteria that is resistant to one or more classes of antibiotics

  • Discuss annual MDRO risk assessment (calculation of MDRO rates discussed in “data and analysis”)

  • Past and current hospital surveillance data is the core of the MRSA risk assessment.

  • MRSA risk assessment is developed annually, whenever there is a change based on continuing surveillance, and when change of populations or services occurs.

  • Information from the MRSA risk assessment drives improvement processes.


  • Prevention is key!

  • Use contact isolation (gowns and gloves before entering room, remove before leaving the room)

  • Educate the patients and family members with hospital MDRO literature (kept on each unit)

  • Hand washing before and after patient care

  • Wipe down equipment shared between patients with hospital approved disinfectant.

Fungi – Some are well adapted human pathogens, but most are accidental pathogens that we acquire through decaying organic matter or airborne spores.

  • Two groups

  • Yeasts – i.e. Candida species, Cryptococcus

  • 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.

    Review ICRA with the group

Viruses cannot multiply on their own need living cells to live and grow
Viruses – cannot multiply on their own, need living cells to live and grow

  • Multiplication occurs in 5 steps

  • Attachment

  • Penetration

  • Replication

  • Maturation

  • Release

Parasites to live and grow

  • 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.

Direct antigen testing
Direct antigen testing to live and grow

  • 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
DNA Probes – another non-culturing method to live and grow

  • 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 gonorrhoeae and Chlamydia.

Pcr polymerase chain reaction another non culture detection method
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
Pulse field Gel Electrophoresis detection method.

  • PFGE technique can be used with remarkable precision to determine relatedness of isolates from an outbreak…

Infection vs colonization with normal flora
Infection VS Colonization with normal flora detection method.

  • 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 VS Endogenous detection method.

  • Exogenous organisms are those that come from outside the host.

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

Environmental testing
Environmental testing detection method.

  • “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.

Staphylococcus aureus most frequently seen microbe in human infections
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 infections1
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
Pseudomonas aeruginosa human infections

  • 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
Mycobacterium Tuberculosis human infections

  • 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
Herpes Simplex Virus human infections

  • 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)

Wbc count and differential
WBC count and differential human infections

  • Normal WBC count is 5,000 – 10,000

  • White blood cells originate in the bone marrow.

  • Types of WBC

  • Phagocytic – ingest and destroy bacteria, protozoa, cells and cellular debris. (neutrophils, eosinophils, basophils, monocytes, and macrophages)

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

Meningitis cerebral spinal fluid

CSF human infections

Normal CSF




< 5

> 1,000

5 – 500


< 50

> 100

30 –150


2/3 serum glucose

< 40

< 30 - 70

Meningitis – Cerebral spinal fluid

  • Lumbar puncture – The results of the CSF fluid; WBC count, protein, and glucose are important in diagnosis between Bacterial (septic) and Viral (aseptic) meningitis

Meningitis Overview human infectionsInflammation of the meninges, which surrounds the brain and spinal cord. The inflammation may have infectious or non-infectious causes.

Presentation – both viral and bacterial present the same (fever, neck stiffness, altered mental status, headache photophobia, nausea, skin rash in meningococcal meningitis).

  • Bacterial – often called septic meningitis, it has an identified bacterial cause. (Streptococcus, Neisseria, Haemophilus, Listeria)

  • Viral – often called aseptic meningitis, which refers to all non bacterial causes of the meningitis, such as viruses, fungi, parasitic, medication related, and malignancies.

Diagnostic tests
Diagnostic Tests human infections

  • CSF Culture

  • Blood Cultures

  • CSF and Blood Cultures take time.

  • Antigen Testing (Serology) Main advantage is speed. The quicker the appropriate antibiotics are given for bacterial meningitis the better!

Components of surveillance

Basic Infection Prevention Training human infections

Components of Surveillance

Components of surveillance1
Components of Surveillance human infections

  • Surveillance Methods

    • Facility wide

    • Periodic (Quarterly)

    • Targeted

    • Outbreak Thresholds

  • CDC/NHSN definitions of HAI and criteria for specific types of infections in the acute care setting. (introduction to the CDC document, more intense review in intermediate and advance courses)

Surveillance human infections

  • Collecting Relevant Data

  • Managing Data

  • Analyzing and Interpreting Data

  • Communicating Results

Reports human infections

  • Announcements that need to be recorded in the minutes

  • News related to Infection Prevention

  • Updates from any construction projects

  • Reports from regular surveillance

  • Reports from Employee Health

  • Reports from Dialysis water cultures

  • Reports from IC Rounding

Annual review
Annual Review human infections

  • Evaluate program annually

    • Highlight accomplishments

    • Evaluate goals

    • Set new goals based on risk assessment

  • Review a sample program evaluation

MRSA incidence human infectionsIncidence = the number of new cases (1st lab ID specimen) of a given disease in a given time period.

Analysis –

“Past and current hospital surveillance data is the core of the MRSA risk assessment”.

Healthcare associated MRSA human infectionsCDC definition – Lab ID specimen collected > 3 days after admission to the facility (i.e. on or after day 4)

Analysis – Based on annual data, HA MRSA goal is < 1 per 1000 patient days.

Healthcare associated vre
Healthcare associated VRE human infections

Breakdown of ssi cultures december 2010 january 2010
Breakdown of SSI cultures human infectionsDecember 2010 – January 2010

Annual tb risk assessment
Annual TB risk assessment human infections

2009 2010 (rates per 100,000)

  • Oklahoma county TB rate 3.3 3.8

  • State TB rate 2.8 2.3

  • National TB rate 3.8 3.6

    In 2011, The hospital continues to be low risk according to the CDC risk classification of inpatient hospitals with < 200 beds, and outpatient clinics (both must have < 3 confirmed TB patients per year)

    Issues found during risk assessment and 11/2010 state health visit.

    1. Only 1 ICP got immediate notification via email when PPD placed – this was fixed and now both ICP’s get immediate notification, so that prompt assessment can be made regarding negative airflow.

Tb risk assessment
TB Risk assessment human infections

2. ACH in negative airflow rooms now checked quarterly and reported to EOC committee. Recommended ACH is 12.

3. Noted that compliance for annual fit testing not 100% as stated in TB control plan – Employee Health working on compliance issue.

4. “TB reference book” placed in nurse house supervisor office. This book has the list of “fit tested” team members and provides reference to reading TBST’s, discontinuation of airborne isolation and references TB control plan.

Infection control risk assessments

Basic Infection Prevention Training human infections

Infection Control Risk assessments

ICRA human infections

  • Multi-disciplinary Risk Assessment

  • Construction Risk Assessment

  • TB Risk assessment

  • Multi-drug resistant Risk Assessment

Disease transmission and isolation

Basic Infection Prevention Training human infections

Disease Transmission and isolation

Reportable diseases in oklahoma
Reportable Diseases in Oklahoma human infections

  • 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?,_Prevention,_Preparedness/Acute_Disease_Service/Disease_Reporting/What_to_Report/index.html

Infectious disease process
Infectious Disease Process human infections

  • Exposure

  • Incubation Period (time from exposure to onset of symptoms)

  • Onset of symptoms/clinical disease

  • Recovery, disability or death

Chain of infection
Chain of Infection human infections

  • Infectious agent

  • Reservoir

  • Portal of Exit

  • Means of Transmission

  • Portal of entry

  • Susceptible Host

Transmission based isolation
Transmission Based Isolation human infections

  • The spread of infection requires 3 elements:

    • Source

    • Susceptible host

    • Transmission






Standard precautions
Standard Precautions human infections

  • Apply standard precautions to all:

    • Patients

    • Contaminated equipment, surfaces & materials

  • Use judgement to determine when personal protective equipment is necessary

Standard precautions1
Standard Precautions human infections

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 precautions2
Standard Precautions human infections

  • 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 precautions3
Standard Precautions human infections

  • 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 precautions4
Standard Precautions human infections

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

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

Standard precautions5
Standard Precautions human infections

Clean re-useable equipment

between patients to prevent

transfer of microorganisms to

other patients, staff

or environment

Standard precautions6
Standard Precautions human infections

  • Use:

    • Mouthpieces

    • Resuscitation bags

    • Ventilatory device

  • As an alternative to mouth-to-mouth resuscitation methods

Contact isolation standard precautions
Contact Isolation Standard Precautions human infections

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 precautions1
Contact Isolation Standard Precautions human infections

Patient may have:

  • Incontinence

  • Diarrhea

  • Ileostomy

  • Colostomy

  • Wound drainage not contained by dressings

Contact isolation standard precautions2
Contact Isolation human infectionsStandard 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 isolation standard precautions3
Contact Isolation human infectionsStandard Precautions

  • Limit transport to essential purposes

  • Communicate precautions to appropriate departments

  • Maintain Contact Isolation

Patient transport:

Contact isolation standard precautions4
Contact Isolation human infectionsStandard 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

Patient Care Equipment:

Droplet isolation standard precautions
Droplet Isolation human infections Standard Precautions

Patients infected or colonized


  • Microorganisms

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

Droplet isolation standard precautions1
Droplet Isolation human infections 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
Airborne Isolation human infections Standard Precautions

Patients infected with:

  • Pulmonary tuberculosis (TB)

  • Rubeola (measles)

  • Varicella (chicken pox)

Airborne isolation standard precautions1
Airborne Isolation human infections 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 precautions2
Airborne Isolation human infections Standard Precautions

  • Tuberculosis - wear particulate respirator to enter room

  • Varicella & Rubeola - susceptible care givers not to enter room if immune caregivers are available

    • Susceptible = mask

    • Immune persons = no mask

Cdc management of multidrug resistant organisms in healthcare settings 2006
CDC - Management of Multidrug-Resistant Organisms In human infectionsHealthcare Settings, 2006

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

  • Administrative measures

    • Make MDRO prevention and control an organizational patient safety priority.

Cdc management of multidrug resistant organisms mdro s in healthcare settings 2006
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
MDRO’s In Healthcare Settings, 2006

  • 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 s1
MDRO’s In Healthcare Settings, 2006

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

  • Discussion

Mdro s2
MDRO’s In Healthcare Settings, 2006

  • 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
Appendix A, Isolation guideline In Healthcare Settings, 2006

  • 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

Scabies In Healthcare Settings, 2006

  • You identify this burrow like rash as Scabies and place the patient on Contact Isolation until 24 hours after the patient is treated for the scabies.

  • Notify the Dr., and obtain an order for Lindane (Kwell) Follow directions on the bottle.

  • The patients belongings need to be bagged and sent home. How will you tell the family to treat the belongings. Do the family members need to be treated?

Scabies In Healthcare Settings, 2006

Diagnosis – definitive diagnosis of scabies infestation can be made by a skin scraping of the burrow.

Transmission – Prolonged direct skin to skin contact. Mites can burrow under the skin in 2.5 minutes.

Incubation – 2-6 weeks after exposure OR 1-4 days in people previously infected.

Lice pediculosis
Lice (Pediculosis) In Healthcare Settings, 2006

Lice In Healthcare Settings, 2006

  • Contact Isolation until 24 hours after treatment. Call Physician for Rx treatment.

  • Apply Prescription lice medicine, according to the label instructions. , re-treatment in 7-10 days is not necessary unless crawling bugs are seen.

  • After treatment, use the nit comb to remove nits and dead lice from the hair shaft.

  • All of the patient belongings should be bagged and sent home for laundering or bagged for 2 weeks

Lice In Healthcare Settings, 2006

  • Do family members need to be treated?

  • Mode of transmission – Direct contact with an infested person, and objects used by them.

  • Incubation – 7-15 days.

C difficile
C- difficile In Healthcare Settings, 2006

  • 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.

C diff prevention
C – Diff Prevention In Healthcare Settings, 2006

  • Hand Hygiene – soap, water, and friction.

    Alcohol hand foam is not effective in killing the spores of C – Diff.

  • 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 prevention1
C – Diff Prevention In Healthcare Settings, 2006

  • 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 In Healthcare Settings, 2006

  • Infectious disease caused by bacteria.

  • Usually affects lungs.

  • Other body parts can be affected.

TRANSMISSION In Healthcare Settings, 2006

  • 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
SYMPTOMS OF TB In Healthcare Settings, 2006

  • Weak

  • Weight loss

  • Fever

  • Night sweats

  • Cough

  • Chest pain

  • Coughing up blood

Tb infection vs tb disease
TB INFECTION VS. TB DISEASE In Healthcare Settings, 2006

  • 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
MULTI DRUG RESISTANT TB (MDR TB) In Healthcare Settings, 2006

  • 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
TREATMENT FOR TB In Healthcare Settings, 2006

  • 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.

Federal and state regulations

Basic Infection Prevention Training In Healthcare Settings, 2006

Federal and State Regulations

State health regulations for hospitals chapter 667
State Health Regulations for Hospitals Chapter 667 In Healthcare Settings, 2006

  • Employee and/or worker Health examinations chapter 667-5-4

    • Pre 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
Chapter 667 In Healthcare Settings, 2006

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 Testing

    2-step Testing


    Hepatitis B

Chapter 6671
Chapter 667 In Healthcare Settings, 2006

  • (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 6672
Chapter 667 In Healthcare Settings, 2006

  • TB Skin Test

    • Based on annual TB risk assessment

  • Communicable Diseases

Chapter 6673
Chapter 667 In Healthcare Settings, 2006

  • 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 6674
Chapter 667 In Healthcare Settings, 2006

  • 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 6675
Chapter 667 In Healthcare Settings, 2006

  • 667-13-1 Infection Control Program

    • Provide a sanitary environment

    • Avoid sources and transmission of infection

    • Provide 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 6676
Chapter 667 In Healthcare Settings, 2006

  • 667-13-2 Infection Control Committee

    • Shall meet at least quarterly

    • Attendees – at least one person with appropriate background who can speak for the relevant department(s) attends the meeting or is consulted.

Chapter 6677
Chapter 667 In Healthcare Settings, 2006

  • 667-13-3 Policies and Procedures

    • The 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 6678
Chapter 667 In Healthcare Settings, 2006

  • 667-13-4 Policy and Procedure content

    • Record of all reported infections generated by surveillance activities

    • Handling and disposal of biomedical waste

    • Related to admixture and drug reconstitution

    • Indications for and type of isolation for each specific disease

    • A definition for nosocomial infection

    • Designation of an Infection Control officer

Chapter 6679
Chapter 667 In Healthcare Settings, 2006

  • 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
CMS Regulations (State Operations Manual) In Healthcare Settings, 2006

  • 482.42 Infection Control

    • Provide 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
CMS Regulations In Healthcare Settings, 2006

  • 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.

OSHA In Healthcare Settings, 2006

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

    • Purpose

    • Scope

    • Definitions

    • Exposure determination

OSHA In Healthcare Settings, 2006

  • Control Measures

    • Engineering Controls

    • Work Practice Controls

    • PPE (personal protective equipment)

  • Hepatitis B vaccination

  • Post exposure evaluation and follow-up

  • Sharps Injury log

  • Training and Education

  • Recordkeeping

OSHA In Healthcare Settings, 2006

  • Bloodborne pathogens 1910.1030 29CFR


  • 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 In Healthcare Settings, 2006

  • TB Control plan and Risk Assessment


  • Risk Assessment Appendix B must be done annually.

    • Low

    • Medium

    • High

  • Contact Investigation

The joint commission
The Joint Commission In Healthcare Settings, 2006

I. Planning

  • Responsibility

  • Resources

  • Risks

  • Goals

  • Activities

  • Influx


  • Activities

  • Medical Equipment, devices, supplies

  • Transmission of Infections

  • Influenza Vaccinations

    III.Evaluation and Improvement

Other regulatory bodies
Other regulatory bodies… In Healthcare Settings, 2006

  • DNV