Hospital Patient Safety Initiatives: Infection Control

Michele Kala, MS,RN

October 2011-Developed by CMS • Related to three Conditions of Participation

(CoPs)– 482.21 Quality Assessment and Performance

Improvement (HFAP Hospital Chapter 12)

– 482.42 Infection Control (HFAP Hospital Chapter 7)

– 482.43 Discharge Planning (HFAP Hospital Chapter 15)

Worksheet Purpose

• Reduce hospital acquired conditions (HAC) including hospital acquired infections (HAI) and preventable readmissions.

• Designed to assist surveyors and hospital staff to identify when and where compliance is an issue.

CMS Worksheet Development

• In draft format

• Currently in use by state surveyors, accredited facilities and accrediting agencies.

CMS Worksheets:

• Facilitate recording of observations by surveyors

• Are a self-assessment tool

Findings

• Hospitals with higher readmission rates may be at greater risk for noncompliance with all three CoPs.

• The tools assist facilities in focusing on key issues that impact positive patient outcomes and thereby compliance.

Verification Methods

• Interview

• Observation

• Topic Specific Document Review

• Medical Record Review

• Other Document Review

Hospital Patient Safety Initiatives

• Quality Assessment and Performance Improvement

• Infection Control

• Discharge Planning

Infection Control Worksheet

Five Sections1.Infection Prevention2.General Elements3.Equipment Reprocessing4.Tracer Patient5.Special Care Environment

1. Infection Prevention

• Prevention Program

• Infection Control Quality Systems

• Multiple Drug Resistant Organism Prevention (MDRP) and Antibiotic Stewardship

a. Prevention Program & Resources

1. A designated Infection Control Officer (ICO)2. Qualifications of ICO3. Practice and policies based on nationally

recognized standards and state law4. Infection Control Risk Assessment related to

construction(Above scored at 07.01.01)5. Air exchange rates (07.01.02)

Construction Risk Assessment

www.ashe.org– ICRA Matrix

Air exchange rates

Airborne Infection Isolation Room (AIIR)• Existing construction-

6 air exchanges per hour, OR

• New construction or renovation –12 exchanges per hour, OR

• Per state licensure rules, if more stringent.

Air exchange rates (cont’d)

• Direct exhaust to the outside, or recycled through a HEPA filter

• Daily monitoring of pressure with visual indicators.

• Door is closed(Scored at 07.01.02)

b. Hospital Quality Systems Related to Infection Prevention and Control

1. IC Problems are Identified and Addressed(07.01.04)

2. Non-punitive Approach to Reporting(12.00.21)

3. Leadership Support(07.01.04)

3. Infection Control Risk Assessment (NOT SCORED)

Infection Control Risk Assessment: References

• Infection Control Risk Assessment APIC 2011-Baltimore (Web search)

• http://oregonpatientsafety.org/healthcare-professionals/infection-prevention-toolkit/section-1-infection-prevention-programdevelopment/473/oregonpatientsafety.org/healthcare.../infection...toolkit/...infection.../473/

c. Prevent MDROs and Promote Antibiotic Stewardship, Surveillance

1. Policies to minimize transmission of Multiple Drug Resistant Organism (MDROs)

2.Facility MDRO policy effectiveness: identification process preventing development and transmission of MDROs

(1 & 2 NOT SCORED)

c. Prevent MDROs and Promote Antibiotic Stewardship, Surveillance (cont’d)3. Antibiotic Stewardship• Process to review Antibiotic Utilization, Susceptibility and

Availability• Appropriate antibiotic selection• Indications for Use Documented• 72-hour review• Timely IV to oral switch• Resistance Pattern Notification

(NOT SCORED)

c. Prevent MDROs and Promote Antibiotic Stewardship, Surveillance (cont’d)• Colonized or Infected Patients on Admission and

HEALTHCARE PERSONNEL are Identified and Isolated (07.01.02)

• List of Current Reportable Diseases (not scored)• Reportable Diseases are Reported to local and

State Health Departments (07.01.02

d. Infection Control Training

• Job Specific IC Training on Hire and ANNUALLY (04.00.11 also)

• Bloodborne Pathogen Training as Appropriate• Policies on Sharps Injuries and Exposures—patient

and staff • Treatment and Prophylaxis following exposure• TB Conversion Follow-up

(all scored at 07.01.02)

d. Infection Control Training (cont’d)• Respiratory Protection System

(N95 disposable respirator system) with polices and procedures regarding use

• Annual fit testing• Employee health policies:

• Reporting of illness without penalty• Staff education regarding prompt reporting of illness

• Annual calculation of TB conversion rates

(these questions not scored)

d. Infection Control Training (cont’d)

• Staff annual (at a minimum) IC training and competency validation and also following identification of IC issues. (also 04.00.12)

• Corrective action and causal analysis following employee exposures

(both scored at 07.01.04)

d. Infection Control Training (cont’d)• Hep B Vaccinations Offered (not scored)• TB Testing Done Upon Hire (two step process)

& follow-up based on the facility risk classification and state requirements (07.01.23)

• Annual Flu Immunizations Offered to all Staff. (scored at 07.01.25)

2. General Infection Control Elements

• Applicable in all locations where patients are treated

a. Hand Hygiene (07.01.01 & 07.01.21 )b. Injection Practices and Sharps Safety (07.01.02)c. Personal Protective Equipment (PPE) (07.01.02)d. Environmental Services (07.01.02)

a. Hand Hygiene

• Availability of hand-washing areas• Availability of alcohol-based hand rub solution• Hand hygiene is performed (even though gloves are

worn):• before patient care• prior to leaving a patient environment• prior to an aseptic task• following contact with blood, body fluids

or contaminated surfaces

a. Hand Hygiene (cont’d)

• Soap and water cleansing occurs when hands are visibly soiled

• Artificial nails are prohibited in high risk areas

b. Injection Practices and Sharps Safety• Injection preparation areas clean and free of

contaminates• Single use needles• Syringes are used for only one patient, including

insulin pens• Rubber stopper disinfection • Medication vial access with a clean needle ONLY• Medication vial access with a clean syringe ONLY

b. Injection Practices and Sharps Safety (cont’d)• Single Patient Use Items:

Single dose vials IV bagsMedication tubing and connectors

• Multidose vials are dated for 28-day expiration• Multidose vial use for multiple patients are not kept in

treatment areas• Use of sharps containers for disposal • Sharps container replacement

c. Personal Protective Equipment

• PPE availability at point of use• Staff glove when in contact with blood, body fluids,

mucous membranes or non-intact skin• A glove change and hand hygiene prior to moving

from a contaminated to a clean body site• Gown use• Mouth, nose, and eye protection• Surgical mask use when entering an epidural or

subdural space

d. Environmental Services

• Environmental service worker PPE use (also 07.03.08)• Patient care area cleaning processes—high touch

areas are cleaned daily• Terminal Cleaning and removal of linen• Use of cleaners and disinfectants reflect

manufacturers guidelines for use• Clean cloths for each patient room/corridor (also

07.03.06)

d. Environmental Services (cont’d)

• Mop head and cloth cleaning daily (also 07.03.06)

• Blood and body fluid cleaning process--spills

• Equipment cleaning schedules (HVAC, eyewash stations, ice machines, refrigerators, scrub sinks and aerators on faucets)

d. Environmental Services (cont’d)

• Handling of clean and dirty laundry with no potential for cross contamination

• Bagging and storage of dirty linen

• Segregation of clean from dirty in laundry processing area

(also 07.04.01 for all three)

d. Environmental Services (cont’d)

• Disinfection of non-critical reusable patient care items, using manufacturers instructions if applicable is specifically assigned by policy and staff can articulate the process

• Cleaning of hydrotherapy equipment

3. Equipment Reprocessing

a. Reprocessing of Semi-Critical Equipment(Scored at 07.01.02)

b. Reprocessing of Critical Equipment (Scored at 07.01.02)

c. Single Use Devices (Scored at 07.01.01)

a. Processing of Semi-Critical Equipment

• High Level Disinfection Policy—make sure the policy is consistent for Ultrasound, TEE probes and outpatient areas (also 07.02.08)

• Flexible endoscope inspection and testing• Pre-cleaning processes• Use of enzymatic cleaners• Cleaning brush maintenance

a. Processing of Semi-Critical Equipment (cont’d)

• Chemicals used in high level disinfection• Automated equipment processing• Appropriate processing length of time and

temperature recorded• Rinsing process following disinfection

a. Processing of Semi-Critical Equipment (cont’d)

• Drying of equipment following disinfection• Maintenance records for disinfection

equipment• Equipment storage following disinfection• Logs regarding equipment use

b. Reprocessing of Critical Equipment

• Pre-cleaning process

• Use of enzymatic cleaners

• Cleaning brush maintenance

• Wrapping/packaging process

b. Reprocessing of Critical Equipment (cont’d) • Use of chemical indicators in all packs in every load• Use of biological indicators at least weekly and with

all implants• Bowie-Dick testing in pre-vacuum steam sterilization gravity displacement vs. pre-vacuum steam sterilizers(also 07.02.05)• Labeling of sterile packs—sterilizer, load number and

date (also 07.02.09)

b. Reprocessing of Critical Equipment (cont’d)

• Sterilizer logs are kept for all loads (also 07.02.06)

• Maintenance of sterilizers is per manufacturers recommendations

• Storage of sterilized items prevents contamination (also 07.02.04)

b. Reprocessing of Critical Equipment (cont’d) • Inspection of processed items prior to use

• Immediate Use Steam Sterilization (IUSS) previously know as flash sterilization: Item must be thoroughly cleaned Sterilizer cycle is appropriate for the instrumentAll appropriate chemical and biological indicators are usedThe facility has adequate instrumentation to meet the

needs defined by surgical volume.

b. Reprocessing of Critical Equipment (cont’d)

• Immediate use of flashed equipment(also 07.02.01 for flash sterilization process)• Recall of sterilized equipment (also 07.02.10)

c. Single-Use Devices

• Disposal after use or opening

OR

• FDA-registered vendors used for reprocessing (also 07.02.03)

Patient Tracers

Policies and procedures to identify and prevent infections for the following:

• Urinary Catheter• Central Venous Catheter• Ventilator/Respiratory Care• Spinal Injection Procedures• Point of Care Devices • Isolation Precautions• Surgical Procedures

Patient Tracers, Cont.

• Issues identified during the survey which indicate the processes in place are not controlling and preventing infections would be scored at 07.01.01

• Protocols are not required but policies and procedures and staff compliance must demonstrate effectiveness in controlling and preventing infections

Urinary Catheter Tracer

• Use of urinary catheters in a manner to minimize infectionUse of urinary catheters in a manner to minimize infection• Hospital maintains guidelines for appropriate use of urinary Hospital maintains guidelines for appropriate use of urinary

catheterscatheters• Hand hygieneHand hygiene• Before and after insertionBefore and after insertion

• Placement of catheter using aseptic techniquePlacement of catheter using aseptic technique• Catheter properly secured after insertionCatheter properly secured after insertion

(scored at 07.01.02)(scored at 07.01.02)

Urinary Catheter Tracer• Catheter insertion and indication are documented Catheter insertion and indication are documented (10.01.04)(10.01.04)

• Hand hygiene before and after manipulation of catheterHand hygiene before and after manipulation of catheter

• Avoid irrigationAvoid irrigation

• Collection bag emptied using aseptic techniqueCollection bag emptied using aseptic technique

• Aseptic collection of urine samplesAseptic collection of urine samples• Small amounts through needleless portSmall amounts through needleless port

• Keep urine collection bag below level of bladder at all timesKeep urine collection bag below level of bladder at all times

• Catheter tubing unobstructed with no kinkingCatheter tubing unobstructed with no kinking

(07.01.02)(07.01.02)

Urinary Catheter Tracer

• Need for catheter reviewed dailyNeed for catheter reviewed daily• Prompt removal when deemed unnecessaryPrompt removal when deemed unnecessary• No “convenience”No “convenience”

(Not scored)(Not scored)

Central Venous Catheter Tracer• Central venous catheters are inserted, assessed and maintained in a manner to Central venous catheters are inserted, assessed and maintained in a manner to

minimize infectionminimize infection• Hand Hygiene performed before and after insertionHand Hygiene performed before and after insertion• Maximal barrier precautions used for insertionMaximal barrier precautions used for insertion

• Surgical protection including full patient body drapeSurgical protection including full patient body drape• Use of >0.5% chlorhexidine with alcohol used for skin antisepsis prior to Use of >0.5% chlorhexidine with alcohol used for skin antisepsis prior to

insertioninsertion• Can use tincture of iodine, iodophor or 70% alcohol alternativelyCan use tincture of iodine, iodophor or 70% alcohol alternatively

Dressing to cover catheter insertion siteDressing to cover catheter insertion site• Sterile gauzeSterile gauze• Sterile transparent, semi-permeable dressingSterile transparent, semi-permeable dressing

• Well healed and tunneled catheters may not need to be coveredWell healed and tunneled catheters may not need to be covered

(07.01.02)

Central Venous Catheter Tracer• Central line insertion and indication documented Central line insertion and indication documented (10.01.04)(10.01.04)

• Hand hygiene performed before and after manipulating catheterHand hygiene performed before and after manipulating catheter• GlovesGloves• Soiled dressings are changed promptly Soiled dressings are changed promptly • All dressings changed using aseptic techniqueAll dressings changed using aseptic technique• GlovesGloves

• Access port is scrubbed with an appropriate antiseptic prior to accessingAccess port is scrubbed with an appropriate antiseptic prior to accessing• Chlorhexidine, Povidone iodine, an iodophor, or 70% alcoholChlorhexidine, Povidone iodine, an iodophor, or 70% alcohol

• Catheter accessed with sterile devicesCatheter accessed with sterile devices(07.01.02 & 07.01.19)

Central Venous Catheter Tracer

• Need to central venous catheters reviewed daily with prompt Need to central venous catheters reviewed daily with prompt removal when not necessary removal when not necessary (Not scored)(Not scored)

Ventilator/Respiratory Therapy Tracer

General Respiratory Therapy Practices for all Patients:General Respiratory Therapy Practices for all Patients:• Hand hygiene Hand hygiene • GlovesGloves• Sterile water for nebulizationSterile water for nebulization• Single dose vials for aerosolized medicationsSingle dose vials for aerosolized medications• Using manufacturer’s instructions for handling, storing and Using manufacturer’s instructions for handling, storing and

dispensing of medicationsdispensing of medications

Ventilator/Respiratory Therapy Tracer

• If multi-dose vials for aerosolized medications are used for If multi-dose vials for aerosolized medications are used for more than one patient—more than one patient—• Restricted to a centralized medication locationRestricted to a centralized medication location• They do not enter the immediate patient treatment areaThey do not enter the immediate patient treatment area(07.01.02 & 17.00.04)(07.01.02 & 17.00.04)• Comprehensive oral hygiene program for all at risk patientsComprehensive oral hygiene program for all at risk patients• Elevated HOB for all at risk patients (ventilator or enteral tube Elevated HOB for all at risk patients (ventilator or enteral tube

placement) placement) (not scored) (not scored)

Ventilator/Respiratory Therapy Tracer

• Ventilator Care:Ventilator Care:• Ventilator circuit is changed if visibly soiled or mechanically Ventilator circuit is changed if visibly soiled or mechanically

malfunctioningmalfunctioning• Sterile water is used to fill bubbling humidifiersSterile water is used to fill bubbling humidifiers• Condensate in tubing is periodically drained and discardedCondensate in tubing is periodically drained and discarded

• Condensate should not drain toward the patientCondensate should not drain toward the patient• Use of sterile single-use suction catheterUse of sterile single-use suction catheter• Multi-use closed system catheterMulti-use closed system catheter

– Only sterile fluid is used to remove secretionsOnly sterile fluid is used to remove secretions

(07.01.02 & 17.00.04)(07.01.02 & 17.00.04)

Ventilator/Respiratory Therapy Tracer• Sedation is lightened daily in eligible patientsSedation is lightened daily in eligible patients

• Spontaneous breathing trials are performed daily in eligible Spontaneous breathing trials are performed daily in eligible patientspatients• ““Weaning”Weaning”(not scored)(not scored)

Spinal Injection Procedures

• Spinal injection procedures:Spinal injection procedures:• Hand hygieneHand hygiene• Spinal injectionSpinal injection• Aseptic techniqueAseptic technique• Surgical masks are used when placing a catheter Surgical masks are used when placing a catheter

or injecting materials into the epidural or or injecting materials into the epidural or subdural spacesubdural space

(07.01.02)(07.01.02)

Point of Care Devices

• Blood Glucose MeterBlood Glucose Meter

• INR Monitor INR Monitor

Point of Care Devices• Hand hygieneHand hygiene

• GlovesGloves• Used for “finger-stick” proceduresUsed for “finger-stick” procedures• Removed after the procedure, followed by hand hygieneRemoved after the procedure, followed by hand hygiene

• Finger stick devices are used for one patientFinger stick devices are used for one patient• Lancet Lancet • Lancet holding deviceLancet holding device

Point of Care Devices

• Point of Care device is cleaned and disinfected after every use Point of Care device is cleaned and disinfected after every use according to manufacturer’s instructionsaccording to manufacturer’s instructions• Single use only if no manufacturer’s instructions for cleaning and Single use only if no manufacturer’s instructions for cleaning and

disinfectiondisinfection(07.01.02)(07.01.02)

Isolation: Contact Precautions

• Gloves are available and located near point of useGloves are available and located near point of use

• Signs indicating that the patient is in contact isolationSigns indicating that the patient is in contact isolation

• Patients in contact isolation are in single roomsPatients in contact isolation are in single rooms• Can be cohorted based on clinical risk assessmentCan be cohorted based on clinical risk assessment

Isolation: Contact Precautions

• Soap and water must be used when bare hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus during an outbreak. In all other situations, ABHR is preferred.

Isolation: Contact Precautions• Gloves and gownsGloves and gowns• Before entering patient care environmentBefore entering patient care environment• Removed and discarded; hand hygiene is performed before Removed and discarded; hand hygiene is performed before

leaving the patient care environmentleaving the patient care environment

Isolation: Contact Precautions• Dedicated or disposable noncritical patient- care equipment Dedicated or disposable noncritical patient- care equipment

(e.g., blood pressure cuffs) is used or if not available, then (e.g., blood pressure cuffs) is used or if not available, then equipment is cleaned and disinfected prior to use on another equipment is cleaned and disinfected prior to use on another patient according to manufacturer's instructions. patient according to manufacturer's instructions.

Isolation: Contact Precautions• Traffic controlTraffic control

• Into patient’s roomInto patient’s room• Patient moving out of the room to other parts of the hospitalPatient moving out of the room to other parts of the hospital

• Contact precautions outside the patient’s roomContact precautions outside the patient’s room

• Cleaning of objects and patient care areas that are touched in patient’s isolation room Cleaning of objects and patient care areas that are touched in patient’s isolation room • When visibly soiledWhen visibly soiled• At least once a dayAt least once a day

• Terminal cleaningTerminal cleaning• All surfaces thoroughly cleaned and disinfected and all textiles are replaced with clean All surfaces thoroughly cleaned and disinfected and all textiles are replaced with clean

textilestextiles

• Cleaners and disinfectants are labeled and used in accordance with hospital policy and Cleaners and disinfectants are labeled and used in accordance with hospital policy and procedure and manufacturer’s instructionsprocedure and manufacturer’s instructions

(07.01.02)(07.01.02)

Isolation: Droplet Precautions• Masks• On entering• Discarded when leaving

• Signs

• Patient on droplet precautions are housed in a single room or cohorted based on clinical risk assessment

• Hand hygiene

• Limited patient movement for droplet isolation patients• Medically necessary procedures• Patient wears surgical mask when transported• Communication of patient’s status

Isolation: Droplet Precautions• CleaningCleaning• Once a day per policy and manufacturer’s instruction while Once a day per policy and manufacturer’s instruction while

patient is admittedpatient is admitted• Terminal cleaning after discharge including wiping and Terminal cleaning after discharge including wiping and

disinfection of all hard surfacesdisinfection of all hard surfaces• Changing all textiles in the isolation roomChanging all textiles in the isolation room

• All cleaners are used in accordance with hospital policy and All cleaners are used in accordance with hospital policy and procedure and manufacturer’s instructions (dilution, storage, procedure and manufacturer’s instructions (dilution, storage, shelf-life, contact time)shelf-life, contact time)

(07.01.02)

Isolation: Airborne precautions

• Use of N-95 or higher particulate respirators Use of N-95 or higher particulate respirators • Available and near point of useAvailable and near point of use• Signs indicating patient is on airborne precautionsSigns indicating patient is on airborne precautions• Clear and visibleClear and visible

• Patients on airborne isolation are housed in airborne isolation roomsPatients on airborne isolation are housed in airborne isolation rooms

• Hand hygiene before enteringHand hygiene before entering• And leavingAnd leaving

• N-95 or higher particulate respirator to be worn when entering patient N-95 or higher particulate respirator to be worn when entering patient room for confirmed or suspected TBroom for confirmed or suspected TB

Isolation: Airborne precautions

• Facility limits movement of patients on airborne isolation to Facility limits movement of patients on airborne isolation to medically necessary purposesmedically necessary purposes• Patient wears surgical mask per hospital policyPatient wears surgical mask per hospital policy• Hospital has means to communicate patient’s statusHospital has means to communicate patient’s status

(07.01.02)

Surgical procedure tracer• Surgical scrub before donning of sterile gloves for a surgical Surgical scrub before donning of sterile gloves for a surgical

procedure in the ORprocedure in the OR

• Use of eitherUse of either

• Antimicrobial surgical scrubAntimicrobial surgical scrub

• FDA-approved alcohol-based antiseptic surgical hand rubFDA-approved alcohol-based antiseptic surgical hand rub

• Visibly soiled hands should be washed with soap and water prior to the Visibly soiled hands should be washed with soap and water prior to the above proceduresabove procedures

• After surgical scrub hands and arms are dried with a sterile towel and After surgical scrub hands and arms are dried with a sterile towel and sterile surgical gown and gloves are donned in the ORsterile surgical gown and gloves are donned in the OR

Surgical procedure tracer• Surgical attireSurgical attire• ScrubsScrubs• Surgical caps/hoods covering all head and facial hairSurgical caps/hoods covering all head and facial hair• Worn by all personnel in semi restricted and restricted areasWorn by all personnel in semi restricted and restricted areas

• Restricted areas includeRestricted areas include• OROR• Procedure roomsProcedure rooms• Clean coreClean core

• Semi restricted areas includeSemi restricted areas include• Peripheral support areas of the surgical suitePeripheral support areas of the surgical suite

Surgical procedure tracer• MasksMasks

• Properly tied and fully covering mouth and nose are worn by all personnel in Properly tied and fully covering mouth and nose are worn by all personnel in restricted areas where open sterile supplies or scrubbed persons are locatedrestricted areas where open sterile supplies or scrubbed persons are located

• Sterile drapes are used to establish the sterile fieldSterile drapes are used to establish the sterile field

• Sterile fieldSterile field• Items in sterile field are sterileItems in sterile field are sterile• Items introduced to the sterile field are opened, dispensed and transferred in a Items introduced to the sterile field are opened, dispensed and transferred in a

manner to maintain sterilitymanner to maintain sterility• Established in a location where it will be used and as close as possible to the Established in a location where it will be used and as close as possible to the

time of usetime of use• Movement around the sterile field is done in a manner to maintain sterilityMovement around the sterile field is done in a manner to maintain sterility

Surgical procedure tracer• Traffic in and out of the OR is kept to a minimum and is limited

to essential staff• Traffic Control Policies and Procedures

• Surgical masks are removed when leaving the sterile areas and are not reused when returning

Surgical procedure tracer

• Cleaners and disinfectantsCleaners and disinfectants• Used according to hospital policy and procedure and Used according to hospital policy and procedure and

manufacturer’s instructionsmanufacturer’s instructions

Surgical procedure tracer• Cleaning—start of the dayCleaning—start of the day• Horizontal surfacesHorizontal surfaces• Damp dusted with a lint-free cloth and EPA-registered Damp dusted with a lint-free cloth and EPA-registered

hospital detergent/disinfectanthospital detergent/disinfectant

• High touch surfaces cleaned and disinfected between patientsHigh touch surfaces cleaned and disinfected between patients

• Anesthesia equipment is cleaned and disinfected between Anesthesia equipment is cleaned and disinfected between patientspatients

• Reusable noncritical items (BP cuffs, etc.) are cleaned and Reusable noncritical items (BP cuffs, etc.) are cleaned and disinfected between patientsdisinfected between patients

Surgical procedure tracer• Terminal cleaning of Operating RoomsTerminal cleaning of Operating Rooms• After the last procedure of the dayAfter the last procedure of the day• Including weekends!Including weekends!• IncludesIncludes

• Wet-vacuuming or moping the floor with an EPA-registered disinfectantWet-vacuuming or moping the floor with an EPA-registered disinfectant

• All surfacesAll surfaces• Internal components of anesthesia machine breathing circuit are Internal components of anesthesia machine breathing circuit are

cleaned according to manufacturer’s instructionscleaned according to manufacturer’s instructions

Surgical procedure tracer• Ventilation requirementsVentilation requirements• Positive pressure, 15 air exchanges per hour—at least 3 of which Positive pressure, 15 air exchanges per hour—at least 3 of which

are fresh airare fresh air• 90% filtration90% filtration• HEPA optionalHEPA optional• Air filters are checked regularly and replaced according to hospital Air filters are checked regularly and replaced according to hospital

policies and procedurespolicies and procedures• Temperature and relative humidity are maintained at required levelsTemperature and relative humidity are maintained at required levels• Doors are self-closingDoors are self-closing• Air vents and grill work are clean and dryAir vents and grill work are clean and dry

(07.01.02 & 07.01.20)(07.01.02 & 07.01.20)

A Protective Environment (e.g. Bone Marrow patients) • Positive pressure—air flow out to the corridor from the roomPositive pressure—air flow out to the corridor from the room

• 12 air exchanges per hour12 air exchanges per hour

• Supply air is HEPA filteredSupply air is HEPA filtered

• Well sealed rooms so that there are no penetration spaces in the walls, Well sealed rooms so that there are no penetration spaces in the walls, ceilings or windowsceilings or windows

• Self closing door that fully closes on all room exitsSelf closing door that fully closes on all room exits

• Failures are addressed and documentedFailures are addressed and documented

(07.01.02)(07.01.02)

A Protective Environment (e.g. Bone Marrow patients) • Ventilation requirements are monitored using visual methodsVentilation requirements are monitored using visual methods• ““Kleenex test”; flutter strips, etc. Kleenex test”; flutter strips, etc. (07.01.04)(07.01.04)

QUESTIONS?

Please submit questions to:

info@hfap.org

POST TEST• This presentation has been awarded 1.5 hours

of AOA Category 2-B CME credit. To receive your CME certificate, please complete the post test at the following link:

• https://testmoz.com/359881 This should bring up “PSI Infection Control Test”.Type in your name and the passcode “PSIIC”.(those are upper case i’s, not lower case L’s)Your certificate will be submitted electronically.