TJC Infection Control Standards 2011 Supplement Resources.

TJC Infection Control Standards2011 Supplement

Resources

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National Healthcare Safety Network (NHSN) NHSN was previously known as the National

Nosocomial Infection Surveillance System

It is a voluntary, web-based surveillance system by CDC Healthcare Quality Promotion

Goal to obtain national data on HAIs

Hospitals and ASCs may participate in the network

Available at www.cdc.gov/nhsn

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Risk Assessment

Infection Preventionist Tools

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www.infectionpreventiontools.com/home

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TJC Surveyor

May look at both the infection control plan and your risk assessment 1

May look for local statistics and data, relationship with outside agencies and that you prioritized the risks

May look at your review of the last two years of interventions and program related to hand hygiene

May observe an OR cases and observe the processing of instruments in Central Supply

1 www.unc.edu/depts/spice/jcaho.html

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Resources

TJC has Speak Up Initiatives including five things you can do to prevent infections

www.jointcommission.org/GeneralPublic/Speak+Up/about_speakup.htm

Options to Increase Isolation Surge Capacity www.jcrinc.com/common/PDFs/document_collection/

resources/collections/00032482/00032984-0001.pdf

Preparing for a Pandemic, EM Case Study, How the Health First Hospital Developed a Pandemic Influenza Plan

www.jcrinc.com/common/pdfs/qualityandsafety/preparing_for_a_pandemic_brevard_county_FL.pdf

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www.unc.edu/depts/spice

Spice

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TJC Crosswalk

http://www.jcrinc.com/common/pdfs/csr/forms%20and%20tools,%20newsletters/ic/CSR%20IC%20Self-Assessment%20June%20Update%20HAP%200709.doc

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www.cdc.gov/nhsn/mdro_cdad.html

AORN Updated Surgical Attire

All hospitals should be aware of the updated AORN surgical attire recommended practice

Hospital must launder all scrubs

States wearing scrubs as street attire creates exposure to infectious pathogens in the community

Recommendations for safe footwear and wearing jewelry

Recommendation on cleaning of stethoscopes and ID badges

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IV Spiking is 1 hour

IV should not spiked more than one hour before use

USP 797 requirement

APIC also has out a position paper that advices administering has soon as possible

Hospitals should also have a safe injection practices policy

Hospitals should follow the 10 CDC guidelines found in the isolation standards

CMS also has an infection control sheet (15 pages) that all ASCs must complete by the surveyor

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Reducing Surgical Site Infections

Land mark trial shows that chlorahexidine reduces surgical site infections instead of povidone-iodine

This changes the standard of care

Same edition of NEJM shows you can prevent surgical site infections by swabbing nasal site (rapid screen) and if staph aureus then decolonize

This can be done by rinse with chlorahexidine soap and use mupirocin nasal ointment

NEJM 362;18-26 January 7

Recent Issues June 2010 OSHA makes bold move to regulate

infection prevention and publishes in FR (new IC police) Issued May 6, 2010

June 2010 Environmental team at Mayo Clinic wipes out C-diff with bleach wipe program

June 2010 VA hospitals cut MRSA by 77% in ICUs with active surveillance

June 2010 SHEA and IDSA issues new C-diff guidelines

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8 Things to Reduce Post-operative Pneumonia Researchers from VA Palo Alto Healthcare System

and Stanford University employed 8 things to reduce pneumonia on the surgery floor

1. Education of all surgical and ward nursing staff about their role in pneumonia prevention

2. Cough and deep-breathing exercises with incentive spirometer

3. Twice-daily oral hygiene with chlorhexidine swabs

4. Ambulation with good pain control24

5. Head-of-bed elevation to at least 30 degrees and sitting up for all meals ("up to eat")

6. Quarterly discussion of the progress of the program and results for nursing staff

7. Pneumonia bundle documentation in the nursing documentation

8. Computerized physician pneumonia prevention order set in the physician order entry system.

Wren SM, Martin M, Yoon JK, and Bech F. Postoperative Pneumonia-Prevention Program for the Inpatient Surgical Ward.J Am Coll Surg; April 2010, Vol. 210, Issue 4: 491-495

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8 Things to Reduce Post-operative Pneumonia

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Institute for Healthcare Improvement

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Source: www.shea-online.org

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Source: www.his.org.uk

www.who.int/en

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www.theific.org

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Source: www.idsociety.org

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PA Patient Safety Authority

Source: www.patientsafetyauthority.org/Pages/Default.aspx

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Recent cases of improperly sterilized equipment.

PA Safety Authority reports number of reported cases of contaminated equipment from prior surgery

Portland VA sent out 2,270 letters of TRUS guided prostate biopsy equipment

FDA alert July 2006 and 2009 on prostate biopsy equipment

Called bioburden

Old dried blood and tissue came out of tissue protector on drill, triple trocar full of dried blood, suture remained on tunneler, and particles of tissue found on cannulated instruments

Sterilized Equipment Issue

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Sterilized Equipment Issue (continued)

Adequate cleaning is required to remove all residual that remains, if not prevents sterilization

Many wipe instruments with wet lap or gauze sponge with sterile water during or after procedure

CMS and TJC issue information on flash sterilization so make sure you pay attention to this issue

Soaking instrument in enzymatic solution after procedure and follow manufacturers instructions Immediately soak all instruments

May need to use brushes to remove material

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Cleaning of Medical Equipment

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MRDOs ResourcesCDC MRSA resources

www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Includes fact sheet on MRSA, MRSA in healthcare setting 2007, educational material, data, lab testing and practices, etc.

Isolation precaution 2007 www.cdc.gov/ncidod/dhqp/gl_isolation.html

VRE resources www.cdc.gov/ncidod/dhqp/ ar_vre.html

Guidelines for Prevention of Surgical Site Infections

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Resources APIC resources at www.apic.org and see

standards and guidelines

Guidelines for Environmental Infection Control in Health Care Facilities

Guidelines for Prevention of Surgical-Site Infections

Recommendations for Preventing the Spread of VRE

Guidelines to Prevent Intravascular Catheter Related Infections

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Many are on infection control

Implement best practices to prevent multiple drug resistant organisms MDROs

Educate staff and patients about MDRO and necessity for prevention

Measure MRSA and CDAD (C-diff associated disease)

Clean and disinfect equipment and patient care environment

TJC NPSGs

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IHI ICU Improvements VHA united with IHI to improve ICU care

Better control of blood sugars with glucose monitoring protocols1

Aggressive treatment of sepsis/blood stream infections (see central line bundle)

Prevention of ventilator associated pneumonia (see VAP bundle), surgical infections

Developed toolkits (order sets, protocols, daily goal sheets), report templates for monthly reporting of change

1 www.ihi.org

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Head of bed (HOB) elevation > 30 degrees

Deep venous thrombosis (DVT) prophylaxis

Peptic ulcer disease (PUD) prophylaxis

Daily sedation vacations

Assessment of readiness of wean

Oral care

Use a checklist and document each!

Ventilator Bundle

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Hand hygiene

Maximal barrier precautions upon insertion

Chlorhexidine skin antisepsis

Optimal catheter site selection with subclavian vein as the preferred site for non-tunneled catheters

Daily review of line necessity with prompt removal of unnecessary lines

Central Line Bundle

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Over 750,000 patients a year develop sepsis or septic shock in the US

Severe sepsis will kill 30% of infected patients and another 20% will die within six months

Surviving sepsis campaign

Can listen to presentations

Sepsis bundle lists seven tasks to be done during first six hours

Sepsis Bundle

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If hypotension, give serum lactate >4 mmol/L (deliver initial minimum of 20 mL/kg of crystalloid and vasopressors for arterial pressure less 65 mm Hg)

Bundle 5 is for persistent hypotension achieve central venous pressure > 8mm Hg and venous oxygen sat of > 70%

Sepsis Resuscitation Bundle

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Administer low dose steroids with standardized ICU policy

Administer recombinant human activated protein C (rhAPC) in accordance with a standardized ICU policy. If not administered, document why the patient did not qualify for rhAPC.

Maintain glucose control >70, but <150 mg/dL.

Sepsis Management Bundle

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Surviving Sepsis Campaign website1

Sepsis bundle website2

Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Critical Care Medicine. 2004;32(3):858-873.

See IHI, Defeating Sepsis; 25% by 20093 1 www.survivingsepsis.org2 www.survivingsepsis.org/implement/bundles3 www.ihi.org/IHI/Topics/CriticalCare/Sepsis/ImprovementStories/

FSDefeatingSepsis25Percentby2009.htm

Sepsis Bundle

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Do not put in unless absolutely necessary

Make sure meticulous care is followed in inserting

Remove ASAP

Document everyday considerations as to whether foley can come out

Follow evidence based literature and CDC guidelines on preventing catheter associated UTI

Many UTIs can be prevented with proper management of the indwelling urethral catheter

Maintain sterile closed system CDC 2009 guidelines at

www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html

Preventing UTI from Catheters

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Additional Resources

2011 CDC Guidelines for Prevention of Intravascular Catheter Related Infections, (pending)

CDC Guidelines for the Prevention of catheter-Induced Urinary Tract Infections, December 2009

www.cdc.gov/hicpac/cauti/002_cauti_toc.html

AHRQ toolkit

www.ahrq.gov/qual/haiflyer.htm

CA-UTI Resources

Pa Patient Safety has toolkit to prevent CA-UTIs http://patientsafetyauthority.org/EducationalTools/

PatientSafetyTools/cauti/Pages/home.aspx

APIC guidelines to eliminate catheter-associated UTI

AORN article Jan 2010 on new scip measure regarding urinary catheter removal www.aorn.org/News/Managers/November2009Issue/Catheter

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CA-UTI Resources

IDSA as the Diagnosis, Prevention, & Treatment of Catheter-Associated Urinary Tract Infections in Adults: 2009 International Clinical Practice Guidelines from the Infectious Disease Society of America

http://cid.oxfordjournals.org/content/50/5/625.full

Iowa Healthcare Collaborative toolkit

www.ihi.org/IHI/Programs/ImprovementMap/PreventCatheterAssociatedUrinaryTractInfections.htm

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Accreditation Connection, 6-28-2010

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Injection Safety CDC

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Advancing ASC Quality

ASC Quality Collaboration has ASC tool kit for infection prevention

Includes one on hand hygiene and safe injection practices

Includes a basic and expanded version of the toolkit

Available at www.ascquality.org/advancing_asc_quality.cfm

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2011 NPSG Chapter Outline

Proposed for 2012 NPSG

TJC is seeking comments on NPSGs for 2012

Looking at two proposed additions

Ventilator-associated pneumonia (VAP)

–Has seven elements of performance

Catheter-associated urinary tract infections (CAUTI)

–Has four elements of performance

Comment period ended January 27, 2012

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2011 NPSG Chapter Outline

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Goal 7: Reduce the Risk of HAIGoal: Reduce the risk of HAI

4 of 5 sections remain in 2011

Deleted 7 B on HAI as a sentinel event

In August 2010 Perspective noted changes to NPSG 07.04.01 and 07.05.01

NPSG.07.04.01 EP11

Added to use an antiseptic for skin preparation during insertion of central line that is cited in the scientific literature

Removed “use chlorahexidine” even though currently the standard of care but in the event it changes

Reduce Risk of HAI InfectionsIn August 2010 Perspective changes to NPSG 07.05.01 EP7 & 8 on implementing evidenced based practices for preventing surgical site infections (SSI)

EP7 Administer antimicrobial agents for prophylaxis for a procedure or disease

Removed “evidenced based practices”

Added to do this according to methods cited in the scientific evidence or endorsed by professional organizations

Removed give antibiotics one hour before the surgery and discontinue within 24 hours or 48 for cardiothoracic patients

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Reduce Risk of HAI Infections

EP8 Removed the section to “use clippers or depilatories” when hair is removed

Removed the note that shaving is an inappropriate hair removal method

Added to use a method that is cited in the scientific literature or endorsed by professional organizations

This is currently the standard of care

However, this new wording is flexible so if the new literature shows a new standard of care TJC does not have to go back and revise the standard

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Reduce Risk of HAI InfectionsIn March 2010 Perspective change to NPSG.07.03.01

The word “prevention” was accidentally omitted from EP3 in the 2010 NPSG publication

Patients and families should be educated, when needed, who are colonized with MDRO about health-care associated infection prevention strategies

Retained hand hygiene, MDRO, reducing central line associated blood steam infections, and preventing surgical site infections

Good resource is the April 2010 updates to the NQF 34 Safe Practices for Better Healthcare

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Hand Hygiene NPSG.07.01.01

Reduce the Risk of HAI: Comply with current CDC or WHO hand hygiene guidelines

Has 3 EPs

EP1 Implement a program that follows categories 1A, 1B, and 1C on one of the above

EP2 Set goals for improving compliance with hand hygiene guidelines

EP3 Improve compliance with hand hygiene guidelines based on established goals

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Implement Evidenced-Based Practices Implement evidenced-based practices to prevent

HAI due to multi-drug resistant organisms (MDROs)

07.03.01 (7C)

9 EPs

Applies to, but not limited to, MRSA, VRE, C-Diff, and MDRO gram negative bacteria

Patients continue to acquire health care associated (HAI) infections at an alarming rate

Need prevention and control strategies

Increased focus on cleaning and disinfecting equipment appropriately (IC.02.02.01)

Proper use of flash sterilization

Making sure all scopes are cleaned according to the manufacturer

Cleaning the patient environment is also important

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Implement Evidenced-Based Practices

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Evidenced-Based HAI Prevention

1. Conduct periodic risk assessment for MDROs acquisition and transmission

In time frame set by hospital

See IC.01.03.01, EPs 1-5 that talks about identifying the risk of acquiring and transmitting infections

Following slides on this provided for reference

TJC infection control chapter very important and dovetails with these infection control NPSGs

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Identify Risks for Transmitting Infections

IC.01.03.01 Hospital identifies risks for acquiring and transmitting infections

EP1 Hospital identifies risks based on geographic location, community, and population served

– NPSG.07.03.01 EP1 Conduct periodic risk assessments in time frames set by hospital for multidrug-resistent organisms (MDRO) acquisitions and transmission

– MDRO includes methicillin-resistant Staphylococcus Aureus (MRSA), Vancomycin-resistant Enterococcus (VRE), Klebsiella, and Acinetobacter

– CDC has free MDRO infection (and CDAD) surveillance and training on the National Healthcare Safety Network (NISN)

– 1 www.cdc.gov/nhsn/wc_MDRO_CDAD.html

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Identify Risks for Transmitting Infections IC.01.03.01

EP2 Hospital identifies risk for acquiring and transmitting infections based on the care and treatment it provides (on MDRO)

EP3 Look at risk for acquiring or transmitting an infection by doing an analysis of surveillance activities and other infection control data (including MRDO and adverse tissue reactions)

EP4 Review and identify risks annually and when there is a significant change and get input from IP, MS, nursing, and leadership including MRDO

EP5 Prioritize these risks

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Evidenced-Based HAI Prevention MDRO

2. Educate staff and LIPS about HAI, MDROs, and preventive strategies in orientation

At hire and annually

Use information from your risk assessment

Education must reflect their diverse roles

3. Educate patient and their families about HAI strategies who are infected or colonized with MRDO, as needed

4. Implement a MDRO surveillance program based on your risk assessment

Surveillance may be targeted rather than hospital-wide

CDC has MDRO surveillance training at www.cdc.gov/nhsn/wc_MDRO_CDAD.html

Has many resources including training videos on MDRO surveillance, slide sets, protocols, reporting plan, etc.

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5. Measure and monitor MDRO prevention processes and outcomes including; MDRO infection rates using evidence based metrics, compliance with evidenced based practice, and evaluate education provided

6. Provide MRDO process and outcome data to key stakeholders, nurses, doctors, LIPs and other clinicians

7. Implement P&Ps to reduce transmission of MRDOs which meet CDC and other professional organization standards (APIC,SHEA,OSHA, AORN)


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Evidenced-Based Practices MDRO

8. Implement a laboratory based alert system that identifies new patients with MDRO when indicated by the risk assessment

The alert system can be manual or electronic and can use faxes, pages, telephones etc.,

9. Implement an alert system that identifies readmitted or transferred MRDO positive patient when indicated by risk assessment

Alert system can be in a separate database or integrated and can manual or electronic

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MRDOs Resources CDC Management of MRDOs in Healthcare Settings

2006, 74 pages, at www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

Provides strategies and practices to prevent MRSA, VRE and other MDROs,

Includes gram neg bacilli (GNB), E. coli and Klebsiella pneumoniae, stenotrophomonas maltophilia, burkholderia cepacia, and ralstonia picketti

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MRDOs Resources

CDC MRSA resources at www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Includes fact sheet on MRSA, MRSA in healthcare setting 2007, educational material, data, lab testing and practices, etc.

Isolation precaution 2007 at www.cdc.gov/ncidod/dhqp/gl_isolation.html

VRE resources at www.cdc.gov/ncidod/dhqp/ar_vre.html


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Resources

APIC resources at www.apic.org and see standards and guidelines

Guidelines for Environmental Infection Control in Health Care Facilities


Recommendations for Preventing the Spread of VRE

Guidelines to Prevent Intravascular Catheter Related Infections

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Central Lines 07.04.01 (7D)

Implement best practices to prevent central line associated bloodstream infections,

13 EPs

IHI has how to guides and other resources at www.ihi.org (Keystone project)

EP1 Educate staff and LIPs involved in procedures about HAI, central line infection and importance of prevention

Must do education in orientation and annually and if procedure added to your job

Revised How-to Kit Central Lines

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Central Lines

Note that under reform law hospitals with ICUs or NICU must report central lines infections on the CDC National Healthcare Safety Network (NHSN)

2. Educate patients and families before inserting central line about central line associated bloodstream infection prevention (BSI), as needed

3. Implement P&Ps to reduce risk of BSI that meet regulatory and evidenced based standards

Central Lines 07.04.01 P&P need to meet the regulatory requirements

Need to be aligned with the CDC requirements

And professional standards of care (APIC, AORN, SHEA, etc.)

4. Conduct periodic risk assessments for central line infection, measure BSI (blood stream infection) rate, and monitor compliance with best practices and how effective the prevention efforts are

Need to do risk assessment conducted in the time frames defined by the hospital

Surveillance is hospital wide and not targeted101

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Central Lines

5. Provide CLAI (central line associated infection) rate data and prevention outcome measurement to staff and LIPs and clinicians

6. Use a catheter checklist and standard protocol for central line insertion

7. Perform hand hygiene before catheter insertion or manipulation

8. Do not put in femoral vein unless last resort for adult patients

9. Use standardized supply care or kit for central lines

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Central Lines

10. Use standardized protocol for maximum sterile barrier precautions during insertion

11. Use antiseptic for skin prep in patients during insertion that is cited in the scientific literature or endorsed by professional organizations

12. Use standardized protocol to disinfect catheter hubs and injection ports before accessing

Such as wipe vigorously for 15 sections and let dry

Surveyor will ask to see the protocol or P&P

13. Evaluate all central lines routinely and remove none essential catheters


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Surgical Site Infections (SSI)

Implement best practices to prevent surgical site infections

There are 8 EPs

1. Educate hospital staff and LIPs involved in procedures about HAI, surgical site, and the importance of prevention

Educate during orientation, annually, and if added to your job

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Surgical Site Infections

2. Educate patients and families, who are undergoing surgical procedures, about preventing surgical site infections (SSI)

3. Implement P&P to reduce SSI that meet regulations and evidenced based practice (such as the CDC and other professional organizations)

4. Conduct periodic risk assessments for SSI, select measures using best practices or evidence based guidelines and monitor compliance with them and how effective they are

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5. Measure surgical site infection rates for the first 30 days following a procedure that does not involve inserting implantable devices

Measure for the first year procedures involving implantable devices

Need to follow evidence based guidelines

Surveillance may to targeted to certain procedures based on hospital risk assessment

6. Provide process and outcome data on SSI to stakeholders etc, such as the SS infection rate

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7. Antimicrobial agents for prophylaxis are administered according to methods cited in the scientific literature or endorsed by professional organizations

Still want to be sure that prophylactic antibiotics are administered timely in the operating room and rebolused when indicated

8. When hair removal is necessary, use a method that is cited in the scientific literature or endorsed by professional organizations

www.cdc.gov/hicpac/CAUTI_fastFacts.html

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www.cdc.gov/hicpac/Disinfection_Sterilization/acknowledg.html

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www.cdc.gov/hicpac/pubs.html

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The End Questions?

Sue Dill Calloway RN Esq. CPHRM

AD, BA, BSN, MSN, JD

Medical Legal Consultant

614 791-1468

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TJC Infection Control Standards 2011 Supplement Resources.

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