LEADERSHIP Philosophy -Reflect facility mission & vision Administrative accountability

1. LEADERSHIP • Philosophy -Reflect facility • mission & vision • Administrative accountability • Whom responsible for employee • compliance to policy/protocol, standards • of care?

2. Authority to take action - • Designate person/position to act • when indicated • Responsibility • * Designate scope of responsibilityand • program management • * Infection Control position description • * IC professional development plan • * Competency measurement/performance • evaluation • * Time allocation for program functions

3. Responsibility, continued • Policy, procedure, protocol development • * Determine need/title • * Research • * Prepare • * Seek approval • * Education employees affected • * Implement • * Assess

4. Oversight: Function/committee • Infection Control Committee? • Quality Committee? • * Multi-disciplinary membership • * Reporting structure • * Goals and objectives • * Program evaluation

5. Performance Improvement * Performance measures consistent with goals/objectives * Process/methods for data collection, data analysis description, reporting formats, improvements/recommendations, intervention/follow-up

6. Regulatory compliance and/or • Community standards of care • Reflect in policy, procedure, protocols • Bloodborne pathogens • Clinical laboratory improvement amendments • (CLIA) - waived testing • Communicable disease reporting • Construction and renovation standards • Dietary practices • Employee health and safety

7. Regulatory Compliance and/or • Community Standards of Care (continued) • First responder notification • Hand hygiene • Housekeeping and building maintenance • HIV: resident or employee • Vaccinations: resident, employee • Isolation/precautions

8. Surveillance of Nosocomial Infections: Long Term Care • Gail Bennett, RN, MSN, CIC • www.icpasssociates.com

9. Surveillance: The Method “The ongoing, systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know.” CDC Definition

10. Reasons for Surveillance Activities • Establish baseline endemic nosocomial infection rates • Facilitate early awareness of epidemics or clusters of nosocomial infections • Identify problems for which there is action that may decrease rates and actions that may lead to prevention of future infections

11. Types of Surveillance • Traditional, total house surveillance • Finding ALL nosocomial infections ALL of the time • Useful to establish endemic rates • Time consuming

12. Types of Surveillance • Targeted Surveillance Geographic locations or types of nosocomial infections may be targeted for review May consider: High risk High volume Problem prone • Be alert to your state surveyors’ expectations re: type of surveillance

13. Methods of Finding Infections/Data Sources • Microbiology (culture) reports • Unit generated report forms • 24 hour report • Antibiotic monitoring • Unit rounds/communication forms/verbal reports • Medical record review • Review should be concurrent, not retrospective

14. Some facilities collect: Resident name Record number Physician Admission date Symptoms & onset Site Culture date/pathogen Risk factors Other Data to CollectWhat is essential to your analysis?

15. Making an Infection Determination • Is infection present? • Definitions of infection • If yes, is it nosocomial? • Based on time (48 hour rule)

16. Definitions of Infections for LTC • McGeer definitions • American Journal of Infection Control, 1991; 19;1-7.

17. Methods of Presentation of Data • Line listing • Monthly summary of infections • Tables, graphs, charts

18. Data Interpretation • Clusters of infections (closely grouped series of infections) • Outbreak (excess cases over normal) • Sentinel events (single occurrence which requires action) • Trend (increase in specific infections over time) • Seasonal occurrence

19. Outbreaks • Require quick identification and action • 10 published steps for outbreak investigation (see outbreak investigation form) • You may need to seek assistance • Report to the health department as required by your state law

20. Numerators • New cases of infection for the period of review

21. Denominators • Census • Patient days • Device days

22. Nosocomial Infection Rates New cases of infection ___________________X 100 =___% Census

23. Nosocomial Infection Rates New cases of infection ________________X 1000= Total resident days # infections/1000 resident days [This has become the preferred method of calculation if you choose to do an overall rate.]

24. Nosocomial Infection Rates using Device Days New cases of UTI ________________ X 1000= Total urinary device days # UTIs per 1000 urinary device days

25. Forms • Example forms provided: • Monthly summary • Summary of device related infections • Line listing • Outbreak investigation

26. Surveillance resources • Bennett, G. Infection control manual for long term care. 2004 edition. HCPro, Marblehead, MA. $199.00 • Lee TB, Baker OG, Lee JT, Scheckler WE, Steele L, Laxton CE, APIC Surveillance Initiative Working Group. Recommended Practices for Surveillance. American Journal of Infection Control 1998;26:277-288.

27. Surveillance resources • McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, Peppler C, Rivera A, Schollenberger DG, Simor AE, Smith PW, Wang E. Definitions of Infection for Surveillance in Long Term Care Facilities. American Journal of Infection Control 1991;19(1):1-7. • Nicolle, L. Preventing infections in non-hospital settings: long term care. EID, vol. 7, no. 2, Mar/Apr, 2001. www.cdc.gov/ncidid/eid/vol7no2/nicolle.htm • Smith, P. and Rusnak, P. Infection prevention and control in the long term care facility. AJIC, 1997; 25; 488-512.

28. EDUCATION • New-hire orientation: All employees • * Hand hygiene • * Infectious Disease model • * Exposure Control Plan: Bloodborne • * Tuberculosis • * Work restriction policy • * Immunization program

29. EDUCATION, continued • New-hire: certain employees • * Information specific to responsibility • Annual • * Bloodborne Pathogen • * Others, as/if required by regulation • On-going • * Change in policy/procedure/protocol • * IC/ID information, if indicated

30. Employee Health: Bloodborne Pathogens and TB • Gail Bennett, RN, MSN, CIC • www.icpassociates.com

31. Health assessments • Pre-placement evaluation • Annual assessment

32. Assess: • General health • History of communicable diseases • Immunization status • Hepatitis B • Measles, mumps, rubella • Varicella • Tetanus • Influenza if hired during flu season

33. Employee Health: Bloodborne Pathogens and TB • Governed by OSHA regulations • Potential for OSHA fines for non-compliance

34. Exposure Control Plans • Bloodborne pathogens • Tuberculosis • Must be written and accessible.

35. Hepatitis B (HBV)Hepatitis C (HCV)Human Immunodeficiency Virus (HIV)Hepatitis Immunization

36. Hepatitis Immunization • Training must occur • prior to offering immunization • Prior to obtaining consent or declination • Training must include a qualified person available to answer questions if video is used

37. Hepatitis Immunization • 10 working days from hire to offer and administer • Schedule of immunization: 0,1,6 months • Deltoid muscle • Post testing – antibody • Can be fined by OSHA if not done – not following PHS recommendations • If 3 immunizations with negative titer, repeat series

38. Form • A sample consent/declination form is included in handouts • Form includes up to six immunizations and antibody screens

39. Still… • No vaccine for Hepatitis C or HIV

40. BBP Exposures • OSHA requires detailed actions and documentation of BBP exposures. • Handout: Comprehensive form for documenting exposures. • Must maintain exposure records the length of employment plus 30 years! Mark those files - “may destroy 2033” (example).

41. BBP Exposures • If we have documented + antibody to Hepatitis B, do not have to test associate for Hepatitis B. Still test for Hepatitis C and HIV. • If Hepatitis B status not documented, test. • Test resident for Hepatitis B, C, HIV unless positive status is already known • Follow state regulations regarding obtaining consent • Follow CDC guidelines for subsequent testing

42. HIV exposure • Exposure to a known positive resident with HIV, follow the CDC guidelines • Timeliness of follow-up is critical • Many LTCFs have a relationship with a hospital to assess HIV exposures and intitiate appropriate prophylaxis

43. Tuberculosis

44. PPD Skin Testing • Employees: • 2 step on hire (unless tested in last 12 months and documented) • Requirement for annual PPDs (or more often based on annual facility TB risk assessment) • Test after exposure (immediately then in 10-12 weeks)

45. PPD Skin Testing • Employees: • If positive prior to hire - have them bring x-ray results and documentation of no active disease • If they do not have an evaluation, we must get one. • If positive, assessment for symptoms on hire and annually.

46. PPD Skin Testing • Employees: • If convert during employment, have an evaluation done (PHD should do this and give free INH as indicated) • Report on OSHA 300 log • Start annual assessment for symptoms

47. Training of all Associates • All associates should receive orientation and annual training on bloodborne pathogens and TB

48. TB Risk Assessment • Must be done every each year • Determines if we can continue annual PPDs on associates vs. more frequently

49. Employee Illnesses • Maintain a log of associates with infections. • Requires all department heads to assist. • Many facilities have the logs turned in to IC/EH.

50. Work Restrictions • Policy on work restrictions – CDC occupational health guidelines have a work restrictions table. • Adopt a policy for your facility. • Enforce it.