SAMPLE

INFECTION PREVENTION AND CLINICAL EPIDEMIOLOGY

ANNUAL RISK ASSESSMENT/STRATEGIC WORK PLAN for ASC Name and Year

Infection Control/Epidemiology Risk Characteristics

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Risk Category Determination

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Goal

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Objective

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Indicators

Data Analysis

(Refer to attachment 1 for in depth rates) /

Plan of Action

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Hand Hygiene (HH) Practices
Obs Correct HH < 90%
Obs Correct HH 90-99%
Obs Correct HH 100% / X High
/ Enforcement and enhancement of hand hygiene practices are implemented within the organization. / ASC-wide hand hygiene program is implemented that complies with CDC guidelines and TJC NPSG 7. 90-100%
Coordinate/consult/educate all areas of ASC on Infection Prevention Process and Outcome Measures. / 1.  Daily/weekly focused random hand hygiene practice observations per month are being captured
2.  alcohol gel usage reports. / Enforce education and compliance with results from the monthly hand hygiene observations and all other rounds described for hand hygiene.
Patient speak up campaign brochure.
Governing body Quality Committee/Board receive reports of compliance monthly /quarterly
Hand Hygiene compliance reported out thru the ICC/Quality committee.
Reinforce good behavior with incentives.
Strategic goal for the organization Target-84%, Maximum 86%
Surgical Site Infections (SSI)
Ortho, ENT, Plastics, Vasectomies etc. and any Focused Studies. / X High / Decrease SSI rates to target X.
Full compliance with IHI bundle CDC recommendations for SSI prevention and SCIP measures. / Analyze data collected on SSIs, including numerators and denominators.
Generate baseline rates and benchmark against historical data and NHSN.
Make recommendations for improvement using the IHI SSI prevention bundle and other infection prevention strategies.
Investigate identified clusters/focused studies.
Coordinate/consult/educate all areas of ASC on Infection Prevention Process and Outcome Measures. Working with surgeons to have accurate Wound Class and ASA scores assigned to patints by surgeon. / Put data here:
SSI rates for selected procedures / To investigate potential causes of rates occurring above the CDC 50th percentile in either of these 2 procedures, IC continues to perform retrospective chart reviews on those patients with SSI looking for breaches in those processes associated with the SSI bundle that include: appropriate initiation and discontinuation of antibiotics, clipping versus shaving for hair removal and perioperative glucose control.
The systematic collection and analysis of data noting the compliance rate to all the SSI bundle measures should ideally be done for all surgery types, so that a comparison can be made of the compliance rates between those patients with SSI and patients without SSI for the same type of surgical procedure.
Implementation of the SSI bundle continues in collaboration SCIP and NSQIP.
TJC – Continued Readiness. / X High / Constant State of Readiness. / Protect patients, employees and physicians by promoting best Infection Prevention Practices
Coordinate/consult/educate all areas of ASC on Infection Prevention Process and Outcome Measures. / Compliance to NPSG #7 Prevention of Health care associated Infections
Control TJC and DHS standards. / o  Surveillance Rounds
o  EOC rounds
o  Construction Rounds
o  IC rounds
o  Education to Leaders, physicians and Staff
Cluster/Outbreaks
Emerging Infectious Disesases
Community:
MRSA, MDRO’s, Pertussis, varicella, Norovirus,, Influenza, hepatitis A&B, pandemic flu and any new emerging infectious disease
Facility: None / X High
X Medium / Implementation of infection prevention strategies in relationship to the mechanisms of transmission, care, treatment, and the pathogens that place communities at risk.
Reduce morbidity and mortality due to these pathogens.
Implementation of respiratory etiquette /hand hygiene programs. / Investigate the cause of an unexpected increase in community and/or health care associated infections.
Recommend interventions that result in prevention or a sustained decrease in the infection rate.
Coordinate/consult/educate/rounds all areas of ASC on Infection Prevention Process and Outcome Measures. / Data here:
MRSA rates / Compliance with standard & transmission based precautions, hand hygiene and appropriate PPE use.
Compliance with environmental cleaning practices and patient equipment cleaning and disinfection
Screening for exposures and immunity per policy.
Referral for assessment, testing, immunizations up to date on all staff and is achieved at 100% for individuals who may put population at risk and who have been occupationally exposed to infectious agents.
Compliance with patient hygiene, oral care and bathing when clinically appropriate.
Influenza/Pandemic Influenza
Bioterrorism and Emergency Preparedness. / X High / Prevent health care associated transmission and outbreaks. / Continually update and monitor a comprehensive flu plan in coordination with local, state and federal authorities. Monitor trends and implement IC practices known to minimize the spread of influenza.
Train in the rapid isolation or cohorting of infectious patients.
Immunize staff with direct patient care and susceptible patients.
Educate and inform staff & physicians as new information arises.
Coordinate/consult/educate all areas of ASC on Infection Prevention Process and Outcome Measures. / Compliance with offering all employees, LIP’s, volunteers, etc. Flu vaccination.
Use of proper respiratory etiquette and hand hygiene.
Mask fit testing as needed.
Adherence and compliance to the Aerosol Transmissible Disease (ATD) Standards/TB Control Plan / Offer flu vaccine to all ASC employees, LIP’s etc.
Healthy incentive for HCW’s tied to compliance with vaccination status or declination.
Facility Construction
Current or planned construction/renovation/demolition activities.
§  Dust Control and Containment / X High / Reduce HAI associated with construction activities. / Maintain and monitor an aggressive surveillance, dust control & containment, humidity and mold abatement program.
Continuously evaluate and educate for IC compliance by subcontractors, project managers, engineers, inspectors of record.
Daily rounds in construction areas.
Review of all construction projects and sign off on major projects for dust control and containment. IC involved in any unanticipated construction projects in patient care areas from preconstruction through all the stages of construction. IC rounds on the project sites to monitor compliance with containment. ICRA signed and posted at site. / 100% compliance with ICRA.
No trends in diseases known to be associated with construction.
. / An infection control risk assessment and dust control and containment policy and procedure is followed for all construction projects.
Do rounds daily on all major construction projects and regularly evaluates the scope of level 1 and 2 in the event that the acuity is higher.
IC rounds weekly and as needed. IC has the oversight for all projects and asks for action plans when there is poor compliance on major construction projects.
All contractors go thru Dust control and containment P&P before starting a project.
Presence of Multi Drug Resistant Organisms (MDRO)
Patient population > 20% resistance :
MRSA, VRE, C. difficile, ESBL / X High / Prevent transmission of MDRO. / Undertake actions to evaluate incidence of health care associated transmission.
Implement strategies to reduce health care associated transmission.
Recommend interventions based on findings and assessment of risk.
Coordinate/consult/educate all areas of ASC on Infection Prevention Process and Outcome Measures.
Enhanced environmental cleaning protocals with housekeeping and Nursing. / Attachment data MRSA rates
. / Monitor compliance with standard precautions, hand hygiene and environmental cleaning.
Screen at pre-op outpatient visit all elective orthopedic surgical patients
Nasal swab (anterior nares) by RN sent for “MRSA screen”
Based on Culture Results (only if MRSA and CHG bathing pre op and post op. Prophy for MRSA + Vancomycin. Cefazolin for MRSA -. Environmental cleaning per protocal
Tuberculosis
Pulmonary TB cases in past 6 months
§  / X High
X Medium
X Low
X Medium / Prevent transmission of pulmonary TB in community and healthcare workers. / Review and revise Aerosol Transmissible Disease (ATD) Standards/ TB exposure and control plan annually and as needed.
Identify all suspect and actual cases of pulmonary TB and initiate airborne precautions upon entry to ASC.
Continued education to physicians and staff on preventative measures (fit testing and annual skin testing and use of appropriate PPE). / TB screening Compliance in X
Fit Testing Compliance in : Overall compliance is X / Active Management of pulmonary tuberculosis remains a significant activity over time. The early recognition of tuberculosis and placement in appropriate airborne precautions minimizes the risk of transmission to staff and other patients.
Infection Control Surveillance in the:
·  Ambulatory Surgery Services / X High / Prevent transmission of Infectious Diseases and exposure to opportunistic pathogens. / Monitor rates of targeted diseases such as Tuberculosis, MRSA, hand hygiene compliance,
Undertake actions to evaluate incidence of health care associated transmission.
Implement strategies to reduce health care associated transmission. / See Attachment Data.
Targeted surveillance of SSI, hand hygiene, / Recommend interventions based on findings and assessment of risk.
Coordinate/consult/educate all areas of ASC on Infection Prevention Process and Outcome Measures.

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