Creating a Seamless Infection Control Risk Assessment & Plan

Creating a Seamless Infection Control Risk Assessment & Plan Kimberly A. Simon MSN, CIC, FAPIC

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What comes first, the chicken or the egg? • Your risk assessment is done first and helps you to create your infection control plan • Your risk assessment helps you to prioritize your goals • WHY SHOULD I DO THIS? • improves patient safety • improves staff safety • improves efficiency • identifies staff training issues • avoid adverse events

Elements of a risk assessment • Risks for acquiring and transmitting infections is based upon geographic location, community and population served and services provided LTC- device-assoc infections ASC- SSI Medical offices/practices- procedure associated infections Endoscopy- Infections r/t reprocessing failures

Risk for acquiring and transmitting infection based on the analysis of surveillance activities and other infection control data Elements of a risk assessment Are your numbers going up?

Elements of a risk assessment • Review and identify risks at least annually and whenever significant changes occur with input from infection control personnel, medical staff, nursing and leadership • Consider regulatory requirements (state, federal, OSHA) and organizational recommendations (CDC, AORN, etc)

Prioritize risks and document • After the analysis is complete, the most significant risks should be selected and documented • Results can appear in a stand-alone document but the findings must be integrated and evident in the IPC plan

Risk Assessment Critical Steps • Select the appropriate method and tools • Quantitative • Qualitative • Combination of the two

Selecting risk categories and topics • types of infections • organisms of epidemiological significance • at-risk patient population • geographical considerations • supplies and equipment risks • communication risks • emergency preparedness • environmental issues • personnel risks • community considerations

Setting goals • Upon completion of the risk assessment, writing goals and measurable objectives is imperative to developing your IP plan and determining your activities • Each goal should be accompanied by a measurable objective, an action plan and an evaluation process to determine whether the objective has been met

Goals should include • limiting unprotected exposure to pathogens • limiting the transmission of infections associated with procedures • limiting the transmission of infections associated with the use of medical equipment, devices and supplies • improving hand hygiene compliance

Creating SMART goals • Specific • Measurable • Action-oriented • Realistic and relevant • Timely or time-based

Example • Goal- Reduce sharps injuries in employees • Measurable Objectives- • Reduce needlestick injuries among direct care staff by at least 50% from the 2018 rate within the first 6 months of 2019 • Reduce scalpel injuries in surgical staff by 50% from current rate with implementation of a “pass zone” by July 2019

Your infection control plan • Must include a written description of the activities, including surveillance, to minimize, reduce or eliminate the risk of infection • In ambulatory care settings, surveillance is focused primarily on processes or practices (immunization rates, hand hygiene compliance rates, environmental cleanliness), rather than outcomes of care, such as infections. However, ambulatory settings performing invasive procedures can measure infections (r/t surgery, endoscopy, etc).

Elements of your plan • Mission and values of the program • Reporting structure • Staffing • Authority of the medical director/IC • Services provided • Incorporation of the plan within patient safety and QA

Common deficiencies in plans/risk assessments • Failure to prioritize goals • Failure to align plan with prioritized goals • Failure to make the plan unique to your organization (demographics, location, services provided)

Food for thought… • More than 50% of ASCs surveyed have been cited for deficiencies in infection control • lack of adherence to hand hygiene or appropriate use of PPE • safe injection practices, medication handling • surgical equipment reprocessing • blood glucose monitoring (MIFU) • environmental cleaning

Strategies • Designate an onsite person responsible for IC daily • Make sure that person is supported, trained and competent • Review your plan and risk assessment at quarterly or bi-annual QA meetings, what has changed? DOCUMENT!!!!

Evaluation • Were the IP goals and objectives met for the year? • Did infections decrease and practices improve? If not, why? • What can be added to the list of interventions to improve infection prevention efforts? • What measurements can be dropped and what needs to replace them for the coming year?

In summary • Implementing and managing infection prevention programs in ambulatory settings is a dynamic process, often changing in needs and complexities. By conducting a risk assessment and developing a comprehensive plan, the facility can proactively meet the challenges unique to the ambulatory care setting. The organization must be continuously ready to adapt the program to the needs of its patients and staff.

Thank you for your time and attention!!! Questions/Answers

Creating a Seamless Infection Control Risk Assessment & Plan