The hospital, in accordance with The Joint Commission Standards, ensures our patients and the community are protected by following guidelines set forth by The Joint Commission. Compliance recommendations include four areas…Information Management, Infection Control, Communication and Medication Management. By focusing on these compliance recommendations, Nightingale Community Hospital focuses on patient safety and providing the highest quality of care available.
Infection control is a priority focus area. The goal is to protect everyone who enters the hospital setting. Infection control involves surveillance and identification, prevention and control of infections for all patients, employees, and visitors within the hospital setting. Infection control involves every person who enters the hospital and all departments and employees within the hospital setting.
The table provides the four Joint Commission standards that will be the focus of this report. The next planned visit for Nightingale Community Hospital by The Joint Commission is in 13 months. We will review current compliance standards that are met, as well as, the compliance standards that need to be improved upon.
Joint Commission Standard
The hospital implements its infection prevention and control program, including surveillance, to minimize, reduce, or eliminate the risk of infection. NPSG.07.01.01 Comply with either the current CDC (Centers for Disease Control and Prevention) hand hygiene guidelines or the current WHO (World Health Organization) hand hygiene guidelines. NPSG.07.03.01 Implement evidence-based practices to prevent health care–associated infections due to multi-drug resistant organisms in acute care hospitals.
This requirement applies to, but is not limited to, epidemiologically important organisms such as MRSA (methicillin-resistant staphylococcus aureus), CDI (clostridium difficile), VRE (vancomycin-resistant enterococci), and multi-drug resistant gram-negative bacteria. Use proven guidelines to prevent infections that are difficulty to treat. NPSG.07.04.01
Implement evidence-based practices to prevent central line–associated bloodstream infections. This requirement covers short- and long-term central venous catheters and PICC (peripherally inserted central catheter ) lines. Use proven guidelines to prevent infection of the blood from the central lines. NSPG.07.05.01
Implement evidence-based practices for preventing surgical site infections. Use proven guidelines to prevent infection after surgery.
The following areas will need to be monitored, due to present deficiencies: Surgical site infection (SSI) rate following total knee replacement was higher than the following SSI rates for the same procedure at comparable hospitals. SSI rate following general surgery procedures was higher than the same type of procedures at comparable hospitals.
Additional analyses were performed. NCH patient statistics were used to identify high risk patients using the NNIS risk index. Patients at highest risk for SSI (NNIS risk index of 2 or greater) showed a significant increase of SSI complications and had almost two-times higher rate of SSI following general surgery at Nightingale Memorial Hospital when compared to the highest risk patients undergoing general surgery at comparable hospitals.
Infection Control reports show deficiencies with Central Line -Blood Stream Infections (CL-BSI). The rate of infection increased in March. A consistent rolling rate (rolling rate is the rate per patient or device days over a rolling 12 month period) was observed through July. The infection rate then increased in August and again increased in the month of September. Thus, the rolling rate increased from July to September. However, the rate of infection decreased in October and remained the same at the same rate to the end of the year, in December.
Hand hygiene compliance showed an overall decrease hospital-wide, in relation to the previous year. Nursing and ancillary departments maintained compliance without rate changes identified. However, Physicians did show improvement and increased compliance from the previous year.
Compliance increased minimally in the central line bundle between the first and the second quarters. Compliance significantly increased the third quarter, but then had a very significant decline by the fourth quarter. The fourth quarter percentage had decreased so much that is was even lower than the initial first quarter in January.
Environment rounds data show the following changes from initial reporting to bi-annual rounds:
Seven of the environment aspects decreased on bi-annual rounds. Seven other aspects improved. Two of the aspects stayed the same, with no statistical changes. The seven environment aspects that decreased and need improvement are the following:
1. General environment is dust-free including air vents.
2. Staff compliance with food/drink restrictions.
3. Refrigerator temperatures are checked daily and clean.
4. Patient rooms/bathrooms are clean and free of dust, spills, and excessive trash; walls are clean and rooms are in good repair.
5. Alcohol foam/gel is easily accessible and not expired.
6. Supplies are not expired (e.g. hemocult, specimen containers/tubes) 7.
BGM (Blood Glucose Monitors) kit cleanliness and expiration. Plan for Compliance
Infection control requires a process that is integrated system-wide. Infection control requires implementation in all settings within the hospital system.
The infection control process includes all patients, employees, volunteers and visitors at Nightingale Community Hospital. Infection control requires maximum effort from all involved to effectively identify potential problems so steps can be implemented to correct these issues. Some processes used in infection control and prevention include the following: surveillance of hospital procedures, identification of potential problems, prevention of transmission of organisms, reporting any transmissions, and measuring the results of the transmissions and those affected.
1. Plan for compliance for NPSG.07.01.01: use of appropriate hand washing techniques to prevent the spread of infection from one patient to another: Observe direct patient care staff routinely washing his/her hands according to facility policy and procedure. Staff responsible for surveillance are the director of nursing, department managers, infection control personnel, risk management personnel and charge nurses. Require all staff to wash his/her hands after each direct patient contact and as needed. Hand washing and changing of gloves after each patient care task.
Hand washing and changing of gloves when performing tasks between individuals to reduce the opportunity for cross-contamination to occur. Interview facility staff and patients for hand washing compliance and what situations caused a breach in compliance. Maintain and provide easily accessible hand washing stations be available for all staff in all areas of the hospital facility. No artificial nails will be allowed to be worn while providing direct patient care. The CDC’s Guideline for Hand washing and Hospital Environmental Control will be followed.
A thorough investigation will be take place upon notification of a violation in the hand washing policies and procedures set forth by the facility. to identify why a break in policy and procedure was made and what can be done to prevent further instances. Compliance to the hand hygiene policy regarding use of Alcohol gel/foam should be monitored through direct observation. Alcohol based gel/foam should be easily and readily accessible to all staff, visitors and patients. The education department will provide all employee instruction regarding policy and procedures for effective reduction in the spread of disease though hand washing.
This will take place on all shifts to ensure the presence of every employee at NCH. To ensure attendance a dated, sign-in sheet will be completed. This will be a mandatory quarterly in-service. Each department within NCH will maintain an infection control log to identify any infections. The log will be discussed during weekly Quality Improvement and Risk Management meeting. The director of QI and RM programs will monitor departmental processes and include each department of the hospital. The infection control department and director of nursing will help conduct inspections to ensure follow through of the program.
2. Plan for compliance for NPSG.07.03.01: the process for infection control and prevention, due to multidrug-resistant organism infections:
Full compliance under this infection control area has been maintained, thus there is not any deficiency at this time. The number of Multi Drug Resistant Organisms (MDRO) cases, the rate of infections by MDRO and the rolling rates have decreased since the beginning of the year and have maintained low rates or decreased even further by the year end.
MDRO bundle compliance increased every quarter. The first quarter was 78%, second quarter 85%, third quarter 89% and finally the fourth 95%. The average compliance for the year is 88%. The decrease in transmission has been possible due to extensive MDRO education. The focus was on staff and patient education. However, multi-drug resistant infections can be acquired in almost any setting, including homes, schools, and public areas making the need for effective infection prevention and control in the hospital setting all the more important.
3. Plan for compliance for NPSG.07.04.01: Implement evidence-based practices to prevent central line–associated bloodstream infections, this requirement cover short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines: Primary Bloodstream Infections: Facility-wide surveillance for 12 months. With implementation of infection reduction strategies including six-sigma project
(Is a more rigorous approach to ensuring quality — one that extends beyond the QAPI department, and actually becomes a foundation for creating a culture of excellence throughout Nightingale Community Hospital), reporting central line infections per 1000 patient days and 1000 central line days facility wide, implementing daily chlorahexadine gluconate (CHG) bathing in ICU (Bathing of ICU patients has been associated with decreased rates of CLA-BSI (Bleasdale, et. al, 2007)) Goal: Reduce the CL-BSI rate to < 0.1/1000 patient days by the end of the year. Goal of “Zero” for CL-BSI infections bundle compliance. All device-related nosocomial infections for 12 months involving central line bundle compliance.
Maintain an infection control log involving CL-BSI related infections, to identify infections and these patients are being sufficiently monitored for infection. This log will be discussed in weekly QAPI meetings. Infection Control, QAPI, and director of nursing will monitor The Education Department, will provide instruction on the policy and procedures for CL on all shifts, making sure the presence of every nursing employee at Nightingale Community Hospital is present. A dated sign-in sheet will be required.
The education department will instruct the staff, about the implemented policies and practices directed at reducing the risk of central line–associated bloodstream infections. These policies and practices meet regulatory requirements and are aligned with evidence-based standards. Direct patient care staff will be observed while working with CL patients. The responsible staff for surveillance and/or monitoring are director of nursing, infection control, QAPI and charge nurses.
Cross-contamination will be prevented by implementing hand washing procedures and/or changing gloves before and after providing CL procedures. Education for patients and families will be provided prior to central venous catheter (CVC) placement regarding bloodstream infection prevention and signs/symptoms of infection A standardized protocol for sterile barrier precautions during CVC insertion will be implemented and utilized with every CVC insertion (Dutcher, et. al, 2013).
A standardized protocol for care of the CVC hubs and injection ports during use and while not in use will be implemented and utilized with every CVC (Dutcher, et. al, 2013). A CVC will be monitored every 2 hours for S/S of infection while in use and every 6 hours when not in use. A CVC is to be removed if nonessential (Dutcher, et.
4. Plan of compliance for NSPG.07.05.01: standards for creating a sterile field, the implementation of practices for preventing surgical site infections:
The rate of SSI following total knee replacement was higher than the mean rate of SSI following similar procedures at comparable hospitals.
Thus, we will continue to monitor rates of SSI following these procedures. A recommendation implementing a system to ensure that appropriate peri-operative antimicrobial agents are administered within one hour prior to incision. In addition, weight-based dosing for obese patients and re-dosing of antibiotics for prolonged procedures may help reduce rates of SSI.
The rate of SSI in general surgery procedures was statistically higher than the mean rate of SSI following general surgery at comparable hospitals. Thus, we will continue to monitor rates of SSI following these procedures. A recommendation of strict adherence to appropriate antimicrobial prophylaxis, including administering an appropriate agent within one hour prior to incision.
In addition, administering an additional dose if the procedure is greater than 3 hours in length. Finally, adjusting doses of antibiotics for obese patients to a weight based formula is recommended. Improvement in Evidence Based Score (EBS) compliance related to antibiotic administered within 1 hour, Beta blockers, and VTE prophylaxis. Goal: EBS >90% before the end of the fiscal year. Follow National Healthcare Safety Network (NHSN) procedures by means of surgeon surveys, lab reports, referrals, unit rounds and coders (readmissions) utilizing the risk adjusted SSI database.
Procedures must be followed to prevent cross-contamination, including hand washing and/or changing gloves before and after providing surgical procedures, or when performing tasks among individuals which provide the opportunity for cross-contamination to occur. Hands and arms will be cleaned up to the elbows with an antiseptic agent prior to surgery. The hands will need to be cleaned with soap and water or an alcohol based hand rub before and after caring for each patient even if gloves are worn. Antibiotics will be administered prior to surgical care. In most cases, the patients will get their antibiotics within 60 minutes of planned surgical care.
Antibiotics will be continued for 24 hours and then discontinued. Surgical suites are to remain as aseptic as possible and mandatory caps, gowns, surgical scrubs and gloves are to be worn. Absolutely no outside shoes may be worn in the surgical suite, only shoes worn within the hospital facility may be worn and need to have shoe booties in place prior to entering surgical area. Patients who require hair removal prior to surgery will have electric clippers used only. Razors may not be used prior to a surgical incision being made.
The skin will be cleansed with chlorahexadine gluconate after all hair clippings have been removed. Maintain an infection control log involving SSI related infections, to identify infections and these patients are being sufficiently monitored for infection. This log will be discussed in weekly QAPI meetings. Infection Control, QAPI, and director of nursing will monitor. The Education Department will provide a quarterly in-service on all shifts regarding the policy and procedures for SSI. Attendance will be recorded making sure the presence of every employee, normally involve in this kind of surgical procedure, is present and a dated sign-in sheet will be completed.
The education department will instruct the staff, about the implemented policies and practices directed at reducing the risk of SSI–associated infections. These policies and practices meet regulatory requirements and are aligned with evidence-based standards. Direct patient care staff will be observed while working with surgical patients. The responsible staff for surveillance and/or monitoring are director of nursing, infection control, QAPI and charge nurses.
The goal is “Zero” for SSI infections bundle compliance. All device-related nosocomial infections for 12 months involving surgical site bundle compliance. Periodic risk assessments for SSI infections will be conducted, monitor compliance with evidence-based practices, and evaluate the effectiveness of prevention efforts. This infection surveillance activity will be hospital-wide, not targeted.
5. Plan for compliance for Environmental rounds data showing decline:
Maintain an environmental control log involving the deficiencies, described in the executive summary, to ensure that these deficiencies are being identified and that the patient rooms and bathrooms are being adequately
monitored, medical supplies are in order regarding the expiration dates, refrigerators temperature checking and cleanliness are being done daily. This log will be discussed in monthly QAPI meetings. Infection Control, QAPI, and director of nursing will monitor. The BGM (Blood Glucose Monitors) kits cleanliness and expiration, will be under the responsibilities of the nursing staff. This will also be monitored for compliance by the director of nursing, department managers and the charge nurses.
A control log will be maintained Staff compliance with food/drink restrictions will be under the responsibilities of the dietary department on a daily basis. Any food or drink item, left in the refrigerator, without being dated, will need to be removed. If the date has passed more that three days, this food/drink item will be removed from the refrigerator. Housekeeping will be helping to monitor the issue. Justification
Infection Control is an integral part in a healthcare system. Prevention of infection can reduce hospital costs and stays. In fact, healthcare workers can take simple steps to reduce the spread of disease. The World Health Organization in 2007 stated hand hygiene (hand washing) is the single most important way to prevent the spread of disease. We need to recognize that an infection prevention and control program plays a major role in improving patient safety and quality of care.
A hospital’s infection control department should perform comprehensive surveillance for infections associated with healthcare workers. The department should then work to create and implement evidence-based interventions to prevent these transmissions and infections. The infection control department may be what stands in the way of a healthcare acquired infection, which is one of the leading causes of death. This, in itself, is a valuable resource for both the healthcare worker and a patient. References
Bleasdale, S.C., Trick, W.E., Gonzalez, I.M., Lyles, R.D., Hayden, M.K., and Weinstein, R.A., Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med. 2007;167(19):2073-2079. doi:10.1001/archinte.167.19.2073
Dutcher, K., Lederman, E., Brodine, S., and Patel, S., Impact of the 2013 revised centers for disease control and prevention central line–associated bloodstream infection (CLABSI) surveillance definition on inpatient hospital CLABSI rates: Is it enough?
Infection Control and Hospital Epidemiology Vol. 34, No. 9 (September 2013), pp. 999-1001 Published by: The University of Chicago Press
http://www.who.int/csr/bioriskreduction/infection_control/en/index.html retrieved on August 25, 2013