Infection Control Risk Assessment

2. Infection Control Risk Assessment Terrie B. Lee, RN, MS, MPH, CIC Director, Infection Prevention & Employee Health Charleston Area Medical Center Charleston, WV

3. Organizational Infection Risk Assessment • Part of infection prevention and control planning process • Serves as starting point of well-developed plan • Together with plan, form foundation of program • Assists in focusing surveillance and other program activities • Meets regulatory requirements

4. Infection Risk AssessmentRegulatory Influence • Identify risks for acquiring and transmitting infections based on: • Geographic location, community, and population served • Care, treatment, and services provided • Analysis of surveillance activities and other infection data • Risks identified annually and when significant changes occur

5. Infection Risk AssessmentRegulatory Influence • Risk assessment occurs with interdisciplinary input: • Infection prevention personnel • Medical staff • Nursing • Leadership • Others • Prioritize and document risks

6. Risk Assessment Process • Homework and Planning • Forms • Preliminary completion of organization evaluation form • Preparation of risk assessment form • Standards • Reports: Surveillance data • Knowledge of current issues

7. Risk Assessment Process • Team Recruitment • Invitation • Solicit information in advance • What are the most important infection prevention and control problems? • What are our most frequent reasons for visit, admission, procedures performed, etc.?

8. Risk Assessment Team • IP Staff • Employee Health • Medical Staff • Laboratory • Pharmacy • Nursing • Surgery • Ambulatory Services • Environmental Services • Engineering • Administration • Central Processing • Quality/Performance Improvement • JC Coordinator

9. Risk Assessment Meeting • Commitment for attendance/ participation • Time for thoughtful discussion • Prioritizing risks • Determining IP Plan

10. Organization Evaluation • Factors to Include: • Geographic and environmental • Population characteristics • Area endemic infections • Other area-related risks • Medical care characteristics • Services provided

11. Organization Evaluation • Description of factors • Characteristics that increase risk for infection • Characteristics that decrease risk for infection • Get input at meeting for final completion of form • Include findings in risk assessment

12. Risk Assessment • The group work begins!

13. Risk Groups • Antibiotic-resistant organisms • Failure of prevention activities • Isolation activities • Policy & procedure • Preparedness • HAIs • Environment • Employee Health • Other

14. Assigning Three Values to Each Risk • Probability of event occurring • Impact/severity • Current systems

15. Probability Considerations • Known risks • Historical data • Reports in literature

16. Impact Considerations • Threat to life and/or health • Disruption of services • Loss of function • Loss of community trust • Financial impact • Legal issues • Regulatory impact • Standards/requirements

17. Current Systems Considerations • Current policy & procedure • Implementation of plans • Training status • Measures of outcome or process • Availability of backup systems • Community/public health resources

18. How to Assign Values • There are no right or wrong answers! • Allow discussion • Push group for consensus • Keep group focused, on target • Important to be consistent • Go through entire list of risks • Assign someone to calculate risk scores

19. Risk Score • Derived from multiplication of three component numbers • Group consensus vs. mathematical averaging or summation

20. Prioritization • Rank order risks using risk scores • Each organization’s priorities will be different

21. Risk Assessment Exercise • Determine fictitious setting • Discuss each potential risk • Come to group consensus on assignment of number for each component • Multiply component numbers to calculate risk score • Occasionally compare risk scores to validate with group

22. Infection Prevention PlanRegulatory Influence • Written infection prevention plan • Goals • Measureable objectives • Strategies for implementation

23. Infection Prevention PlanRegulatory Influence • Goals based on prioritized risks and include: • Limiting unprotected exposure to pathogens (isolation precautions and use of PPE) • Limiting transmission related to procedures • Limiting transmission related to medical equipment , devices, supplies • Improving hand hygiene

24. Infection Prevention Progress Report • Priority • Goal • Objectives • Strategies • Evaluation method • Current status/ Evaluation/ Next Steps

25. Infection Prevention Progress Report

26. Sample Goal & Objectives Assessment: Personnel wash hands or use alcohol hand rub during direct patient care activities. Goal: Increase use of hand hygiene Objective: Increase use of hand hygiene by direct care providers on 3 North by 40% in the next 6 months

27. Infection Prevention Progress Report Exercise • For top three scored risks, complete the following: • Goal • At least one objective • Strategies to reach objective • Method of evaluation

28. Benefits of Risk Assessment Meeting • Spreading the knowledge of what you “do” • Getting buy-in and support from key organizational stakeholders • No individuals to blame for priorities – organizational decisions • Many people able to articulate how IP plan was created • Meets regulatory requirements

29. Infection Prevention Progress Report • Tracks most important aspects of IP program • Reporting mechanism • Demonstrates program results/ improvement

30. Summary • Each organization must conduct an infection risk assessment that is unique to itself. This risk assessment is used to set priorities for the infection prevention program. • Once priorities are identified, goals, objectives, and strategies help to create the organizational infection prevention plan.

31. Summary, cont. • The risk assessment process is ongoing, with a focused revision taking place annually. • A progress report can be used to track and report priorities and accomplishments of the infection prevention program.

32. Questions