Customize Your Infection Control Manual

1. Customize Your Infection Control Manual James Marx, RN, MS, CIC Broad Street Solutions May 2006

2. What Infection Control Manual? • Regulatory • Title 22 • Federal Conditions of Participation • JCAHO • OSHA

3. Establish your practice • Many practices are not specified in law • Isolation practice • Surveillance methods and definitions • Outbreak identification and followup • “Its our policy to ….” • Not to isolate residents • Do two step TST for new admissions

4. Critical policies • Surveillance system • Definition of infection • Case finding methods • Reporting schedule • Isolation system • When to start and stop isolation precautions • Employee health • Required vaccines

5. Foundation • Infection Control Risk Assessment (ICRA) • Describe your unique resident population • Describe your unique staff population • How limited are your resources • What current trends will effect IC practice

6. Essential Elements • Program description • Job description • Surveillance System • Isolation System • Hand Hygiene • Outbreak Management • Employee Health • Tuberculosis Control Program • Bloodborne Pathogens Program • Reportable Diseases

7. Program description • Broad policies that are used throughout the facility • Department specific policies • Nursing • Housekeeping and Laundry • Facilities • Activities • Therapies • Food Services

8. Job description • What is expected? • What training is provided? Initial? On-going? • What support is available? • What written resources are available? • How do you keep up with changes?

9. Surveillance System • Infection Prevention Risk Assessment • Definition of infection • Analysis of the information • Comparing the data • Creating reports • Quarterly meeting

10. Isolation System • New guideline from CDC expected 2006 • Will include information for LTC • Last guideline published 1996 • Needs to be modified for LTC • California guideline on Antibiotic Resistant Microorganisms • Local county based guidelines

11. 1996 CDC Isolation Guideline • Standard Precautions • Transmission Precautions • Airborne • Droplet • Contact

12. Airborne Precautions Tuberculosis, Chickenpox, Measles • Requires a negative pressure room • Requires 6-12 air exchanges per hour • Requires the use of N95 respirators • Requires fit testing program • Modify policy to address each disease

13. Tuberculosis • Use 2005 CDC guideline for Prevention and Control of TB • Perform annual risk assessment • Define a suspect TB cases • Positive AFB smear • Suspicious chest x-ray with symptoms • Pre-plan for transfer of suspect cases

14. Chickenpox • Screen all healthcare workers (100%) • Check blood titer of potential non-immune workers (8-10 %) • Vaccinate susceptible workers (1-2%)

15. Measles • Generally not a problem in adult LTC populations • Vaccine is recommended for any adult who does have history or vaccination

16. Droplet Precautions • Influenza • Standard surgical mask • Advise staff, physicians, residents and family • Suspend socialization (activities/dining, visitation) • Consider antiviral therapy • Room door may remain open • Annual resident and staff vaccination program is critical to prevent and contain an outbreak • Consider mandatory vaccination/declination program

17. Contact Precautions • Need to modify 1996 CDC guideline • Socialization during activities • Dining room • Degree of Precautions • Colonization and infection • Infection only • Standard Precautions only

18. Scabies

19. Antibiotic Resistant Bacteria • Colonized residents • MRSa- 25% for 3months to 3 years • VRE- 25-67% for 3-4 months • GNR- 22% for 2 months

20. MRSa • Methicillin Resistant Staphylococcus aureus • Can be normal skin flora • An undesirable side effect of antibiotic use • Regular hand hygiene indicated • Routine cleaning of the environment • Cleaning of multi-use resident care equipment • Blood pressure cuff • Stethoscope • Thermometer

21. VRE • Vancomycin Resistant Enterococcus • Can be normal bowel flora • An undesirable side effect of antibiotic use • Routine cleaning of the environment • Special attention to items with stool contact • Eliminate electronic rectal thermometers • Develop a system to disinfect bedpans after use • Dispose enema equipment after use • Disinfect shower chairs between use

22. Common questions about isolation in skilled nursing • Can we use isolation signs? • Should we do Admission/Periodic surveillance cultures? • When do we discontinue isolation? How many negative cultures are needed? • MRSA, VRE, C. diff • How should isolation be documented in the medical record? Care Plan? • Should we use masks with MRSa? • Is antibacterial soap required?

23. Hand Hygiene • CDC guideline- 2002 • Alcohol hand sanitizer in all clinical situations • Soap and water when hands are visibly soiled, before eating and after using the bathroom • Decide placement of containers • Conform to local fire laws

24. Cleaning and Disinfection • Identify surface to be cleaned • Use according to Direction for Use • Create a cleaning schedule • Assign responsibility for cleaning • Decide on the supplies needed to clean

25. Storage of sterile items • Identify area storage area • Clean, cool, no sunlight, dry • Establish a schedule to rotate stock • Insure that outdates are monitored • Assign responsibility

26. Outbreak Management • Define an outbreak • Define a case • Find additional cases • Institute control measures • Formulate a hypothesis • Communicate findings

27. Employee Health • Initial and annual TB screen • Two step TST for employees who have not been tested in past year • Include volunteers with > 10 hours per week • Initial health examination • Annual health examination • Can be done by questionnaire only with RN review (need Program Flexibility) • Vaccine Preventable Diseases screen • Measles, Mumps, Rubella, Varicella, Hepatitis B, Influenza (Oct-March), Tetnus/diphtheria/pertussis

28. Tuberculosis Control Program • Resident screening • Initial tuberculin skin test (TST)- required • Annual screening (determine your policy) • Not required by Title 22 or Federal COP • Not recommended by the CDC • Recommended by California TB Controllers Association and DHS • Employee screening

29. Bloodborne Pathogens Program • Identify staff at exposure risk • Identify techniques and devices that reduce the risk of exposure • Provide education • Implement hepatitis B vaccination program • Include required post vaccine titers • Define exposure follow up protocol

30. Reportable Conditions • Contact local county/city health department • Conditions like Alzhiemer Disease and lapse of consciousness

31. Index and Table of Contents • Have electronic version of policies • Some software will create and index for you • Different color pages • Isolation Table

32. References • Principles of Infection Control and Epidemiology- APIC 2003 • www.cdc.gov • www.immunize.org • www.apic.org

33. References and Resources • www.cdc.gov/nip • www.apic.org • James Marx, RN, MS, CIC P.O. Box 16557, San Diego, CA 92176 619-656-7887 Voice/Fax www.InfectionControl.net

34. References and Resources • National Immunization Program at the Centers for Disease Control and Prevention http://www.cdc.gov/nip • S Bradley, Prevention of Influenza in Long-Term Care Facilities, ICHE, September 1999 • Adult Immunization Programs in Nontraditional Settings and Use of Standing Orders Programs to Increase Adult Vaccination Rates, MMRW, March 24, 2000 • http://new.cms.hhs.gov/AdultImmunizations/Downloads/2005-2006QAGuide.pdf

35. Essential Elements Exercise • Seasonal Influenza • Isolation Systems • Hepatitis B vaccination

36. Influenza planning exercise • Seasonal influenza • Vaccination planning and promotion • Early detection • Reducing transmission • Pandemic influenza • Bed capacity • Staffing capabilities • Supplies- masks, medications, vaccine, tissues • Temporary morgue

37. Hepatitis B vaccination • Determine who should be vaccinated • How will they be educated? • How will they get vaccinated? Describe process of the three vaccine series • How will post- vaccine titer be done?

38. James Marx, RN, MS, CIC Broad Street Solutions P.O. Box 16557 San Diego, CA 92176 619-656-7887 Voice/Fax www.InfectionControl.net