August 2011Department of Quality and Safety
Mount Auburn Hospital
Infection PreventionJC Readiness
Environment of Care: Areas of Focus
SEPARATION OF CLEAN AND DIRTY
• Only clean/sterile items stored in clean utility space • Clean items stored outside of designated clean utility or
clean storage space must be clearly labeled as clean • Only dirty items stored in dirty utility room• PPE (gloves, fluid resistant gowns, and faceshields)
should be routinely available in dirty utility areas• No clean supplies stored under sinks
Environment of Care: Areas of Focus
PATIENT EQUIPMENTEvery non-disposable patient equipment must have a routine cleaning/disinfection schedule
• Non-critical items (contact only with intact skin of patients - e.g. BP cuffs, pulse oximetry, etc.) Define frequency/schedule i.e. between every patient, daily, weekly AND whenever soiling occurs
Precaution Patients – equipment is designated to that patient only or must be cleaned/disinfected after each use.
Environment of Care: Areas of Focus
PATIENT EQUIPMENT• Semi-critical (contact with mucous membranes of
patients e.g. thermometers, laryngoscopes, vaginal probes, TEEs, flexible endoscopes) 1. Pre-cleaning process (using enzymatic detergent)
2. Timed immersion in liquid chemical (Cidex OPA/Meticide)
3. Triple rinse
4. Dried and stored in clean draw/cabinet (not open to air)
Intense scrutiny on quality control documentation (logs on test strips and solution) and personnel training/competency.
Environment of Care: Areas of Focus
PATIENT EQUIPMENT• Critical Items (contact with normally sterile body cavities
e.g. biopsy forceps, bronchoscopes) 1. Decontamination and sterilization must be
controlled/centralized (i.e. SPD)
2. If sterilization performed outside SPD (e.g. OR – Immediate Use Steam Sterilization) process must meet same standards as SPD
Intense scrutiny on quality control documentation (e.g. cycle contents and parameters, biological indicators) and personnel
training/competency.
6
NPSGs: Focus on Processes of Care
NPSG.07.01 Hand Hygiene - Elements of Performance
1. Implement CDC or WHO hand hygiene guidelines
MAH policy revised in 2011 to incorporate CDC specific
indications for hand hygiene (not just In and Out)
2. Set Goals for Performance
3. Improve Performance
CDC Indications•Decontaminate hands before having direct contact with patients
•Decontaminate hands before donning sterile gloves
•Decontaminate hands before inserting invasive devices (non surgical procedure)
•Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient)
•Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings
•Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care
•Decontaminate hands after contact with objects (including medical equipment) in the immediate vicinity of the patient
•Decontaminate hands after removing gloves
•Before eating and after using a restroom wash hands with soap and water
“Five Moments”WHO 5 Moments for Hand Hygiene – Critical times
when hand hygiene should be performed
9
Performance Goals
Medical Safety Steering Committee June Meeting – 20 minutes of observations per
month from all areas
11
NPSGs: Focus on Processes of Care
NPSG.07.03.01 Implement Best Practices to
prevent MDRO (MRSA, CDI, VRE, ESBL) -
Elements of Performance
1. Measure and monitor MDRO prevention processes and
outcomes
2. Educate patients, and their families as needed, who are
infected or colonized with MDRO about prevention
Measure and Monitor MDRO Prevention
PROCESS OUTCOME
Measure and Monitor MDRO Prevention
PROCESS OUTCOME
14
NPSGs: Focus on Processes of Care
NPSG.07.04.01 Implement Best Practices to prevent central line
associated bloodstream infection (CLABSI) - Elements of
Performance
1. Educate patients and, as needed, their families about CLABSI Prevention
2. Perform hand hygiene prior to catheter insertion OR MANIPULATION
3. Do not insert catheters into femoral vein unless other sites are unavailable
4. Use supply/procedure cart that contains all necessary components for
insertion
15
NPSGs: Focus on Processes of Care
NPSG.07.04.01 Implement Best Practices to prevent central line
associated bloodstream infection (CLABSI) - Elements of
Performance
6. Full barrier precautions (includes full body patient drape)
7. Standardized protocol to disinfect catheter hubs and injection ports
8. Standardized protocol to disinfect catheter hubs and injection ports
9. Daily evaluate all central venous catheters and remove nonessential
catheters
Process Measure: CL checklist
• Implemented in ED and OR early 2011
• Value stems from empowered assistant/observer to monitor and attest to standards of asepsis
• Monitoring of checklist usage ongoing
Outcome Measure (rate)
18
Newest NPSG: Full implementation 2012
NPSG.07.06.01 Implement Best Practices to prevent indwelling
catheter-associated urinary tract infections (CAUTI) - Elements
of Performance
1. Insert according to evidence based guidelines addressing aseptic technique, equipment, and supplies
2. Appropriate management including:– Securing catheters for unobstructed flow– Maintain sterility of collection systems– Aseptic collection of urine samples/replacing collection system when required– Maintain drainage bag below level of bladder– Daily assessment of medical necessity and prompt removal of unnecessary
catheters
3. Monitor compliance with best practices – i.e. auditing
Outcome Measure (rate)
caUTI Rates by UnitNational
Rate (50%ile)
UNIT CasesFoley Days Rate Cases
Foley Days Rate Cases
Foley Days Rate
MICU 4 1489 2.69 0 155 0.00 4 1659 2.41 1.7N3 3 829 3.62 0 67 0.00 2 990 2.02 1.4N7 3 461 6.51 0 82 0.00 1 392 2.55 1.4N8 3 1213 2.47 0 152 0.00 2 1190 1.68 1.4PCU 3 1338 2.24 1 166 6.02 6 1601 3.75 1.2S3 15 2743 5.47 0 330 0.00 6 2965 2.02 1.4S4 4 583 6.86 0 100 0.00 3 619 4.85 1.4S5 0 0 0.00 0 0 0.00 0 0 0.00 0.0SICU 7 1282 5.46 0 205 0.00 1 1687 0.59 1.4ST3 3 864 3.47 0 100 0.00 2 902 2.22 1.4WYM2 0 73 0.00 0 23 0.00 0 56 0.00 0.0
TOTAL 45 10875 4.14 1 1380 0.72 27 12061 2.24
FY 10 Jul-11 FY 11
SSI and VAP
NPSG.07.05.01 relates to prevention of surgical site infections (SSI) – Elements of Performance are essentially SCIP measures
No NPSG related to VAP but MDPH requires monitoring of VAP process measures and rates (also tied to reimbursement)
Top Related