Infection Control and Prevention On-site Review Tool Hospitals Section 1.C. Systems to Prevent Transmission of MDROs Ask these questions of the IP. 1.C.2 Systems are in place to designate patients known to be colonized or infected with a targeted MDRO including C. auris and to notify receiving units and personnel prior to movement of such patients within the hospital. 1.C.4 The hospital can provide a list of target MDROs including C. auris. te: Hospitals should able to provide a list of MDROs including C. auris that are targeted for infection control because they are epidemiologically important (e.g., MRSA, VRE). Please refer to CDC s Guideline for Isolation Precautions for criteria that may be used to define epidemiology important organisms: http://www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf. 1.C.7 The hospital has evidence of an established system(s) to ensure prompt notification to the Infection Control Officer when a novel resistance pattern or novel organism based on microbiology results is detected. 1.C.8 Patients identified as colonized or infected with target MDROs including C. auris are placed on Contact Precautions. te: This does not imply that hospitals are required to perform active surveillance testing to detect MDRO colonization among a specific subset or all patients. Describe how surveillance is done for target MDROs in real or near-real time? How are individual patients with targeted MDROs identified or flagged so appropriate precautions can be applied at readmission? Section 1.D. Infection Prevention Systems, and Training Related to Personnel
1.D.11 Personnel competency and compliance with job specific infection prevention policies and procedures are ensured through routine training and when the Infection Control Officer has identified problems requiring additional training. Describe how the facility ensures personnel competency with hand hygiene, use of PPE, and cleaning and disinfection of equipment? Includes both clinical staff and Environmental Services staff. Section 2.A. Hand Hygiene (Observation) Hand hygiene is performed in a manner consistent with hospital infection control practices, policies, and procedures to maximize the prevention of infection and communicable disease including the following: 2.A.1 Soap, water, and a sink are readily accessible in appropriate locations including, but not limited to, patient care areas and food and medication preparation areas. te: Medications should not be prepared near areas of splashing water (e.g. within 3 feet of a sink). Alternately when space is limited, a splash guard can be mounted beside the sink. 2.A.2 Alcohol - based hand rub is readily accessible and placed in appropriate locations. The locations may include: Entrances to patient rooms, at the bedside, in individual pocket - sized containers carried by healthcare personnel, staff workstations, and/or other convenient locations. 2.A.4 Personnel perform hand hygiene: after contact with the patient, after contact with blood, body fluids, or visibly contaminated surfaces, after removing gloves. Ask facility staff when to use alcohol based hand rub versus soap and water.
2.A.5 Personnel perform hand hygiene using soap and water when hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus. te: In most other situations, alcohol - based hand rub is preferred. 2.A.6 Personnel do not wear artificial fingernails and/or extenders when having direct contact with patients at high risk of infection. Ask the IP how hand hygiene adherence is monitored and how feedback is provided. Section 2.C. Personal Protective Equipment/Standard Precautions (Observation) 2.C.1 Supplies for adherence to Standard Precautions using personal protective equipment (e.g., gloves, gowns, mouth, eye, nose, and face protection) are available and located near point of use. 2.C.4 Gowns are worn to prevent contamination of skin and clothing during procedures/activities where contact with blood, body fluids, secretions, or excretions could occur. 2.C.5 Gowns and gloves are removed and hand hygiene is performed: before leaving the patient s environment (e.g. including moving to another patient). Section 2.D. Environmental Services (Observation terminal and daily cleaning of patient rooms) (Ask questions of the IP, clinical staff, and/or environmental staff, as appropriate.) 2.D.1 During environmental cleaning procedures, personnel wear appropriate PPE to prevent exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection).
2.D.2 Environmental surfaces in patient care areas are cleaned and disinfected, using an EPA - registered disinfectant registered for use in health care facilities on a regular basis (e.g., daily), when spills occur and when surfaces are visibly contaminated. For C. difficile and C. auris, facility uses products labeled as effective against C. difficile. te: High - touch surfaces (e.g., bed rails, over - bed table, bedside commode, lavatory surfaces in patient bathrooms) should be cleaned and disinfected more frequently than minimal - touch surfaces. 2.D.3 After a patient vacates a room, all visibly or potentially contaminated surfaces are thoroughly cleaned and disinfected and towels and bed linens are replaced with clean towels and bed linens. 2.D.4 Cleaners and disinfectants, including disposable wipes, are used in accordance with manufacturer s instructions (e.g., dilution, storage, shelf - life, contact time). 2.D.5 Separate clean (laundered if not disposable) cloths are used to clean each room and corridor. 2.D.6 Mop heads and cleaning cloths are laundered at least daily using appropriate laundry techniques (e.g., following manufacturer instructions when laundering microfiber items). Is environmental cleaning and disinfection routinely monitored in your facility? (ask IP these questions) By whom? If so, how do you measure effectiveness? If monitored, is feedback provided to staff? Which cleaning products are used in your facility, under what circumstances are each of them used, and what is the contact time for each? te: Ask infection preventionist(s), clinical staff (e.g. nurses), and environmental services. Wait to ask environmental services staff until after you watch at least one of them clean a room. (Infection preventionists should at a minimum know to use a product with a claim for Clostridium difficile spores for C. auris. If caring for patients with C. auris, then clinical staff and environmental services staff should also know to clean rooms of those patients with products
with a claim for C. difficile spores. Environmental services staff and clinical staff should know the contact time for the products they use and which are appropriate for C. difficile.) Observe daily and/or terminal cleaning and disinfection of a room housing a person with C. auris if possible, or otherwise housing a person with C. difficile, or otherwise housing a person on Contact Precautions, or otherwise any room) -Appropriate product used (EPA-registered hospital grade disinfectant; claim for Clostridium difficile spores for rooms of patients with Clostridium difficile or C. auris) -High-touch surfaces/objects (e.g. bed rails, over-bed table, bedside commode, surfaces in patient bathrooms) are cleaned and disinfected at least daily and when visibly soiled -Appropriate contact time for product is followed Links with (Source: CMS ICWS 4.F.11) and (Source: CMS ICWS 2.D.2) After observation of cleaning and disinfection, ask environmental services staff how many rooms they are expected to clean in what amount of time. Response should be consistent with the time taken to clean the room observed and with the contact time of the product used. Reprocessing of non-critical items is accomplished in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease including the following: 2.D.14 Reusable noncritical patient care devices (e.g. blood pressure cuffs, oximeter probes) are disinfected on a regulator basis (e.g. after use on each patient, once daily, or once weekly) and when visibly soiled. Which cleaning products do you use for reusable noncritical items, under what circumstances are each of them used, and what is the contact time for each? te: Ask infection preventionist(s), clinical staff (e.g. nurses), and environmental services. Answers should be consistent to avoid confusion about who cleans what equipment.
2.D.15 For patients on Contact Precautions, if dedicated, disposable devices are not available, noncritical patient-care devices are disinfected after use on each patient. 2.D.16 There is clear designation of responsibility for disinfection of reusable noncritical patient-care devices. Who is responsible for cleaning equipment that is shared between patients (e.g. blood pressure cuffs, computers on wheels, mechanical lifts, ventilators, PT/rehab equipment)? (Ask IP, frontline clinical staff, and environmental services staff answers should be consistent and cover all equipment) Follow up question to staff responsible for cleaning: How such equipment is to be cleaned and disinfected? 2.D.17 Manufacturers instructions for cleaning noncritical medical equipment are followed. Section 4.C. Ventilator/Respiratory Therapy The facility considers ventilators a high touch surface area when in use and assesses the frequency of cleaning during use. Section 4. E. Point of Care Devices (e.g. Blood Glucose Meter, INR monitor) 4. E.3 Finger stick devices are not used by more than one patient. te: This includes both the lancet and the lancet holding device 4. E. 4 If used for more than one patient, the point-of-care testing device (e.g. blood glucose meter, INR monitor) is cleaned and disinfected after every use according to manufacturer s instructions. te: if manufacturer does not provide instructions for cleaning and disinfecting, then the device should not be used for more than one patient. Section 4.F. Isolation: Contact Precautions (Observation) 4.F.1 Patient with known or suspected (C. diff or C. auris) infections or with evidence of syndromes that represent an increased risk for contact transmission are placed on Contact Precautions.
4.F.2 Gloves and gowns are available and located near point of use. 4.F.3 Signs indicating patient is on Contact Precautions are clear and visible. 4.F. 4 Patients on Contact Precautions are housed in single patient rooms when possible or cohorted based on a clinical risk assessment. Ask how single rooms are assigned. 4.F.5 Hand hygiene is performed before entering patient care environment. te: Soap and water must be used when bare hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected candida auris, C. difficile or norovirus. In most other situations, alcohol-based hand rub is preferred. 4.F.6 Gloves and gowns are donned upon entry into the room or cubicle. 4.F.7 Gloves and gowns are removed and discarded, and hand hygiene is performed before leaving the patient care environment. 4.F.8 Dedicated or disposable noncritical patient-care equipment (e.g., blood pressure cuffs) is used, or if not available, then equipment is cleaned and disinfected prior to use on another patient according to manufacturers instructions. 4.F.9 The hospital limits the movement of patients on Contact Precautions outside of their room to medically necessary purposes only. 4.F.10 If a patient on Contact Precautions must leave their room for medically necessary purposes, there are methods followed to communicate that patient s status and to prevent transmission of infectious disease.
Is PPE adherence measured? If yes, how is feedback returned? (Ask IP) What types of PPE would be used for: Droplet Contact Airborne te: Ask clinical staff, e.g. CNAs and environmental services. When or where (if at all) may staff enter a room with a patient on Contact precautions without donning PPE? Example of unacceptable answers: immediately after room cleaned, if you don t expect to touch the patient. (Acceptable answers will depend on facility policy.) Z. Interfacility Communication Can be in HERDS Z.1 The hospital has a process and can demonstrate evidence that communication of patient infection, colonization or known history of positive culture with multidrug-resistant organism, C. difficile, or other epidemiologically important organism (e.g. scabies) is prominently indicated to receiving provider before or at the time of transfer? Z.2 The hospital has a process and can demonstrate evidence that communication of the presence of clinical signs or symptoms of potentially communicable diseases (e.g., vomiting, diarrhea, cough) is sent to receiving provider before or at the time of transfer? Z.3 The hospital has a process and can demonstrate evidence that communication of the rationale and use of transmission-based precautions/ppe is sent to receiving provider before or at the time of transfer (e.g. C difficile with diarrhea)? Z.5 The hospital has a process for and can demonstrate evidence that they have sent additional information about potentially transmissible infections, resistant organisms, and antibiotic use to the receiving provider, as soon as available, if missing or unavailable at the time of patient arrival at the receiving provider. Z.6 The hospital has evidence that essential information about potentially transmissible infections, resistant organisms, and antibiotic use is reviewed and addressed (e.g. transmission-based precautions) at the time of patient arrival from a transferring facility (e.g. nursing home)? What does your facility do if such documentation is not received? If your facility admits a patient from a sending facility and detects a potentially transmissible infection, does it inform the sending facility?
te any general breaches of Infection Control practice not otherwise captured by this tool: