IPC Program Assessment

Getting Started or so you are the new Infection Preventionist – what now?

Karen HooverRuss OlmstedRuth Anne Rye

Supp

ort

New Hire Orientation All personnel Personnel specificOngoing Regulatory mandate Task-specific Facility-determined

Pre-placement evaluationRoutine screeningWork restrictionsOccupational exposure managementPersonal hygiene

Blood Stream - Eyes, Ears & ThroatGastrointestinal, Genitourinary Tract -

SkinRespiratory Tract –

Central Nervous System

- --

Dental Service Dietary Services Equipment: Cleaning Disinfection/Sterilization Environmental Cleaning Emergency preparedness Facility operations; air, water construction/renovation Laboratory/Pathology Waste management

EmployeeHealth

Prevention

Body System Review

Leadership

Education

Clin

ical

Pra

ctice Supp

ort

Serv

ices

Surveillance/PerformanceMeasurement

MI MODEL:INFECTION

PREVENTIONPROGRAM

ã MSIPC Reviewed 2013

Scope: Processes & outcomesPatient: Community & Healthcare- Associated InfectionPersonnel: Health & Injury Prevention Environment of Care (EOC)Outbreak and Sentinel Events

Philosophy-Authority-ResponsibilityI.P. Program ElementsPatient & Personnel Safety CultureOversight: Function and CommitteesPerformance ImprovementRegulatory ComplianceCommunity Standards of Care

Antimicrobial use AsepsisContinuum of careHand HygieneImmunizationIsolation PrecautionsPatient Care Plan

Is there a facility-specific Infection Prevention & Control Plan?

Infection Prevention & Control Program Plan Risk Assessment: Assessment of services provided Assessment of populations served Prioritized strategies for risk reduction Surveillance plan including data analysis Plan is reviewed annually or as often as

needed

Where to begin?

Evaluation of potential risk for infections, contamination and exposures among population served by the facility;1) Sources of information: known risks, historical

data, local public health, publically reportable data, reports in literature, etc. – Do you have any surveillance data available?

2) Evaluation of preventable harms [HAIs, falls, pressure ulcers, inter-facility transfers]

3) Evaluation of organization’s preparedness to eliminate or mitigate the harm or risk of preventable harm

Infection Control Risk Assessment: Purpose

Risk Assessment

Setting Services & Care Delivery

Descriptive analysis– Geographic area served– Environmental factors– Populations served– Breakdown of major payors– CMS survey requirements– Local public agency: county population assessment

Care, Treatment & Services Provided Skilled care, Rehab, Long

Term Acute Care, Home care/Hospice, Critical access hospital

Surgery, medicine, both Critical care? Obstetrics? Combination of acute +

LTC?

Multidisciplinary team– Employee health, environmental services, lab, pharmacy, nursing, administration etc. Perform at least annually – Remember to update if new services are added Review & approval by IPC and/or

Patient Safety/Quality Committee Organization/committee consensus for

priorities

Who Does the Risk Assessment?

Priority Level = 1 (top) Topic: Catheter Associated UTI (CAUTI) Goal- Achieve zero CAUTIs in medical surgical patients by December 2012 Objectives - 1. Provide CAUTI prevention education for 95% of clinical staff by

June 2012 2. Implement Nurse protocol for Foley catheter removal by June

2012 Strategies/Tactics - 1. Develop educational program 2. Schedule in-services for med surg nursing 3. Develop nurse driven Foley catheter removal criteria

Evaluation

Progress/Analysis/Reporting

Example of IPC Plan Element

Let’s Practice shall we?