Infection Prevention and Control Program

Transcription

1 Infection Prevention and Control Program UNDERSTANDING AND MANAGING THE REGULATORY CHANGES IN YOUR PROGRAM Melissa J. Mitchell, R.N., B.S.N F Tag 880 According to F Tag 880 the Infection Prevention and Control Program must be a system for preventing, identifying and controlling infection and communicable diseases. 1

2 Your Infection Prevention and Control Program must include: A. A system that covers all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement, is based on the individual facility assessment and IPCP at least annually (f), and follows national standards (a)(1) B. Written standards, policies and procedures in accordance with (a)(2) C. A system for recording incidents under the IPCP and corrective actions taken by the facility (a)(4) D. Linen Procedures (e) E. An Antibiotic Stewardship Program (F Tag 881) F. Appointment of an Infection Prevention and Control Program Specialist. (Phase III) 2

3 What is (a)(2)? Clarification for your policies and procedures which must include, but are not limited to: A. A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. B. When and to whom possible incidents of communicable disease or infections should be reported. C. Standard and Transmission-based precautions to be followed to prevent spread of infections D. When and how isolation should be used for a resident E. The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents, their food, if direct contact will transmit the disease; and F. The hand hygiene procedures to be followed by staff involved in direct resident contact. Surveillance Routine, Ongoing, Systematic Collection of Data Analysis, Interpretation, and Dissemination of Data Identification of Infections, Risks, Communicable Disease Outbreaks, and Maintenance or Improvement of Resident Status 3

4 Surveillance Data Collection Tool Nationally Recognized Surveillance Criteria Surveillance System Management of potentially infectious resident Report and follow up on communicable diseases, HA infections and outbreaks Transfer and Discharge Communication Care planning (48 hours) Transmission Based Precautions Surveillance In addition to the Surveillance System for the facility, two further steps must be taken: Process Surveillance-The review of practices by staff directly related to resident care. Outcome Surveillance- The process of collecting/documenting data on individual resident cases and comparing the collected data to stand written definitions of infections. 4

5 Surveillance Transmission Based Precaution Observation Environmental Cleaning Linens (483.80(e) PPE Usage Process Surveillance Suggestions Management of Blood Borne Pathogen Exposure Infection Control Practices for resident care (i.e. catheter care, wound care) Injection Safety Point-of-Care testing ( i.e. blood glucose monitoring) Hand Hygiene Surveillance Lab Cultures and Diagnostic test results for clusters, trends, patterns Outcome Surveillance Suggestions Documentation such as progress notes, physician orders Transfer/Discharge Summaries for New and Readmitted Residents Antibiotic Orders Medication Regimen Review Reports 5

6 What is (a)(4)? Clarification for recording incidents identified under the facility s IPCP and the corrective actions taken to include, but not limited to: A. How the facility will obtain information on incidents from residents, family and direct care/direct access staff B. A description of how the facility addresses and investigates the incident(s). C. Measures to be implemented for the prevention of incidents or potential incidents as they relate to infection prevention and control. D. Development and implementation of corrective actions E. Monitoring for the effectiveness of its implemented changes F. Methods for feedback to appropriate individuals involved in the failed practices. ICPC Incidents Identify Monitor QAPI Analyze Correct Report 6

7 What is (e)? Clarification for developing and following practices pertaining to laundry which include but are not limited to: A. Handling B. Transport C. Linen Storage D. Processing E. Offsite laundry F. Mattress and pillow maintenance Laundry Resident s clothing What is laundry? Linen from other departments Bed Linens Pillows Towels and Washcloths 7

8 F Tag 881 According to F Tag 881, the Infection Control and Prevention Program must include an Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. Antibiotic Stewardship Program Who should be involved in development? Medical Director Consulting Pharmacist Nursing leadership Administrative leadership Infection Control Specialist 8

9 Antibiotic Stewardship Program According to the CDC, the core elements should include: A. Facility leadership commitment to safe and appropriate antibiotic use B. Accessing pharmacists and others with experience or training in antibiotic stewardship C. Implementing policies or practices to improve antibiotic use D. Track measures of antibiotic use in the facility E. Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff F. Education of staff and residents about antibiotic stewardship. Antibiotic Stewardship Program Protocols must: A. Be incorporated in the Infection Control and Prevention Program B. Be reviewed on an annual basis and as needed C. Contain a system of reports related to monitoring antibiotic usage (think QAPI) D. Incorporate monitoring of antibiotic use, including the frequency of monitoring/review. E. Assess residents for any infection using standardized tools and criteria (i.e. SBAR, Loeb Minimum Criteria for Initiation of Antibiotics F. Include the mode of education for physicians and nursing staff on antibiotic use stewardship and the facility s antibiotic use protocols. 9

10 Antibiotic Stewardship Program Remember! Assessment, monitoring, and communication of antibiotic use is guided by your consulting pharmacist and ties in with F Tag 756 Drug Regimen Review!! Specific Timelines Due November 28, 2017: Development of the Infection Prevention and Control Program based on the facility assessment Policies and procedures based on (a)(2) A system for recording incidents and corrective actions within the Infection Control and Prevention Program An Antibiotic Stewardship Program Due November 28 th, 2018: A. Appointment of an Infection Prevention and Control Specialist 10

11 So how do we do this? Review and compare your current program to the F Tags: A. What does our facility assessment reveal about our facility and community risks? B. How does what you are doing now compare with what the new tags require? C. Who will be responsible for writing policies and procedures, surveillance and reporting? D. What is our goal for completion? E. How will we educate everyone to include staff, residents, physicians, families, visitors? F. How will we implement the program? G. What resources do we have in assisting us with all of this? So how do we do this? Your Resources A. Websites as listed in the F Tags, to include but not limited to: in_hcf_o3.pdf B. Educational Opportunities: GHCA seminars Corporate in-services GANLTC events- district council meetings, convention C. Your Quality Assurance Performance Improvement Program and Committee D. Your Staff E. The Long Term Care Survey- Regulations 11

12 How do we do this? Read, Read, Read and Read Some More!!! We are all in this together! An ounce of prevention is worth a pound of cure.- Benjamin Franklin Unless we are making progress in our nursing every year, every month, every week, take my word for it, we are going back.- Florence Nightingale 12

13 Resource State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities. (2017). Retrieved from: Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf 13