1 of 19 Crystal Run Healthcare 2012 Plan Revised May 14, 2012 This plan has been developed by the Committee with input and collaboration from the following: Nursing Leadership Departmental Management Medical Director and Departmental Directors A risk assessment is a component of this plan. Crystal Run Healthcare s Plan is formally reviewed annually with additional revisions as necessary when changes occur in the elements that affect risk.
2 of 19 Purpose Plan The purpose of the Program is to ensure the organization has a functioning, coordinated process in place to reduce the risk and transmission of endemic, epidemic, and clinic acquired infections in both patients and health care workers. This is accomplished through the coordinated efforts of the medical staff, administration, and the governing board. These efforts include the following activities: Ongoing surveillance through chart review and data collection Investigation of outbreaks Monitoring of compliance with hand hygiene, isolation procedures, and methods to reduce the spread of disease Reporting data to local health departments and agencies, in accordance with NYS law Development of policy to address sterilization of equipment, influx of patients, and infectious waste management Active monitoring of employee disease and illnesses Employee vaccination program in accordance with the Center for Disease and Prevention Annual flu vaccine program for all staff and medical staff members Staff education on infection control and prevention practices, including annual Education as per OSHA This process is overseen by a qualified practitioner who, in addition to conducting surveillance, is responsible for analyzing and reporting such data internally and externally. Goals & Objectives The goals and objectives of the Program of Crystal Run Healthcare, LLP are accomplished by the following: Risk Prioritization Limiting unprotected exposures to pathogens Limiting the transmission of infections associated with procedures Limiting the transmission of infections associated with the use of devices, medical equipment, and supplies Improving hand hygiene compliance
3 of 19 Improving vaccination rates, specifically for influenza Evaluating the scope of the program for risks associated with new services or sites of care, which may impact the practice, staff, visitors, and community Risk Prioritization A formalized risk assessment is conducted at least annually to determine risk associated with delivery of care at Crystal Run Healthcare LLP. Collection, consolidation, and analysis of data lead to determinations regarding areas of priority. Action plans are then developed to accomplish the set goals for each risk. Action planning is completed within a multi-disciplinary setting. Communication An integral part of the success of the Program is communication. Communication is inclusive of the daily interaction between the Manager, and both internal and external stakeholders in regard to the Program. It expands to include all pertinent federal and state regulations pertaining to as required by the Practice and law. Communication is necessary to provide follow up information for local or state agencies with regard to certain communicable diseases, all done within the scope of protection of patient s right to confidentiality. An additional element of communication is between Crystal Run Healthcare LLP and any facility in which patient transfer occurs, also including internal transfers. It is incumbent upon the Practice to fully communicate information regarding the potential infectivity of patients to all receiving parties. In the event such critical information becomes known after the transfer, the responsibility lies with the Manager to notify the receiving facility as soon as this information is available. Program Description The program is based on principles of surveillance, wherein the Manager, in collaboration with the committee members, collect, consolidate, analyze, and evaluate information regarding the control and prevention of infection specific to the ambulatory care setting. The team examines real and potential risks to transmission, selects and implements the best plan to minimize adverse outcomes, monitors and evaluates process outcomes, and institutes revisions as needed.
4 of 19 1. Surveillance: Surveillance is completed to determine the incidence of infection within the organization and identify areas in need of investigation. Data is collected on the specified areas of interest, from the following sources: a. Focus Surveillance by chart Review on: i. Multi-Drug Resistant Organisms ii. Device Related iii. Employee Exposures iv. Wound Cultures v. Blood Cultures vi. Perioperative Hair Removal vii. Nosocomial s / Procedure-related infections viii. Influenza ix. Sexually Transmitted Diseases b. Reporting by laboratory for culture and drug sensitivity or resistance c. Surveillance rounds to include: i. Hand hygiene and available products in all patient care areas ii. Proper disposal of waste iii. Reprocessing procedures, testing, and documentation in accordance with Crystal Run Healthcare LLP policy iv. Laminar flow hoods cleaning, and documentation v. Proper cleaning and disinfecting of instruments and clinical equipment vi. Expiration date monitoring vii. Environment of care Surveillance data shall be reviewed and revised as necessary based on changing demographics of our patient population, needs of the Practice/staff, and current recommendations by state and federal agencies. This ongoing review is required to continue to meet the needs of Crystal Run Healthcare LLP. The review shall be facilitated by the Manager, with involvement by all departments, and final approval by the Committee. 2. Investigation of Outbreaks Once a significant increase in rate of disease or infection is detected, the Manager notifies the Director of Quality and Patient Safety and the Chief Medical Officer. At that time it is determined whether a formal investigation is needed. The role of the Manager is to lead the investigation, collect all pertinent information and report to the Director of Quality and Patient Safety and the Chief Medical Officer. If required, the
5 of 19 Manager will report to, and request assistance from the Department of Health that oversees the county in which the outbreak occurred. a. Collection of data (reported or by means of active surveillance) b. Analysis of data, including statistical and epidemiological methods c. Formalization of cause d. Notification to staff, medical staff, and appropriate agencies (if required) e. Formalization of preventions (vaccination, interventions, procedures) for further and or future outbreaks f. Education of staff, medical staff, and administration g. Evaluation 3. Staff Vaccinations/Immunizations, and Testing a. Immunizations The Manager, and the Employee Health Department work collaboratively to evaluate, update, and revise guidelines or requirements for employee vaccinations as current guidelines mandate. Such vaccinations may include, but not limited to: 1. Measles, Mumps, Rubella 2. Tetanus, Diptheria, Pertussis 3. Varicella 4. Hepatitis B b. Annual Influenza Vaccination Program i. Influenza prevention is hosted annually in accordance with CDC guidelines ii. CRHC offers free vaccination to all employees and strongly encourages vaccination. Vaccine is provided at accessible times and sites iii. Declination form available if an employee requires/needs exemption iv. Vaccination rates reported and monitored at the conclusion of the annual program by the Committee, Employee Health, and ICP c. TB Skin testing Initial and annual testing for TB will be conducted through employee health by means of a PPD test and questionnaire, and radiographic examination, as needed in accordance with CRHC policy. 4. Prevention of Exposure to Staff, Visitors, and Patients
6 of 19 a. Safety Devices i. The department, along with Employee Health, work together to provide safe equipment for the prevention of blood borne pathogen, and respiratory exposures for employees in the Practice. ii. All needle safety devices are evaluated annually for efficacy and safety iii. Respiratory protection provided throughout organization in all clinical areas and in PPE kits. Fit testing for N- 95 masks provided for employees that are at high risk of being in contact patients requiring airborne precautions (tuberculosis) b. Isolation i. Isolation precautions according to CDC guidelines are accessible to providers and employees on the Crystal Run Healthcare Intranet and through ii. Crystal Run Healthcare specifies which level of precautions are necessary for the patient on isolation and are categorized as follows: 1. Standard for all patients regardless of additional precautions required 2. Contact 3. Droplet 4. Airborne c. Cover Your Cough Campaign: As recommended by the CDC instituted facility-wide. Flyers, posters, hand hygiene supplies and respiratory protection available in all clinical areas and at front desk for patients or staff. 5. Cleaning, Disinfecting, and Sterilization a. Sites that perform sterile processing functions report deficiencies in processing equipment. The Manager investigates all discrepancies and determines the need for further intervention. Surveillance activities include routine review of sterilization logs and procedures. The ICP routinely reviews sterilization and disinfectant procedures. b. Clinical equipment is cleaned or disinfected according to Crystal Run Healthcare policy c. Laminar flow hood cleaned daily per Crystal Run Healthcare Policy d. processes for Radiology Services Department 6. Hang Hygiene a. Hand Hygiene is the most effective method of preventing disease transmission. Staff is formally educated at least annually by the Manager and Education Department on the importance of hand hygiene and on recommended technique put forth by the CDC, and during monthly site-infection control rounds.
7 of 19 b. Hand Hygiene and washing compliance is monitored by the Manager. Data collection and analysis of compliance is reported to the Committee. Compliance is achieved by implementation of hand hygiene awareness programs, product availability, recording observations from a quantitative and qualitative perspective, and staff education. c. Penny for Your Thoughts Campaign 7. Program Effectiveness The Plan and corresponding program is reviewed at least annually, revisions implemented as required. Review and evaluation of the program is discussed within the multidisciplinary setting of the Committee.
8 of 19 Risk Assessment Factors: Risk Assessment: Geographic location and community environment Middletown, Rock Hill, Goshen, Newburgh, Warwick, Monroe, and Harriman are located in lower New York State. The region is adjoined by New Jersey to the south and is approximately 50 miles north of New York City. When looking at the wellbeing of patients served by Crystal Run Healthcare LLP, infectious diseases are a key health status indicator. Communicable diseases unique to this region of New York: Lyme Disease- caused by the bacterium Borrelia burgdorferi and is transmitted by the bite of infected blacklegged ticks. Peak season is usually May through August. Pertussis- Over the past year, local health department has identified an increase in Pertussis. Caused by Bordetella pertussis, this bacterium is easily transmitted and highly communicable. Vaccine preventable Sexually Transmitted Diseases- to include Chlamydia trachomatis, the bacteria that causes Chlamydia, and Neisseria gonorrhea, the bacteria that causes Gonorrhea, and Treponema pallidum, the cause of Syphilis Characteristics that Increase Risk Rural and suburban areas Sparsely to densely populated areas Varying socioeconomic status Immigration from other countries Medically underserved and uninsured may delay treatment for illness Crystal Run Healthcare LLP provides care in both Orange and Sullivan counties and serves patients in nearby regions. Date: Yr. 2012 Characteristics that Decrease Risk The local health department communicates routinely with CRHC. Based on conversations with the health departments, both physicians and the ICP within the organization report specific disease data Use of standard and isolation precautions, as needed, in the Practice when providing patient care Implementation of programs to monitor and address risks of infection STD education in public schools and during visits to physician for at-risk age group
9 of 19 Risk Assessment Factors: Care, treatment, and services provided Radiology: MRI Characteristics that increase risks Volume of patients Limited access Zone IV Limitations on cleaning equipment permitted in various zones Cleaning is responsibility of staff Knowledge deficit related to cleaning techniques Surgical Reprocessing Reprocessing of instrumentation by personnel Equipment failure in sterilization process Instrumentation turnaround time Loaned instrumentation Glutaraldehyde use Yr: 2012 Characteristics that decrease risk Hand hygiene compliance Current cleaning practices in place for MRI area with equipment Pillows and positioning pads have waterproof covering and disposable covers Approved cleaning agents and processes for non-critical equipment. Cleaning policy with checklist for staff completion New hires receive orientation to unit with departmental specific training Certification encouraged Follow AAMI, APIC, AORN, TJC, CDC, OSHA guidelines Biological spore and Bowie dick daily testing, autoclave maintenance log, internal chemical indicators with each load, and every pack. Quality monitoring by ICP Cases scheduled in accordance with reprocessing work flow Policy on loaned instrumentation Glutaraldehyde monitoring semi-
10 of 19 Urgent Care Departments 36,968 patients are treated in the Urgent Care at 155 and 21,015 at the Rock Hill location in 2011 Infectious patients who present to Urgent Care (T.B, Meningococcal Meningitis) Potential for presentation of highly infectious diseases such as Pertussis and Influenza Minor injuries and illness treated Pediatric Department Infectious diseases (i.e. RSV, Pertussis, gastroenteritis, Influenza) Adolescent STD exposure Vaccine administration Tdap and influenza vaccines offered for employees Infusion Centers Administration and preparation of chemotherapy and biotherapy Immunocompromised annually. Cidex spill kit. Patients are triaged to designate level of care required Patients suspected of having an airborne infectious disease are isolated and the exam room is cleaned per CRHC policy Standard precautions for all pt Follow-up on all exposures of infectious disease Physicians are kept informed of any significant epidemiological concerns within the community Participation in preparedness planning Standard precautions for all patients Transmission based precautions as required Patient/parent education: STD Vaccine schedules, standing orders Aseptic technique in preparation and administration of parenteral medications Preparation of medications in Laminar flow hood and
11 of 19 patients Peripheral intravenous, and central line venous access devices Tdap and influenza vaccines offered for employees administered within 1 hour Cleaning and disinfection of Laminar flow hood and surfaces Peripheral lines monitored and changed Central line access with sterile non-coring Huber needle using sterile technique, sites monitored High, or Medium Risk High Volume Patient Safety Goal: Hand Hygiene Immunocompromised patients related to medical devices related to infected patients/staff related to procedures ANALYSIS OF INFECTION PREVENTION AND CONTROL DATA Intervention Compliance with hand hygiene Routine changing of IV line, and monitoring for signs of infection Aseptic admixing of medications, specifically chemotherapeutic and biotherapeutic drugs Compliance with device cleaning and disinfection procedures related to instrumentation and surfaces Compliance with standard precautions, and use of isolation Compliance with OSHA Bloodborne pathogens program. Use of needle protection devices Compliance with policy on prevention of SSI Risk Assessment: The risk assessment is determined by plotting the events with risk of negative impact (e.g. specific type of infection) against the likelihood that it will occur. The risk of negative impact or outcome is placed in on of three categories: minimal (1), moderate (2), and high impact (3). The likelihood of the event occurring is placed in the following category: never (0), improbable (1), unlikely (2), likely (3), very likely (4). Adding the risks by the likelihood of occurrence scores an event. Priority is based upon the score, higher scores have first priority.
12 of 19 RISK PRIORITIZATION IN DESCENDING ORDER Impact Probability Score Priority Risk High (3) Likely (3) 6 1 Cross contamination resulting in nosocomial infection from noncompliance with hand hygiene policies High (3) Likely (3) 6 2 Potential spread of infectious diseases related to infectious patients/staff High (3) Unlikely (2) 5 3 Risk of transmission of infections associated with the use of equipment and medical devices during procedures, including non-critical equipment High (3) Unlikely (2) 5 4 Unprotected exposure to blood borne pathogens or OPIM Moderate (2) Unlikely (2) 4 5 Potential for development of Procedural Site High (3) Improbable (1) 4 6 Risk of transmission of infection associated with parenteral medication preparation, and administration FOR EACH PRIRITIZED RISK, GOALS, OBJECTIVES, STRATEGIES, AND PROCESSES OF IMPLEMENTATION ARE IDENTIFIED Priority/Score Goals Objective Strategies Implementation 1. Six Cross contamination resulting in nosocomial infection from noncompliance with hand Increase compliance with hand hygiene policies Increase hand hygiene compliance and reach and maintain at least 90% compliance Review appropriateness of approved hand hygiene products Ensure product availability Educate staff Penny for your Responsible Party Nursing Leadership Manager Staff Timeframe Ongoing 2012 year Penny for your thoughts survey annually Method of Evaluation Data collection and analysis with comparison to any benchmark data available Reporting at Committee meeting Observation and recording during
13 of 19 hygiene policies 2. Six Potential spread of infectious disease related to infectious patients Limit spread of infectious disease within practice by use of standard precaution, vaccination. And proper surface disinfection Improve rate of flu vaccination Improve number of declination forms on file for those declining rate Practicewide Noncritical surfaces are disinfected per policy after each observed patient visit Reach 55% influenza vaccination rate, practicewide for 2012-2013 flu season Of those employees that decline the flu vaccine, reach 100% of declination thoughts survey Observe & report departmentspecific compliance Standard precautions for all patients, triage & isolate as needed Safe transport of infectious patients within facility/bring services to pt Supply of Sani-Wipes in each exam room and education on proper use Cover your Cough campaign Influenza vaccine program Appropriate availability of Clinical Staff Triage staff Front desk staff Preparedness multidisciplinary team ICP Housekeeping 2012 Year practice rounds Surveillance Observation Education during Rounds Monitoring of available supplies Quarterly reporting to IC committee
14 of 19 3. Five Risk of transmission of infections associated with use of medical devices and instruments. Minimize risk of infections associated with the use of medical devices and equipment forms on file Zero infections related to the use of medical equipment or devices, within CRHC hand hygiene products and respiratory precaution supplies Annual education and as needed Public reporting Compliance with IC policies related to cleaning, disinfecting, and sterilizing devices and equipment Compliance with departmentspecific policies related to procedures and use of medical devices MRI Cleaning policy and checklist Ongoing staff ICP Department managers All clinical personnel Radiology personnel EOC Committee 2012 Year Occurrence reporting Observation Surveillance Quarterly sterilization reports to IC committee
15 of 19 4. Five Unprotected exposure to pathogens throughout the organization 5. Four Potential for development of Procedural Site Limit & minimize unprotected exposure to bloodborne pathogens Minimize risk of infection related to invasive procedure Zero needle sticks within Practice Zero healthcare acquired infections related to invasive procedures education Appropriate use of PPE Compliance with federal and local requirements regarding blood borne pathogen education and policies for protection Exposure Plan Cleaning and disinfection of equipment Safety devices Compliance with organizational policy related to proper cleaning and disinfection of medical devices and equipment Aseptic technique Hand Hygiene Clinical Personnel Department managers and directors Manager Employee Health Housekeeping ICP All clinical departments All clinical staff 2012 year Ongoing surveillance during 2012 and comparison with historical data Occurrence reporting Annual reporting of exposures throughout the practice Monthly tabulation by Employee Health Annual review of safety devices Annual review of BBPECP Occurrence reporting Surveillance Reports to Committee
16 of 19 6. Four Risk of transmission of infection associated with parenteral medication preparation, and administration Minimize risk of infection associated with medication administrati on Zero infection occurrences related to administrati on of parenteral medications Compliance with preprocedural antibiotic regimen and hair removal, as ordered Annual staff education Compliance with IC & nursing policies on medication administration Aseptic technique Education Occurrence reporting for accurate documentation Nursing Radiology Infusion Centers Urgent Care ICP Managers Pharmacy 2012 Year Occurrence reports Observation Surveillance Quarterly reports to IC committee Inter-departmental communication Important Aspects of Care Patient Safety Prevention of Nosocomial infections INFECTION CONTROL SURVEILLANCE PLAN Indicators Benchmarks Data Source Data Sample Collector Hand Hygiene Other Ambulatory Care Centers Observations of patient encounters control committee members Observation of opportunities during Collected/Tabulated/Reported Hand hygiene Ongoing Tabulated and reported Yearly
17 of 19 related to poor hand hygiene Medium Risk High Volume Problem Prone Patient, visitor, and staff safety Needle stick prevention High Risk High Volume Bloodborne pathogen exposure rates The Joint Commission standards In-house baseline data Baseline data are past exposures Soap and alcohol usage Reports from observations Penny for your thoughts survey Employee Health Occurrence reports Employee Health, control, Management rounding coupled with product measurement in specific areas. Review Policies Observe for compliance with use of safety devices and PPE Ongoing practice and observation Employee Health tabulated and reports on exposures yearly, reported in Environment of Care,, and Quality and Patient Safety Committees Patient Safety Risk of transmission of infections s/p procedures from use of medical Positive cultures from procedures or medical equipment National standards found in the review of current literature Positive lab cultures, referrals from nurses, physicians Manager Microbiology Management Institute additional education as needed Chart review for all positive cultures, internal and external reporting as required Ongoing practice and observation Reporting any recalls and/or actions taken regarding possible exposures to contaminated instruments, equipment, and medical devices
18 of 19 equipment, medical devices, and surfaces High Risk High Volume Patient Safety Risk of transmission of infection related to invasive procedure High Risk Medium Volume Patient Safety Risk of transmission of infections s/p intravenous access High Risk High Volume Positive cultures, clinical presentation of infection, occurrence reports rates and occurrence reports r/t IV infusion and medication compounding National Standards, Professional Organizations Target for zero National Standards found in review of the literature policies related to cleaning, disinfection, and sterilization of medical equipment Positive lab cultures, referrals from physicians or nurses, infectious disease consultations, occurrence reports Positive lab cultures Referrals from clinical staff policies and directors of specialty departments Manager Manager Microbiology Management Clinical Areas Recalls for equipment and medical devices Verification of surface disinfection practices Chart review for all positive cultures, internal and external reporting as required Education as needed and annually All positive lab cultures undergo chart review Device Related: Quarterly Reported and tabulated quarterly Ongoing observation and surveillance Reporting of any positive infections post-procedure Device Related: Quarterly Reported and tabulated quarterly Ongoing practice and observation IV site and blood stream: Quarterly Reported and tabulated quarterly
19 of 19 Patient Safety and Prevention Minimize risks related to influenza and community acquired pneumococcal disease Medium Risk Patient Safety and Prevention Minimize impact to the organization based on influx and emergence of infectious disease in the community Vaccination rates: employee and patient Positive Pertussis diagnosis Review of community Pneumonia and Influenza morbidity and mortality data DOH and community data related to aseptic technique Medical Records CDC NYS DOH Pertussis outbreak protocols Urgent Care Infusion Centers Manager Urgent Care Director Employee Health Pharmacy Manager Clinical Staff Urgent Care Director and Practice Managers Vaccination rates, morbidity and mortality reports Public health data Vaccination rate: Quarterly and annually Reported and tabulated quarterly for period designation by CDC criteria through Crystal Run Healthcare reports for the practice and the providers of care Health Department reports Clinic reports Quarterly as needed Reported and tabulated quarterly Medium Risk