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
F441 §483.65 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.
F441 §483.65(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 cited • “The 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 cited • Surveillance retrospective not concurrent • Current tracking of infections did not show follow up or resolution • Surveillance data inaccurate • Surveillance data collection processes not dependable • Surveillance data was incomplete
What they cited • Interventions not implemented appropriately • Staff dressing change techniques • Incorrect linen handling by CNA and Laundry staff • Incorrect hand hygiene during feeding of residents • Incorrect management of applesauce/pudding during med pass
What we Had • No coordinated IC program • Person responsible did not have the proper training • Other departments not involved, dietary, clinic, housekeeping, etc. • No IC Committee • No provider involvement • Only about 3 hours a month dedicated to IC specifically
What we had • Infections not followed up with appropriate interventions in a timely manner • All staff did not understand isolation • Isolation equipment and supplies not readily available
What did we need to do? • Develop processes and policies for concurrent surveillance of infections • Exam 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 IC • Appreciate the need to invest more hours • Examine the IC/IP role in our facility • Infection Control Committee • Provide education for IP
Who would be the IP/IC? Divided the duties between the D.O.N. and the QI Director Developed processes and forms so that the DON could track infections on the floor The QI Dir. would get the education, manage the program and do the data. Work as a team. Our biggest Challenges
Infection Preventionist Education • Joined APIC- $185, MT. APIC Chapter Dues $30-awesome price for what you get. • Utilized the APIC website- huge resource for information and education • Attended MT APIC Conference • Attended the EPI 101 course in S.F. • MT APIC Listserv- excellent networking with IPs around the state Our biggest Challenges
How 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 Challenges
Staff Education and Involvement New policies Basic IC education for all nursing staff Increased “teaching moments” Emphasized importance and involvement Our biggest Challenges
An 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 prevention • Involved all departments in the IC Program Key Improvements
Provided IP with educational opportunities and support • Implemented new processes with lab for notification of results • Implemented improved Public Health Communication processes • Involved medical staff via the IC committee and at Med Staff Meetings • Updated all policies Key Improvements
Provided staff with resources, guidelines, books, reference materials Improved “Sharps Injury” processes, policy, manager and staff education, forms and documentation Initiated process changes R/T Single use tourniquets Improved endoscopy cleaning procedures Other Improvements
Initiated process changes R/T specimen transport Initiated process changes R/T how housekeepers refill disinfectant bottles Worked with providers to establish criteria for urine C&S orders Other Improvements
Implemented new policy for Blood and Body Fluids Exposure and Follow Up • Provided info, forms and process guidance for providers, managers and staff in the ER for any exposures. • Implemented an aggressive but fun immunization program for staff • Implemented employee illness tracking, new process and forms Other Improvements
The Bottom Line • Education • Staff Involvement • Teamwork • Administrative Support
Complimentary of the work we had done. Cited two issues, use of “Definitions of Infection for Surveillance” and Antibiotic Use Review. March 2011 LTC Survey
Implement processes for antibiotic use review Opportunity for medical staff involvement Another learning moment Antibiotic Review
The Road ahead • Growing 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.