INFECTION CONTROL ASSESSMENT AND RESPONSE USER GUIDE HTTPS://ICAR-HAI.ORG Prepared by the Carolina Center for Health Informatics in the Department of Emergency Medicine, University of North Carolina at Chapel Hill Version 2.0 March 6, 2017 Questions? Contact us at cchi@listserv.med.unc.edu
Table of Contents Login... 3 User Profile... 7 My Facility List... 15 s... 17 Acute Care Hospital Questions... 20 Dialysis Questions... 42 LTCF Questions... 59 Outpatient Questions... 68 Page 2 of 79
Login To begin the assessment process, please go to https://icar-hai.org and click on login. All users need an NCID to complete an assessment. NCID is the standard identity management and access service provided to state, local, business, and individual users. Please go to https://ncidp.nc.gov/ncidsspr/ to register for an NCID if you do not already have one. Please select to register as a business user. The NCID will be activated and ready for use immediately. Figure 1: ICAR HAI Homepage Page 3 of 79
Figure 2: NCID New User Registration Register for your NCID as a Business User. Page 4 of 79
Once you have your NCID, use the login button to login. The login button on https://icar-hai.org will redirect you to the NCID login page. Figure 3: Login Button on ICAR HAI Home Page Page 5 of 79
Figure 4: NCID Login Page Page 6 of 79
User Profile The first time users successfully log in to ICAR HAI, they will be asked to complete a User Profile. Some of the information will already be populated from the NCID login, but additional information is required. Once all information has been entered, click the Next button to continue. Figure 5: User Profile Page 7 of 79
After clicking the Next button, first-time users are provided an instructional overview of the process for completing the assessments. 1. The first step is to register the facility(ies) users want to assess by entering the NPI for that facility. If users do not know the NPI for a facility, they can use the CMS-provided NPI search feature available at https://npiregistry.cms.hhs.gov/. 2. After users validate the NPI information, they can submit the information to add it to their Facility List. a. Users should provide a secure fax number for their facility, but a placeholder can be provided until the secure fax can be determined (enter an unknown number as 111-111-1111). 3. NC Division of Public Health will activate facility registrations so that users can complete the infection control assessment. Users will be notified by email when the assessment is available. The Facility List page will show the status of all assessments. 4. When users click on the NEXT button, they are directed to the Register Facility page. Page 8 of 79
Figure 6: First-time User Instructions Use these links to Access all reports available to you View the User Guide Update your user Profile Logout Page 9 of 79
The first step is to register the facility(ies) users want to assess by entering the NPI for that facility. If users do not know the NPI for a facility, they can use the CMS-provided NPI search feature available at https://npiregistry.cms.hhs.gov/. Figure 7: NPI Search Page 10 of 79
The user has the opportunity to review the information stored for the NPI entered by that user. If all information is correct, the user can simply click on the Register Facility button. If the information is incorrect, the user can make edits and then click on the Register Facility button. If the incorrect NPI was entered by the user, he/she can click on the Cancel button to enter a different NPI. If the NPI for a user s facility is not found in the system, the user should contact the help desk at cchi@listserv.med.unc.edu for more information. The Help Desk can add the facility to the system. Users are required to provide a secure fax number for their facility. If the secure fax number is not known at the time of facility registration, the user should enter all 1 s, e.g., 1111111111. The user can update the secure fax number at any time by clicking on the facility name on the My Facilities and s Reports Page. NOTE: The hospital names used in this User Guide are for explanatory purposes only and do not reflect real assessments. Page 11 of 79
Figure 8: Register Facility - Acute Care Hospital Example Page 12 of 79
For Long Term Care Facilities (LTCF), there are three additional questions. The users are asked if the LTCF is affiliated with a hospital/hospital system and, if so, to provide additional information. Figure 9: Register Facility - Long Term Care Facility Example Page 13 of 79
Figure 10: Facility Registration Confirmation - Long Term Care Facility Example Page 14 of 79
My Facility List Once facilities are registered, users can view them on the Facility List page. The facility will have a status of Requested, Pending. The Facility List page can be accessed from the Facility Registration Confirmation Page or from the Reports page. On the Reports Page, select My Facilities and s. Figure 11: Reports Page Showing My Facilities and s Report After the NC Division of Public Health has activated an assessment for a facility registered by a user, that user will receive an email notification that the assessment is available for completion. At activation, the Status will be changed to Ready to Begin and will be hyperlinked to the assessment page. The sample screenshot below shows facilities with different Status types. The user can click on the link in Status to complete the assessment at any time during an active assessment time period. Users can update the address, phone and secure fax information for a facility by clicking on the Facility Name. Page 15 of 79
Figure 12: Sample Facility List showing the different Status Types Click on hyperlinks to begin assessments. Click on the facility name to update address, telephone, etc. for that facility Page 16 of 79
s The s are organized into sections or tabs. Each section covers a different infection control component. Required questions are marked with a red asterisk (*). These questions must be answered for a section to be considered complete. Please complete the assessment based on practices and policies that are currently practiced routinely. Please do not include practices that are currently implemented on a pilot or trial basis in your responses. Click the SAVE button at the bottom of the page to save any data entered before moving to another tab. Remember to save your data entry regularly even if you are staying on the same tab/section. Your session will timeout after 30 minutes without saving your responses. The Status section will provide a summary of your assessment progress. Page 17 of 79
Figure 13: Sample Screenshot from Acute Care Hospital Red asterisks * mark required questions. Page 18 of 79
Users must click on the Save button at the bottom of each section to save their answers before proceeding to another section. Users must also save at least once every 30 minutes to avoid data loss resulting from a session time-out. Figure 14: SAVE Button Please save any data entry before clicking on another tab. A warning message will appear if users do not save their data entry before clicking on another tab. Figure 15: Warning Message if a User Clicks on Another without Saving Current Page 19 of 79
The remaining pages of this User Guide list the questions for each facility type: Acute Care Hospitals, Dialysis, Long Term Care Facilities and Outpatient settings. Acute Care Hospital Questions The questions asked for Acute Care Hospitals are included in the table below. The questions are organized by section to correspond with the Web interface. Table 1: Acute Care Hospital Questions Hospital Question # Question Possible Answers (if applicable) Facility Information 1 Rationale for (Select all that apply): Outbreak Participation in Infection Control and Response (ICAR) Recommendation of accrediting organization or state survey agency Increase in healthcare-associated infections in the past 12 months Participation in prevention collaborative NHSN Data Other Facility Information 2 If you selected "Increase in healthcare-associated infections" above, please select infection types that have increased. (Select all that apply): (If other, please specify) CAUTI CLABSI SSI CDI VAE MDRO Other (If other, please specify) Page 20 of 79
Hospital Question # Question Possible Answers (if applicable) Facility Information 3 Facility type: Acute Care Hospital Critical Access Hospital Long-term Acute Care Hospital (LTACH) Other Facility Information 4 Number of Licensed Beds Facility Information 5 Number of Infection Preventionist Full-Time Equivalents Infrastructure 1 Hospital provides fiscal and human resources support for maintaining the infection prevention and control program. Infrastructure 2 The person(s) charged with directing the infection prevention and control program at the hospital is/are qualified and trained in infection control. Infrastructure 2a The person responsible for the Infection Prevention program has successfully completed the certification exam developed by the Certification Board for Infection Control & Epidemiology (CIC) Infrastructure 2b The person responsible for the Infection Prevention program participates in infection control courses organized by recognized professional societies or universities (e.g., APIC, SHEA, SPICE) Infrastructure 3 Infection prevention and control program performs an annual facility infection risk assessment that evaluates and prioritizes potential risks for infections, contamination, and exposures and the program s preparedness to eliminate or mitigate such risks. Infrastructure 4 Written infection control policies and procedures are available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations, or standards. Infrastructure 5 Infection prevention and control program provides infection prevention education to patients, family members, and other caregivers. (If other, please specify) Page 21 of 79
Hospital Question # Question Possible Answers (if applicable) Hand Hygiene 1 Hospital has a competency-based training program for hand hygiene. Hand Hygiene 1a Training is provided to all healthcare personnel, including all ancillary personnel not directly involved in patient care but potentially exposed to infectious agents (e.g., food tray handlers, housekeeping, volunteer personnel). Hand Hygiene 1b Training is provided upon hire, prior to provision of care at this hospital. Hand Hygiene 1c Training is provided at least annually. Hand Hygiene 1d Personnel are required to demonstrate competency with hand hygiene following each training. Hand Hygiene 1e Hospital maintains current documentation of hand hygiene competency for all personnel. Hand Hygiene 2 Hospital regularly audits (monitors and documents) adherence to hand hygiene. Hand Hygiene 3 Hospital provides feedback from audits to personnel regarding their hand hygiene performance. Hand Hygiene 4 Supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible in patient care areas. Hand Hygiene 5 Hand hygiene policies promote preferential use of alcohol-based hand rub over soap and water except when hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus. PPE 1 Hospital has a competency-based training program for personal protective equipment (PPE). PPE 1a Training is provided to all personnel who use PPE. PPE 1b Training is provided upon hire, prior to provision of care at this hospital. Page 22 of 79
Hospital Question # Question Possible Answers (if applicable) PPE 1c Training is provided at least annually. PPE 1d Training is provided when new equipment or protocols are introduced. PPE 1e Training includes 1) appropriate indications for specific PPE components, 2) proper donning, doffing, adjustment, and wear of PPE, and 3) proper care, maintenance, useful life, and disposal of PPE. PPE 1f Personnel are required to demonstrate competency with selection and use of PPE (i.e., correct technique is observed by trainer) following each training. PPE 1g Hospital maintains current documentation of PPE competency for all personnel who use PPE. PPE 2 Hospital regularly audits (monitors and documents) adherence to proper PPE selection and use, including donning and doffing. PPE 3 Hospital provides feedback to personnel regarding their performance with selection and use of PPE. PPE 4 Supplies necessary for adherence to personal protective equipment recommendations specified under Standard and Transmission-based Precautions (e.g., gloves, gowns, mouth, eye, nose, and face protection) are available and located near point of use. PPE 5 The hospital s respiratory protection program provides annual respiratory fit testing for all personnel who are anticipated to require respiratory protection. PPE 5a Hospital maintains supplies of respiratory protection devices (e.g., Powered air purifying respirator) to be used by personnel who cannot be fitted. PPE 5b Healthcare personnel are educated about factors that may compromise proper fit and function of respiratory protection devices (e.g., weight gain/loss, facial hair). Page 23 of 79
Hospital Question # Question Possible Answers (if applicable) CAUTI 1 Hospital has physician and/or nurse champions for CAUTI prevention activities. CAUTI 2 Hospital has a competency-based training program for insertion of urinary catheters. CAUTI 2a Training is provided to all personnel who are given responsibility for insertion of urinary catheters. Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and physicians. CAUTI 2b Training is provided upon hire, prior to being allowed to perform urinary catheter insertion. CAUTI 2c Training is provided at least annually. CAUTI 2d Training is provided when new equipment or protocols are introduced. CAUTI 2e Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training. CAUTI 2f Hospital maintains current documentation of competency with urinary catheter insertion for all personnel who insert urinary catheters. CAUTI 3 Hospital regularly audits (monitors and documents) adherence to recommended practices for insertion of urinary catheters. CAUTI 4 Hospital provides feedback from audits to personnel regarding their performance for insertion of urinary catheters. CAUTI 5 Hospital has a competency-based training program for maintenance of urinary catheters. Page 24 of 79
Hospital Question # Question Possible Answers (if applicable) CAUTI 5a Training is provided to all personnel who are given responsibility for urinary catheter maintenance (e.g., perineal care, emptying the drainage bag aseptically, maintaining the closed drainage system, maintaining unobstructed urine flow). Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and transport personnel. CAUTI 5b Training is provided upon hire, prior to being allowed to perform urinary catheter maintenance. CAUTI 5c Training is provided at least annually. CAUTI 5d Training is provided when new equipment or protocols are introduced. CAUTI 5e Personnel are required to demonstrate competency with catheter maintenance (i.e., correct technique is observed by trainer) following each training. CAUTI 5f Hospital maintains current documentation of competency with urinary catheter maintenance for all personnel who maintain urinary catheters. CAUTI 6 Hospital regularly audits (monitors and documents) adherence to recommended practices for maintenance of urinary catheters. CAUTI 7 Hospital provides feedback from audits to personnel regarding their performance for maintenance of urinary catheters. CAUTI 8 Patients with urinary catheters are assessed, at least daily, for continued need for the catheter. CAUTI 8a Hospital routinely audits adherence to daily assessment of urinary catheter need. CLABSI 1 Hospital has physician and/or nurse champions for CLABSI prevention activities. CLABSI 2 Hospital has a competency-based training program for insertion of central venous catheters. Page 25 of 79
Hospital Question # Question Possible Answers (if applicable) CLABSI 2a Training is provided to all personnel who are given responsibility for insertion of central venous catheters. Personnel may include, but are not limited to, physicians, physician assistants, and members of line insertion teams. CLABSI 2b Training is provided upon hire, prior to being allowed to perform central venous catheter insertion. CLABSI 2c Training is provided at least annually. CLABSI 2d Training is provided when new equipment or protocols are introduced. CLABSI 2e Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training. CLABSI 2f Hospital maintains current documentation of competency with central venous catheter insertion for all personnel who insert central venous catheters. CLABSI 3 Hospital regularly audits (monitors and documents) adherence to recommended practices for insertion of central venous catheters. CLABSI 4 Hospital provides feedback from audits to personnel regarding their performance for insertion of central venous catheters. CLABSI 5 Hospital has a competency-based training program for maintenance of central venous catheters. CLABSI 5a Training is provided to all personnel who maintain central venous catheters (e.g., scrub the hub, accessing the catheter, dressing changes). Personnel may include, but are not limited to, nurses, nursing assistants, physicians, and physician assistants. CLABSI 5b Training is provided upon hire, prior to being allowed to perform central venous catheter maintenance. CLABSI 5c Training is provided at least annually. Page 26 of 79
Hospital Question # Question Possible Answers (if applicable) CLABSI 5d Training is provided when new equipment or protocols are introduced. CLABSI 5e Personnel are required to demonstrate competency with maintenance (i.e., correct technique is observed by trainer) following each training CLABSI 5f Hospital maintains current documentation of competency with central venous catheter maintenance for all personnel who maintain central venous catheters. CLABSI 6 Hospital regularly audits (monitors and documents) adherence to recommended practices for maintenance of central venous catheters. CLABSI 7 Hospital provides feedback from audits to personnel regarding their performance for maintenance of central venous catheters. CLABSI 8 Patients with central venous catheters are assessed, at least daily, for continued need for the catheter. CLABSI 8a Hospital routinely audits adherence to daily assessment of central venous catheter need. VAE N/A Does your facility provide care to ventilated patients? (If answer is no, VAE section is considered complete) VAE 1 Hospital has physician and/or nurse champions for VAE prevention activities. VAE 2 Hospital has a competency-based training program addressing prevention of VAEs. VAE 2a Training is provided to all personnel who provide respiratory therapy for ventilated patients (e.g., suctioning, administration of aerosolized medications). Personnel may include, but are not limited to, respiratory therapists and nurses. VAE 2b Training is provided upon hire, prior to being allowed to provide respiratory therapy for ventilated patients. Page 27 of 79
Hospital Question # Question Possible Answers (if applicable) VAE 2c Training is provided at least annually. VAE 2d Training is provided when new equipment or protocols are introduced. VAE 2e Personnel are required to demonstrate competency with respiratory therapy practices (i.e., correct technique is observed by trainer) following each training. VAE 2f Hospital maintains current documentation of competency with respiratory practices for all personnel who provide respiratory therapy for ventilated patients. VAE 3 Hospital regularly audits (monitors and documents) adherence to recommended practices for management of ventilated patients (e.g., suctioning, administration of aerosolized medications). VAE 4 Hospital provides feedback from audits to personnel regarding their performance for management of ventilated patients. VAE 5 Patients requiring invasive ventilation are assessed, at least daily, for continued ventilator need. VAE 5a Hospital routinely audits adherence to daily assessment of ventilator need. VAE 6 Hospital has a program that includes daily spontaneous breathing trials and lightening of sedation in eligible patients. VAE 7 Hospital has an oral hygiene program for ventilated patients. Injection Safety 1 Hospital has a competency-based training program for preparation and administration of parenteral medications (e.g., SQ, IM, IV) outside of the pharmacy. Injection Safety 1a Training is provided to all personnel who prepare and/or administer injections and parenteral infusions. Injection Safety 1b Training is provided upon hire, prior to being allowed to prepare and/or administer injections and parenteral infusions. Injection Safety 1c Training is provided at least annually. Page 28 of 79
Hospital Question # Question Possible Answers (if applicable) Injection Safety 1d Training is provided when new equipment or protocols are introduced. Injection Safety 1e Personnel are required to demonstrate competency with preparation and/or administration of injections and parenteral infusions following each training. Injection Safety 1f Hospital maintains current documentation of competency with preparation and/or administration procedures for all personnel who prepare and/or administer injections and parenteral infusions. Injection Safety 2 Hospital regularly audits (monitors and documents) adherence to safe infection practices. Injection Safety 3 Hospital provides feedback from audits to personnel regarding their adherence to safe injection practices. Injection Safety 4 Hospital has a drug diversion prevention program that includes consultation with the IP program to assess patient safety risks when drug tampering (involving alteration or substitution) is suspected or identified. Injection Safety 4a Hospital has a written protocol or plan to describe how the hospital would assess risk to patients if tampering is suspected or identified. Injection Safety 4b Protocol/plan includes notification of public health / health Not Applicable department to assist with risk assessment for disease transmission. SSI N/A Does your facility perform surgical procedures? (If answer is no, SSI section is considered complete) SSI 1 Hospital has a surgical care improvement program. SSI N/A The surgical care improvement program addresses appropriate N/A prophylactic antibiotic use including the following: SSI 1a Preoperative timing of prophylactic antibiotic administration (within 1 hour prior to incision or 2 hours for vancomycin or fluoroquinolones). Page 29 of 79
Hospital Question # Question Possible Answers (if applicable) SSI 1b Appropriate prophylactic antibiotic selection based on procedure type. SSI 1c Discontinuation of prophylactic antibiotics within 24 hours (48 hours for CABG or other cardiac surgery) after surgical end time. SSI 1d The surgical care improvement program addresses prompt removal of urinary catheter on post-op day 1 or 2, unless there is a documented appropriate reason for continued use. SSI 2 Hospital regularly audits (monitors and documents) adherence to elements of surgical care improvement program. SSI 3 Hospital provides feedback from audits to personnel regarding their adherence to elements of the surgical care improvement program. SSI 4 Hospital regularly audits (monitors and documents) adherence to recommended infection control practices for SSI prevention. SSI N/A Auditing includes the following: N/A SSI 4a Adherence to preoperative surgical scrub and hand hygiene. SSI 4b Appropriate use of surgical attire and drapes. SSI 4c Adherence to aseptic technique and sterile field. SSI 4d Proper ventilation requirements in surgical suites. SSI 4e Minimization of traffic in the operating room. SSI 4f Adherence to cleaning and disinfection of environmental surfaces. SSI 5 Hospital provides feedback from audits to personnel regarding their adherence to surgical infection control practices. CDI 1 Hospital has physician and/or nurse champions for CDI prevention activities. CDI 2 Hospital regularly audits (monitors and documents) adherence to recommended infection control practices for CDI prevention. CDI N/A Auditing includes the following: N/A CDI 2a Adherence to hand hygiene. CDI 2b Appropriate use of PPE. Page 30 of 79
Hospital Question # Question Possible Answers (if applicable) CDI 2c Compliance with Contact Precautions, including use of dedicated or disposable equipment. CDI 2d Adherence to cleaning and disinfection procedures, including use of sporicidal disinfectants if part of hospital policy. CDI 3 Hospital provides feedback from audits to personnel regarding their adherence to recommended infection control practices for CDI prevention. CDI 4 Hospital has specific antibiotic stewardship strategies in place to reduce CDI. CDI N/A Strategies include the following: N/A CDI 4a Hospital has strategies to reduce unnecessary use of antibiotics that are high risk for CDI (e.g., fluoroquinolones, 3rd/4th generation cephalosporins). CDI 4b Hospital reviews appropriateness of antibiotics prescribed for treatment of other conditions (e.g., urinary tract infection) for patients with new or recent CDI diagnosis. CDI 4c Hospital educates providers about the risk of CDI with antibiotics. CDI 4d Hospital educates patients and family members about the risk of CDI with antibiotics. Environmental 1 Hospital has a competency-based training program for Cleaning Environmental Cleaning environmental cleaning. N/A Training program includes the following: N/A Page 31 of 79
Hospital Environmental Cleaning Environmental Cleaning Environmental Cleaning Environmental Cleaning Environmental Cleaning Environmental Cleaning Environmental Cleaning Environmental Cleaning Environmental Cleaning Question # Question Possible Answers (if applicable) 1a Training is provided to all personnel who clean and disinfect patient care areas. Personnel may include, but are not limited to, environmental services staff, nurses, nursing assistants, and technicians. 1b Training is provided upon hire, prior to being allowed to perform environmental cleaning. 1c Training is provided at least annually. 1d Training is provided when new equipment or protocols are introduced. 1e Personnel are required to demonstrate competency with environmental cleaning (i.e., correct technique is observed by trainer) following each training. 1f Hospital maintains current documentation of competency with environmental cleaning procedures for all personnel who clean and disinfect patient care areas. 1g If the hospital contracts environmental services, the contractor has a comparable training program. 2 Hospital has policies that clearly define responsibilities for cleaning and disinfection of non-critical equipment, mobile devices, and other electronics (e.g., ICU monitors, ventilator surfaces, bar code scanners, point-of-care devices, mobile work stations, code carts, airway boxes). 3 Hospital has protocols to ensure that healthcare personnel can readily identify equipment that has been properly cleaned and disinfected and is ready for patient use (e.g., tagging system, placement in dedicated clean area). Not Applicable Page 32 of 79
Hospital Environmental Cleaning Environmental Cleaning Question # Question Possible Answers (if applicable) 4 Hospital regularly audits (monitors and documents) adherence to cleaning and disinfection procedures, including use of products in accordance with manufacturers' instructions (e.g., dilution, storage, shelf-life, contact time). 5 Hospital provides feedback from audits to personnel regarding their adherence to cleaning and disinfection procedures. 1 Hospital has a competency-based training program for reprocessing of critical devices. 1a Training is provided to all personnel who reprocess critical devices. 1b Training is provided upon hire, prior to being allowed to reprocess critical devices. 1c Training is provided at least annually. 1d Training is provided when new devices or protocols are introduced. 1e Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training. 1f Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess critical devices. 1g If the hospital contracts reprocessing of critical devices, the contractor has a comparable training program which includes the specific devices used by the hospital. 2 Hospital regularly audits (monitors and documents) adherence to reprocessing procedures for critical devices. Not Applicable Page 33 of 79
Hospital Question # Question Possible Answers (if applicable) 2a Audits occur in all locations where critical devices are reprocessed (e.g., central sterile reprocessing, operating suites), including locations where initial cleaning steps are performed (e.g., point of use). 3 Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for critical devices. 4 Hospital has a competency-based training program for reprocessing of semi-critical devices. 4a Training is provided to all personnel who reprocess semi-critical devices. 4b Training is provided upon hire, prior to being allowed to reprocess semi-critical devices. 4c Training is provided at least annually. 4d Training is provided when new devices or protocols are introduced. 4e Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training. 4f Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess semicritical devices. 4g If the hospital contracts reprocessing of semi-critical devices, the contractor has a comparable training program which includes the specific devices used by the hospital. 5 Hospital regularly audits (monitors and documents) adherence to reprocessing procedures for semi-critical devices. Not Applicable Page 34 of 79
Hospital Question # Question Possible Answers (if applicable) 5a Audits occur in all locations where semi-critical devices are reprocessed (e.g., central sterile reprocessing, endoscopy suites), including locations where initial cleaning steps are performed (e.g., point of use). 6 Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for semi-critical devices. 7 Hospital reuses single-use devices. 7a If yes, the single-use devices are reprocessed by an FDA-approved Not Applicable entity. 8 Hospital maintains documentation of reprocessing activities. N/A Documentation includes the following: N/A 8a Hospital maintains logs for each sterilizer cycle that include the results from each load. 8b Hospital has documentation that the chemicals used for high-level disinfection are routinely tested for appropriate concentration and replaced appropriately. 9 Hospital allows adequate time for reprocessing to ensure adherence to all steps recommended by the device manufacturer, including drying and proper storage. 9a Hospital has an adequate supply of instruments for the volume of procedures performed to allow sufficient time for all reprocessing steps. 9b Scheduling of procedures allows sufficient time for all reprocessing steps. 9c Hospital rarely/never uses immediate-use steam sterilization (IUSS). Page 35 of 79
Hospital Question # Question Possible Answers (if applicable) 10 IP program is consulted whenever new devices or products will be purchased or introduced to ensure implementation of appropriate reprocessing policies and procedures. 11 Hospital has policies and procedures outlining hospital response (i.e., risk assessment and recall of device) in the event of a reprocessing error or failure. 11a Hospital has a procedure to identify which patients may have been exposed to an improperly reprocessed device. MDROs 1 Hospital has system in place for early detection and management of potentially infectious persons at initial points of entry to the hospital, including rapid isolation as appropriate. MDROs 1a Travel and occupational history are included as part of admission and triage protocols. MDROs 1b Hospital has system to identify (flag) patients with targeted MDROs upon readmission so appropriate precautions can be applied. MDROs 2 The hospital has a respiratory/hygiene cough etiquette program. MDROs N/A The etiquette program includes the following: N/A MDROs 2a Posting signs at entrances. MDROs 2b Providing tissues and no-touch receptacles for disposal of tissues. MDROs 2c Providing hand hygiene supplies in or near waiting areas. MDROs 2d Offering face masks to coughing patients and other symptomatic individuals upon entry to the facility. MDROs 2e Providing space in patient waiting areas (e.g., ED waiting room) and encouraging individuals with symptoms of respiratory infections to sit as far away from others as possible. MDROs 3 Hospital has systems in place for early detection and isolation of infectious patients identified during the hospital stay, including rapid isolation of patients as appropriate. Page 36 of 79
Hospital Question # Question Possible Answers (if applicable) MDROs 3a There is a mechanism for prompt notification of the IP by the clinical microbiology laboratory when novel resistance patterns and/or targeted antimicrobial-resistant pathogens are detected. MDROs 4 Hospital has system in place for INTER-facility communication of infectious status and isolation needs of patients prior to transfer to other facilities. MDROs 4a The hospital has system to notify receiving facilities of microbiological tests (e.g. cultures) that are pending at the time of transfer. MDROs 5 Hospital has system in place for INTER-facility communication to identify infectious status and isolation needs of patients prior to accepting patients from other facilities. MDROs 5a The hospital has system to follow-up on microbiological results (e.g., cultures) that are pending at the time of transfer. MDROs 5b If the hospital identifies an infection that may be related to care provided at another facility (e.g., hospital, nursing home, clinic), the facility is notified. MDROs 6 Hospital has system in place for INTRA-facility communication to identify infectious status and isolation needs of patients prior to transfer to other units or shared spaces (e.g., radiology, physical therapy, emergency department) within the hospital. MDROs 6a IP ensures infectious status and isolation needs are communicated with receiving units. MDROs 7 Hospital has a surveillance program to monitor incidence of epidemiologically-important organisms (e.g., CRE) and targeted healthcare-associated infections. MDROs 7a IP is familiar with how the hospital determines which organisms and HAIs to track. Page 37 of 79
Hospital Question # Question Possible Answers (if applicable) MDROs 8 Hospital uses surveillance data to implement corrective actions rapidly when transmission of epidemiologically-important organisms (e.g., CRE) or increased rates or persistently elevated rates of healthcare-associated infections are detected. MDROs 8a Data collection method allows for timely response to identified problems. MDROs 9 Hospital has an antibiotic stewardship program that meets the 7 CDC core elements listed below (a-g). MDROs 9a Hospital leadership commitment: Hospital has a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship) AND/OR hospital provides salary support for dedicated time for antibiotic stewardship activities. MDROs 9b Program leadership (accountability): There is a leader responsible for outcomes of stewardship activities at the hospital. MDROs 9c Drug expertise: There is at least one pharmacist responsible for improving antibiotic use at the hospital. Page 38 of 79
Hospital Question # Question Possible Answers (if applicable) MDROs 9d Act (at least one prescribing improvement action below):hospital has a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry.hospital has hospital-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions.there is a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g., antibiotic time out).hospital has specified antibiotic agents that need to be approved by a physician or pharmacist prior to dispensing at the hospital.physician or pharmacist reviews courses of therapy for specified antibiotic agents and communicates results with prescribers. MDROs 9e Track: Hospital monitors antibiotic use (consumption). MDROs 9f Report: Prescribers receive feedback by the stewardship program about how they can improve their antibiotic prescribing. MDROs 9g Educate: Stewardship program provides education to clinicians and other relevant staff on improving antibiotic use. MDROs 10 Hospital has an occupational health program that, in addition to complying with state and federal requirements (e.g., OSHA), has policies regarding contact of personnel with patients when personnel have potentially transmissible conditions. Page 39 of 79
Hospital Question # Question Possible Answers (if applicable) MDROs 10a The program has work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits or job status. MDROs 10b Personnel are educated regarding prompt reporting of illness to their supervisor and the occupational health programs. MDROs 11 Hospital follows recommendations of the Advisory Committee on Immunization Practices (ACIP) for immunization of healthcare personnel, including offering Hepatitis B and influenza vaccination. MDROs 12 Hospital is compliant with mandatory reporting requirements for notifiable diseases, healthcare-associated infections (as appropriate), and potential outbreaks. MDROs 12a Hospital can identify point(s) of contact at the local or state health department for HAI concerns MDROs 13 Hospital implements infection control measures relevant to construction, renovation, demolition, and repairs including performance of an infection control risk assessment (ICRA) before a project gets underway. MDROs 13a IP program is consulted anytime construction, renovation, demolition or repairs will be performed. MDROs 13b ICRA elements are included in all contracts related to construction, renovation, demolition, and repairs. NHSN 1 Infection Preventionist knows how to import data into NHSN. NHSN 2 Infection Preventionist knows how to export data from NHSN. NHSN 3 Infection Preventionist uses analysis tools within NHSN. NHSN 4 How many times per month does the Infection Preventionist login 0 1 2 or more to NHSN? NHSN 5 Hospital monitors HAI data and uses data to direct prevention activities. NHSN 6 Hospital provides feedback of NHSN data to frontline personnel. Page 40 of 79
Hospital Question # Question Possible Answers (if applicable) NHSN 7 How often are HAI surveillance reports (NHSN data and/or other HAI data) disseminated within your hospital? Quarterly Monthly Weekly Ad NHSN 8 Who receives surveillance reports (NHSN data and/or other HAI data)? (Select all that apply.) Hoc Never Physicians Nurses C-Level Quality Improvement We do not disseminate surveillance reports / Not Applicable Other NHSN 8a What level of detail is included in your reports? Line Level / Patient Record Level data only Aggregate data only Combination of line level / patient record level and aggregate Reports are customized for each department We do not disseminate surveillance reports / not applicable Other Page 41 of 79
Dialysis Questions Dialysis Facility Information Facility Information Facility Information Facility Information Facility Information Facility Information Question # Question 1 Rationale for (Select all that apply): 2 If you selected "Increase in healthcareassociated infections" above, please select infection types that have increased. (Select all that apply) 3 Who staffs the facility? (Select all that apply) 4 Please indicate this facility's association with a dialysis chain: 5 What services are offered at the facility? (Select all that apply) 6 What is the typical daily patient census? (include all dialysis patients cared for by the facility) Infrastructure 1 What training does the person in charge of infection control at the facility have? Select the best answer. Possible Answers (if applicable) Outbreak Input from ESRD Network or state survey agency Participation in Infection Control and Response (ICAR) Recommendation of accrediting organization or state survey agency Increase in healthcare-associated infections Participation in Prevention Collaborative Other Bloodstream Infection (BSI) Vascular Access Infection (VAI) Local Access Site Infection (LASI) Access-related Bloodstream Infection (ARBI) Other Hospital Staff Contract with a dialysis company Dialysis center employs staff directly Other DaVita Fresenius Medical Care Dialysis Clinic, Inc. (DCI) This facility is NOT part of a dialysis chain Other Adult in-center hemodialysis Pediatric in-center hemodialysis Home hemodialysis Nocturnal hemodialysis Peritoneal dialysis Inpatient hemodialysis (in addition to outpatient hemodialysis) 1-25 26-50 51-75 76-100 101-150 151-200 > 200 Certified in Infection Control (CIC) No specific training in infection control Not applicable (no person in charge of infection control at the facility) Other Page 42 of 79
Dialysis Question # Question Infrastructure 2 Is the facility participating in their ESRD Network Healthcare-Associated Infection (HAI) Quality Improvement Activity (QIA)? Infrastructure 3 Has the facility participated in the CDC Dialysis BSI Prevention Collaborative? Infrastructure 4 In the past two years, has the facility participated in any other intensive program focused on HAI prevention? (e.g., clinical trial, company-led quality improvement project) Infrastructure 4a If yes, please specify: Infrastructure 5 Does the facility have a system for early detection and management of potentially infectious persons at initial points of patient encounter? Note: System may include taking a travel history, assessing for diarrhea or draining infected wounds, and elements described under respiratory hygiene/cough etiquette. Infrastructure 6 Does the facility have a policy/protocol for implementing Contact Precautions when warranted? Note: CDC does not recommend Contact Precautions for multidrug resistant organisms (MDROs) in dialysis clinics. However, in certain circumstances (e.g., known or suspected MDRO transmission), Contact Precautions may be necessary. Possible Answers (if applicable) Yes, system applies at (or prior to) point of facility check-in Yes, system applies when patient arrives in dialysis treatment area No Page 43 of 79
Dialysis Question # Question Infrastructure 7 Are there signs posted in the facility that encourage patients to take an active role in and express their concerns about facility infection control practices? Infrastructure 8 Does the facility provide standardized education to all patients on vascular access care? Infrastructure 9 Does the facility provide standardized education to all patients on hand hygiene? Infrastructure 10 Does the facility provide standardized education to all patients on risks related to catheter use? Infrastructure 11 Does the facility provide standardized education to all patients on recognizing signs of infection? Infrastructure 12 Does the facility provide standardized education to all patients on instructions for access management when away from the dialysis unit? Infrastructure 13 What is the distance separating adjacent dialysis treatment stations? Infrastructure 13a If using an embedded/shared computer terminal, what is the policy/protocol for routinely cleaning the embedded/shared computer terminal? Infrastructure 14 Does the facility have an isolation room that is available for isolation of conditions other than hepatitis B? (i.e., not currently in use for hepatitis B patients?) Possible Answers (if applicable) Embedded/shared computer terminal (0 feet) < 3 feet 3 feet - 6 feet 6 feet or more Computer terminal is cleaned after each patient Computer terminal is cleaned after each shift Computer terminal is cleaned at the end of each day Facility does not have a policy/protocol for routinely cleaning the computer terminal Not Applicable Other Page 44 of 79
Dialysis Question # Question Infrastructure 15 Does the facility use hemodialysis machine Waste Handling Option (WHO) ports? (Note: the WHO port is a machine port used for prime waste.) Infrastructure 15a If yes, does the facility have a policy/protocol in place for disinfecting the WHO port? Infrastructure 16 Are patients in the facility ever "bled onto the machine" (i.e., where blood is allowed to reach or almost reach the prime waste receptacle or WHO port)? (Note: This practice is discouraged because it can result in patient blood loss and blood contamination of the environment.) Audits 1 Does the facility provide job-specific training to healthcare personnel (HCP) on infection prevention policies and procedures upon hire, prior to provision of care? Note: This includes those employed by outside agencies and available by contract or on a volunteer basis to the facility. Audits 2 Does the facility provide job-specific training to healthcare personnel (HCP) on infection prevention policies and procedures at least annually? Note: This includes those employed by outside agencies and available by contract or on a volunteer basis to the facility. Possible Answers (if applicable) Not Applicable Page 45 of 79
Dialysis Question # Question Audits 3 Does the facility assess and document competency (i.e., correct technique observed by a trainer) with job-specific infection prevention policies and procedures upon hire, prior to provision of care? Audits 4 Does the facility assess and document competency (i.e., correct technique observed by a trainer) with job-specific infection prevention policies and procedures at least annually? Audits 5 Does the facility routinely audit staff infection control practice (i.e., systematically collect and monitor data)? Audits 5a If yes, does the facility provide feedback on adherence to clinical staff? Possible Answers (if applicable) Not Applicable Page 46 of 79
Dialysis Question # Question Audits 6 Does the facility routinely use standardized tools for educating staff and/or assessing practice? (Select all that apply) HCP Safety 1 Does the facility provide post-exposure evaluation and follow-up, including prophylaxis as appropriate, to healthcare personnel (HCP) at no cost following an exposure event? HCP Safety 2 Does the facility track HCP exposure events, evaluate event data and develop/implement correction action plans to reduce incidence of such events? Possible Answers (if applicable) No standardized tools used AHRQ/CMS Checklist Tools Corporate Tools CDC Video: Preventing BSIs in Outpatient Hemodialysis Patients: Best Practices for Dialysis Staff CDC Approach to BSI Prevention in Dialysis Facilities (i.e., Core Interventions for Dialysis BSI Prevention) CDC Hemodialysis Central Venous Catheter Scrub-the-Hub Protocol CDC Dialysis Audit tools for Hand Hygiene CDC Dialysis Audit tools for catheter connection & disconnection CDC Dialysis Audit tools for catheter exit site care CDC Dialysis Audit tools for arteriovenous fistula and graft cannulation and decannulation CDC Dialysis Audit tools for injectable medication preparation and administration CDC Dialysis Audit tools for routine disinfection of dialysis station CDC Dialysis checklists for catheter connection & disconnection CDC Dialysis checklists for catheter exit site care CDC Dialysis checklists for arteriovenous fistula and graft cannulation and decannulation CDC Dialysis checklists for injectable medication preparation and administration CDC Dialysis checklists for routine disinfection of dialysis station Other Page 47 of 79
Dialysis Question # Question HCP Safety 3 Does the facility offer hepatitis B vaccine to personnel who may be exposed to blood or body fluids through their job duties? HCP Safety 4 Does the facility offer influenza vaccine to all personnel? HCP Safety 5 Does the facility conduct baseline tuberculosis (TB) screening of healthcare personnel? HCP Safety 6 Does the facility have work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits, or job status? HCP Safety 7 Does the facility educate healthcare personnel on prompt reporting of illness or job-related injury to supervisor and/or occupational health? Surveillance 1 Does someone in the facility know the facility's bloodstream infection (BSI) rate in NHSN or BSI standardized infection ratio (SIR)? Surveillance 1a If yes, does the facility share rate data with front-line clinical staff? Surveillance 2 Does the facility have a policy that mandates blood culture collection before antimicrobial administration any time a BSI is suspected? Possible Answers (if applicable) Not Applicable (data are not reported to NHSN) Not Applicable Page 48 of 79
Dialysis Question # Question Surveillance 3 Does the facility conduct routine screening of hemodialysis patients for hepatitis C antibody at the recommended interval? (on admission and 6 months thereafter for susceptible patients) Surveillance 4 Does the facility know how to report clusters of infections, adverse events, or a new hepatitis B/C case to public health? Surveillance 5 Does the facility have a system in place to communicate infection or colonization with a multidrug resistant organism (MDRO) to other healthcare facilities upon transfer? Respiratory 1 Does the facility have signs posted at entrances with instructions to patients with symptoms of respiratory infection to cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions? Respiratory 2 Does the facility provide a means for patients to perform hand hygiene in or near waiting areas? Respiratory 3 Does the facility provide space and encourage persons with symptoms of respiratory infection to sit as far away from others as possible? Respiratory 4 Does the facility provide tissues and notouch receptacles for disposal of tissues? Possible Answers (if applicable) Page 49 of 79