Springhill Medical Center. Infection Prevention and Control Plan. Submitted by: Beth Beck, MT (ASCP), CIC

Transcription

1 Springhill Medical Center Infection Prevention and Control Plan 2015 Submitted by: Beth Beck, MT (ASCP), CIC

2 Springhill Medical Center Infection Prevention and Control Plan 2015 I. Purpose: The purpose of the Springhill Medical Center (SMC) Infection Prevention and Control Plan is to serve as a foundation for a hospital-wide program for the prevention, identification and control of health care-associated infections by providing ongoing surveillance, evaluation, intervention and education. The Infection Prevention and Control Department directs and coordinates all Infection Prevention and Control activities and programs to establish baseline healthcare-associated infections infection rates; to prospectively identify populations at increased risk for infection by performing surveillance, observing trends in infections; to comply with regulatory requirements; and to effectively improve delivery of health care, based on thorough, and risk-adjusted data analysis, as well as, intervention modalities and community trust designed to lower risk of infection. II. Authority Statement: Springhill Medical Center Governing Body, the Medical Staff and SMC Executive Leadership grant the Infection Prevention and Control committee the authority to monitor and evaluate surveillance, prevention and control activities and to make recommendations to SMC Executive Leadership. The SMC Executive Leadership is responsible for approval of programs to minimize infection and to improve and maintain Infection Prevention and Control standards of care. III. Responsibilities: Infection Prevention and Control Director Infection Prevention and Control Director must be a Registered Nurse (RN) with current license in the State of Alabama, a Medical Technologist (ASCP), Bachelor s degree in healthcare field and eligible for Certification in Infection Prevention and Control (CIC) or have a Masters in Public Health. CIC is preferred. Responsibilities include: Collects and analyses data as defined by the Centers for Disease Control and Prevention (CDC) and presents the findings to the Infection Prevention and Control Chairman for review and follow-up action. Monitors the implementation of the CDC isolation guidelines and standard precautions for all areas. Provides consultation and direction in the development and implementation of improved patient care services. In conjunction with Human Resources and individual departments, insures that associates are oriented to the importance of infection control practice and Occupational Safety and Health Administration (OSHA) regulations. Investigates clusters of infections. 2

3 Function as a resource to all departments in relation to the prevention of infection. Identifies and reports cases of communicable diseases in accordance with health department's rules and regulations. Serves as consultant for issues relating to sterilization, disinfection and decontamination issues. Coordinate infectious disease exposure management. Oversight of Construction Infection Risk. Assume responsibility for operation of the Infection Prevention and Control Program with Infectious Disease support. Coordinate development, implementation and evaluation of the Infection Prevention and Control Plan and compliance with relevant regulatory requirements, legal issues, and financial impact. Collaborates with the Infection Prevention and Control Chairman and hospital departments and services, develops policies and procedures related to infection prevention and control practices. Evaluated each department for sanitation and aseptic techniques used in the hospital. Initiates special surveillance or investigation as needed. Serves as a consultant relative to any change in infection prevention and control related products or techniques within the hospital. Evaluates guidelines for the selection, storage, handling, use and disposal of nonreusable equipment used in the hospital. Serves on the Environment of Care Committee. Serves on the Pharmacy and Therapeutic Committee and encourages antibiotic stewardship. Maintain professional age related competency including infant, toddler, pre-school, adolescents, young adult, middle adult, and older adult. Infection Prevention and Control Chairman The chairperson is a physician board-certified in Infectious Diseases. Responsibilities include: Provides leadership for the development of surveillance objectives. Provides educational support in infectious disease for the hospital medical staff. Provides consultation for outbreaks in patients, associates, and the community. Leads the Infection Prevention and Control Director in formulating policies, procedures and practice. Provides consultation for the Infection Prevention and Control and Employee Health Departments for infection and/or infectious disease questions/issues in all hospital patients and employees. Provides consultation in matters of infection prevention and control to medical and hospital staff as needed. Collaborates with the Infection Prevention and Control Director regarding the Infection Prevention and Control program and identified issues. Interprets surveillance reports to physicians. Provides management of regulatory issues as they impact physician practice. 3

4 Provides medical interpretations of regulatory standards. Infection Prevention and Control Committee Infection Prevention and Control Committee is a multidisciplinary hospital committee, comprised of members from the patient care services, Infection Prevention and Control, and ancillary departments. The committee meets quarterly allowing four meetings per year. Responsibilities include: Assessment of the Infection Prevention and Control Program and directs activities to correct any deficiencies. Directs the environmental sampling and any culturing of employees. Discuss the results of personnel and environmental culturing requested by the chairman, federal, state, or local agencies, and determines the necessary actions to be taken. Reviews antimicrobial susceptibility and resistance studies. Reviews infection control studies conducted throughout the hospital and discuss results. Disseminates analyzed data to appropriate committees, physicians and employees. When necessary gives education for interventions. Supported through collaboration with the laboratory. Establishes guidelines for the type of surveillance and reporting of selected types of infections. The Infection Prevention and Control Committee will approve the type and scope of surveillance activities. Reviews the infection and surveillance data and recommend methods for the prevention and control of infections in the hospital. A review will be done on any unusual epidemics, clusters of infections. Infections due to unusual pathogens and any occurrence of healthcare-associated infections that exceeds the usual baseline levels. Reports findings of the committee to Medical Executive Committee and Medical Staff through Quality Assurance. Executes authority to approve or recommend revisions to all policies and procedures that relate directly to Infection Prevention and Control. IV: Scope of Care Provided at Springhill Medical Center: Springhill Medical Center (SMC) is comprised of: 252 beds hospital 20 bed ICU 6 pediatric beds Significant elderly population A network of on-campus ambulatory care 4

5 Off-site ambulatory care The medical staff, comprised of numerous primary and specialty care physicians The Medical Center's 252 licensed beds accommodate referrals for specialty care in such areas of expertise as cardiovascular care, obstetrics, oncology, orthopedics, pediatrics, gastroenterology, urology, geriatric, diagnostic radiology, sleep studies, and wound care clinic. V. Objectives of the Infection Prevention and Control Program: The Department of Infection Prevention and Control activities must be in compliance with Alabama Administrative Code. Objectives include: Determine the type and scope of routine and special surveillance activities. Review surveillance data for unusual epidemics, clusters of infection, infections due to unusual pathogens, and occurrences of healthcare-associated infection that exceed the usual baseline levels. Recommend or approve actions based on surveillance data. Review and approve policies and procedures related to infection control. The policies and procedures are located in the Infection Prevention and Control Departmental Policy and Procedure Manual. This manual is located in the Infection Prevention and Control department or may be accessed on-line along with other hospital policies. Policies and procedures are reviewed as necessary to insure that the policies comply with current infection prevention and control practices. Keep abreast of all regulatory standards related to infection prevention and control and manage continuous compliance. Evaluate and compare each infection rate to the state findings, published infection rates, and our historic data. VI. Methodology Used to Identify Risks: Each year a comprehensive risk based analysis is completed in order to assist in determining annual objectives and resource allocation. The variables considered in this risk assessment include: Geography - The primary service area Mobile, Alabama and Mobile County as well as other counties surrounding the Mobile area. Mobile offers an international deepwater port on the Gulf of Mexico. Community being served includes high population from Asia, Philippines, Korea, Mexico and South America. Monitoring the case mix of our patient population including nursing homes and rehabilitation centers primarily from the local community. Prevalence of disease in the community served. Utilization of the J. L Morgan & Associates patient satisfaction survey for inpatient and outpatient services. Infection Prevention and Control problems, significant trends, or special events that have occurred within the previous year. 5

6 National and local initiatives such as CDC, OSHA, Alabama Department of Public Health, Association for Professionals in Infection Prevention and Control and Epidemiology (APIC), and Society for Healthcare Epidemiology of America (SHEA). Care Fusion/MedMined benchmarking data both state and national comparisons. Review of current literature. For the full details of the annual Risk Assessment refer to Attachment VII. High Priority Risk for 2015: Risk assessment determined the following indicators: Care Fusion/Med Mined scorecard and patterns Catheter-Associated Urinary Tract Infection (CAUTI) collection and reporting. Numerator: Symptomatic CAUTI (SUTI) and Asymptomatic Bacteremic UTI (ABUTI) that is catheter associated. Denominator: Patients with indwelling urinary catheter device days. Central Line-Associated Bloodstream Infections (CLABSI) collection and reporting. Numerator: Bloodstream Infection that is catheter associated. Denominator: Patients with Central Line Catheter device days. Ventilator Associated Event (VAE) surveillance monthly collection and reporting. Numerator: Ventilated patients who develop Ventilator-Associated Condition (VAC), Infection-Related Ventilator-Associated Complication (IVAC), Possible Ventilator- Associated pneumonia, or Probable Ventilator-Associated pneumonia. Denominator: Patient ventilator days. Surgical site infection risk stratification - The National Healthcare Safety Network (NHSN) risk index consists of a score from 0-3 based on the number of risk factors present among these three: American Society of Anesthesiologists (ASA) preoperative assessment score 3, 4 or 5. Operation classified as either contaminated or dirty-infected. Operation cut time with duration of surgery more than T hours, where T depends on the operative procedure being performed. Post-discharge surveillance of surgical site infections is done on a monthly basis. As a result of the 2014 HAI data and the 2015 Infection Prevention and Control Risk Assessment the following organisms have been identified as high risk and are most in need of organizational focus and resource planning: Methicillin-Resistant Staphylococcus aureus (MRSA) and Clostridium difficile (CDI). Organisms identified for moderate risk: resistant Pseudomonas, resistant Acinetobacter, Vancomycin-Resistant Enterococcus, and Extended Spectrum Beta Lactamase. Surveillance of multidrug resistant organisms will be done in keeping with National Patient Safety Goals. Electronic alerts have been established in the Sunrise System and Care Fusion/Med Mined System. Refer to attachment for full risk assessment 6

7 VII. Internal Risk by Location: A review of literature combined with historical data has identified the following hospital locations as high risk/high morbidity areas of the medical center: Intensive Care Unit (ICU) Cardiac Intervention Unit Surgery Labor and Delivery Oncology IX. Surveillance and Prevention Strategy: The goal of the SMC Infection Prevention and Control Program is to assess, prevent, and control healthcare-associated infections. Targeted areas for intensive surveillance, prevention, and control are determined by the impact of infection on morbidity and mortality. Data used for making such determinations are obtained from the medical literature and SMC surveillance data. Research shows as surgical wound infections, healthcare-associated pneumonia, and invasive device related sepsis have the highest impact on morbidity and mortality, our primary surveillance and prevention activities involve programs designed to reduce the number of these healthcare associated infections utilizing continual quality improvement methodologies and techniques. SMC embodies the philosophy of priority-directed surveillance. Priority-directed, sitespecific benefits: flexible and adaptable to needs and problems, external data for comparison, and resource-based epidemiologically sound method. Surveillance must include infection reporting in compliance with Centers for Medicare and Medicaid Services (CMS), Hospital Engagement Network (HEN) and the Mike Denton Infection Reporting Act. Data is submitted through National Healthcare Safety Network (NHSN) which includes Central Line Associated Blood Stream Infections (CLABSI) in all Nursing Units defined as Unit 1100, 1200, 2200, 3200, 3300, 3400, 3500, 4200, and ICU, Catheter Associated Urinary Tract Infections (CAUTI) in all Nursing Units, all inpatient colon and all inpatient abdominal hysterectomy procedure infections, MRSA bacteremia Lab ID Events, CDI Lab ID Events, CRE Lab ID Events, and Ventilator-Associated Events. In addition, daily review of the reports available from the Microbiology laboratory on positive cultures results and Care Fusion/Med Mined data. Monitoring of isolation and hand hygiene compliance will be on going by the Infection Prevention and Control staff. Problem oriented surveillance is utilized when dictated by outbreak or exposure situations. Underlying our total program is the philosophy of continuous quality improvement (CQI). Data collection is ongoing and includes risk factors that contribute to the development of healthcare-associated infections. Data will be collected and analyzed by the Infection Prevention and Control Department under the supervision of the Director of Infection Prevention and Control and the Chairman of the Infection Prevention and Control Committee. Case findings are accomplished through evaluation of daily Care Fusion/Med Mined reports, daily rounds, with an emphasis in targeted areas; referrals by unit nurses, allied health professionals, case management, laboratory reports, computer based reports and related surveillance mechanisms. 7

8 Analysis is conducted on an ongoing basis that includes stratification of risk factors related to infection. Results will be reported at least quarterly and when appropriate, to the Infection Prevention and Control Committee. Trends found will be discussed, then recommendations for actions will be made and interaction/information will be sent to appropriate committees. Support services include microbiology and serological services seven days a week. Influenza Vaccination Methodology: Influenza vaccination of adults has shown to be cost-effective by reducing both direct medical costs and indirect costs from absenteeism. Several studies demonstrated that the vaccination of adults aged less than 65 years resulted in fewer healthcare provider visits, fewer lost workdays, fewer days working with reduced effectiveness, and a decrease in antibiotic use. Seasonal influenza vaccines and mist will be offered to all staff, volunteers, students, physicians, and contract staff free of charge. All staff must have a medical contraindication or religious belief form if they do not take the influenza vaccine or mist. Multiple options will be available to provide vaccine to staff including clinics, personal appointments, rolling cart with unit-to-unit offering, and staff meeting as manager s request. Compliance rates of influenza vaccine or mist are determined by the percent of staff receiving the vaccine or mist. Numerator: Healthcare Provider (HCP) receiving the vaccine Denominator: Number of HCP who worked at this healthcare facility for at least 1 day between October 1 st and March 31 st (The staff population does not include any staff on leave). Influenza rates are reported to the Infection Prevention and Control Committee. Data is submitted through NHSN to CMS. X. Staffing: The Infection Prevention and Control Department recommends and approves 4.8 FTE's and the following resource allocations. One full-time Director of Epidemiology, 1.0 FTE One full-time Infection Preventionist, 1.0 FTE One full-time Infection Prevention/ Employee Health Nurse, 1.8 FTE One part-time Employee Health Nurse, 0.5 FTE One part-time Infection Prevention/Employee Health Office Manager, 0.5 FTE The department is available Monday through Friday during normal business hours. Continuous access to an Infection Prevention and Control Director is available through the on-call system 24 hours a day, 7 days per week and back-up coverage by the Employee Health Nurse. 8

9 XI. Other Key Functions of Infection Control: Response to Bioterrorism SMC has policies and procedures that provide for the continuation of patient care during an event involving bioterrorism. During a disaster situation, SMC has adopted an Emergency Management plan in an effort to prepare and respond to a biological event. As a level I trauma center for adults and pediatrics, the Operational Medical Response Disaster Plan, a component of the Alabama Department of Public Health's Medical Disaster Plan which allows for communication between SMC, area hospitals, physicians and patient families. SMC participates in community wide exercises. SMC is a part of the Operations Plan for the state of Alabama Emergency Management Agency (AEMA). The Disaster Plan would be implemented upon notification of federal activation of AEMA from appropriate authorities. All emergencies requiring external assistance will result in notification of appropriate agencies as directed by the particular situation. This may include the Mobile County Health Department, outside local, state, and federal agencies. Over site of Construction Infection Prevention and Control Risk Assessment as follows: The Infection Prevention and Control Department will review the Infection Prevention and Control Risk Assessment (ICRA) for all construction projects. Infection Prevention and Control permits will be issued as necessary before any demolition or construction work is done. The Infection Prevention and Control Department will make visits to the work sites to ensure compliance of Infection Prevention and Control policies. Air quality will be monitored throughout the project as needed. Education Educational programs for the needs of the associates include annual Infection Prevention and Control updates, requirements of various regulatory bodies, and individual needs of the departments identified by surveillance and consultative requests. General Orientation - The Infection Prevention and Control department provides an Infection Prevention and Control program for all new employees. RN Orientation - The Infection Prevention and Control department provides an Infection Prevention and Control Nursing Orientation program for all new nursing staff. Care Tech Orientation - The Infection Prevention and Control department provides an Infection Prevention and Control Care Tech program for all care tech staff. Annual Continuing Education - The Infection Prevention and Control department provides Infection Prevention and Control Annual Continuing Education Program for all employees through self-directed computer based learning modules. These modules can be used by individual employees or as a guide for group presentations. Modules are reviewed and/or revised as necessary. All employees at SMC are required to participate in annual infection control training. 9

10 XII. Construction Infection Prevention and Control Training - Infection Prevention and Control department provides Infection Prevention and Control training relating to construction. Department Specific Training - The Infection Prevention and Control department provides Infection Prevention and Control department specific training as necessary. Influenza Training- transmission, diagnosis, prevention training includes vaccine and non-vaccine prevention measures is provided to via on-line computer-based module, and one-on-one training. Students - training delivered via on-line computer-based modules. Infection Prevention and Control department provides nursing student Infection Prevention and Control training and packet information. Medical staff - training delivered via on-line computer-based modules and newsletters. In addition, the Chairman of Infection Prevention and Control provides educational support in Infection Prevention and Control activities. Community - via participation in health fairs, lectures and other events as needed or requested. Reporting of Information Internally: Results of key infection control measures are reported to the Infection Prevention and Control Committee. Additional reports are provided: Quarterly to the Environment of Care Committee Quarterly to the Surgery Committee Quarterly to the Pharmacy and Therapeutic Committee Quarterly to the Governing Council Department Managers Report to Infection Control Committee Monthly Quarterly Sterile Processing Department X Exposures X Employee Health X Infection Prevention and Control Care Fusion/Med X Mined Benchmarking Unit based hand washing observation report X Construction Blood Culture Contamination Rate NIMS/Patterns Board of Health Report of Communicable Disease X X X X 10

11 XIII. Reporting of Information Externally: Reporting of communicable diseases to the Alabama Department of Public Health (Board of Health) authorities is done by the Infection Prevention and Control Department in compliance with guidelines and regulations. National Healthcare Safety Network (NHSN) reporting to be in compliance with the Mike Denton Infection Reporting Act. The Department of Infection Prevention and Control will assist in reporting to other regulatory bodies as indicated, including Centers for Medicare and Medicaid Services (CMS), Joint Commission of Accreditation of Healthcare Organizations (TJC), etc. XIV. Integration of Infection Prevention and Control with Employee Health: The Director of the Department of Infection Prevention and Control directs Employee Health to: Provides consultation to the Employee Health Department for infection prevention and control issues. Review needle/sharps injuries and TB skin test conversions. The findings are used to help plan strategies to reduce the risk of exposure. Respiratory Fitness Questionnaire and N-95 Particulate Respirator annual or as needed testing is done for all employees in Patient Care Areas. Assist with the administration of seasonal influenza immunization and mist. Assist Employee Health with Medical Staff and employee health issues/exposures. XV. External Risks from the Community: Completion of the annual risk assessment has identified the following primary external risk from the community: Community Acquired MRSA Community Acquired Pneumonia TB Pertussis Influenza Other contagious community acquired infections XVI. Infection Prevention and Control Goals: Goals for the Infection Prevention and Control Program will be established annually based on the prioritized risk assessment, as well as the identification of key operational strategies. Prioritized risks are addressed. Maintain hospital-associated infections of 1.92% in 2014 Care Fusion/Med Mined NIMS for

12 Limit unprotected exposure to pathogens by isolation precautions and use of personal protective equipment (PPE). Alabama Mandatory Reporting per Mike Denton Infection Reporting Act. Continue Infection Control National Patient Safety Goals o Improve compliance with hand hygiene guidelines. NPSG Improve Hand Hygiene from 45.0% in 2014 by 15% in o Comply with Hand Hygiene Guidelines Wash all hand surfaces when performing hand hygiene Culture non-compliant staff member s hands and report to administration Can use soap and water for 20 seconds or waterless hand sanitizer Waterless hand sanitizer should not be used for patients with Clostridium difficile or when hands are visibly soiled Computer screen reminders for hand hygiene. Patient TV Channel with CDC hand hygiene video. o Limit the transmission of infections associated with the use of medical equipment, devices, and supplies. NPSG Prevent Healthcare Associated Infections due to infections that are hard to treat such as Multidrug Resistant Organisms. Maintain MRSA NIMS rate as 0.10%. Monitor compliance with prevention strategies Isolation compliance Hand Hygiene Antimicrobial stewardship o NPSG Prevent Central Line Associated Bloodstream Infections. Maintain goal to near zero. Educate patients and families about central line associated bloodstream infection prevention prior to line insertion Monitor evidence based practices to prevent these infections Hand hygiene Wearing full PPE for insertion Full body drape for patient Use Biopatch Chlorhexidine-based antiseptic for skin preparation Avoid femoral catheters Standardized protocol for disinfection hubs/ports Daily evaluation and chart documentation for the need of catheters and remove unnecessary catheters Central line dressing change weekly by the PICC team o Limit the transmission of infections associated with procedures. NPSG Continue Best Practices to Prevent Surgical Site Infections. Maintain 1.26% for Class 1 surgeries. Monitor best practices to prevent surgical site infections Administer antimicrobial prophylaxis within one hour before incision (2 hours for vancomycin and fluoroquinolones) 12

13 Discontinue antimicrobial prophylaxis within 24 hours after surgery (48 hours for cardiothoracic procedures) Hair removal performed with clippers only Remove Foley catheter within hours Control glucose Maintain patient s body temperature o NPSG Continue evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). Reduce Urine NIMS and CAUTI rate of 2.3% in 2014 by 1% in Criteria based Foley Catheter insertion Silver impregnated Foley catheters Theraworx protocol Securement devices Foley urine collection kits with preservatives Removal of baby powder Purchased better quality diapers Education on insertion as well as handling and care of Foley catheters Marking the Foley bags so the physicians and hospital staff could clearly identify how long the Foley had been in place Prompt removal of the Foley Catheter to limit duration Weekly reporting of the Urine NIMS to the Unit Managers Influenza Vaccination Reporting Measure- SMC rate was 98.8% for The goal for 2015 will be to maintain. 13

14 XVII. Confidentiality Statement: All information, reports, minutes, statement or other memoranda or data which serve or are the outcome of the Infection Prevention and Control Department, which is part of the quality assessment and improvement process, shall be considered privileged and strictly confidential in their entirety. Such material shall be used only for the evaluation and improvement of patient care, for granting, limiting or revoking individually delineating privileges. XVII. Annual Evaluation: The structure and functions of the Infection Prevention and Control Program are appraised annually in written summary of rates and activities submitted to the Governing Council, Medical Executive Committee. To assure the program is achieving the set objectives and is having a positive impact on the hospital. Infection Prevention and Control Plan is evaluated and approved annually by the Infection Prevention and Control Committee based on population at risk, data, and goals. Springhill Medical Center Infection Prevention and Control Plan for 2015 Approvals: The attached Infection Prevention and Control Plan has been reviewed, revised and approved by all appropriate Springhill Medical Center authorities as attested by the signatures below. Director of Infection Prevention and Control Date CEO Date 14

15 HIGH MED NONE LIFE THREAT HEALTH /SAFETY HIGH MOD POOR FAIR GOOD Infection Control Risk Assessment Springhill Medical Center 2015 PROBABILITY RISK PREPAREDNESS TOTAL SCORE BLOODBORNE PATHOGENS HIV HBV HCV

16 HIGH MED NONE LIFE THREAT HEALTH/ SAFETY HIGH DISRUPTION TO MOD DISRUPTION TO POOR FAIR GOOD EVENT PROBABILITY RISK PREPAREDNESS TOTAL SCORE Healthcare- Associated Infections Catheter- Associated Urinary Tract Infection Central Line Related Blood Stream Infections Ventilator Associated Pneumonia Surgical Site Infections MRSA VRE Acinetobacter Carbapenem- Resistant Klebsiella pneumonia Clostridium difficile Norovirus Other MDRO ESBL Scabies RSV Rotavirus Chickenpox Outbreak

17 HIGH MED NONE LIFE THREAT HEALTH /SAFETY HIGH MOD POOR FAIR GOOD HIGH MED NONE LIFE THREAT HEALTH/ SAFETY HIGH MOD POOR FAIR GOOD EVENT PROBABILITY RISK PREPAREDNESS TOTAL SCORE Biological Anthrax Plague Tularemia Brucellosis Q Fever Bacterial Diarrhea Smallpox Viral Encephalitis Viral Hemorrhagic Fevers to include Ebola Botulinum Enterotoxins PROBABILITY RISK PREPAREDNESS TOTAL SCORE Construction Aspergillus Legionella

18 HIGH MED NONE LIFE THREAT HEALTH/ SAFETY HIGH MOD POOR FAIR EVENT PROBABILITY RISK PREPAREDNESS TOTAL GOOD SCORE Community- Associated Infections MRSA Clostridium difficile MDRO ESBL Meningitis Pertussis Scabies TB Pneumonia Epidemic Flu Pandemic Flu RSV Rotavirus Chickenpox Mumps Disseminated Shingles SARS Vibrio

19 HIGH MED NONE LIFE THREAT HEALTH /SAFETY HIGH MOD POOR FAIR GOOD EVENT PROBABILITY RISK PREPAREDNESS TOTAL SCORE Failure to Prevent Measure Failure of Hand Hygiene Failure of Isolation Compliance Failure to Immunize Employees PPD Screening Environment of Care Environmental Cleanliness Proper storage of clean and dirty

20 2015 Annual Risk Assessment for Tuberculosis Skin Test Conversions Springhill Medical Center 2014 Mantoux PPD skin test conversions 2014 Mantoux PPD skin tests given 1/345 = 0.29% PPD Conversion Rate One confirmed Mycobacterium tuberculosis case was admitted or treated at SMC in 2014: This patient had multiple visits in February, June, and August 2014, and was seen and/or treated in the Emergency Department, ICU, Unit 1100, and Bronch Lab. This resulted in a total of one Mycobacterium tuberculosis exposure for the year 2014: 1 st Quarter = 1 patient with TB exposing 13 employees 2 nd Quarter = 1 patient with TB exposing 10 employees 3 rd Quarter = 1 patient with TB exposing 5 employees 4 th Quarter = 0 employees exposed Mantoux PPD skin test baseline and one month post exposure were performed as a result of these exposures. One post-exposure conversion occurred on these 28 employees from this one patient. Quantiferon tests were performed when needed. There was one Unit 1100 conversion for 2014 from annual PPD testing. Mobile Community Tuberculosis Profile from the Mobile County Health Department is < 2% of the population. SMC is in a minimal risk category for 2015 and annual Mantoux PPD skin tests will be given to high risk departments, see attached list. Pre-employment Mantoux PPD two step skin tests will include a baseline and a second step at least one week apart. 20

21 PPD Skin Test for 2015 Departments: Lab ICU 3500 RT ED Radiology Admitting 21