So, You Think You Know

What You Are Looking For –

What is Hiding From You?

Carol Calabrese, R.N., B.S., C.I.C.

Senior Clinical Advisor – Infection Prevention

Indiana Annual Fall Conference

Conflict of Interest

I am employed by Diversey, however, the

content of this presentation was developed

solely from my experience as an Infection

Preventionist and Evidence Based literature

Goals and Objectives

Describe 2 different types of rounds

State 3 goals of conducting rounds

Identify the process(s) in which solutions to the findings are

acted upon

IC.01.03.01, EP 1:

The [organization] identifies risks for acquiring and

transmitting infections based on the following: Its

geographic location, community, and population served.

(See also NPSG.07.03.01, EP 1)

Rounding Types

Rounding to Influence

Environment of Care Rounds

Infection Prevention Rounds

Point Prevalence

Rounding to Influence

Rounding to influence:

is one element of an evidence-based bundle of

leadership methods used in highly reliable

organizations that is focused on driving the

successful execution of specific safety or

infection control practices.

EOC – Environment of Care

EC.04.01.01: The [organization] collects information to

monitor conditions in the environment

EP 1: The [organization] establishes a process(s) for

continually monitoring, internally reporting, and investigating

the following: Utility systems management problems, failures,

or use errors

Environment of Care

Frequency

Who performs

The physical building

The equipment used to support patient care or safely operate

the building or space the people – including those working in

the hospital, other patients and anyone else who enters the

EOC

The people – including those working in the hospital, other

patients and anyone else who enters the EOC

EC Toolbox

Environment of Care documentation checklist

https://www.jcrinc.com/my-account/free-resources/

Infection Prevention Rounds

ENVIRONMENTAL HYGIENE TJC/CMS ASSESSMENT TOOLHOSPITAL EXAMPLE

TAG Environmental Hygiene TJC/CMS Assessment YES NOUnable to

Observe N/A Number Follow Up Notes

2.D.1 /LLD #4

During environmental cleaning procedures, personnel wear appropirate

PPE to prevent exposure to infectious agents or chemicals (PPE can include

gown, gloves, masks, and eye protectetion

X

Use of PPE was noted when entering rooms of patients

on Precautions. However, when dispensing chemicals,

staff verbalized that PPE is not used.

2.D.2

Environmental surfaces in patient care areas are cleaned and disinfected

using an EPA - registered disinfectant on a regular basis (e.g., daily), when

spills occure and when surfaces are visibly contaminated. Note: High- touch

surevaces (e.g., bed rails, overbed table, bedside commode, lavatory

surfaces in patient bathrooms) are cleaned and disinfected more frequently

than minimal touch surfaces

x

This is not well defined. High touch surfaces, based upon

P/P are only cleaned once per day. Education regarding

increased cleaning frequency and expectations needs to

be evaluated and supported by senior leadership

2.D.3

After a patient vacates a room, all visibly and potentially contaminated

surfaces are throughly cleaned and disinfected and towels and bed linens

are replaced with clean towels and bedlinens

X *? Use of approved products

2.D.4

Cleaners and Disinfectants, including disposable wipes, are used in

accordance with manufacturer's instructions (e.g., dilution, storage, shelf -

life, contact time)

x

*Wipes used for room disinfection are not designed for

cleaning. They are like a paper towel and lack the design

to clean

2.D.5Separate clean (laundered if not disposable) cloths are used to clean each

room and corridorx x

2.D.6

Mop heads and cleaning cloths are laundered at least daily using appropiate

laundry techniques (e.g., following manufacturer instructions when

laundering microfiber items).

x A combination of string and microfiber mobs are used.

2.D.7

The hospital decontaminates spills of blood or other body fluids according

to its policies and procedures, using appropiate EPA - registered

disinfectants.

x

2.D.8

The hospital has established and follows a schedule for areas/equipmentto

be cleaned/serviced regularly (e.g., HVAC equipment, refrigerators, ice

machines, eye wash stations, scrub sinks)

x

Facilities is responsible for the cleaning of ice machines.

An ice machine was noted to have considerable build up

at the dispenser and around draingage area.

2.D.14

Reusable noncritical patient - care devices (e.g., blood pressure cuffs,

oximeter probes) are disinfected on a regular basis (e.g., after use on each

patient, once daily or once weekly) and when visable soiled.

x x

ER tech observed conducting turnover cleaning, partically

cleaned top surface of mattress, side rails were not

cleaned/disinfected. Cables and bld pressure cuff

cleaned, however, no other surfaces in the bay were

disinfected.

2.D.15

For patients on Contact Precautions, if dedicated, dsiposable devices are not

available, noncritical patient - care devices are disnfected after use on each

patient,

X

Disinfectants, both a quat/alcohol and bleach were

availble in the majority of patient rooms. Bleach should

only be available if pt with CDI, C auris, or Norovius -

some equipement have brackets to hold disinfectant

container while others don't. Did not observe equipment

being wiped between patients. One nurse stated that

they use bleach on everything.

2.D.16/TJC LLD #1/NsgTracer #2, There is clear disgnation of responsibility for disinfection of reusable

noncritical patient - care devices.x

Staff verbalized that they are unsure of whO is to clean

certain equipment or who is cleaning the invasive

procedural area of the Hybrid Cath Lab - the hybrid cath

lab can be used to perform, open heart surgery,

placement of ICD and/or pacemakers. There is not clear

distincition of a "restricted" area entering the

department. Flies found (6) dead on floor in core area of

this department.

MONTHLY INFECTION CONTROL ROUNDS

DATE RECORDER

Completed by:DQM/Infection Control Practioner, or designee

Specific Directions: Indicators with an * require sampling of 10 observations or interactions. Record as number met, i.e., 8/10

INDICATOR MET NOT MET N/A ACTION TAKEN IMMEDIATELY FOLLOW-UP NEEDED

HALLS & COMMON AREAS

Floors are clean, free of trash and boxes on floors

Lights are free of dust/bugs

*

Furniture is clean & in good repair (nurse station & visitor areas)

Bottom storage shelves have 6" clearance for cleaning

Linen carts are covered

Linen carts are in good repair

Nothing stored on top of linen carts

PERSONNEL STANDARDS Compliant: YES Compliant: NO DESCRIPTION/COMMENTS

Attire:

Properly tied surgical masks

Surgical caps/hood covering all hair

Dress code followed:

Jewelry

Fanny packs

Long sleeves

Turtlenecks

Shirts tucked

Only those in appropriate attire enter the OR

Surgical Hand Scrub

Product used Name product:

Correct procedure for product

Nail cleaner used for first case

No artificial nails, natural nails correct length

Sterile Field:

Sterile items left open no > than 30 minutes prior to patient entering room

Scrubbed persons maintain sterility of sterile gown, gloves, supplies

Hands remain above waist

Sterile field constantly monitored

Items introduced into sterile field opened, dispensed, transferred by methods to maintain sterility/integrity

Items/devices dropped below level of the OR table are considered contaminated

All personnel moving in/around sterile field do so in manner to maintain sterility

Adjacent sterile fields not at disparate heights

Separation of sterile team from non-sterile team maintained

Staff do not turn back to sterile field

Traffic in and out of room kept to minimum

ADDITIONAL STANDARDS Compliant: YES Compliant: NO DESCRIPTION/COMMENTS

Anesthesiology:

Drainage bags kept off the floor

Aseptic practice used for IV tubing, fluids, medications

Aseptic practice used for all invasive procedures: (epidurals, blocks, IV insertion)

Anesthesia cart appears clean

Cleans shared equipment (e.g, stethoscope) between cases

OSHA/Bloodborne Pathogens

Appropriate eye protection used

Sharps containers not overfull

Shoe covers/boots if indicated

Surgeons/first assistants double gloved (recommended)

Circulators wear latex/nitrile gloves for handling contaminated items. Performs hand hygiene after glove removal

Sharps are passed in a basin or by using neutral zone rather than by hand

Sharps safety devices Devices used:

General Infection Control:

Patients with communicable disease handled appropriately

Sterile team removes gloves and washes hands at end of case

Policies regarding flash sterilization are followed

Personnel appear free from communicable disease (no open skin lesions on hands/face)

Observers comply with “Observers Protocol” for Surgical Services

Clean, sterile, and soiled items are kept separate

Patient transported via clean corridor

OR OBSERVATION CHECKLIST

Date of observation: ______ Time: from ________ to ________ OR# ________ Observers:

____________________________________

Procedure(s): _______________________ Service: _____ Attending: _____________ Anesthesia

Attending: ____________ # Persons in OR: ____

Specify parts of procedure observed:

___________________________________________________________________________________

SURGERY INFECTION PREVENTION & CONTROL CHECKLISTScore: 0=non-compliant or 1 = compliant for each measure assessed. Mark N/A if not assessed.Compliance rate: _____/______ measures met OVERALL________%

CATEGORY SCORE COMPONENTS

PREOPERATIVE AREA

HAND HYGIENE

Hand hygiene performed:performed before & after patient contactafter removing glovesbefore performing invasive proceduresafter contact with blood, body fluids, or contaminated surfaces

Alcohol based hand rubs available

Standard Precautions used for all patients

HAIR REMOVAL

Clippers used for needed hair removal

OPERATIVE AREA

PPE

Personal protective equipment, including mask with face shield or mask with goggles, donned when splashing is likely

Appropriate PPE available & used

ATTIRE

Rings, watches, bracelets must be removed before beginning surgical hand scrub

All jewelry is confined within scrub attire or removed when personnel enter the semirestricted or restriced zones of the surgical suite

A fluid-resistant mask is worn in the restricted zones of the operating suite.

Hair covering: covers & contains all hair

Artificial fingernails or extenders are restricted. Natural nails are kept < 1/4 inch long.

New mask per case, not hanging around neck

Shoe covers removed when soiled, torn & when leaving the surgical area

Hoods cover facial hair.

SHARPS

Sharps disposal in rigid containers enforced.

Sharps containers replaced when 3/4 full.

EQUIPMENT

Mattresses & vinyl coverings intact on all positioning equipment (OR beds, arm boards, roller, etc)

Stored equipment has dust covers

ENVIRONMENT

OR lighting intact

Operating rooms are terminally cleaned daily

Floors & horizonatal surfaces cleaned on a daily basis

Department maintained in a clean & orderly manner

Traffic is restricted to authorized appropriately attired personelL

Required use of disinfectants & germicides in accordance with manufacturers' instructions.

Appropriate use of facility & medical equipment, including air filtration equipment, UV lights, etc.

Fluid warmers <104 degrees F

Blanket warmers <130 degrees F

Emergency carts: code carts, malignant hyperthermia cart checked for expired supplies & medications.

Linen and waste bags remain in the OR room until the patient has been transferred out of the room

Red bag waste handled appropriately

OSHA compliant eyewash/shower equipment available in decontamination & clean processing areas; tested weekly

INTRAOPERATIVE

ASEPSIS SURGICAL ENVIRONMENT

Sterile technique used for all sterile procedures.

Scrubbed persons wear sterile gowns & gloves

Sterile drapes used to establish a sterile field

Items used within sterile field are sterile

sterile field is monitored and maintained.

All items introduced onto a sterile field are opened, dispensed, & transferred by methods that maintain sterility & integrity.

All personnel moving within or around a sterile field maintain integrity of sterile field.

Policies & procedures for basic aseptic technique are written, reviewed annually, & readily available within the practice setting.

Surgical counts completed appropriately: sponge count per package

Surgical instruments counted by type or grouping

VIALS/MEDICATIONS

Single dose (single-use) vials used for only one patient.

Measures specific to safe practices for injecting medications & saline or other infusates.

Multi-dose injectable medications used for only one patient

No multiple-use fluids (e.g., alcohol, betadine, lubricant)

Medications locations secured. (e.g., satellite pharmacy, anesthesia carts)

OTHER

DISINFECTION

Blood glucose meters disinfected between patients

OneSource: Employees knowledgeable of reference used for access to manuracturer recommendations.

Disinfection of medical equipment is done according to manufacturer recommendations.

STORAGE & TRANSPORT

Items are stored in a manner that will not compromise sterility

No expired supplies

Sterile supplies stored in closed cabinets or open shelves with solid bottoms, or bottom shelves with liners.

Linen stored & covered.

Supplies are removed from their outside (shipping/transport) containers before entering the operating room.

Items transported are covered or contained during transport.

Soiled items are covered in containers or case carts during transport from the individual operating room through the semirestricted zone to a decontamination area for temporary storage until reprocessing.

All soiled items are contained & stored separately from clean or sterile items.

Transport carts have solid bottom shelf

Carts, covers, and containment devices are disinfected between uses.

REFERENCEs:

1. Allen George, Frye Cathy. Infection Control A practical guide for health care facilities. Operating Room, Chapter 6.2. APIC text of infection control & epidemiology. Available from: http://text.apic.org/item-49/chapter-45-surgical-services. Retrieved May 22, 2014.

Point Prevalence

PPE for

Isolation

APIC Implementation Guide to Preventing Catheter-Associated Urinary Tract Infections

2014

Rounding Goals

Identify Compliance

Build relationships

Discuss concerns

Identify what is going well

In The News

Clinical Leadership & Infection Control

Bone, blood, bugs found on instruments at Denver hospital after surgical

breach, report says

Written by Alyssa Rege | June 14, 2018

Clinical Leadership & Infection Control

Infection Prevention Rounds: 15 Items to Address

March 21, 2011

https://www.beckersasc.com/asc-quality-infection-control/infection-

prevention-rounds-15-items-to-address.html

ww.apic.org/ambulatorynewsletter.

Across the board

Items that need to be addressed across the

facility

Got Singles

Are departments using items sold as “single use” that they are “cleaning” and using again?

Salter Labs ThermiSense Sensor Cadwell Adult Kit

Transport of Instruments

TJC

AAMI

Accreditation and Certification

4-1-1 on Survey Enhancements: New scoring revisions for

IC.02.02.01 now in effect

Infection Control (IC) standard IC.02.02.01 — which requires

hospitals to reduce the risk of infections associated with

medical equipment, devices and supplies — continues to be

one of the most commonly cited standards listed as

noncompliant. In 2017, 72 percent of surveyed hospitals and

critical access hospitals were found to be noncompliant with

this standard.

After a careful evaluation of high-level disinfection (HLD) and

sterilization process steps, The Joint Commission has refined

its scoring to focus on the process steps that pose the highest

risk to patients if they fail.

Sept 5, 2018

Central Supply

Patient Care Units

Patient rooms

Clean utility room

Soiled utility room

EVS closet

Medication room/area

Nutritional area

Procedural areas

Negative Pressure Rooms

ResearchGate

Endoscopy/Bronchoscopy

Process for transporting used

Storage

Re-processing – “Hang Time”

https://www.hmark.com/7day.php

Linen/Laundry Services

Curtain changing rotation

Tour of where laundry services are done

Transportation of clean and soiled laundry

Use the Healthcare Laundry Accreditation

Council’s standards as assess the facility

Operating Rooms

OR turnover

Monitoring of traffic flow

Decontamination room

Foley and central line insertion

Line access

Terminal Cleaning

Instruments handling

Immediate Use SterilizationGetty Images

Pharmacy

Compounding Areas

Medication Prep area

The "clean room" at Massachusetts General Hospital's central

pharmacy

Radiology

Interventional Radiology – room turnover and

terminal daily cleaning, traffic flow pattern, hospital

provided scrubs

Management of injectable dyes

Cleaning of equipment and lead aprons

Foley management in MRI

Insertion of Central Line

Dyes

Multi-dose vials

Cardiac Catheterization Lab/Interventional

Radiology

Scrubs – hospital provided – attire

Room turnover/Terminal cleaning logs

Doors/traffic flow

Ventilation

Dust

Aseptic technique

Management of contaminated instruments

Respiratory Therapy

Bronchoscopy scope HLD

Humidifiers and dehumidifiers

Sleep lab – CPAP equipment, Thermistors,

monitor cables

Cleaning of ventilator equipment

? Use of multi – dose inhalers

Sterile supplies where they don’t

belong

Rooms without temp and humidity control

Rotation of stock

Checking for outdates

Dust control

Shoe Leather Rounding – Going for a

Walk!

Being visible is good

Staff invariably have questions

related to their area, or perhaps

outside of the hospital

Being approachable is good

We don’t always need to have

paper in hand, so to speak!

Shoe Leather Infection ControlMifa

What do you do with all the findings?

Reporting – to whom, what and when

Resolution of findings

The APIC /JCR

Infection Prevention and

Control Workbook Third Edition

Summary

What are possible concerns that can be observed across the organization

Infection Prevention covers the breath and depth of an organization

It is important to have a process of reporting and resolution

There are many different types of rounds to aide in identifying what may need to be addressed