UCSF STANFORD HEALTH CARE INFECTION CONTROL DEPARTMENT



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|Infection Control/Epidemiology Risk |Risk Category |Goal |Objective |Indicators |Plan of Action |

|Characteristics |Determination | | |Data Analysis | |

| | | | |(Refer to attachment 1 for in depth | |

| | | | |rates) | |

|Hand Hygiene (HH) Practices | |Enforcement and enhancement|ASC-wide hand hygiene program is |Daily/weekly focused random hand |Enforce education and compliance with results |

|Obs Correct HH < 90% |X High |of hand hygiene practices |implemented that complies with CDC |hygiene practice observations per |from the monthly hand hygiene observations and |

|Obs Correct HH 90-99% | |are implemented within the |guidelines and TJC NPSG 7. 90-100% |month are being captured |all other rounds described for hand hygiene. |

|Obs Correct HH 100% | |organization. |Coordinate/consult/educate all areas of |alcohol gel usage reports. |Patient speak up campaign brochure. |

| | | |ASC on Infection Prevention Process and | |Governing body Quality Committee/Board receive|

| | | |Outcome Measures. | |reports of compliance monthly /quarterly |

| | | | | |Hand Hygiene compliance reported out thru the |

| | | | | |ICC/Quality committee. |

| | | | | |Reinforce good behavior with incentives. |

| | | | | |Strategic goal for the organization Target-84%,|

| | | | | |Maximum 86% |

|Surgical Site Infections (SSI) |X High |Decrease SSI rates to |Analyze data collected on SSIs, including |Put data here: |To investigate potential causes of rates |

|Ortho, ENT, Plastics, Vasectomies | |target X. |numerators and denominators. |SSI rates for selected procedures |occurring above the CDC 50th percentile in |

|etc. and any Focused Studies. | |Full compliance with IHI |Generate baseline rates and benchmark | |either of these 2 procedures, IC continues to |

| | |bundle CDC recommendations |against historical data and NHSN. | |perform retrospective chart reviews on those |

| | |for SSI prevention and SCIP|Make recommendations for improvement using| |patients with SSI looking for breaches in those|

| | |measures. |the IHI SSI prevention bundle and other | |processes associated with the SSI bundle that |

| | | |infection prevention strategies. | |include: appropriate initiation and |

| | | | | |discontinuation of antibiotics, clipping versus|

| | | | | |shaving for hair removal and perioperative |

| | | | | |glucose control. |

| | | |Investigate identified clusters/focused | | |

| | | |studies. | |The systematic collection and analysis of data |

| | | |Coordinate/consult/educate all areas of | |noting the compliance rate to all the SSI |

| | | |ASC on Infection Prevention Process and | |bundle measures should ideally be done for all |

| | | |Outcome Measures. Working with surgeons to| |surgery types, so that a comparison can be made|

| | | |have accurate Wound Class and ASA scores | |of the compliance rates between those patients |

| | | |assigned to patints by surgeon. | |with SSI and patients without SSI for the same |

| | | | | |type of surgical procedure. |

| | | | | |Implementation of the SSI bundle continues in |

| | | | | |collaboration SCIP and NSQIP. |

|TJC – Continued Readiness. |X High |Constant State of |Protect patients, employees and physicians|Compliance to NPSG #7 Prevention of |Surveillance Rounds |

| | |Readiness. |by promoting best Infection Prevention |Health care associated Infections |EOC rounds |

| | | |Practices |Control TJC and DHS standards. |Construction Rounds |

| | | |Coordinate/consult/educate all areas of | |IC rounds |

| | | |ASC on Infection Prevention Process and | |Education to Leaders, physicians and Staff |

| | | |Outcome Measures. | | |

|Cluster/Outbreaks |X High |Implementation of infection|Investigate the cause of an unexpected |Data here: |Compliance with standard & transmission based |

|Emerging Infectious Disesases | |prevention strategies in |increase in community and/or health care |MRSA rates |precautions, hand hygiene and appropriate PPE |

|Community: | |relationship to the |associated infections. | |use. |

|MRSA, MDRO’s, Pertussis, varicella, | |mechanisms of transmission,|Recommend interventions that result in | |Compliance with environmental cleaning |

|Norovirus,, Influenza, hepatitis A&B,| |care, treatment, and the |prevention or a sustained decrease in the | |practices and patient equipment cleaning and |

|pandemic flu and any new emerging | |pathogens that place |infection rate. | |disinfection |

|infectious disease | |communities at risk. |Coordinate/consult/educate/rounds all | |Screening for exposures and immunity per |

| | |Reduce morbidity and |areas of ASC on Infection Prevention | |policy. |

|Facility: None | |mortality due to these |Process and Outcome Measures. | |Referral for assessment, testing, immunizations|

| |X Medium |pathogens. | | |up to date on all staff and is achieved at |

| | |Implementation of | | |100% for individuals who may put population at |

| | |respiratory etiquette /hand| | |risk and who have been occupationally exposed |

| | |hygiene programs. | | |to infectious agents. |

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| | | | | |Compliance with patient hygiene, oral care and |

| | | | | |bathing when clinically appropriate. |

|Influenza/Pandemic Influenza |X High |Prevent health care |Continually update and monitor a |Compliance with offering all |Offer flu vaccine to all ASC employees, LIP’s |

|Bioterrorism and Emergency | |associated transmission and|comprehensive flu plan in coordination |employees, LIP’s, volunteers, etc. |etc. |

|Preparedness. | |outbreaks. |with local, state and federal authorities.|Flu vaccination. |Healthy incentive for HCW’s tied to compliance |

| | | |Monitor trends and implement IC practices |Use of proper respiratory etiquette |with vaccination status or declination. |

| | | |known to minimize the spread of influenza.|and hand hygiene. | |

| | | | |Mask fit testing as needed. | |

| | | |Train in the rapid isolation or cohorting |Adherence and compliance to the | |

| | | |of infectious patients. |Aerosol Transmissible Disease (ATD) | |

| | | |Immunize staff with direct patient care |Standards/TB Control Plan | |

| | | |and susceptible patients. | | |

| | | |Educate and inform staff & physicians as | | |

| | | |new information arises. | | |

| | | |Coordinate/consult/educate all areas of | | |

| | | |ASC on Infection Prevention Process and | | |

| | | |Outcome Measures. | | |

|Facility Construction | |Reduce HAI associated with |Maintain and monitor an aggressive |100% compliance with ICRA. |An infection control risk assessment and dust |

|Current or planned |X High |construction activities. |surveillance, dust control & containment, |No trends in diseases known to be |control and containment policy and procedure is|

|construction/renovation/demolition | | |humidity and mold abatement program. |associated with construction. |followed for all construction projects. |

|activities. | | |Continuously evaluate and educate for IC | |Do rounds daily on all major construction |

|Dust Control and Containment | | |compliance by subcontractors, project | |projects and regularly evaluates the scope of |

| | | |managers, engineers, inspectors of record.| |level 1 and 2 in the event that the acuity is |

| | | |Daily rounds in construction areas. | |higher. |

| | | |Review of all construction projects and | |IC rounds weekly and as needed. IC has the |

| | | |sign off on major projects for dust | |oversight for all projects and asks for action |

| | | |control and containment. IC involved in | |plans when there is poor compliance on major |

| | | |any unanticipated construction projects in| |construction projects. |

| | | |patient care areas from preconstruction | | |

| | | |through all the stages of construction. IC| |All contractors go thru Dust control and |

| | | |rounds on the project sites to monitor | |containment P&P before starting a project. |

| | | |compliance with containment. ICRA signed | | |

| | | |and posted at site. | | |

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|Presence of Multi Drug Resistant |X High |Prevent transmission of |Undertake actions to evaluate incidence of|Attachment data MRSA rates |Monitor compliance with standard precautions, |

|Organisms (MDRO) | |MDRO. |health care associated transmission. | |hand hygiene and environmental cleaning. |

|Patient population > 20% resistance :| | |Implement strategies to reduce health care|. | |

|MRSA, VRE, C. difficile, ESBL | | |associated transmission. | | |

| | | |Recommend interventions based on findings | | |

| | | |and assessment of risk. | | |

| | | |Coordinate/consult/educate all areas of | | |

| | | |ASC on Infection Prevention Process and | | |

| | | |Outcome Measures. | | |

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| | | |Enhanced environmental cleaning protocals | | |

| | | |with housekeeping and Nursing. | | |

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| | | | | |Screen at pre-op outpatient visit all elective |

| | | | | |orthopedic surgical patients |

| | | | | |Nasal swab (anterior nares) by RN sent for |

| | | | | |“MRSA screen” |

| | | | | |Based on Culture Results (only if MRSA and CHG |

| | | | | |bathing pre op and post op. Prophy for MRSA + |

| | | | | |Vancomycin. Cefazolin for MRSA -. Environmental|

| | | | | |cleaning per protocal |

|Tuberculosis | |Prevent transmission of |Review and revise Aerosol Transmissible |TB screening Compliance in X |Active Management of pulmonary tuberculosis |

|Pulmonary TB cases in past 6 months | |pulmonary TB in community |Disease (ATD) Standards/ TB exposure and |Fit Testing Compliance in : Overall |remains a significant activity over time. The |

| | |and healthcare workers. |control plan annually and as needed. |compliance is X |early recognition of tuberculosis and placement|

| |X High | |Identify all suspect and actual cases of | |in appropriate airborne precautions minimizes |

| | | |pulmonary TB and initiate airborne | |the risk of transmission to staff and other |

| |X Medium | |precautions upon entry to ASC. | |patients. |

| | | |Continued education to physicians and | | |

| |X Low | |staff on preventative measures (fit | | |

| | | |testing and annual skin testing and use of| | |

| |X Medium | |appropriate PPE). | | |

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|Infection Control Surveillance in |X High |Prevent transmission of |Monitor rates of targeted diseases such as|See Attachment Data. |Recommend interventions based on findings and |

|the: | |Infectious Diseases and |Tuberculosis, MRSA, hand hygiene |Targeted surveillance of SSI, hand |assessment of risk. |

|Ambulatory Surgery Services | |exposure to opportunistic |compliance, |hygiene, |Coordinate/consult/educate all areas of ASC on |

| | |pathogens. |Undertake actions to evaluate incidence of| |Infection Prevention Process and Outcome |

| | | |health care associated transmission. | |Measures. |

| | | |Implement strategies to reduce health care| | |

| | | |associated transmission. | | |

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