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Infection Control Risk Assessment

Terrie B. Lee, RN, MS, MPH, CICDirector, Infection Prevention & Employee

HealthCharleston Area Medical Center

Charleston, WV

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Organizational Infection Risk Assessment

• Part of infection prevention and control planning process

• Serves as starting point of well-developed plan• Together with plan, form foundation of program• Assists in focusing surveillance and other

program activities• Meets regulatory requirements

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Infection Risk AssessmentRegulatory Influence

• Identify risks for acquiring and transmitting infections based on:– Geographic location, community, and

population served– Care, treatment, and services provided– Analysis of surveillance activities and other

infection data

• Risks identified annually and when significant changes occur

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Infection Risk AssessmentRegulatory Influence

• Risk assessment occurs with interdisciplinary input:– Infection prevention personnel– Medical staff– Nursing– Leadership– Others

• Prioritize and document risks

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Risk Assessment Process

• Homework and Planning– Forms

• Preliminary completion of organization evaluation form

• Preparation of risk assessment form

– Standards– Reports: Surveillance data– Knowledge of current issues

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Risk Assessment Process

• Team Recruitment– Invitation– Solicit information in advance

• What are the most important infection prevention and control problems?

• What are our most frequent reasons for visit, admission, procedures performed, etc.?

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Risk Assessment Team

• IP Staff• Employee Health• Medical Staff• Laboratory• Pharmacy• Nursing• Surgery• Ambulatory Services

• Environmental Services

• Engineering• Administration• Central Processing• Quality/Performance

Improvement• JC Coordinator

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Risk Assessment Meeting

• Commitment for attendance/ participation

• Time for thoughtful discussion

• Prioritizing risks

• Determining IP Plan

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Organization Evaluation

• Factors to Include:– Geographic and environmental– Population characteristics– Area endemic infections– Other area-related risks– Medical care characteristics– Services provided

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Organization Evaluation

• Description of factors

• Characteristics that increase risk for infection

• Characteristics that decrease risk for infection

• Get input at meeting for final completion of form

• Include findings in risk assessment

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Risk Assessment

• The group work begins!

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Risk Groups

• Antibiotic-resistant organisms• Failure of prevention activities• Isolation activities• Policy & procedure• Preparedness• HAIs• Environment• Employee Health• Other

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Assigning Three Values to Each Risk

• Probability of event occurring

• Impact/severity

• Current systems

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Probability Considerations

• Known risks

• Historical data

• Reports in literature

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Impact Considerations

• Threat to life and/or health

• Disruption of services

• Loss of function

• Loss of community trust

• Financial impact

• Legal issues

• Regulatory impact

• Standards/requirements16

Current Systems Considerations

• Current policy & procedure

• Implementation of plans

• Training status

• Measures of outcome or process

• Availability of backup systems

• Community/public health resources

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How to Assign Values

• There are no right or wrong answers!

• Allow discussion

• Push group for consensus

• Keep group focused, on target

• Important to be consistent

• Go through entire list of risks

• Assign someone to calculate risk scores

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Risk Score

• Derived from multiplication of three component numbers

• Group consensus vs. mathematical averaging or summation

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Prioritization

• Rank order risks using risk scores

• Each organization’s priorities will be different

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Risk Assessment Exercise

• Determine fictitious setting

• Discuss each potential risk

• Come to group consensus on assignment of number for each component

• Multiply component numbers to calculate risk score

• Occasionally compare risk scores to validate with group

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Infection Prevention PlanRegulatory Influence

• Written infection prevention plan– Goals– Measureable objectives– Strategies for implementation

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Infection Prevention PlanRegulatory Influence

• Goals based on prioritized risks and include:– Limiting unprotected exposure to pathogens

(isolation precautions and use of PPE)– Limiting transmission related to procedures– Limiting transmission related to medical

equipment , devices, supplies– Improving hand hygiene

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Infection Prevention Progress Report

• Priority

• Goal

• Objectives

• Strategies

• Evaluation method

• Current status/ Evaluation/ Next Steps

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Infection Prevention Progress Report

Rank-ordered priorities From risk assessment

Goals (broad statements) To address each priority

Objectives (measureable) To achieve each goal

Strategies Steps to achieve each objective

Evaluation method For each objective (how to measure success)

Progress and Analysis How are we doing? Next steps defined

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Sample Goal & Objectives

Assessment: Personnel wash hands or use alcohol hand rub during direct patient care activities.

Goal: Increase use of hand hygiene

Objective: Increase use of hand hygiene by direct care providers on 3 North by 40% in the next 6 months

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Infection Prevention Progress Report Exercise

• For top three scored risks, complete the following:– Goal– At least one objective– Strategies to reach objective– Method of evaluation

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Benefits of Risk Assessment Meeting

• Spreading the knowledge of what you “do”

• Getting buy-in and support from key organizational stakeholders

• No individuals to blame for priorities – organizational decisions

• Many people able to articulate how IP plan was created

• Meets regulatory requirements

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Infection Prevention Progress Report

• Tracks most important aspects of IP program

• Reporting mechanism

• Demonstrates program results/ improvement

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Summary

• Each organization must conduct an infection risk assessment that is unique to itself. This risk assessment is used to set priorities for the infection prevention program.

• Once priorities are identified, goals, objectives, and strategies help to create the organizational infection prevention plan.

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Summary, cont.

• The risk assessment process is ongoing, with a focused revision taking place annually.

• A progress report can be used to track and report priorities and accomplishments of the infection prevention program.

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Questions

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