Medical Facility Education Tracking and Reporting Software



Tulare Regional Medical Center

Education Services

Reduction of Healthcare Associated Infections

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REDUCTION OF HEALTHCARE ASSOCIATED INFECTIONS

Module #003

Revised 1-2014

Introduction:

Welcome to our Reduction of Healthcare Associated Infection Module. This is module is for Tulare Regional Medical Center personnel who have patient, client, or customer contact while performing their regular work for the organization.

Description:

The purpose of this module is to provide a better understanding of what you can do to prevent a healthcare associated infection from occurring.

This module consists of information from Policy #20-8033 Reduction of Healthcare Associated Infections (HAI) and Policy #20-8030 Cleaning and Performing Low Level Disinfection and a general test for non-patient care staff or a clinical test for patient care staff.

Objectives:

By the completion of this module, the employee will:

1. Explain what is a healthcare associated infection or HAI.

2. Recognize the impact healthcare associated infections have on the community.

3. Identify five different infection prevention activities that reduce HAI from occurring.

Target Group:

All TRMC Personnel

Physicians: In service credit only.

RN’s; LVN’s: 1 C.E.

Prepared by your Infection Prevention Team:

Shawn Elkin, MPA, BSN, RN, PHN

RN Infection Preventionist

Daniel Boken, MD

Infectious Disease Physician

Fee:

No fee

Course Date:

Start date: January 13th t, 2014

Continued with New Employees

Course Sequence:

A. TRMC Infection Prevention Team

B. HAI Facts

C. Read The Tulare Regional Medical Center HAI Poster

D. Read Policy #20-8033 Reduction of Healthcare Associated Infections (HAI)

E. Read Policy #20-8030 Cleaning and Performing Low Level Disinfection

F. Read Hospital Acquired Infection 101 (February 10, 2011)

G. Take the Test

a. HAI General for Non-patient Care Staff (No C.E.)

b. HAI Clinical for Patient Care Staff (1 C.E.)

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TO: All Departments

FROM: Administration

SUBJECT: Reduction of Healthcare Associated Infections (HAI)

PURPOSE:

To promote the reduction of Healthcare Associated Infections (HAIs) while advancing

the well-being and safety of our patients, ultimately decreasing their total length of stay

resulting in minimizing the cost of care when an infection does occur.

Tulare Regional Medical Center has established leadership and hospital support for all practices related to the reduction of Healthcare Associated Infections (HAI). Senior Leadership has identified the Infection Control Officer and other specified leaders for HAI reduction, and various strategies for prevention will be implemented through the Infection Prevention and Control Committee. In addition, the Healthcare Associated Infection (HAI) Committee has been developed in order to coordinate these efforts.

TABLE OF CONTENTS:

This policy is sectioned as follows:

I. Definitions

II. Structure

III. Risk Assessment

IV. Reporting Agencies

V. Surgical Site Infection Prevention Bundle

VI. Multi-Drug Resistant Organisms

VII. Central Venous Catheter Associated Blood Stream Infection (CLABSI) Prevention Bundle

VIII. Ventilator Associated Pneumonia Prevention Bundle

IX. Catheter Associated Urinary Tract Infection (CAUTI) Prevention Bundle

I. DEFINITIONS:

CDC: Centers for Disease Control

CDI: Clostridium difficile Infection

CAUTI: Catheter Associated Urinary Tract Infection

CDPH: California Department of Public Health

CHG: Chlorhexidine Gluconate

CLABSI: Central Line Associated Bloodstream Infection

CMS: Centers for Medicare/Medicaid

Colonization: Presence of an organism in or on a body site without signs or

symptoms of illness. (Reference: # 20-8031 MRSA Active Surveillance Testing (AST) Policy).

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HAI: Healthcare Associated Infection “means an infection defined by the National Health and Safety Network of the Federal CDC (SB158 sec 4.b)”

Infection: Presence of an organism in or on a body site with associated clinical signs or symptoms of illness.

LIP: Licensed Independent Practioners

Multi-Drug

Resistant

Organism

(MDRO): A strain of organisms that has developed resistance to antibiotics.

MRSA-AST : Methicillin-Resistant Staphylococcus aureus – Active Surveillance Testing

NPSG: National Patient Safety Goals

PICC : Peripherally Inserted Central Catheter

PPE : Personal Protective Equipment

SCIP : Surgical Care Improvement Project

SSI : Surgical Site Infection

TJC : The Joint Commission

VRE : Vancomycin Resistant Enterococcus

VAP : Ventilator Associated Pnuemonia

II. Structure

Tulare Regional Medical Center will consistently utilize best prevention practices as it relates to the reduction of healthcare associated infections. These practices will be addressed within the confines of the Infection Prevention and Control Committee. This policy will further discuss these best practices regarding Healthcare Associated Infections (i.e. SSIs, MDROs and CLABSIs).

III. Risk Assessment (TRMC, 2009) Infection Prevention & Control Program)

The organization will conduct periodic risk assessments collecting appropriate data and surveillance outcomes for the purposes of identifying the acquisition and potential transmission of HAIs. These risk assessments will be performed on at least a quarterly basis and whenever there is reason to believe that assessed risks may have significantly changed (i.e. new services added, etc.)

The results of the risk assessment shall be presented to the Infection Prevention and Control Committee for quarterly review. Prevention strategies will be developed based on the results of the risk assessment.

IV. Reporting Agencies

As per recommendations from The Joint Commission (TJC) National Patient Safety Goal (NPSG) Number Seven, California Senate Bill 739 (SB739), California Senate Bill 1058 (SB1058), California Senate Bill 158 (SB158), Tulare Regional Medical Center (TRMC) reports

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Healthcare Associated Infections (HAIs) as indicated through California Department of Health (CDPH) and the National Health and Safety Network (NHSN).

V. SURGICAL-SITE INFECTION PREVENTION (SSI) Bundle:

The average expense of a Healthcare Associated Surgical Site Infection is costly for the patient, hospital and community at large. Several factors (CDC, 2009) are noted to influence surgical site infections, which are:

• patient characteristics

• preoperative issues

• intra-operative issues

• postoperative issues

A. Prevention

Known preventative measures to reduce surgical site infection suggested by

(CDC,1999) are:

• glucose control

• preoperative CHG showers

• appropriate hair removal

• proper hand hygiene (see CDC Hand Hygiene Policy #20-8025)

• skin antisepsis

• antimicrobial prophylaxis

• normothermia

B. Infection Prevention Data Collection

The Infection Prevention Department of Tulare Regional Medical Center routinely collects information related to Healthcare Associated Infections (HAIs) on all surgical patients. Identified Healthcare Associated Surgical Site Infections are calculated on a percentage on specific identified patients based on the annual risk assessment. The data is analyzed and compared to benchmarks and should an increase in infections be noted, the Infection Prevention Department will begin the performance improvement process as per the Organizational Performance Improvement Plan (Policy #10-1028) and develop an action plan for reduction (#20-8022 Infection Prevention and Control Program Policy). All outcome measures are reported to all key stakeholders should an increase be noted.

C. Surgical Care Improvement Project (SCIP) Process

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As part of the performance improvement process Tulare Regional Medical Center routinely collects data on the following prevention measures in concert with the Centers for Medicare/Medicaid (CMS) and The Joint Commission as follows:

• SCIP Inf-1 (SIP-1)

o Prophylactic antibiotic received within 1 hour prior to surgical incision.

• SCIP Inf-2 (SIP-2)

o Appropriate antibiotic selection for surgical patients (recommendations based on type of surgery).

• SCIP Inf-3 (SIP-3)

o Prophylactic antibiotics discontinued within 24 hours after surgery time.

• SCIP Inf-6

o Surgery patients with appropriate hair removal.

• SCIP Inf-7

o Colorectal surgery patients with immediate post-op normothermia.

• SCIP Card-2

o Surgery patients on a beta-blocker prior to arrival that received a beta-blocker during the perioperative period.

• SCIP VTE-1

o Surgery patients with recommended venous thrombolism prophylaxis ordered.

• SCIP VTE-2

o Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery.

The data on the above measures are collected on a quarterly basis and compared to the ongoing Centers for Medicare/Medicaid benchmarks. All Tulare Regional Medical Center staff work together as a team in order to prevent surgical site infections. The information is analyzed through the Tulare Regional Medical Center performance improvement process and reported to the Performance Improvement & Infection Prevention and Control Committees. Should an area not meet the CMS benchmark, a team will be developed through the performance improvement process and an action plan for improvement will be developed at that time

(#10-1028 Organizational Performance Improvement Plan Policy).

D. Skin Prep Project

In an effort to further reduce Surgical Site Infections, Tulare Regional Medical Center participates in the “Skin Prep Project” which is instituted when the surgical patient is seen prior to surgery in the pre-assessment area. All patients are given a 4 ounce bottle of Chlorhexidine Gluconate (CHG) scrub with instructions to wash with this product directly prior to surgery, especially the surgery site area. This prevention measure was chosen based on CDC’s best practice recommendations for antimicrobial skin preparation, (CDC, 1999).

E. Education

Tulare Regional Medical Center in concert with the TRMC Education Department provides SSI prevention education in the following manner:

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• We participate in the “You can help prevent Healthcare Associated Infections!” campaign in which a prevention poster is displayed throughout the hospital and given to all employees in General Orientation as well as Annual Update. Also, it is posted in the physicians lounge. The information is continually updated as needed.

• All formal educational sessions are documented.

• Through the process of daily rounds of the facility by the Infection Prevention Staff, employee infection prevention practices are monitored (i.e. hand hygiene, etc.). Education is provided during daily rounds as necessary, in addition to the initial education in General Orientation and in Annual Update.

• In 2009, the Infection Prevention Department officially launched their Hand Hygiene campaign “Are you Gellin?” This campaign satisfied the SB158 law that went into effect in January 2009. The campaign educates staff on proper hand hygiene to be used in all areas of the Medical Center.

• The use of Personal Protective Equipment (PPE) is reinforced, promoted and supplied in all appropriate areas of the Medical Center.

• All patients are educated in relation to surgical site after-care and are provided instructions by the RN prior to discharge.

F. Surveillance of Surgical-Site Infections

Case Management meetings are attended by the Infection Prevention and Control Staff a minimum of twice per week to monitor patients who have had surgeries and may develop an infection due to those procedures.

Daily microbiology reports are scanned and reviewed by the Infection Prevention Department. Appropriate medical charts are reviewed further for possible HAIs as needed.

Rounds throughout the facility are made daily by the Infection Preventionist to ensure that patients are being isolated properly. The Infection Prevention & Control Department also has an isolation policy in place for proper procedure when necessary (#20-8003 Isolation Policy). Rounds and specific surveys are performed at least annually to high risk areas such as Operating Room, Central Processing and Ambulatory Care, Nursery, etc. based on a checklist developed through best practices from CDC.

OR employees scrubbing in for surgical procedures will be monitored to assure adherence to CDC Guidelines and hospital Hand Hygiene policy (CDC Hand Hygiene Guidelines #20-8025). The results are reported through the OR performance improvement documentation.

VI. MULTI-DRUG RESISTANT ORGANISMS (MDROs):

PURPOSE:

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To provide guidelines to prevent the acquisition and transmission of multi-drug resistant organisms (MDROs), including but not limited to, MRSA (methicillin resistant Staphylococcus aureus), VRE (Vancomycin Resistant Enterococcus), CDI (Clostridium difficile) and other epidemiologically significant multi-drug resistant gram negative bacteria (TJC).

A. Prevention Best Practices (5,000,000 Lives Campaign; TJC; CDC and TRMC, 2008, Isolation Precautions for Infection Control Policy # 20-8003)

1. Leadership and hospital-wide buy-in

2. Hand Hygiene: Before and after contact

3. Decontamination of the environment and equipment

4. Active surveillance testing (AST)

5. Contact Precautions for actively infected patients

6. Practice stellar Standard Precautions for all patients

7. Education: facility-wide

8. Judicious use of antimicrobial agents (antibiotics): antimicrobial

stewardship

9. Two-tiered approach: Surveillance and problem noted; increase

measures to control

10. CDC 12 step Campaign for Elimination

B. Surveillance of MDROs

The organization will implement a surveillance program to identify MDRO’s consistent with the results of the quarterly risk assessment. Surveillance is conducted daily by the Infection Prevention and Control Staff through facility rounds and by reviewing microbiology reports. Alert systems are in place to properly notify appropriate staff of MDROs, through existing secured electronic means for new, re-admitted and transferred patients.

Through the ongoing Risk Assessment, if indicated, the organization shall further implement a laboratory-based alert system that identifies new patients with a MDRO. The Infection Prevention and Control Committee shall determine whether or not an alert system is indicated, and the extent and nature of this system.

Surveillance may be organization-wide or targeted to specific areas or settings. Surveillance can often encompass the entire population treated in that area (e.g. nasal swabbing of each patient admitted to the ICU (SB1058/SB158 laws), or focused on specific populations (e.g. at risk patients or patients with clinical signs of infection).

As previously stated, Methicillin Resistant Staphylococcus Aureus –Active Surveillance Testing will be conducted according to policy # 20-8031. All results of the MRSA-AST tests are sent to the Infection Prevention Department. A log of such results is accessible to nursing staff for historical purposes. No pilot testing was performed, as the program was fully implemented in ICU, Pre-Assessment and for other specified patients in April 2009.

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Targeted surveillance (i.e. multi-drug resistant organisms) prevalence rates will be reported to the Infection Prevention and Control Committee through the Infection Prevention quarterly Performance Improvement report. MDROs will be ongoingly monitored; increased documentation trends and evidence-based best practice strategies for prevention will be initiated, if necessary. Outcomes will also be provided to key stakeholders including leaders, physicians, nursing staff and other clinicians as necessary.

C. Procedures to Prevent the Acquisition and Transmission of MDROs (TRMC, 2008, Isolation Precautions for Infection Control Policy, pg 30-33)

1. Organism Specific Prevention Measures:

a. Methicillin Resistant Staphylococcus aureus (MRSA):

1). Strict Standard Precautions are employed, unless an active infection is present. If an active infection (febrile, coughing, etc.) is present, Contact Precautions are instituted. Standard precautions are practiced for MRSA urine and blood, unless the patient is unable to contain their own bodily fluids, then Contact Precautions and a private room would be added.

2). As airborne transmission may occur when patients have draining wounds, burns or areas of dermatitis that are colonized and infected, a mask is recommended (in addition to Contact Precautions).

3). Droplet Precautions (in addition to Contact Precautions) should also be in effect in the event a patient is coughing, sneezing and/or has MRSA pneumonia.

4). Special caution should be exercised in dedicating equipment to the patient (i.e., stethoscope, B/P cuff, bedside commode, and thermometer.)

5). Environmental Services/nursing staff should thoroughly clean all surfaces that the patient may touch (i.e., bedside table, phone, side rails, etc) daily and as needed. (TRMC, March, 2009, Environment of Care Cleaning & Disinfection Policy # 20-8030).

b. Vancomycin Resistant Enterococci (VRE):

The following recommendations are adapted from HICPAC guidelines and reflect efforts to reduce and prevent the spread of vancomycin resistance microorganisms in the hospital. The guidelines present three areas of consideration,

1) Prompt culturing / identification of microorganisms

2) Use of appropriate isolation techniques

3) Prudent vancomycin use in the facility.

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c. Clostridium difficile:

C. difficile is a spore forming gram positive anaerobic bacillus that is a major cause of healthcare-associated diarrhea, which has been responsible for many large hospital outbreaks that are extremely difficult to control. Any patient identified with C. difficile will be placed in Contact Precautions. “Because No EPA-registered products are specific for inactivating Clostridium difficile spores, use hypochlorite-based (bleach) products for disinfection of environmental surfaces in accordance with guidance from the scientific literature in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of C. difficile. Category II. ” No further recommendations are offered by CDC regarding the use of “specific EPA-registered hospital disinfectants with respect to environmental control of C. difficile. Unresolved issue”. Also, please refer to the following CDC website for additional information:

2. Overall Prevention Measures:

Tulare Regional Medical Center’s Infection Prevention and Control Department follows recommendations and guidelines consistent with the California Department of Public Health (CDPH) and CDC in the control and management of Multi-drug Resistant Organisms (such as MRSA and VRE). The CDC document, Management of Multi-drug-Resistant Organisms in Healthcare Settings, 2006 located at . will be referred to when establishing protocols related to MDROs.

TRMC will manage MDROs according to risk assessment outcomes, utilizing the two-tiered approach as recommended in the CDC guidelines described above (TRMC, 2008, pg. 31). The 1st tier during an absence of a MDRO upward trend, is considered to be the “working” tier. Consistent and thorough Standard Precautions, as well as an active surveillance program of microbiology lab tests will routinely occur. Standard Precautions will prevail in the event a “colonized’ patient presents without an active infection (case-by-case basis). Under this protocol, should an active MDRO infection be detected, Contact Precautions will be employed. The 2nd tier (an outbreak is identified) consists of intensified interventions to further prevent MDRO transmission at TRMC, as recommended in the document on MDROs within the TRMC Isolation Policy #20-8003, pg. 31.

3. Prompt Microorganism Identification:

The laboratory microbiology department and the patient’s attending physician shall work closely together in establishing a microbiological diagnosis of the infectious process. Appropriate cultures need to be taken upon admission and as clinically necessary.

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Concurrent laboratory/physician communication should occur, as identification and susceptibility studies become known. When a multidrug resistant microorganism is identified, the Infection Control Department and Pharmacy are to be notified as soon as possible.

4. Use of Barrier Precautions and Isolation Techniques:

Appropriate infection control measures shall be maintained at the hospital. Patient care staff shall utilize the proper infection control measures as outlined in this policy. These procedures define measures to provide adequate barrier precautions to reduce or prevent cross contamination. Specifically, Contact Precautions shall be initiated with any epidemiologically significant organism. Use special attention to dedication of equipment in patient rooms and environmental cleaning of frequently “touched” surfaces.

5. Hand Hygiene Practices:

Tulare Regional Medical Center follows all appropriate guidelines as recommended by CDC, SB158 and hospital policy CDC Hand Hygiene Guidelines #20-8025, as well as Standard Precautions detailed in policy, Isolation Precautions for Infection Control # 20-8003. Clinical areas collect ongoing data through monitoring hand hygiene practices, in addition to the Infection Prevention Department. This data is reported through various committees. Special emphasis is placed on hand hygiene before and after patient contact.

6. Environmental Cleaning and Equipment:

In order to reduce infections related to MDROs, environmental cleaning is emphasized through policy, Environment of Care Disinfection Cleaning Policy #20-8030.

7. Antimicrobial Stewardship:

An antimicrobial stewardship program can increase improvements in quality, safety, and cost performance of Tulare Regional Medical Center. The antimicrobial stewardship program shall be developed by the Director of Pharmacy through the Pharmacy and Therapeutics Committee and Infection Prevention & Control Committees.

Vancomycin Usage data reports vancomycin is a consistent risk factor for infection and colonization with Vancomycin resistant enterococci (VRE). Staff is routinely educated regarding limited Vancomycin use through the “Project Wipeout” Campaign mentioned below. A more detailed discussion of MDROs and prevention strategies is outlined in the CDC guideline located at:

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8. Education of Staff and Licensed Independent Practitioners

The organization will provide education to staff and licensed independent practitioners (LIP) regarding healthcare associated infections and risk mitigation strategies. This education will be provided upon hire and on an annual basis thereafter. In addition, the information is communicated through the Medical Staff office to the physicians and extended clinicians on an ongoing basis.

Since January 2009, ongoing education is provided throughout the facility on the “Gellin’” Hand Hygiene campaign and the “Project Wipeout” MDRO campaign through General Orientation and Annual Update. The CDC 12 step campaign (CDC, 2003) is referred to in “Project Wipeout” for MDRO Reduction. In August 2009, the HAI Prevention campaign “You can help prevent Healthcare Associated Infections” was created and posters were sent out to all staff regarding prevention of healthcare associated infections. This is also part of the curriculum in General Orientation and Annual Update.

The education will be evaluated through monitoring multi-drug resistant organisms and outcomes, as well as the completion of subjective evaluations after the classes.

Environmental Services staff shall be trained by the Director of EVS and shall be observed for compliance with hospital sanitation measures. The training shall be given at the start of employment, when new prevention measures have been adopted and annually thereafter (SB158 sec 7.d).

9. Education of Patients and Families

Per policy #20-8031, MRSA Active Surveillance Testing (AST), patients who are colonized or infected with an MDRO – and when appropriate their families – will be educated about strategies to prevent healthcare associated infections. The education is provided by printed material. Furthermore, a patient information sheet regarding Infection Prevention safety precautions (such as hand hygiene) is given to the patient upon admission. Homecare instruction paperwork is given to patient/family member upon discharge which satisfies the SB1058 law passed in January 2009.

10. Monitoring of MDRO Processes

The organization will measure and monitor MDRO prevention processes and outcomes including the following:

• MDRO infection rates using evidence-based metrics, such as data definitions and calculation methodology consistent with Centers for Disease Control and Prevention (CDC) guidelines.

• Compliance with evidence-based guidelines or best practices such as from the CDC Hospital Infection Control Practices Advisory Committee (HICPAC).

• Evaluation of the education program provided to staff and licensed independent practitioners.

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VII. CENTRAL VENOUS CATHETER ASSOCIATED BLOOD STREAM INFECTION

(CLABSI) PREVENTION BUNDLE:

PURPOSE:

To reduce the incidence of central venous catheter associated blood stream infections.

This organization-wide program applies to all care settings involved in the insertion and management of central venous catheters. It is the policy of Tulare Regional Medical Center to implement best practices consistent with evidence-based standards of care to reduce the risk of central venous catheter associated blood stream infections. Tulare Regional Medical Center refers to the Guidelines for the Prevention of Intravascular Catheter-Related Infections (CDC, MMWR, 2002) for practice. Tulare Regional Medical Center will incorporate practices recommended by California SB739. The Joint Commission (TJC) and National Patient Safety Goal (NPSG) 07.04.01 related to preventing Central Venous Catheter Blood Stream Infections. These practices include, but are not necessarily limited to, the following:

A. Infection Prevention Measures:

1. Education of Staff

All staff is educated regarding prevention strategies pertaining to Central Line Associated Infections upon hire, in General Orientation and during the facilities Annual Update program thereafter. Registered nurses who are required to access central lines receive a specific educational session related to central line access resulting in the completion of a competency assessment tool.

Physicians are educated regarding central line associated infections through their ongoing Medical Staff Committee involvement, prevention strategies through the Infection Prevention & Control Committee, as well as whenever necessary.

2. Education of Patients and Family

When possible, and consistent with the patient’s clinical condition and emergent need of the procedure, the patient and/or family will be educated about central line associated blood stream infections. In compliance with SB 739, Tulare Regional Medical Center demonstrates evidence of education by having either the patient or the patient’s family member sign the procedure note before insertion of any central line indicating that education has taken place.

3. Periodic Risk Assessment & Monitoring

The organization shall include all central lines in its infection surveillance activities. The following data are collected regarding central line associated blood stream infections:

• Central line procedure notes (outcome of barriers used during

procedure)

• Calculated central line days

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• All central line infection rates (compared to NHSN benchmarking)

Appropriate data is reported to NHSN and to the Infection Prevention & Control Committee on a quarterly basis. Ongoing risk assessments will be performed quarterly based on analysis of data and surveillance. Upward trends will be evaluated and appropriate measures will be instituted for positive outcome. All outcome measures are reported to key stakeholders through various committees should an increase be noted.

4. Bedside Central Line Insertion Monitoring

The RN monitors the insertion of the line (or the PICC) using the Standardized Procedure Checklist (Central Line Insertion Procedure) assuring a standardized protocol, incorporating best practices (use of cap, mask/eye shield, sterile gloves, sterile drape, sterile gown, washing of hands, use of antiseptic, appropriate location of insertion, etc.) for CDC insertion. A time out procedure is utilized before every procedure to assure correct processes are being practiced. (See Department of Clinical Services Standard of Care-Venous Access Devices 4/2009).

The original form is kept in the patient’s chart and a copy is sent to the Infection Prevention & Control Department for entry into the NHSN system for reporting purposes. Outcomes are reported on the Infection Prevention Dashboard on a quarterly basis.

5. Other Best Practices

a. To reduce the risk of infection, accessing central venous catheters should be limited to necessary use.

b. Non-essential catheters should be removed. Daily monitoring for continued line necessity as mandated by SB739 will be performed by the physician. A Daily Assessment for Central Line Necessity sticker will be placed in the chart by the RN (or their designee).

c. Catheter hubs and injection ports shall be disinfected (three times with alcohol) prior to each hub or port access (See Department of Clinical Services Standard of Care-Venous Access Devices 4/2009).

d. Catheter site dressing changes following the procedure for catheter dressing changes (See Department of Clinical Services Standard of

Care-Venous Access Devices 4/2009). Only a PICC or VAD’s

certified RN may perform dressing changes.

e. Catheters should not be inserted into the femoral vein unless other sites are NOT available.

f. If body hair needs to be removed, it should be clipped rather than shaved.

g. Hand hygiene MUST be performed by all staff performing the procedure prior

to the catheter insertion or manipulation.

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h. Gloving of all personnel as well as sterile draping of the body site should take

place.

i. Chlorhexadine-based antiseptic skin preparation should be used

appropriately on all patients above the age of 2 months, unless contraindicated.

j. Do not routinely culture catheter tips.

k. A standardized kit is used for insertion, in which cap, gown, mask and

Procedure Standardized Check List have been added to assure use and

easy access.

VIII. VENTILATOR ASSOCIATED PNEUMONIA (VAP) PREVENTION BUNDLE

PURPOSE:

To prevent ventilator associated pneumonia occurring in patients receiving care at Tulare Regional Medical Center. It is the policy of Tulare Regional Medical Center to implement best practices consistent with evidence-based standards of care to reduce the risk of Ventilator Associated Pneumonia. Tulare Regional Medical Center refers to the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals (CDC MMWR, 2003 and SHEA, 2008 Recommendations).

A. Infection Prevention Measures:

1. Education of staff and clinicians:

a. Educate clinicians about the use of alternative nonventilator strategies

b. Educate clinical staff about the risk factors and outcomes of VAP

2. General Strategies:

a. Conduct surveillance for VAP

b. Adhere to hand-hygiene guidelines (see Policy #20-8025 CDC Hand Hygiene

Guidelines)

3. Periodic Risk Assessment & Monitoring

a. Perform biannual high risk area assessment of the ICU/PICU with attention to

monitoring for implementation of best practices associated outlined in the VAP

Preventation Bundle

b. The organization shall include all ventilator in its infection surveillance

activities. The following data are collected regarding ventilator associated pneumonia:

1) Calculated ventilator days

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2) All ventilator associated pneumonia infection rates

4. Other Best Practices

a.. Use noninvasive ventilation whenever possible such as BIPAP

b. Minimize the duration of ventilation

c. Perform daily assessments of readiness to wean and use weaning protocols

(see Policy 13-8022 Mechanical Ventilation Weaning Procedure and \

Protocol)

d. Maintain patients in a semi-recumbent position (30o to 45o elevation of the head of the bed) unless there are contraindications

e. Avoid gastric over distention

f. Avoid unplanned extubation and reintubation

g. Use a cuffed endotracheal tube with in-line or subglottic suctioning

h. Maintain endotracheal tube pressure of at least 20 cm H2O

i. Orotracheal intubation is preferable to nasotracheal intubation

j. Avoid histamine receptor 2 (H2)-blocking agents and proton pump inhibitors for patients who are not at high risk for developing a stress ulcer or stress gastritis.

k. Perform regular oral care with an antiseptic solution.

l. Remove condensate from ventilatory circuits. Keep ventilator circuit closed during condensate removal.

m. Change ventilator circuit only when visibly soiled or malfunctioning

n. Store and disinfect respiratory therapy equipment properly.

IX. CATHETER ASSOCIATED URINARY TRACT INFECTION (CAUTI) PREVENTION

BUNDLE

PURPOSE:

To prevent the occurrence of indwelling urinary catheter associated urinary tract infections.

A. Infection Prevention Measures

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1. Education of staff and clinicians

All staff is educated regarding prevention strategies pertaining to Catheter Associated Urinary Tract Infections upon hire, in General Orientation and during the facilities Annual Update program thereafter. Licensed nursing service employees who are required to place indwelling urinary catheters must demonstrate proper technique based on TRMC Procedure for Urinary Catheter Insertion (Fundamentals of Nursing, Perry and Potter, 6th edition, 2005) and TRMC competency assessment tool.

Physicians are educated regarding catheter associated urinary tract infections through their ongoing Medical Staff Committee involvement, prevention strategies through the Infection Prevention & Control Committee, as well as whenever necessary.

2. Periodic Risk Assessment and Monitoring

The organization shall include all indwelling urinary catheter lines in its infection surveillance activities. The following data are collected regarding catheter associated urinary tract infections.

• Calculated indwelling urinary catheter line days

• All catheter associated urinary tract infection rates (compared to NHSN benchmarking)

Appropriate data is reported to NHSN and to the Infection Prevention & Control Committee on a quarterly basis. Ongoing risk assessments will be performed quarterly based on analysis of data and surveillance. Upward trends will be evaluated and appropriate measures will be instituted for positive outcome. All outcome measures are reported to key stakeholders through various committees should an increase be noted.

3. Other best practices

a. Use indwelling catheter only when medically necessary

b. Use aseptic insertion technique with appropriate hand hygiene and gloves

c. Allow only trained healthcare providers to insert catheter

d. Properly secure catheters after insertion to prevent movement and urethral traction

e. Maintain a sterile closed drainage system

f. Maintain good hygiene at the catheter-urethral interface

g. Maintain unobstructed urine flow

h. Maintain drainage bag below level of bladder at all times

i. Remove catheters when no longer needed

TULARE LOCAL HEALTH CARE DISTRICT

dba TULARE REGIONAL MEDICAL CENTER

POLICY/GUIDELINE MANUAL

j. Do not change indwelling catheter or urinary drainage based at arbitrary fixed intervals

k. Document indication for urinary catheter on each day of use

l. Use reminder system to target opportunities to remove catheter

m. Use external (or condom-style) catheters if appropriate in men

n. Use portable ultrasound bladder scan to detect residual urine amounts

o. Consider alternatives to indwelling catheters, such as intermittent catheterization

REFERENCES

Centers for Disease Control (CDC). (2003). Fact sheet: 12 Step campaign for

antimicrobial resistance – hospitals. Retrieved October 2, 2009 from



Centers for Disease Control (CDC). (2002). Guidelines for the prevention of

intravascular catheter related infections. Morbidity & Mortality Weekly Report, 51

pg 1-31.

Centers for Disease Control (CDC). (1999). Guideline for Prevention of Surgical Site

Infections.

Centers for Disease Control (CDC). (2008). Guidelines for Prevention of Catheter

Associated Urinary Tract Infections (CAUTI)

Curtis, R. (2009). Management of Multi-Drug Resistant Organisms Template Policy.

CIHQ

Septimus, E. (Aug 2009). Prevention of SSIs beyond core measures. Presentation to

San Joaquin APIC.

The Joint Commission (TJC). (2009). Comprehensive Accreditation Manual. Department of Publications.

Tulare Regional Medical Center (TRMC). (2008). Isolation Precautions for Infection

Control. Policy #20-8003

Tulare Regional Medical Center (TRMC). (2009). Infection Prevention & Control

Program. Policy #20-8022

Tulare Regional Medical Center (TRMC). (March, 2009). CDC Hand Hygiene Guidelines. Policy # 20-8025

TULARE LOCAL HEALTH CARE DISTRICT

dba TULARE REGIONAL MEDICAL CENTER

POLICY/GUIDELINE MANUAL

Tulare Regional Medical Center (TRMC). (March, 2009). Environment of Care Cleaning

& Disinfection. Policy # 20-8030

Tulare Regional Medical Center (TRMC). (March, 2009). MRSA Active surveillance Testing (AST) Policy. Policy # 20-8031

Tulare Regional Medical Center. (TRMC). (4/2009). Venous Access Devices.

Department of Clinical Services Standard of Care,

SHEA/IDSA Practice Recommendation (2008). Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals

Questions concerning any aspect of this policy/guideline should be referred to Administration.

This policy/guideline replaces and supersedes all previous policies/guidelines concerning this matter and is effective immediately.

Descriptive Name: Reduction of Healthcare Associated Infections (HAI)

Descriptive Type: Revised

Document Number: 20-8033

Attachments: None

Author: Melissa Janes, Shawn Elkin

Typist: Shawn Elkin

Creation Date: 02/10/11

Previous Dist. Date: 02/25/10

|Committee Review and Approval: |Approval Date: |Comments: |

|Infection Prevention and Control |10/25/11 | |

|MEC |11/09/11 | |

|Board of Directors |12/07/11 | |

Effective Date: 12/08/11

Forward To: Policy Binders (PBX and Administration) and Post to Intranet

Disposition: Copy and Distribution - Administration

TULARE LOCAL HEALTH CARE DISTRICT

dba TULARE REGIONAL MEDICAL CENTER

POLICY/GUIDELINE MANUAL

TO: All Departments

FROM: Administration

SUBJECT: Cleaning and Performing Low Level Disinfection

I. PURPOSE

To insure that patient care equipment and environment is clean and disinfected to prevent transmission of infection.

II. POLICY

Patient care equipment and environment in this policy is limited to non-critical items which require low level disinfection to prevent transmission of infection. Non-critical items are equipment that will only come in contact with the patient’s intact skin. Items that come in contact with non-intact skin and mucus membranes require high level disinfection and are addressed in a separate policy (See Policy #20-8038 High Level Disinfection, Sterilization and Storage of Sterile Supplies).

III. GENERAL CLEANING/DISINFECTION GUIDELINES:

Cleaning is the physical removal of organic material or soil from objects. It is usually accomplished using water, mechanical action and a detergent. The item must be visually inspected after the process to assure that the item is visibly clean.

Disinfection is the killing or inactivation of all microorganisms, except for some spore forms on inanimate objects. The efficacy of disinfection is affected by a number of factors, including the type and level of microbial contamination, the activity of the disinfectant and the disinfectant contact time. Organic material and soil can block disinfection contact and may inhibit disinfectant activity.

Therefore, cleaning may precede all disinfection processes. Some products are formulated to be a cleaner-disinfectant using a “one-step” process. In these cases, follow the manufacturer directions.

Germicidal wipes (or large bucket) may be used following the manufacturer’s instructions assuring correct “wet contact time”. Registered tuberculocidal agent may be used for blood spills, terminal cleaning, etc, (CDC, 2008, p. 85). Sodium hypochlorite (bleach) may be used if high rates of Clostridium difficile (see Isolation

Precautions for Infection Control, 20-8003, Section on C.d.)

TULARE LOCAL HEALTH CARE DISTRICT

dba TULARE REGIONAL MEDICAL CENTER

POLICY/GUIDELINE MANUAL

For the regular removal of accumulations of bodily fluid and intravenous substances (SB 1058) see policy Medical Waste Management Plan #22-1019 for intravenous substances and #21-2008 p.2 Code Orange: Hazardous Materials Spill/Release for removal of fluids.

Personal Protective Equipment (PPE) should be used at all times when cleaning and disinfecting. Single-use medical equipment devices and supplies are not cleaned and re-used.

The Infection Control Committee must approve all disinfectants used at the hospital.

IV. DISINFECTION AND CLEANING OF SURFACES AND PATIENT CARE EQUIPMENT:

Medical equipment surfaces, such as those with switches and knobs of patient monitoring equipment may play a role in the transmission of infection.

High risk areas (i.e. OR, Central Processing, OB delivery rooms, Catheterization Lab, Endoscopy/ Bronchoscopy Labs & Pediatric Treatment Room) should use recent AORN (2008) recommendations for cleaning.

V. CLEANING EQUIPMENT:

Portable patient care equipment will be cleaned between patient uses. After cleaning a clear bag will be placed over the equipment with a tag indicating date, time and initial of person who performed the cleaning. Do not use any equipment on a patient unless you are certain it has been cleaned.

Some larger items of equipment may be sent to maintenance for thorough cleaning and preventative maintenance. Schedule determined by the environmental services and maintenance departments. A tag will be placed on the equipment indicating that preventive maintenance has been done which will include steam cleaning.

All patient care equipment should be cleaned between patient uses, upon discharge and when visibly soiled.

VI. SPECIFIC ENVIRONMENT AND EQUIPMENT CLEANING:

TULARE LOCAL HEALTH CARE DISTRICT

dba TULARE REGIONAL MEDICAL CENTER

POLICY/GUIDELINE MANUAL

|Item |Dept |Nursing |EVS |CP |How to clean |Other |

|Computer keyboards |General | |Daily and PRN | | Hospital Approved | Follow |

| | | | | |Disinfectant |Manufacturer |

| | | | | | |Instructions |

|Workstation on Wheels |Daily during NOC |Keyboard/ Mouse/ | PRN | |Hospital Approved |Follow manufacture |

|(W.O.W.) |Shift |Bar Code Scanner | | |Disinfectant |instructions for |

| | |between patient use| | | |cleaning monitor |

|Computer Tablets |General |Keyboard between |PRN | |Hospital Approved |Follow manufacture |

| | |patient use | | |Disinfectant |instructions |

|Storage Units |General | |PRN | |Hospital Disinfectant |Each dept is |

| | | | | | |responsible for |

| | | | | | |their own area. |

|Nursing Stations |Patient Care | |Daily | |Hospital Disinfectant |Each dept is |

| | | | | | |responsible for |

| | | | | | |their own work area.|

|Patient equipment/items |Patient Care |Clean upon arrival | | |Germicidal Wipe | |

|from home | |and when visibly | | | | |

| | |soiled | | | | |

|Patient Rooms/Other Patient|Patient Care |Clean 3 feet around|3 ft Rule around | |Hospital Disinfectant |After discharge. |

|Care areas: | |patient PRN. |the patient and | |and/or Tuberculocidal |Detail Patient rooms|

|(i.e. restrooms, | | |room Daily & PRN | | |when become |

|televisions, telephones, | | |Promptly clean | | |available. EVS keeps|

|bedding, furniture, | | |spills of blood and| | |log. |

|countertops & surfaces) | | |OPIM ASAP. (CDC, | | | |

| | | |2008, p. 85) | | | |

|Bedside Commode |Patient Care |When in use: |When No Longer in | |Hospital Disinfectant | |

| | |Empty and Clean |Use: | | | |

| | |PRN. |After emptied by | |Germicidal Wipe PRN | |

| | | |Nursing Staff | | | |

| | | |clean. | | | |

|Beds/over bed trays/patient|Patient Care | |Clean daily as | |Wipe with disinfectant|Clean inside and |

|room countertops | | |above. | | |outside |

|Medication Rooms |Patient Care |Wipe own stations/|Clean daily | |Germicidal Wipe | |

| | |countertops | | | | |

|Blood Glucose Monitor |Patient Care |Clean once a day | | |Gluco-chlor both |Follow Manufacturer |

| | |and PRN | | |interior and exterior |Instructions |

| | | | | |surfaces | |

|Bedpan/ |Patient Care |Empty body fluids | | |Wipe bedpan |Discard when no |

|Urinals | |and clean in room | | |w/disinfectant PRN. |longer in use. |

| | |and/or dirty | | | | |

| | |utility room. | | | | |

|Crash cart |Patient Care |Keep outside | |Clean between uses.|Wipe with disinfectant|Supervisor when CP |

| | |visibly clean when | |Clean top of cart |after each use |not there |

| | |not in use | |with disinfectant. | | |

| | | | |Exchange Cart with | | |

| | | | |clean cart and | | |

| | | | |thoroughly clean | | |

| | | | |used downstairs. | | |

|Fluid warmers, IV pumps |Patient Care |Clean when visibly |Clean if left in | |Germicidal Wipe | |

| | |soiled |the room | | | |

| | | | | | | |

| | |Use disinfectant |Use disinfectant | | | |

| | |between uses |between uses | | | |

|Hoyer lift, Sara lift |Patient Care |Clean between uses.| | |Germicidal Wipe | |

|Bed/Chair Scales | | | | | | |

|Medication Dispenser |Patient Care | | | |Pharmacy to clean | |

|Inside/Outside | | | | |inside weekly | |

| | |Clean outside daily| | | | |

|Patient transfer equipment |Patient Care |Clean after each |If equipment is | |Germicidal Wipe | |

| | |use. |left in the room | | | |

|Privacy curtains |Patient Care |Notify EVS when |Insect daily and | |Laundry |Remove & clean when |

| | |visibly soiled |clean when visibly | | |detailing (terminal)|

| | | |soiled / | | |room. |

| | | |PRN | | | |

|Reusable blood pressure |Patient Care |Disinfect between | | |Use hospital approved | |

|cuff | |uses / PRN. | | |disinfectant | |

|Reusable toys |Patient Care |After each use. | | |Hospital Disinfectant |Process in place |

|Stretchers |Patient Care |Clean after each |Will wipe down once| |Germicidal Wipe |Environmental |

| | |patient use. |each day | | |services will detail|

| | | | | | |once a month. |

|Telemetry box and |Patient Care |Clean between uses | | |Germicidal Wipe | |

|connecting cables | | | | | | |

|Vital signs machine |Patient Care |Clean daily & | | |Germicidal Wipe | |

| | |between patient | | | | |

| | |uses if touches the| | | | |

| | |patient | | | | |

|Wheelchairs |Patient Care |Clean between each | | |Germicidal Wipe. |Environmental |

| | |patient use. | | | |services will detail|

| | | | | | |once a month. |

|Walkers |Patient Care/ |Between patient | | |Germicidal Wipe |Physical Therapy |

| |Physical Therapy |uses | | | |after each use. |

|CPM |Physical |Clean if soiled. | | |Germicidal Wipe |In between uses. |

|(Continuous Passive Motion)|Therapy | | | | | |

|Gait belts |Physical Therapy |Wipe down between | | |Send to Launder if |Physical Therapy |

| | |uses. | | |soiled. |Staff after each |

| | | | | | |use. |

|EKG machine |Resp Care |Daily & PRN | | |Germicidal Wipe |Respiratory cleans |

| | | | | | |between uses. |

|Portable O2 Sat Machine |Resp Care |If soiled | | |Germicidal |Respiratory cleans |

| | | | | |Wipe |after discharge. |

|Ventilator |Resp Care |After each use and | | |Germicidal Wipe |Respiratory cleans |

| | |PRN | | | |between uses |

|Plates for portable x-ray |Medical Imaging | | | |Germicidal Wipe |Cleaned by MI After |

| | | | | | |every use |

|Portable x-ray machine |Medical Imaging | | | |Germicidal Wipe |Damp dusted daily & |

| | | | | | |PRN |

|Mammography Equipment |Medical Imaging | | | |Follow manufacturer |Performed by |

| | | | | |instructions |Technologist between|

| | | | | | |patient uses |

|Dialysis Equipment |Contract Dialysis |Contracted Staff | | |Germicidal |Staff will wipe |

| |Services |RNs | | | |machine with |

| | | | | | |germicidal and bag |

| | | | | | |it prior to leaving |

| | | | | | |patient room. |

|Other medical equipment not|Patient Care areas |Clean after each | | |Follow manufacturer | |

|mentioned | |use on patient. | | |instructions | |

|Laboratory Equipment. and |Laboratory | | | |Germicidal Wipes |Follow Manufacturer |

|Supplies | | | | | |Instructions |

|Medical Equipment. Devices|ALL as appropriate | | | |Germicidal Wipes or |Contract |

|and Supplies in Isolation | | | | |Hospital Disinfectant |Precautions: - |

| | | | | | |Educate use of |

| | | | | | |non-critical patient|

| | | | | | |care equipment to a |

| | | | | | |single patient. |

| | | | | | |(i.e., blood, |

| | | | | | |pressure cuffs. Use|

| | | | | | |disposable items and|

| | | | | | |discard). |

TULARE LOCAL HEALTH CARE DISTRICT

dba TULARE REGIONAL MEDICAL CENTER

POLICY/GUIDELINE MANUAL

VII. EDUCATION OF STAFF:

Education of staff will take place during General Orientation and Annual Update, also as needed.

REFERENCES:

▪ CDC Guidelines for Environmental Infection Control in Healthcare Facilities (2003)

▪ CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities (2008)

▪ Current AORN 2008 Guidelines

Questions concerning any aspect of this policy/guideline should be referred to Administration.

This policy/guideline replaces and supersedes all previous policies/guidelines concerning this matter and is effective immediately.

Descriptive Name: Cleaning and Performing Low Level Disinfection

Descriptive Type: Revised

Document Number: 20-8030

Attachments: None

Author: Melissa Janes; revised by Shawn Elkin

Typist: Shawn Elkin/ Delicia Dimberg/ Gillian Busch

Creation Date: 01/25/11 revised 12/29/11

Previous Dist. Date: 05/26/11

|Committee Review: |Approval Date: |Comments: |

|Infection Prevention Committee |01/24/12 | |

|MEC |02/08/12 | |

|Board of Directors |02/22/12 | |

Effective Date: 02/23/12

Forward To: Policy Binders (PBX and Administration) and Post to Intranet

Disposition: Copy and Distribution - Administration

Comments:

-----------------------

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Current Regulation

• Centers for Medicare and Medicaid Services (CMS) Guidelines.

• Joint Commission: NPSG #7

• California State Law:

SB 739

SB158

SB 1058 (MRSA AST)

• TRMC Policies:

Reduction of Healthcare Associated Infection, #20-8033

Cleaning and Performing Low Level Disinfection, #20-8030

Isolation Precautions for Infection Control, #20-8003

MRSA Active Surveillance Testing (AST) Policy, 20-8031

• Reference: Centers for Disease Control (CDC) Prevention Guidelines

Project Wipe Out

Top Ten Ways to Reduce MDROs

(Multidrug Resistant Organisms)

1. Wash Your Hands

Before and after patient contact,

Between glove use, and moving from a dirty site to a clean site

2. MRSA Surveillance Test

Active Surveillance Testing (AST) anterior nares swab per procedure

3. Isolate MDROs in “Contact Precautions”

Wear gloves on entry and gown if you will have patient contact. Dedicate equipment (B/P cuff, stethoscope, etc.) or disinfect between uses.

4. Increase Environmental Cleaning Assure all equipment touching a patient is disinfected before use. Patient area cleaned at least daily (3ft minimum).

5. Remove urinary catheters

6. Diagnose and treat infection effectively

Target the pathogen, practice antimicrobial control, use local data, treat infection – not contamination, stop antimicrobial treatment when cured.

7. Reduce use of Vancomycin

8. Vaccinate at-risk patients

Influenza/pneumococcal

9. Consult infectious disease experts

10. Stay home when you are sick

Get the flu vaccine.

HAIs Quick Facts

• HAIs cause nearly 100,000 deaths each year in the United States.

• HAIs cost $28 - $33 billion each year.

• HAIs are the leading cause of preventable deaths in the United States.

• Methicillin-resistant Staphylococcus aureus (MRSA) can last up to 56 days on a surface.

• Clostridium difficile (C. diff) spores can last up to 5 months on a surface.

• TRMC Infection Prevention Team recommends Best Practices to prevent and control infections.

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Infection Prevention: Revised and Approved: 8.16.11

1. Wash Hands

Hand hygiene is the number one way to prevent the spread of infections. It takes just 15 seconds to practice hand hygiene.

Clean Hands Save Lives…..Be Caught Gellin’!

2. Reduce Surgical Site Infections (SSI)

Help your patient prepare for surgery:

• Encourage improved blood glucose control before and after surgery.

• Encourage smoking cessation before surgery.

• Request patient wash with provided chlorhexidine scrub before surgery. Bathe inpatients with chlorhexidine before surgery, if possible.

• Insure Operating Room Staff washes with surgical scrub before surgery.

• Use appropriate skin surgical scrub on patient before surgery.

• Encourage discharge planning orders for wound care after surgery.

3. Reduce C.difficile (C.diff) and MDROs (Multidrug-Resistant Organisms)

4. Reduce Central Line Infections

Use careful venous catheter access:

• Prior to insertion of a central or peripheral catheter, prepare the skin using the provided chlorhexidine solution with a back and forth friction scrub for 30 seconds.

• Allow area to dry prior to access.

• Use Venous Access Devices (VADs) Standard of Care.

Before access, triple wipe all central line intravenous ports with alcohol.

5. Cautious Urinary Catheter Use

• Follow appropriate indications for indwelling catheter use.

• Remove Foley catheters when no longer necessary.

• Use proper techniques for urinary catheter maintenance.

• Properly secure catheter tubing.

• Avoid use of catheters for management of incontinence.

• Use external catheters if possible.

6. Ventilator Associated Pneumonia (VAP)

• Perform regular oral care with a antiseptic solution.

• Remove condensate from ventilator circuits.

• Use cuffed Endotracheal Tube with in-line or subglottic suctioning.

• Maintain patient in semi-recumbent position.

(30-45 degree head elevation unless there are contraindications)

7. Patient Hygiene

• Educate patients and visitors on “Respiratory Etiquette” and Hand Hygiene.

• Review “Patient Safety” handout upon admission.

Infection Prevention: Revised and Approved: 8.16.11

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