Transcript Slide 1
TJC Infection Control Standards
2011 Supplement
Resources
National Healthcare Safety Network (NHSN)
NHSN was previously known as the National
Nosocomial Infection Surveillance System
It is a voluntary, web-based surveillance system by
CDC Healthcare Quality Promotion
Goal to obtain national data on HAIs
Hospitals and ASCs may participate in the network
Available at www.cdc.gov/nhsn
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Risk Assessment
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Infection Preventionist Tools
www.infectionpreventiontools.com/home
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TJC Surveyor
May look at both the infection control plan and your
risk assessment
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May look for local statistics and data, relationship
with outside agencies and that you prioritized the
risks
May look at your review of the last two years of
interventions and program related to hand hygiene
May observe an OR cases and observe the
processing of instruments in Central Supply
1 www.unc.edu/depts/spice/jcaho.html
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Resources
TJC has Speak Up Initiatives including five things
you can do to prevent infections
www.jointcommission.org/GeneralPublic/Speak+Up/
about_speakup.htm
Options to Increase Isolation Surge Capacity
www.jcrinc.com/common/PDFs/document_collection/
resources/collections/00032482/00032984-0001.pdf
Preparing for a Pandemic, EM Case Study, How the
Health First Hospital Developed a Pandemic
Influenza Plan
www.jcrinc.com/common/pdfs/qualityandsafety/
preparing_for_a_pandemic_brevard_county_FL.pdf
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Spice
www.unc.edu/depts/spice
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TJC Crosswalk
http://www.jcrinc.com/common/pdfs/csr/forms%20and%20tools,%20newsletters/ic/CSR%20IC%20Self-Assessment%20June%20Update%20HAP%200709.doc
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www.cdc.gov/nhsn/mdro_cdad.html
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AORN Updated Surgical Attire
All hospitals should be aware of the updated AORN
surgical attire recommended practice
Hospital must launder all scrubs
States wearing scrubs as street attire creates
exposure to infectious pathogens in the community
Recommendations for safe footwear and wearing
jewelry
Recommendation on cleaning of stethoscopes and
ID badges
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IV Spiking is 1 hour
IV should not spiked more than one hour before use
USP 797 requirement
APIC also has out a position paper that advices
administering has soon as possible
Hospitals should also have a safe injection
practices policy
Hospitals should follow the 10 CDC guidelines
found in the isolation standards
CMS also has an infection control sheet (15 pages)
that all ASCs must complete by the surveyor
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Reducing Surgical Site Infections
Land mark trial shows that chlorahexidine reduces
surgical site infections instead of povidone-iodine
This changes the standard of care
Same edition of NEJM shows you can prevent
surgical site infections by swabbing nasal site
(rapid screen) and if staph aureus then decolonize
This can be done by rinse with chlorahexidine
soap and use mupirocin nasal ointment
NEJM 362;18-26 January 7
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Recent Issues
June 2010 OSHA makes bold move to regulate
infection prevention and publishes in FR (new IC
police) Issued May 6, 2010
June 2010 Environmental team at Mayo Clinic
wipes out C-diff with bleach wipe program
June 2010 VA hospitals cut MRSA by 77% in ICUs
with active surveillance
June 2010 SHEA and IDSA issues new C-diff
guidelines
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8 Things to Reduce Post-operative Pneumonia
Researchers from VA Palo Alto Healthcare System
and Stanford University employed 8 things to
reduce pneumonia on the surgery floor
1. Education of all surgical and ward nursing staff
about their role in pneumonia prevention
2. Cough and deep-breathing exercises with
incentive spirometer
3. Twice-daily oral hygiene with chlorhexidine
swabs
4. Ambulation with good pain control
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8 Things to Reduce Post-operative Pneumonia
5. Head-of-bed elevation to at least 30 degrees and
sitting up for all meals ("up to eat")
6. Quarterly discussion of the progress of the
program and results for nursing staff
7. Pneumonia bundle documentation in the nursing
documentation
8. Computerized physician pneumonia prevention
order set in the physician order entry system.
Wren SM, Martin M, Yoon JK, and Bech F. Postoperative
Pneumonia-Prevention Program for the Inpatient Surgical Ward.J
Am Coll Surg; April 2010, Vol. 210, Issue 4: 491-495
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Institute for Healthcare Improvement
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Source: www.shea-online.org
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Source: www.his.org.uk
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www.who.int/en
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www.theific.org
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Source: www.idsociety.org
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PA Patient Safety Authority
Source: www.patientsafetyauthority.org/Pages/Default.aspx
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Sterilized Equipment Issue
Recent cases of improperly sterilized equipment.
PA Safety Authority reports number of reported cases
of contaminated equipment from prior surgery
Portland VA sent out 2,270 letters of TRUS guided
prostate biopsy equipment
FDA alert July 2006 and 2009 on prostate biopsy
equipment
Called bioburden
Old dried blood and tissue came out of tissue protector
on drill, triple trocar full of dried blood, suture remained
on tunneler, and particles of tissue found on
cannulated instruments
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Sterilized Equipment Issue (continued)
Adequate cleaning is required to remove all residual
that remains, if not prevents sterilization
Many wipe instruments with wet lap or gauze
sponge with sterile water during or after procedure
CMS and TJC issue information on flash
sterilization so make sure you pay attention to this
issue
Soaking instrument in enzymatic solution after
procedure and follow manufacturers instructions
Immediately soak all instruments
May need to use brushes to remove material
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Cleaning of Medical Equipment
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MRDOs Resources
CDC MRSA resources
www.cdc.gov/ncidod/dhqp/ar_mrsa.html
Includes fact sheet on MRSA, MRSA in
healthcare setting 2007, educational material,
data, lab testing and practices, etc.
Isolation precaution 2007
www.cdc.gov/ncidod/dhqp/gl_isolation.html
VRE resources
www.cdc.gov/ncidod/dhqp/ ar_vre.html
Guidelines for Prevention of Surgical Site
Infections
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Resources
APIC resources at www.apic.org and see
standards and guidelines
Guidelines for Environmental Infection Control in
Health Care Facilities
Guidelines for Prevention of Surgical-Site
Infections
Recommendations for Preventing the Spread of
VRE
Guidelines to Prevent Intravascular Catheter
Related Infections
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TJC NPSGs
Many are on infection control
Implement best practices to prevent multiple drug
resistant organisms MDROs
Educate staff and patients about MDRO and
necessity for prevention
Measure MRSA and CDAD (C-diff associated
disease)
Clean and disinfect equipment and patient care
environment
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IHI ICU Improvements
VHA united with IHI to improve ICU care
Better control of blood sugars with glucose
monitoring protocols1
Aggressive treatment of sepsis/blood stream
infections (see central line bundle)
Prevention of ventilator associated pneumonia
(see VAP bundle), surgical infections
Developed toolkits (order sets, protocols, daily
goal sheets), report templates for monthly
reporting of change
1 www.ihi.org
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Ventilator Bundle
Head of bed (HOB) elevation > 30 degrees
Deep venous thrombosis (DVT) prophylaxis
Peptic ulcer disease (PUD) prophylaxis
Daily sedation vacations
Assessment of readiness of wean
Oral care
Use a checklist and document each!
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Central Line Bundle
Hand hygiene
Maximal barrier precautions upon insertion
Chlorhexidine skin antisepsis
Optimal catheter site selection with subclavian
vein as the preferred site for non-tunneled
catheters
Daily review of line necessity with prompt removal
of unnecessary lines
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Sepsis Bundle
Over 750,000 patients a year develop sepsis or
septic shock in the US
Severe sepsis will kill 30% of infected patients and
another 20% will die within six months
Surviving sepsis campaign
Can listen to presentations
Sepsis bundle lists seven tasks to be done during
first six hours
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Sepsis Resuscitation Bundle
If hypotension, give serum lactate >4 mmol/L
(deliver initial minimum of 20 mL/kg of crystalloid
and vasopressors for arterial pressure less 65 mm
Hg)
Bundle 5 is for persistent hypotension achieve
central venous pressure > 8mm Hg and venous
oxygen sat of > 70%
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Sepsis Management Bundle
Administer low dose steroids with standardized ICU
policy
Administer recombinant human activated protein C
(rhAPC) in accordance with a standardized ICU
policy. If not administered, document why the
patient did not qualify for rhAPC.
Maintain glucose control >70, but <150 mg/dL.
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Sepsis Bundle
Surviving Sepsis Campaign website1
Sepsis bundle website2
Dellinger RP, Carlet JM, Masur H, et al. Surviving
Sepsis Campaign guidelines for management of
severe sepsis and septic shock. Critical Care
Medicine. 2004;32(3):858-873.
See IHI, Defeating Sepsis; 25% by 20093
1 www.survivingsepsis.org
2 www.survivingsepsis.org/implement/bundles
3 www.ihi.org/IHI/Topics/CriticalCare/Sepsis/ImprovementStories/
FSDefeatingSepsis25Percentby2009.htm
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Preventing UTI from Catheters
Do not put in unless absolutely necessary
Make sure meticulous care is followed in inserting
Remove ASAP
Document everyday considerations as to whether foley can
come out
Follow evidence based literature and CDC guidelines on
preventing catheter associated UTI
Many UTIs can be prevented with proper management of the
indwelling urethral catheter
Maintain sterile closed system
CDC 2009 guidelines at
www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html
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Additional Resources
2011 CDC Guidelines for Prevention of
Intravascular Catheter Related Infections, (pending)
CDC Guidelines for the Prevention of catheterInduced Urinary Tract Infections, December 2009
www.cdc.gov/hicpac/cauti/002_cauti_toc.html
AHRQ toolkit
www.ahrq.gov/qual/haiflyer.htm
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CA-UTI Resources
Pa Patient Safety has toolkit to prevent CA-UTIs
http://patientsafetyauthority.org/EducationalTools/PatientSafety
Tools/cauti/Pages/home.aspx
APIC guidelines to eliminate catheter-associated
UTI
AORN article Jan 2010 on new scip measure
regarding urinary catheter removal
www.aorn.org/News/Managers/November2009Issue/Catheter
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CA-UTI Resources
IDSA as the Diagnosis, Prevention, & Treatment of
Catheter-Associated Urinary Tract Infections in
Adults: 2009 International Clinical Practice
Guidelines from the Infectious Disease Society of
America
http://cid.oxfordjournals.org/content/50/5/625.full
Iowa Healthcare Collaborative toolkit
www.ihi.org/IHI/Programs/ImprovementMap/PreventC
atheterAssociatedUrinaryTractInfections.htm
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Accreditation Connection, 6-28-2010
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www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html
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Injection Safety CDC
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Advancing ASC Quality
ASC Quality Collaboration has ASC tool kit for
infection prevention
Includes one on hand hygiene and safe injection
practices
Includes a basic and expanded version of the
toolkit
Available at
www.ascquality.org/advancing_asc_quality.cfm
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2011 NPSG Chapter Outline
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Proposed for 2012 NPSG
TJC is seeking comments on NPSGs for 2012
Looking at two proposed additions
Ventilator-associated pneumonia (VAP)
–Has seven elements of performance
Catheter-associated urinary tract infections
(CAUTI)
–Has four elements of performance
Comment period ended January 27, 2012
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2011 NPSG Chapter Outline
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Goal 7: Reduce the Risk of HAI
Goal: Reduce the risk of HAI
4 of 5 sections remain in 2011
Deleted 7 B on HAI as a sentinel event
In August 2010 Perspective noted changes to NPSG
07.04.01 and 07.05.01
NPSG.07.04.01 EP11
Added to use an antiseptic for skin preparation during
insertion of central line that is cited in the scientific
literature
Removed “use chlorahexidine” even though currently the
standard of care but in the event it changes
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Reduce Risk of HAI Infections
In August 2010 Perspective changes to NPSG
07.05.01 EP7 & 8 on implementing evidenced based
practices for preventing surgical site infections (SSI)
EP7 Administer antimicrobial agents for prophylaxis
for a procedure or disease
Removed “evidenced based practices”
Added to do this according to methods cited in the
scientific evidence or endorsed by professional
organizations
Removed give antibiotics one hour before the surgery and
discontinue within 24 hours or 48 for cardiothoracic patients
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Reduce Risk of HAI Infections
EP8 Removed the section to “use clippers or
depilatories” when hair is removed
Removed the note that shaving is an inappropriate
hair removal method
Added to use a method that is cited in the scientific
literature or endorsed by professional organizations
This is currently the standard of care
However, this new wording is flexible so if the new
literature shows a new standard of care TJC does
not have to go back and revise the standard
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Reduce Risk of HAI Infections
In March 2010 Perspective change to
NPSG.07.03.01
The word “prevention” was accidentally omitted from EP3
in the 2010 NPSG publication
Patients and families should be educated, when needed,
who are colonized with MDRO about health-care associated
infection prevention strategies
Retained hand hygiene, MDRO, reducing central
line associated blood steam infections, and
preventing surgical site infections
Good resource is the April 2010 updates to the NQF 34
Safe Practices for Better Healthcare
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Hand Hygiene NPSG.07.01.01
Reduce the Risk of HAI: Comply with current CDC
or WHO hand hygiene guidelines
Has 3 EPs
EP1 Implement a program that follows categories
1A, 1B, and 1C on one of the above
EP2 Set goals for improving compliance with hand
hygiene guidelines
EP3 Improve compliance with hand hygiene
guidelines based on established goals
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Implement Evidenced-Based Practices
Implement evidenced-based practices to prevent
HAI due to multi-drug resistant organisms (MDROs)
07.03.01 (7C)
9 EPs
Applies to, but not limited to, MRSA, VRE, C-Diff,
and MDRO gram negative bacteria
Patients continue to acquire health care associated
(HAI) infections at an alarming rate
Need prevention and control strategies
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Implement Evidenced-Based Practices
Increased focus on cleaning and disinfecting
equipment appropriately (IC.02.02.01)
Proper use of flash sterilization
Making sure all scopes are cleaned
according to the manufacturer
Cleaning the patient environment is also
important
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Evidenced-Based HAI Prevention
1. Conduct periodic risk assessment for
MDROs acquisition and transmission
In time frame set by hospital
See IC.01.03.01, EPs 1-5 that talks about
identifying the risk of acquiring and transmitting
infections
Following slides on this provided for reference
TJC infection control chapter very important and
dovetails with these infection control NPSGs
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Identify Risks for Transmitting Infections
IC.01.03.01 Hospital identifies risks for acquiring
and transmitting infections
EP1 Hospital identifies risks based on geographic
location, community, and population served
– NPSG.07.03.01 EP1 Conduct periodic risk assessments in time
frames set by hospital for multidrug-resistent organisms (MDRO)
acquisitions and transmission
– MDRO includes methicillin-resistant Staphylococcus Aureus
(MRSA), Vancomycin-resistant Enterococcus (VRE), Klebsiella,
and Acinetobacter
– CDC has free MDRO infection (and CDAD) surveillance and
training on the National Healthcare Safety Network (NISN)
– 1 www.cdc.gov/nhsn/wc_MDRO_CDAD.html
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Identify Risks for Transmitting Infections
IC.01.03.01
EP2 Hospital identifies risk for acquiring and
transmitting infections based on the care and
treatment it provides (on MDRO)
EP3 Look at risk for acquiring or transmitting an
infection by doing an analysis of surveillance
activities and other infection control data (including
MRDO and adverse tissue reactions)
EP4 Review and identify risks annually and when
there is a significant change and get input from IP,
MS, nursing, and leadership including MRDO
EP5 Prioritize these risks
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Evidenced-Based HAI Prevention MDRO
2. Educate staff and LIPS about HAI, MDROs, and
preventive strategies in orientation
At hire and annually
Use information from your risk assessment
Education must reflect their diverse roles
3. Educate patient and their families about HAI
strategies who are infected or colonized with
MRDO, as needed
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Evidenced-Based HAI Prevention MDRO
4. Implement a MDRO surveillance program based
on your risk assessment
Surveillance may be targeted rather than
hospital-wide
CDC has MDRO surveillance training at
www.cdc.gov/nhsn/wc_MDRO_CDAD.html
Has many resources including training videos on
MDRO surveillance, slide sets, protocols,
reporting plan, etc.
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Evidenced-Based HAI Prevention MDRO
5. Measure and monitor MDRO prevention processes
and outcomes including; MDRO infection rates
using evidence based metrics, compliance with
evidenced based practice, and evaluate education
provided
6. Provide MRDO process and outcome data to key
stakeholders, nurses, doctors, LIPs and other
clinicians
7. Implement P&Ps to reduce transmission of MRDOs
which meet CDC and other professional
organization standards (APIC,SHEA,OSHA, AORN)
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Evidenced-Based Practices MDRO
8. Implement a laboratory based alert system that
identifies new patients with MDRO when
indicated by the risk assessment
The alert system can be manual or electronic
and can use faxes, pages, telephones etc.,
9. Implement an alert system that identifies
readmitted or transferred MRDO positive patient
when indicated by risk assessment
Alert system can be in a separate database or
integrated and can manual or electronic
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MRDOs Resources CDC
Management of MRDOs in Healthcare Settings
2006, 74 pages, at
www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
Provides strategies and practices to prevent
MRSA, VRE and other MDROs,
Includes gram neg bacilli (GNB), E. coli and
Klebsiella pneumoniae, stenotrophomonas
maltophilia, burkholderia cepacia, and ralstonia
picketti
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MRDOs Resources
CDC MRSA resources at
www.cdc.gov/ncidod/dhqp/ar_mrsa.html
Includes fact sheet on MRSA, MRSA in healthcare
setting 2007, educational material, data, lab testing
and practices, etc.
Isolation precaution 2007 at
www.cdc.gov/ncidod/dhqp/gl_isolation.html
VRE resources at www.cdc.gov/ncidod/dhqp/ar_vre.html
Guidelines for Prevention of Surgical Site Infections
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Resources
APIC resources at www.apic.org and see
standards and guidelines
Guidelines for Environmental Infection Control in
Health Care Facilities
Guidelines for Prevention of Surgical Site
Infections
Recommendations for Preventing the Spread of
VRE
Guidelines to Prevent Intravascular Catheter
Related Infections
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Central Lines 07.04.01 (7D)
Implement best practices to prevent central line
associated bloodstream infections,
13 EPs
IHI has how to guides and other resources at
www.ihi.org (Keystone project)
EP1 Educate staff and LIPs involved in
procedures about HAI, central line infection and
importance of prevention
Must do education in orientation and annually
and if procedure added to your job
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Revised How-to Kit Central Lines
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Central Lines
Note that under reform law hospitals with ICUs
or NICU must report central lines infections on
the CDC National Healthcare Safety Network
(NHSN)
2. Educate patients and families before inserting
central line about central line associated
bloodstream infection prevention (BSI), as
needed
3. Implement P&Ps to reduce risk of BSI that meet
regulatory and evidenced based standards
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Central Lines 07.04.01
P&P need to meet the regulatory requirements
Need to be aligned with the CDC requirements
And professional standards of care (APIC, AORN,
SHEA, etc.)
4. Conduct periodic risk assessments for central
line infection, measure BSI (blood stream infection)
rate, and monitor compliance with best practices
and how effective the prevention efforts are
Need to do risk assessment conducted in the time frames
defined by the hospital
Surveillance is hospital wide and not targeted
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Central Lines
5. Provide CLAI (central line associated infection)
rate data and prevention outcome measurement to
staff and LIPs and clinicians
6. Use a catheter checklist and standard protocol for
central line insertion
7. Perform hand hygiene before catheter insertion or
manipulation
8. Do not put in femoral vein unless last resort for
adult patients
9. Use standardized supply care or kit for central lines
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Central Lines
10. Use standardized protocol for maximum sterile
barrier precautions during insertion
11. Use antiseptic for skin prep in patients during
insertion that is cited in the scientific literature or
endorsed by professional organizations
12. Use standardized protocol to disinfect catheter
hubs and injection ports before accessing
Such as wipe vigorously for 15 sections and let dry
Surveyor will ask to see the protocol or P&P
13. Evaluate all central lines routinely and remove
none essential catheters
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www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html
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Surgical Site Infections (SSI)
Implement best practices to prevent
surgical site infections
There are 8 EPs
1. Educate hospital staff and LIPs involved
in procedures about HAI, surgical site, and
the importance of prevention
Educate during orientation, annually,
and if added to your job
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Surgical Site Infections
2. Educate patients and families, who are
undergoing surgical procedures, about
preventing surgical site infections (SSI)
3. Implement P&P to reduce SSI that meet
regulations and evidenced based practice
(such as the CDC and other professional
organizations)
4. Conduct periodic risk assessments for SSI,
select measures using best practices or
evidence based guidelines and monitor
compliance with them and how effective they
are
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Surgical Site Infections
5. Measure surgical site infection rates for the
first 30 days following a procedure that does
not involve inserting implantable devices
Measure for the first year procedures involving
implantable devices
Need to follow evidence based guidelines
Surveillance may to targeted to certain procedures
based on hospital risk assessment
6. Provide process and outcome data on SSI to
stakeholders etc, such as the SS infection
rate
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Surgical Site Infections
7. Antimicrobial agents for prophylaxis are
administered according to methods cited in the
scientific literature or endorsed by professional
organizations
Still want to be sure that prophylactic antibiotics are
administered timely in the operating room and
rebolused when indicated
8. When hair removal is necessary, use a method
that is cited in the scientific literature or endorsed
by professional organizations
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www.cdc.gov/hicpac/CAUTI_fastFacts.html
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www.cdc.gov/hicpac/Disinfection_Sterilization/
acknowledg.html
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www.cdc.gov/hicpac/pubs.html
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The End
Questions?
Sue Dill Calloway RN Esq. CPHRM
AD, BA, BSN, MSN, JD
Medical Legal Consultant
614 791-1468
5447 Fawnbrook Lane
Dublin, Ohio 43017
[email protected]
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