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Infection Prevention
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CONTENTS
INTRO
INTRODUCTION
INTRODUCTION....................................................................................................... 11
CHAPTER ONE
THE CONNECTION: Infection Control and the Physical Environment................. 16
Infection Control Standards and the Infection Control Program.............. 17
• GUIDELINES & REQUIREMENTS: Summary: The Joint Commission
Infection Prevention and Control (IC) Standards; Summary:
Joint Commission International (JCI) Prevention and Control
of Infections (PCI) Standards............................................................................ 18
• Planning for the Infection Control Program....................................................... 17
• Implementation of the Infection Control Plan.................................................... 17
• Evaluation and Improvement of the Infection Control Plan................................ 20
ONE
Infection Control and Standards Related to the Physical Environment.... 20
• GUIDELINES & REQUIREMENTS: Summary: The Joint Commission
Environment of Care (EC) Standards Addressing Infection Control;
Summary: Joint Commission International (JCI) Facility Management
and Safety (FMS) Standards Addressing Infection Control............................... 21
• Standards for Demolition, Renovation, and/or Construction.............................. 20
• Standards for Medical Equipment and Utility Systems...................................... 22
• Standards for Hazardous Materials and Waste................................................. 22
• Standards for Emergency Power Sources......................................................... 22
• Standards for a Safe and Functional Environment............................................. 22
Infection Control and Patient Safety Goals................................................... 23
• Patient Safety Goals and Evidence-Based Practices........................................ 23
• Patient Safety Goals, CLABSI, and CAUTI......................................................... 23
Collaboration Among Infection Control and Environmental
Professionals....................................................................................................... 23
•
•
•
•
A Multidisciplinary Infection Control Team........................................................ 23
Typical Collaborative Relationships................................................................... 23
A Common Understanding: Infectious Organisms............................................ 24
CASE STUDY: Infection Control Issues in Opioid
Treatment Facilities........................................................................................... 25
• Environmental Tours for Infection Control.......................................................... 27
• Elements of the Environmental Tour.................................................................. 27
• TOOL: Infection Control Checklist for Environmental Tours............................... 28
Tracers for Infection Control............................................................................ 29
• Tracers to Evaluate and Assist.......................................................................... 29
• Infection Control System Tracer........................................................................ 29
• TRACER: Sample Scenario: Infection Control System Tracer............................ 30
Conclusion........................................................................................................... 30
References........................................................................................................... 30
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
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CHAPTER TWO
THE HUMAN ELEMENT: Staff and Infection Control Compliance........................ 32
Collaboration Made Easier................................................................................ 33
TWO
• Collaboration with Leadership Support............................................................. 33
• Collaboration Over Time and Across Teams..................................................... 33
Human Factors and Hand Hygiene................................................................. 33
• Human Factors Barriers to Hand Hygiene Practice.......................................... 33
• Insufficient Time Spent in Hand Hygiene.......................................................... 34
• GUIDELINES & REQUIREMENTS: Comparison of US CDC and WHO
Hand Hygiene Guidelines................................................................................. 35
• Delayed Feedback on Hand Hygiene................................................................ 34
• Overcoming the Human Factors Barriers to Hand Hygiene.............................. 39
• Target Solutions Tool® for Hand Hygiene........................................................... 40
• Environmental Input to Hand Hygiene Approaches........................................... 40
• TOOL: Checklist for Environmental-Related Hand Hygiene Elements............... 41
• GUIDELINES & REQUIREMENTS: Life Safety Standards for
Alcohol-Based Hand Rub Dispensers............................................................... 42
Human Error and Sharps Management.......................................................... 43
•
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Sharps Injury Prevention Program..................................................................... 43
CASE STUDY: Performance Initiative for Sharps Injury Prevention.................... 44
Logging and Reporting Sharps Injuries............................................................ 46
TOOL: Sharps Injuries Log................................................................................ 47
Safety Training for Sharps................................................................................. 46
Sharps Disposal Containers............................................................................. 47
TOOL: Sharps Risk Assessment Questionnaire................................................ 48
GUIDELINES & REQUIREMENTS: US NIOSH Performance Criteria
for Sharps Disposal Containers........................................................................ 50
Human Nature and Staff Training and Competency.................................... 49
•
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•
Multidisciplinary Team Approach...................................................................... 49
Basic Education on Infection Control................................................................ 49
Collaborative Orientation on Infection Control................................................... 49
Infection Control Training for Contract Staff....................................................... 51
Infection Control Competency........................................................................... 51
Conclusion........................................................................................................... 52
References........................................................................................................... 52
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Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
CHAPTER THREE
CONSTRUCTION PROJECTS: Infection Control Considerations......................... 53
Infection Control Regulations for Construction Projects........................... 54
THREE
• FGI Guidelines.................................................................................................. 54
• Other Infection Control and Construction Guidelines........................................ 54
• GUIDELINES & REQUIREMENTS: Sample of Key Changes in the
2014 FGI Guidelines......................................................................................... 55
• RESOURCES: Online Guidelines for Infection Control and Construction........... 56
Construction Project Collaboration................................................................ 54
• Executive Project Team..................................................................................... 54
• Expert Input...................................................................................................... 55
• Scope of Infection Control Practitioner Involvement.......................................... 56
Design Elements for Infection Control........................................................... 56
• Design Elements for Clinical and Ancillary Rooms............................................ 57
• Design Elements Posing Challenges for Infection Control................................. 57
• Design Elements for Infection Control in Specific Areas................................... 58
Sustainable Design and Infection Control..................................................... 59
• Maximizing Environmental and Infection Control Goals.................................... 59
• RESOURCES: Online Information on Sustainable Design................................. 60
Infection Control Before Construction........................................................... 59
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Risk Assessments............................................................................................. 59
TOOL: Infection Control Risk Assessment (ICRA) Matrix................................... 61
Project Responsibility and Accountability......................................................... 65
Worker Education and Safety............................................................................ 65
Safe Airflow....................................................................................................... 65
SPECIFICATIONS & RECOMMENDATIONS: Engineered Specifications
for Positive- and Negative-Pressure Rooms...................................................... 67
• Preconstruction Checklists for Infection Control................................................ 66
• TOOL: Infection Control Checklist for Construction Projects............................. 68
Infection Control During Construction........................................................... 67
•
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Monitoring Construction Zone Materials............................................................ 69
Air and Water Samples..................................................................................... 69
Common Construction-Related Contaminants.................................................. 70
CASE STUDY: Air Quality During Construction.................................................. 71
Infection Control After Construction.............................................................. 70
• Postconstruction Agreements........................................................................... 70
• Pre-Occupancy Walk-Through.......................................................................... 72
Conclusion........................................................................................................... 73
References........................................................................................................... 73
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
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CHAPTER FOUR
MEDICAL EQUIPMENT: Reprocessing for Infection Control................................ 74
A Systematic Approach to Reprocessing...................................................... 75
FOUR
• A Reprocessing Policy...................................................................................... 75
• RESOURCES: Organizations to Consult in Developing a Reprocessing
Policy................................................................................................................ 76
• The Spaulding System...................................................................................... 75
• Cleaning Medical/Surgical Items...................................................................... 76
• Disinfecting Medical/Surgical Items.................................................................. 77
• SPECIFICATIONS & RECOMMENDATIONS:
Spectrum of Activity Achieved by the Main Disinfectants................................. 79
• CASE STUDY: Infection Control Risks and Point-of-Care Testing...................... 80
• Sterilizing Medical/Surgical Items..................................................................... 78
• SPECIFICATIONS & RECOMMENDATIONS: Advantages and
Disadvantages of Various Sterilization Methods............................................... 82
• SPECIFICATIONS & RECOMMENDATIONS: Level of Reprocessing
Required for Medical/Surgical Items................................................................. 84
Monitoring Reprocessing ................................................................................. 81
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Sterilizing: Mechanical Indicators..................................................................... 81
Sterilizing: Chemical Indicators......................................................................... 83
Sterlizing: Biological Indicators......................................................................... 83
SPECIFICATIONS & RECOMMENDATIONS: Protocol for Investigating
Exposure Risk Due to Disinfection or Sterilization Failure................................. 86
• Sterilizer Maintenance....................................................................................... 85
• Monitoring for Policy Compliance...................................................................... 86
Central Processing............................................................................................. 87
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Location and Areas of Central Processing....................................................... 87
Packaging and Inspecting................................................................................ 87
Storage and Transport...................................................................................... 87
Surgical Services Department.......................................................................... 88
Central Processing Staff Education and Training.............................................. 88
SPECIFICATIONS & RECOMMENDATIONS: AAMI Recommendations
for Reprocessing Staff Competency.................................................................. 89
Biomedical Engineering.................................................................................... 88
• Infection Risk in Biomedical Engineering.......................................................... 88
• Biomedical Staff Education and Training........................................................... 88
AEM and Reprocessing Equipment................................................................. 90
• AEM Restrictions............................................................................................... 90
Collaboration in Reprocessing......................................................................... 90
Reprocessing Single-Use Devices................................................................... 90
• Regulations Regarding SUDs............................................................................ 91
• SPECIFICATIONS & RECOMMENDATIONS: SUDs and Reprocessing
for TSE Precautions........................................................................................... 93
Reprocessing Endoscopes................................................................................ 91
• Standards for Reprocessing Endoscopes......................................................... 92
• CASE STUDY: Verifying the Manual Cleaning Process of Flexible
Endoscopes...................................................................................................... 95
• Addressing Endoscope Reprocessing Challenges........................................... 92
• TOOL: Sample Checklist for Reprocessing Endoscopes.................................. 97
Conclusion........................................................................................................... 94
References........................................................................................................... 99
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Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
CHAPTER FIVE
UTILITY SYSTEMS: Infection Control Concerns.................................................. 100
Infection Control Regulations for Utility Systems..................................... 101
• Infection Control in the Utility Systems Plan.................................................... 101
FIVE
Infection Control and HVAC Systems........................................................... 101
• SPECIFICATIONS & RECOMMENDATIONS: HVAC and UVGI to Control
Spread of Tuberculosis Infection.................................................................... 102
• SPECIFICATIONS & RECOMMENDATIONS: Sick Building Syndrome............. 103
• HVAC Systems Variable: Pressure Relationships............................................. 102
• SPECIFICATIONS & RECOMMENDATIONS: Areas with Special
Ventilation Requirements................................................................................. 104
• HVAC Systems Variable: Air Change Rates..................................................... 104
• HVAC Systems Variable: Filtration................................................................... 105
Infection Control and HVAC System Maintenance.................................... 105
• TOOL: Indoor Air-Quality Maintenance Checklist............................................ 106
• HVAC Systems Maintenance Tasks................................................................. 105
• AEM for Utility Systems................................................................................... 105
Other Options: New Technologies and Sustainable Approaches........... 107
• Effective and Economical Future Options........................................................ 107
• Environmentally Sustainable Options.............................................................. 107
Infection Control and Water Distribution Systems.................................... 108
• EXAMPLES & ILLUSTRATIONS: Water-Linked Infection Outbreaks in
Health Care Organizations.............................................................................. 109
• Preventing Waterborne Pathogens from Colonizing........................................ 108
• EXAMPLES & ILLUSTRATIONS: Interventions for Waterborne
Pathogens in a Health Care Facility................................................................ 110
• Disinfecting Water........................................................................................... 112
Legionella........................................................................................................... 112
• SPECIFICATIONS & RECOMMENDATIONS: What Every Clinician
Needs to Know About Legionnaire’s Disease................................................. 113
• Surveillance for Legionnaire’s Disease Outbreaks.......................................... 112
• Prevention Methods for Legionnaire’s Disease Outbreaks.............................. 114
• Routine Sampling for Legionella..................................................................... 115
• Tracing for Legionella...................................................................................... 115
• TRACER: Sample Scenario: Infection Control System Tracer.......................... 116
Conclusion......................................................................................................... 115
References......................................................................................................... 118
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
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CHAPTER SIX
ENVIRONMENTAL SERVICES AND MEDICAL WASTE DISPOSAL:
Infection Control Issues........................................................................................ 120
SIX
Housekeeping and Infection Control............................................................ 121
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•
TOOL: Checklist for Housekeeping Infection Control...................................... 122
Basic Cleaning Methods and Materials .......................................................... 121
Choosing the Right Cleaning Product ............................................................ 123
Challenges of Cleaning Patient Rooms........................................................... 123
RESOURCES: US EPS Registered Disinfectants............................................. 124
CASE STUDY: Technology Solutions for Effective Cleaning............................. 125
Protecting Housekeeping Staff........................................................................ 124
ADVANTAGES & DISADVANTAGES: Glove Materials....................................... 128
Housekeeping Hot Spots ............................................................................... 127
Laundry Operations and Infection Control.................................................. 127
• SPECIFICATIONS & RECOMMENDATIONS: US CDC, NIOSH, and
OSHA Laundry Practices................................................................................ 129
• Laundry Sorting and Transporting.................................................................. 129
• Protecting Laundry Staff................................................................................. 130
• Policies and Procedures for the Laundry Operations...................................... 130
• GUIDELINES & REQUIREMENTS: Healthcare Laundry Accreditation
Council: Sample Standards............................................................................ 131
Regulated Medical Waste Disposal and Infection Control....................... 130
• Categories of Regulated Medical Waste......................................................... 132
• Treatment and Disposal of Regulated Medical Waste..................................... 132
• ADVANTAGES & DISADVANTAGES: Treatment Methods for Regulated
Medical Waste................................................................................................ 133
• Fluid Waste Disposal....................................................................................... 132
• Ebola-Contaminated Waste............................................................................. 134
• SPECIFICATIONS & RECOMMENDATIONS: Recommendations for
Disposal of Ebola-Contaminated Waste.......................................................... 135
Conclusion......................................................................................................... 136
References......................................................................................................... 136
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Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
CHAPTER SEVEN
EMERGENCY MANAGEMENT: Infection Control for Disasters........................... 137
The EOP/EM Plan.............................................................................................. 138
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SEVEN
The Four Phases of Emergency Management................................................ 138
Surge Capacity............................................................................................... 138
The Hazard Vulnerability Analysis................................................................... 139
TOOL: Hazard Vulnerability Analysis............................................................... 140
Recommendations for Environmental Leaders................................................ 138
Infectious Patient Surges............................................................................... 141
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Communication and Infectious Patient Surges................................................ 141
TOOL: Organizational Assessment for Influenza Preparedness...................... 143
Managing a Surge of Infectious Patients........................................................ 142
Managing Epidemics...................................................................................... 144
Environmental Considerations for Infectious Disease Outbreaks ......... 144
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Isolation Rooms and Anterooms for Infectious Disease Outbreaks................. 144
Use of PPE for Infectious Disease Outbreaks................................................. 145
Cleaning for Infectious Disease Outbreaks..................................................... 145
CASE STUDY: Resuming Service After Blackwater Flooding........................... 146
Infectious Waste from Infectious Disease Outbreaks...................................... 145
Decontamination ............................................................................................. 145
• Victim Decontamination Program.................................................................... 147
• Decontamination Incidents............................................................................. 147
• Triage for Decontamination............................................................................. 148
Decontamination Facilities.......................................................................... 148
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Outdoor Decontamination Facilities................................................................ 148
Indoor Decontamination Facilities................................................................... 149
Additional Decontamination Facilities Issues.................................................. 149
Decontamination Team.................................................................................... 150
Conclusion......................................................................................................... 150
References......................................................................................................... 151
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
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CHAPTER EIGHT
PERFORMANCE IMPROVEMENT: Measuring Infection Control
in the Physical Environment................................................................................. 152
EIGHT
A Multidisciplinary Team Approach..................................................................... 153
• Performance Improvement Team Tasks........................................................... 153
• Team Communication and Collaboration......................................................... 153
What to Measure............................................................................................... 153
• Outcome Measures and Process Measures.................................................... 154
• CASE STUDY: Proactive Infection Control Based on Data............................... 155
Collecting Data................................................................................................. 157
• Environmental Rounds.................................................................................... 157
• Employee Interviews....................................................................................... 157
• TOOL: Check Sheet: Six-Month Employee Injury Report................................. 158
Intervention Responses and Follow-Up........................................................ 157
Using Data Tools to Improve Infection Control........................................... 159
• TOOL: Performance Improvement Tool Selection Matrix.................................. 159
• Data Displays: Performance Data on Competency Assessments................... 159
• EXAMPLES & ILLUSTRATIONS: Sample Bar Chart: Posttest Scores
for Infection Transmission Education............................................................... 160
• EXAMPLES & ILLUSTRATIONS: Sample Run Chart: Effectiveness of
Training in Decontamination Procedures......................................................... 161
• Using Data to Set Target Rates....................................................................... 162
US CDC Performance Measurement Recommendations.......................... 162
Conclusion......................................................................................................... 163
Reference........................................................................................................... 163
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Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
INTRODUCTION
INTRO
The Ebola outbreak in 2014 was the largest in history, affecting
multiple nations and continuing to spread despite worldwide
emergency responses. This epidemic garnered much public
attention, and rightly so. However, many infection control
concerns do not make the news but still affect millions of people
in developed and developing nations alike. Chief among these
are health care–associated infections (HAIs).
Patients getting sick or sicker while in a health care setting may
be ironic, but it is not new. More than 75,000 patients die every
year from HAIs in the United States alone.1 Although global
statistics are not available, the World Health Organization
(WHO) has estimated that hundreds of millions of patients
around the world are affected by HAIs each year, and the burden
of these infections is significantly higher in low- and middleincome nations.2 In addition to the human cost, there are
financial repercussions: In the United States, treating patients
who acquire HAIs costs an estimated $9.8 billion annually.3
Furthermore, the US Centers for Medicare & Medicaid Services
(CMS) no longer reimburses for extra costs associated with
certain types of HAIs acquired while the patient was receiving
care, giving hospitals and other health care facilities even more
incentive to implement prevention measures.4
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
11
Challenges of Infection Control
Every health care setting—not just hospitals—faces the
challenge of keeping patients and staff free of infection,
including HAIs. Those challenges differ, of course, by setting.
Behavioral health care settings, for example, will not need to
worry about negative-pressure isolation rooms, but they may
need to address higher numbers of patients with certain
infections, like tuberculosis or hepatitis C. Home care
organizations will handle infection control differently because
their staff members are providing care in patients’ homes, where
One example of the interconnectedness of infection control and
the physical environment is the use of hand-washing sinks. As
noted, hand hygiene is a critical infection control issue; to
minimize infection risk, staff members must wash their hands.
But if sinks are far from patient care areas, or are not cleaned
regularly, or the water supply to the sinks is interrupted by a
renovation project, then hand hygiene suffers and infection risk
increases. In this example and myriad others, the physical
environment has a direct impact on the ability of the
organization to effectively manage its infection risks.
the organization has little control over the environment.
Many factors that contribute to HAI rates seem to be beyond
the control of health care organizations, regardless of setting.
Increasing numbers of patients have compromised immune
systems. Emerging technology improves medical outcomes
but introduces more complicated procedures that increase
opportunities for the introduction of pathogens. Staff and
supplies may be limited. Facilities and equipment become old
or obsolete, requiring renovation or construction. New infectious
organisms appear, and familiar ones gain resistance.
However overwhelming the obstacles may seem, many HAIs can
be prevented, often with something as simple as hand hygiene.
Despite the universal acknowledgment of the importance of
hand hygiene by organizations such as The Joint Commission,
Joint Commission International (JCI), WHO, and the US Centers
for Disease Control and Prevention (CDC), compliance with
established hand hygiene procedures is historically very low.
This is the case even in developed countries such as the United
States, which is estimated to have only around 50% compliance
with hand hygiene guidelines.5
Leadership in Infection Control
Joint Commission and JCI standards and requirements
recognize this connection. These standards require
organizations to monitor, analyze, and improve conditions in the
environment—including conditions affecting infection control.
And to a much greater degree than ever before, the
requirements compel organization leadership to assume
responsibility for reducing the risk and transmission of HAIs,
including environmental risks. These standards and
requirements place accountability for the effectiveness of an
organization’s infection control program squarely with its
leaders, who are responsible for ensuring adequate staff training
in infection control, communicating and coordinating efforts with
the health department and other community agencies, and
allocating sufficient resources to support the program.
Of course, leadership in infection control relies significantly on
the presence and effectiveness of an infection preventionist
(or other infection control practitioner). This individual has the
specialized education and training needed to manage the
complex set of issues entailed by infection control. The
importance of this role was demonstrated in a US study of
Infection Control and the Physical Environment
hospitals in California, where researchers found that US health
These challenges underscore the need for a strong, thorough,
care organizations that employed a certified infection
consistent infection control program in every type of health care
preventionist had significantly lower rates of MRSA (methicillin-
setting. But operating in tandem is the need for an equally
resistant Staphylococcus aureus) bloodstream infections than
strong program to manage the physical environment. In the
those organizations without one.6
United States, this is commonly called the environment of care;
internationally, it is known as the health care environment or
patient environment. An organization’s physical environment—
the building, its furnishings, the equipment, and the utilities that
support all of these—is inextricably linked to its ability to prevent
and control infection. A well-designed, thoughtfully managed
environment is the foundation upon which most infection control
activities are built.
12
But the infection preventionist cannot do it alone. In some cases,
such as most of these occuring in home care settings, there
may not even be an infection preventionist on staff. These
factors underscore the importance of making infection control
an organizationwide effort. This can only work when leadership
establishes and promotes a culture of safety. Staff need to feel
comfortable questioning procedures and pointing out areas that
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
need improvement. Open communication should be encouraged
including those developed by professional and regulatory
among all levels. There can be no punitive atmosphere, explicit
organizations, as well as strategies devised through long-term
or implied. This is so important that the Joint Commission
experiences by organizations.
standards require organization leadership to create and
maintain this atmosphere. Every employee of the organization
This book is intended for use by health care professionals
must feel they are important to infection control—which, of
around the world. Some situations and requirements are not
course, they are.
universally applicable. Unless otherwise stated in the text, the
concepts included in this book will be treated as applicable to
Inside This New Edition
This new edition of Infection Prevention and Control Issues in the
all health care organizations. Users of this book are encouraged
to consult the appropriate Joint Commission or JCI accreditation
manual to determine specific requirements.
Environment of Care is designed to help infection preventionists
(and other infection control practitioners) and physical
Following is a chapter-by-chapter description of the book’s
environment professionals collaborate on infection control issues
contents.
to develop an infection control program that will protect patients,
staff, and visitors from the threat of infection. This edition
explores various infection control risks, in the United States and
abroad, that can be minimized or eliminated through proper
management of the physical environment in the following areas:
• Hand hygiene and sharps management
•Construction
• Medical equipment
• Utility systems
• Environmental services
• Infectious materials and waste
• Emergency management
This book provides information about policies, procedures, and
guidelines that can help organizations to manage and benchmark
infection control efforts. Case studies profile plans or projects that
have proven effective in other facilities. The book also lists online
resources, provides examples of useful tools, presents pros and
cons of various infection control approaches, shares tracer
scenarios and offers general and specific recommendations for
infection control.
How to Use This Book
All health care organizations and facilities are responsible for
establishing preventive measures for eliminating and mitigating
infection control risks in their own environment. Some risks are
the same in all environments, geographic locations, and health
care settings; others are particular to the individual facility.
Some solutions or guidelines will be applicable to many
countries, while others may be specific to the United States.
Most organizations will find strategies and approaches
described in this book that may be combined in useful ways,
INTRODUCTION
Chapter 1 — The Connection: Infection Control and the
Physical Environment: This chapter discusses current
standards from The Joint Commission and JCI that relate to
infection control and the physical environment as well as
regulations and guidelines from other organizations. It explores
the components of a strong infection control program and plan
and emphasizes the importance of collaboration between
infection control and environmental professionals. It also
describes the use of tracers and environmental tours, which
serve as proactive risk assessment tools.
Chapter 2 — The Human Element: Staff and Infection Control
Compliance: The importance of understanding human factors,
human errors, and human nature in the working partnership
between infection control and physical environment
professionals is the focus of this chapter. Specifically, it covers
staff performance in relation to the issues of hand hygiene and
sharps management, as well as staff training and competency.
The chapter also includes a comparison of the US CDC and
WHO guidelines for hand hygiene in addition to descriptions of
other guidelines for hand hygiene and sharps.
Chapter 3 — Construction Projects: Infection Control
Considerations: This chapter focuses on infection control
related to construction and renovation of health care facilities,
including the infection control risk assessment, specific design
elements that support infection control, maintaining air quality
during construction, and the multidisciplinary approach to
minimizing risk in all stages of building projects. Infection
control that incorporates sustainable principles and practices
and construction worker safety and education are among other
topics covered.
13
Chapter 4 — Medical Equipment: Reprocessing for Infection
sustain progress, no matter what the setting. As in other
Control: Cleaning and decontamination, disinfection, and
chapters, the role of a multidisciplinary team approach is
sterilization methods for varying types of medical/surgical items
stressed as well as the need for staff training and education.
are the focus of this chapter. The role of central processing and
biomedical engineering, including maintenance of sterilizer
equipment, is also covered. A special section on reprocessing
recommendations for endoscopes is included.
Chapter 5 — Utility Systems: Infection Control Concerns:
This chapter discusses the heart of the infection control and
physical environment connection with issues such as air
handling, ventilation, and water distribution systems. One of the
most common waterborne pathogens, Legionella, is discussed
at length. The chapter explores standards related to utility
systems and their maintenance. In addition, this chapter gives
information on sick building syndrome; pressure relationships
and air change rates; the use of high-efficiency particulate air
Notes on Language
Infection control is a complex and critical matter in all health
care settings. In the United States, The Joint Commission has
the following accreditation programs:
• Ambulatory health care
• Behavioral health care
• Critical access hospital
• Home care
•Hospital
•Laboratory
• Nursing care centers
• Office-based surgery
filters; and the latest recommendations regarding no-touch
Joint Commission International has the following accreditation
faucets and decorative water features (fountains).
programs:
Chapter 6 — Environmental Services and Medical Waste
Disposal: Infection Control Issues: The issues examined in
this chapter relate to maintaining the physical environment and
infection control based on guidelines developed by the US CDC
and WHO. The first half of the chapter focuses on housekeeping
activities such as cleaning and laundry. This includes a
discussion of how various types of surfaces may harbor
• Ambulatory health care
• Clinical laboratory
• Home care
• Hospitals (including academic medical centers)
• Long term care
• Medical transport organizations
• Primary care centers
infectious particles. The second half of the chapter turns to the
The term health care organization is used to recognize and
management of regulated medical waste, with special
include all these organizations.
information on Ebola-contaminated waste.
To help make this book accessible and relevant to organizations
Chapter 7 — Emergency Management: Infection Control for
around the world, an effort has been made to use inclusive
Disasters: How infection control issues relate to all four phases
language while still distinguishing between Joint Commission
of emergency management is the focus of this chapter. It
and JCI terminology. The term physical environment is used as a
discusses specifics of the emergency management plans,
global term to describe what is known in the United States as
including surge capacity as well as infectious patient surges
the environment of care and internationally as patient care
and preparing for infectious disease outbreaks. The use of
environment. When specific US and international standards are
isolation rooms, anterooms, and personal protective equipment
referenced, they will be referred to using appropriate terms and
(PPE) is explored, and the pros and cons of indoor and outdoor
abbreviations; for example, Infection Prevention and Control (IC),
decontamination are weighed.
Environment of Care (EC), and Emergency Management (EM)
Chapter 8 — Performance Improvement: Measuring Infection
Control in the Physical Environment: This chapter focuses on
performance improvement in the environmental aspects of
for standards in the Joint Commission manuals, and in JCI
manuals, Prevention and Control of Infections (PCI) and Facility
Management and Safety (FMS).
infection control. It includes strategies for collecting and displaying
Throughout the book, information not explicitly stated as
data to measure improvements in the physical environment and
requirements of The Joint Commission or JCI standards should
infection control so that health care organizations can make and
be considered recommendations.
14
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
References
1. US Centers for Disease Control and Prevention. HealthcareAssociated Infections (HAIs). (Updated Oct 15, 2015.)
Accessed Oct 26, 2015. http://www.cdc.gov/HAI/surveillance/.
2. World Health Organization (WHO). Report on the Burden
Acknowledgments
Joint Commission Resources thanks the following reviewers:
Tracy Collander, LCSW
Jeff Conway, MPH
of Endemic Health Care-Associated Infection Worldwide:
John Fishbeck
A Systematic Review of the Literature. Geneva: WHO, 2011.
Jessica Gacki-Smith, MPH
Accessed Oct 26, 2015. http://www.who.int/iris
/bitstream/10665/80135/1/9789241501507_eng.pdf?ua=1.
3. The JAMA Network. Press Release: Study Estimates Costs of
Claudia Jorgenson, RN, MSN
Michael Kulczycki, MBA, FASAE
Health Care-Associated Infections. Sep 2, 2013. Accessed
Margherita Labson, RN, MS, CPHQ, CCM
Oct 26, 2015. http://media.jamanetwork.com/news-item
John Maurer, SASHE,CHFM, CHSP
/study-estimates-costs-ofhealth-care-associated-infections/.
4. US Centers for Medicare & Medicaid Services. HospitalAcquired Conditions (Present on Admission Indicator).
Stacy Olea, MT(ASCP), FACHE
Kelly Podgorny, DNP, MS, CPHQ, RN
(Updated: Sep 29, 2014.) Accessed Oct 26, 2015.
Paul Reis
http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-
Karen (Kathy) Reno, PhD, MBA, RN, EDAC
Acquired_Conditions.asp.
Diane M. Sosovec, RN, MS
5. McGuckin M, Waterman R, Govednik J. Hand hygiene
compliance rates in the United States—A one-year
Barbara M. Soule, RN, MPA, CIC, FSHEA
multicenter collaboration using product/volume usage
Lisa Waldowski, MS,APRN,CIC
measurement and feedback. Am J Med Qual. 2009
Gina Zimmerman, MS
May–Jun;24(3):205–213.
6. Pogorzelska M, Stone PW, Larson EL. Certification in
infection control matters: Impact of infection control
department characteristics and policies on rates of
multidrug-resistant infections. Am J Infect Control. 2012
Mar;40(2):96–101.
INTRODUCTION
15
THE CONNECTION:
Infection Control and the Physical Environment
ONE
16
Through their standards and other initiatives, The Joint
Commission and Joint Commission International (JCI) have
made it a top priority to prevent and control infection in health
care organizations. This chapter addresses how that effort is
supported by an understanding of the connection between
infection control and the physical environment. This connection
is apparent in Joint Commission and JCI standards for infection
control, related standards for the physical environment, and
specific patient safety goals. Those responsible for complying
with these standards—infection preventionists (and other
infection control practitioners), directors of nursing, facilities
directors, and/or accreditation professionals—therefore need to
collaborate, ideally as part of a multidisciplinary infection control
team. Part of that collaboration is demonstrated in developing
and operationalizing an infection prevention and control
program, participating in environmental tours, and conducting
infection control tracers, all of which are aimed at discovering
the many infection risks present in the physical environment.
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
Infection Control Standards and
the Infection Control Program
The Joint Commission Infection Prevention and Control (IC)
standards and the JCI Prevention and Control of Infections (PCI)
standards are designed to help health care organizations
prevent and control infection. To do so effectively, the standards
require health care organizations—regardless of size and
setting—to have an infection control program that includes a
written plan.
Creating a written plan: The planning standards specifically
require an organization to develop an infection control plan
using the data derived from the risk assessments.* The
organization provides access to information needed to support
the plan and also identifies, prioritizes, and documents the risks.
The plan must include, among other things, a written description
of activities that include surveillance and the process for
evaluating the plan.
• Plan activities: The written, measureable infection control
activities and associated goals should include the following:
An effective infection control program does the following:
Addressing the organization’s prioritized risks
• Requires the support and involvement of organization
Limiting unprotected exposure of patients, visitors, and
staff to pathogens
leadership
Limiting the transmission of infections associated with
• Emphasizes organizationwide communication and collaboration
procedures
• Includes everyone involved in the organization’s daily
Limiting the transmission of infections associated with the
operations (from care providers to nonclinical staff)
use of medical equipment, devices, and supplies
• Meets the needs of the organization’s location, services, and
Improving compliance with hand hygiene guidelines
population served
• Plan evaluation: At least annually, the organization should
The accreditation standards also call for ongoing risk assessment
review its risk for acquiring and transmitting infections based
and monitoring that makes use of performance measures.
on the following:
Geographic location(s)
In short, the IC/PCI accreditation standards address creating
Population(s) served
and maintaining an effective infection control program by means
Care, treatment, and services it provides
of careful planning, implementation, and evaluation (see pages
Analysis of surveillance activities and other infection
18–19, for an summary of the IC and PCI standards).
control data
• Other plan components: In addition, the plan should address
Planning for the Infection Control Program
the following:
Integration of all of the organization’s components and
Planning for the infection control program involves assigning
functions
responsibility, performing risk assessments, and creating a
Methods for communicating responsibilities and reporting
written infection control plan.
data to external organizations.
Assigning responsibility: Leadership assigns one person or a
Obtaining new information regarding current and
team of people (possibly including employees, contractors, and/
emerging infections, including evidence-based guidelines
or consultants) to develop the program. This individual or team
The process for investigating outbreaks of infectious
may be different within different organizations and may play
disease, including responding to an infectious outbreak or
different roles.
influx of infectious patients
Performing a risk assessment: The responsible party gathers
key people with expertise in infection control and facilities
Implementation of the Infection Control Plan
management to perform a risk assessment. A review of the
To implement the infection control plan, the responsible party
organization’s specific infection risks should be done annually and
should take practical action, emphasizing collaboration and
whenever risks significantly change. The infection control team
communication among departments and staff, and clearly
uses the information gleaned from this review to prioritize goals
defining roles.
for reducing the risks, and to plan focused activities or action
plans based on professional guidelines and scientific practices.
* Refer to the program-specific Joint Commission or JCI accreditation manual
for relevant standard numbers.
CHAPTER 1 | THE CONNECTION: Infection Control and the Physical Environment
17
Summary: The Joint Commission
Infection Prevention and Control (IC)
Standards
The following is an summary of the Joint Commission’s
IC standards.* Organizations must do the following:
• Identify individuals or positions within the organization
that will have the authority to take the appropriate
steps in prevention or control of transmission of
infectious agents.
• Ensure that this individual has clinical authority over
the infection control program and consults with those
who have expertise in infection control in order to
make informed decisions.
• Allocate adequate resources to infection prevention
and control, including access to information, relevant
laboratory resources, and appropriate equipment and
supplies.
• Have leaders who identify risks for the acquisition and
transmission of infectious agents, as an ongoing activity.
• Identify and minimize risks associated with development
of a health care–associated infection (HAI).
• Create an infection control plan that exhibits the
following components:
Evidence-based national guidelines
Written descriptions of activities
Written descriptions of how processes are evaluated
Written processes for investigating outbreaks of
infectious diseases
Integration of all applicable organization
components and functions
• Establish communication methods to report infection
control issues to licensed independent practitioners,
staff, visitors, patients, and families.
• Establish and use methods of how infection
surveillance and control information is reported to
external organizations.
• Implement strategies—with licensed independent
practitioners and with staff—to prevent the transmission
of infectious diseases in the organization’s population.
18
• Prepare to respond to a higher quantity of a
potentially infectious population.
• Reduce the risk of infections associated with medical
equipment, devices, and supplies.
• Offer and encourage immunization against influenza
to staff and licensed independent practitioners.
• Evaluate the effectiveness of the infection control plan.
Summary: Joint Commission
International (JCI) Prevention and
Control of Infections (PCI) Standards
The following is a summary of JCI’s PCI standards.*
Organizations must do the following:
• Identify one or more qualified individuals to oversee
all IC activities.
• Designate a mechanism for coordinating infection
control activities that involves physicians, nurses,
infection control professionals, and others as needed.
• Base the infection control program on current
scientific knowledge, accepted practice guidelines,
and local laws and regulations, and on national or
local agencies’ standards for cleanliness and
sanitation.
• Report results of infection control activities to public
health agencies, as required, and take action on
relevant reports received from public health agencies.
• Have leaders who provide resources necessary to
carry out and support the infection control program,
including staff and information management systems.
• Design and implement a comprehensive program, in
every area of the health care environment, to reduce
the risks of HAIs in patients and staff, including
determining endemic infection rates and investigating
outbreaks of infectious diseases.
• Collect data and identify trends in infection risks and
rates, specifically infections in the following areas:
Respiratory tract
Urinary tract
Intravascular invasive devices
Surgical sites
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition
•
•
•
•
•
•
Epidemiologically significant diseases or
organisms, such as multidrug-resistant organisms
(MDROs)
Emerging or reemerging infections in the
community
Identify processes and procedures that carry risk
of infection, and implement strategies to minimize
that risk.
Ensure adequate cleaning and sterilization of medical
equipment and proper laundry management.
Create a process for managing expired supplies
and reuse of single-use devices, consistent with law
and regulation.
Implement practices for proper waste disposal and
safe handling and disposal of sharps.
Minimize infection risk associated with food services.
Minimize infection risk associated with mechanical
and engineering controls, and during demolition,
construction, and renovation.
• Provide barriers and isolation procedures to protect
against the spread of communicable disease and
infections in patients, visitors, staff, and
immunosuppressed patients.
• Develop and implement processes to manage a
sudden influx of patients with airborne infections.
• Provide personal protective equipment (including but
not limited to gloves, masks, and eye protection) and
ensure it is used correctly.
• Ensure that hand hygiene is performed consistently
and correctly.
• Integrate the infection control activities into the
organization’s quality improvement and patient safety
programs.
• Provide education on infection control practices to staff,
physicians, patients, families, and other caregivers.
*N
ot all requirements apply to all settings. Refer to the
appropriate accreditation manual for requirements that
are applicable to a particular setting.
Addressing prioritized process risks: First, surveillance data
influenza vaccination program and educating staff about
are reviewed to identify which areas are at risk. After those
influenza and vaccinations. The organization also should
areas and their risks are identified and prioritized, the
annually evaluate vaccination rates and the reasons given by
responsible party can determine which critical processes
staff for declining influenza vaccination, and take steps to
present the greatest danger of introducing error. Processes
increase influenza vaccination rates. (For details on the Joint
examined should include those that are key to both standard
Commission requirements regarding influenza vaccinations, see
precautions (to prevent the spread of infection via health care
Standard IC.02.04.01). Organizations may want to also consider
personnel) and transmission-based precautions (to prevent the
instituting other vaccination programs, as appropriate for their
spread of infection via patients who may be or are infected).
needs; for example, chicken pox vaccinations for pediatric staff,
Activities outlined in the infection control plan to address such
or organizationwide tuberculosis screening.
process risks are then implemented.
Addressing equipment and waste risks: The organization
Addressing risks of infectious disease: Implementation also
should determine risk of infections associated with use and
requires that the organization investigate outbreaks of infectious
reprocessing (cleaning, disinfecting, and/or sterilizing) as well
disease and prevent its transmission among patients, licensed
as storing and disposing of medical equipment, devices, and
independent practitioners, and staff by screening for exposure
supplies. Storing and disposing of infectious waste is another
and/or immunity to infectious disease. When staff or patients
area in which organizations need to implement activities to
have or are suspected of having an infectious disease that puts
minimize the risk of infection.
others at risk, the organization should provide or refer them for
the following, as applicable: further assessment or testing,
Addressing communication and information: Vital to infection
treatment, and/or counseling.
control efforts is implementing methods to communicate
responsibilities for preventing and controlling infection to staff,
Addressing influenza risks: In addition, it is critically important
patients, and their families. Infection control information should
that organizations offer vaccination against influenza to licensed
also be made available to all staff, as well as patients and their
independent practitioners and staff by establishing an annual
families, as appropriate. This information should address the
CHAPTER 1 | THE CONNECTION: Infection Control and the Physical Environment
19
safety of everyone in the facility and be available to everyone
• The building or space and its arrangement and features
in the facility. For example, occupational health statistics on
• The equipment used to operate the building and support
employee exposure to infectious diseases, tests for
seroconversions from exposure to tubercle bacilli, rates and
types of sharps injuries, and employee exposures to blood and
patient care
• The activities involved in maintaining a safe and functional
environment for patients, visitors, and staff
other body fluids can help make infection control and
environmental professionals alike aware of issues that can be
monitored and controlled to increase worker safety. Trending
and disseminating such data can validate effective program
activities and point out where others might be improved.
Evaluation and Improvement of the Infection
Control Plan
The Joint Commission’s Environment of Care (EC) and JCI’s
Facility Management and Safety (FMS) standards help
organizations achieve a safe physical environment, minimizing
risk and ensuring a functional space. In fact, the standards
require that an individual or group of individuals be appointed to
manage environmental risks and intervene when situations
threaten people or property. (Note: Due to their fundamental
nature, home care organizations have fewer requirements
Continual improvement and evaluation are crucial components
related to the physical environment than other settings. It is
of an effective infection control program. As noted above, the
important to consult the appropriate accreditation manual to
infection control individual or team should perform a risk
determine the extent of these requirements.)
assessment annually or whenever risks significantly change, to
make sure that known risks are being effectively minimized and
Like the IC and PCI standards, the EC and FMS standards
to identify others that may arise. The team should also review the
include requirements for planning, implementing, and evaluating
measureable objectives listed in the organization’s infection control
to minimize risks and create and sustain improvements. The EC
plan to ensure that they are being met and are still relevant.
and FMS standards address risks in the following specific areas:
• Safety and security
Scheduling evaluations: Evaluations should be planned and
• Hazardous materials and waste
conducted regularly throughout the year to ensure that the plan
• Fire safety
is achieving the desired goals. For best quality-of-care
• Medical equipment
performance results, the organization should establish and
• Utility systems (including ventilation systems)
maintain a schedule for reviewing the goals, activities, and
• Built or functional environment (including environmental
outcomes. Such evaluations should conclude with a statement
of the current effectiveness of the plan and any actionable
factors such as humidity and temperature, and objects in the
environment such as furnishings)
recommendations to address opportunities for improvement.
• Renovation, demolition, and construction projects
Sharing findings from evaluations: Findings from the
In addition, the Joint Commission Emergency Management (EM)
evaluation should be communicated at least annually to the
standards and the JCI FMS standards address the
individuals or interdisciplinary group that manages the patient
environmental threats during an emergency. This is discussed
safety program. The organization should use these findings
in greater detail in Chapter 7.
when revising the infection control plan.
Several of the EC and FMS standards address issues related
Infection Control and Standards
Related to the Physical
Environment
to infection control (see page 21 for a summary of those
standards). The following sections take a further look at The
Joint Commission’s EC and JCI’s FMS standards that relate to
infection control.
A health care organization’s physical environment (referred to as
the environment of care in the Joint Commission standards and
as the patient environment in the JCI standards) encompasses
the physical area(s) in which patient care, treatment, and services
Standards for Demolition, Renovation,
and/or Construction
The organization must manage its environment during
take place. This physical environment includes the following:
demolition, renovation, or new construction to reduce risk to
20
Infection Prevention and Control Issues in the Environment of Care, 3rd Edition