Wisconsin Department of Health Services
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To protect and promote the health and safety of the people of Wisconsin
Assessing Your
Infection Prevention Program
Wisconsin Hospital IP Boot Camp
Linda Coakley, RN, MS, CIC
Infection Preventionist
October 23, 2019
Wisconsin Department of Health Services
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Objectives
• Describe program and risk assessment tools
• Review documentation and training competencies
• Review antibiotic stewardship (AS) elements
• Review point-of-care testing and injection safety
• Identify construction, renovation, and repair concerns
Wisconsin Department of Health Services
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Key Documents
• IP and control plan and structure
• Healthcare personnel safety policies
• Bloodborne pathogens standard and exposure control plan
• Tuberculosis (TB) risk assessment
• CMS worksheets for hospitals and ambulatory surgery centers
• Infection control assessment and response (ICAR) survey
• Infection control risk assessment (ICRA) matrix
• IP program risk assessment
• Targeted assessment and prevention (TAP) strategy
Wisconsin Department of Health Services
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• Healthcare-associated infection
(HAI) data
• Education and competencies of
infection prevention (IP) practices
• Changes in products or practices
• Facility construction, renovation,
repair, or monitoring
• Employee health issues
Infection Prevention/Quality
Committee Review
Wisconsin Department of Health Services
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Infection Prevention/Quality
Committee Review
• Reportable diseases
• Antibiotic stewardship (AS)
• Sterilization and disinfection monitoring
• Annual and as needed infection prevention policy review
• Unusual events
Wisconsin Department of Health Services
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Who is on your team?
Administration Environmental Services Nursing
Surgical Services Sterile Processing Pharmacy
Physicians Surgeons Employee Health Dietary
Admitting Human Resources Laundry Patients
Visitors Purchasing Vendors Therapists Architects
Maintenance Radiology Laboratory Informatics
Social Services Medical Records Finance Transport
Engineering Contractors Public Health
Wisconsin Department of Health Services
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You are Not Alone
Wisconsin Department of Health Services
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Infection Control Assessment and
Response (ICAR)
• ICARs are educational, non-regulatory assessments that
cover CDC minimum standards.
• The Wisconsin HAI Prevention Program conducts ICARs
after outbreaks or infection control breaches, and upon
request.
Wisconsin Department of Health Services
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ICAR Assessment Access
• The hospital assessment includes 25 pages of questions,
five pages of resources, and takes three or more hours to
complete.
o Hospital assessment:
https://www.cdc.gov/infectioncontrol/pdf/icar/hospital.pdf
o Outpatient assessment:
https://www.cdc.gov/infectioncontrol/pdf/icar/outpatient.pdf
• The DHS ICAR visit offers a facility walk-through with “fresh
eyes.”
Wisconsin Department of Health Services
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Centers for Medicare and Medicaid
(CMS) Assessment Access
• The 49-page Hospital assessment is available at:
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-cert-
letter-15-12-Attachment-1.pdf
• The 17-page Ambulatory Surgical Center (ASC) assessment is
available at: https://www.cms.gov/Regulations-and-
Guidance/Guidance/manuals/downloads/som107_exhibit_351.pdf
Wisconsin Department of Health Services
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ICAR and CMS Domains
• Infection prevention program and infrastructure
• Respiratory and cough etiquette
• AS
• Employee health and safety
• Communicable disease reporting
• Environmental cleaning
• Device reprocessing
• Methods to detect, protect, and respond to MDROs
• Transmission-based precautions (i.e., isolation)
Wisconsin Department of Health Services
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Documentation and
Competency Training
• Hand hygiene (HH)
• Personal protective equipment (PPE)
• Prevention of:
• Catheter-associated urinary tract infections (CAUTI)
• Central line-associated bloodstream infections (CLABSI)
• Ventilator-associated events (VAE)
• Surgical site infections (SSI)
• Clostridioides difficile infection (CDI)
• Safe injection practices
Wisconsin Department of Health Services
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Targeted Assessment
for Prevention (TAP)
• Quality improvement framework developed by CDC
• Three components:
1. Target: Use NHSN data TAP reports
2. Assess: Administer TAP survey tool
3. Prevent: Compile and review survey results and link
them to resources for “leading” and “lagging” issues
identified
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Available TAP Assessments
• CAUTI
• CLABSI
• CDI
*Electronic and manual paper copies available
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TAP Process
Wisconsin Department of Health Services
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• HCP include almost everyone: staff,
students, volunteers, and contracted
workers.
• Allow HCP to stay home when sick
and document communicable
illnesses.
• Look for trends.
Healthcare Personnel (HCP)
Wisconsin Department of Health Services
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Influenza Immunizations
• Offer annual influenza vaccine to HCP.
• Develop a vaccine distribution plan during shortages.
• Maintain a list of vaccinated HCP and assess compliance
rates.
Wisconsin Department of Health Services
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Immunization Documentation
• A written facility immunization policy is recommended.
• Document reasons for vaccination refusal.
o Facility policy dictates whether HCP can refuse.
o HCP that refuse influenza vaccination may be required to
wear a mask or be restricted during flu season.
• Document vaccinations in WIR.
Wisconsin Department of Health Services
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Assessing HCP for TB
• Medical evaluation: Assessment of signs and symptoms of
active TB disease
• Risk assessment: Questionnaire to determine a person’s
risk for TB infection
• Testing: Interferon gamma release assay (IGRA) blood test
or tuberculin skin test (TST) to determine if a person has
been infected with M. tuberculosis complex bacteria
Wisconsin Department of Health Services
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Assessing HCP for TB
Upon hire, HCP should:
• Complete baseline medical evaluation and TB risk
assessment questionnaire.
• Receive baseline IGRA (preferred) or TST.
• Provide, at the discretion of the facility, previous
documented negative IGRA or TST results within 12
months.
Wisconsin Department of Health Services
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Assessing HCP for TB
• Most healthcare facilities in Wisconsin are low risk for TB.
• Serial (annual) testing by IGRA or TST is not
recommended.
• Instead of annual testing, low-risk facilities should consider
an annual TB risk assessment questionnaire.
• Perform medical evaluation and IGRA or TST after a TB
exposure event.
Wisconsin Department of Health Services
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Birth, residence, or travel to country
with high TB prevalence?
Recent TB symptoms:
• Cough longer than 3 weeks AND
o Coughing up blood and/or
o Fever and/or
o Night sweats and/or
o Unexplained weight loss and/or
o Fatigue
Close contact to an individual with
TB?
Current or former employee or
resident of high risk congregate
setting in a state with an elevated TB
rate, such as AL, CA, HI, NJ, NY, TX
or Washington D.C.?
Four TB Risk Assessment Questions
https://www.dhs.wisconsin.gov/forms/f02314.pdf
Wisconsin Department of Health Services
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Assessing HCP for TB
For HCP with known positive IGRA or TST:
• Do not perform additional IGRA or TST.
• Obtain a baseline medical evaluation and chest x-ray.
• Annual chest x-rays are not recommended.
• An annual TB risk assessment questionnaire should be
administered.
Wisconsin Department of Health Services
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Bloodborne Pathogens (BBP) Standard
Occupational Safety and Health Administration (OSHA)
standard elements include:
• Exposure control plan with annual review and necessary
updates.
• Standard precautions.
• Engineering controls for safer practices.
• Readily available PPE in appropriate sizes.
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BBP Standard
• Offer Hepatitis B vaccine within 10 days of employment.
• Conduct post-exposure evaluation and prophylaxis (PEP)
with a ready plan.
• Use biohazard labels, bags, sharps containers, and regulate
medical waste.
• Provide annual BBP training and documentation.
• Keep HCP medical records for 30 years.
https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf
Wisconsin Department of Health Services
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PEPline
• Provides expert healthcare post-exposure management
guidance seven days a week from 11 a.m. to 8 p.m. ET
• Addresses immediate PEP needs for HIV/AIDS and
Hepatitis B and C
1-888-448-4911
Wisconsin Department of Health Services
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Alcohol-based hand rub (ABHR)
preferred in HH policy
Soap and water for C. difficile
and Norovirus
Hand Hygiene
Wisconsin Department of Health Services
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1. Before touching patient
2. Before clean (aseptic) procedure
3. After blood or body fluid exposure or risk
4. After touching patient
5. After touching patient’s surroundings
https://www.who.int/gpsc/tools/Five_moments/en/
World Health Organization
HH Five Moments
Wisconsin Department of Health Services
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• Perform competency training on both
methods upon hire and annually.
• Conduct “secret shopper”
observations of current practice.
• Report data to the quality committee,
provide feedback to staff, and
document in HR records.
• Ensure adequate supplies are
available.
HH Audits of HCP
Wisconsin Department of Health Services
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Respiratory and Cough Etiquette
• Make stations visible and available at
the front entrance (not hidden or difficult
to reach).
• Ensure stations are available and fully
stocked year-round, not just during flu
season.
• Provide education for HCP, patients,
families, and visitors. Include information
in newsletters and posters.
Wisconsin Department of Health Services
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Seven Antibiotic Stewardship
(AS) Core Elements
1. Demonstrate leadership support.
2. Establish committee member expertise in antibiotics (e.g.,
infectious disease, physician, or pharmacist).
3. Develop written antibiotic prescribing policies and
protocols, including indication, dose, and duration.
4. Review a six-month summary of antibiotic use, including
new starts, type, and number of days.
Wisconsin Department of Health Services
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Seven AS Core Elements
5. Provide feedback about usage to clinical
prescribers.
6. Provide AS education to all nursing staff
within the past 12 months.
7. Provide AS education to all clinical
prescribers of antibiotics within the past 12
months.
https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
Wisconsin Department of Health Services
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Injection Safety and
Point-of-Care Testing
• Establish injection safety policies and protocols and review
annually and as needed.
• Train and assess competency for HCP who perform finger
sticks or give IM/IV fluids/injections (include contracted
personnel):
o On hire
o Annually
o When products change
Wisconsin Department of Health Services
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Injection Safety and
Point-of-Care Testing
• Conduct routine audits to monitor and document
adherence to policy.
• One needle, one use, one patient, one time.
• Provide HCP audit feedback with follow-up
documentation.
• Ensure availability of necessary supplies (e.g., single use
needles and syringes, auto-disabling lancets, and sharps
containers).
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• Ensure proper cleaning after each
resident glucometer use.
• Have cleaning instructions readily
accessible.
• Track HCP access to controlled
substances to prevent drug
diversion.*
Injection Safety and
Point-of-Care Testing
*Important in case non-sterile injections are given.
Wisconsin Department of Health Services
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Infection Control
Risk Assessment (ICRA)
ICRA must be carried out to
assess infection hazards and
risks and ensure that, where
possible, infection risks are
eliminated, reduced, contained,
and managed appropriately.
www.ashe.org/resources/tools/pdfs
/assessment_icra.pdf
Wisconsin Department of Health Services
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Wisconsin Department of Health Services
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Next ICRA Class Offered
Date: Thursday, December 19, 2019
8:00 a.m. to 4:00 p.m.
Location: Carpenters Training Institute
N25W2055 Paul Road
Pewaukee, WI 53072
Register online: Doug Volland, [email protected],
phone: (262) 389-5432, https://conta.cc/2HhLm3K
Wisconsin Department of Health Services
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IP Program Risk Assessment
• Used to stratify or rank infection risks and guide your IP
program.
• Divided into three sections:
o Probability—How likely is it to occur?
o Impact—How serious is it if it occurs?
o Current systems—How good are your current systems in
preventing it from occurring?
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What are Your Risks?
• Surgical procedures (e.g., new, different, implants,
transplants)
• Special venous access (e.g., PICCs, ports, fistulas)
• Instrument reprocessing concerns (e.g., new items,
endoscopes, lack of space in department)
• Immunocompromised populations (e.g., neonatal, elderly,
oncology, transplant)
• Outbreaks (e.g., measles, Legionella, MDROs, others)
• Building concerns (e.g., new construction, old construction)
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IP Program Risk Assessment Exercise
Wisconsin Department of Health Services
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Stop the Line
