INSTRUCTIONS:

The infection prevention program (IPP)plan should include descriptions of:

  • Use of evidence based guidelines, including documentation of those specific guidelines
  • Surveillance activities (including surveillance and quality improvement indicators) and how the findings will be evaluated
  • Process for investigating outbreaks of infectious diseases
  • How all infection prevention components, functions, and activities are integrated
  • Method used to communicate concerns, and program findings to LIPs, staff, visitors, patients, families.
  • Method to report infection control related concerns externally to other organizations

The IPP plan should address the following CMS questions:

  • Does the ASC have a system to actively identify infections that may be related to procedures performed?
  • How does the ASC obtain this information?
  • How is supportive documentation confirming the tracking activity maintained?

The Infection Control Committee (ICC):

  • The ICC should review all risk assessment documents and approve of the findings
  • The ICC needs to be involved with the annual program evaluation
  • The ICC needs to approve of IPP annual goals and plan

Results of annual evaluation and planning should be shared with all staff.At least annually and when risks significantly change:

  • Evaluate the plans successes, shortcomings, and barriers
  • Prioritize risks, plan goals and activities to mitigate the risks
  • Use findings to revise the plan

PROGRAMRISK BACKGROUND

The [insert your facility name]ASC performs over [insert #] surgical procedures each year. The Infection Prevention Program (IPP) at the ambulatory surgery center provides service to a patient population that includes the following patient populations:

[Insert your scope of services. Example:

  • surgical specialties, including orthopedic, plastics, and gynecology

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  • adult oncology patients

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  • general medicine patients

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  • women’s health
  • pediatric patients between 4-18 years of age]

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The IPP is staffed by one 0.20 FTE Infection Preventionist. [Note: Include the FTE percentage worked by the designated licensed Infection Control professional]. The Infection Preventionist is an Oregon licensed RN, who is certified in Infection Control (CIC) and a member of the Association of Professionals in Infection Control (APIC) national and local chapters. The designated Infection Preventionist will:

  • Provide staff with consultation on infection prevention and control issues

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  • Act as the infection prevention liaison to, and resource for, the community and state health departments

MISSION & OBJECTIVE

The main objective and mission of the Infection Prevention Program (IPP) is to provide and maintain a systematic, coordinated infection control process to identify and reduce the risks for acquisition and transmission of infectious agents among patients, students, volunteers, licensed independent practitioners (LIPs), visitors, and staff at the ASC. This is accomplished by:

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  • Education on methods for recognition and control of infections

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  • Surveillance of surgical site infections in patients undergoing surgical procedures at the ASC
  • Performance improvement efforts to develop initiatives to improve infection related clinical outcomes and/or infection prevention processes
  • Design ofinfection prevention strategies to improve organizational compliance with regulatory standards

RISK ASSESSMENT

[Briefly describe the patient risk factors and geographic location risks.]

Annually, an assessment considering the geographic location and community environment of the ASC’s program/services provided and the characteristics of the population served is conducted. Based in Oregon’s largest metropolitan area and located near an international airport and international shipping port, the ASC provides care to a large immigrant, indigent, homeless, and IV drug using population who are at risk for infections such as HIV, TB, Hepatitis A, B, and C, and emerging pathogens. The Portland area also has several mass transit systems that may be a targetof bioterrorism. Patients who are nursing home residents, diabetics, obese,smoke or use IV drugs may also carry or acquire organisms such as C. difficile or drug resistant organisms such as VRE, MRSA, or ESBLs.These patients are also at risk of acquiring surgical site infections. The assessed risks, prioritized scoring, and strategies to minimize, reduce, or eliminate the infection risks are attached in the 2011 Annual Infection Prevention Program’s Risk Assessment and Program Goals.

SERVICES

To minimize risks associated with transmission of infectious agents, the identified scope of services the Infection Prevention Program (IPP) provides its customersincludes:

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  • Conducting surveillance for healthcare acquired infections, antibiotic resistant pathogens and infectious disease outbreaks

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  • Developing and implementing isolation precautions appropriate for the ASC’s physical environment and patient population based on national infection control guidelines, recommendations, and the IPP’s risk assessment

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  • Initiating investigations of patient, student, LIP, volunteer, and employee illnesses or exposures to communicable diseases

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  • Reviewing aseptic practices including cleaning, disinfection, and sterilization procedures to ensure they follow national published guidelines based on the ASC’s risk assessment

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  • Developing and annually reviewing facility-wide infection control policies (the Infection Control Manual) adapted from the CDC, SHEA, AORN,OSHA,and APIC guidelines and other professional evidence based guidelines

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  • Serving as an infection control resource and consultant

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  • Orienting and educating all employees, medical staff, health care practitioners with ASC privileges, and volunteers on the cause, transmission, and prevention of infections to ensure a safe environment for patients, visitors, students, volunteers, and staff
  • Participation in QAPI projects as they relate to infection prevention opportunities

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  • Participatingin the review of policy and procedures to ensure CDC, APIC, and other evidence-based infection prevention practices are incorporated into policy and practices as appropriate

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  • Participatingin planning for construction and renovation at the ASC so that construction risks to patients will be minimized
  • Reviewing hazardous waste management and disposal throughoutthe facility

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  • Developing policies and processes for employee, medical staff, volunteer and student immunizations, screening, and exposure follow-up
  • Developing disease management policies for potential bioterrorist actions according to the county and state health department recommendations
  • Collaborating with facilities management contacts in planning, monitoring and designing the operation of buildings and systems
  • Ensuring an ongoing state of regulatory compliance

ANNUAL PLANNING

Based on the findings of the annual risk assessment and prioritization of those risks, the review of surveillance and key performance measurements and outcomes performed annually for purposes of monitoring and evaluating the effectiveness and impact of the Infection Prevention and Control Plan, and an assessment of available Infection Prevention Program Resources, the IPP proposes strategies to minimize, reduce, or eliminate the prioritized risks. These strategies may be in the form of policies, process improvement teams, quality control activity, or communication with the ICC or staff. The program risk assessment, goals and priorities, and surveillance plans are developed in collaboration with key facility leaders, LIPs, and staff. They are then reviewed and approved for implementation by the multi-disciplinary [insert name of committee]committeeresponsible for investigating, controlling and preventing infection in the facility.

DATA MANAGEMENT & ANALYSIS

Based on the annual approved surveillance plan, surveillance will be conducted to actively identify infections that may have been related to procedures performed at the ASC. The ASC conducts surveillance by [Note: describe your surveillance system (i.e., sends emails to patients after discharge asking if they developed a post-operative infection, or the ASC follows-up with the physician performing the procedure to obtain this information at a follow-up visit after discharge and asks them to report it to the ASC]. The ASC maintains supporting documentation confirming this tracking activity [describe how you maintain the records].

CDC definitions of healthcare-associated infections will be used in the IPP’s surgicalinfection surveillance process, which follows the surveillance strategies outlined by the National Healthcare Safety Network (NHSN). When available, thresholds for surveillance data are established after review and analysis of current research literature, national norms, and region/community specific trends. If benchmarks are unavailable, comparison of the ASC’s rates over time shall be evaluated and improved performance thresholds established.

REPORTING STRUCTURE & RESPONSIBILITIES

Surveillance data analysis is initially performed by the Infection Preventionist and is then reviewed by the ICC for further interpretation and input. Data analysis results are then distributed to the governing body for further input. Infection prevention surveillance reports and opportunities for improvement are shared with the employees, medical staff and ASC health professionals during update meetings.

The multi-disciplinary group overseeing the Infection Prevention Program is responsible for:

  • Risk assessment, program planning, regulatory compliance, and goal setting
  • Activities and decisions related to the prevention of infections, including performance improvement initiatives
  • Review and evaluation of the Employee Health Immunization and Screening Program compliance rates and bloodborne pathogen and communicable diseases exposures
  • Evaluation of investigation findings and development of action plans as needed
  • Development, approval, and implementation of effective infection control policies and procedures

The multi-disciplinary group overseeing the Infection Prevention Program (IPP) consists of the following individuals:

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  • List members and their positions

The ICC meetings are documented in the minutes that are approved at each meeting and stored in the administrator’s office.

[Type text]

ASC personnel and medical staff members share responsibility in the reporting of isolation cases and reports of suspected infections or outbreaks of infections to the IPP. There is collaboration between all staff and LIPs and the IPP to identify any nosocomial infection trends or patterns that may occur or opportunities for outcome improvement in the control and prevention of transmission of nosocomial infections. Post-operative infections will be reported to the IPPand to the Oregon Patient Safety Commission.

Licensed independent practitioners (LIPs) are responsible to report state required reportable infections to the county of patient residence and to the ASC administrator. If contacted, the IP program is available to assist with reporting infections to the county health departments.

Local county health departments are available to provide consultation and, if required, assistance to ASCs should questions or concerns arise related to potential infection, disease management, or outbreaks.

REFERENCES

Horan, T.C., Andrus, M., Dudeck, M.A. (2008). CDC/NHSN Surveillance Definition of Healthcare-Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting. American Journal of Infection Control, 36, 309-32. (see Surgical Site Infection definitions)

DISCLAIMER: All data and information provided by the Oregon Patient Safety Commission is for informational purposes only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations are followed.The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these recommendations.