Download The Road to a better infection control program

THE ROAD TO AN EFFECTIVE INFECTION
PREVENTION PROGRAM
PIN QI Showcase 2011
Linda Matranga, R.N.
QI Director
Infection Preventionist
Safety Officer
Asst. Dir. Public Health
Clinical Information Systems Project Manager
 Federal
LTC Survey on
2/25/2010
 F441
F441
§483.65 Infection Control
The facility must establish and maintain an Infection Control
Program designed to provide a safe, sanitary and comfortable
environment and to help prevent the development and
transmission of disease and infection.
§483.65(a) Infection Control Program
The facility must establish an Infection Control Program under
which it –
(1) Investigates, controls, and prevents infections in the facility;
(2) Decides what procedures, such as isolation, should be
applied to an individual resident; and
(3) Maintains a record of incidents and corrective actions related
to infections.
F441
§483.65(b) Preventing Spread of Infection
(1) When the Infection Control Program determines that a
resident needs isolation to prevent the spread of infection, the
facility must isolate the resident.
(2) The facility must prohibit employees with a communicable
disease or infected skin lesions from direct contact with
residents or their food, if direct contact will transmit the disease.
(3) The facility must require staff to wash their hands after each
direct resident contact for which hand washing is indicated by
accepted professional practice.
§483.65(c) Linens
Personnel must handle, store, process and transport linens so
as to prevent the spread of infection.
WHAT THEY CITED


“The facility failed to implement an
infection control program through which all
infections were tracked and preventative
measures implemented.
Additionally the facility failed to ensure
that staff techniques during cares
minimized the potential for cross
contamination and the spread of
infections.”
WHAT THEY CITED
Surveillance retrospective not
concurrent
 Current tracking of infections did not
show follow up or resolution
 Surveillance data inaccurate
 Surveillance data collection
processes not dependable
 Surveillance data was incomplete

WHAT THEY CITED
Interventions not implemented
appropriately
 Staff dressing change techniques
 Incorrect linen handling by CNA and
Laundry staff
 Incorrect hand hygiene during
feeding of residents
 Incorrect management of
applesauce/pudding during med
pass

WHAT WE HAD






No coordinated IC program
Person responsible did not have the
proper training
Other departments not involved, dietary,
clinic, housekeeping, etc.
No IC Committee
No provider involvement
Only about 3 hours a month dedicated to
IC specifically
WHAT WE HAD
Infections not followed up with appropriate
interventions in a timely manner
 All staff did not understand isolation
 Isolation equipment and supplies not readily
available

WHAT DID WE NEED TO DO?
Develop processes and policies
for concurrent surveillance of
infections
 Exam our policies and practice for
infection prevention, isolation,
dressing changes, pericare and
others.
 Educate staff

WHAT DID WE NEED TO DO?
 Involve
all departments in IC
 Appreciate the need to invest more
hours
 Examine the IC/IP role in our facility
 Infection Control Committee
 Provide education for IP
OUR BIGGEST CHALLENGES





Who would be the IP/IC?
Divided the duties between the D.O.N.
and the QI Director
Developed processes and forms so that
the DON could track infections on the
floor
The QI Dir. would get the education,
manage the program and do the data.
Work as a team.
OUR BIGGEST CHALLENGES
 Infection


Preventionist Education
Joined APIC- $185, MT. APIC Chapter
Dues $30-awesome price for what you
get.
Utilized the APIC website- huge resource for
information and education
Attended MT APIC Conference
 Attended the EPI 101 course in S.F.
 MT APIC Listserv- excellent networking
with IPs around the state

OUR BIGGEST CHALLENGES
 How
can the IP know what
infections are in the facility?
Worked with lab staff to develop process
to receive C&S and other reports.
 Worked with unit secretary to develop a
process to get all antibiotic orders.
 Worked with nurses to notify IP of
infections.

Attachment A, Infection Control Program Policy
Infection Control Program Data Sources and Surveillance Activities
Staff nurses, clinical
managers, employees &
providers report residents
and patients and employees
of concern. Concurrent
tracking and interventions
documentation is
maintained using the
worksheet tool.
Lab provides
copies of positive
cultures, unusual
organisms,
reportable
diseases & other
isolates of clinical
significance.
Staff nurses, clinical
managers, employees &
providers report employee
illness of concern.
Infection Control Preventionist (ICP) uses
referred patient data to identify chart
review needed to achieve surveillance
strategies.
Patients are placed in
appropriate isolation and
education provided to
health care workers
During surveillance rounds the ICP reviews each chart to
determine whether the infection is healthcare associated or
was acquired in the community using standard CDC/NHSN
case definitions.
Reportable Diseases as defined by MT State law are
reported to Public Health in compliance with state law and HIPAA regulations
(LTC, CAH, Hospice, ALF & Clinic staff report diseases within their department)
Data is collected on healthcare-associated cases, as is appropriate depending on
the type of infection identified
Data is collected, trended, analyzed and reported for each specific area (LTC, CAH)
using surveillance tools.
The Infection Control Committee oversees the surveillance, investigation, reporting,
control and prevention of infections; occupational exposures to blood, body fluids, or
other potentially infectious materials; and monitoring for proper implementation of and
adherence to infection control policies and procedures.
Quarterly summary reports are given to Board of Directors, Medical Staff, QIC/QAA
Committees, Clinical Managers and Directors.
Infection Control Program
Results to be sent to the Infection Preventionist, Linda Matranga, R.N.
Who
 All patients and residents seen or cared for at the PMC
W hat
 Microbiology Lab Results
 Smear, stain results (gram stain, AFB smear)
 Bacterial culture and sensitivity, parasitology
 AFB culture and sensitivity
 Virology Lab Results
 Immunology/titer results (hepatitis, HIV, chickenpox)
 Rapid tests (influenza, RSV, etc.)
 Viral cultures
Where
 Please place copies in the “Confidential” folder in Linda
Matranga’s mailbox in front office
Note: Please notify the Charge Nurse or Infection Preventionist of
any results indicating that an MDRO (MRSA, VRE, ESBLs) is
present.
Infection Control Worksheet
CAH
PO Box 1228, Big Timber, MT.
406-932-4603 Fax: 406-932-5468
(Acute, OBS, Swing Skilled, Swing Intermediate)
Site
Onset Date_________
Name:______________________________
Acute OBS Sw. Skilled Sw. Int.
Age______ M F Room #________
Signs/Symptoms
EENT
GI
Upper RT
Lower RT
 Skin/ Soft tissue
 Urinary Tract
Other:
Provider Diagnosis
 UTI
 Conjunctivitis
Site
Name:______________________________
Acute OBS Sw. Skilled Sw. Int.
Age______ M F Room #________
Signs/Symptoms
EENT
GI
Upper RT
Lower RT
 Skin/ Soft tissue
 Urinary Tract
Other:
 Bronchitis
Other:
Site
Name:______________________________
Acute OBS Sw. Skilled Sw. Int.
Age______ M F Room #________
Signs/Symptoms
EENT
GI
Upper RT
Lower RT
 Skin/ Soft tissue
 Urinary Tract
Other:
Treatment Plan (include dates)
HAI (Hospital Acquired)
 Community Acquired
Outcome
Provider Diagnosis
 UTI
Culture Date__________
 Pneumonia
 Conjunctivitis
Culture Results:
 Cellulitis
 Bronchitis
Other:
Treatment Plan (include dates)
Onset Date_________
Culture Results:
 Cellulitis
Treatment Plan (include dates)
Onset Date_________
Culture Date__________
 Pneumonia
HAI (Hospital Acquired)
 Community Acquired
Outcome
Provider Diagnosis
 UTI
Culture Date__________
 Pneumonia
 Conjunctivitis
Culture Results:
 Cellulitis
 Bronchitis
Other:
HAI (Hospital Acquired)
 Community Acquired
Outcome
OUR BIGGEST CHALLENGES
 Staff
Education and
Involvement
New policies
 Basic IC education for all nursing
staff
 Increased “teaching moments”
 Emphasized importance and
involvement

 You have a wound that starts to drain.
 It looks purulent.
 You expect an order for C&S and probably antibiotics.
Or
 You have a resident/patient with new onset, frequent
uncontrolled and uncontained diarrhea.
 You suspect C. Diff
Or
 You suspect some other type of infection
 Make sure that infectious material is contained as much
as possible.
 Place the resident/patient in the appropriate precautions.
 Get the signs out of the Infection Control Book.
 Get the right equipment up from the basement.
 Don’t wait for the culture or the results.
 The bug could be infecting others while you wait.
 “Isolation precautions” is a nursing decision. You can
get that order later.
 Isolation precautions can be discontinued if not indicated
by the culture results.
 It is better to be safe than sorry
If you have questions, call Linda at ext #257 or her cell.
80% of PMC
staff were
immunized.
Sheriff Matranga will be signing up the
posse on Payday from 1300-1500 this Friday,
10/1. The Sheriff will also be making rounds
at different times in October to rustle up
any stragglers.
Any posse hand that takes a “shot” at the
villain will get their name put in the hat for a
reward.
There are three rewards,
 Wine and Cheese Picnic Backpack
 $40.00 PMC Grub ticket
 $25.00 Starbucks Card
Nursing Guidelines for Symptomatic UTI Assessment and Intervention
(LTC and Swing)
Follow these guidelines in determining when to implement interventions for a
suspected urinary tract infection.
One of the following criteria must be met:
1. The resident has at least one of the following signs and symptoms:
a. Fever (≥ 100.4) or chills,
b. New or increased burning pain on urination, frequency or urgency,
c. New flank or suprapubic pain or tenderness,
d. Worsening of mental or functional status, (may be new or increased
incontinence).
 Note: A change in the character of the urine alone does not meet the
criteria. The resident must have at least one of the above symptoms
also.
2. If the resident has at least one of the above symptoms;
a) Document the findings and vital signs,
b) Send a UA, and then a C&S as indicated by standing orders,
c) Monitor VS and resident status Q Shift and document,
d) Notify the provider of UA and C&S results,
e) Obtain order for treatment as indicated.
KEY IMPROVEMENTS
An infection control program was implemented for
all patients and residents which; investigates,
controls, and prevents infections; decides what
procedures, such as isolation should be applied to
an individual resident; and maintains a record of
incidents and corrective actions related to
infections.
 Redefined the IP role and expanded hours for
infection control and prevention
 Involved all departments in the IC Program

KEY IMPROVEMENTS
 Provided
IP with educational opportunities
and support
 Implemented new processes with lab for
notification of results
 Implemented improved Public Health
Communication processes
 Involved medical staff via the IC committee
and at Med Staff Meetings
 Updated all policies
OTHER IMPROVEMENTS
Provided staff with resources,
guidelines, books, reference materials
 Improved “Sharps Injury” processes,
policy, manager and staff education,
forms and documentation
 Initiated process changes R/T Single
use tourniquets
 Improved endoscopy cleaning
procedures

OTHER IMPROVEMENTS
Initiated process changes R/T specimen
transport
 Initiated process changes R/T how
housekeepers refill disinfectant bottles
 Worked with providers to establish criteria for
urine C&S orders

OTHER IMPROVEMENTS
Implemented new policy for Blood and Body
Fluids Exposure and Follow Up
 Provided info, forms and process guidance for
providers, managers and staff in the ER for any
exposures.
 Implemented an aggressive but fun
immunization program for staff
 Implemented employee illness tracking, new
process and forms

THE BOTTOM LINE
 Education
 Staff
Involvement
 Teamwork
 Administrative
Support
MARCH 2011
LTC SURVEY

Complimentary of the work we had done.

Cited two issues, use of “Definitions of
Infection for Surveillance” and Antibiotic Use
Review.
Definitions of Infection for Surveillance in Long-term Care Facilities
Reference: Definitions of Infection for Surveillance in Long-term Care Facilities; Allison McGeer, Beverly Campbell, T. Grace Emori, Walter J. Hierholzer, Marguerite M. Jackson, Lindsay E. Nicolle, Carla Peppler, Amersolo Rivera, Debra G.
Schollenberger, Andrew E. Simor, Philip W. Smith, and Elaine E-L. Wang Copyright 1996, APIC
RESPIRATORY INFECTIONS
Common cold syndromes/
pharyngitis The resident must
have at least two of the
following signs or symptoms:
1. runny nose or
sneezing,
2. stuffy nose (i.e.,
congestion),
3. sore throat or
hoarseness or
difficulty in
swallowing,
4. dry cough,
5. swollen or tender
glands in the neck
(cervical
lymphadenopathy).
Comment. Fever may or may
not be present. Symptoms must
be new, and care must be taken
to ensure that they are not
caused by allergies.
Influenza-like illness
Both of the following criteria must be met:
1. Fever (>100.4° F)* *A single
temperature of .100.4°, taken at any
site.
2. The resident must have at least
three of the following signs or
symptoms:
a. chills,
b. new headache or eye pain,
c. myalgias,
d. malaise or loss of appetite,
e. sore throat,
f. new or increased dry
cough.
Comment. This diagnosis can be made only
during influenza season. If criteria for
influenza-like illness and another upper or
lower respiratory tract infection are met at
the same time, only the diagnosis of
influenza-like illness should be recorded.
Pneumonia
Both of the following criteria must be
met:
1. Interpretation of a chest
radiograph as demonstrating
pneumonia, probable
pneumonia, or the presence of
an infiltrate. If a previous
radiograph exists for
comparison, the infiltrate
should be new.
2. The resident must have at
least two of the signs and
symptoms described under
‘‘other lower respiratory tract
infections.’’
Comment. Noninfectious causes of
symptoms must be ruled out. In
particular, congestive heart failure may
produce symptoms and signs similar to
those of respiratory infections.
Other lower respiratory tract infection
(bronchitis, tracheobronchitis) The resident must
have at least three of the following signs or
symptoms:
1. new or increased cough,
2. new or increased sputum production, (c)
fever (>100.4),
3. pleuritic chest pain,
4. new or increased physical findings on chest
examination (rales, rhonchi, wheezes,
bronchial breathing),
5. one of the following indications of change
in status or breathing difficulty:
new/increased shortness of breath or
respiratory rate .25 per minute or worsening
mental or functional status.* (*Significant
deterioration in the resident’s ability to carry
out the activities of daily living or in the
resident’s cognitive status, respectively.)
Comment. This diagnosis can be made only if no
chest film was obtained or if a radiograph failed to
confirm the presence of pneumonia.
URINARY TRACT INFECTIONS
Urinary tract infection Urinary tract infection includes only symptomatic
urinary tract infections. Surveillance for asymptomatic bacteriuria (defined
as the presence of a positive urine culture in the absence of new signs and
symptoms of urinary tract infection) is not recommended, as this represents
baseline status for many residents.
Symptomatic urinary tract infection One of the following criteria must
be met:
1. The resident does not have an indwelling urinary catheter and
has at least three of the following signs and symptoms:
a. fever (>100.4° F) or chills,
b. new or increased burning pain on urination, frequency or
urgency,
c. new flank or suprapubic pain or tenderness,
d. change in character of urine,
e. worsening of mental or functional status (may be new or
increased incontinence).
2.
The resident has an indwelling catheter and has at least two of the following signs or
symptoms:
a. fever (>100.4° F) or chills,
b. new flank or suprapubic pain or tenderness,
c. change in character of urine,
d. worsening of mental or functional status.
Comment. It should be noted that urine culture results are not included in the criteria. However, if
an appropriately collected and processed urine specimen was sent and if the resident was not taking
antibiotics at the time, then the culture must be reported as either positive or contaminated. Because
the most common occult infectious source of fever in catheterized residents is the urinary tract, the
combination of fever and worsening mental or functional status in such residents meets the criteria
for a urinary tract infection. However, particular care should be taken to rule out other causes of
these symptoms. If a catheterized resident with only fever and worsening mental or functional
Change in character may be clinical (e.g., new bloody urine, foul smell, or amount of sediment)
or as reported by the laboratory (new pyuria or microscopic hematuria). For laboratory changes,
this means that a previous urinalysis must have been negative.
McGeer Definitions of Infection for LTC
EYE, EAR, NOSE, AND MOUTH INFECTION
Conjunctivitis One of the following criteria must be met:
1. Pus appearing from one or both eyes, present for at
least 24 hours.
2. New or increased conjunctival redness, with or
without itching or pain, present for at least 24
hours (also known as ‘‘pink eye’’).
Comment. Symptoms must not be due to allergy or trauma
to the conjunctiva.
Ear infection One of the following criteria must be met:
1. Diagnosis by a provider* of any ear infection.
2. New drainage from one or both ears. (Non-purulent drainage must
be accompanied by additional symptoms, such as ear pain or
redness.)
*Requires a written note or a verbal report from a provider specifying the
diagnosis. usually implies direct assessment of the resident by a provider. An
antibiotic order alone does not fulfill this criterion.
Mouth and perioral infection
Oral and perioral infections,
including oral candidiasis, must be
diagnosed by a provider or a
dentist.
Sinusitis The diagnosis of sinusitis
must be made by a pprovider.
SKIN INFECTION
Cellulitis/soft tissue/wound infection One of the following
criteria must be met:
1. Pus present at a wound, skin, or soft tissue site.
2. The resident must have four or more of the following
signs or symptoms:
a. fever (>100.4) or worsening mental/functional
status; and/or, at the affected site, the presence
of new or increasing
b. heat,
c. redness,
d. swelling,
e. tenderness or pain, serous drainage.
Fungal skin infection The resident must have
both
1. a maculopapular rash and
2. either provider diagnosis or laboratory
confirmation.†
Herpes simplex and herpes zoster infection. For a
diagnosis of cold sores or shingles, the resident must have
both
1. a vesicular rash and
2. either provider diagnosis or laboratory confirmation.
†For Candida or other yeast, laboratory
confirmation includes positive smear for yeast
or culture for Candida spp.; for herpetic
infections, positive electron microscopy or
culture of scraping or swab; for scabies,
positive microscopic examination of scrapings.
Scabies The resident must have both
1. a maculopapular and/or itching rash and
2. either provider diagnosis or laboratory confirmation.
Comment. Care must be taken to ensure that a rash is not
allergic or secondary to skin irritation.
SYSTEMIC INFECTIOJN
GI TRACT INFECTIONS
Primary bloodstream infection One of the following criteria must
be met:
1. Two or more blood cultures positive for the same organism.
2. A single blood culture documented with an organism
thought not to be a contaminant and at least one of the
following:
a. fever (>/= 100.4),
b. new hypothermia (<94.1° F, or does not register on
the thermometer being used),
c. a drop in systolic blood pressure of > 30 mm Hg
from baseline, or
d. worsening mental or functional status.
Gastroenteritis
One of the following criteria must be met:
1. Two or more loose or watery stools above what is
normal for the resident within a 24-hour period.
2. Two or more episodes of vomiting in a 24-hour
period.
3. Both of the following:
a. a stool culture positive for a pathogen
(Salmonella, Shigella, E. coli O157:H7,
Campylobacter) or a toxin assay positive for
C. difficile toxin and
b. at least one symptom or sign compatible with
gastrointestinal tract infection (nausea,
vomiting, abdominal pain or tenderness,
diarrhea).
Comment. Bloodstream infections related to infection at another site
are reported as secondary bloodstream infections and are not
included as separate infections.
Unexplained febrile episode The resident must have documentation
in the medical record of fever (>/=100.4° F) on two or more
occasions at least 12 hours apart in any 3-day period, with no known
infectious or noninfectious cause.
Comment. Care must be taken to rule out noninfectious causes of
symptoms. For instance, new medications may cause both diarrhea
and vomiting; vomiting may be associated with gallbladder disease.
McGeer Definitions of Infection for LTC
Principles: The definitions presented here
are not all-inclusive. They focus on infections
for which surveillance is expected to be
useful (i.e., infections that are common and
can be acquired and detected in the facility).
Three important conditions apply to all of the
definitions: 1. All symptoms must be new or
acutely worse. Many residents have chronic
symptoms, such as cough or urinary urgency,
that are not associated with infection.
However, a change in the resident’s status is
an important indication that an infection may
be developing.
2. Noninfectious causes of
signs and symptoms should always be
considered before a diagnosis of infection is
made. 3. Identification of infection should not
be based on a single piece of evidence.
Microbiologic and radiologic findings should
be used only to confirm clinical evidence of
infection. Similarly, provider diagnosis
should be accompanied by compatible signs
and symptoms of infection.
ANTIBIOTIC REVIEW
 Implement
processes
for antibiotic use review
 Opportunity for medical
staff involvement
 Another learning
moment
THE ROAD AHEAD
Growing emphasis nationally
on the importance of infection
prevention.
 PPS hospitals currently
required to report certain
infections.
 Trend toward mandatory
reporting in other states.
 Will this be the future for CAH
too?
 The Right Thing To Do.

COLLABORATION BETWEEN AGENCIES
MTDPHHS
MHA
MPQH
Standardization of
surveillance
activities through
use of NHSN and
existing information
systems
Encourage use of
NHSN for
surveillance
Enrolled all IPPS
facilities into NHSN
Evidence-Based Standardization of
Practices
isolation practices
CUSP
CAH MRSA
Project
Surgical Care
Improvement Project
MRSA
Coaching
All infection
prevention and
control activities
CUSP
Surgical Care
Improvement Project
MRSA
Communication
& Education
Web Site
IP Training
HCW Training
IP Listserv Mgmt
PIN
Liaison to
CEO/CFO
Advocacy
IP Training
Sharepoint site
IP Listserv Hosting
Surveillance
THANK YOU
QUESTIONS?