Creating and Maintaining an ACTIVE Infection Prevention Program

This article is written by Gordon C. Merrick, MBA, Project Manager, Advantage Healthcare Systems

One of the most common deficiencies listed in Medicare, state and accreditation surveys is not having an active infection prevention/control program. Surveyors not only want you to be able to talk the talk of infection prevention, they want to see how you have documented and analyzed your infection prevention activities. Below are some basic activities which can show inspectors that your center has an active infection prevention program:

Policies with references from nationally recognized organizations

As many of you know, surveyors often ask why you, say, soak something for 12 minutes in glutaraldehyde. The correct response is either "that's what the manufacturer recommends" or "that's what the CDC says." Your policies MUST have references from CDC, WHO, AORN or another nationally recognized organization. This can be time-consuming if you are writing your own policies.  Most consultants include references in their policies. There are resources on the CDC and WHO websites where you can obtain articles free of charge. AORN has lots of documentation available for members. Make sure you have references for things like sterilization, cleaning, hand washing and hand rubbing, etc. As often as you can!

Trained infection control coordinator
You must have a designated infection control coordinator who must be named in the center's minutes (with a job description outlining the duties of the ICC) and this person must have received some sort of training. There are a few websites that offer online IC training with varying degrees of thoroughness. An expensive three-day seminar is not necessary. When asked, staff must know who the ICC is! Most centers have realized that their ICC needs "training" but make sure it is documented (usually the web sites let you print out a "certificate" – it's corny, but effective) and happens annually.

An active IC program includes ongoing education. Your coordinator must be responsible for directing periodic in-services of all staff. Some surveyors want to include doctors. Some ideas include:

•    Performing annual in-services with physicians and having them sign that they have read and understand the center's IC, pain, emergency policies and that they agree to adhere to them.
•    Have staff watch on-line videos (on the popular video websites) and print out a screen capture of the first slide or page to put behind your sign-in sheet. There are lots of videos available.

The second aspect of education is ongoing awareness. You can achieve this by plastering posters around the Center reminding staff AND patients of the importance of good hand hygiene as well as reminding staff of safe injection practices. There are good posters on the CDC website for hand hygiene, "Cover your cough," "How To Handrub" and other things like that.

Confirmation and documentation of adherence to established hand hygiene guidelines
Since good hand hygiene is the most effective infection prevention tool, how can you prove that your staff has good hygiene on an ongoing basis? By documenting that you observe them, of course! Do it often enough that you observe each employee quarterly. If you are small, that could mean documenting the observation only once a quarter. For larger centers, it may mean doing it weekly so you can catch all the per diem nurses and doctors. And don't skip anesthesia providers! You can use the CMS Interpretive Guidelines Infection Control worksheet as a basis for your evaluation.

Confirmation and documentation of adherence to established safe injection practices
The CDC has their One and Only Campaign and this is a great resource for observation tools (and posters and in-service material as well). Again, the way you prove that you adhere to the nationally recognized safe injection practices is to document that you observe staff. The most common offense we have found? Anesthesia providers not wiping IV ports prior to use (this from the CMS worksheet). Again, the size of your staff will determine how often you need to document these observations. Of course, during your quarterly/semi-annual QI meetings, you will review and discuss the findings of these observations. Again, don't have your Infection Control Coordinator documenting breaks in safe practices and ignore that. Document what action took place (e.g., education, physical change) and discuss in your minutes.

Using only appropriate cleaning agents
You must clean your center with an EPA-registered bacteriacidal/fungicidal/germicidal/tuberculocidal. And avoid any wipes with a TB-kill time of greater than five minutes. No surveyor will believe that you keep surfaces wet for seven and 10 minutes. They know you need to turn the bed and get to the next patient if you are to remain profitable. The fine print is pretty tortuous on those wipes containers. We always suggest that you note, with a large felt marker, the TB-kill time on each container of wipes. It's a reminder and informs the surveyors that you have an ACTIVE infection prevention program since everyone knows how long it takes to kill TB spores. If your cleaning crew brings in the cleaning agents, make sure they are EPA-registered (look for fine print on the front label that says EPA Reg No. XXXXX) agents and that they are bacteriacidal/fungicidal/germicidal/tuberculocidals. If not, replace them.

Querying physicians

Whether you query surgeons monthly or quarterly, make sure you ask them if they had any infections, return to OR, admit to ER within X days, bleeders, etc. And don't ignore the results! There is nothing worse than a surveyor finding a form that said the surgeon reported an infection and the paper was filed away in a binder neatly with no response. Really bad. Staff must be able to verbalize the procedure for reporting an infection, and know what is a reportable disease (you can find a list of reportable diseases in your area by going to your local department of health website). As with most data, it's a good idea to trend results. (And trending just means putting the months across the top of the columns and the unwanted occurrences on the rows and writing in all the zeroes.)

Analyze data and the program
Often, the hardest thing is to convert what you see, hear and document into data. So, make sure that you have data available on the number and percentage of infections/incidents. Convert your surgeon queries to percentages. And then discuss the results in minutes. Discuss your sterilization and biological indicator results, even if there are no outliers. Document your analysis of the effectiveness of your IP program in the minutes of your Governing Body meetings at least annually. (We recommend using a template for your minutes so you don't forget items.) Of course, an analysis of the effectiveness of the center's infection prevention program must include a review of objective data, not general feelings. Did you get better? Worse? What percentage of bad hand hygiene activities were observed? How many breaks of safe injection practices? Overall infection rate? Trend EVERYTHING you have time to trend.

In closing
Like most things in the accreditation/certification world, it is not the end of the world if there IS an untoward event. The important thing is how you as a staff and a center, as a whole, react to the event. This is the subject of an entirely different article, however.

Documentation of infection control activities is often about finding the right form to document your activity and following up on what you find/observe. Just like QA/PI activities, you can get dizzy with the enormity of the entire subject, so break it down into pieces and address each piece directly. Then the large, amorphous beast of Infection Prevention becomes a series of smaller, not-as-frightening tasks. Finding the TIME to find the right form isn't always easy, but maybe if you enlist the help of a young, internet-savvy tech or front office person to help search the internet, you can find some good starting points.

More Articles on Infection Control:

Making Hand Hygiene Personal: Caregiver-Specific Data to Improve Compliance

Patient Safety Tool: Severe Sepsis Audit Tool

7 Steps to Reach Healthcare Performance Measure Potential

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