Information
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Healthcare Facility
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Conducted on
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Prepared by
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Location
Acute Care Infection Control Assessment
Infection Control Program and Infrastructure
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1. Hospital provides fiscal and human resource support for maintaining the infection prevention and control program.
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2. The person(s) charged with directing the infection prevention and control program at the hospital is/are qualified and trained in infection control.
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Verify qualifications, which should include:
- Successful completion of initial and recertification exams developed by the Certification Board for Infection Control & Epidemiology (CIC)
- Successful completion of initial and recertification exams recognized professional societies (e.g., APIC, SHEA)
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3. Infection prevention and control program performs an annual facility infection risk assessment that evaluates and prioritizes potential risks for infections, contamination, and exposures and the program’s preparedness to eliminate or mitigate such risks.
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4. Written infection control policies and procedures are available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations, or standards.
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Verify that the respondent can describe the process for reviewing and updating policies (e.g., policies are dated and reviewed annually and when new guidelines are issued)
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5. Infection prevention and control program provides infection prevention education to patients, family members, and other caregivers.
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Verify that the respondent can describe how this education is provided (e.g., information included in the admission or discharge packet, videos, signage, in-person training)
Infection Control Training, Competency, and Implementation of Policies and Procedures
Hand Hygiene
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1. Hospital has a competency-based training program for hand hygiene.
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Verify the following:
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a. Training is provided to all healthcare personnel, including all ancillary personnel not directly involved in patient care but potentially exposed to infectious agents (e.g., food tray handlers, housekeeping, and volunteer personnel).
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b. Training is provided upon hire, prior to provision of care at this hospital.
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c. Training is provided at least annually.
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d. Personnel are required to demonstrate competency with hand hygiene following each training.
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e. Hospital maintains current documentation of hand hygiene competency for all personnel.
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2. Hospital routinely audits (monitors and documents) adherence to hand hygiene.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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3. Hospital provides feedback from audits to personnel regarding their hand hygiene performance.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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4. Supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible in patient care areas.
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5. Hand hygiene policies promote preferential use of alcohol-based hand rub (ABHR) over soap and water in most clinical situations.
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Note: Soap and water should be used when hands are visibly soiled (e.g., blood, body fluids) and is also preferred after caring for a patient with known or suspected C. difficile or norovirus during an outbreak or if rates of C. difficile infection (CDI) in the facility are persistently high.
Personal Protective Equipment (PPE)
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1. Hospital has a competency-based training program for use of personal protective equipment (PPE).
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Verify the following:
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a. Training is provided to all personnel who use PPE.
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b. Training is provided upon hire, prior to provision of care at this hospital.
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c. Training is provided at least annually.
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d. Training is provided when new equipment or protocols are introduced.
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e. Training includes 1) appropriate indications for specific PPE components, 2) proper donning, doffing, adjustment, and wear of PPE, and 3) proper care, maintenance, useful life, and disposal of PPE.
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f. Personnel are required to demonstrate competency with selection and use of PPE (i.e., correct technique is observed by trainer) following each training.
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g. Hospital maintains current documentation of PPE
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2. Hospital routinely audits (monitors and documents) adherence to proper PPE selection and use, including donning and doffing.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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3. Hospital provides feedback to personnel regarding their performance with selection and use of PPE.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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4. Supplies necessary for adherence to personal protective equipment recommendations specified under Standard and Transmission-based Precautions (e.g., gloves, gowns, mouth, eye, nose, and face protection) are available and located near point of use.
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5. The facility respiratory protection program provides employees protection from recognized hazards.
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Verify the following:
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a. Annual fit testing of respirators is provided for all personnel who are anticipated to require respiratory protection.
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b. Supplies of respiratory protection devices (e.g., powered air purifying respirators) are maintained for those who cannot be fitted.
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c. Employees are educated about conditions that may compromise proper fit and function of respiratory devices (e.g., weight gain/loss, facial hair).
Prevention of Catheter-associated Urinary Tract Infection (CAUTI)
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1. Hospital has physician and/or nurse champions for CAUTI prevention activities.
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2. Hospital has a competency-based training program for insertion of urinary catheters.
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Verify the following:
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a. Training is provided to all personnel who are given responsibility for insertion of urinary catheters. Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and physicians.
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b. Training is provided upon hire, prior to being allowed to perform urinary catheter insertion.
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c. Training is provided at least annually.
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d. Training is provided when new equipment or protocols are introduced.
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e. Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training.
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f. Hospital maintains current documentation of competency with urinary catheter insertion for all personnel who insert urinary catheters.
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3. Hospital routinely audits (monitors and documents) adherence to recommended practices for insertion of urinary catheters.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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4. Hospital provides feedback from audits to personnel regarding their performance for insertion of urinary catheters.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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5. Hospital has a competency-based training program for maintenance of urinary catheters.
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Verify the following:
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a. Training is provided to all personnel who are given responsibility for urinary catheter maintenance (e.g., perineal care, emptying the drainage bag aseptically, maintaining the closed drainage system, maintaining unobstructed urine flow). Personnel may include, but are not limited to, nurses, nursing assistants, medical assistants, technicians, and transport personnel.
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b. Training is provided upon hire, prior to being allowed to perform urinary catheter maintenance.
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c. Training is provided at least annually.
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d. Training is provided when new equipment or protocols are introduced.
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e. Personnel are required to demonstrate competency with catheter maintenance (i.e., correct technique is observed by trainer) following each training.
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f. Hospital maintains current documentation of competency with urinary catheter maintenance for all personnel who maintain urinary catheters.
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6. Hospital routinely audits (monitors and documents) adherence to recommended practices for maintenance of urinary catheters.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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7. Hospital provides feedback from audits to personnel regarding their performance for maintenance of urinary catheters.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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8. Patients with urinary catheters are assessed, at least daily, for continued need for the catheter.
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Verify the following:
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a. Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, nurse directed protocol, reminders, or stop orders).
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b. Hospital routinely audits adherence to daily assessment of urinary catheter need.
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9. Hospital monitors CAUTI data and uses it to direct prevention activities.
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Verify the following:
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a. Respondent is familiar with National Healthcare Safety Network (NHSN) CAUTI data.
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b. Respondent can describe how CAUTI data are used to direct prevention activities.
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10. Hospital provides feedback of CAUTI data to frontline personnel.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
Prevention of Central line-associated Bloodstream Infection (CLABSI)
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1. Hospital has physician and/or nurse champions for CLABSI
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prevention activities.
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2. Hospital has a competency-based training program for insertion of central venous catheters.
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If hospital does not insert central lines, proceed to question #5
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Verify the following:
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a. Training is provided to all personnel who are given responsibility for insertion of central venous catheters. Personnel may include, but are not limited to, physicians, physician assistants, and members of line insertion teams.
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b. Training is provided upon hire, prior to being allowed to perform central venous catheter insertion.
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c. Training is provided at least annually.
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d. Training is provided when new equipment or protocols are introduced.
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e. Personnel are required to demonstrate competency with insertion (i.e., correct technique is observed by trainer) following each training.
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f. Hospital maintains current documentation of competency with central venous catheter insertion for all personnel who insert central venous catheters.
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3. Hospital routinely audits (monitors and documents) adherence
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to recommended practices for insertion of central venous
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catheters.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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4. Hospital provides feedback from audits to personnel regarding
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their performance for insertion of central venous catheters.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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5. Hospital has a competency-based training program for maintenance of central venous catheters.
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Verify the following:
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a. Training is provided to all personnel who maintain central venous catheters (e.g., scrub the hub, accessing the catheter, dressing changes). Personnel may include, but are not limited to, nurses, nursing assistants, physicians, and physician assistants.
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b. Training is provided upon hire, prior to being allowed to perform central venous catheter maintenance.
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c. Training is provided at least annually.
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d. Training is provided when new equipment or protocols are introduced.
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e. Personnel are required to demonstrate competency with maintenance (i.e., correct technique is observed by trainer) following each training.
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f. Hospital maintains current documentation of competency with central venous catheter maintenance for all personnel who maintain central venous catheters.
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6. Hospital routinely audits (monitors and documents) adherence to recommended practices for maintenance of central venous catheters.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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7. Hospital provides feedback from audits to personnel regarding their performance for maintenance of central venous catheters.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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8. Patients with central venous catheters are assessed, at least daily, for continued need for the catheter.
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Verify the following:
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a. Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, and reminders).
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b. Hospital routinely audits adherence to daily assessment of central venous catheter need.
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9. Hospital monitors CLABSI data and uses it to direct prevention activities.
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Verify the following:
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a. Respondent is familiar with National Healthcare Safety network (NHSN) CLABSI data.
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b. Respondent can describe how CLABSI data are used to direct prevention activities.
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10. Hospital provides feedback of CLABSI data to frontline personnel.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
Prevention of Ventilator-associated Event (VAE)
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1. Hospital has physician and/or nurse champions for VAE prevention activities.
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2. Hospital has a competency-based training program addressing prevention of VAEs.
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Verify the following:
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a. Training is provided to all personnel who provide respiratory therapy for ventilated patients (e.g., suctioning, administration of aerosolized medications). Personnel may include, but are not limited to, respiratory therapists and nurses.
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b. Training is provided upon hire, prior to being allowed to provide respiratory therapy for ventilated patients.
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c. Training is provided at least annually.
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d. Training is provided when new equipment or protocols are introduced.
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e. Personnel are required to demonstrate competency with respiratory therapy practices (i.e., correct technique is observed by trainer) following each training.
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f. Hospital maintains current documentation of competency with respiratory practices for all personnel who provide respiratory therapy for ventilated patients.
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3. Hospital routinely audits (monitors and documents) adherence to recommended practices for management of ventilated patients (e.g., suctioning, administration of aerosolized medications).
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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4. Hospital provides feedback from audits to personnel regarding their performance for management of ventilated patients.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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5. Patients requiring invasive ventilation are assessed, at least daily, for continued need for the ventilator.
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Verify the following:
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a. Respondent can describe methods used to trigger the daily assessments (e.g., patient safety checklist, daily rounds, reminders)
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b. Hospital routinely audits (monitors and documents) adherence to daily assessment of ventilator need.
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6. Hospital has a program that includes daily spontaneous breathing trials and lightening of sedation in eligible patient.
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7. Hospital has an oral-hygiene program.
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8. Hospital monitors VAE data and uses it to direct prevention activities.
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Verify the following:
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a. Respondent can describe how VAE data are used to direct prevention activities.
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The hospital reports VAE data to NHSN?
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If the hospital reports VAE data to NHSN, verify the following:
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b. Respondent is familiar with NHSN VAE data.
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- Successful completion of initial and recertification exams developed by the Certification Board for Infection Control & Epidemiology (CIC)
- Successful completion of initial and recertification exams recognized professional societies (e.g., APIC, SHEA)
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If the hospital does not report VAE data to NHSN, verify the following:
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c. Respondent can describe how VAE data are collected.
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9. Hospital provides feedback of VAE data to frontline personnel.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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If facility does not provide care to ventilated patients and move to item Injection Safety
Injection Safety (This element does not include assessment of pharmacy practices)
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1. Hospital has a competency-based training program for preparation and administration of parenteral medications (e.g., SO, IM, and IV) outside of the pharmacy.
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Verify the following:
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a. Training is provided to all personnel who prepare and/or administer injections and parenteral infusions.
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b. Training is provided upon hire, prior to being allowed to prepare and/or administer injections and parenteral infusions.
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c. Training is provided at least annually.
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d. Training is provided when new equipment or protocols are introduced.
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e. Personnel are required to demonstrate competency with preparation and/or administration of injections and parenteral infusions following each training.
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f. Hospital maintains current documentation of competency with preparation and/or administration procedures for all personnel who prepare and/or administer injections and parenteral infusions.
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2. Hospital routinely audits (monitors and documents) adherence to safe injection practices.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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3. Hospital provides feedback from audits to personnel regarding their adherence to safe injection practices.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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4. Hospital has a drug diversion prevention program that includes consultation with the IP program when drug tampering (involving alteration or substitution) is suspected or identified to assess patient safety risks.
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Verify the following:
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a. Respondent can describe how the hospital would assess risk to patients if tampering is suspected or identified.
Prevention of Surgical Site Infection (SSI)
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1. Hospital has a program to improve surgical care.
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Verify the following:
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The program to improve surgical care addresses appropriate prophylactic antibiotic use including:
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a. Preoperative timing of prophylactic antibiotic administration (within 1 hour prior to incision or 2 hours for vancomycin or fluoroquinolones).
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b. Appropriate prophylactic antibiotic selection based on procedure type.
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c. Discontinuation of prophylactic antibiotics within 24 hours (48 hours for CABG or other cardiac surgery) after surgical end time.
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d. The program to improve surgical care addresses prompt removal of urinary catheter on post-op day 1 or 2, unless there is a documented appropriate reason for continued use.
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2. Hospital routinely audits (monitors and documents) adherence to elements of program to improve surgical care.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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3. Hospital provides feedback from audits to personnel regarding their adherence to elements of the program to improve surgical care.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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4. Hospital routinely audits (monitors and documents) adherence to recommended infection control practices for SSI prevention.
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Verify the following:
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Auditing includes:
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a. Adherence to preoperative surgical scrub and hand hygiene
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b. Appropriate use of surgical attire and drapes
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c. Adherence to aseptic technique and sterile field
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d. Proper ventilation requirements in surgical suites
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e. Minimization of traffic in the operating room
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f. Adherence to cleaning and disinfection of environmental surfaces
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g. Respondent can describe process used for audits.
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h. Respondent can describe frequency of audits.
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i. Respondent can describe process for improvement when non-adherence is observed.
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5. Hospital provides feedback from audits to personnel regarding their adherence to surgical infection control practices.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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6. Hospital monitors SSI data and uses it to direct prevention activities.
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Verify the following:
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a. Respondent is familiar with NHSN SSI data.
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b. Respondent can describe how SSI data are used to direct prevention activities.
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7. Hospital provides feedback of SSI data to surgeons and other surgical personnel.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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If facility does not perform surgeries and move to item Clostridium difficile Infection
Prevention of Clostridium difficile Infection (CDI)
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1. Hospital has physician and/or nurse champions for CDI prevention activities.
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2. Hospital routinely audits (monitors and documents) adherence to recommended infection control practices for CDI prevention.
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Verify the following:
Auditing includes: -
a. Adherence to hand hygiene
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b. Appropriate use of PPE
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c. Compliance with Contact Precautions, including use of dedicated or disposable equipment
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d. Adherence to cleaning and disinfection procedures, including use of sporicidal disinfectants if part of hospital policy
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e. Respondent can describe process used for audits.
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f. Respondent can describe frequency of audits.
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g. Respondent can describe process for improvement when non-adherence is observed.
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3. Hospital provides feedback from audits to personnel regarding their adherence to recommended infection control practices for CDI prevention.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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4. Hospital has specific antibiotic stewardship strategies in place to reduce CDI.
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Verify the following:
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a. Hospital has strategies to reduce unnecessary use of antibiotics that are high-risk for CDI (e.g., fluoroquinolones, 3rd/4th generation cephalosporins).
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b. Hospital reviews appropriateness of antibiotics prescribed for treatment of other conditions (e.g., urinary tract infection) for patients with new or recent CDI diagnosis.
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c. Hospital educates providers about the risk of CDI with antibiotics.
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d. Hospital educates patients and family members about the risk of CDI with antibiotics.
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5. Hospital monitors CDI data and uses it to direct prevention activities.
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Verify the following:
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a. Respondent is familiar with NHSN CDI data.
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b. Respondent can describe how CDI data are used to direct prevention activities.
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6. Hospital provides feedback of CDI data to frontline personnel.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
Environmental Cleaning
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1. Hospital has a competency-based training program for environmental cleaning.
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Verify the following:
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a. Training is provided to all personnel who clean and disinfect patient care areas. Personnel may include, but are not limited to, environmental services staff, nurses, nursing assistants, and technicians.
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b. Training is provided upon hire, prior to being allowed to perform environmental cleaning.
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c. Training is provided at least annually.
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d. Training is provided when new equipment or protocols are introduced.
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e. Personnel are required to demonstrate competency with environmental cleaning (i.e., correct technique is observed by trainer) following each training.
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f. Hospital maintains current documentation of competency with environmental cleaning procedures for all personnel who clean and disinfect patient care areas.
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g. If the hospital contracts environmental services, the contractor has a comparable training program.
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2. Hospital has policies that clearly define responsibilities for cleaning and disinfection of non-critical equipment, mobile devices, and other electronics (e.g., ICU monitors, ventilator surfaces, bar code scanners, point-of-care devices, mobile work stations, code carts, airway boxes).
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3. Hospital has protocols to ensure that healthcare personnel can readily identify equipment that has been properly cleaned and disinfected and is ready for patient use (e.g., tagging system, placement in dedicated clean area).
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4. Hospital routinely audits (monitors and documents) adherence to cleaning and disinfection procedures, including use of products in accordance with manufacturers’ instructions (e.g., dilution, storage, shelf-life, contact time).
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Verify the following:
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a. Respondent can describe process used for audits (e.g., monitoring technology, direct observation).
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b. Respondent can describe frequency of audits.
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c. Respondent can describe process for improvement when non-adherence is observed.
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5. Hospital provides feedback from audits to personnel regarding their adherence to cleaning and disinfection procedures.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
Device Reprocessing
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This section refers to all medical devices that may be reused in the hospital. Device categories include:
• Critical items (e.g., surgical instruments) are objects that enter sterile tissue or the vascular system and must be sterile prior to use.
• Semi-critical items (e.g., endoscopes for upper endoscopy and colonoscopy, laryngoscope blades) are objects that contact mucous membranes or non-intact skin and require, at a minimum, high-level disinfection prior to reuse.
• Non-critical items (e.g., blood pressure cuffs, point-of-care devices) are objects that may come in contact with intact skin but not mucous membranes and should undergo cleaning and low- or intermediate-level disinfection depending on the nature and degree of contamination (See Environmental Cleaning Section I. above).
Single-use devices (SUDs) are labeled by the manufacturer for a single use and do not have reprocessing instructions. They may not be reused unless they have been reprocessed for reuse by entities which have complied with FDA regulatory requirements and have received FDA clearance to reprocess specific SUDs. -
1. Hospital has a competency-based training program for reprocessing of critical devices.
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Verify the following:
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a. Training is provided to all personnel who reprocess critical devices.
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b. Training is provided upon hire, prior to being allowed to reprocess critical devices.
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c. Training is provided at least annually.
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d. Training is provided when new devices or protocols are introduced.
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e. Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training.
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f. Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess critical devices.
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g. If the hospital contracts reprocessing of critical devices, the contractor has a comparable training program which includes the specific devices used by the hospital.
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2. Hospital routinely audits (monitors and documents) adherence to reprocessing procedures for critical devices.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Audits occur in all locations where critical devices are reprocessed (e.g., central sterile reprocessing, operating suites), including locations where initial cleaning steps are performed (e.g., point of use).
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d. Respondent can describe process for improvement when non-adherence is observed.
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3. Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for critical devices.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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If facility does not reprocess critical devices and move to question #4
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4. Hospital has a competency-based training program for reprocessing of semi-critical devices.
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Verify the following:
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a. Training is provided to all personnel who reprocess semi- critical devices.
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b. Training is provided upon hire, prior to being allowed to reprocess semi-critical devices.
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c. Training is provided at least annually.
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d. Training is provided when new devices or protocols are introduced.
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e. Personnel are required to demonstrate competency with device reprocessing (i.e., correct technique is observed by trainer) following each training.
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f. Hospital maintains current documentation of competency with reprocessing procedures for all personnel who reprocess semi-critical devices.
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g. If the hospital contracts reprocessing of semi-critical devices, the contractor has a comparable training program which includes the specific devices used by the hospital.
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5. Hospital routinely audits (monitors and documents) adherence to reprocessing procedures for semi-critical devices.
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Verify the following:
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a. Respondent can describe process used for audits.
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b. Respondent can describe frequency of audits.
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c. Audits occur in all locations where semi-critical devices are reprocessed (e.g., central sterile reprocessing, endoscopy suites), including locations where initial cleaning steps are performed (e.g., point of use).
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d. Respondent can describe process for improvement when non-adherence is observed.
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6. Hospital provides feedback from audits to personnel regarding their adherence to reprocessing procedures for semi-critical devices.
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Verify the following:
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a. Respondent can describe how feedback is provided.
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b. Respondent can describe frequency of feedback.
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7. If hospital reuses single-use devices, the devices are reprocessed by an FDA-approved entity.
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Check if hospital does not reuse single-use devices.
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8. Hospital maintains documentation of reprocessing activities.
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Verify the following:
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a. Hospital maintains logs for each sterilizer cycle that include the results from each load.
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b. Hospital has documentation that the chemicals used for high-level disinfection are routinely tested for appropriate concentration and replaced appropriately.
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c. Hospital maintains documentation of reprocessing activities.
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9. Hospital allows adequate time for reprocessing to ensure adherence to all steps recommended by the device manufacturer, including drying and proper storage.
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Verify the following:
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a. Hospital has an adequate supply of instruments for the volume of procedures performed to allow sufficient time for all reprocessing steps.
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b. Scheduling of procedures allows sufficient time for all reprocessing steps.
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c. Hospital does not routinely use immediate-use steam sterilization (IUSS).
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10. IP program is consulted whenever new devices or products will be purchased or introduced to ensure implementation of appropriate reprocessing policies and procedures.
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11. Hospital has policies and procedures outlining hospital response (i.e., risk assessment and recall of device) in the event of a reprocessing error or failure.
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Verify the following:
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a. The IP can describe how the risk assessment would be performed including how the hospital would identify which patients may have been exposed to an improperly reprocessed device.
Systems to Detect, Prevent, and Respond to Healthcare-Associated Infections and Multidrug-Resistant Organisms (MDROs)
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1. Hospital has system in place for early detection and management of potentially infectious persons at initial points of entry to the hospital, including rapid isolation as appropriate.
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Verify the following:
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a. Travel and occupational history is included as part of admission and triage protocols.
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b. Hospital has system to identify (flag) patients with targeted MDROs upon readmission so appropriate precautions can be applied.
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The hospital has a respiratory/hygiene cough etiquette program that includes:
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c. Posting signs at entrances
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d. Providing tissues and no-touch receptacles for disposal of tissues
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e. Providing hand hygiene supplies in or near waiting areas
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f. Offering facemasks to coughing patients and other symptomatic individuals upon entry to the facility
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g. Providing space in patient waiting areas (e.g., ED waiting room) and encouraging individuals with symptoms of respiratory infections to sit as far away from others as possible
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2. Hospital has systems in place for early detection and isolation of infectious patients identified during the hospital stay, including rapid isolation of patients as appropriate.
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Verify the following:
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a. There is a mechanism for prompt notification of the IP by the clinical microbiology laboratory when novel resistance patterns and/or targeted antimicrobial-resistant pathogens are detected.
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3. Hospital has system in place for INTER-facility communication of infectious status and isolation needs of patients prior to transfer to other facilities.
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Verify the following:
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a. Respondent can describe methods employed to ensure infectious status and isolation needs are communicated with receiving facilities.
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b. The hospital has system to notify receiving facilities of microbiological tests (e.g., cultures) that are pending at the time of transfer.
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4. Hospital has system in place for INTER-facility communication to identify infectious status and isolation needs of patients prior to accepting patients from other facilities.
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Verify the following:
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a. Respondent can describe methods employed to ensure infectious status and isolation needs are obtained from transferring facilities.
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b. The hospital has system to follow-up on microbiological results (e.g., cultures) that are pending at the time of transfer.
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c. If the hospital identifies an infection that may be related to care provided at another facility (e.g., hospital, nursing home, clinic), the facility is notified.
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5. Hospital has system in place for INTRA-facility communication to identify infectious status and isolation needs of patients prior to transfer to other units or shared spaces (e.g., radiology, physical therapy, emergency department) within the hospital.
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Verify the following:
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a. Respondent can describe methods employed to ensure infectious status and isolation needs are communicated with receiving units.
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6. Hospital has a surveillance program to monitor incidence of epidemiologically-important organisms (e.g., CRE) and targeted healthcare-associated infections.
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Verify the following:
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a. Respondent can describe how the hospital determines which organisms and HAIs to track.
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7. Hospital uses surveillance data to implement corrective actions rapidly when transmission of epidemiologically-important organisms (e.g., CRE) or increased rates or persistently elevated rates of healthcare-associated infections are detected.
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Verify the following:
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a. Data collection method allows for timely response to identified problems.
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8. Hospital has an antibiotic stewardship program that meets the 7 CDC core elements listed below (a – g).
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Note: The antibiotic stewardship program should be assessed in consultation with personnel knowledgeable about antibiotic stewardship activities (e.g., physician or pharmacist stewardship lead). Responses can be obtained from or cross-checked with the NHSN Annual Hospital Survey Antibiotic Stewardship Practice questions (Q 23 – 34) if available.
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Verify the following:
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a. Hospital leadership commitment
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o Hospital has a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship) AND/OR
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o Hospital provides salary support for dedicated time for antibiotic stewardship activities.
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b. Program leadership (accountability)
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o There is a leader responsible for outcomes of stewardship activities at the hospital.
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c. Drug expertise
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o There is at least one pharmacist responsible for improving antibiotic use at the hospital.
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d. Act (at least one prescribing improvement action below)
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o Hospital has a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry.
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o Hospital has hospital-specific treatment
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recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions.
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o There is a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g., antibiotic time out).
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o Hospital has specified antibiotic agents that need to be approved by a physician or pharmacist prior to dispensing at the hospital.
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o Physician or pharmacist reviews courses of therapy for
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specified antibiotic agents and communicates results with prescribers.
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e. Track
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o Hospital monitors antibiotic use (consumption).
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f. Report
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o Prescribers receive feedback by the stewardship
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program about how they can improve their antibiotic prescribing.
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g. Educate
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o Stewardship program provides education to clinicians and other relevant staff on improving antibiotic use.
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9. Hospital has occupational health program that, in addition to complying with state and federal requirements (e.g., OSHA), has policies regarding contact of personnel with patients when personnel have potentially transmissible conditions.
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Verify the following:
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a. The program has work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits or job status.
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b. Personnel are educated regarding prompt reporting of illness to their supervisor and the occupational health programs.
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10. Hospital follows recommendations of the Advisory Committee on Immunization Practices (ACIP) for immunization of healthcare personnel, including offering Hepatitis B and influenza vaccination.
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11. Hospital is compliant with mandatory reporting requirements for notifiable diseases, healthcare-associated infections (as appropriate), and potential outbreaks.
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Verify the following:
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a. Hospital can identify point(s) of contact at the local or state health department for HAI concerns.
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12. Hospital implements infection control measures relevant to construction, renovation, demolition, and repairs including performance of an infection control risk assessment (ICRA) before a project gets underway.
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Verify the following:
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a. IP program is consulted anytime construction, renovation, demolition, or repairs will be performed.
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b. ICRA elements are included in all contracts related to construction, renovation, demolition, and repairs.
Completion
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Comments/Recommendations
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Conducted by: Name and Signature
