A Midyear Checkup for Infection Prevention and Control Programs

A Midyear Checkup for Infection Prevention and Control Programs

Have you ever completed an educational PowerPoint presentation on hand hygiene, presented on personal protective equipment (PPE) technique at a daily unit huddle, or created a procedure you thought superbly covered all of the details of cleaning medical equipment or devices, and then clicked send via email? After all that hard work, the expectation is that your team would digest the information and immediately put it into practice. The reality is that connecting with human beings to impact their behavior always requires more than a slide deck or an email (no matter how brilliantly crafted it may be).

As the midyear point of 2019 is upon us, it’s time to check the status of your annual IP plan. Are the planned goals with their associated activities that you presented being executed to your expectations? Is there anything you need to redirect or alter at this point to stay on track?

Connect to the purpose

In Infection Prevention, there is an important driving purpose behind our work–we strive every day to prevent or minimize the risk of transmitting a healthcare-associated infection (HAI), in order to keep patients safe while in receipt of our care. Connecting your team to that message will help them internalize and own new procedures. In addition to the message of what your colleagues need to do, you may find greater success by tying in the why.

Give feedback in real-time

After the education with demonstrated competency has occurred and the policy or procedure has been written, learners will have ongoing needs that must be recognized if a change is to become practice. Real-time feedback is essential to validate and sustain a consistently reliable practice. A thorough and frequent auditing process that creates a pathway for this feedback will help you achieve successful outcomes–whether it is hand hygiene, PPE donning/doffing, or cleaning, disinfecting, and sterilizing medical equipment and devices.

Look ahead

At this point in the year accrediting organizations like The Joint Commission start giving notice about upcoming changes to standards, with the expectation of compliance by the first of the year. While the updates aren’t always specific to infection control, midyear is the perfect time to check, saving your team from a year end compliance scramble.

Audit for reliability

From the most recent HAI Hospital Prevalence Survey conducted in 2015, the CDC estimates that on any given day, about 1 in 31 hospital patients has at least one healthcare-associated infection. While there are multiple contributing factors that may be associated with acquiring a healthcare-associated infection, let’s focus our midyear checkup on areas within the Infection Prevention and Control realm that are commonly included in both the Infection Prevention and Control Risk Assessment and Plan.

Below are guidelines and tools to help you complete an audit on your program:

Hand Hygiene (HH) Compliance

Hand Hygiene Observations are based upon selected evidence-based guidelines, audit tool, and organization’s policy and procedure. Real time feedback with correction is imperative to prevent potential transmission of an infectious agent.

Guidelines:

Audit Tools:

§482.42 TAG: A-0747 §482.42 Condition of Participation: Infection Control
Hand Hygiene Program | NPSG.07.01.01 EPs 1-3
Hand Hygiene Missed Opportunity | IC.02.01.01 EP2

Use of Personal Protective Equipment (PPE) and Correct Donning/Doffing Technique of PPE
(Standard & Transmission-based Precautions)

Regularly audit PPE practices. Validate correct PPE technique post education and demonstration for appropriate application and usage.

Guidelines:

Audit Tool:

§482.42 TAG: A-0747 §482.42 Condition of Participation: Infection Control
IC.02.01.01 EPs 2,3

Cleaning, disinfection, and sterilization of medical equipment, and devices according to manufacturer instructions for use and selected evidence-based guidelines

Observe and validate adherence to low and intermediate level, high-level disinfection, and sterilization practices, based on manufacturer instructions for use, and selected evidence-based guidelines for re-usable equipment, devices and supplies based on intended use. This includes non-critical, semi-critical, and critical items.

Sterilization Guidelines:

HLD Guidelines:

Audit tools:

Prevention of central-line associated bloodstream infections (CLASBI)

Observe and validate adherence to central line established procedures, manufacturer instructions for use for equipment, devices and supplies, and selected evidence-based guidelines. Provide real-time feedback.

Guideline: CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011

Audit tools:

SHEA Strategy: Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

§482.42 TAG: A-0747 §482.42 Condition of Participation: Infection Control
NPSG.07.04.01 EPs 1-13

 

Prevention of catheter-associated urinary tract infections (CAUTI)

Observe and validate adherence to urinary catheter established procedures, manufacturer instructions for use with equipment, devices, and supplies, and selected evidence-based guidelines. Provide real-time feedback.

Guideline: CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009
Audit tool: CDC Infection Prevention and Control Assessment Tool for Acute Care Hospitals
SHEA Strategy: Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update

§482.42 TAG: A-0747 §482.42 Condition of Participation: Infection Control
NPSG.07.06.01 EPs 1-5

 

Prevention of surgical site infections (SSIs)

Observe and validate adherence to surgical site prevention established procedures that include the procedural “Time-Out”, manufacturer instructions for use for equipment, devices, and supplies, and selected evidence-based guidelines. Provide real-time feedback.

Guideline: Guideline for Prevention of Surgical Site Infection, 2017
Audit tool: CDC Infection Prevention and Control Assessment Tool for Acute Care Hospitals
SHEA Strategy: Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update

§482.42 TAG: A-0747 §482.42 Condition of Participation: Infection Control
NPSG.07.05.01 EPs 1-8

 

Prevention of transmission of multidrug resistant organisms (MDROs)

Observe and validate adherence to transmission-based precautions, manufacturer instructions for use for products and supplies used, and selected evidence-based guidelines. Provide real-time feedback.

Guideline: Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006

Audit tool: CDC Acute Care Facility Multidrug-resistant Organisms Control Activity Assessment Tool

SHEA Strategies:

§482.42 TAG: A-0747 §482.42 Condition of Participation: Infection Control
NPSG.07.03.01 EPs 1-9

How TiER1 Healthcare can help

If your organization needs help assessing your Infection Prevention and Control Program or remediating deficiencies, please call our office at (800) 241-0142 or email healthcare@tier1performance.com.

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