Spectrum Health Infection Control and Prevention Review of Program Plan & Goals 2013 Targeted Surveillance: 1. Hand Hygiene Wash In Wash Out Percent Compliance 2. Central Line Associated Bloodstream Infections ACC/MCC/SCC per 1,000 Line Days 3. Central Line Associated Bloodstream Infections Adult Med/Surg per 1,000 Line Days 4. Ventilator Associated Event ACC/MCC/SCC per 1,000 Vent Days 5. Ventilator Associated Event 6 South Burn Unit per 1,000 Vent Days 6. Surgical Site Deep Incisional Hip Infections per 100 THA Procedures 7. Surgical Site Deep Incisional Knee Infections per 100 TKA procedures 8. Surgical Site Sternal Mediastinitis Infections per 100 procedures 9. Surgical Site Infections for Colon procedures/100 procedures 10. Surgical Site Infections for Abdominal Hysterectomy procedures/100 procedures 11. Surgical Site Infections following Pacer/ICD implantation /100 procedures 12. Catheter Associated Urinary Tract Infections Adult Med/Surg per 1,000 Catheter Days 13. Urinary Catheter Utilization Ratio Adult Med/Surg (catheter days/patient days) 14. Healthcare Associated Infections (HAI) in Bone Marrow Transplant patients 15. Healthcare Associated Infections (HAI) in Burn patients 16. Lab ID C-Diff/10,000 Patient Days 17. MRSA Bacteremia per 1000 Patient Days. 18. CRE surveillance per 10,000 Patient Days Goal 1. Continue Leadership on Hospital-Wide Hand Hygiene Intervention: Work with departments to improve compliance with audit data input into electronic data base Monthly analysis of data and develop interventions as needed Goal of 97% or greater compliance 2. Analyze surveillance of Central Line Associated Bloodstream Infections (CLABSI), target zero (NPSG 07.04.01): Partner with the house wide multidisciplinary CLABSI team by attending Review HH goal changed to 98% 7/2014. We have not met the new goal. We have identified flaws with the data collection. Education provided to Nurse Managers in November. HH education is provided at New Employee Orientation with emphasis on Wash in & Wash out. Infection Prevention has attended & participated in the monthly CLABSI Reviewed by ICPIC: April 25, 2012 page 1 of 7
meetings, providing expertise input and identifying opportunities to eliminate CLABSIs Continue maintenance bundle work by disseminating and assisting with implementation in Med/Surg units Review and apply current evidence-based literature for reduction strategies Continue NHSN reporting for CLABSI for Adult Critical Care 3. Apply definition & analyze surveillance of Ventilator Associated Event (VAE), target zero: Assess VAP bundle compliance on identified cases Facilitate and assess implementation of CHG oral care in ED and pre-hospital settings 4. Reduce Surgical Site Infections (SSI): Perform surveillance on targeted SSIs (Total Hip/Knee, C-Section, Sternal Mediastinitis, Hysterectomy and Colon procedures) Plan for new Surgical Procedure Surveillances (Lung, etc) Monitor positive cultures for potential Surgical Site Infections Investigate each SSI for opportunities missed and identification of previously unidentified risks (mini RCA) Review and implement strategies as appropriate from: APIC Guide for the Prevention of Surgical Site Infections Assist with the implementation of the QCP Surgical Module. Participate in the Michigan Arthroplasty Registry CQI (MARCQI) and look for opportunities for improvement team. New CL dressing have been introduced on the med/surg units to provide a good occlusive site. Introduce house wide alcohol caps for all central lines. This will eliminate the need to scrub the hub if the caps are used properly. All ICU CLABSIs are entered into NHSN by CMS deadline. In addition, critical care has a CL task force to focus on critical care issues. Rates have remained flat for 2013 compared to 2012. Utilized VAP & VAE definitions to meet reporting requirements. Rates remain low. We will be shifting to VAE reporting for 2014. SSI surveillance added lung transplant this year. Mastectomy infections were investigated with opportunities identified for improvement and presented to leadership and Surgical Quality Committee. Colon surgery SSI information and opportunities for improvement have been presented to the Colon surgeons. Hysterectomy SSI data has been presented to the Gyn surgeons with opportunities for improvement presented. Reviewed by ICPIC: April 25, 2012 page 2 of 7
5. Analyze surveillance of Clostridium difficile (Cdiff) infection (HO-HCFA) (NPSG 07.03.01): Develop and educate clinical decision-making tool for contact enteric precautions Complete an A3 for C-diff isolation (based on 2012 findings) to provide appropriate isolation. Monitor impact of initiating Cdiff PCR testing An A3 was completed by the infection Prevention team for reducing isolation of r/o C.diff. The program was piloted on 2 units successfully and rolled out to all the nursing units on Nov 8, 2013. Ongoing monitor of HO-CDI continues. CDI infections in 2013 decreased 10% compared to 2012. 6. Analyze surveillance of Catheter Associated Urinary Tract Infections (CAUTI) Adult Med/Surg: Collaborate with Nursing Quality on CAUTI surveillance Partner with nursing to implement evidence-based strategies to decrease catheter utilization ratios Participate in MHA Keystone On the CUSP: Stop CAUTI program Assess the Cerner prompt for appropriate utilization. Infection Prevention participates in the monthly CAUTI team meetings. Continuous improvement opportunities are sought. New triggers built into Cerner for identifying appropriateness of urinary catheter based on CDC definition. 2 improvement process shifts occurred this year for catheter utilization rate. Still more work needed in ACC. 7. Conduct annual MDRO (MRSA, CDI, VRE, AMP-C, ESBL, Acinetobacter baumannii) risk assessment (NPSG 07.03.01): Educate staff on MDRO organisms and prevention strategies at hire and annually Assist in developing patient and family education materials Review and apply current evidence-based literature for reduction strategies Provide consultation for active surveillance cultures: Burn Unit, total hip/knee replacements. Research protocols for clearing patients from MDROs. Education provided to QSOs.. No hospital acquired CRE. Lab ID MRSA rates have decreased steadily over 2013. Need additional work with clearing protocols. Developed new process for R/O CDI patients that reduced isolation use by 85%. CDI infections in 2013 decreased 10% compared to 2012. Reviewed by ICPIC: April 25, 2012 page 3 of 7
8. Perform Annual and Periodic Infection Control and Prevention Plan Risk Assessment: Reassess risks as indicated by emerging pathogens and high risk populations Collaborate with Guest Services to refine healthy visitor screening process Establish prevention measures (Cover Your Cough) at points of entry Partner with departments to establish processes for Prion Disease (CJD) Provide support and maintain awareness of Disaster and Emergency Preparedness planning Amend goals as necessary according to risk assessment 9. Infection Control and Prevention Interdisciplinary Committee Establish standardized agenda topics and routine reports Review membership and make changes as appropriate Review infection control and prevention program plan 10. Provide Resources for Infection Control and Prevention Program Development Assess work flow and processes and recommend strategies to improve efficiencies Provide educational opportunities through local and national conferences and participation in webinars. Seek opportunities for continuing education to maintain expertise 11. Provide Consultation for Spectrum Health System Entities and other Health Care or Community Partners Provide mock Joint Commission survey as requested Assist with Infection Prevention program development as requested Educate on Spectrum Health infection prevention initiatives Refine long term strategy for Systems Infection Prevention Response Monitor Dashboard effectiveness; assist with updates 12. Improve Compliance with Isolation Precautions: Analyze data collected on isolation compliance and develop interventions as Assessment matched expectations. Much work has been invested in the new BMT program with anticipation of risk and implementation of activities to mitigate risk including HEPA filtration, Protective isolation rooms, cleaning protocols and clinic space as well as patient & family education materials. Partnered with Emergency Preparedness for Influenza season for Healthy Visitor screening, patient placement, testing and staff communication. ICPIC has met monthly. Membership has been redefined. Infection Preventionists were able to attend State and Nat l conferences. The team also participated in several webinars, Novice IP attended Nat l EPI course. Served as a resource for Spectrum Health, both inpatient, outpatient and long term care. Began redefining long term goals for Infection Prevention at the system level through a Center for Infection Prevention. Audits indicate good compliance with isolation practices. Reviewed by ICPIC: April 25, 2012 page 4 of 7
appropriate Develop decision making tools for RN at bedside. Review and update isolation precautions policy 13. Partner with Employee Health Services to Prevent Staff Exposures to Communicable Diseases Analyze and review reported exposure data monthly at Infection Control Committee once data is available from ISIS. Continue to provide consultation on a as- needed basis Provide BBP education at new employee orientation for Employee Health Services Assist in planning for mandatory employee influenza immunization Represent Infection Control on Medical and Non-Medical Review Committee for influenza immunization exemptions Ongoing work for decision making tools for RNs required Assisted in planning of staff influenza vaccination program. Have not identified a good way to evaluate staff exposures. Continue to explore opportunities with EHS. 14. Collaborate with Critical Care Units on implementation strategies to reduce infections Analyze surveillance data from critical care units weekly Review epidemiologic significant pathogens; recommend implementation of interventions as appropriate IP work closely with ICU developing and participating on teams to reduce CLABSI, VAP/VAE & CAUTI. Participates in environmental rounds & safety huddles and prevention teams. 15. Collaborate with Bone Marrow Transplant Unit staff on strategies to prevent infection Analyze all culture reports from BMT unit patients weekly Perform periodic risk analysis and develop metrics as indicated IPC has participated in the planning and polices for the BMT program. Also have consulted on temporary clinic space as well as permanent location. IP has developed a surveillance plan for the BMT patients that includes Aspergillosis and Legionella. 16. Collaborate with Burn Unit staff on strategies to prevent infection Analyze all culture reports from Burn unit patients weekly IP participates in weekly Burn Team meetings and unit rounding. Reviewed by ICPIC: April 25, 2012 page 5 of 7
Perform periodic risk analysis and develop metrics as indicated Outbreak investigation conducted following increase in MRSA cultures. Common source not identified. Instituted Contact Precautions for all Burn patients. Surveillance ongoing. 17. Assess Infection Risk for waterborne pathogens Work with outside consultant and facilities to formalize a Legionella plan Update Water Pathogen Policy to reflect recommendations from outside consultant Report Legionella water testing results at the ICPIC. Take corrective action when problems are identified. 18. Partner with Facilities, Design and Construction Educate facilities and construction on new ICRA policy. Review and sign off on all Infection Control Risk Assessment documents per policy Update Monitoring of Negative/Positive Pressure Rooms policy Consult as necessary on water intrusion events Perform annual review of hospital blueprint for assignment of risk and criticality 19. Collaborate with Clinical and Ancillary Services to Establish Infection Prevention Processes for High Risk Populations Solid organ transplant Hematology Oncology Dialysis Interventional Radiology Perioperative Services Emergency Department Cystic Fibrosis Endoscopy Bronchoscopy Sterile Processing Department Environmental Services Lemmon Holton Cancer Pavilion Partnering with facilities. Legionella testing performed quarterly, Still waiting on final National guidelines to draft hospital plan. New Education designed for construction. Weekly ICRA meetings held. Annual hospital risk blueprint updated. Infection Prevention has been available to assist units & departments meet their infection control needs. IPC has participated in many RIEs to improve process and eliminate waste in a manner that will not increase infection risk. 20. Establish Infection Prevention Services in Ambulatory Surgical Centers Ambulatory surgery sites added to Reviewed by ICPIC: April 25, 2012 page 6 of 7
Assign and dedicate infection control resources when available Provide consultation on request Identify ambulatory sites where sterile processing is done and could be relocated to a central location. 21. Consolidate Infection Prevention & Control polices across Spectrum Health Participate in IC System Policy Efficiency and Redesign meetings Complete policy consolidation by 08/01/13 22. Partner with Facilities and Design/Construction to identify environmentally safe alternatives for existing indoor water features and plantscapes in high risk areas. Provide recommendations for LHCP, South Pavilion, BW lobby, and MHC Lobby scheduled rounding. Off site rehab units rounding with education on equipment cleaning. Initial group of policies approved and posted in Policy Tech. 11/2013. Ongoing work for additional policies continues. All indoor water features replaced with plants and architecture. Established rule prohibiting indoor water features at SHGR. Reviewed by ICPIC: April 25, 2012 page 7 of 7