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Infection Control Risk Assessment

By Carrie Boyd,2014-10-17 12:50
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Infection Control Risk Assessment

    _____________ Infection Control Plan and Risk Assessment

    This Plan has been approved by the Executive Committee with input and collaboration from the following:

    ; Safety Committee -Surgery IDT -Ortho IDT -Cardiac IDT -Critical Care IDT

    ; Leadership including Department Managers

    ; Performance Improvement

    ; Medical Staff Director for Infection Control

    A risk assessment is a component of this plan. The plan and risk assessment are formally reviewed at least annually and whenever significant changes occur in the elements that affect risk.

I. Risk Assessment Date: November 2008

    Factors Characteristics that increase risks Characteristics that decrease risks Geographic location and community environment No prenatal care for many OB patients Four Seasons/Winter has decreased risk of West Nile

    _______________ Decreased number of people with health insurance Virus.

     International travel Excellent healthcare in Pacific Northwest. City/County

     ________ County has more terrorist activities than other disaster planning committee actively involved in

     counties in Washington planning and prevention. Care, treatment and services provided Neutropenic population No transplant services

    ; Medical Implant surgeries No intensive pediatric cases

    ; Surgical Lack of Level 1 trauma services

    ; Emergency Lack of Neonatal Intensive Care Level 1

    ; NICU Ventilator usage

    ; ICU Invasive procedures

    ; CCU Central lines and Foley Catheters

    ; Cardiac

    ; OB

    ; Oncology

    Population Characteristics 48% Staph aureus isolates are methicillin resistant (MRSA) in Endemic tuberculosis has a very low rate.

     both ____________ labs Low endemic rate VRE

     Low vaccination rates in surrounding counties

Analysis of infection Prevention and Control Data

    High Risk: Problem-Prone:

    Total Hip Arthroplasty Employee exposure to BBP

    Total Knee Arthroplasty Vascular & Ortho Surgical Site infections

    CABG Valve Open heart High UTI rate in both ICU and

    NICU

    Vascular graft surgeries

    ICU, CCU patients with Invasive procedures

    Neutropenic patients

    High Volume: Improvement needed:

    Total joints Evaluation of additional interventions to decrease surgical site infections Discectomies Monitor timing of pre-op prophylactic antibiotics

    Increase in care of patients with MRSA Use of pneumococcal and influenza vaccine for patients Volunteers and employees screened for tuberculosis & immunity to vaccine preventable Hand hygiene compliance

    diseases. Isolation Precautions used appropriately

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II. Based on the risk assessment, the facility has identified the following risks and prioritized them in descending order

    1. -Sentinel event, Root Cause Analysis

    2. -Surgical Site Infections

    3. Total knee arthroplasty, Total hip arthroplasty, CABG, Valve open hearts, Vascular graft surgery

    4. -NICU concern for BSI 5. ICU/CCU invasive procedure related infections

    6. Ventilator associated pneumonia, Central Line Associated BSI, Foley Associated UTI 7. Incidence of MRSA in community

    8. -TB screening and Vaccine Preventable diseases for employees, volunteers & patients 9. -Outbreak prevention and control

    III. Action Plan (For each prioritized risk, identify goal, strategies, responsible person, time frame and evaluation of effectiveness)

Risks Goals Strategies Implementation

     Interventions Responsible person Timeframe Method of Evaluation Root Cause Analysis Identify systems Review cases of death or loss of Infection Control Ongoing Document evaluation in Infection of Sentinel Event problems function involving infections with PI to Performance Improvement Control and PI reports and Joint identify need for RCA. Commission Book Total Joint Maintain rate below Provide alcohol surgical scrub, monitor Infection Control Continuous data collection SSI rate with data analysis compare SSI CDC Mean timing prophylactic antibiotics, screen Physician with reporting and analysis to CDC Mean and our historical data. for MRSA in high risk patients, OR/Anesthesia staff every 6 months OR PI monitor of prophylactic feedback. antibiotic use. CABG Maintain rate below Provide alcohol surgical scrub, monitor Infection Control Continuous data collection SSI rate with data analysis compare SSI CDC Mean timing prophylactic antibiotics, screen Cardiac outcomes staff with reporting and analysis to CDC Mean and historical data. for MRSA in high risk patients, Physician every 6 months OR PI monitor of prophylactic feedback. OR/Anesthesia staff antibiotic use. Cardiac Valve Maintain 0% Cardiac Provide alcohol surgical scrub; monitor Infection Control Continuous data collection SSI rate with data analysis compare SSI Valve SSI through 2006, timing of prophylactic antibiotics, Cardiac outcomes staff with reporting and analysis to CDC Mean and our historical data 2007, and 2008 feedback. Physician every 6 months OR PI monitor of prophylactic OR/Anesthesia staff antibiotic use. Vascular Graft Maintain 0% rate in Provide alcohol surgical scrub, monitor Infection Control Continuous data collection SSI rate with data analysis compare SSI 2007 through 2008 timing of prophylactic antibiotics, Cardiac outcomes staff with reporting and analysis to CDC Mean and our historical data. feedback. Physician every 6 months OR PI monitor of prophylactic OR/Anesthesia staff antibiotic use. NICU Prevention of infections Vermont Oxford program monitor for ____________ Continuous Rate comparison with Vermont BSI Oxford participants. CICU Decrease rate to below Insertion Site, Hand Hygiene, Prep ICU/CCU night nurse Continuous data collection Rates benchmarked to CDC mean CLBSI CDC mean of 1.6 Chlorhexidine, Maximum barriers, daily denominator data. with reporting and analysis and unit historical data. evaluation to dc. Optional use of Stat Infection Control every 6 months Locks. Feedback. Numerators

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Risks Goals Strategies Implementation

     Interventions Responsible person Timeframe Method of Evaluation CICU Maintain rate below Head of bed > 30 degrees, daily ICU/CCU night nurse Continuous data collection Rates benchmarked to CDC mean VAP CDC mean of 5.7 sedation vacation & evaluate for denominator data. with reporting and analysis and unit historical data. extubation, ulcer/DVT prophylaxis, oral Infection Control every 6 months care. Continuous hand hygiene Numerators education. Feedback. CICU 2008 goal to decrease Mandatory hand hygiene education ICU/CCU night nurse Continuous data collection Rates benchmarked to CDC mean UTI rate to below CDC Staff feedback denominator data. with reporting and analysis and unit historical data. mean of 3.7 2007 Implemented silver gel catheter; Infection Control every 6 months 2008 ensure silver coated catheters are Numerators in use and used appropriately. ICU 2008 goal to maintain Insertion Site, Hand Hygiene, Prep ICU/CCU night nurse Continuous data collection Rates benchmarked to CDC mean CLBSI unit rate of 0% since Chlorhexidine, Maximum barriers, daily denominator data. with reporting and analysis and unit historical data. Jan 2006. evaluation to dc. Optional use of Stat Infection Control every 6 months Locks. Feedback. Numerators ICU Maintain rate below Head of bed > 30 degrees, daily ICU/CCU night nurse Continuous data collection Rates benchmarked to CDC mean VAP CDC mean of 2.7 sedation vacation & evaluate for denominator data. with reporting and analysis and unit historical data. extubation, ulcer/DVT prophylaxis, oral Infection Control every 6 months care. Continuous hand hygiene Numerators education. Feedback. ICU Maintain rate below Mandatory hand hygiene education. ICU/CCU night nurse Continuous data collection Rates benchmarked to CDC mean UTI CDC mean of 3.1 Staff feedback denominator data. with reporting and analysis and unit historical data. 2007 Implement silver gel catheter; Infection Control every 6 months 2008 ensure silver coated catheters are Numerators in use and used appropriately. Multiple drug Reduce transmission in Hand hygiene monitoring and Patient Care Ongoing 1-Availability of alcohol gel during resistant organisms facility education. Infection Control Safety Rounds as well as measuring Identify those with history of or positive Safety Committee soap and sanitizer use quarterly cultures and isolate. MRSA task force 2-Log ongoing ESD’s Monitor correct use of isolation 3-Environmental checklists precautions. 4-Monitoring Contact Isolation Monitor environmental cleaning; ensure 5-Evaluation & Quarterly report to cleaning is done according to check list Exec. and done correctly. 6-Safety to monitor use of alcohol gel Vaccine preventable New Employees, Screen new employees, Employee Health Ongoing 100% compliance expected diseases Volunteers, Volunteers Leadership & Students Contract with schools Case management, PI Pneumococcal ongoing, Immunity 100% Influenza vaccines offered to Patient care physicians Influenza Oct-March Patient immunity 100% employees, volunteers, and patients CMS Monitoring comparisons Pneumococcal vaccine offered to patients TB screening No disease transmission Health history for Volunteers Employee Health Ongoing 100% compliance expected for skin Tuberculin skin test (TST) Screening of tests employees Monitor for exposures See TB Assessment Outbreak Prevention Identify and prevent Respiratory/Cough Etiquette Patient Care Ongoing Quarterly infection control monitoring & Control acquisition and Hand Hygiene Safety Committee Visitor signs during flu Emergency Plans Manual updates transmission of disease Visitor signs Infection Control season Documentation of assessment for Use of PPE & prophylaxis during Employee Health At time of outbreak prophylaxis. community pertussis outbreaks. Add smallpox, SARS & Pandemic influenza to Disaster Plan

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Risks Goals Strategies Implementation

     Interventions Responsible person Timeframe Method of Evaluation Neutropenic Patients Prevention of Neutropenic precautions Patient Care Ongoing Monitor plant records for showerhead acquisition and Hand Hygiene changes. transmission of Change or clean shower head 11/2/05 system is working. infections when neutropenic precautions ordered. 1/07 system is not working after a computer upgrade. 3/07 system working again.

IV. Formal Evaluation Original 1/05 re-evaluate 11/05, 8/06, 2/07, 1/08

    A. Areas with Continuing Risk

    1. Sentinel Events

     There have been no infection prevention and control sentinel events

    2. Total Joints

    Hip Prosthesis goal of maintaining SSI rate below CDC ____Goal met. Hip Prosthesis SSI rate= _____________ .

    Knee Prosthesis goal of maintaining SSI rate below CDC mean for 2006 was not met. Knee Prosthesis SSI rate= _________.

    The interventions of 1) Changing razor/clipper documentation to reflect usage of clippers only

     2) Evaluating surgical site prep process

     3) Decreasing use of flash sterilization by purchasing new instruments

     4) Enforcing dress code on ortho unit and continue aseptic technique education

     5) Decreasing traffic flow in OR room and 6) monitoring prophylactic antibiotics were effective.

     Education in OR continues;

     Consider additional interventions by 12/31/08, such as placing UV lights in OR suites where ortho and cardiac surgeries occur, screening high risk

     patients for MRSA by nasal swab pre-op, then initiating treatment to decrease the colonization pressure before surgery if MRSA positive. 3. CABG

     CABG goal of maintaining SSI rate below CDC means was met. ___________________________________________________ interventions of providing alcohol scrub and

    monitoring timing of prophylactic antibiotics were effective. Consider additional interventions listed above.

    4. Cardiac Valve

     Cardiac Valve goal of maintaining 0% SSI rate for 2006 and 2007 has been met. Interventions of providing alcohol surgical scrub and monitoring prophylactic antibiotics have

    been effective. Interventions listed in total joint section were effective. Consider additional interventions listed in Ortho section.

    5. Vascular

     Vascular goal of continuing to decrease rate from high rates in 2004 has been met. Each year there has been a decrease; total for 2007 was 0%.

     6. NICU

     See NICU program.

     7. CICU CLBSI

    CICU goal to maintain CLBSI rate below CDC ______________.

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8. CICU VAP

    CICU goal of maintaining a VAP rate below CDC mean of 5.7 was met __________________________________.

     Interventions of 1) Head of the Bed >30 degrees

     2) Daily Sedation Vacation and daily assessment of readiness to extubate

     3) Ulcer Prophylaxis/ DVT Prophylaxis

     4) Oral care and

     5) Mandatory hand hygiene were effective.

    9. CICU UTI

    CICU goal of decreasing the 2006 rate of 5.0 to CDC mean of 3.7 was met. The interventions of using Stat Locks and silver coated catheters, mandatory hand hygiene and staff

    feedback were effective.

    10. ICU CLBS

     ICU goal of maintaining a rate below CDC mean of 2.2 was met. The ICU has not had a BSI since January of 2006. The interventions of insertion site, hand hygiene, Chlorhexidine prep, maximum barriers & daily evaluation to discontinue were effective.

    11. ICU VAP The ICU goal of maintaining a VAP rate below the CDC mean of 2.7 was met Interventions of 1) Head of the Bed >30 degrees 2) Daily Sedation Vacation and daily assessment of readiness to extubate 3) Ulcer Prophylaxis/ DVT Prophylaxis 4) Oral care and 5) Mandatory hand hygiene were effective.

    12. ICU UTI

     The ICU goal of decreasing the 2006 rate of 7.6 to below CDC Mean of 3.1 was met ______________________________________. The interventions of using Stat Locks

    and silver coated catheters, mandatory hand hygiene and staff feedback were effective.

    13. Multiple Resistant Organisms

     The rate of methicillin resistance in all Staph aureus isolates is 48%. There is ongoing evaluation for contact isolation. A quarterly report of multiple resistant organisms is

    generated and used for feedback to units involved. A graphic of potential transmission by unit by month was implemented. A MRSA task force committee was formed to

    evaluate areas of potential concern such as hand hygiene, environmental cleaning and isolation precautions. A baseline for hand hygiene was developed using a hand

    hygiene tool by direct observation and measuring soap and sanitizers for the ICU and 9T. Environmental cleaning is monitored by using a checklist (from IHI) and walk-a-

    rounds are done to ensure appropriate use of isolation precautions. These are some of the recommendations from the 5 Million Lives campaign and we will continue to

    implement them and to improve where needed. Active surveillance cultures for ICU admits will not be done as our rates for MRSA are very low and CDC recommends ASC’s

    only if rates are high and other interventions have failed to decrease the rate. We will re-evaluate at the end of 2008.

    14. Employee Health

     New employee, volunteer & students meet goals for 100% employee health follow-up.

    15. TB

     There were no employee exposures to tuberculosis in 2007. See TB risk assessment.

    16. Outbreak Exposure

     The goal of outbreak prevention has been met through the effective interventions of Respiratory/Cough Etiquette, Hand Hygiene, use of PPE & prophylaxis during community pertussis outbreaks. Smallpox and SARS policies were added to Disaster Plan and pandemic influenza would follow SARS plan.

    17. CDC Pneumonia Guidelines

     The CDC pneumonia guidelines are being reviewed and improvement is needed in patient vaccine programs. P.I. has developed order sheets and is working with staff.

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    18. An intervention for neutropenic patients was to change the shower head before they showered. Therefore, we will monitor plant involvement with this intervention.

    B. Areas No Longer at Risk (Evaluation Complete)

C/Section Surgical Site Infection Rate decreased and surveillance was stopped since it was not significant. No reported concern.

    NICU Vent associated Pneumonia and Central Line Associated BSI had very low rates, which substantiated Vermont Oxford study. Delete from Infection Control Surveillance plan

    and continue Vermont Oxford BSI surveillance and performance program. NICU continues to have low rates.

    Concern was expressed in Ortho IDT re: laminectomy disc surgery infections so rates will be monitored

    Cardiac Cath Lab: Surveillance of pacemakers and ICD’s will discontinue as rates have been low for past 3 years. See risk assessment for detailed rates.

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