infection prevention and control essentials for …
TRANSCRIPT
INFECTION PREVENTION AND CONTROL ESSENTIALS FOR
AMBULATORY CAREA RESOURCE WORKBOOK
Table of Contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
MODULE 1: Infection Preventionist’s Role in Ambulatory Care . . . . . . . . 4
MODULE 2: Infection Prevention & Control Plan/Risk Assessments . . . 11
MODULE 3: Infection Prevention & Control Basics . . . . . . . . . . . . . . . . . . . 78
MODULE 4: Epidemiology & Infectious Diseases . . . . . . . . . . . . . . . . . . . . 117
MODULE 5: Occupational-Employee Health . . . . . . . . . . . . . . . . . . . . . . . . 118
MODULE 6: Construction & Water Management . . . . . . . . . . . . . . . . . . . .127
MODULE 7: Environmental Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
MODULE 8: Cleaning/Disinfection/Sterilization . . . . . . . . . . . . . . . . . . . . 156
2
Acknowledgements
Development of this Workbook required input and expertise from a team of subject matter experts who selected and organized the materials from a range of facilities and other resources . The Association for Professionals in Infection Control and Epidemiology acknowledges the valuable contributions from the following individuals:
Contributors
Judie Bringhurst, RN, MSN, CICInfection Preventionist and Instrument Reprocessing SpecialistUniversity of North Carolina HospitalsChapel Hill, NC
Pamela S . Falk, MPH, CIC, FAPIC, FSHEAEpidemiologistNorthside HospitalSandy Springs, GA
Carolyn Kiefer, BSN, RN, CICInfection PreventionistCarilion Medical CenterRoanoke, VA
Carol McLay, DrPH, MPH, RN, CIC, FAPICCEOInfection Control InternationalLexington, KY
Sara Townsend, MS, HQS, CIC, FAPICInfection Prevention ManagerChildren’s Hospital of PhiladelphiaPhiladelphia, PA
Project Management
Elizabeth M .R . HartkeDirector, Practice ResourcesAssociation for Professionals in Infection Control and Epidemiology
Elizabeth GarmanVice President, Communications and Practice ResourcesAssociation for Professionals in Infection Control and Epidemiology
Groff CreativeCover Design, Text Design and LayoutSilver Spring, MD
3
Module 1
Infection Preventionist’s Role in Ambulatory Care
Contents
1.1 Emerging Models of Ambulatory Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Constance Cutler, RN, MS, CIC, FSHEA, FAPIC; Jill Lindmair-Snell, MSN, RN, CIC, FAPIC, and Brian Dennen, MBA, AIA, NCARB Prevention Strategist, Winter 2018, p .56-60https://apic .org/publication_types/prevention-strategist/
1.2 Infection Control Compliance Rounding Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Forms & Checklists for Infection Prevention, Volume 1
Resources
Infection Preventionist Competency ModelAssociation for Professionals in Infection Control and Epidemiology (APIC)https://apic .org/professional-practice/infection-preventionist-ip-competency-model/
One and Only CampaignCenters for Disease Control and Prevention (CDC)https://www .cdc .gov/injectionsafety/1anonly .html
Bloodborne Pathogen and Needlestick PreventionOccupational Safety and Health Administration (OSHA)https://www .osha .gov/SLTC/bloodbornepathogens/gen_guidance .html
Healthcare-Associated Infections in Outpatient SettingsCDChttps://www .cdc .gov/hai/settings/outpatient/outpatient-settings .html
4
FEATURE
Emerging models of ambulatory care
BY CONSTANCE CUTLER, RN, MS, CIC, FSHEA, FAPIC, JILL LINDMAIR-SNELL, MSN, RN, CIC, FAPIC, AND BRIAN DENNEN, MBA, AIA, NCARB
I t used to be that an infection preventionist (IP) was responsible for only one location, usually a hospital, but now they have more than one outpatient venue because of acquisitions and mergers.
Those days are coming to an end as healthcare evolves in new ways with many outpatient facilities now under the IP’s umbrella. If your facility is similar to the authors’, you may have an outpatient pain clinic, cancer care center, immediate/urgent care facility(ies), owned physician offices, offsite endoscopy procedure site, and an ambula-tory surgery center, as well as others. All provide new opportunities and challenges, which this article will address to give you an idea how to start and what resources are able to assist you.
Healthcare data show increasing shifts from inpatient to outpatient care.1 Figure 1 illustrates this trend, which is predicted to continue into at least the next 10 years. As healthcare facilities compete on value not volume, there are six market forces driving this change (Figure 2):11. Compression 2. Care management 3. Contraction 4. Consolidation 5. Consumerism 6. Connectivity
There is also a change in all specialties for which patients will be treated as outpatients, ranging from a slight increase (5.6 per-cent) in colorectal patients to a substantial
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56 | WINTER 2018 | Prevention
1.1
5
increase (44.4 percent) in hematology oncol-ogy patients.1 Studies show that revenue derived from outpatients is rising dramati-cally, as compared to inpatient revenue.2
Outpatient ophthalmology and colorec-tal surgeons’ offices have also been impli-cated in disease transmission, as shown in these headlines (Figure 3) that show some occurrences, including a shocking one where anal catheters were reused in 2018.
Now that the stage is set for our shift-ing focus as IPs, we can prepare to take on these new arenas. To start, do your research on historic outbreaks when care was mostly provided to inpatients.
PATIENT-TO-PATIENT TRANSMISSION
As recently as the 1970s, outpatient hemodialysis centers saw clusters of cases of both hepatitis B and C occurring at their free-standing centers. These were addressed by recommendations from the Centers for Disease Control and Prevention (CDC) and other agencies to do blood testing and use separate cleaning protocols and machines on known positive patients. Thankfully, in recent years the numbers of these blood-borne pathogens in dialysis patients have decreased with improved oversight by both dialysis personnel and IPs. Dialysis cen-ter issues haven’t completely disappeared, though. An article reviewing hepatitis B virus (HBV) in dialysis centers summarized several outbreaks that occurred from 1992 through 2014. There were 16 outbreaks that involved 118 patients on maintenance dialysis; 10 fatal cases occurred; multiple deficiencies in standard or hemodialysis-specific procedures was the most common route of patient-to-patient transmission of HBV.3
A survey of clinicians found that 12 percent of physicians and 3 percent of nurses indicated syringe reuse occurs in their workplace.4 This, along with other surprising and depressing results, led the CDC to develop the “One Needle, One Syringe, One Time” Campaign.
AMBULATORY SURGICAL CENTERS
An assessment performed by the Centers for Medicare & Medicaid Services (CMS) of ambulatory surgical centers (ASCs)
WHAT CAN AN IP DO?• Review what kind of issues have occurred in the past and with what frequency.• Make the business case that it is “potentially” scary out there but that regular
visits from a qualified IP can mitigate the real risks. • Go out and see for yourself what’s actually happening, focusing first on the
riskiest areas: - Those performing sterilization of instruments. - Those doing high-level disinfection. - The others “just” providing routine patient care such as using syringes.
Figure 1. Increasing shift to outpatient care. Adapted from Truven Market Expert. 2017-2027 Total US Market.1
Figure 2. Six types of market forces. Adapted from Truven Market Expert. 2017-2027 Total US Market.1
Figure 3. Infection prevention headlines. Adapted from Truven Market Expert. 2017-2027 Total US Market.1
www.apic.org | 57 6
showed that practices in those increas-ingly prevalent areas also pose infection prevention risks, leading to a specialization in ASCs for IPs.5 The actual pilot survey is summarized in Figure 4.
ASCs pose unique challenges and an IP may take on responsibility for them, specializing in them. The concept of hav-ing surgery and going home on the same day started in 1970, when two physicians opened the first freestanding ASC in Phoenix.6 Surgery in an ASC offers patients a cost-effective and convenient alternative to surgery in a hospital setting. As of 2017, there were approximately 5,500 Medicare-certified ASCs in the United States.7 The shift continues from inpatient to outpa-tient as CMS adds to the 3,500 procedures approved for payment in an ASC.6 Surgeries that were typically scheduled in hospital operating rooms are being performed in ASCs. In January 2018, CMS no longer required total knee replacement surgery to be performed only in an inpatient setting.8
Since CMS reimburses for surgical pro-cedures, there is an expectation that ASCs follow CMS’s Conditions for Coverage (CfC). In 2009, CMS enhanced the CfC by adding specific requirements for an IPC program in an ASC.9 The ASC infection control surveyor worksheet (ICSW) is an 18-page document that assists the CMS
surveyor in evaluating healthcare practices during an onsite visit.10 The surveyor will observe at least one surgical procedure and follow a patient from registration through discharge.10 The ICSW will be used to obtain details about the facility includ-ing the types of procedures performed, number of procedural rooms, types of contracted or employed services, hand hygiene, medication practices, cleaning and reprocessing of reusable medical devices, environmental cleaning, point of care testing, and the infection prevention program.10 The surveyor will interview or perform observations to acquire enough information to complete the worksheet; however, if a breach in IPC practices is noted, the breach will be documented.10
Infection prevention has become more important as the number of complex sur-gical procedures that are performed in ambulatory settings increases. If the IP has not previously worked in a periopera-tive setting, they may not feel comfortable with the environment. It is vital for the IP to inquire and learn about all processes within the ASC. Additionally, to be effec-tive, the IP must develop relationships with anesthesia providers, surgeons, surgical techs, nursing, sterile processing, environ-mental services, facilities, nursing, and leadership. The IP can use the ICWS to
make sure the ASC is prepared for a regula-tory visit any time. In addition to the work-sheet, the IP should establish and maintain an environmental rounding program. A multi-disciplinary team can examine the center for potential patient safety and infection prevention concerns. The team should observe medication administra-tion in all areas: aseptic technique, surgi-cal procedures, cleaning of patient care items, reprocessing of medical equipment including transporting, decontaminating, and sterilizing of surgical instruments. Observing these practices can assist the IP in creating a prioritized risk assessment to develop a successful IPC program plan.
MICROHOSPITALMicrohospitals, sometimes known as
neighborhood hospitals, are an emerging model of care delivery. Components of a microhospital typically include 8-12 emergency department rooms, a similar count of inpatient beds, and limited diag-nostics; they often incorporate procedural and medical office space as well (Figure 5). The characteristics of some health systems that have built microhospitals can be seen in Figure 6. These facilities are typically located in suburban and exurban areas and are predominantly in states without certif-icate-of-need regulations. Many facilities
FEATURE
Figure 4. Summary of ASC pilot survey findings. Adapted from Truven Market Expert. 2017-2027 Total US Market.1
58 | WINTER 2018 | Prevention 7
share resources, including IPs, with their parent organization.
HOSPITAL AT HOMEAnother concept which is taking hold
is called “hospital at home.” My 90-year-old mother may benefit from this in the near future because she travels to and from physician visits, and an inpatient stay could become unnecessary if this becomes more prevalent. I know she would prefer to receive care this way. These “hospital at home” programs provide hospital-level care and monitoring and lead to quick recovery at a lower cost. To take part in this concept, a patient would be “admitted” from the emergency department and transported home by ambulance, then met there by a nurse with equipment who would provide daily physical rounding.11
METHODOLOGYThe decisions of healthcare networks to
move care outside the four walls of the hos-pital are strategic to increase market share or locations in far-flung areas. The strate-gies shown in Figure 7 display the method-ical approach health systems follow.
An article published in the American Journal of Infection Control describes a
Figure 5. Components of aa microhospital. Adapted from Truven Market Expert. 2017-2027 Total US Market.1
Figure 7. Methodical approach to health systems. Adapted from Truven Market Expert. 2017-2027 Total US Market.1
Figure 6. Health systems with microhospitals. Adapted from Truven Market Expert. 2017-2027 Total US Market.1
www.apic.org | 59
ST. VINCENT (Indianapolis)
ST. LUKE’S HEALTH SYSTEM (Kansas City)
BAYLOR SCOTT & WHITE HEALTH (Dallas)
8
systematic approach to determine how a healthcare system has changed, or would need to change, the staffing models for IPs and support staff required to build and sustain effective IPC programs.12
The challenges may seem insurmount-able, especially to a novice IP, but doing your homework and making the business case for increased resources are good first steps. Physically going to see these outpa-tient/ambulatory facilities is the key, and prioritization based on a risk assessment of infection transmission will assist in break-ing this down into manageable steps.
It’s possible to survive and thrive because of growing needs for IPC expertise in the current and future healthcare environ-ment. So, what resources does the IP have when facing shifting focus from inpatient to outpatient? Fortunately, there are many, with more coming out from a variety of sources all the time.
These areas are all surveyed by accred-iting agencies, and even accrediting bod-ies such as The Joint Commission have developed, and are developing, publica-tions to assist the IP.13 A potential concern
I do have, because patients do not always understand the definition of surgical site infections or other HAIs, is if the agency includes the following question in its sur-vey of outpatient and ambulatory surgery centers: “At any time after leaving the facil-ity, did you have any signs of infection?”
There’s no need to reinvent the wheel, just educate yourself by attending courses especially designed with a focus on ambu-latory surgery centers or other outpatient venues. The basic principles haven’t changed though. If it’s necessary to do for safe inpatient care, it’s necessary to do for safe outpatient care.
In conclusion, movement of care is hap-pening and will continue to occur in health systems and hospitals from inpatient to outpatient venues. My hope is that the IP will embrace this change and understand and be able to use the information and resources provided in this article to survive and thrive in this new world of outpatient and ambulatory healthcare.
Jill Lindmair-Snell, MSN, CIC, FAPIC, is a system infection prevention manager for Advocate Aurora Health where she is responsible for acute care and ambulatory surgery centers. Jill has more than 25 years of healthcare experience, with the last 11 years in infection prevention and control. She has a Master of Science in Nursing from the University of Phoenix.
Constance Cutler, RN, MS, CIC, FSHEA, FAPIC, spent 37 years as a hospital/healthcare system-based infection preventionist, and is now a consultant for Chicago Infection Control, Inc. She has worked in both large and small hospi-tals, many with extensive networks of outpatient/ambulatory sites. Connie is a former treasurer and board member on the Certification Board of Infection Control and Epidemiology, and past president of the Chicago Metropolitan Chapter of APIC. She has a Bachelor of Science in Nursing from Creighton University, a bachelor’s in biol-ogy from Villanova University, and a master’s in biology from Drexel University.
Brian Dennen, MBA, is a director with Ankura’s Healthcare Capital Asset Strategy team. He has served in senior positions in healthcare admin-istration and in project management of major capital initiatives. Brian works with national and regional health systems, academic medical
FEATURE
centers, physician practices, and other health-care clients on engagements ranging from broad strategic visioning to focused operational initia-tives. He has a Master of Business Administration from Northwestern University’s Kellogg School of Management and a Bachelor of Architecture from Iowa State University; he is a licensed architect in Illinois and a member of the National Council of Architectural Registration Boards.
References
1. Truven Market Expert. 2017-2027 Total US Market. Accessed September 2018.
2. American Hospital Association. Trendwatch Chartbook 2016: Trends Affecting Hospitals and Health Systems. https://www.aha.org/system/files/research/reports/tw/chartbook/2016/2016chartbook.pdf. Published 2016. Accessed September 2018.
3. Fabrizi F, Dixit V, Messa P, Martin P. Transmission of hepati-tis B virus in dialysis units: a systematic review of reports on outbreaks. Int J Artif Organs, 2015;38(1):1-7. doi:10.5301/ijao.5000376.
4. Kossover-Smith RA, Coutts K, Hatfield KM. One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety. Am J Infect Control, doi.org/10.1016/j.ajic.2017.04.292. Published June 2017. Accessed June 2018.
5. Schaefer MK, Jhung M, Dahl M, et al. Infection control assessment of ambulatory surgical centers. JAMA, 2010; 303(22):2273-9. doi: 10.1001/jama.2010.744.
6. Ambulatory Surgery Center Association. Ambulatory Surgery Centers: A Positive Trend in HealthCare. Published October 2011.
7. Rechtoris, M. 51 Things to Know About the ASC Industry. Becker’s ASC Review. https://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/50-things-to-know-about-the-asc-industry-2017.html. Published February 2017. Accessed September 2018.
8. 2018 Final ASC Medicare Payment Rule Released. Ambulatory Surgery Center Association website. https://www.ascassociation.org/aboutus/latestnews/news-archive/newsarchive2017/latestnews112017/201711finalrule2018. Published November 2017. Accessed September 2018.
9. Temple, M. Chapter 64: Ambulatory Surgery Centers. In: Grota P, ed. APIC Text Online. APIC 2018.
10. Ambulatory Surgery Center Infection Control Surveyor Worksheet. Center for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-43.pdf. 2015.
11. Healthcare solutions: Hospital at home. Johns Hopkins University website. https://www.johnshopkinssolutions.com/solution/hospital-at-home/. Accessed October 2018.
12. Bartles R, Dickson A, Oluwatomiwa B. A systemic approach to quantifying infection prevention staffing and coverage needs. Am J Infect Control, 2018;46(5):487-91.
13. CDC Outpatient Settings Policy Options for Improving Infection Prevention. The Joint Commission website. https://www.jointcommission.org/cdc_outpa-tient_settings_policy_options_for_improving_infec-tion_prevention.aspx. Accessed September 2018.
Additional resources The Environment of Care and Healthcare-Associated Infections. (published by ASHE)
Guidelines for Design and Construction (published by Facility Guidelines Institute).
OSHA Bloodborne Pathogens and Needlestick Prevention Standard
CDC’s Guidelines Library: https://www.cdc.gov/infection-control/guidelines/index.html CDC’s Injection Safety: https://www.cdc.gov/injectionsafety/
60 | WINTER 2018 | Prevention
READ MORE ABOUT AMBULATORY CARE IN THE AMERICAN JOURNAL OF INFECTION CONTROLHealth care worker hand contamination at critical moments in outpatient care set-tings. Bingham J, Abell G, Kienast L, et al. Am J Infect Control, Vol. 44, Issue 11, p1198–1202.
Safe Injection Practices: Opportunities for Improvement in Ambulatory Care. Kuznets N, Lerner B, Davidson J. Am J Infect Control, Vol. 46, Issue 6, S4–S5.
A pragmatic approach to infection preven-tion and control guidelines in an ambula-tory care setting. Ng J, Le-Abuyen S, Mosley J, et al. Am J Infect Control, Vol. 42, Issue 6, p671–673.
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6-3. Infection Control Compliance Rounding Checklist
Compliance Rounding Check List: Infection Control
Date:
Location:
Individual(s)performingComplianceRounds:
Otherindividualspresent:
YES NO N/A Action Plan Owner
Patientroomsappearcleanandsanitary;freefromclutterandvisibledebris.
Alcoholbasedhandrubs(ABHR)nearpointofuse,inworkingorder,not
locatedoverelectricaloutlets/switchesandnotexpired.Soapdispenserand
towelsavailablenearsinks.
DisposableglovesandotherPPElocatedconventienttoareasofuse.
Datedsupplieswithinexpirationdates.
Sharpscontainerslessthan3/4fullandlocatednearpointofuse.
Cleanequipmentisstoredincleanarea,dirtyequipmentindesignatedsoiled
holdingareas(i.e.soiledutilityrooms).
Soiledlinenislocatedincontainedhampers/bagsandnotoverfilled.
Areafreefromvisibledustincludingfiresprinklerheadsandventgrills.
Patientcontactsurfacesaredisinfectedbetweenpatients.
Overheadlightsfreefromvisibleinsects,dustanddebris.
Floorscoveringsappeartobewellmaintainedinhallsandpublicareas.
Floorfinishappearstobewellmaintainedinpatientrooms,visiblyclean.
Patientequipmentcleanedanddisinfectedbetweeneachpatientuse.
Icemachineexteriorcomonentsvisiblycleanuponinspection.
Refrigeratorsclean,maintainedperpolicy.
Eyewashstationsvisiblyclean,maintainedperpolicy.
EVSclosetsclean,orderly.Floorsinkcleanedonregularbasis.
ReferenceDebbie Hurst, RN, BSN, CHESP, CIC
Forms & Checklists for Infection Prevention, Volume 1160
1.2
10
Module 2
Infection Prevention & Control Plan/ Risk Assessments
Contents
2.1 Ambulatory Care Suite of Quick Observation Infection Prevention Tools . . . . . . . . . . . . . .13Centers for Disease Control and Prevention (CDC)https://www .cdc .gov/infectioncontrol/pdf/QUOTS/Ambulatory-Care-Suite-P .pdf
2.2 Tuberculosis (TB) Risk Assessment Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31CDC, Division of Tuberculosis Elimination
2.3 Risk Assessment for Infection Surveillance, Prevention and Control Programs in Ambulatory Healthcare Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.4 IPC Assessment Tool for Outpatient Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CDC/HHS
2.5 A pragmatic approach to IPC guidelines in an ambulatory care setting . . . . . . . . . . . . . . 72Jessica Ng, MSc, CIC; Sheila Le-Abuyen, MPH, CPHI(C); Jane Mosley, MScN, RN; Michael Gardam, MD, MSc, CM, FRCPC, CICAmerican Journal of Infection Control, June 2014 Vol 42, Issue 6, p . 671-673https://www .ajicjournal .org/article/S0196-6553(14)00127-8/fulltext
2.6 Infection Prevention in a System of Ambulatory Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Sandy SmithPrevention Strategist, Fall 2019, p . 49-50https://rise .apic .org/web/apic/publications/issue .aspx?issueId=prevention_strategist_-_fall_2019&issueTitle=Prevention%20Strategist%E2%80%94Fall%202019
Resources
Outpatient Settings Policy Options for Improving Infection PreventionCDChttps://www .cdc .gov/hai/pdfs/prevent/Outpatient-Settings-Policy-Options .pdf
Infection Prevention Observation Tools Library Association for Professionals in Infection Control and Epidemiology (APIC) http://ipcobservationtools .site .apic .org/observation-tools-library
Tuberculosis Control in Healthcare Settings CDChttps://www .cdc .gov/tb/topic/infectioncontrol/TBhealthCareSettings .htm
11
Tuberculosis Centers of ExcellenceCDChttps://www .cdc .gov/tb/education/tb_coe/default .htm
State Tuberculosis ResourcesCDChttps://www .cdc .gov/tb/links/tboffices .htm
National Tuberculosis Controllers Associationhttp://www .tbcontrollers .org
Find TB Resourceshttps://findtbresources .cdc .gov
Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019Lynn E . Sosa, MD; Gibril J . Njie, MPH; Mark N . Lobato, MD; et al . Morbidity and Mortality Weekly ReportMay 17, 2019; 68(19); 439-443https://www .cdc .gov/mmwr/volumes/68/wr/mm6819a3 .htm?s_cid=mm6819a3_w
12
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14
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ient
room
or p
oint
of
care
?
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
4Ar
e fa
ce m
asks
read
ily a
vaila
ble
near
eac
h pa
tient
roo
m o
r poi
nt
of ca
re?
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
5Ar
e al
coho
l disp
ense
rs re
adily
ac
cess
ible
and
func
tioni
ng?
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
Tota
l YES
and
TO
TAL
OBS
ERVE
D
Stan
dard
Pre
caut
ions
: Obs
erva
tion
of
Pers
onal
Pro
tect
ive
Equi
pmen
t Pro
visio
nIn
stru
ctio
ns: O
bser
ve p
atie
nt c
are
area
s or a
reas
out
side
of p
atie
nt ro
oms.
For
eac
h ca
tego
ry, r
ecor
d th
e ob
serv
atio
n. In
the
colu
mn
on th
erig
ht,
sum
(acr
oss)
the
tota
l num
ber o
f “Ye
s” a
nd th
e to
tal n
umbe
r of o
bser
vatio
ns (“
Yes”
+ “
No”
). S
um a
ll ca
tego
ries (
dow
n) fo
r ove
rall
perf
orm
ance
.
AMB-
2
15
Date
:___
____
____
___
Obs
erve
r Rol
e:
Nur
se
Tech
O
ther
____
____
__
Initi
als:
____
__
Loca
tion/
Uni
t:___
____
____
_
Not
es a
nd co
mm
ents
:
Stan
dard
Pre
caut
ions
: Obs
erva
tion
of
Pers
onal
Pro
tect
ive
Equi
pmen
t Pro
visio
nAM
B-2
16
Isol
atio
n ro
om: O
bser
vatio
n Ca
tego
ries
Room 1
Room 2
Room 3
Sum
mar
y of
Obs
erva
tions
Yes
Tota
l “Y
es”&
“N
o”
1Is
an
isola
tion
sign
at th
e pa
tient
’s do
or?
Ye
s
No
Ye
s
No
Ye
s
No
2Ar
e gl
oves
ava
ilabl
e ou
tsid
e of
eac
h pa
tient
room
or
trea
tmen
t are
a?
Ye
s
No
N
/A
Ye
s
No
N
/A
Ye
s
No
N
/A
3Ar
e co
ver g
owns
ava
ilabl
e ne
ar e
ach
patie
nt ro
om
or tr
eatm
ent a
rea?
Ye
s
No
Ye
s
No
Ye
s
No
4Is
oth
er P
PE fo
r sta
ndar
dpr
ecau
tions
(e.g
., ey
e pr
otec
tion,
face
mas
ks) a
vaila
ble
near
eac
h pa
tient
ro
om o
r tre
atm
ent a
rea?
Ye
s
No
N
/A
Ye
s
No
N
/A
Ye
s
No
N
/A
5Ar
e su
rgic
al fa
ce m
asks
or f
ace
shie
lds
or N
95
resp
irato
rs a
vaila
ble
near
pat
ient
room
?
Ye
s
No
N
/A
Ye
s
No
N
/A
Ye
s
No
N
/A
6Is
dedi
cate
d pa
tient
equ
ipm
ent,
such
as s
teth
osco
pes
or b
lood
pre
ssur
e cu
ffs, a
vaila
ble?
Ye
s
No
Ye
s
No
Ye
s
No
TOTA
L (D
o no
t inc
lude
N/A
in to
tals)
Isol
atio
n: O
bser
vatio
n of
Are
a Ex
terio
r to
Cont
act I
sola
tion
Room
s
Inst
ruct
ions
: Obs
erve
are
asou
tsid
e of
isol
atio
n ro
oms.
Obs
erve
eac
h pr
actic
e an
d re
cord
the
obse
rvat
ion.
In th
e co
lum
n on
the
right
, sum
(acr
oss)
the
tota
l num
ber
of “
Yes”
and
the
tota
l num
ber o
f obs
erva
tions
(“Ye
s” +
“N
o”).
Sum
all
cate
gorie
s (d
own)
for o
vera
ll pe
rfor
man
ce. D
isreg
ard
not a
pplic
able
cate
gorie
s. F
or e
xam
ple,
co
ver g
owns
shou
ld b
e ou
tsid
e co
ntac
t pre
caut
ions
room
s, b
ut m
ay n
ot b
e re
quire
d ou
tsid
e a
room
with
airb
orne
isol
atio
n pr
ecau
tions
onl
y.
AMB-
3
17
Date
:___
____
____
___
Obs
erve
r Rol
e:
Nur
se
Tech
O
ther
____
____
__
Initi
als:
____
__
Loca
tion/
Uni
t:___
____
____
_
Not
es a
nd co
mm
ents
:
Isol
atio
n: O
bser
vatio
n of
Are
a Ex
terio
r to
Isol
atio
n Ro
oms
AMB-
3
18
Isol
atio
n ro
om: O
bser
vatio
n Ca
tego
ries
Room 1
Room 2
Room 3
Sum
mar
y of
Obs
erva
tions
Yes
Tota
l Obs
erve
d
1Is
an
Airb
orne
Infe
ctio
n Is
olat
ion
sign
at th
e pa
tient
’s do
or?
Ye
s
No
Ye
s
No
Ye
s
No
2Is
the
door
to th
e ro
om cl
osed
?
Yes
N
o
Yes
N
o
Yes
N
o
3Do
es a
man
omet
er o
r oth
er m
easu
rem
ent
mec
hani
sm in
dica
te n
egat
ive
pres
sure
in th
e ro
om?
Ye
s
No
Ye
s
No
Ye
s
No
4Ar
e ap
prop
riate
resp
irato
rs, (
N-9
5)in
mul
tiple
size
s an
d/or
cha
rged
, pow
ered
air
purif
ying
resp
irato
rs
(PAP
R), a
vaila
ble?
Ye
s
No
Ye
s
No
Ye
s
No
5Ar
e re
spira
tors
stor
ed o
utsid
e th
e ro
om o
r in
an
ante
room
?
Yes
N
o
Yes
N
o
Yes
N
o
Tota
l YES
and
TO
TAL
OBS
ERVE
D
Isol
atio
n: O
bser
vatio
n of
Are
a Ex
terio
r to
Airb
orne
In
fect
ion
Isol
atio
n Ro
oms
Inst
ruct
ions
: If t
here
are
any
pat
ient
s req
uirin
g Ai
rbor
ne In
fect
ion
Isol
atio
n on
uni
t, ob
serv
e ar
ea o
utsid
e of
eac
h is
olat
ion
room
. Obs
erve
eac
h pr
actic
e an
d re
cord
the
obse
rvat
ion.
In th
e co
lum
n on
the
right
, sum
(acr
oss)
the
tota
l num
ber o
f “Ye
s” a
nd th
e to
tal n
umbe
r of o
bser
vatio
ns (“
Yes”
+ “
No”
). S
um a
ll ca
tego
ries
(dow
n) fo
r ove
rall
perf
orm
ance
.
AMB-
4
19
Isol
atio
n: O
bser
vatio
n of
Are
a Ex
terio
r to
Airb
orne
Infe
ctio
n Is
olat
ion
Room
s
Date
:___
____
____
___
Obs
erve
r Rol
e:
Nur
se
Tech
O
ther
____
____
__
Initi
als:
____
__
Loca
tion/
Uni
t:___
____
____
_
Not
es a
nd co
mm
ents
:
AMB-
4
20
Stan
dard
Pre
caut
ions
: Obs
erva
tion
Cate
gorie
sRo
om/
Area 1
Room
/Ar
ea 2
Room
/Ar
ea 3
Room
/Ar
ea 4
Room
/Ar
ea 5
Sum
mar
y of
O
bser
vatio
ns
Yes
Tota
l Obs
erve
d
1Ar
e sh
arps
con
tain
ers a
vaila
ble?
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
2Ar
e sh
arps
con
tain
ers p
rope
rly
secu
red
and
not f
ull?
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
3Ar
e sh
arps
con
tain
ers p
ositi
oned
at
52”
to 5
6” a
bove
floo
r?
Yes
N
o
Yes
N
o
Yes
N
o
Yes
N
o
Yes
N
o
4Ar
e ha
mpe
rs fo
r soi
led
laun
dry
labe
led
or co
lor-
code
d?
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
5Ar
e cl
ean
linen
sup
plie
s spa
tially
se
para
ted
from
soile
d ar
eas o
rw
aste
and
cove
red
or co
ntai
ned
with
in a
cab
inet
?
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
Ye
s
No
Tota
l YES
and
TO
TAL
OBS
ERVE
D
Stan
dard
Pre
caut
ions
: Obs
erva
tion
of N
eedl
estic
kPr
even
tion
and
Care
of L
aund
ryIn
stru
ctio
ns: O
bser
ve p
atie
nt c
are
area
s or a
reas
out
side
of p
atie
nt ro
oms.
For
eac
h ca
tego
ry, r
ecor
d th
e ob
serv
atio
n. In
the
colu
mn
on th
erig
ht,
sum
(acr
oss)
the
tota
l num
ber o
f “Ye
s” a
nd th
e to
tal n
umbe
r of o
bser
vatio
ns (“
Yes”
+ “
No”
). S
um a
ll ca
tego
ries (
dow
n) fo
r ove
rall
perf
orm
ance
.
AMB-
5
21
Date
:___
____
____
___
Obs
erve
r Rol
e:
Nur
se
Tech
O
ther
____
____
__
Initi
als:
____
__
Loca
tion/
Uni
t:___
____
____
_
Not
es a
nd co
mm
ents
:
Stan
dard
Pre
caut
ions
: Obs
erva
tion
of N
eedl
estic
kPr
even
tion
and
Care
of L
aund
ryAM
B-5
22
Med
icat
ion
prep
arat
ion
room
: Obs
erva
tion
Cate
gorie
s
1If
mul
ti-do
se in
ject
able
med
icat
ions
are
pre
sent
, is t
he m
edic
atio
n co
ntai
ner
mai
ntai
ned
in a
ded
icat
ed m
edic
atio
n pr
epar
atio
n sp
ace?
Yes
N
o
N/A
2Is
the
med
icat
ion
prep
arat
ion
area
free
of o
pene
d sin
gle
dose
via
ls or
ope
ned
singl
e us
e co
ntai
ners
?
Yes
N
o
3If
open
mul
ti-do
se v
ials
are
pres
ent,
are
they
dat
ed a
nd w
ithin
the
Beyo
nd U
se
Date
(BU
D) a
nd th
e m
anuf
actu
rer’s
exp
iratio
n pe
riod?
Ye
s
No
N
/A
4M
edic
atio
nsar
e pr
epar
ed in
a c
lean
are
a fr
ee fr
om co
ntam
inat
ion
or co
ntac
t with
bl
ood,
bod
y flu
ids,
or c
onta
min
ated
equ
ipm
ent.
Ye
s
No
5Ar
esp
lash
gua
rds i
nsta
lled
at si
nks t
hat a
re lo
cate
d cl
ose
to m
edic
atio
n pr
ep
area
s?
Yes
N
o
6Ar
e sin
ks re
adily
acc
essib
le to
hea
lthca
re p
rovi
ders
?
Yes
N
o
7Ar
e ha
nd w
ashi
ng su
pplie
s, s
uch
as so
ap, a
nd p
aper
tow
els,
ava
ilabl
e?
Yes
N
o
8Ar
e al
coho
l disp
ense
rs re
adily
ava
ilabl
e, fi
lled,
and
func
tioni
ng p
rope
rly?
Ye
s
No
TOTA
L (T
otal
YES
and
No
Onl
y)
Inje
ctio
n Sa
fety
: Obs
erva
tion
of C
entr
alize
d M
edic
atio
n Ar
ea
Inst
ruct
ions
: Obs
erve
med
icat
ion
prep
arat
ion
area
. For
eac
h ca
tego
ry, r
ecor
d th
e ob
serv
atio
n. O
bser
ve e
ach
prac
tice
belo
w a
nd a
nsw
er Y
es, N
o, o
r N/A
. Su
m a
ll Ye
s and
No
resp
onse
s. D
ivid
e by
sum
of “
Yes”
+”N
o”. D
isreg
ard
not a
pplic
able
cat
egor
ies.
AMB-
6
23
Date
:___
____
____
___
Obs
erve
r Rol
e:
Nur
se
Tech
O
ther
____
____
__
Initi
als:
____
__
Loca
tion/
Uni
t:___
____
____
_
Not
es a
nd co
mm
ents
:
Inje
ctio
n Sa
fety
: Obs
erva
tion
of C
entr
alize
d M
edic
atio
n Ar
eaAM
B-6
24
Ambu
lato
ry W
aitin
g Ro
om: O
bser
vatio
n Ca
tego
ries
Sum
mar
y of
O
bser
vatio
ns
1As
pat
ient
s firs
t reg
ister
for c
are,
is th
ere
visib
le si
gnag
e in
stru
ctin
g th
em to
ale
rt th
e st
aff
of a
resp
irato
ry in
fect
ion?
Ye
s
No
2Ar
e fa
ce m
asks
and
tiss
ues r
eadi
ly a
vaila
ble
for p
atie
nts a
nd v
isito
rs w
ith re
spira
tory
or
flu-li
ke sy
mpt
oms?
Ye
s
No
3Ar
e ha
nd h
ygie
ne su
pplie
s rea
dily
ava
ilabl
e to
visi
tors
in th
e w
aitin
g ro
om?
Ye
s
No
4Ar
e tr
ash
rece
ptac
les r
eadi
ly a
vaila
ble
to v
isito
rs in
the
wai
ting
room
?
Yes
N
o
TOTA
L
Coug
h Co
urte
sy: W
aitin
g Ro
om
Inst
ruct
ions
: Obs
erve
the
ambu
lato
ry c
are
poin
t of c
are
test
ing
area
. For
eac
h ca
tego
ry, r
ecor
d th
e ob
serv
atio
n. S
um a
ll Ye
s and
No
resp
onse
s.Di
vide
by
sum
of “
Yes”
+ ”
No”
.
AMB-
7
25
Date
:___
____
____
___
Obs
erve
r Rol
e:
Nur
se
Tech
O
ther
____
____
__
Initi
als:
____
__
Loca
tion/
Uni
t:___
____
____
_
Not
es a
nd co
mm
ents
:
Coug
h Co
urte
sy: W
aitin
g Ro
omAM
B-7
26
Vacc
ine
Stor
age
Area
: O
bser
vatio
n Ca
tego
ries
Sum
mar
y of
O
bser
vatio
ns
1Ar
e va
ccin
e st
orag
e re
frig
erat
or a
nd fr
eeze
r tem
pera
ture
s with
in th
e ap
prop
riate
rang
es
(Ref
riger
ator
: 2°C
to 8
°C; 3
6°F
to 4
6°Fr
eeze
r:-5
0°C
to -1
5°C;
-58°
F to
+5°
F)?
Ye
s
No
2Ar
e va
ccin
e st
orag
e re
frig
erat
or a
nd fr
eeze
r tem
pera
ture
s rec
orde
d tw
ice
daily
?
Yes
N
o
3Ar
e sa
fegu
ards
, suc
h as
self-
clos
ing
hing
esan
d do
or a
larm
s,in
pla
ce to
ens
ure
that
the
refr
iger
ator
/fre
ezer
doo
rs re
mai
n cl
osed
.
Yes
N
o
4Ar
e re
frig
erat
or/f
reez
er d
oor g
aske
ts c
lean
?
Yes
N
o
5Ar
e va
ccin
es st
ored
in th
e ce
nter
of t
here
frig
erat
or a
nd fr
eeze
r spa
ces,
in th
e or
igin
al p
acka
ging
, an
d in
side
desig
nate
d st
orag
e tr
ays?
Ye
s
No
6Ar
e dr
inks
and
food
abs
ent f
rom
the
refr
iger
ator
/fre
ezer
?
Yes
N
o
TOTA
L
Envi
ronm
ent o
f Car
e: V
acci
ne S
tora
ge A
reas
Inst
ruct
ions
: Obs
erve
vac
cine
stor
age
area
. For
eac
h ca
tego
ry, r
ecor
d th
e ob
serv
atio
n. S
um a
ll Ye
s and
No
resp
onse
s.
Divi
de b
y su
m o
f “Ye
s” +
”N
o”.
AMB-
8
27
Date
:___
____
____
___
Obs
erve
r Rol
e:
Nur
se
Tech
O
ther
____
____
__
Initi
als:
____
__
Loca
tion/
Uni
t:___
____
____
_
Not
es a
nd co
mm
ents
:
Envi
ronm
ent o
f Car
e: V
acci
ne S
tora
ge A
reas
AMB-
8
28
Patie
nt C
are
Area
: Obs
erva
tion
Cate
gorie
sSu
mm
ary
of O
bser
vatio
ns
1Ar
e sh
arps
cont
aine
rs p
rope
rly se
cure
d an
d no
t ful
l?
Yes
N
o
2Ar
e sh
arps
cont
aine
rs a
vaila
ble
at th
e po
int o
f use
?
Yes
N
o
3Ar
e cl
eani
ngan
d di
sinfe
ctio
n su
pplie
s for
exa
min
atio
n ta
bles
and
test
surf
aces
read
ily
avai
labl
e?
Yes
N
o
4Is
a ne
w si
ngle
-use
aut
o-di
sabl
ing
lanc
ing
devi
ce u
sed
for e
ach
patie
nt?
Ye
s
No
N
/A
5Ar
e al
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onal
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use
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s
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L
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ctio
n Sa
fety
: Poi
nt o
f Car
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are
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AMB-
9
29
Date
:___
____
____
___
Obs
erve
r Rol
e:
Nur
se
Tech
O
ther
____
____
__
Initi
als:
____
__
Loca
tion/
Uni
t:___
____
____
_
Not
es a
nd co
mm
ents
:
Inje
ctio
n Sa
fety
: Poi
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f Car
e Te
stin
g AM
B-9
30
______
______
__________
_____ _____
______
09/27/2006 Centers for Disease Control and Prevention Division of Tuberculosis Elimination
Appendix B. Tuberculosis (TB) risk assessment worksheet This model worksheet should be considered for use in performing TB risk assessments for health-care facilities and nontraditional facility-based settings. Facilities with more than one type of setting will need to apply this table to each setting.
Scoring √ or Y = Yes X or N = No NA = Not Applicable
1. Incidence of TB What is the incidence of TB in your community (county or region served by Community rate_______ the health-care setting), and how does it compare with the state and national State rate ____________ average? What is the incidence of TB in your facility and specific settings National rate _________ and how do those rates compare? (Incidence is the number of TB cases in Facility rate your community the previous year. A rate of TB cases per 100,000 persons Department 1 rate _______ should be obtained for comparison.)* This information can be obtained from Department 2 rate _______ the state or local health department. Department 3 rate _______
Are patients with suspected or confirmed TB disease encountered in your Yes No setting (inpatient and outpatient)? If yes, how many patients with suspected and confirmed TB disease are treated in your health-care setting in 1 year (inpatient and outpatient)? Review laboratory data, infection-control records, and databases containing discharge diagnoses.
Year No. patients Suspected Confirmed
1 year ago 2 years ago _____ _____ 5 years ago _____ _____
If no, does your health-care setting have a plan for the triage of patients with Yes No suspected or confirmed TB disease? Currently, does your health-care setting have a cluster of persons with Yes No confirmed TB disease that might be a result of ongoing transmission of Mycobacterium tuberculosis within your setting (inpatient and outpatient)?
2. Risk Classification Inpatient settings How many inpatient beds are in your inpatient setting? How many patients with TB disease are encountered in the inpatient setting in 1 Previous year year? Review laboratory data, infection-control records, and databases 5 years ago ______ containing discharge diagnoses. Depending on the number of beds and TB patients encountered in 1 year, what ο Low risk is the risk classification for your inpatient setting? (See Appendix C.) ο Medium risk
ο Potential ongoing transmission
Does your health-care setting have a plan for the triage of patients with Yes No suspected or confirmed TB disease? Outpatient settings How many TB patients are evaluated at your outpatient setting in 1 year? Previous year Review laboratory data, infection-control records, and databases containing 5 years ago discharge diagnoses. Is your health-care setting a TB clinic? Yes No (If yes, a classification of at least medium risk is recommended.) Does evidence exist that a high incidence of TB disease has been observed in Yes No the community that the health-care setting serves? Does evidence exist of person-to-person transmission of M. tuberculosis in the Yes No health-care setting? (Use information from case reports. Determine if any tuberculin skin test [TST] or blood assay for M. tuberculosis [BAMT] conversions have occurred among health-care workers [HCWs]). Does evidence exist that ongoing or unresolved health-care–associated Yes No
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2.2
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______
__________________
______
________
09/27/2006 Centers for Disease Control and Prevention Division of Tuberculosis Elimination
transmission has occurred in the health-care setting (based on case reports)? Is there a high incidence of immunocompromised patients or HCWs in the Yes No health-care setting? Have patients with drug-resistant TB disease been encountered in your health- Yes No care setting within the previous 5 years? Year ________
When was the first time a risk classification was done for your health-care setting? Considering the items above, would your health-care setting need a higher risk Yes No classification? Depending on the number of TB patients evaluated in 1 year, what is the risk ο Low risk classification for your outpatient setting? (See Appendix C) ο Medium risk
ο Potential ongoing transmission
Does your health-care setting have a plan for the triage of patients with Yes No suspected or confirmed TB disease? Nontraditional facility-based settings
How many TB patients are encountered at your setting in 1 year? Previous year 5 years ago
Does evidence exist that a high incidence of TB disease has been observed in Yes No the community that the setting serves? Does evidence exist of person-to-person transmission of M. tuberculosis in the Yes No setting? Have any recent TST or BAMT conversions occurred among staff or clients? Yes No
Is there a high incidence of immunocompromised patients or HCWs in the Yes No setting? Have patients with drug-resistant TB disease been encountered in your health- Yes No care setting within the previous 5 years? Year When was the first time a risk classification was done for your setting?
Considering the items above, would your setting require a higher risk Yes No classification? Does your setting have a plan for the triage of patients with suspected or Yes No confirmed TB disease? Depending on the number of patients with TB disease who are encountered in a nontraditional setting in 1 year, what is the risk classification for your setting? (See Appendix C)
ο Low risk ο Medium risk ο Potential ongoing transmission
3. Screening of HCWs for M. tuberculosis Infection Does the health-care setting have a TB screening program for HCWs?If yes, which HCWs are included in the TB screening program? (Check all that apply.)
ο Physicians ο Mid-level practitioners (nurse practitioners [NP] and physician’s assistants [PA])ο Nurses ο Administrators ο Laboratory workers ο Respiratory therapists
Yes No
ο Janitorial staffο Maintenance or engineering staffο Transportation staffο Dietary staffο Receptionistsο Trainees and studentsο Volunteersο Others_________________
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_________________________________ _________________________________
_________
09/27/2006 Centers for Disease Control and Prevention Division of Tuberculosis Elimination
ο Physical therapistsο Contract staff
ο Construction or renovation workersο Service workersIs baseline skin testing performed with two-step TST for HCWs? Yes No
Is baseline testing performed with QFT or other BAMT for HCWs? Yes No
How frequently are HCWs tested for M. tuberculosis infection?
Are the M. tuberculosis infection test records maintained for HCWs? Yes No
Where are the M. tuberculosis infection test records for HCWs maintained? Who maintains the records?
If the setting has a serial TB screening program for HCWs to test for M. tuberculosis infection, what are the conversion rates for the previous years? †
1 year ago _________________ 4 years ago _________________ 2 years ago _________________ 5 years ago _________________ 3 years ago _________________Has the test conversion rate for M. tuberculosis infection been increasing or decreasing, or has it remained the same over the previous 5 years? (check one)
ο Increasing ο Decreasing ο No change
Do any areas of the health-care setting (e.g., waiting rooms or clinics) or any group of HCWs (e.g., lab workers, emergency department staff, respiratory therapists, and HCWs who attend bronchoscopies) have a test conversion rate for M.tuberculosis infection that exceeds the health-care setting’s annual average?
Yes No If yes, list _________________________
For HCWs who have positive test results for M. tuberculosis infection and who leave employment at the health setting, are efforts made to communicate test results and recommend follow-up of latent TB infection (LTBI) treatment with the local health department or their primary physician?
Yes No Not applicable
4. TB Infection-Control Program Does the health-care setting have a written TB infection-control plan? Yes No Who is responsible for the infection-control program? When was the TB infection-control plan first written? When was the TB infection-control plan last reviewed or updated? Does the written infection-control plan need to be updated based on the timing of the previous update (i.e., >1 year, changing TB epidemiology of the community or setting, the occurrence of a TB outbreak, change in state or local TB policy, or other factors related to a change in risk for transmission of M. tuberculosis)?
Yes No
Does the health-care setting have an infection-control committee (or another committee with infection control responsibilities)?
Yes No
If yes, which groups are represented on the infection-control committee? (Check all that apply.)
ο Physiciansο Nursesο Epidemiologistsο Engineersο Pharmacists
ο Laboratory personnelο Health and safety staffο Administratorο Risk assessmentο Quality control (QC)ο Others (specify)
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_____
_____
_____
_____
___________
___________
_____
_____
_____
___________
___________
______________________ ______________________
09/27/2006 Centers for Disease Control and Prevention Division of Tuberculosis Elimination
If no, what committee is responsible for infection control in the setting?
5. Implementation of TB Infection-Control Plan Based on Review by Infection-Control Committee Has a person been designated to be responsible for implementing an infection-control plan in your health-care setting? If yes, list the name: _________________________
Yes No
Based on a review of the medical records, what is the average number of days for the following:• Presentation of patient until collection of specimen _____ • Specimen collection until receipt by laboratory• Receipt of specimen by laboratory until smear results are provided to health-care provider• Diagnosis until initiation of standard antituberculosis treatment• Receipt of specimen by laboratory until culture results are provided to health-care provider• Receipt of specimen by laboratory until drug-susceptibility results are provided to
health-care provider• Receipt of drug-susceptibility results until adjustment of antituberculosis treatment,
if indicated• Admission of patient to hospital until placement in airborne infection isolation (AII)Through what means (e.g., review of TST or BAMT conversion rates, patient medical records, and time analysis)are lapses in infection control recognized? What mechanisms are in place to correct lapses in infection control? Based on measurement in routine QC exercises, is the infection-control plan being properly implemented?
Yes No
Is ongoing training and education regarding TB infection-control practices provided for HCWs?
Yes No
6. Laboratory Processing of TB-Related Specimens, Tests, and Results Based on Laboratory Review Which of the following tests are either conducted in-house at your health-care setting’s laboratory or sent out to a reference laboratory?
In-house Sent out
Acid-fast bacilli (AFB) smears Culture using liquid media (e.g., Bactec and MB-BacT) Culture using solid media Drug-susceptibility testing Nucleic acid amplification (NAA) testing What is the usual transport time for specimens to reach the laboratory for the following tests?
AFB smears Culture using liquid media (e.g., Bactec, MB-BacT)Culture using solid media ___________Drug-susceptibility testingOther (specify)NAA testing ___________
Does the laboratory at your health-care setting or the reference laboratory used by your health-care setting report AFB smear results for all patients within 24 hours of receipt of specimen? What is the procedure for weekends?
Yes No
7. Environmental Controls Which environmental controls are in place in your health-care setting? (Check all that apply and describe)
Environmental control Description ο AII rooms _____________________
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__________________________________________
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
09/27/2006 Centers for Disease Control and Prevention Division of Tuberculosis Elimination
ο Local exhaust ventilation (enclosing devices and exterior devices) ο General ventilation (e.g., single-pass system, recirculation system.)ο Air-cleaning methods (e.g., high-efficiency particulate air [HEPA] filtration and ultraviolet germicidal
irradiation [UVGI]) ___________________________________________________________ What are the actual air changes per hour (ACH) and design for various rooms in the setting?
Room ACH Design
Which of the following local exterior or enclosing devices such as exhaust ventilation devices are used in your health-care setting? (Check all that apply) ο Laboratory hoodsο Booths for sputum inductionο Tents or hoods for enclosing patient or procedure What general ventilation systems are used in your health-care setting? (Check all that apply) ο Single-pass systemο Variable air volume (VAV) ο Constant air volume (CAV)ο Recirculation systemο Other____________________
What air-cleaning methods are used in your health-care setting? (Check all that apply) HEPA filtration
ο Fixed room-air recirculation systems ο Portable room-air recirculation systems
UVGIο Duct irradiationο Upper-air irradiationο Portable room-air cleaners
How many AII rooms are in the health-care setting?
What ventilation methods are used for AII rooms? (Check all that apply) Primary (general ventilation):ο Single-pass heating, ventilating, and air conditioning (HVAC) ο Recirculating HVAC systems
Secondary (methods to increase equivalent ACH): ο Fixed room recirculating units ο HEPA filtration ο UVGI ο Other (specify) _________________
Does your health-care setting employ, have access to, or collaborate with an environmental engineer (e.g., professional engineer) or other professional with appropriate expertise (e.g., certified industrial hygienist) for consultation on design specifications, installation, maintenance, and evaluation of environmental controls?
Yes No
Are environmental controls regularly checked and maintained with results recorded in maintenance logs?
Yes No
Are AII rooms checked daily for negative pressure when in use? Yes No Is the directional airflow in AII rooms checked daily when in use with smoke tubes or visual checks?
Yes No
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______________________________________
_________________ _______________________________ _______________________________ _______________________________ _______________________________
______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
____________________________
____________________________
______________________________________________________________________________________ ______________________________________________________________________________________
______________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
09/27/2006 Centers for Disease Control and Prevention Division of Tuberculosis Elimination
Are these results readily available? Yes No What procedures are in place if the AII room pressure is not negative? Do AII rooms meet the recommended pressure differential of 0.01-inch water column negative to surrounding structures?
Yes No
8. Respiratory-Protection Program Does your health-care setting have a written respiratory-protection program? Yes No Which HCWs are included in the respiratory protection program? (Check all that apply)
ο Physicians ο Mid-level practitioners (NPs and PAs) ο Nurses ο Administrators ο Laboratory personnel ο Contract staff ο Construction or renovation staff ο Service personnel
ο Janitorial staff ο Maintenance or engineering staff ο Transportation staff ο Dietary staff ο Students ο Others (specify)
Are respirators used in this setting for HCWs working with TB patients? If yes, include manufacturer, model, and specific application (e.g., ABC model 1234 for bronchoscopy and DEF model 5678 for routine contact with infectious TB patients).
Manufacturer Model Specific application
Is annual respiratory-protection training for HCWs performed by a person with advanced training in respiratory protection?
Yes No
Does your health-care setting provide initial fit testing for HCWs? If yes, when is it conducted?
Yes No
Does your health-care setting provide periodic fit testing for HCWs? If yes, when and how frequently is it conducted?
Yes No
What method of fit testing is used? Describe.
Is qualitative fit testing used? Yes No Is quantitative fit testing used? Yes No
9. Reassessment of TB risk How frequently is the TB risk assessment conducted or updated in the health-care setting? When was the last TB risk assessment conducted? What problems were identified during the previous TB risk assessment?
1)
2)
3)
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_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
______________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
09/27/2006 Centers for Disease Control and Prevention Division of Tuberculosis Elimination
4)
5)
What actions were taken to address the problems identified during the previous TB risk assessment? 1)
2)
3)
4)
5)
Did the risk classification need to be revised as a result of the last TB risk assessment? Yes No * If the population served by the health-care facility is not representative of the community in which the
facility is located, an alternate comparison population might be appropriate. † Test conversion rate is calculated by dividing the number of conversions among HCWs by the number of
HCWs who were tested and had prior negative results during a certain period (see Supplement, Surveillance and Detection of M. tuberculosis infections in Health-Care Settings).
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Risk Assessment for Infection Surveillance, Prevention and Control Programs in Ambulatory Healthcare Settings
Explanation of Risk Assessment Tool and the Template for a Risk Assessment Report
This Risk Assessment tool, beginning on page 43, can be used to conduct a facility risk assess-ment for acquiring and transmitting infections in a variety of ambulatory healthcare settings . The results of the risk assessment can then be reported using the accompanying template for a Risk Assessment Report (beginning on page 40) . The findings of the risk assessment should be used to provide information about where an organization should focus its infection surveillance, prevention and control activities.
A facility risk assessment is conducted by identifying and reviewing potential risk factors for infection related to the care, treatment, and services provided and to the environment of care in a specific healthcare setting . The identified risks of greatest importance and urgency are then selected and prioritized . Based on these identified risks, facility personnel should develop the organization’s Infection Surveillance, Prevention and Control (ISPC) Plan (i.e., an action plan).
The ISPC Plan should include a goal for reducing the risk of infection associated with each of these identified risks, a measurable objective for each goal, and evidence based strategies for meeting each of these objectives . The Plan should also identify the personnel responsible for implementing the strategies and include mechanisms for evaluating the effectiveness of meet-ing the ISPC Plan’s objectives .
Assessment Process
1 . Convene a team to conduct the risk assessment .
2 . Identify potential risk factors in each of the following categories:
• Community and populations served
• Potential for specific infection
• Treatment and care practices
• Instrument and medical device cleaning, disinfection and handling
• Environment of care
• Emergency management
• Others identified by the organization
3 . Assess and score each potential risk factor based on the following:
a . Potential impact of the event/condition on patients and personnel, determined by evaluating the potential for patient illness, injury, infection, death, need for admission to an inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to impact the organization’s ability to function/remain open; and degree of clinical and financial impact .
2.3
38
b . Probability of the event/condition occurring determined by evaluating the risk of the potential threat actually occurring . Information regarding historical data, infection surveillance data, the scope of services provided by the facility, and the environment of the surrounding area (topography, interstate roads, chemical plants, railroad, ports, etc .) are considered when determining this score .
c . Organization’s preparedness to deal with the event/condition determined by consider-ing policies and procedures already in place, staff experience and response to actual situations, and available services and equipment .
4 . After risk scores are assigned in the three assessment groups, total the numbers in each group to provide a numerical risk level for each event/ condition .
5 . Rank the events/conditions from the highest to lowest score in the table provided . Select the risks with the highest scores for priority focus for developing the annual ISPC Plan . NOTE: Some events/conditions with a lower score may be selected because they are an accreditation or regulatory requirement .
The risk assessment and ISPC Plan should be reviewed and approved by the organization’s quality assurance and performance improvement committee (or other designated committee) . The risk assessment and ISPC Plan should be reviewed annually (and sooner if circumstances change) .
39
Cover Page for Risk Assessment Report
Risk Assessment Report for Infection Surveillance, Prevention and Control (ISPC) Program
Year: 20__
Organization Name: ________________________________
Date of Report: __________________
Overview
A facility risk assessment for acquiring and transmitting infections should be conducted annu-ally in each healthcare facility . [Note: An annual risk assessment is required for organizations accredited by The Joint Commission and other accreditation organizations .] The risk assess-ment provides a foundation for the Infection Surveillance, Prevention and Control Program because it is used is used to provide information about where an organization should focus its infection surveillance, prevention and control activities .
This facility risk assessment was conducted by identifying and reviewing potential risk factors for infection related to the care, treatment, and services provided and to the environment of care in a specific healthcare setting . The identified risks of greatest importance and urgency were selected and prioritized and are noted below . Based on these identified risks, facility personnel will develop the organization’s Infection Surveillance, Prevention and Control (ISPC) Plan (i .e ., an action plan, with goals and measurable objectives .)
The ISPC Plan includes a goal for reducing the risk of infection associated with each of the prioritized risks, a measurable objective for each goal, and evidence based strategies for meeting each of these objectives . The Plan also (1) identifies the personnel responsible for developing the Plan and implementing the ISPC Program strategies and (2) includes mecha-nisms for evaluating the effectiveness of the meeting the ISPC Program’s objectives .
Assessment Tool
An organizational Infection Risk Assessment tool (below) was reviewed and adapted for use by (Organization name) by the following personnel:
______________________________________________________________________________
The Risk Assessment tool was used to identify potential infection risk factors in each of the following categories:
• Community and populations served
• Potential for specific infection
40
• Treatment and care practices
• Instrument and medical device cleaning, disinfection and handling
• Environment of care
• Emergency management
• Others identified by the organization
Process
The following personnel conducted the risk assessment:
______________________________________________________________________________
The group identified, assessed and scored each potential risk factor based on the following:
1 . Potential impact of the event/condition on patients and personnel, determined by evaluat-ing the potential for patient illness, injury, infection, death, need for admission to an inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to impact the organization’s ability to function/remain open; and degree of clinical and financial impact .
2 . Probability of the event/condition occurring, determined by evaluating the risk of the potential threat actually occurring . Information regarding historical data, infection surveil-lance data, the scope of services provided by the facility, the environment of the surround-ing area (topography, interstate roads, chemical plants, railroad, ports, etc .), and health department data, are considered when determining this score .
3 . Organization’s preparedness to deal with the event/condition, determined by considering policies and procedures already in place, staff experience and response to actual situations, and available services and equipment .
Ranking of Scores
After risk scores are assigned in the three assessment groups, the numbers in each group were totaled to provide a numerical risk level for each event/condition . The numerical risk level can range from 0 (lowest vulnerability) to 9 (highest vulnerability) . The risk factors (i .e ., events/conditions) were then ranked from highest to lowest risk level in the table below . The risks with the highest scores will be used for priority focus for developing the annual ISPC Plan . NOTE: Some events/conditions with a lower score may be selected because they are an accreditation or regulatory requirement, or can be quickly and easily implemented .
41
Distribution of Risk Assessment
The Risk assessment was shared with others, such as the ____________________, to solicit comments . The original group evaluated and incorporated the comments, as needed, and finalized this risk assessment . The risk assessment will be taken to the (governing body) ______________ and the ______________Committee for final approvals before the Infection Surveillance, Prevention and Control Plan is developed . After final approval of the risk assess-ment findings, the ISPC Plan will be developed by __________with periodic reports back to the ____________Committee until the Plan has been fully implemented .
Results
A numerical risk level of 9 is identified as the highest perceived potential risk .
Event or Condition Score
42
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Risk
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43
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44
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46
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ENT:
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ER:
1.
Po
tent
ial i
mpa
ct o
f the
eve
nt/c
ondi
tion
on p
atie
nts a
nd p
erso
nnel
: det
erm
ined
by
eval
uatin
g th
e po
tent
ial f
or p
atie
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lnes
s, in
jury
, inf
ectio
n, d
eath
, nee
d fo
r adm
issi
on to
an
inpa
tient
faci
lity;
the
pote
ntia
l for
per
sonn
el il
lnes
s, in
jury
, inf
ectio
n, sh
orta
ge; p
oten
tial t
o im
pact
the
orga
niza
tion’
s abi
lity
to fu
nctio
n/re
mai
n op
en; a
nd d
egre
e of
clin
ical
an
d fin
anci
al im
pact
. 2.
Pr
obab
ility
of t
he e
vent
/con
ditio
n oc
curr
ing:
det
erm
ined
by
eval
uatin
g th
e ris
k of
the
pote
ntia
l thr
eat a
ctua
lly o
ccur
ring.
Info
rmat
ion
rega
rdin
g hi
stor
ical
dat
a, in
fect
ion
surv
eilla
nce
data
, the
scop
e of
serv
ices
pro
vide
d by
the
faci
lity,
and
the
envi
ronm
ent o
f the
surr
ound
ing
area
(top
ogra
phy,
inte
rsta
te ro
ads,
chem
ical
pla
nts,
railr
oad,
por
ts,
etc.
) are
con
side
red
whe
n de
term
inin
g th
is sc
ore.
3.
O
rgan
izat
ion’
s pre
pare
dnes
s to
deal
with
the
even
t/con
ditio
n: d
eter
min
ed b
y co
nsid
erin
g po
licie
s and
pro
cedu
res a
lread
y in
pla
ce, s
taff
exp
erie
nce
and
resp
onse
to a
ctua
l si
tuat
ions
, and
ava
ilabl
e se
rvic
es a
nd e
quip
men
t.
Dev
elop
ed b
y: K
. Aria
s, M
. Pat
rick,
K. D
elah
anty
and
S. O
dach
owsk
i
47
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1of1
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GO
ALS
AN
D O
BJE
CTI
VES
RIS
K E
VEN
T/ C
ON
DIT
ION
G
OA
L O
BJE
CTI
VE
(mea
sura
ble,
incl
udes
tim
efra
me
for c
ompl
etio
n)
48
Page1
2of1
2R
ISK
EVE
NT/
C
ON
DIT
ION
G
OA
L O
BJE
CTI
VE
(mea
sura
ble,
incl
udes
tim
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me
for c
ompl
etio
n)
STR
ATEG
IES
IMPL
EMEN
TATI
ON
Res
pon-
sibl
e Pe
rson
(s)
Met
hod
for E
valu
atin
g
Effe
ctiv
enes
s
49
Infection Prevention and Control Assessment Tool for Outpatient Settings
This tool is intended to assist in the assessment of infection control programs and practices in outpatient settings. In order to complete the assessment, direct observation of infection control practices will be necessary. To facilitate the assessment, health departments are encouraged to share this tool with facilities in advance of their visit.
Please note, Not Applicable should only be checked if the element or domain is not applicable to the types of services provided by the facility (e.g., the facility never performs point-of-care testing, controlled substances are never kept at the facility). If a particular service is provided by the facility but is unable to be observed during the visit (e.g., no injections were prepared or administered during the visit) that section should still be completed by interviewing relevant personnel about their practices.
Overview
Section 1: Facility Demographics
Section 2: Infection Control Program and Infrastructure
Section 3: Direct Observation of Facility Practices
Section 4: Infection Control Guidelines and Other Resources
Infection Control Domains for Gap Assessment
I. Infection Control Program and Infrastructure
II. Infection Control Training and Competency
III. Healthcare Personnel Safety
IV. Surveillance and Disease Reporting
V.a/b. Hand Hygiene
VI.a/b. Personal Protective Equipment (PPE)
VII.a/b. Injection Safety (if applicable)
VIII.a/b. Respiratory Hygiene/Cough Etiquette
IX.a/b. Point-of-Care Testing (if applicable)
X.a/b. Environmental Cleaning
XI.a/b. Device Reprocessing
XII. Sterilization of Reusable Devices (if applicable)
XIII. High-level Disinfection of Reusable Devices (if applicable)
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Section 1: Facility Demographics
Facility Name (for health department use only) NHSN Facility Organization ID (for health department use only) State-assigned Unique ID Date of Assessment
Type of Assessment ☐ On-site ☐ Other (specify): Rationale for Assessment (Select all that apply)
☐ Outbreak ☐ Input from accrediting organization or state survey agency ☐ Other (specify):
Is the facility licensed by the state?
☐ Yes ☐ No
Is the facility certified by the Centers for Medicare & Medicaid Services (CMS)?
☐ Yes ☐ No
Is the facility accredited? ☐ Yes ☐ No
If yes, list the accreditation organization: ☐ Accreditation Association for Ambulatory Health Care (AAAHC) ☐ American Association for Accreditation of Ambulatory Surgery
Facilities (AAAASF) ☐ American Osteopathic Association (AOA) ☐ The Joint Commission (TJC) ☐ Other (specify):
Is the facility affiliated with a hospital?
☐ Yes (specify – for health department use only): ☐ No
Which procedures are performed by the facility?
Select all that apply.
☐ Chemotherapy ☐ Endoscopy ☐ Ear/Nose/Throat ☐ Imaging (MRI/CT) ☐ Immunizations ☐ OB/Gyn ☐ Ophthalmologic ☐ Orthopedic ☐ Pain remediation ☐ Plastic/reconstructive ☐ Podiatry ☐ Other (specify):
What is the primary procedure-type performed by the facility?
Select only one.
☐ Chemotherapy ☐ Endoscopy ☐ Ear/Nose/Throat ☐ Imaging (MRI/CT) ☐ Immunizations ☐ OB/Gyn ☐ Ophthalmologic ☐ Orthopedic ☐ Pain remediation ☐ Plastic/reconstructive ☐ Podiatry ☐ Other (specify):
How many physicians work at the facility? What is the average number of patients seen per week?
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Section 2: Infection Control Program and Infrastructure
I. Infection Control Program and Infrastructure
Elements to be assessed Assessment Notes/Areas for Improvement
A. Written infection prevention policies and procedures are available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations, or standards.
Note: Policies and procedures should be appropriate for the services provided by the facility and should extend beyond OSHA bloodborne pathogens training
Yes No
B. Infection prevention policies and procedures are re-assessed at least annually or according to state or federal requirements, and updated if appropriate.
Yes No
C. At least one individual trained in infection prevention is employed by or regularly available (e.g., by contract) to manage the facility’s infection control program.
Note: Examples of training may include: Successful completion of initial and/or recertification exams developed by the Certification Board for Infection Control & Epidemiology; participation in infection control courses organized by the state or recognized professional societies (e.g., APIC, SHEA).
Yes No
D. Facility has system for early detection and management of potentially infectious persons at initial points of patient encounter.
Note: System may include taking a travel and occupational history, as appropriate, and elements described under respiratory hygiene/cough etiquette.
Yes No
II. Infection Control Training and Competency
Elements to be assessed Assessment Notes/Areas for Improvement
A. Facility has a competency-based training program that provides job-specific training on infection prevention policies and procedures to healthcare personnel.
Note: This includes those employed by outside agencies and available by contract or on a volunteer basis to the facility.
See sections below for more specific assessment of training related to: hand hygiene, personal protective equipment (PPE), injection safety, environmental cleaning, point-of-care testing, and device reprocessing
Yes No
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III. Healthcare Personnel Safety
Elements to be assessed Assessment Notes/Areas for Improvement
A. Facility has an exposure control plan that is tailored to the specific requirements of the facility (e.g., addresses potential hazards posed by specific services provided by the facility).
Note: A model template, which includes a guide for creating an exposure control plan that meets the requirements of the OSHA Bloodborne Pathogens Standard is available at: https://www.osha.gov/Publications/osha3186.pdf
Yes No
B. HCP for whom contact with blood or other potentially infectious material is anticipated are trained on the OSHA bloodborne pathogens standard upon hire and at least annually.
Yes No
C. Following an exposure event, post-exposure evaluation and follow-up, including prophylaxis as appropriate, are available at no cost to employee and are supervised by a licensed healthcare professional.
Note: An exposure incident refers to a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an individual’s duties.
Yes No
D. Facility tracks HCP exposure events and evaluates event data and develops/implements corrective action plans to reduce incidence of such events.
Yes No
E. Facility follows recommendations of the Advisory Committee on Immunization Practices (ACIP) for immunization of HCP, including offering Hepatitis B and influenza vaccination.
Note: Immunization of Health-Care Personnel: Recommendations of the ACIP available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm
Yes No
F. All HCP receive baseline tuberculosis (TB) screening prior to placement; HCP receive repeat testing, if appropriate, based on the facility-level risk assessment.
Note: For more information, facilities should refer to the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5417a1.htm ?s_cid=rr5417a1_e
Yes No
G. If respirators are used, the facility has a respiratory protection program that details required worksite-specific procedures and elements for required respirator use, including provision of medical clearance, training, and fit testing as appropriate.
Yes No Not Applicable
H. Facility has well-defined policies concerning contact of personnel with patients when personnel have potentially transmissible conditions.
These policies include: i. Work-exclusion policies that encourage reporting of
illnesses and do not penalize with loss of wages, benefits, or job status.
ii. Education of personnel on prompt reporting of illness to supervisor.
Yes No
Yes No
Yes No
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IV. Surveillance and Disease Reporting
Elements to be assessed Assessment Notes/Areas for Improvement
A. An updated list of diseases reportable to the public health authority is readily available to all personnel.
Yes No
B. Facility can demonstrate knowledge of and compliance with mandatory reporting requirements for notifiable diseases, healthcare associated infections (as appropriate), and for potential outbreaks.
Yes No
C. Patients who have undergone procedures at the facility are educated regarding signs and symptoms of infection that may be associated with the procedure and instructed to notify the facility if such signs or symptoms occur.
Yes No
V.a. Hand Hygiene
Elements to be assessed Assessment Notes/Areas for Improvement
A. All HCP are educated regarding appropriate indications for hand hygiene:
i. Upon hire, prior to provision of care
ii. Annually
Yes No
Yes No B. HCP are required to demonstrate competency with hand
hygiene following each training Yes No
C. Facility routinely audits (monitors and documents) adherence to hand hygiene.
Yes No
D. Facility provides feedback from audits to personnel regarding their hand hygiene performance.
Yes No
E. Hand hygiene policies promote preferential use of alcohol-based hand rub (ABHR) over soap and water in most clinical situations.
Note: Soap and water should be used when hands are visibly soiled (e.g., blood, body fluids) and is also preferred after caring for a patient with known or suspected C. difficile or norovirus during an outbreak.
Yes No
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VI.a. Personal Protective Equipment (PPE)
Elements to be assessed Assessment Notes/Areas for Improvement
A. HCP who use PPE receive training on proper selection and use of PPE:
i. Upon hire, prior to provision of care
ii. Annually
iii. When new equipment or protocols are introduced
Yes No
Yes No Yes No
B. HCP are required to demonstrate competency with selection and use of PPE following each training.
Yes No
C. Facility routinely audits (monitors and documents) adherence to proper PPE selection and use.
Yes No
D. Facility provides feedback from audits to personnel regarding their performance with selection and use of PPE.
Yes No
VII.a. Injection Safety (This element does not include assessment of pharmacy/compounding practices)
If injectable medications are never prepared or administered at the facility check Not Applicable here and skip to Section VIII.a. Respiratory Hygiene/Cough Etiquette.
Elements to be assessed Assessment Notes/Areas for Improvement
A. HCP who prepare and/or administer parenteral medications receive training on safe injection practices:
i. Upon hire, prior to being allowed to prepare and/or administer parenteral medications
ii. Annually iii. When new equipment or protocols are introduced
Yes No
Yes No Yes No
B. HCP are required to demonstrate competency with safe injection practices following each training.
Yes No
C. Facility routinely audits (monitors and documents) adherence to safe injection practices.
Yes No
D. Facility provides feedback from audits to personnel regarding their adherence to safe injection practices.
Yes No
E. Facility has policies and procedures to track HCP access to controlled substances to prevent narcotics theft/diversion.
Note: Policies and procedures should address: how data are reviewed, how facility would respond to unusual access patterns, how facility would assess risk to patients if tampering (alteration or substitution) is suspected or identified, and who the facility would contact if diversion is suspected or identified.
Yes No Not Applicable (Facility does not prepare or administer controlled substances)
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VIII.a. Respiratory Hygiene/Cough Etiquette
Elements to be assessed Assessment Notes/Areas for Improvement
A. Facility has policies and procedures to contain respiratory secretions in persons who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing through the duration of the visit.
Policies include: i. Offering facemasks to coughing patients and other
symptomatic persons upon entry to the facility, at a minimum, during periods of increased respiratory infection activity in the community.
ii. Providing space in waiting rooms and encouraging persons with symptoms of respiratory infections to sit as far away from others as possible.
Note: If available, facilities may wish to place patients with symptoms of a respiratory infection in a separate area while waiting for care.
Yes No
Yes No
Yes No
B. Facility educates HCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens.
Yes No
IX.a. Point-of-Care Testing (e.g., blood glucose meters, INR monitor)
If point-of-care testing is never performed at the facility check Not Applicable here and skip to Section X.a. Environmental Cleaning
Elements to be assessed Assessment Notes/Areas for Improvement
A. HCP who perform point-of-care testing receive training on recommended practices:
i. Upon hire, prior to being allowed to perform point-of-care testing
ii. Annually
iii. When new equipment or protocols are introduced
Yes No
Yes No
Yes No B. HCP are required to demonstrate competency with
recommended practices for point-of-care testing following each training.
Yes No
C. Facility routinely audits (monitors and documents) adherence to recommended practices during point-of-care testing.
Yes No
D. Facility provides feedback from audits to personnel regarding their adherence to recommended practices.
Yes No
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X.a. Environmental Cleaning
Elements to be assessed Assessment Notes/Areas for Improvement
A. Facility has written policies and procedures for routine cleaning and disinfection of environmental surfaces, including identification of responsible personnel.
Yes No
B. Personnel who clean and disinfect patient care areas (e.g., environmental services, technicians, nurses) receive training on cleaning procedures
i. Upon hire, prior to being allowed to perform environmental cleaning
ii. Annually
iii. When new equipment or protocols are introduced
Note: If environmental cleaning is performed by contract personnel, facility should verify this is provided by contracting company.
Yes No
Yes No Yes No
C. HCP are required to demonstrate competency with environmental cleaning procedures following each training.
Yes No
D. Facility routinely audits (monitors and documents) adherence to cleaning and disinfection procedures, including using products in accordance with manufacturer’s instructions (e.g., dilution, storage, shelf-life, contact time).
Yes No
E. Facility provides feedback from audits to personnel regarding their adherence to cleaning and disinfection procedures.
Yes No
F. Facility has a policy/procedure for decontamination of spills of blood or other body fluids.
Yes No
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X.a. Environmental Cleaning, continued
Operating Room
For the purposes of this checklist, an operating room is defined as a patient care area that met the Facilities Guidelines Institute’s (FGI) or American Institute of Architects’ (AIA) criteria for an operating room when it was constructed or renovated. This is the same definition that is used in the National Healthcare Safety Network’s Procedure-associated Module for the SSI Event (http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf)
If the facility does not have an operating room check Not Applicable here and skip to section XI.a. Device Reprocessing Elements to be assessed Assessment Notes/Areas for Improvement
G. Operating rooms are terminally cleaned after last procedure of the day.
Yes No
H. Facility routinely audits (monitors and documents) adherence to recommended infection control practices for surgical infection prevention including:
i. Adherence to preoperative surgical scrub and hand hygiene
ii. Appropriate use of surgical attire and drapes
iii. Adherence to aseptic technique and sterile field
iv. Proper ventilation requirements in surgical suites
v. Minimization of traffic in the operating room
vi. Adherence to cleaning and disinfection of environmental surfaces
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
I. Facility provides feedback from audits to personnel regarding their adherence to surgical infection prevention practices.
Yes No
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XI.a. Device Reprocessing
The following basic information allows for a general assessment of policies and procedures related to reprocessing of reusable medical devices. Outpatient facilities that are performing on-site sterilization or high-level disinfection of reusable medical devices should refer to the more detailed checklists in separate sections of this document devoted to those issues.
Categories of Medical Devices:
• Critical items (e.g., surgical instruments) are objects that enter sterile tissue or the vascular system and must be sterile prior to use (see Sterilization Section).
• Semi-critical items (e.g., endoscopes for upper endoscopy and colonoscopy, vaginal probes) are objects that contact mucous membranes or non-intact skin and require, at a minimum, high-level disinfection prior to reuse (see High-level Disinfection Section).
• Non-critical items (e.g., blood pressure cuffs) are objects that may come in contact with intact skin but not mucous membranes and should undergo cleaning and low- or intermediate-level disinfection depending on the nature and degree of contamination.
Single-use devices (SUDs) are labeled by the manufacturer for a single use and do not have reprocessing instructions. They may not be reprocessed for reuse except by entities which have complied with FDA regulatory requirements and have received FDA clearance to reprocess specific SUDs.
Note: Cleaning must always be performed prior to sterilization and disinfection
Elements to be assessed Assessment Notes/Areas for Improvement
A. Facility has policies and procedures to ensure that reusable medical devices are cleaned and reprocessed appropriately prior to use on another patient.
Note: This includes clear delineation of responsibility among HCP for cleaning and disinfection of equipment including, non-critical equipment, mobile devices, and other electronics (e.g., point-of-care devices) that might not be reprocessed in a centralized reprocessing area.
Yes No
B. The individual(s) in charge of infection prevention at the facility is consulted whenever new devices or products will be purchased or introduced to ensure implementation of appropriate reprocessing policies and procedures.
Yes No
C. HCP responsible for reprocessing reusable medical devices receive hands-on training on proper selection and use of PPE and recommended steps for reprocessing assigned devices:
i. Upon hire, prior to being allowed to reprocess devices ii. Annually
iii. When new devices are introduced or policies/procedures change.
Note: If device reprocessing is performed by contract personnel, facility should verify this is provided by contracting company.
Yes No Yes No Yes No
D. HCP are required to demonstrate competency with reprocessing procedures (i.e., correct technique is observed by trainer) following each training.
Yes No
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XI.a. Device Reprocessing, continued
Elements to be assessed Assessment Notes/Areas for Improvement
E. Facility routinely audits (monitors and documents) adherence to reprocessing procedures.
Yes No
F. Facility provides feedback from audits to personnel regarding their adherence to reprocessing procedures.
Yes No
G. Facility has protocols to ensure that HCP can readily identify devices that have been properly reprocessed and are ready for patient use (e.g., tagging system, storage in designated area).
Yes No
H. Facility has policies and procedures outlining facility response (i.e., risk assessment and recall of device) in the event of a reprocessing error or failure.
Yes No
I. Routine maintenance for reprocessing equipment (e.g., automated endoscope reprocessors, steam autoclave) is performed by qualified personnel in accordance with manufacturer instructions; confirm maintenance records are available.
Yes No Not Applicable (Reprocessing equipment is not used at the facility)
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Section 3: Direct Observation of Facility Practices
Certain infection control lapses (e.g., reuse of syringes on more than one patient or to access a medication container that is used for subsequent patients; reuse of lancets) have resulted in bloodborne pathogen transmission and should be halted immediately. Identification of such lapses warrants appropriate notification and testing of potentially affected patients.
If an element is unable to be observed during an assessment (e.g., no patients received point-of-care testing during the visit), assess the element by interviewing appropriate personnel about facility practices. Notation should also be made in the notes section that the element was not able to be directly observed.
V.b. Hand hygiene
Elements to be assessed Assessment Notes/Areas for Improvement
A. Supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible to HCP in patient care areas.
Yes No
Hand hygiene is performed correctly:
B. Before contact with the patient Yes No C. Before performing an aseptic task (e.g., insertion of IV or
preparing an injection, administering eye drops) Yes No Not Applicable
D. After contact with the patient Yes No E. After contact with objects in the immediate vicinity of the
patient Yes No
F. After contact with blood, body fluids or contaminated surfaces Yes No G. After removing gloves Yes No H. When moving from a contaminated-body site to a clean-body
site during patient care Yes No Not Applicable
VI.b. Personal Protective Equipment (PPE)
Elements to be assessed Assessment Notes/Areas for Improvement
A. Sufficient and appropriate PPE is available and readily accessible to HCP.
Yes No
PPE is used correctly:
B. PPE, other than respirator, is removed and discarded prior to leaving the patient’s room or care area. If a respirator is used, it is removed and discarded (or reprocessed if reusable) after leaving the patient room or care area and closing the door.
Yes No
C. Hand hygiene is performed immediately after removal of PPE. Yes No
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VI.b. Personal Protective Equipment (PPE), continued
Elements to be assessed Assessment Notes/Areas for Improvement D. Gloves
i. HCP wear gloves for potential contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated equipment.
ii. HCP do not wear the same pair of gloves for the care of more than one patient.
iii. HCP do not wash gloves for the purpose of reuse.
Yes No
Yes No
Yes No E. Gowns
i. HCP wear gowns to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated.
ii. HCP do not wear the same gown for the care of more than one patient.
Yes No Not Applicable
Yes No Not Applicable
F. Facial protection i. HCP wear mouth, nose, and eye protection during
procedures that are likely to generate splashes or sprays of blood or other body fluids.
Yes No Not Applicable
VII.b. Injection safety (This element does not include assessment of pharmacy/compounding practices)
If injectable medications are never prepared or administered at the facility check Not Applicable here and skip to Section VIII.b. Respiratory Hygiene/Cough Etiquette
Elements to be assessed Assessment Notes/Areas for Improvement A. Injections are prepared using aseptic technique in a clean area
free from contamination or contact with blood, body fluids or contaminated equipment.
Yes No
B. Needles and syringes are used for only one patient (this includes manufactured prefilled syringes and cartridge devices such as insulin pens).
Yes No
C. The rubber septum on a medication vial is disinfected with alcohol prior to piercing. Yes No
D. Medication containers are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient.
Yes No
E. Single dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution are used for only one patient. Yes No
F. Medication administration tubing and connectors are used for Yes No only one patient.
Not Applicable (Facility does not use tubing or connectors)
G. Multi-dose vials are dated by HCP when they are first opened Yes No and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Not Applicable
(Facility does not use
Note: This is different from the expiration date printed on the vial. multi-dose vials or discards them after single patient use)
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VII.b. Injection safety (This element does not include assessment of pharmacy/compounding practices), continued
Elements to be assessed Assessment Notes/Areas for Improvement
H. Multi-dose vials to be used for more than one patient are kept in Yes No a centralized medication area and do not enter the immediate patient treatment area (e.g., operating room, patient Not Applicable room/cubicle). (Facility does not use
multi-dose vials or Note: If multi-dose vials enter the immediate patient treatment area discards them after
they should be dedicated for single-patient use and discarded single patient use)
immediately after use.
I. All sharps are disposed of in a puncture-resistant sharps container.
Yes No
J. Filled sharps containers are disposed of in accordance with state regulated medical waste rules.
Yes No
K. All controlled substances (e.g., Schedule II, III, IV, V drugs) are kept locked within a secure area.
Yes No Not Applicable (Controlled substances are not kept at the facility)
L. HCP wear a facemask (e.g., surgical mask) when placing a Yes No catheter or injecting material into the epidural or subdural space (e.g., during myelogram, epidural or spinal anesthesia). Not Applicable
(Facility does not perform spinal injection procedures)
VIII.b. Respiratory Hygiene/Cough Etiquette
Elements to be assessed Assessment Notes/Areas for Improvement
A. Facility:
i. Posts signs at entrances with instructions to patients with symptoms of respiratory infection to: a. Inform HCP of symptoms of a respiratory
infection when they first register for care, and b. Practice Respiratory Hygiene/Cough Etiquette
(cover their mouths/noses when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands have been covered with respiratory secretions).
ii. Provides tissues and no-touch receptacles for disposal of tissues.
iii. Provides resources for performing hand hygiene in or near waiting areas.
Yes No
Yes No
Yes No
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IX.b. Point-of-Care Testing (e.g., blood glucose meters, INR monitor)
If point-of-care testing is never performed at the facility check Not Applicable here and skip to Section X.b. Environmental Cleaning
Elements to be assessed Assessment Notes/Areas for Improvement
A. New single-use, auto-disabling lancing device is used for each patient.
Note: Lancet holder devices are not suitable for multi-patient use.
Yes No Not Applicable
B. If used for more than one patient, the point-of-care blood testing meter is cleaned and disinfected after every use according to manufacturer’s instructions.
Note: If the manufacturer does not provide instructions for cleaning and disinfection, then the testing meter should not be used for >1 patient.
Yes No Not Applicable
X.b. Environmental Cleaning
Elements to be assessed Assessment Notes/Areas for Improvement
A. Supplies necessary for appropriate cleaning and disinfection procedures (e.g., EPA-registered disinfectants) are available.
Note: If environmental services are performed by contract personnel, facility should verify that appropriate EPA-registered products are provided by contracting company
Yes No
B. High-touch surfaces in rooms where surgical or other invasive procedures (e.g., endoscopy, spinal injections) are performed are cleaned and then disinfected with an EPA-registered disinfectant after each procedure.
Yes No Not Applicable
C. Cleaners and disinfectants are used in accordance with manufacturer’s instructions (e.g., dilution, storage, shelf-life, contact time).
Yes No
D. HCP engaged in environmental cleaning wear appropriate PPE to prevent exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection).
Note: The exact type of correct PPE depends on infectious or chemical agent and anticipated type of exposure.
Yes No
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XI.b. Device Reprocessing
Elements to be assessed Assessment Notes/Areas for Improvement
A. Policies, procedures, and manufacturer reprocessing instructions for reusable medical devices used in the facility are available in the reprocessing area(s).
Yes No
B. Reusable medical devices are cleaned, reprocessed (disinfection or sterilization) and maintained according to the manufacturer instructions.
Note: If the manufacturer does not provide such instructions, the device may not be suitable for multi-patient use.
Yes No
C. Single-use devices are discarded after use and not used for more than one patient unless they have been appropriately reprocessed as described in the note below.
Note: If the facility elects to reuse single-use devices, these devices must be reprocessed prior to reuse by a third-party reprocessor that it is registered with the FDA as a third-party reprocessor and cleared by the FDA to reprocess the specific device in question. The facility should have documentation from the third party reprocessor confirming this is the case.
Yes No
D. Reprocessing area: i. Adequate space is allotted for reprocessing activities.
ii. A workflow pattern is followed such that devices clearly flow from high contamination areas to clean/sterile areas (i.e., there is clear separation between soiled and clean workspaces).
Yes No Yes No
E. Adequate time for reprocessing is allowed to ensure adherence to all steps recommended by the device manufacturer, including drying and proper storage.
Note: Facilities should have an adequate supply of instruments for the volume of procedures performed and should schedule procedures to allow sufficient time for all reprocessing steps.
Yes No
F. HCP engaged in device reprocessing wear appropriate PPE to prevent exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection).
Note: The exact type of correct PPE depends on infectious or chemical agent and anticipated type of exposure.
Yes No
G. Medical devices are stored in a manner to protect from damage and contamination.
Yes No
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XII. Sterilization of Reusable Devices
If all device sterilization is performed off-site, complete elements M-O and check Not Applicable for the remaining elements in this section.
If sterilization of reusable devices is never performed (either at the facility or off-site) check Not Applicable here and skip to Section XIII.
Elements to be assessed Assessment Notes/Areas for Improvement A. Devices are thoroughly cleaned according to manufacturer
instructions and visually inspected for residual soil prior to sterilization.
Note: Cleaning may be manual (i.e., using friction) and/or mechanical (e.g., with ultrasonic cleaners, washer-disinfector, washer-sterilizers).
Ensure appropriately sized cleaning brushes are selected for cleaning device channels and lumens.
Yes No Not Applicable
B. Cleaning is performed as soon as practical after use (e.g., at the point of use) to prevent soiled materials from becoming dried onto devices.
Yes No Not Applicable
C. Enzymatic cleaner or detergent is used for cleaning and discarded according to manufacturer’s instructions (typically after each use)
Yes No Not Applicable
D. Cleaning brushes are disposable or, if reusable, cleaned and high-level disinfected or sterilized (per manufacturer’s instructions) after use.
Yes No Not Applicable
E. After cleaning, instruments are appropriately wrapped/packaged for sterilization (e.g., package system selected is compatible with the sterilization process being performed, items are placed correctly into the basket, shelf or cart of the sterilizer so as not to impede the penetration of the sterilant, hinged instruments are open, instruments are disassembled if indicated by the manufacturer).
Yes No Not Applicable
F. A chemical indicator (process indicator) is placed correctly in the instrument packs in every load.
Yes No Not Applicable
G. A biological indicator, intended specifically for the type and cycle parameters of the sterilizer, is used at least weekly for each sterilizer and with every load containing implantable items.
Yes No Not Applicable
H. For dynamic air removal-type sterilizers (e.g., prevacuum steam sterilizer), an air removal test (Bowie-Dick test) is performed in an empty dynamic-air removal sterilizer each day the sterilizer is used to verify efficacy of air removal.
Yes No Not Applicable
I. Sterile packs are labeled with a load number that indicates the sterilizer used, the cycle or load number, the date of sterilization, and, if applicable, the expiration date.
Yes No Not Applicable
J. Sterilization logs are current and include results from each load. Yes No Not Applicable
K. Immediate-use steam sterilization, if performed, is only done in circumstances in which routine sterilization procedures cannot be performed.
Yes No Not Applicable
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XII. Sterilization of Reusable Devices, continued
Elements to be assessed Assessment Notes/Areas for Improvement
L. Instruments that undergo immediate-use steam sterilization are used immediately and not stored.
Yes No Not Applicable
M. After sterilization, medical devices are stored so that sterility is not compromised.
Yes No Not Applicable
N. Sterile packages are inspected for integrity and compromised packages are reprocessed prior to use.
Yes No Not Applicable
O. The facility has a process to perform initial cleaning of devices (to prevent soiled materials from becoming dried onto devices) prior to transport to the off-site reprocessing facility.
Yes No Not Applicable
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XIII. High-Level Disinfection of Reusable Devices
If all high-level disinfection is performed off-site, complete elements L-N below and check Not Applicable for the remaining elements in this section.
If high-level disinfection of reusable devices is never performed (either at the facility or off-site) check here: Not Applicable Elements to be assessed Assessment Notes/Areas for Improvement
A. Flexible endoscopes are inspected for damage and leak tested as part of each reprocessing cycle. Any device that fails the leak test is removed from clinical use and repaired.
Yes No Not Applicable
B. Devices are thoroughly cleaned according to manufacturer instructions and visually inspected for residual soil prior to high-level disinfection.
Note: Cleaning may be manual (i.e., using friction) and/or mechanical (e.g., with ultrasonic cleaners, washer-disinfector, washer-sterilizers).
Ensure appropriately sized cleaning brushes are selected for cleaning device channels and lumens.
Yes No Not Applicable
C. Cleaning is performed as soon as practical after use (e.g., at the point of use) to prevent soiled materials from becoming dried onto instruments.
Yes No Not Applicable
D. Enzymatic cleaner or detergent is used and discarded according to manufacturer instructions (typically after each use).
Yes No Not Applicable
E. Cleaning brushes are disposable or, if reusable, cleaned and high-level disinfected or sterilized (per manufacturer instructions) after use.
Yes No Not Applicable
F. For chemicals used in high-level disinfection, manufacturer instructions are followed for:
i. Preparation Yes No Not Applicable
ii. Testing for appropriate concentration Yes No Not Applicable
iii. Replacement (i.e., upon expiration or loss of efficacy) Yes No Not Applicable
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XIII. High-Level Disinfection of Reusable Devices, continued
Elements to be assessed Assessment Notes/Areas for Improvement
G. If automated reprocessing equipment (e.g., automated endoscope reprocessor) is used, proper connectors are used to assure that channels and lumens are appropriately disinfected.
Yes No Not Applicable
H. Devices are disinfected for the appropriate length of time as specified by manufacturer instructions.
Yes No Not Applicable
I. Devices are disinfected at the appropriate temperature as specified by manufacturer instructions.
Yes No Not Applicable
J. After high-level disinfection, devices are appropriately rinsed as specified by the manufacturer.
Yes No Not Applicable
K. Devices are dried thoroughly prior to reuse.
Note: For lumened instruments (e.g., endoscopes) this includes flushing all channels with alcohol and forcing air through channels.
Yes No Not Applicable
L. After high-level disinfection, devices are stored in a manner to protect from damage or contamination.
Note: Endoscopes should be hung in a vertical position.
Yes No Not Applicable
M. Facility maintains a log for each endoscopy procedure which includes: patient’s name and medical record number (if available), procedure, date, endoscopist, system used to reprocess the endoscope (if more than one system could be used in the reprocessing area), and serial number or other identifier of the endoscope used.
Yes No Not Applicable
N. The facility has a process to perform initial cleaning of devices (to prevent soiled materials from becoming dried onto devices) prior to transport to the off-site reprocessing facility.
Yes No Not Applicable
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Section 4: Infection Control Guidelines and Other Resources
• General Infection Prevention
☐ CDC/HICPAC Guidelines and recommendations: http://www.cdc.gov/HAI/prevent/prevent_pubs.html
• Healthcare Personnel Safety
☐ Guideline for Infection Control in Healthcare Personnel: http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf
☐ Immunization of HealthCare Personnel: http://www.cdc.gov/vaccines/spec-grps/hcw.htm
☐ Occupational Safety & Health Administration (OSHA) Bloodborne Pathogens and Needlestick Prevention Standard: http://www.osha.gov/SLTC/bloodbornepathogens/index.html
☐ OSHA Respiratory Protection Standard: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=12716&p_table=STANDARDS
☐ OSHA Respirator Fit Testing: https://www.osha.gov/video/respiratory_protection/fittesting_transcript.html
• Hand Hygiene
☐ Guideline for Hand Hygiene in Healthcare Settings: http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
☐ Hand Hygiene in Healthcare Settings: http://www.cdc.gov/handhygiene/
Examples of tools that can be used to conduct a formal audit of hand hygiene practices:
☐ http://www.jointcommission.org/assets/1/18/hh_monograph.pdf
☐ http://compepi.cs.uiowa.edu/index.php/Research/IScrub
• Personal Protective Equipment
☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
☐ Guidance for the Selection and Use of Personal Protective Equipment in Healthcare Settings: http://www.cdc.gov/HAI/prevent/ppe.html
• Injection Safety
☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
☐ CDC Injection Safety Web Materials: http://www.cdc.gov/injectionsafety/
☐ CDC training video and related Safe Injection Practices Campaign materials: http://www.oneandonlycampaign.org/
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• Respiratory Hygiene/Cough Etiquette
☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
☐ Recommendations for preventing the spread of influenza: http://www.cdc.gov/flu/professionals/infectioncontrol/
• Environmental Cleaning
☐ Guidelines for Environmental Infection Control in Healthcare Facilities: http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf
☐ Options for Evaluating Environmental Infection Control: http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html
• Equipment Reprocessing
☐ Guideline for Disinfection and Sterilization in Healthcare Facilities: http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf
☐ FDA regulations on reprocessing of single-use devices: http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm071434
• Point-of-Care Testing
☐ Infection Prevention during Blood Glucose Monitoring and Insulin Administration: http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html
☐ Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration: http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html
• Resources to assist with evaluation and response to breaches in infection control
☐ Patel PR, Srinivasan A, Perz JF. Developing a broader approach to management of infection control breaches in health care settings. Am J Infect Control. 2008 Dec; 36(10); 685-90 http://www.ajicjournal.org/article/S0196-6553(08)00683-4/abstract
☐ Steps for Evaluating an Infection Control Breach: http://www.cdc.gov/hai/outbreaks/steps_for_eval_IC_breach.html
☐ Patient Notification Toolkit: http://www.cdc.gov/injectionsafety/pntoolkit/index.html
• Antibiotic Stewardship
☐ Get Smart Programs & Observances: http://www.cdc.gov/getsmart/
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Practice forum
A pragmatic approach to infection prevention and control guidelinesin an ambulatory care setting
Jessica Ng MSc, CIC a,*, Sheila Le-Abuyen MPH, CPHI(C) a, Jane Mosley MScN, RN a,Michael Gardam MD, MSc, CM, FRCPC, CIC a,b
aDepartment of Infection Prevention and Control, Women’s College Hospital, Toronto, Ontario, CanadabDepartment of Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
Key Words:OutpatientInfection Prevention and Control ProgramTransitionPractice change
The vast majority of infection prevention and control (IPAC) experience and practice guidance relates tothe inpatient setting. We have taken a pragmatic approach to applying IPAC guidance in our ambulatorysetting, and here we identify and describe the 4 key areas where we modified our IPAC program andadapted current guidelines to fit with our setting.
Copyright � 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc.Published by Elsevier Inc. All rights reserved.
Women’s College Hospital (WCH) is an academic health carefacility in Ontario, Canada, with a primary focus on the health ofwomen. WCH transitioned from an acute care hospital to anambulatory care hospital during 2006. The transition of infectionprevention and control (IPAC) practices from an acute careapproach to an approach appropriate to ambulatory care has beengradual but determined.
The vast majority of IPAC experience and practice guidance re-lates to inpatient settings. The Centers for Disease Control andPrevention,1 Public Health Agency of Canada,2 World Health Or-ganization,3 College of Physicians and Surgeons of Ontario,4 andProvincial Infectious Diseases Advisory Committee5 all publish IPACguidance documents but provide little concrete direction forambulatory care settings. As a result, until recently, we looselyadapted inpatient practices to fit our ambulatory setting.
In light of this, we conducted an extensive review of our IPACprogram in 2011, evaluating where gaps existed and identifyingwhere practice changes were needed to fit our new reality. We alsoconsciously moved to a less rigid, more pragmatic approach toapplying IPAC guidelines in our setting. In this report, we identifyand describe the 4 key areas where we modified our program andadapted current guidelines, specifically screening and surveillance,isolation practices and personal protective equipment (PPE) use,environmental cleaning, and hand hygiene (Table 1).
SCREENING AND SURVEILLANCE
In contrast to inpatient settings, the antibiotic resistant organ-ism (ARO) status of patients is largely unknown in standaloneambulatory care settings. Laboratory turnaround times are criticalfor preventing ARO transmission amongst inpatients.6 When WCHwas an inpatient facility, this was achieved by patient AROscreening upon admission and immediate telephone calls to IPACwhen a positive laboratory result was received. As we transitionedinto an ambulatory care setting, ARO screening became mootbecause patients would visit and leave the hospital within a day,long before results were available. Therefore, we worked with thelaboratory to stop immediate ARO reporting by telephone. In a fewof our clinical areas, we also eliminated ARO screening for thepurpose of implementing IPACmeasures and encouraged screeningonly for clinical decision-making purposes such as choosing theappropriate perioperative antimicrobial prophylaxis.
Because it is difficult to attribute a patient infection to a healthcare encounter in an ambulatory care setting, we do not formallytrack and publicly report infection rates. Instead, we have focusedour efforts on public health reporting of communicable diseasesand process surveillance of IPAC practices within our hospital, suchas promoting good respiratory etiquette, improving compliancewith antibiotic prophylaxis guidelines, and ensuring the use of asurgical safety checklist.
ISOLATION PRACTICES AND PPE USE
Despite understanding that Routine Practices (RP)7 (ie, Centersfor Disease Control and Prevention standard precautions) should
* Address correspondence to Jessica Ng, MSc, CIC, Department of InfectionPrevention and Control, Women’s College Hospital, 76 Grenville St, Toronto,Ontario, Canada M5S 1B2.
E-mail address: [email protected] (J. Ng).Conflicts of interest: None to report.
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.aj ic journal .org
American Journal of Infection Control
0196-6553/$36.00 - Copyright � 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.ajic.2014.02.011
American Journal of Infection Control 42 (2014) 671-32.5
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be applied to all patients at all times, staff members often relied onthe patient flagging system to guide practice. Before becoming anambulatory care hospital, WCH screened inpatients for AROs andpatients who were positive for an ARO were identified with anelectronic flag. When a patient was flagged for an ARO, there wouldbe heightened attention to perform hand hygiene, use PPE (often inexcess), and ensure appropriate environmental cleaning. Because ofthis, adherence to RP for patients not flaggedwith an AROwas oftenlax.
To provide clarity and address the inconsistent use of RP andAdditional Precautions (AP),7 we revised our policy to emphasizethe systematic application of RP for all patients, including patientsknown to be carrying an ARO. For staff, this meant that ARO statusdoes not automatically necessitate AP; instead, it would depend onthe risk of exposure to uncontained secretions. Finally, to furtherprevent the selective use of RP, we are in the process of deactivatingthe ARO flagging option in our patient record system.
ENVIRONMENTAL CLEANING
The cleaning practices for patients and hospital environmentsare not as well defined in an ambulatory care setting. Generally,because outpatient visits create less environmental contamination,less intensive cleaning is needed compared with an inpatientsetting. At WCH, there have often been misconceptions regardingwhat needs to be cleaned and how frequently; RP for environ-mental cleaning were often only focused on ARO-positive patients.To facilitate cleaning, ARO-positive patients would be scheduled asthe final visit of the day and then a so-called terminal clean wouldbe performed. These practices posed a risk because RP for envi-ronmental cleaning were not being applied to all patients.
In 2012, we discontinued these practices and engaged thefrontline staff, clinical managers, and clinical directors to allocateadequate resources to ensure that routine practice environmentalcleaning could be applied to all patients. We also emphasized thatspecial cleaning by environmental services was no longer requiredfor ARO-positive patients if there was no visible soiling of theenvironment. We explained that with diligent use of RP, ARO-positive patients could be scheduled at any time. An audit con-ducted April 2013-December 2013 confirmed that 97% of frontlinestaff (N ¼ 67) were following this policy and cleaned patientequipment between uses. Lastly, best practices for environmentalcleaning in an inpatient setting include specific guidelines on dailyand terminal cleaning of patient rooms.8With no patients requiringdischarge or transfer from our hospital, we shifted from the con-cepts of daily and terminal cleaning to applying RP of environ-mental cleaning between patient visits and thorough cleaning atthe end of each day.
HAND HYGIENE
Until recently, there have been few resources addressing specifichand hygiene practice guidelines for an outpatient setting. Since2008, the WCH approach to hand hygiene practices has been basedon the program developed by the Ontario Ministry of Health andLong-Term Care.9 This program was created primarily to helpinpatient facilities improve health care worker hand hygienecompliance. Therefore, we found that applying the moments forhand hygiene in an ambulatory care setting required adaptations.We had to redefine the patient environment and focus on theconcept of performing hand hygiene at the point-of-care in a clinicroom. Although the Hand Hygiene Human Factors Toolkit issued bythe Canadian Patient Safety Institute10 recommends installingalcohol-based hand rub dispensers by the door inside and outside apatient room, we chose to focus resources on ensuring that, at aminimum, alcohol-based hand rubs are provided at the point-of-care; that is, on a health care provider’s desk or within reach ofexam bed areas. As a result of this work, hand hygiene compliancebefore contact with patients or patient environments increasedfrom 80%-93% during the period 2010-2013.
In accordance with best practices for monitoring hand hy-giene,3,11,12 WCH began monitoring hand hygiene practices bydirect observation. However, adapting this approach to our clinicalareas proved difficult because most patient visits involve 1 patientand 1 health care provider in a private examination room. Toobserve practices meant that an auditor would have to be presentin the same room as the patient and health care provider. Not onlywas this highly uncomfortable for all involved, but it also raisedconcerns related to patient privacy and workflow disruption.Moreover, the Hawthorne effect would have significantly biasedthe results for health care providers’ hand hygiene compliance.Compounding the challenges was the fact that the direct observermethod was labor-intensive because few hand hygiene indicationswere observed during a typical patient visit lasting 15-30 minutes.
To address these challenges, we instituted an alternativemethod for hand hygiene monitoring that was inspired by anapproach described by Bittle and LaMarche.13 This method engagespatients to observe their health care providers’ compliance to handhygiene. We invited patients to complete a survey card after theirvisit with their health care provider. During the pilot program,patients returned 75.1% of the survey cards distributed, and overallhand hygiene compliance was 96.8%. The accuracy/interrater reli-ability of patient observations were determined to be in concor-dance with an independent observer 87% of the time, suggestingthat patients were generally able to correctly evaluate health careprovider hand hygiene practices. Based on these results, weconcluded that engaging patients as observers is an effective
Table 1Key areas differing in approach to infection prevention and control (IPAC) in an ambulatory care setting
Area Inpatient care Ambulatory care
Screening Patients are screened upon admission to implement AP Patients are not screened for IPAC purposesSurveillance Larger focus on outcome surveillance; infection rates for AROs
such as MRSA and Clostridium difficile are trackedDifficult to attribute causation and track infection rates. Main focus is
on process surveillance such as antibiotic prophylaxis and use of asurgical safety checklist
Isolation precautionsand PPE use
AP are implemented, which include specific strategies forpatient placement, use of PPE, and environmental cleaning
Emphasis on use of RP for all patients, including patients with aknown ARO
Environmentalcleaning
Daily and terminal cleaning for patient rooms. Terminal cleaningrequired for patients identified with an ARO
Focus on cleaning patient equipment between use and a thoroughend-of-day room cleaning for all patients, including patients witha known ARO
Hand hygiene Patient environment is well defined in the moments for handhygiene. A direct observer can monitor hand hygiene at ease
Patient environment is less defined in the moments for hand hygieneDirect observer for monitoring hand hygiene raises numerous issues
Alternative methods such as engaging patients as observers havebeen effective
AP, Additional Precautions; ARO, antibiotic resistant organism; MRSA, methicillin-resistant Staphylococcus aureus; PPE, personal protective equipment; RP, Routine Practices.
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method for monitoring health care provider hand hygiene practicesin an ambulatory care setting.14
CONCLUSIONS
The dearth of practical IPAC guidelines appropriate for anambulatory care setting motivated us to assume a more prag-matic approach to applying IPAC best practice guidelines to ourhospital. The decision to take this approach has allowed us totranslate and define current best practice guidelines for use inambulatory care settings. We have identified IPAC practices thatmay be applicable for an inpatient setting but do not easilytransfer to an outpatient setting. Our hope is that this work willlead to further development of IPAC best practice guidelines forambulatory care settings.
References
1. Centers for Disease Control and Prevention. Guide for IPAC for outpatientsettings: minimum expectations for safe care 2011. Available from: http://www.cdc.gov/HAI/pdfs/guidelines/standatds-of-ambulatory-care-7-2011.pdf.Accessed September 1, 2013.
2. Canadian Committee on Antibiotic Resistance (CCAR). Infection preventionand control best practices for long term care, home and community careincluding health care offices and ambulatory clinics 2007. Available from: http://www.phac-aspc.gc.ca/amr-ram/ipcbp-pepci/pdf/amr-ram-eng.pdf. AccessedSeptember 1, 2013.
3. World Health Organization. Hand hygiene in outpatient care, home-based careand long-term care facilities 2012. Available from: http://www.who.int/gpsc/5may/EN_GPSC1_PSP_HH_Outpatient_care/en/. Accessed September 1, 2013.
4. The College of Physicians and Surgeons of Ontario. Infection control in thephysician’s office 2004. Available from: http://www.cpso.on.ca/uploadedFiles/policies/guidelines/office/Infection_Controlv2.pdf. Accessed September 1, 2013.
5. Ontario Agency for Health Protection and Promotion, Provincial InfectiousDiseases Advisory Committee. Infection prevention and control programs
in Ontario 2012. Available from: http://www.publichealthontario.ca/en/eRepository/BP_IPAC_Ontario_HCSettings_2012.pdf. Accessed September 1, 2013.
6. Ontario Agency for Health Protection and Promotion, Provincial InfectiousDiseases Advisory Committee. Annex A e screening, testing and surveillancefor antibiotic-resistant organisms (AROs). Annexed to: Routine Practices andAdditional Precautions in all health care settings 2013. Available from: http://www.publichealthontario.ca/en/eRepository/PIDAC-IPC_Annex_A_Screening_Testing_Surveillance_AROs_2013.pdf. Accessed September 1, 2013.
7. Ontario Agency for Health Protection and Promotion, Provincial Infectious Dis-eases Advisory Committee. Routine Practices and Additional Precautions in AllHealth Care Settings. 3rd edition. Toronto, ON: Queen’s Printer for Ontario;November 2012. Available from: http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf. Accessed April 15, 2014.
8. Ontario Agency for Health Protection and Promotion, Provincial InfectiousDiseases Advisory Committee. Environmental Cleaning for Prevention andControl of Infections 2012. Available from: http://www.publichealthontario.ca/en/eRepository/Best_Practices_Environmental_Cleaning_2012.pdf. AccessedSeptember 1, 2013
9. Ontario Agency for Health Protection and Promotion. Just Clean YourHands program. 2013. Available from: http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/JustCleanYourHands/Pages/Just-Clean-Your-Hands.aspx#.Uionu-FsGHV. Accessed September 1, 2013.
10. Canadian Patient Safety Institute. Human Factors Toolkit. 2012. Available from:http://www.handhygiene.ca/English/Tools/Pages/Human-Factors-Toolkit.aspx.Accessed September 1, 2013.
11. Ontario Agency for Health Protection and Promotion, Provincial InfectiousDiseases Advisory Committee. Hand Hygiene 2010. Available: http://www.publichealthontario.ca/en/eRepository/2010-12%20BP%20Hand%20Hygiene.pdf.Accessed September 1, 2013.
12. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee,HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygienein health-care settings: recommendations of the Healthcare Infection ControlPractices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand HygieneTask Force. MMWR Recomm Rep 2002;51:1-45.
13. Bittle MJ, LaMarche S. Engaging the patient as observer to promote handhygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf 2009;35:519-25.
14. Le-Abuyen S, Ng J, Kim S, De La Franier A, Khan B, Gardam M, et al. Patient-as-observer approach: an alternative method for hand hygiene auditing in anambulatory care setting. Am J Infect Control 2014;42:439-42.
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48 | FALL 2019 | Prevention
ith an extensive network that stretches close to a 200-mile radius and includes a 540-plus-bed main hospital, a research center, four surgery centers, 31 physician practices, 11 specialty care centers, and emergency care, the Children’s Hospital of Philadelphia (CHOP) wants to
ensure that it offers quality care in the places where patients are seen most frequently: facilities in the ambulatory setting. In a session titled “Making a Case for an Ambulatory IPC Program,” at the APIC 2019 Annual Conference, Lori Handy, MD, MSCE, associate medical director, infection prevention, and Sara Townsend, MS-HQS, CIC, FAPIC, infection prevention supervisor for the Philadelphia-based hospital, discussed how CHOP has successfully restructured its infection prevention and control (IPC) program to cover its vast system.
W
FEATURE
Infection prevention in a system of ambulatory settingsChildren’s Hospital of Philadelphia shows how it’s doneBY SANDY SMITH
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Members of the Children’s Hospital of Philadelphia ambulatory infection prevention control team, from left to right: Regina Wagoner, infection preventionist; Sara Townsend, infection prevention supervisor; Lori Handy, associate medical director, infection prevention and control; Grayson Privette, infection preventionist II; and Kimberly Wilson, hand hygiene manager. Sara Townsend (left) and Lauren Satchell, infection prevention associate II.
The ambulatory care setting is “where most of our patients are seen, so it was a cornerstone when we were thinking about what our restructured program would look like,” Handy said. “We were already providing infection prevention services in ambulatory settings, but we wanted to do it in a more formalized way,” she noted. To support this vision of infection prevention in ambulatory care, Sarah Smathers, the department’s senior
manager, had developed a business case for this restructure, recognizing the growth of the institution.
GETTING THE IPC HOUSE IN ORDERBefore implementing any system-wide changes, the IPC
department itself had to change. Prior to the launch of CHOP’s dedicated ambulatory program, the department
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had one part-time infection preventionist (IP) devoted to the ambulatory setting, with ambulatory sites assigned to IPs within the department. With limited ability to regularly visit sites, CHOP “relied on those offices to call to ask for help,” Handy said. “Sometimes, we’d get a lot of informa-tion from these calls and sometimes we didn’t know what we didn’t know.”
Knowing this was not an ideal way to deliver reliable infec-tion prevention practice, the IPC leadership began to think through a holistic approach for the system. “We wanted to look at our program in a different way, to see if we could find a way to improve role clarity within the department,” said Townsend.
With this in mind, CHOP reorganized the IPC department. Handy and Townsend formed a strong physician-administra-tive leader dyad, which had shown to be successful in other areas of the network and was known to be supported by the literature, to oversee CHOP’s IPC ambulatory and procedure services program.
Additional staffing changes were also made during the department reorganization. Today, the department has an entire team focused on ambulatory care and procedure ser-vices that includes two full-time IPs; the ambulatory team is also supported by the department’s data and logistics team. The latter includes two IP associates who manage data and surveillance, a clinical practice analyst, and the hand hygiene program manager. This ambulatory team works throughout the CHOP enterprise.
SETTING FIRST PRIORITIESA first step for the newly constituted ambulatory IPC team
was assessing IP practices and knowledge across CHOP’s vast network. A survey was sent out to partners, asking both quan-titative and qualitative questions. “We really wanted to better understand where we were at, so we could understand where we should be going,” Townsend said. While the responses were
generally positive, answers revealed a need for better monitor-ing of respiratory etiquette and more education about infection prevention, Townsend said.
In another early initiative, the IPC team worked with ambula-tory partners on a risk assessment, determining the likelihood of events, identifying the risks to the organization if those events occurred, and evaluating current systems for readiness. These data were then used to help the team set priorities. “The problem with collecting that much data at the beginning is you feel you have to do everything,” Handy said.
Using the CHOP system’s own framework for improve-ment, the team began by developing a charter to clearly identify the work that lay ahead. “We wanted to iron out how we could move this project forward,” Handy said. She noted that this process “feels a little tedious sometimes, but is really important. For example, we had to write down the goal that we wanted a program-based approach to the ambulatory network.”
Additionally, measures had to be clarified. Handy noted key questions: “How are we going to know that what we’re doing is better than what we did before? Would we look at the number of people educated? Or the number of exposure events?”
The team set specific goals for what would be accomplished in the first year, identifying primary drivers for these goals—responsive learning and proactive prevention—as well as sec-ondary drivers. It also included a “parking lot” for ideas that were worth exploring in the future.
Putting an idea on hold is “hard to do, but it’s really impor-tant,” Handy explained. “It allows you to focus on the first couple of priorities.” At the same time, Handy advised choos-ing one’s words carefully in these situations. “Try to say to your stakeholders, ‘That’s important work, and I can get back to you in October.’ We found decent response when we were able to phrase things like that, compared to ‘I can’t get to that right now.’”
Members of the Children’s Hospital of Philadelphia ambulatory infection prevention control team.Grayson Privette and Regina Wagoner review hand hygiene data for Children’s Hospital of Philadelphia primary care sites.
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READ MORE ABOUT INFECTION PREVENTION IN AMBULATORY CARE SETTINGS IN THE AMERICAN JOURNAL OF INFECTION CONTROLAmbulatory infection prevention risk assessment: Not all ambulatory sites are created equal. Havill NL, Nucci D, Sullivan L, Dembry L-M. Am J Infect Control, Vol. 42, Issue 6, S87-S88.
Infection surveillance systems in primary health care: A literature review. Manning ML, Pogorzelska-Maziarz M. Am J Infect Control, Vol. 44, Issue 4, 482-484.
Once potential goals were identified, the team ranked them in terms of effort needed to execute the task and levels of impact. Emphasis was placed on those goals with the highest impact and lowest barriers to implementation. Additionally, the ambulatory IPC team agreed that if a facility asked a question about an idea that didn’t make the list of goals, the team would be available to consult.
MAKING CONNECTIONSThe team has faced multiple hurdles, to be sure, including the
sheer number of sites and the distances between them. To help make in-person connections, the team identified a number of ambulatory forums where leaders of certain areas—like nurse managers or medical directors—would meet. The ambulatory IPC team began attending those meetings, which allowed them to “start identifying groups of people we could meet face to face,” Handy said.
Even with these outreach efforts, the team cannot possibly meet everyone. In the beginning, the team struggled to get the attention of staff outside the main facility, who were suddenly receiving emails from people they didn’t know. Recognizing that important messages are better received when the recipient connected with the person sending it, “we needed to leverage our regional medical directors for impact,” Handy said. “At times, for key messaging, I would send an email out to the regional medical director, who would then send it out to their staff.”
The team quickly learned there were institutional differences that needed to be overcome. For example, most of their initial resources provided a five-digit phone number, but some locations outside the main campus did not have access to that quick-dial sys-tem—and didn’t know how to complete the rest of the sequence.
In another instance, the IPC team considered various high-tech ideas, such as alerts in the electronic health record system, to help remind nurses to call an IP if they noticed any cases of reportable diseases. But after talking with the ambula-tory teams, “we learned that we didn’t need to be fancy; what they actually wanted was a sign for the back of their door, reminding them to call us,” Handy said.
IMPROVING DATA SUBMISSIONThe network already had a hand hygiene program developed in
both the inpatient and ambulatory settings, but data submission was inconsistent in the ambulatory setting. “The variation of data led to variable compliance results,” Townsend said. “Also, there was a lack of understanding about the different hand hygiene moments in the ambulatory setting.” A future focus for the team
will be observing hand hygiene collection practices and revamping the training process to improve compliance and data integrity.
Working in the individual offices and settings was not as easy as it might seem. There were siloes, even within a single small office. Townsend recalled how she thought she had a great relationship with the nurses at a particular site. The nurses were good at letting her know when test results for reportable communicable diseases had come back positive. However, “at the same site, someone told Lori they didn’t know what our website, @CHOP, was.” This comment led the IPC team to start asking questions such as, “Do administrators, physicians, and nurses who work at the same office have meetings together?” According to Townsend, the incident “made us aware of the fact that, just because you talk often to one type of professional, they may not share that information with their colleagues.”
MOVING FORWARDEven with those challenges, CHOP’s IPC team soon learned
that personnel who worked in ambulatory settings “want our team’s input in their daily work and also want our team to understand their work,” Townsend said. “We recognize this is a complicated process, and it’s going to take time and evolve.”
And there is work that remains to be done. “There still is confu-sion over which communicable diseases must be reported to the IPC team. Our infection prevention website needs some work to make it simpler so that staff in clinics and other ambulatory settings can find what they need when they need it,” Handy said.
More generally, “We need to work on how to connect people in the network to our team,” Townsend stressed. “That’s hard with so many sites and so few people. To do this well, you need to be able to adapt and adopt.” Handy further explained the team’s long-term objective: “We hope to provide the opportunity for reliable practices and the ability to develop transparent data because with data we can drive improvement. What we hope to do is reach all the practice partners, to put the picture together regarding what IPC is, and how we can ultimately help them.”
Sandy Smith is a medical writer for Prevention Strategist.
“We wanted to look at our program in a different way, to see if we could find a way to improve role clarity within the department.”
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Module 3
Infection Control & Prevention Basics
Contents
3.1 Hand Sanitizer Factsheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Centers for Disease Control and Prevention (CDC)https://www .cdc .gov/handwashing/pdf/hand-sanitizer-factsheet .pdf
3.2 Core Practices for Infection Prevention in all Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC)https://www .cdc .gov/hicpac/pdf/core-practices .pdf
3.3 Clean Hands Count . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Association for Professionals in Infection Control and Epidemiology (APIC)Forms & Checklists for Infection Prevention, Volume 1
3.4 Personal Protective Equipment Efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98APICForms & Checklists for Infection Prevention, Volume 1
3.5 Personal Protective Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100APICForms & Checklists for Infection Prevention, Volume 1
3.6 Cover Your Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103CDC Posters in English and Spanish
3.7 Handwashing, at Home, at Play, and Out and About . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105CDC Posters in English and Spanish
3.8 Five Moments for Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107World Health Organization (WHO)
3.9 Healthcare worker hand contamination at critical moments in outpatient care settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108James Bingham, MS; Ginnie Abell, BA, RN, CIC; LeAnne Kienast, BS, et al . American Journal of Infection ControlNov . 2016, Vol 44, Issue 11, p . 1198-1202
3.10 Safe Injection Guidelines Pocket Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113CDC
3.11 Safe Injection Practices Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114CDC
3.12 Patient Injection Safety Handout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115CDC
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Resources
Standard Precautions for All Patient CareCDChttps://www .cdc .gov/infectioncontrol/basics/standard-precautions .html
Chart for Recommendations for Application of Standard Precautions for the Care of All Patients in All Healthcare SettingsCDChttps://www .cdc .gov/infectioncontrol/guidelines/isolation/appendix/standard-precautions .html
One and Only CampaignCDChttps://www .cdc .gov/injectionsafety/1anonly .html
Five Moments for Hand HygieneWHO https://www .who .int/gpsc/5may/background/5moments/en/
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U.S. Department of Health and Human ServicesCenters for Disease Control and Prevention
Handwashing and Hand Sanitizer Use at Home, at Play, and Out and About
CS270631
Germs are everywhere! They can get onto hands and items we touch during daily activities and make you sick. Cleaning hands at key times with soap and water or hand sanitizer is one of the most important steps you can take to avoid getting sick and spreading germs to those around you.
There are important differences between washing hands with soap and water and cleaning them with hand sanitizer. For example, alcohol-based hand sanitizers don’t kill ALL types of germs, such as a stomach bug called norovirus, some parasites, and Clostridium difficile, which causes severe diarrhea. Hand sanitizers also may not remove harmful chemicals, such as pesticides and heavy metals like lead. Handwashing reduces the amounts of all types of germs, pesticides, and metals on hands. Knowing when to clean your hands and which method to use will give you the best chance of preventing sickness.
When should I use?
Soap and Water • Before, during, and after preparing food
• Before eating food
• Before and after caring for someone who is sick
• Before and after treating a cut or wound
• After using the bathroom, changing diapers, or cleaning up a child who has used the bathroom
• After blowing your nose, coughing, or sneezing
• After touching an animal, animal food or treats, animal cages, or animal waste
• After touching garbage
• If your hands are visibly dirty or greasy
Alcohol-Based Hand Sanitizer • Before and after visiting a friend or a loved
one in a hospital or nursing home, unless the person is sick with Clostridium difficile (if so, use soap and water to wash hands).
• If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol, and wash with soap and water as soon as you can.
* Do NOT use hand sanitizer if your hands are visibly dirty or greasy: for example, after gardening, playing outdoors, or after fishing or camping (unless a handwashing station is not available). Wash your hands with soap and water instead.
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How should I use?
Soap and Water• Wet your hands with clean running water
(warm or cold) and apply soap.
• Lather your hands by rubbing them together with the soap.
• Scrub all surfaces of your hands, including the palms, backs, fingers, between your fingers, and under your nails. Keep scrubbing for 20 seconds. Need a timer? Hum the “Happy Birthday” song twice.
• Rinse your hands under clean, running water.
• Dry your hands using a clean towel or air dry them.
Alcohol-Based Hand Sanitizer Use an alcohol-based hand sanitizer that contains at least 60% alcohol. Supervise young children when they use hand sanitizer to prevent swallowing alcohol, especially in schools and childcare facilities.
• Apply. Put enough product on hands to cover all surfaces.
• Rub hands together, until hands feel dry. This should take around 20 seconds.
Note: Do not rinse or wipe off the hand sanitizer before it’s dry; it may not work as well against germs.
For more information, visit the CDC handwashing website, www.cdc.gov/handwashing.
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Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee
Preface The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee chartered in 1991 to provide advice and guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services (HHS) regarding the practice of infection control and strategies for surveillance, prevention, and control of healthcare-associated infections, antimicrobial resistance and related events in United States healthcare settings. CDC has been developing recommendations for healthcare infection control to prevent infections in patients and healthcare personnel since the 1970’s. These recommendations continue to evolve over time as evidence bases are built and serve as a foundation for healthcare safety across settings, a basis for quality improvement efforts, and part of the process that identifies important research gaps. Guideline development methods have since moved beyond expert opinion alone and incorporated systematic approaches to evidence analysis. A number of core practices are recommended by CDC and considered standards of care and/or accepted practices (e.g., aseptic technique, hand hygiene before patient contact) to prevent infection in healthcare settings. These widely agreed upon practices are elements of care that are not expected to change based on additional research, either because of an overwhelming preponderance of evidence (e.g., hand hygiene requirements), or in some cases due to ethical concerns (e.g., randomizing patients to procedures performed by trained versus untrained personnel). Therefore, these accepted practices are categorized as strong recommendations, even when high-quality randomized controlled trials are not available to support them. In an effort to streamline and systematize the process for updating existing guidelines without recreating the analytic process for each of these accepted/core practices, in March 2013, CDC charged HICPAC to review existing CDC guidelines and identify all recommendations that warrant inclusion as core practices. A HICPAC workgroup was formed that was led by HICPAC members and contained representatives from the following stakeholder organizations: America’s Essential Hospitals, the Association for Professionals in Infection Control and Epidemiology (APIC), the Council of State and Territorial Epidemiologists (CSTE), the Public Health Agency of Canada (PHAC), the Society for Healthcare Epidemiology of America (SHEA), and the Society of Hospital Medicine (SHM). The Workgroup provided updates and obtained HICPAC input at the June 2013, November 2013, April 2014, and July 2014 public meetings. HICPAC voted to finalize the recommendations at the July 2014
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meeting. Additional information about HICPAC is available at the HICPAC website (www.cdc.gov/hicpac).
Introduction Adherence to infection prevention and control practices is essential to providing safe and high-
quality patient care across all settings where healthcare is delivered. Substantial attention has been focused in recent years on improving infection prevention practices within acute care hospitals to optimize patient safety; many of these practices also need to be applied across multiple aspects of patient care. In addition, changes in healthcare during the past decade, driven at least in part by efforts to contain costs, have resulted in an increasing proportion and range of healthcare services being delivered outside of the acute care setting.1,2 These ambulatory and community-based healthcare encounters also can lead to infectious complications that can be prevented using those same infection prevention and control practices.
This document concisely describes a core set of infection prevention and control practices that are required in all healthcare settings, regardless of the type of healthcare provided. The practices were selected from among existing CDC recommendations and are the subset that HICPAC and its Core Practices Working Group determined were fundamental standards of care that are not expected to change based on emerging evidence or to be regularly altered by changes in technology or practices, and are applicable across the continuum of healthcare settings. This document also is intended to improve consistency of language, reduce redundancy across guidelines, and provide a convenient reference wherein these recommendations are maintained. A review of existing CDC guidelines demonstrated many examples of similar recommendations in multiple guidelines with variability in language. The recommendations outlined in this document are intended to serve as a standard reference and reduce the need to repeatedly evaluate practices that are considered basic and accepted as standards of medical care. Readers are urged to consult the full text of CDC guidelines (see references) for additional background and rationale related to the core practice recommendations captured here.
Scope The core practices in this document should be implemented in all settings where healthcare is
delivered. These venues include both inpatient settings (e.g., acute, long-term care, rehabilitation, behavioral health) and outpatient settings (e.g., physician and nurse practitioner offices, clinics, urgent care, ambulatory surgical centers, imaging centers, dialysis centers, physical therapy and rehabilitation centers, alternative medicine clinics). In addition, these practices apply to healthcare delivered in settings other than traditional healthcare facilities, such as homes, pharmacies, and health fairs.
Healthcare personnel (HCP) referred to in this document include all persons, paid and unpaid, in the healthcare setting having direct patient contact and/or potential for exposure to patients and/or to infectious materials (e.g., body substances, used medical supplies and equipment, soiled environmental surfaces). This also includes persons not directly involved in patient care (e.g., clerical
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staff, environmental services, volunteers) who could be exposed to infectious material in a healthcare setting.
Methods CDC healthcare infection control guidelines3-19 were reviewed, and recommendations included in
more than one guideline were grouped into core infection prevention practice domains (e.g., education and training of HCP on infection prevention, injection and medication safety). Additional CDC materials aimed at providing general infection prevention guidance outside of the acute care setting20-22 were also reviewed. HICPAC formed a workgroup led by HICPAC members and including representatives of professional organizations (see Contributors for full list). The workgroup reviewed and discussed all of the practices, further refined the selection and description of the core practices, and presented drafts to HICPAC at public meetings in June 2013, November 2013, April 2014, and July 2014 to inform HICPAC’s final recommendations. The recommendations (see Table) were approved by the full Committee in July 2014.
Conclusions Adherence to basic infection prevention and control practices are essential, not only in acute care
hospitals but also in settings with limited infection prevention infrastructure. The frequency of infectious outbreaks stemming from errors in infection control across settings (e.g., reuse of syringes between patients leading to transmission of viral hepatitis23-25) underscores the critical importance of adherence to these core infection prevention practices wherever healthcare is provided. Recommendations highlighted in this document represent minimum expectations, and healthcare personnel and facilities will need to supplement them according to their settings, procedures performed, and patient populations.
Readers should consult the full texts of CDC healthcare infection control guidelines for background, rationale, and related infection prevention recommendations for more comprehensive information. We encourage professional associations and societies and the research community to develop tools to facilitate implementation and maintenance of these core infection prevention practices across the continuum of healthcare.
Text References 1. Hsiao CJ, Cherry DK, Beatty PC, Rechsteiner EA. National Ambulatory Medical Care Survey: 2007
Summary. National health statistics reports; no 27. Hyattsville, MD: National Center for Health Statistics. 2010.
2. Medicare Payment Advisory Committee. A data book: Health care spending and the Medicare program, June 2016 [PDF - 4.1 MB] (http://www.medpac.gov/docs/default-source/data-book/june-2016-data-book-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0).
3. Bolyard EA. Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for Infection Control in Healthcare Personnel, 1998 (https://stacks.cdc.gov/view/cdc/7250). Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1998 Jun; 19(6):407-63.
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4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999 (https://stacks.cdc.gov/view/cdc/7160). Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999 Apr 20(4):250-78.
5. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, Society for Healthcare Epidemiology of America, Association for Professionals in Infection Control, Infectious Diseases Society of America, and the Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm). Infect Control Hosp Epidemiol. 2002 Dec 23(12 Suppl):S3-40.
6. Sehulster L, Chin RY, Healthcare Infection Control Practices Advisory Committee. Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee [PDF - 2.31 MB] (https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf). MMWR Recomm Rep 2003 Jun 6:52(RR-10):1-42.
7. Jensen PA, Lambert LA, Iademarco MF, Ridzon R. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 [PDF - 4.2 MB] (https://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf). MMWR Recomm Rep. 2005 Dec 30:54(RR-17):1-141.
8. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006 [PDF - 553 KB] (https://www.cdc.gov/infectioncontrol/pdf/guidelines/mdro-guidelines.pdf). Am J Infect Control, 2007 Dec 35 (10 Suppl 2):S165-93.
9. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings [PDF - 1.42 MB] (https://wwwdev.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf). Am J Infect Control. 2007 Dec 35(10 Suppl 2)S65-164.
10. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee, Guideline for Prevention of Catheter-Associated Urinary Tract Infection 2009 [PDF - 650 KB] (https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf). Infect Control Hosp Epidemiol, 2010 Apr 31(4):319-26.
11. Centers for Disease Control and Prevention. Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities [PDF - 381 KB] (https://www.cdc.gov/hai/pdfs/cre/cre-guidance-508.pdf). MMWR 2009 Mar 20:58 (10):256-60.
12. Division of Viral Disease, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Updated Norovirus Outbreak Management and Disease Prevention Guidelines (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6003a1.htm). MMWR 2011 Mar 4:60(RR-3):1-18.
13. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad I, Randolph AG, Rupp ME, Saint S, Healthcare Infection Control
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Practices Advisory Committee. Guidelines for the Prevention of Intravascular Catheter-Related Infections [PDF - 678 KB] (https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines.pdf). Am J Infect Control. 2011 May 39(4 Suppl 1):S1-34.
14. Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 [PDF - 1.26 MB] (https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf). Am J Infect Control. 2013;41(5 Suppl):S67-71.
15. Tablan OC, Anderson LJ, Besser R, Bridges C, Haijeh R, Healthcare Infection Control Practices Advisory Committee. Guidelines for Preventing Healthcare-associated Pneumonia, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm. MMWR Recomm Rep 204 Mar 26:53(RR-3):1-26.
16. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care [PDF - 4.26 MB] (http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf). Geneva. World Health Organization, 2009.
17. Centers for Disease Control and Prevention. Immunization of Healthcare Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP) [PDF - 705 KB] (https://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf). MMWR Recomm Rep. 2011 Nov 25:60(RR-7):1-45.
18. U.S. Public Health Service Working Group on Occupational Postexposure Prophylaxis, Kuhar DT, Henderson DK, et. al., https://stacks.cdc.gov/view/cdc/20711. September, 2013.
19. US Department of Labor. Occupational Safety & Health Standards. 29 CFR 1910.1030, Bloodborne Pathogens (https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS). March 6, 1992.
20. Centers for Disease Control and Prevention. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm). MMWR. April 27, 2001/50(RR05); 1-43.
21. Centers for Disease Control and Prevention. Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care [PDF - 632 KB] (https://www.cdc.gov/hai/pdfs/guidelines/ambulatory-care-04-2011.pdf). April, 2011.
22. Centers for Disease Control and Prevention. Basic Infection Control and Prevention Plan for Outpatient Oncology Settings [PDF - 1.67 MB] (https://www.cdc.gov/hai/pdfs/guidelines/basic-infection-control-prevention-plan-2011.pdf). December, 2011.
23. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-associated Hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med. 2009;150:33-39.
24. Greeley RD, Semple S, Thompson ND, et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009. Am J Infect Control. 2011;39:663-670.
25. Thompson ND, Perz JF, Moorman AC, et al. Nonhospital health care–associated hepatitis B and C virus transmission: United States, 1998–2008. Ann Intern Med 2009;150:33-39.
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nd re
sour
ces:
1-
12
1.En
sure
that
the
gove
rnin
g bo
dy o
f the
hea
lthca
re fa
cilit
y or
org
aniza
tion
is ac
coun
tabl
e fo
r the
succ
ess o
f inf
ectio
n pr
even
tion
activ
ities
. 2.
Allo
cate
suffi
cien
t hum
an a
nd m
ater
ial r
esou
rces
to in
fect
ion
prev
entio
n to
ens
ure
cons
isten
t and
pro
mpt
act
ion
to re
mov
e or
m
itiga
te in
fect
ion
risks
and
stop
tran
smiss
ion
of in
fect
ions
. Ens
ure
that
st
affin
g an
d re
sour
ces d
o no
t pre
vent
nur
ses,
env
ironm
enta
l sta
ff, e
t. al
., fr
om c
onsis
tent
ly a
dher
ing
to in
fect
ion
prev
entio
n an
d co
ntro
l pr
actic
es.
3.As
sign
one
or m
ore
qual
ified
indi
vidu
als w
ith tr
aini
ng in
infe
ctio
n pr
even
tion
and
cont
rol t
o m
anag
e th
e fa
cilit
y’s i
nfec
tion
prev
entio
n pr
ogra
m.
4.Em
pow
er a
nd su
ppor
t the
aut
horit
y of
thos
e m
anag
ing
the
infe
ctio
n pr
even
tion
prog
ram
to e
nsur
e ef
fect
iven
ess o
f the
pro
gram
.
To b
e su
cces
sful
, inf
ectio
n pr
even
tion
prog
ram
s req
uire
vi
sible
and
tang
ible
supp
ort f
rom
all
leve
ls of
the
heal
thca
re
faci
lity’
s lea
ders
hip.
2. E
duca
tion
and
Trai
ning
of
Hea
lthca
re P
erso
nnel
on
Infe
ctio
n Pr
even
tion
Refe
renc
es a
nd re
sour
ces:
1-
4, 6
-8, 1
0-13
1.Pr
ovid
e jo
b-sp
ecifi
c, in
fect
ion
prev
entio
n ed
ucat
ion
and
trai
ning
to a
ll he
alth
care
per
sonn
el fo
r all
task
s.
2.De
velo
p pr
oces
ses t
o en
sure
that
all
heal
thca
re p
erso
nnel
und
erst
and
and
are
com
pete
nt to
adh
ere
to in
fect
ion
prev
entio
n re
quire
men
ts a
s th
ey p
erfo
rm th
eir r
oles
and
resp
onsib
ilitie
s.
3.Pr
ovid
e w
ritte
n in
fect
ion
prev
entio
n po
licie
s and
pro
cedu
res t
hat a
re
avai
labl
e, c
urre
nt, a
nd b
ased
on
evid
ence
-bas
ed g
uide
lines
(e.g
., CD
C/
HICP
AC, e
tc.)
4.
Requ
ire tr
aini
ng b
efor
e in
divi
dual
s are
allo
wed
to p
erfo
rm th
eir d
utie
s an
d at
leas
t ann
ually
as a
refr
eshe
r. 5.
Prov
ide
addi
tiona
l tra
inin
g in
resp
onse
to re
cogn
ized
laps
es in
ad
here
nce
and
to a
ddre
ss n
ewly
reco
gniz
ed in
fect
ion
tran
smiss
ion
thre
ats (
e.g.
, int
rodu
ctio
n of
new
equ
ipm
ent o
r pro
cedu
res)
.
Trai
ning
shou
ld b
e ad
apte
d to
refle
ct th
e di
vers
ity o
f the
w
orkf
orce
and
the
type
of f
acili
ty, a
nd ta
ilore
d to
mee
t the
ne
eds o
f eac
h ca
tego
ry o
f hea
lthca
re p
erso
nnel
bei
ng
trai
ned.
3. P
atie
nt, F
amily
and
Ca
regi
ver E
duca
tion
Refe
renc
es a
nd re
sour
ces:
2-
5, 7
-8, 1
0-11
1.Pr
ovid
e ap
prop
riate
infe
ctio
n pr
even
tion
educ
atio
n to
pat
ient
s, fa
mily
m
embe
rs, v
isito
rs, a
nd o
ther
s inc
lude
d in
the
care
givi
ng n
etw
ork.
In
clud
e in
form
atio
n ab
out h
ow in
fect
ions
are
spre
ad, h
ow
they
can
be
prev
ente
d, a
nd w
hat s
igns
or s
ympt
oms s
houl
d pr
ompt
reev
alua
tion
and
notif
icat
ion
of th
e pa
tient
’s
heal
thca
re p
rovi
der.
Inst
ruct
iona
l mat
eria
ls an
d de
liver
y sh
ould
add
ress
var
ied
leve
ls of
edu
catio
n, la
ngua
ge
com
preh
ensio
n, a
nd c
ultu
ral d
iver
sity.
87
Core
Infe
ctio
n Pr
even
tion
and
Cont
rol P
ract
ices
for S
afe
Heal
thca
re D
eliv
ery
in A
ll Se
ttin
gs
Reco
mm
enda
tions
of t
he H
ICPA
C La
st u
pdat
ed: M
arch
15,
201
7 Pa
ge 7
of 1
5
Core
Pra
ctic
e Ca
tego
ry
Core
Pra
ctic
es
Com
men
ts
4. P
erfo
rman
ce M
onito
ring
and
Feed
back
Re
fere
nces
and
reso
urce
s:
1-14
1.M
onito
r adh
eren
ce to
infe
ctio
n pr
even
tion
prac
tices
and
infe
ctio
n co
ntro
l req
uire
men
ts.
2.Pr
ovid
e pr
ompt
, reg
ular
feed
back
on
adhe
renc
e an
d re
late
d ou
tcom
es
to h
ealth
care
per
sonn
el a
nd fa
cilit
y le
ader
ship
. 3.
Trai
n pe
rfor
man
ce m
onito
ring
pers
onne
l and
use
stan
dard
ized
tool
s an
d de
finiti
ons.
4.
Mon
itor t
he in
cide
nce
of in
fect
ions
that
may
be
rela
ted
to c
are
prov
ided
at t
he fa
cilit
y an
d ac
t on
the
data
and
use
info
rmat
ion
colle
cted
thro
ugh
surv
eilla
nce
to d
etec
t tra
nsm
issio
n of
infe
ctio
us
agen
ts in
the
faci
lity.
Perf
orm
ance
mea
sure
s sho
uld
be ta
ilore
d to
the
care
ac
tiviti
es a
nd th
e po
pula
tion
serv
ed.
5. S
tand
ard
Prec
autio
ns
Use
Sta
ndar
d Pr
ecau
tions
to c
are
for a
ll pa
tient
s in
all s
ettin
gs.
Stan
dard
Pre
caut
ions
incl
ude:
5a
. Han
d hy
gien
e
5b. E
nviro
nmen
tal c
lean
ing
and
disin
fect
ion
5c
. Inj
ectio
n an
d m
edic
atio
n sa
fety
5d
. Risk
ass
essm
ent w
ith u
se o
f app
ropr
iate
per
sona
l pro
tect
ive
equi
pmen
t (e.
g., g
love
s, g
owns
, fac
e m
asks
) bas
ed o
n ac
tiviti
es b
eing
pe
rfor
med
5e
. Min
imizi
ng P
oten
tial E
xpos
ures
(e.g
. res
pira
tory
hyg
iene
and
cou
gh
etiq
uett
e)
5f. R
epro
cess
ing
of re
usab
le m
edic
al e
quip
men
t bet
wee
n ea
ch p
atie
nt
and
whe
n so
iled
Stan
dard
Pre
caut
ions
are
the
basic
pra
ctic
es th
at a
pply
to a
ll pa
tient
car
e, re
gard
less
of t
he p
atie
nt’s
susp
ecte
d or
co
nfirm
ed in
fect
ious
stat
e, a
nd a
pply
to a
ll se
ttin
gs w
here
ca
re is
del
iver
ed. T
hese
pra
ctic
es p
rote
ct h
ealth
care
pe
rson
nel a
nd p
reve
nt h
ealth
care
per
sonn
el o
r the
en
viro
nmen
t fro
m tr
ansm
ittin
g in
fect
ions
to o
ther
pat
ient
s.
5a. H
and
Hyg
iene
Re
fere
nces
and
re
sour
ces:
3, 7
, 11
1.Re
quire
hea
lthca
re p
erso
nnel
to p
erfo
rm h
and
hygi
ene
in a
ccor
danc
e w
ith C
ente
rs fo
r Dis
ease
Con
trol
and
Pre
vent
ion
(CDC
) re
com
men
datio
ns.
2.U
se a
n al
coho
l-bas
ed h
and
rub
or w
ash
with
soap
and
wat
er fo
r the
fo
llow
ing
clin
ical
indi
catio
ns:
a.Im
med
iate
ly b
efor
e to
uchi
ng a
pat
ient
b.
Befo
re p
erfo
rmin
g an
ase
ptic
task
(e.g
., pl
acin
g an
indw
ellin
g de
vice
) or
ha
ndlin
g in
vasiv
e m
edic
al d
evic
es
c.Be
fore
mov
ing
from
wor
k on
a so
iled
body
site
to a
cle
an b
ody
site
on th
e sa
me
patie
nt
d.Af
ter t
ouch
ing
a pa
tient
or t
he p
atie
nt’s
imm
edia
te e
nviro
nmen
t e.
Afte
r con
tact
with
blo
od, b
ody
fluid
s or c
onta
min
ated
surf
aces
f.
Imm
edia
tely
aft
er g
love
rem
oval
3.
Ensu
re th
at h
ealth
care
per
sonn
el p
erfo
rm h
and
hygi
ene
with
soap
and
w
ater
whe
n ha
nds a
re v
isibl
y so
iled.
4.
Ensu
re th
at su
pplie
s nec
essa
ry fo
r adh
eren
ce to
han
d hy
gien
e ar
e re
adily
acc
essib
le in
all
area
s whe
re p
atie
nt c
are
is be
ing
deliv
ered
.
Unl
ess h
ands
are
visi
bly
soile
d, a
n al
coho
l-bas
ed h
and
rub
is pr
efer
red
over
soap
and
wat
er in
mos
t clin
ical
situ
atio
ns d
ue
to e
vide
nce
of b
ette
r com
plia
nce
com
pare
d to
soap
and
w
ater
. Han
d ru
bs a
re g
ener
ally
less
irrit
atin
g to
han
ds a
nd
are
effe
ctiv
e in
the
abse
nce
of a
sink
.
Refe
r to
“CDC
Gui
delin
e fo
r Han
d Hy
gien
e in
Hea
lth-C
are
Sett
ings
” or
“Gu
idel
ine
for I
sola
tion
Prec
autio
ns: P
reve
ntin
g Tr
ansm
issio
n of
Infe
ctio
us A
gent
s in
Heal
thca
re S
ettin
gs,
2007
” fo
r add
ition
al d
etai
ls.
88
Core
Infe
ctio
n Pr
even
tion
and
Cont
rol P
ract
ices
for S
afe
Heal
thca
re D
eliv
ery
in A
ll Se
ttin
gs
Reco
mm
enda
tions
of t
he H
ICPA
C La
st u
pdat
ed: M
arch
15,
201
7 Pa
ge 8
of 1
5
Core
Pra
ctic
e Ca
tego
ry
Core
Pra
ctic
es
Com
men
ts
5b. E
nviro
nmen
tal
Clea
ning
and
Di
sinf
ectio
n Re
fere
nces
and
re
sour
ces:
4, 7
, 10,
11,
13
, 21
1.Re
quire
rout
ine
and
targ
eted
cle
anin
g of
env
ironm
enta
l sur
face
s as
indi
cate
d by
the
leve
l of p
atie
nt c
onta
ct a
nd d
egre
e of
soili
ng.
a.Cl
ean
and
disin
fect
surf
aces
in c
lose
pro
xim
ity to
the
patie
nt a
nd
freq
uent
ly to
uche
d su
rfac
es in
the
patie
nt c
are
envi
ronm
ent o
n a
mor
e fr
eque
nt sc
hedu
le c
ompa
red
to o
ther
surf
aces
. b.
Prom
ptly
cle
an a
nd d
econ
tam
inat
e sp
ills o
f blo
od o
r oth
er
pote
ntia
lly in
fect
ious
mat
eria
ls.
2.Se
lect
EPA
-reg
ister
ed d
isinf
ecta
nts t
hat h
ave
mic
robi
ocid
al a
ctiv
ity
agai
nst t
he p
atho
gens
mos
t lik
ely
to c
onta
min
ate
the
patie
nt-c
are
envi
ronm
ent.
3.Fo
llow
man
ufac
ture
rs’ i
nstr
uctio
ns fo
r pro
per u
se o
f cle
anin
g an
d di
sinfe
ctin
g pr
oduc
ts (e
.g.,
dilu
tion,
con
tact
tim
e, m
ater
ial
com
patib
ility
, sto
rage
, she
lf-lif
e, sa
fe u
se a
nd d
ispos
al).
Whe
n in
form
atio
n fr
om m
anuf
actu
rers
is li
mite
d re
gard
ing
sele
ctio
n an
d us
e of
age
nts f
or sp
ecifi
c m
icro
orga
nism
s,
envi
ronm
enta
l sur
face
s or e
quip
men
t, fa
cilit
y po
licie
s re
gard
ing
clea
ning
and
disi
nfec
ting
shou
ld b
e gu
ided
by
the
best
ava
ilabl
e ev
iden
ce a
nd c
aref
ul c
onsid
erat
ion
of th
e ris
ks
and
bene
fits o
f the
ava
ilabl
e op
tions
.
Refe
r to
“CDC
Gui
delin
es fo
r Env
ironm
enta
l Inf
ectio
n Co
ntro
l in
Hea
lth-C
are
Faci
litie
s” a
nd “
CDC
Guid
elin
e fo
r Disi
nfec
tion
and
Ster
iliza
tion
in H
ealth
care
Fac
ilitie
s” fo
r det
ails.
5c. I
njec
tion
and
Med
icat
ion
Safe
ty
Refe
renc
es a
nd
reso
urce
s: 1
1, 1
7-20
1.U
se a
sept
ic te
chni
que
whe
n pr
epar
ing
and
adm
inist
erin
g m
edic
atio
ns
2.Di
sinfe
ct th
e ac
cess
dia
phra
gms o
f med
icat
ion
vial
s bef
ore
inse
rtin
g a
devi
ce in
to th
e vi
al
3.U
se n
eedl
es a
nd sy
ringe
s for
one
pat
ient
onl
y (t
his i
nclu
des
man
ufac
ture
d pr
efill
ed sy
ringe
s and
car
trid
ge d
evic
es su
ch a
s ins
ulin
pe
ns).
4.En
ter m
edic
atio
n co
ntai
ners
with
a n
ew n
eedl
e an
d a
new
syrin
ge, e
ven
whe
n ob
tain
ing
addi
tiona
l dos
es fo
r the
sam
e pa
tient
. 5.
Ensu
re si
ngle
-dos
e or
sing
le-u
se v
ials,
am
pule
s, a
nd b
ags o
r bot
tles o
f pa
rent
eral
solu
tion
are
used
for o
ne p
atie
nt o
nly.
6.
Use
flui
d in
fusio
n or
adm
inist
ratio
n se
ts (e
.g.,
intr
aven
ous t
ubin
g) fo
r on
e pa
tient
onl
y 7.
Dedi
cate
mul
tidos
e vi
als t
o a
singl
e pa
tient
whe
neve
r pos
sible
. If
mul
tidos
e vi
als a
re u
sed
for m
ore
than
one
pat
ient
, res
tric
t the
m
edic
atio
n vi
als t
o a
cent
raliz
ed m
edic
atio
n ar
ea a
nd d
o no
t brin
g th
em
into
the
imm
edia
te p
atie
nt tr
eatm
ent a
rea
(e.g
., op
erat
ing
room
, pa
tient
room
/cub
icle
) 8.
Wea
r a fa
cem
ask
whe
n pl
acin
g a
cath
eter
or i
njec
ting
mat
eria
l int
o th
e ep
idur
al o
r sub
dura
l spa
ce (e
.g.,
durin
g m
yelo
gram
, epi
dura
l or s
pina
l an
esth
esia
)
Refe
r to
“Gui
delin
e fo
r Iso
latio
n Pr
ecau
tions
: Pre
vent
ing
Tran
smiss
ion
of In
fect
ious
Age
nts i
n He
alth
care
Set
tings
, 20
07”
for d
etai
ls.
89
Core
Infe
ctio
n Pr
even
tion
and
Cont
rol P
ract
ices
for S
afe
Heal
thca
re D
eliv
ery
in A
ll Se
ttin
gs
Reco
mm
enda
tions
of t
he H
ICPA
C La
st u
pdat
ed: M
arch
15,
201
7 Pa
ge 9
of 1
5
Core
Pra
ctic
e Ca
tego
ry
Core
Pra
ctic
es
Com
men
ts
5d. R
isk
Asse
ssm
ent
with
App
ropr
iate
U
se o
f Per
sona
l Pr
otec
tive
Equi
pmen
t Re
fere
nces
and
re
sour
ces:
7, 1
1, 2
0
1.En
sure
pro
per s
elec
tion
and
use
of p
erso
nal p
rote
ctiv
e eq
uipm
ent (
PPE)
ba
sed
on th
e na
ture
of t
he p
atie
nt in
tera
ctio
n an
d po
tent
ial f
or
expo
sure
to b
lood
, bod
y flu
ids a
nd/o
r inf
ectio
us m
ater
ial:
a.W
ear g
love
s whe
n it
can
be re
ason
ably
ant
icip
ated
that
con
tact
with
bl
ood
or o
ther
pot
entia
lly in
fect
ious
mat
eria
ls, m
ucou
s mem
bran
es,
non-
inta
ct sk
in, p
oten
tially
con
tam
inat
ed sk
in o
r con
tam
inat
ed
equi
pmen
t cou
ld o
ccur
. b.
Wea
r a g
own
that
is a
ppro
pria
te to
the
task
to p
rote
ct sk
in a
nd
prev
ent s
oilin
g of
clo
thin
g du
ring
proc
edur
es a
nd a
ctiv
ities
that
co
uld
caus
e co
ntac
t with
blo
od, b
ody
fluid
s, se
cret
ions
, or
excr
etio
ns.
c.U
se p
rote
ctiv
e ey
ewea
r and
a m
ask,
or a
face
shie
ld, t
o pr
otec
t the
m
ucou
s mem
bran
es o
f the
eye
s, n
ose
and
mou
th d
urin
g pr
oced
ures
an
d ac
tiviti
es th
at c
ould
gen
erat
e sp
lash
es o
r spr
ays o
f blo
od, b
ody
fluid
s, se
cret
ions
and
exc
retio
ns. S
elec
t mas
ks, g
oggl
es, f
ace
shie
lds,
an
d co
mbi
natio
ns o
f eac
h ac
cord
ing
to th
e ne
ed a
ntic
ipat
ed b
y th
e ta
sk p
erfo
rmed
. d.
Rem
ove
and
disc
ard
PPE,
oth
er th
an re
spira
tors
, upo
n co
mpl
etin
g a
task
bef
ore
leav
ing
the
patie
nt’s
room
or c
are
area
. If a
resp
irato
r is
used
, it s
houl
d be
rem
oved
and
disc
arde
d (o
r rep
roce
ssed
if
reus
able
) aft
er le
avin
g th
e pa
tient
room
or c
are
area
and
clo
sing
the
door
. e.
Do n
ot u
se th
e sa
me
gow
n or
pai
r of g
love
s for
car
e of
mor
e th
an
one
patie
nt. R
emov
e an
d di
scar
d di
spos
able
glo
ves u
pon
com
plet
ion
of a
task
or w
hen
soile
d du
ring
the
proc
ess o
f car
e.
f.Do
not
was
h gl
oves
for t
he p
urpo
se o
f reu
se.
2.En
sure
that
hea
lthca
re p
erso
nnel
hav
e im
med
iate
acc
ess t
o an
d ar
e tr
aine
d an
d ab
le to
sele
ct, p
ut o
n, re
mov
e, a
nd d
ispos
e of
PPE
in a
m
anne
r tha
t pro
tect
s the
mse
lves
, the
pat
ient
, and
oth
ers
PPE,
e.g
., gl
oves
, gow
ns, f
ace
mas
ks, r
espi
rato
rs,
gogg
les a
nd fa
ce sh
ield
s, c
an b
e ef
fect
ive
barr
iers
to
tran
smiss
ion
of in
fect
ions
but
are
seco
ndar
y to
the
mor
e ef
fect
ive
mea
sure
s suc
h as
adm
inist
rativ
e an
d en
gine
erin
g co
ntro
ls.
Refe
r to
“Gui
delin
e fo
r Iso
latio
n Pr
ecau
tions
: Pre
vent
ing
Tran
smiss
ion
of In
fect
ious
Age
nts i
n He
alth
care
Set
tings
, 20
07”
as w
ell a
s Occ
upat
iona
l Saf
ety
and
Heal
th
Adm
inist
ratio
n (O
SHA)
requ
irem
ents
for d
etai
ls.
5e. M
inim
izin
g Po
tent
ial E
xpos
ures
Re
fere
nces
and
re
sour
ces:
1, 7
, 11,
16
1.U
se re
spira
tory
hyg
iene
and
cou
gh e
tique
tte
to re
duce
the
tran
smiss
ion
of re
spira
tory
infe
ctio
ns w
ithin
the
faci
lity.
2.
Prom
pt p
atie
nts a
nd v
isito
rs w
ith sy
mpt
oms o
f res
pira
tory
infe
ctio
n to
co
ntai
n th
eir r
espi
rato
ry se
cret
ions
and
per
form
han
d hy
gien
e af
ter
cont
act w
ith re
spira
tory
secr
etio
ns b
y pr
ovid
ing
tissu
es, m
asks
, han
d hy
gien
e su
pplie
s and
inst
ruct
iona
l sig
nage
or h
ando
uts a
t poi
nts o
f en
try
and
thro
ugho
ut th
e fa
cilit
y 3.
Whe
n sp
ace
perm
its, s
epar
ate
patie
nts w
ith re
spira
tory
sym
ptom
s fro
m
othe
rs a
s soo
n as
pos
sible
(e.g
., du
ring
tria
ge o
r upo
n en
try
into
the
faci
lity)
.
Refe
r to
“Gui
delin
e fo
r Iso
latio
n Pr
ecau
tions
: Pr
even
ting
Tran
smiss
ion
of In
fect
ious
Age
nts i
n He
alth
care
Set
tings
, 200
7” fo
r det
ails.
90
Core
Infe
ctio
n Pr
even
tion
and
Cont
rol P
ract
ices
for S
afe
Heal
thca
re D
eliv
ery
in A
ll Se
ttin
gs
Reco
mm
enda
tions
of t
he H
ICPA
C La
st u
pdat
ed: M
arch
15,
201
7 Pa
ge 1
0 of
15
Core
Pra
ctic
e Ca
tego
ry
Core
Pra
ctic
es
Com
men
ts
5f. R
epro
cess
ing
of
Reus
able
Med
ical
Eq
uipm
ent
Refe
renc
es a
nd
reso
urce
s: 2
-4, 7
-8,
11-1
3
1.Cl
ean
and
repr
oces
s (di
sinfe
ct o
r ste
rilize
) reu
sabl
e m
edic
al e
quip
men
t (e
.g.,
bloo
d gl
ucos
e m
eter
s and
oth
er p
oint
-of-c
are
devi
ces,
blo
od
pres
sure
cuf
fs, o
xim
eter
pro
bes,
surg
ical
inst
rum
ents
, end
osco
pes)
pr
ior t
o us
e on
ano
ther
pat
ient
and
whe
n so
iled.
a.
Cons
ult a
nd a
dher
e to
man
ufac
ture
rs’ i
nstr
uctio
ns fo
r rep
roce
ssin
g.
2.M
aint
ain
sepa
ratio
n be
twee
n cl
ean
and
soile
d eq
uipm
ent t
o pr
even
t cr
oss c
onta
min
atio
n.
Man
ufac
ture
r’s in
stru
ctio
ns fo
r rep
roce
ssin
g re
usab
le
med
ical
equ
ipm
ent s
houl
d be
read
ily a
vaila
ble
and
used
to
esta
blish
cle
ar o
pera
ting
proc
edur
es a
nd tr
aini
ng c
onte
nt fo
r th
e fa
cilit
y. In
stru
ctio
ns sh
ould
be
post
ed a
t the
site
whe
re
equi
pmen
t rep
roce
ssin
g is
perf
orm
ed. R
epro
cess
ing
pers
onne
l sho
uld
have
trai
ning
in th
e re
proc
essin
g st
eps a
nd
the
corr
ect u
se o
f PPE
nec
essa
ry fo
r the
task
. Com
pete
ncie
s of
thos
e pe
rson
nel s
houl
d be
doc
umen
ted
initi
ally
upo
n as
signm
ent o
f the
ir du
ties,
whe
neve
r new
equ
ipm
ent i
s in
trod
uced
, and
per
iodi
cally
(e.g
., an
nual
ly).
Addi
tiona
l de
tails
abo
ut re
proc
essin
g es
sent
ials
for f
acili
ties c
an b
e fo
und
in H
ICPA
C’s r
ecom
men
datio
ns E
ssen
tial E
lem
ents
of a
Re
proc
essin
g Pr
ogra
m fo
r Fle
xibl
e En
dosc
opes
(h
ttps
://w
ww
.cdc
.gov
/hic
pac/
reco
mm
enda
tions
/fle
xibl
e-en
dosc
ope-
repr
oces
sing.
htm
l).
Refe
r to
“CDC
Gui
delin
e fo
r Disi
nfec
tion
and
Ster
iliza
tion
in H
ealth
care
Fac
ilitie
s” fo
r det
ails.
6.
Tra
nsm
issi
on-B
ased
Pr
ecau
tions
Re
fere
nces
and
reso
urce
s:
7, 1
1
1.Im
plem
ent a
dditi
onal
pre
caut
ions
(i.e
., Co
ntac
t, Dr
ople
t, an
d/or
Ai
rbor
ne P
reca
utio
ns) f
or p
atie
nts w
ith d
ocum
ente
d or
susp
ecte
d di
agno
ses w
here
con
tact
with
the
patie
nt, t
heir
body
flui
ds, o
r the
ir en
viro
nmen
t pre
sent
s a su
bsta
ntia
l tra
nsm
issio
n ris
k de
spite
adh
eren
ce
to S
tand
ard
Prec
autio
ns
2.Ad
apt t
rans
miss
ion-
base
d pr
ecau
tions
to th
e sp
ecifi
c he
alth
care
sett
ing,
th
e fa
cilit
y de
sign
char
acte
ristic
s, a
nd th
e ty
pe o
f pat
ient
inte
ract
ion.
3.
Impl
emen
t tra
nsm
issio
n-ba
sed
prec
autio
ns b
ased
on
the
patie
nt’s
cl
inic
al p
rese
ntat
ion
and
likel
y in
fect
ion
diag
nose
s (e.
g., s
yndr
omes
su
gges
tive
of tr
ansm
issib
le in
fect
ions
such
as d
iarr
hea,
men
ingi
tis, f
ever
an
d ra
sh, r
espi
rato
ry in
fect
ion)
as s
oon
as p
ossib
le a
fter
the
patie
nt
ente
rs th
e he
alth
care
faci
lity
(incl
udin
g re
cept
ion
or tr
iage
are
as in
em
erge
ncy
depa
rtm
ents
, am
bula
tory
clin
ics o
r phy
sicia
ns’ o
ffice
s) th
en
adju
st o
r disc
ontin
ue p
reca
utio
ns w
hen
mor
e cl
inic
al in
form
atio
n be
com
es a
vaila
ble
(e.g
., co
nfirm
ator
y la
bora
tory
resu
lts).
4.To
the
exte
nt p
ossib
le, p
lace
pat
ient
s who
may
nee
d tr
ansm
issio
n-ba
sed
prec
autio
ns in
to a
sing
le-p
atie
nt ro
om w
hile
aw
aitin
g cl
inic
al
asse
ssm
ent.
5.N
otify
acc
eptin
g fa
cilit
ies a
nd th
e tr
ansp
ortin
g ag
ency
abo
ut su
spec
ted
infe
ctio
ns a
nd th
e ne
ed fo
r tra
nsm
issio
n-ba
sed
prec
autio
ns w
hen
patie
nts a
re tr
ansf
erre
d.
Impl
emen
tatio
n of
Tra
nsm
issio
n-Ba
sed
Prec
autio
ns m
ay
diffe
r dep
endi
ng o
n th
e pa
tient
car
e se
ttin
gs (e
.g.,
inpa
tient
, out
patie
nt, l
ong-
term
car
e), t
he fa
cilit
y de
sign
char
acte
ristic
s, a
nd th
e ty
pe o
f pat
ient
inte
ract
ion,
and
sh
ould
be
adap
ted
to th
e sp
ecifi
c he
alth
care
sett
ing.
Refe
r to
“Gui
delin
e fo
r Iso
latio
n Pr
ecau
tions
: Pre
vent
ing
Tran
smiss
ion
of In
fect
ious
Age
nts i
n He
alth
care
Set
tings
, 20
07”
for d
etai
ls.
91
Core
Infe
ctio
n Pr
even
tion
and
Cont
rol P
ract
ices
for S
afe
Heal
thca
re D
eliv
ery
in A
ll Se
ttin
gs
Reco
mm
enda
tions
of t
he H
ICPA
C La
st u
pdat
ed: M
arch
15,
201
7 Pa
ge 1
1 of
15
Core
Pra
ctic
e Ca
tego
ry
Core
Pra
ctic
es
Com
men
ts
7. T
empo
rary
inva
sive
M
edic
al D
evic
es fo
r Clin
ical
M
anag
emen
t Re
fere
nces
and
reso
urce
s:
8, 1
1.Du
ring
each
hea
lthca
re e
ncou
nter
, ass
ess t
he m
edic
al n
eces
sity
of a
ny
inva
sive
med
ical
dev
ice
(e.g
., va
scul
ar c
athe
ter,
indw
ellin
g ur
inar
y ca
thet
er, f
eedi
ng tu
bes,
ven
tilat
or, s
urgi
cal d
rain
) in
orde
r to
iden
tify
the
earli
est o
ppor
tuni
ty fo
r saf
e re
mov
al.
2.En
sure
that
hea
lthca
re p
erso
nnel
adh
ere
to re
com
men
ded
inse
rtio
n an
d m
aint
enan
ce p
ract
ices
Early
and
pro
mpt
rem
oval
of i
nvas
ive
devi
ces s
houl
d be
par
t of
the
plan
of c
are
and
incl
uded
in re
gula
r ass
essm
ent.
Heal
thca
re p
erso
nnel
shou
ld b
e kn
owle
dgea
ble
rega
rdin
g ris
ks o
f the
dev
ice
and
infe
ctio
n pr
even
tion
inte
rven
tions
as
soci
ated
with
the
indi
vidu
al d
evic
e, a
nd sh
ould
adv
ocat
e fo
r the
pat
ient
by
wor
king
tow
ard
rem
oval
of t
he d
evic
e as
so
on a
s pos
sible
.
Refe
r to
“CDC
Gui
delin
es fo
r Env
ironm
enta
l Inf
ectio
n Co
ntro
l in
Heal
th-C
are
Faci
litie
s” a
nd “
CDC
Guid
elin
e fo
r Di
sinfe
ctio
n an
d St
erili
zatio
n in
Hea
lthca
re F
acili
ties”
for
deta
ils.
8. O
ccup
atio
nal H
ealth
Re
fere
nces
and
reso
urce
s:
1, 7
, 16,
20
1.En
sure
that
hea
lthca
re p
erso
nnel
eith
er re
ceiv
e im
mun
izatio
ns o
r hav
e do
cum
ente
d ev
iden
ce o
f im
mun
ity a
gain
st v
acci
ne-p
reve
ntab
le
dise
ases
as r
ecom
men
ded
by th
e CD
C, C
DC’s
Adv
isory
Com
mitt
ee o
n Im
mun
izatio
n Pr
actic
es (A
CIP)
and
requ
ired
by fe
dera
l, st
ate
or lo
cal
auth
oriti
es.
2.Im
plem
ent p
roce
sses
and
sick
leav
e po
licie
s to
enco
urag
e he
alth
care
pe
rson
nel t
o st
ay h
ome
whe
n th
ey d
evel
op si
gns o
r sym
ptom
s of a
cute
in
fect
ious
illn
ess (
e.g.
feve
r, co
ugh,
dia
rrhe
a, v
omiti
ng, o
r dra
inin
g sk
in
lesio
ns) t
o pr
even
t spr
eadi
ng th
eir i
nfec
tions
to p
atie
nts a
nd o
ther
he
alth
care
per
sonn
el.
3.Im
plem
ent a
syst
em fo
r hea
lthca
re p
erso
nnel
to re
port
sign
s,
sym
ptom
s, a
nd d
iagn
osed
illn
esse
s tha
t may
repr
esen
t a ri
sk to
thei
r pa
tient
s and
cow
orke
rs to
thei
r sup
ervi
sor o
r hea
lthca
re fa
cilit
y st
aff
who
are
resp
onsib
le fo
r occ
upat
iona
l hea
lth
4.Ad
here
to fe
dera
l and
stat
e st
anda
rds a
nd d
irect
ives
app
licab
le to
pr
otec
ting
heal
thca
re w
orke
rs a
gain
st tr
ansm
issio
n of
infe
ctio
us a
gent
s in
clud
ing
OSH
A’s B
lood
born
e Pa
thog
ens S
tand
ard,
Per
sona
l Pro
tect
ive
Equi
pmen
t Sta
ndar
d, R
espi
rato
ry P
rote
ctio
n st
anda
rd a
nd T
B co
mpl
ianc
e di
rect
ive.
It is
the
prof
essio
nal r
espo
nsib
ility
of a
ll he
alth
care
or
gani
zatio
ns a
nd in
divi
dual
per
sonn
el to
ens
ure
adhe
renc
e to
fede
ral,
stat
e an
d lo
cal r
equi
rem
ents
con
cern
ing
imm
uniza
tions
; wor
k po
licie
s tha
t sup
port
safe
ty o
f he
alth
care
per
sonn
el; t
imel
y re
port
ing
of il
lnes
s by
empl
oyee
s to
empl
oyer
s whe
n th
at il
lnes
s may
repr
esen
t a
risk
to p
atie
nts a
nd o
ther
hea
lthca
re p
erso
nnel
; and
no
tific
atio
n to
pub
lic h
ealth
aut
horit
ies w
hen
the
illne
ss h
as
publ
ic h
ealth
impl
icat
ions
or i
s req
uire
d to
be
repo
rted
.
Refe
r to
OSH
A’s w
ebsit
e fo
r spe
cific
det
ails
on h
ealth
care
st
anda
rds:
Occ
upat
iona
l Saf
ety
and
Heal
th A
dmin
istra
tion
- In
fect
ious
Dise
ases
(h
ttps
://w
ww
.osh
a.go
v/SL
TC/h
ealth
care
faci
litie
s/in
fect
ious
_di
seas
es.h
tml).
92
Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings Recommendations of the HICPAC
Last updated: March 15, 2017 Page 12 of 15
Table References 1. Bolyard EA. Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for
Infection Control in Healthcare Personnel, 1998. Hospital Infection control Practices Advisory committee. Infect Control Hosp Epidemiol. 1998 Jun; 19(6):407-63. (Available at https://stacks.cdc.gov/view/cdc/7250.)
2. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Hospital Infection Control Practices Advisory committee. Infect control Hosp Epidemiol 1999 Apr 20(4):250-78. (Available at https://stacks.cdc.gov/view/cdc/7160.)
3. Boyce JM, Pittet D, Healthcare Infection control Practices Advisory Committee, Society for Healthcare Epidemiology of America, Association for Professionals in Infection control, Infectious Diseases Society of America, Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: recommendation of the Healthcare Infection Control Practices Advisory committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect control Hosp Epidemiol. 2002 Dec 23(12 Suppl):S3-40. (Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm.)
4. Sehulster L, Chin RY, Healthcare Infection Control Practices Advisory Committee. Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2003 Jun 6:52(RR-10):1-42. (Available at https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf [PDF - 2.31 MB].)
5. Jensen PA, Lambert LA, Iademarco MF, Ridzon R. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR Recomm Rep. 2005 Dec 30:54(RR-17):1-141. (Available at https://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf [PDF - 4.15 MB].)
6. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. Am J Infect control, 2007 Dec 35 (10 Suppl 2):S165-93. (Available at https://www.cdc.gov/infectioncontrol/pdf/guidelines/mdro-guidelines.pdf [PDF - 553 KB].)
7. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Am J Infect Control. 2007 Dec 35(10 Suppl 2)S65-164. (Available at https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf [PDF - 1.42 MB].)
8. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory committee, Guideline for Prevention of Catheter-Associated Urinary Tract Infection 2009. Infect control Hosp Epidemiol, 2010 Apr 31(4):319-26. (Available at https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf [PDF - 650 KB].)
9. Centers for Disease Control and Prevention. Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities. MMWR 2009 Mar 20:58 (10):256-60. (Available at https://www.cdc.gov/hai/pdfs/cre/cre-guidance-508.pdf [PDF - 381 KB].)
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10. Division of Viral Disease, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Updated Norovirus Outbreak Management and Disease Prevention Guidelines. MMWR 2011 Mar 4:60(RR-3):1-18. (Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6003a1.htm.)
11. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad I, Randolph AG, Rupp ME, Saint S, Healthcare Infection Control Practices Advisory Committee. Guidelines for the Prevention of Intravascular Catheter-Related Infections. Am J Infect Control. 2011 May 39(4 Suppl 1):S1-34. (Available at https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines.pdf [PDF - 678 KB].)
12. Centers for Disease Control and Prevention. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. November, 2015. (Available at https://www.cdc.gov/infectioncontrol/pdf/outpatient/guide.pdf [PDF - 1.43 MB].)
13. Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Am J Infect Control.2013;41(5 Suppl):S67-71. (Available at https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf [PDF - 1.26 MB].)
14. Tablan OC, Anderson LJ, Besser R, Bridges C, Haijeh R, Healthcare Infection Control Practices Advisory Committee. Guidelines for Preventing Healthcare-associated Pneumonia, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 204 Mar 26:53(RR-3):1-26. (Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm.)
15. Centers for Disease Control and Prevention. Immunization of Healthcare Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011 Nov 25:60(RR-7):1-45. (Available at https://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf [PDF - 705 KB].)
16. Centers for Disease Control and Prevention. Injection safety materials. (Available at https://www.cdc.gov/injectionsafety/.)
17. Centers for Disease Control and Prevention. The One & Only Campaign injection safety training materials. (Available at https://www.cdc.gov/injectionsafety/1anonly.html.)
18. U.S. Public Health Service Working Group on Occupational Postexposure Prophylaxis, Kuhar DT, Henderson DK, et. al., Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. September, 2013. (Available at https://stacks.cdc.gov/view/cdc/20711.)
19. US Department of Labor. Occupational Safety & Health Administration. 29 CFR 1910.1030 Bloodborne Pathogens. March 6, 1992. (Available at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS.)
20. Centers for Disease Control and Prevention. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. MMWR. April 27, 2001 / 50(RR05);1-43. (Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm.)
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Suggested Citation Healthcare Infection Control Practices Advisory Committee. Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings–Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) 2017.
Contributors
HICPAC Workgroup Members Ruth M. Carrico, PhD, RN, CIC, HICPAC Member (Workgroup Chair); Gina Pugliese, RN, MS, HICPAC Member (Workgroup Co-Chair); Deborah S. Yokoe, MD, MPH, HICPAC Member (Workgroup Co-Chair); Loretta L. Fauerbach, MS, CIC; Susan Courage, Public Health Agency of Canada; Kathleen Dunn, BScN, MN, RN, Public Health Agency of Canada; Neil O. Fishman, MD, HICPAC; Silvia Munoz-Price, MD, PhD, America’s Essential Hospitals; Michael Anne Preas, RN CIC, Association of Professionals of Infection Control and Epidemiology, Inc. (APIC); Mark E. Rupp, MD, Society for Healthcare Epidemiology of America (SHEA); Sanjay Saint, MD, MPH, Society of Hospital Medicine (SHM); and Rachel Stricof, MPH, Council of State and Territorial Epidemiologists (CSTE).
HICPAC Members Neil O. Fishman, MD, University of Pennsylvania Health System; Hilary M. Babcock, MD, MPH, Washington University School of Medicine; Ruth M. Carrico, PhD, RN, CIC, University of Louisville School of Medicine; Sheri Chernetsky Tejedor, MD, Emory University School of Medicine; Daniel J. Diekema, MD, University of Iowa Carver College of Medicine; Mary K. Hayden, MD, Rush University Medical Center; Susan Huang, MD, MPH; University of California Irvine School of Medicine; W. Charles Huskins, MD, MSc, Mayo Clinic College of Medicine; Lynn Janssen, MS, CIC, CPHQ, California Department of Public Health; Gina Pugliese, RN, MS, Premier Healthcare Alliance; Selwyn O. Rogers Jr., MD, MPH, FACS, The University of Texas Medical Branch; Tom Talbot, MD, MPH, Vanderbilt University Medical Center; Michael L. Tapper, MD, Lenox Hill Hospital; and Deborah S. Yokoe, MD, MPH, Brigham & Women’s Hospital.
HICPAC Ex Officio Members William B. Baine, MD, Agency for Healthcare Research and Quality (AHRQ); David Henderson, MD, National Institutes of Health (NIH); Elizabeth Claverie-Williams, MS, U.S. Food and Drug Administration (FDA); Daniel Schwartz, MD, MBA, Center for Medicare and Medicaid Services (CMS); and Gary A. Roselle, MD, Department of Veterans Affairs (VA); Rebecca Wilson, MPH, CHES, Health Resources and Services Administration (HRSA).
HICPAC Liaison Representatives Kathleen Dunn, BScN, MN, RN, Public Health Agency of Canada; Janet Franck, RN, MBA, CIC, DNV Healthcare, Inc.; Diana Gaviria, MD, MPH, National Association of County and City Health Officials (NACCHO); Michael D. Howell, MD, MPH, Society of Critical Care Medicine (SCCM); Marion Kainer, MD, MPH, Council of State and Territorial Epidemiologists (CSTE); Emily Lutterloh, MD, MPH, Association of State and Territorial Health Officials (ASTHO); Michael Anne Preas, RN CIC, Association of Professionals of Infection Control and Epidemiology, Inc. (APIC); Mark E. Rupp, MD, Society for Healthcare Epidemiology of America (SHEA); Sanjay Saint, MD, MPH, Society of Hospital Medicine
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(SHM); Robert G. Sawyer, MD, FACS, FIDSA, FCCM, Surgical Infection Society (SIS); Margaret VanAmringe, MHS, The Joint Commission; and Amber Wood, MSN, RN, CNOR, CIC, CPN, Association of periOperative Registered Nurses (AORN).
Acknowledgments Melissa Schaefer, MD; Joseph Perz, DrPH; Michael Bell, MD; Erin Stone, MA; and Jeffrey Hageman, MHS, the Division of Healthcare Quality Promotion (DHQP), the Centers for Disease Control and Prevention.
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PATIENTS AND VISITORS
K N OW T H E T R U T H TO P R OT E C TYO U R S E L F F R O M S E R I O U S I N F E C T I O N S
TRUTH On average, healthcare providers clean their hands less than half of the times they should.
THE NITTY GRITTY:This can put you at risk for a serious infection. It’s OK to ask your care team questions like, “Before you start the exam, would you mind cleaning your hands again?” Another way to bring it up is to thank them for cleaning their hands if you are uncomfortable asking.
TRUTH Alcohol-based hand sanitizer kills most of the bad germs that make you sick.
THE NITTY GRITTY:Your hands have good germs on them that your body needs to stay healthy. Your hands can also have bad germs on them that make you sick. Alcohol-based hand sanitizers kill the good and bad germs, but the good germs quickly come back on your hands.
TRUTH Alcohol-based hand sanitizer does not kill C. difficile.
THE NITTY GRITTY:If you have a C. difficile infection, make sure your healthcare providers wear gloves to examine you. You and your loved ones should wash your hands with soap and water to prevent the spread of C. difficile.
WHAT IS C. DIFFICILE?C. difficile or “C. diff” is a common healthcare-associated infection that causes severe diarrhea.
TRUTH Alcohol-based hand sanitizer does not create antibiotic-resistant superbugs.
THE NITTY GRITTY:Alcohol-based hand sanitizers kill germs quickly and in a different way than antibiotics. Using alcohol-based hand sanitizers to clean your hands does not cause antibiotic resistance.
ALCOHOL-BASED HAND SANITIZERis a product that contains at least 60% alcohol to kill germs on the hands.
TRUTH Your hands can spread germs.
THE NITTY GRITTY :Make sure you and your visitors are cleaning your hands at these important times:
www.cdc.gov/Hand Hygiene
This material was developed by CDC. The Clean Hands Count Campaign is made possible by a partnership between the CDC Foundation and GOJO.
ReferenceCDC
3.3
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2-5. Personal Protective Equipment Competency
Personal Protective Equipment (PPE) Competency Validation
DonningandDoffing
StandardPrecautionsandTransmissionBasedPrecautions
Typeofvalidation:Returndemonstration
Orientation
Annual
Other
EmployeeName: JobTitle:
Donning PPECompetent
YES NO
1. PerformHandHygiene
2. Don Gown:
Fullycoveringtorsofromnecktoknees,armstoendofwrists
3. Tie/fasteninbackofneckandwaist
4. Don Mask/Respirator:
Secureties/elasticbandsatmiddleofhead&neck
5. Fitflexiblebandtonosebridge
6. Fitsnugtofaceandbelowchin(Fit-checkrespiratorifapplicable)
7. Don Goggles or Face Shield:
Placeoverfaceandeyes;adjusttofit
8. Don Gloves:
Extendtocoverwristofgown
Doffing PPE
9. Remove Gloves:
Graspoutsideofglovewithoppositeglovedhand;peeloff
10.Holdremovedgloveinglovedhand
11. Slidefingersofunglovedhandunderremaininggloveatwrist
12.Peelgloveoffoverfirstglove
13.Discardglovesinwastecontainer
14.Remove Goggles or Face Shield:
Handlebyheadbandorearpieces
15.Discardindesignatedreceptacleifre-processedorinwastecontainer
16.Remove Gown:
Unfastenties/fastener
Forms & Checklists for Infection Prevention, Volume 1 673.4
2-5. Personal Protective Equipment Competency
Personal Protective Equipment (PPE) Competency Validation
DonningandDoffing
StandardPrecautionsandTransmissionBasedPrecautions
Typeofvalidation:Returndemonstration
Orientation
Annual
Other
EmployeeName: JobTitle:
Donning PPECompetent
YES NO
1. PerformHandHygiene
2. Don Gown:
Fullycoveringtorsofromnecktoknees,armstoendofwrists
3. Tie/fasteninbackofneckandwaist
4. Don Mask/Respirator:
Secureties/elasticbandsatmiddleofhead&neck
5. Fitflexiblebandtonosebridge
6. Fitsnugtofaceandbelowchin(Fit-checkrespiratorifapplicable)
7. Don Goggles or Face Shield:
Placeoverfaceandeyes;adjusttofit
8. Don Gloves:
Extendtocoverwristofgown
Doffing PPE
9. Remove Gloves:
Graspoutsideofglovewithoppositeglovedhand;peeloff
10.Holdremovedgloveinglovedhand
11. Slidefingersofunglovedhandunderremaininggloveatwrist
12.Peelgloveoffoverfirstglove
13.Discardglovesinwastecontainer
14.Remove Goggles or Face Shield:
Handlebyheadbandorearpieces
15.Discardindesignatedreceptacleifre-processedorinwastecontainer
16.Remove Gown:
Unfastenties/fastener
Forms & Checklists for Infection Prevention, Volume 1 67
2-5. Personal Protective Equipment Competency
Personal Protective Equipment (PPE) Competency Validation
DonningandDoffing
StandardPrecautionsandTransmissionBasedPrecautions
Typeofvalidation:Returndemonstration
Orientation
Annual
Other
EmployeeName: JobTitle:
Donning PPECompetent
YES NO
1. PerformHandHygiene
2. Don Gown:
Fullycoveringtorsofromnecktoknees,armstoendofwrists
3. Tie/fasteninbackofneckandwaist
4. Don Mask/Respirator:
Secureties/elasticbandsatmiddleofhead&neck
5. Fitflexiblebandtonosebridge
6. Fitsnugtofaceandbelowchin(Fit-checkrespiratorifapplicable)
7. Don Goggles or Face Shield:
Placeoverfaceandeyes;adjusttofit
8. Don Gloves:
Extendtocoverwristofgown
Doffing PPE
9. Remove Gloves:
Graspoutsideofglovewithoppositeglovedhand;peeloff
10.Holdremovedgloveinglovedhand
11. Slidefingersofunglovedhandunderremaininggloveatwrist
12.Peelgloveoffoverfirstglove
13.Discardglovesinwastecontainer
14.Remove Goggles or Face Shield:
Handlebyheadbandorearpieces
15.Discardindesignatedreceptacleifre-processedorinwastecontainer
16.Remove Gown:
Unfastenties/fastener
Forms & Checklists for Infection Prevention, Volume 1 67
98
17.Pullawayfromneckandshoulders,touchinginsideofgownonly
18.Turngowninsideout
19.Foldorrollintobundleanddiscard
20.Remove Mask/Respirator(respiratorremovedafterexitroom/closed
door):Graspbottom,thentoptiesorelasticsandremove
21.Discardinwastecontainer
22.PerformHandHygiene
Standard Precautions & Transmission Based PrecautionsCompetent
YES NO
21.StaffcorrectlyidentifiestheappropriatePPEforthefollowingscenarios:
a. StandardPrecautions(PPEtobewornbasedonanticipatedlevelof
exposure)*
b.Contact/ContactEntericPrecautions(gown&gloves)
c. DropletPrecautions(surgicalmask)
d.AirbornePrecautions(fit-testedrespiratorifapplicable)
*NOTE: Examples include: mask for coughing/vomiting patient, goggles/face shield for irrigating draining wound, gown for dressing change if scrubs may touch patient, etc.
Comments or follow up actions:
EmployeeSignature
ValidatorSignature /Date
References CDCathttp://www.cdc.gov/HAI/pdfs/ppe/ppeposter148.pdf NCSPICE;9-2016
Forms & Checklists for Infection Prevention, Volume 168
99
SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE)
ThetypeofPPEusedwillvarybasedonthelevelofprecautionsrequired,suchasstandardandcontact,dropletorairborneinfectionisolationprecautions.TheprocedureforputtingonandremovingPPEshouldbetailoredtothespecifictypeofPPE.
1. GOWN• Fullycovertorsofromnecktoknees,armstoendofwrists,andwraparoundtheback
• Fasteninbackofneckandwaist
2. MASK OR RESPIRATOR• Securetiesorelasticbandsatmiddleofheadandneck
• Fitflexiblebandtonosebridge• Fitsnugtofaceandbelowchin• Fit-checkrespirator
3. GOGGLES OR FACE SHIELD• Placeoverfaceandeyesandadjusttofit
4. GLOVES• Extendtocoverwristofisolationgown
USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION
• Keephandsawayfromface• Limitsurfacestouched• Changegloveswhentornorheavilycontaminated• Performhandhygiene
3.5
100
HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1ThereareavarietyofwaystosafelyremovePPEwithoutcontaminatingyourclothing,skin,ormucousmembraneswithpotentiallyinfectiousmaterials.Hereisoneexample.Remove all PPE before exiting the patient roomexceptarespirator,ifworn.Removetherespiratorafterleavingthepatientroomandclosingthedoor.RemovePPEinthefollowingsequence:
1. GLOVES• Outsideofglovesarecontaminated!• Ifyourhandsgetcontaminatedduringgloveremoval,immediately
washyourhandsoruseanalcohol-basedhandsanitizer• Usingaglovedhand,graspthepalmareaoftheotherglovedhand
andpeelofffirstglove• Holdremovedgloveinglovedhand• Slidefingersofunglovedhandunderremaininggloveatwristand
peeloffsecondgloveoverfirstglove• Discardglovesinawastecontainer
2. GOGGLES OR FACE SHIELD• Outsideofgogglesorfaceshieldarecontaminated!• Ifyourhandsgetcontaminatedduringgoggleorfaceshieldremoval,
immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Removegogglesorfaceshieldfromthebackbyliftingheadbandor
earpieces• Iftheitemisreusable,placeindesignatedreceptaclefor
reprocessing.Otherwise,discardinawastecontainer
3. GOWN• Gownfrontandsleevesarecontaminated!• Ifyourhandsgetcontaminatedduringgownremoval,immediately
washyourhandsoruseanalcohol-basedhandsanitizer• Unfastengownties,takingcarethatsleevesdon’tcontactyourbody
whenreachingforties• Pullgownawayfromneckandshoulders,touchinginsideofgownonly• Turngowninsideout• Foldorrollintoabundleanddiscardinawastecontainer
4. MASK OR RESPIRATOR• Frontofmask/respiratoriscontaminated—DONOTTOUCH!• Ifyourhandsgetcontaminatedduringmask/respiratorremoval,
immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Graspbottomtiesorelasticsofthemask/respirator,thentheonesat
thetop,andremovewithouttouchingthefront• Discardinawastecontainer
OR5. WASH HANDS OR USE AN
ALCOHOL-BASED HAND SANITIZERIMMEDIATELY AFTER REMOVINGALL PPE
PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE
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HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2
HereisanotherwaytosafelyremovePPEwithoutcontaminatingyourclothing,skin,ormucousmembraneswithpotentiallyinfectiousmaterials.Remove all PPE before exiting the patient room exceptarespirator,ifworn.Removetherespirator after leavingthepatientroomandclosingthedoor.RemovePPEinthefollowingsequence:
1. GOWN AND GLOVES• Gownfrontandsleevesandtheoutsideofglovesare
contaminated!• Ifyourhandsgetcontaminatedduringgownorgloveremoval,
immediatelywashyourhandsoruseanalcohol-basedhandsanitizer
• Graspthegowninthefrontandpullawayfromyourbodysothatthetiesbreak,touchingoutsideofgownonlywithglovedhands
• Whileremovingthegown,foldorrollthegowninside-outintoabundle
• Asyouareremovingthegown,peeloffyourglovesatthesametime,onlytouchingtheinsideoftheglovesandgownwithyourbarehands.Placethegownandglovesintoawastecontainer
A B
D E
C
2. GOGGLES OR FACE SHIELD• Outsideofgogglesorfaceshieldarecontaminated!• Ifyourhandsgetcontaminatedduringgoggleorfaceshieldremoval,
immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Removegogglesorfaceshieldfromthebackbyliftingheadbandand
withouttouchingthefrontofthegogglesorfaceshield• Iftheitemisreusable,placeindesignatedreceptaclefor
reprocessing.Otherwise,discardinawastecontainer
3. MASK OR RESPIRATOR• Frontofmask/respiratoriscontaminated—DONOTTOUCH!• Ifyourhandsgetcontaminatedduringmask/respiratorremoval,
immediatelywashyourhandsoruseanalcohol-basedhandsanitizer• Graspbottomtiesorelasticsofthemask/respirator,thentheonesat
thetop,andremovewithouttouchingthefront• Discardinawastecontainer
OR
4. WASH HANDS OR USE ANALCOHOL-BASED HAND SANITIZERIMMEDIATELY AFTER REMOVINGALL PPE
PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE
Reference CDC
102
o
despues de toser o estornudar.
o
Minnesota Department of Health717 SE Delaware StreetMinneapolis, MN 55414612-676-5414 or 1-877-676-5414www.health.state.mn.us
MinnesotaAntibioticResistance Collaborative
Cubretetoseral
Deten el contagio de germenes que te enferman a ti y a otros!
cúbrete con la partesuperior del brazo cuandotosas o estornudes, nocon las manos.
Cúbrete la boca y la narizcon un panuelo cuandotosas o estornudes
Tira el panuelo usadoa la basura.
Lávate las manos conagua tibia y jabón
utiliza un limpiadorde manos a base de alcohol.
`
~
``
` `
~
!
Lavatemanoslas
CS 280522A
Handwashing at Home, at Play, and Out and About
Germs are everywhere! They can get onto your hands and items you touch throughout the day. Washing hands at key times with soap and water is one of the most important steps you can take to get rid of germs and avoid spreading germs to those around you.
How can washing your hands keep you healthy? Germs can get into the body through our eyes, nose, and mouth and make us sick. Handwashing with soap removes germs from hands and helps prevent sickness. Studies have shown that handwashing can prevent 1 in 3 diarrhea-related sicknesses and 1 in 5 respiratory infections, such as a cold or the flu.
Handwashing helps prevent infections for these reasons:
People often touch their eyes, nose, and mouth without realizing it, introducing germs into their bodies.
Germs from unwashed hands may get into foods and drinks when people prepare or consume them. Germs can grow in some types of foods or drinks and make people sick.
Germs from unwashed hands can be transferred to other objects, such as door knobs, tables, or toys, and then transferred to another person’s hands.
What is the right way to wash your hands? 1. Wet your hands with clean running water (warm or cold) and
apply soap.
2. Lather your hands by rubbing them together with the soap.
3. Scrub all surfaces of your hands, including the palms, backs, fingers, between your fingers, and under your nails. Keep scrubbing for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song twice.
4. Rinse your hands under clean, running water.
5. Dry your hands using a clean towel or air dry them.
Lavado de manos en casa, en donde jugamos y cuando salimos
¡Los microbios están en todas partes! Pueden llegar a sus manos y a los objetos que toca a lo largo de todo el día. Lavarse las manos con agua y jabón en momentos clave es una de las medidas más importantes que puede tomar para librarse de los microbios y evitar transmitirlos a quienes lo rodean.
¿Cómo es que lavarse las manos lo mantiene sano? Los microbios pueden entrar al cuerpo a través de los ojos, la nariz y la boca, y enfermarnos. Lavarse las manos con jabón elimina los microbios que estén en ellas y ayuda a prevenir las enfermedades. Los estudios han mostrado que lavarse las manos puede prevenir 1 de cada 3 enfermedades diarreicas y 1 de cada 5 infecciones respiratorias, como el resfriado o la influenza (gripe).
Lavarse las manos ayuda a prevenir infecciones por estas razones:
Con frecuencia, las personas se tocan los ojos, la nariz y la boca sin darse cuenta, y de ese modo introducen microbios en el cuerpo.
Los microbios de las manos que no se lavaron pueden llegar a los alimentos y a las bebidas cuando las personas los preparan o los consumen. Los microbios pueden multiplicarse en algunos tipos de alimentos o bebidas y causarles enfermedades a las personas.
Los microbios de las manos sin lavar pueden transferirse a otros objetos, como las manijas de las puertas, las mesas o los juguetes y, luego, transferirse a las manos de otra persona.
¿Cuál es la forma correcta de lavarse las manos? 1. Mójese las manos con agua corriente limpia (tibia o fría) y enjabónelas.
2. Frótese las manos con jabón, formando espuma.
3. Frote todas las superficies, incluidos los dedos, entre los dedos, debajo de las uñas, las palmas y el dorso de las manos. Siga frotándose las manos por al menos 20 segundos. ¿Necesita un reloj? Tararee dos veces la canción “Cumpleaños feliz”.
4. Enjuáguese las manos con agua corriente limpia.
5. Séquese las manos con una toalla limpia o al aire.
CS 280522A MLS-283078
3.8
107
Major Article
Health care worker hand contamination at critical moments inoutpatient care settings
James Bingham MS a,*, Ginnie Abell BA, RN, CIC b, LeAnne Kienast BS a,Lorie Lerner MSN, MDiv, RN, CNS c, Brittney Matuschek BS a,Wanda Mullins MPH, BSN, RN, CIC d, Albert Parker PhD e, Nancy Reynolds BSN, RN, CIC b,Diane Salisbury MSN, RN, CIC f, Joan Seidel MA, BSN, RN, CIC g,Elizabeth Young BSN, RN, CIC h, Jane Kirk MSN, RN, CIC a
a GOJO Industries, Inc, Akron, OHb Summa Health System, Akron, OHc LJL Consulting, Akron, OHd Cleveland Clinic Akron General, Akron, OHe Center for Biofilm Engineering, Department of Mathematical Sciences, Montana State University, Bozeman, MTf Salisbury IP Consulting, LLC, Akron, OHg University Hospitals Portage Medical Center, Ravenna, OHh Infection Prevention Consultant, Vermilion, OH
Key Words:Hand hygieneAmbulatory careWHO 5 MomentsGloveWound careStandard precautions
Background: The delivery of health care in outpatient settings has steadily increased over the past 40years. The risk of infection in these settings is considered to be low. However, the increasing severity ofillness and complexity of care in outpatient settings creates a need to reexamine the transmission of patho-gens in this setting.Materials and Methods: Seventeen health care workers from 4wound care facilities were sampled during46 patient care encounters to determine the presence of health care-associated pathogens (ie, methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, multidrug-resistant Acinetobacter species,and Clostridium difficile) on their hands at key moments of care.Results: Health care workers acquired at least 1 pathogen on their hands during 28.3% of all patient careencounters. Hands sampled before a clean or aseptic procedure and hands sampled after body fluid ex-posure risk were each contaminated in 17.4% of instances. Hand contamination occurred in 19.6% of instanceswhere health care workers wore gloves during care compared with 14.6% when health care workers wereungloved.Conclusions: Contamination of health care workers’ hands presents a significant risk of pathogen trans-mission in outpatient settings. Gloving education, hand hygiene solutions at the point of care, and handhygiene surveillance are important solutions for reducing transmission of pathogenic organisms.© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
BACKGROUND
Thedeliveryof health carehas transitioned fromcentralized, acutecare hospitals to community-based outpatient (ambulatory) caresettings over thepast several decades.Outpatient care settings consist
of physician offices, hospital emergency departments, hospital andnonhospital-basedclinics, surgical centers, andmanyother specializedservice centers.1,2 During the 10-year period from 1997-2007, out-patient care visits increased by 25% to an estimated 1.2 billion visitswith a rate of 4 visits per year per person.3 The rise in utilization ofoutpatient care centershasbeenattributed toadvancement inmedicaltechnology, insurance reimbursement, convenienceof care, andeffortsto control health care costs.
Infection prevention infrastructure and resources in outpatientsettings are often not equivalent to those of acute care hospitals.4,5
The lack of infection prevention resources combined with the
* Address correspondence to James Bingham, MS, GOJO Industries, Inc, PO Box 991,Akron, OH 44309.
E-mail address: [email protected] (J. Bingham).Conflicts of Interest: None to report.
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).http://dx.doi.org/10.1016/j.ajic.2016.04.208
American Journal of Infection Control 44 (2016) 1198-202
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.aj ic journal .org
American Journal of Infection Control
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increasing severity of illness, increasingly complicated proce-dures, and time pressure make infection prevention programs andpractices critical to protect patients and health care workers (HCWs)from health care-associated infections (HAIs) in outpatient set-tings. In 2014, the Centers for Disease Control and Prevention (CDC)updated the guide to infection prevention in outpatient settings tohighlight the need for dedicated infection prevention staff, train-ing, HAI surveillance, and the use of standard precautions.1 Inaddition, the World Health Organization (WHO) adapted their rec-ommendations on hand hygiene best practices for outpatientsettings.2
Hand hygiene is among the most important measures to preventthe transmission and acquisition of HAIs.6 The WHO has defined 5key moments for hand hygiene in outpatient care settings and CDChas suggested 6 key situations when hand hygiene should beperformed.6,7 Despite the hand hygiene recommendations, the sci-entific evidence of microbial transmission during critical momentsof care in outpatient care settings is limited.2 In this study, theprimary research objective was to quantify the presence of healthcare-associated pathogens on the hands of HCWs at 2 of the keymoments for hand hygiene in an outpatient care setting and to de-termine the influence of glove use. In addition, the study sought toclarify the distribution of hand contamination among HCWs in out-patient care facilities.
MATERIALS AND METHODS
Study design
The institutional review board at each facility approved the study.HCWs at 4 wound care facilities in northeastern Ohio were invitedto participate on each day of sampling and those who chose to par-ticipate signed an informed consent. Sampling took place on 2separate days at each facility. Participants were asked to performroutine patient care activities, including hand hygiene, with no de-viation from their routine practices, except requiring hand hygienebefore entering the examination room. Research staff monitored andrecorded the application of hand hygiene before entering the ex-amination room. For this study, a patient care encounter was definedas the entire care process for 1 patient, including patient rooming,initial patient contact, wound care, and patient discharge. Duringthe patient care encounter hand samples were taken before per-forming a clean or aseptic procedure (WHO moment 2) and aftergloves were removed following body fluid exposure risk (WHOmoment 3). In this study moment 2 corresponded to the momentimmediately before wound treatment and moment 3 corresponded
to the moment immediately after wound treatment (Fig 1). WHOmoments 2 and 3 relate to the moments in the Canadian guide-lines 4 moments and are similar to the indications for hand hygienerecommended in the CDC guidelines. Only paired samples takenbefore moment 2 and after moment 3 from the same patient wereincluded in the results. Participants were allowed to be sampledwhile giving care to a maximum of 3 patients (ie, 6 total samples)per day to limit workflow disruption. Samples were only taken fromHCWs who were providing care during the entire patient encoun-ter of a single patient (ie, rooming to exam conclusion). Whenmultiple patient encounters were sampled from the same HCWduring the same clinic day, the encounters sampled were alwaystaken sequentially and never occurred simultaneously. Observa-tion of hand hygiene upon room entry and self-reported glove usewere recorded during patient care. Three of the facilities followedCDC hand hygiene guidelines, whereas 1 facility followed the WHOguidelines.
Hand sampling
A hand sampling method described in the American Society forTesting and Materials Standard Test Method E1115-10 was used torecover bacteria from HCWs’ hands. Briefly, a sterile, powder-freesurgical glove was placed on the dominant hand of the partici-pant, and 50 mL sterile sampling solution (0.075 mol/L phosphatebuffer, pH 7.9, containing 0.1% polysorbate 80, 0.1% sodium thio-sulfate, and 0.3% lecithin) was added to the glove. The glove wassecured at the wrist with a tourniquet, and the gloved hand wasuniformly massaged for 1 minute by the research staff. While theglove remained on the hand, 20 mL sampling solution was asepti-cally removed from the glove and placed in a sterile sample cup.After sampling, the participants washed hands to remove any re-sidual sampling solution.
Bacteria recovery and identification
The sampled solution was centrifuged at 10,000 g for 10minutes,and 15 mL supernatant was discarded. The pellet was resus-pended in the remaining 5 mL supernatant, and the concentratedsample was plated on various growth media. The limit of detec-tion for the identification of each pathogen was 250 CFU per hand.The identification of methicillin-resistant Staphylococcus aureus(MRSA), vancomycin-resistant Enterococcus (VRE), multidrug resis-tant Acinetobacter sp, and Clostridium difficile are describedpreviously.8 Gram stains were performed on all isolates and coagu-lase tests were used to further confirm MRSA-positive samples.
Fig 1. Patient encounter and hand sampling schematic.
1199J. Bingham et al. / American Journal of Infection Control 44 (2016) 1198-202
109
Growth of any single organism was recorded as a positive for handcontamination.
Statistical analysis
The odds of hand contamination was assessed by a mixed effectslogistic regression model with random effects for date crossed withfacility, and HCW nested in facility. The random effects accountedfor the repeated measures taken from each HCW, date, and facili-ty. At moment 2, gloved and ungloved users were analyzedseparately. At moment 3, there were no ungloved users. Thus, theeffect of glove use is based solely onmoment 2 data. Individual valueplots, residual plots, and Hosmer and Lemeshow goodness-of-fit testswere used to assess the fit of the logistic regression model to thedata. All analyses were performed using lme4 in R (R Foundationfor Statistical Computing, Vienna, Austria).9 All statements of sta-tistical significance are based on Wald tests at a significance levelof 5%.
RESULTS
Prevalence of hand contamination
SeventeenHCWs from4 facilitieswere sampled during 46patientcare encounters to determine the presence of health care-associatedpathogens on their hands during critical moments of care. Handhygienewith an alcohol-based handrubwas performed by theHCWwhen entering the patient room to eliminate transient organismspresent from contact with previous patients, environmental sur-faces, or other sources. No confirmation of the effectiveness of handhygiene during this step was performed considering the broad-spectrum antimicrobial activity of alcohol-based handrubs and therelatively high detection limit (250 CFU per hand). Hands weresampled before beginning wound treatment (ie, before clean/aseptic procedure [WHO moment 2]) and after wound treatment(ie, after body fluid exposure risk [WHOmoment 3]). After the handsampling procedure atmoment 2, handwashing to remove the sam-pling solution also removed any remaining transient organisms. Thisprevented any cross-contamination into the sampling at moment3.
HCWs acquired a health care-associated pathogen on their handsduring 28.3% (13 out of 46) of patient care encounters (Table 1).When broken down by moments during care, 17.4% (8 out of 46)of hands sampled at moment 2 and 17.4% (8 out of 46) of handssampled at moment 3 were positive for at least 1 pathogen. Therewere 3 patient care encounters (6.5%) where the HCW’s hands werepositive at both moment 2 and moment 3. However, only 1 of thosecases involved the same organism. No HCWswere sequentially pos-itive between patients for the same organism. This suggests HCWsin the study were contaminated by sources within the outpatient
setting (eg, patients, environment, or staff) and not colonized withany of the targeted organisms. MRSA and C difficile were detectedduring 13.0% and 15.2% of patient care encounters, respectively,whereas VRE and Acinetobacter were each only detected in 2.2% ofencounters. There was no access to patient medical records; there-fore, correlation between the organisms identified from HCW handsand any known patient colonization or infection could not be made.Intrafacility hand contamination rates at moment 2 and moment3 were similar and rates among facilities were also comparable.
Influence of glove use on hand contamination
Glove use during the patient encounter was self-reported by par-ticipants; however, the duration of glove use during care was nottracked. Hence, regardless of duration, wearing gloves at themomentof care was recorded as either positive or negative for glove use.Overall, hand contamination occurred in 19.6% of instances whereHCWs wore gloves during care compared with 14.6% when HCWsdid not wear gloves (Table 2).
During patient care that occurred at moment 2, HCWs woregloves in 10.9% of occurrences (5 out of 46) (Table 2). Appropriate-ness of glove use at this stage of patient care was not assessed andhand hygiene immediately before donning gloves was not re-corded. Hand contamination rates were 14.6% (6 out of 41) forungloved hands and 40.0% (2 out of 5) for gloved hands. The con-tamination rate for ungloved hands was statistically significantly>0% (P < .0005) but the rate of contamination for gloved hands wasnot (P = .657). Lack of significance in the latter case may be due tothe low sample size (n = 5) of glove users at moment 2. The oddsof contamination was 3.9 times larger for gloved HCWs comparedwith ungloved HCWs, but this increase was not statistically signif-icant (P = .181).
Gloves were worn during all wound care treatments (ie, the caregiven atmoment 3) (Table 2). Hands sampled immediately after gloveremoval after wound treatment were found to be contaminated in17.4% (8 out of 46) of occurrences, which was statistically signifi-cantly >0% (P < .0005). A comparison of the odds of contaminationbetween glove users could not be ascertained because there wereno ungloved HCWs during wound care treatment.
Influence of HCWs
Seventeen HCWs from 4 facilities were sampled during the study,which represented 85.0% of the eligible staff. On average, each patientencounter took 60 minutes for established patients or 90-120minutes for new patients, and each HCW provided care to 6-10 pa-tients per clinic day. Paired samples were taken during 9, 15, 10,and 12 patient encounters at facility A, B, C, and D, respectively. Onaverage, each HCWwas sampled during 1.8, 2.1, 2.5, and 1.1 patientencounters at facility A, B, C, and D, respectively, on each sam-pling day. When combined for all facilities, samples were takenduring 1.7 patients encounters per HCW per clinic day, on average.This rate of sampling represented 17.0% of the high to 28.3% of thelow daily patient load for each HCW.
Table 1Breakdown of health care worker hand contamination during patient care encounters
Pathogen
Moment 2 events:Before clean or
aseptic procedure(n = 46)
Moment 3 events:Following body
fluid exposure risk(n = 46)
Patient careencounters(n = 46)
Methicillin-resistantStaphylococcus aureus
4.4 (2) 10.9 (5) 13.0 (6)
Vancomycin-resistantEnterococcus
2.2 (1) 0.0 (0) 2.2 (1)
Acinetobacter 0.0 (0) 2.2 (1) 2.2 (1)Clostridium difficile 10.9 (5) 4.4 (2) 15.2 (7)Any pathogen 17.4 (8) 17.4 (8) 28.3 (13)
NOTE. Values are presented as % (n).
Table 2Incidence of hand contamination based on glove use
Time of care
Positive samples (n = 16)
Gloved Ungloved
Moment 2: Before clean or aseptic procedure 40.0 (2/5) 14.6 (6/41)Moment 3: Following body fluid exposure risk 17.4 (8/46) NA (0/0)Combined 19.6 (10/51) 14.6 (6/41)
NOTE. Values are presented as % (positive samples/total samples).NA, not available.
1200 J. Bingham et al. / American Journal of Infection Control 44 (2016) 1198-202
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Eleven (64.2%) of 17 HCWs in the study were contaminated witha pathogen at least once during the combined 46 patient encoun-ters, whereas 2 (16.7%) of 12 HCWs who gave care to at least 2patients were contaminated during 2 of those patient encounters(Table 3). Eight HCWs (47.1%) were contaminated at least once atmoment 2, whereas 6 HCWs (35.3%) were contaminated at least onceat moment 3. The data indicate that the majority of HCWs’ handsbecome contaminated during patient care and contamination is notassociated with a subset of HCWs.
DISCUSSION
As health care transitions from hospital settings to outpatientsettings the need for scientific evidence to support outpatient in-fection prevention practices increases. Although much has beenpublished about hand hygiene and hand contamination in hospi-tals very little research has been conducted in outpatient caresettings.2,6 This study may be the first to investigate the presenceof pathogens on HCWs’ hands at WHO moments 2 and 3 for handhygiene in an outpatient setting. These moments for hand hygienetypically occur behind privacy curtains or closed doors and evenin hospital settings are less likely to be observed and recorded. Inwound care settings, moments 2 and 3 occur during almost everypatient encounter, providing an opportunity for transmission and/or acquisition of health care-associated pathogens by patients andHCWs.
In this study, HCWs’ hands were contaminated during 28.3% ofpatient care encounters andwhen broken down bymoments of care,17.4% of the time before a clean or aseptic procedure (ie, beforewound treatment) and 17.4% of the time after body fluid exposurerisk (ie, after wound treatment). These contamination rates aresimilar to those reported during different moments of care in otheroutpatient settings, further supporting the importance of handhygiene in these settings.10-14 Hand contamination occurred as fre-quently after casual patient contact as it did after wound care,emphasizing that even brief contact can result in hand contami-nation. Studies, including 2 outpatient studies,12,13,15-18 found handcontamination with organisms such as VRE, S aureus, and C difficilefollowing casual or low-risk contact. Contamination rates in thisstudy support the currentWHO and CDC recommendations for handhygiene before a clean or aseptic procedure and after body fluid ex-posure risk as ways to prevent the transmission of pathogens.
Glove use is explicitly linked with infection prevention and handhygiene practices.6,7,19 Wearing gloves when there is a potential forcontact with blood, body fluids, mucous membranes, nonintact skin,or contaminated equipment is a basic tenet of standard precautions.20
Furthermore, glove use is the strongest recommended infectioncontrol procedure to prevent the contamination of HCWs’ hands.21-24
In this study, gloves were not worn during 89.1% of contact beforewound care. During wound care, when there was potential for ex-posure to blood, body fluids, and nonintact skin, gloves wereuniversally worn. Studies have shown the rate of hand hygiene islower when gloves are worn.25,26 This study suggests that substi-tuting glove use for hand hygiene can place both HCWs and patients
at risk of colonization or infection with pathogenic organisms. De-contaminating hands after glove removal is a CDC recommendation(IB), andWHO guidelines clearly state that wearing gloves does notreplace the need for hand hygiene.6,7 Whether the contaminationis related to the quality of the gloves or HCW practices in donningand doffing of gloves, knowledge and practices of infection pre-vention procedures (including donning and doffing of gloves) shouldbe part of staff onboarding and also regularly reviewed. The recentEbola virus disease outbreak in West Africa demonstrated the po-tential for self-contamination when doffing gloves and otherprotective equipment, and led to the practice of trained observersof HCWs when donning and doffing of protective equipment.27
Because of the contamination of HCW hands at moment 2 andmoment 3 and the time pressure placed on HCWs, hand hygienesolutions need to be placed in convenient locations. Inconvenientplacement of dispensers or sinks is cited as a reason for poor handhygiene compliance by CDC andWHO.2,6 Wound care clinics presenta special challenge to place hand hygiene in convenient locations;therefore, manufacturers of hand hygiene products should consid-er options for nontraditional health care settings so that HCWs donot have to leave the patient zone to perform hand hygiene. As thedelivery of health care shifts toward outpatient care settings, in-fection preventionists and HCWs in these settings should beconsulted to advise a convenient location for hand hygiene dis-pensing products to accommodate their unique workflow patterns.One method to address the workflow and special hand hygiene re-quirements for outpatient settings is workflowmapping. Son et al28
created workflowmaps detailing the steps required to complete the5 most common tasks, including indicating when hand hygiene wasnecessary. This process could be applied to the routine tasks of ad-mitting patients to their room, helping patients onto the exam table,removal of wound dressing, application of new dressing, and helpingthe patient exit the room.
This study sought to understand the distribution of hand con-tamination among HCWs in outpatient care facilities. The majorityof HCWs’ hands (64.2%) became contaminated during patient care,demonstrating that contamination is not concentrated within asubset of HCWs. The distribution of sampling was not controlledin the study. Themajority of HCWswere sampled during 1-2 patientencounters; however, several HCWswere sampled during 5-6 patientencounters. Increasing the sampling of those HCWs who were onlysampled during 1 or 2 patient encounters may result in an in-creased percentage of HCWswith contaminated hands during patientcare. Hand hygiene surveillance programs should be implementedto monitor compliance with hand hygiene guidelines due to thewidespread hand contamination. In the outpatient setting, moni-toring of hand hygiene compliance should include more than justroom entry and room exit, but also within the patient zone. Ob-serving hand hygiene behavior at WHO hand hygiene moments 2and 3 is necessary for patient safety in a wound care setting.
LIMITATIONS
The results reported in this study may not be representative ofall outpatient settings. Wound care facilities were chosen for thisstudy because the care administered in this setting was likely toinclude both a clean or aseptic procedure and body fluid exposurerisk. This setting may bias the results toward higher levels of handcontamination due to the type of care administered and the pres-ence of pathogens in wounds. Wound care center patients may alsobe at higher risk for multidrug resistant organisms due to previ-ous or current antimicrobial therapy, invasive procedures, andhospitalization. The sources of hand contamination could not be de-termined because environment contamination was not quantified
Table 3Analysis of hand contamination by health care workers
Handcontaminationevents
Percent of contaminated health care workers
Moment 2:Before clean or
aseptic procedure
Moment 3:Following body
fluid exposure riskPatient careencounters
1 47.1 (8) 35.3 (6) 64.2 (11)2 0.0 (0) 16.7 (2) 16.7 (2)
NOTE. Values are presented as % (n).
1201J. Bingham et al. / American Journal of Infection Control 44 (2016) 1198-202
111
or characterized, baseline colonization of HCWs was not identified,and patient records were not accessed to determine infection status.
CONCLUSIONS
Outpatient care settings, especially wound care centers, presentunique infection prevention challenges. The hand contamination re-ported at moment 2 and moment 3 provides a strong case forattention to hand hygiene and infection prevention practices in thesesettings to protect both patients and HCWs. The results of this studyemphasize the need for attention to glove donning and doffing prac-tices because glove use did not prevent contamination of the hands.The study also highlights the need for hand hygiene surveillanceand hand hygiene solutions at the point of care so HCWs can cleantheir hands without leaving the patient zone.
References
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2. World Health Organization. Hand hygiene in outpatient care, home-based careand long-term care facilities. Geneva, Switzerland: 2014.
3. Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimatesfor 2007. Vital Health Stat 13 2011;131-8.
4. Jarvis WR. Infection control and changing health-care delivery systems. EmergInfect Dis 2001;7:170-3.
5. Maki DG, Crnich CJ. History forgotten is history relived: nosocomial infectioncontrol is also essential in the outpatient setting. Arch Intern Med2005;165:2565-7.
6. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings.Recommendations of the Healthcare Infection Control Practices AdvisoryCommittee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Societyfor Healthcare Epidemiology of America/Association for Professionals in InfectionControl/Infectious Diseases Society of America. MMWR Recomm Rep 2002;51:1-45.
7. Pittet D, Allegranzi B, Boyce J. TheWorld Health Organization guidelines on handhygiene in health care and their consensus recommendations. Infect Control HospEpidemiol 2009;30:611-22.
8. Istenes N, Bingham J, Hazelett S, Fleming E, Kirk J. Patients’ potential role in thetransmission of health care-associated infections: prevalence of contaminationwith bacterial pathogens and patient attitudes toward hand hygiene. Am J InfectControl 2013;41:793-8.
9. Bates D, Maechler M, Bolker B, Walker S. Lme4: linear mixed-effects models usingEigen and S4. R package version 1.1-5. 2014.
10. Cohen HA, Matalon A, Amir J, Paret G, Barzilai A. Handwashing patterns inprimary pediatric community clinics. Infection 1998;26:45-7.
11. Girier P, Le Goaziou MF. Are multiresistant micro-organisms present in GPs’offices? Med Mal Infect 2005;35(Suppl 2):S69-71.
12. Grabsch EA, Burrell LJ, Padiglione A, O’Keeffe JM, Ballard S, Grayson ML. Risk ofenvironmental and healthcare worker contamination with vancomycin-resistantenterococci during outpatient procedures and hemodialysis. Infect Control HospEpidemiol 2006;27:287-93.
13. Lam RF, Hui M, Leung DY, Chow VC, Lam BN, Leung GM, et al. Extent andpredictors of microbial hand contamination in a tertiary care ophthalmicoutpatient practice. Invest Ophthalmol Vis Sci 2005;46:3578-83.
14. Zuckerman JB, Zuaro DE, Prato BS, Ruoff KL, Sawicki RW, Quinton HB, et al.Bacterial contamination of cystic fibrosis clinics. J Cyst Fibros 2009;8:186-92.
15. Bhalla A, Pultz NJ, Gries DM, Ray AJ, Eckstein EC, Aron DC, et al. Acquisition ofnosocomial pathogens on hands after contact with environmental surfaces nearhospitalized patients. Infect Control Hosp Epidemiol 2004;25:164-7.
16. Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contaminationof the hands of hospital staff during routine patient care. Arch Intern Med1999;159:821-6.
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Injection SafetyPractice
Performed?If answer is No, document plan for remediation
Proper hand hygiene, using alcohol-based hand rub or soap and water, is performed prior to preparing and administering medications.
Yes No
Injections are prepared using aseptic technique in a clean area free from contamination or contact with blood, body fluids, or contaminated equipment.
Yes No
Needles and syringes are used for only one patient (this includes manufactured prefilled syringes and cartridge devices such as insulin pens).
Yes No
The rubber septum on a medication vial is disinfected with alcohol prior to piercing. Yes No
Medication vials are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient.
Yes No
Single-dose or single-use medication vials, ampules, and bags or bottles of intravenous solution are used for only one patient.
Yes No
Medication administration tubing and connectors are used for only one patient. Yes No
Multi-dose vials are dated by healthcare when they are first opened and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
Note: This is different from the expiration date printed on the vial.
Yes No
Multi-dose vials are dedicated to individual patients whenever possible. Yes No
Multi-dose vials to be used for more than one patient are kept in a centralized medication area and do not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle).
Note: If multi-dose vials enter the immediate patient treatment area, they should be dedicated for single-patient use and discarded immediately after use.
Yes No
INJECTION SAFETY CHECKLISTThe following Injection Safety checklist items are a subset of items that can be found in the CDC Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care.
The checklist, which is appropriate for both inpatient and outpatient settings, should be used to systematically assess adherence of healthcare providers to safe injection practices. Assessment of adherence should be conducted by direct observation of healthcare personnel during the performance of their duties.
The One & Only Campaign is a public health effort to eliminate unsafe medical injections. To learn more about safe injection practices, please visit www.cdc.gov/injectionsafety/1anonly.html.
306089-G
3.11
Injection SafetyPractice
Performed?If answer is No, document plan for remediation
Proper hand hygiene, using alcohol-based hand rub or soap and water, is performed prior to preparing and administering medications.
Yes No
Injections are prepared using aseptic technique in a clean area free from contamination or contact with blood, body fluids, or contaminated equipment.
Yes No
Needles and syringes are used for only one patient (this includes manufactured prefilled syringes and cartridge devices such as insulin pens).
Yes No
The rubber septum on a medication vial is disinfected with alcohol prior to piercing. Yes No
Medication vials are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient.
Yes No
Single-dose or single-use medication vials, ampules, and bags or bottles of intravenous solution are used for only one patient.
Yes No
Medication administration tubing and connectors are used for only one patient. Yes No
Multi-dose vials are dated by healthcare when they are first opened and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
Note: This is different from the expiration date printed on the vial.
Yes No
Multi-dose vials are dedicated to individual patients whenever possible. Yes No
Multi-dose vials to be used for more than one patient are kept in a centralized medication area and do not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle).
Note: If multi-dose vials enter the immediate patient treatment area, they should be dedicated for single-patient use and discarded immediately after use.
Yes No
INJECTION SAFETY CHECKLISTThe following Injection Safety checklist items are a subset of items that can be found in the CDC Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care.
The checklist, which is appropriate for both inpatient and outpatient settings, should be used to systematically assess adherence of healthcare providers to safe injection practices. Assessment of adherence should be conducted by direct observation of healthcare personnel during the performance of their duties.
The One & Only Campaign is a public health effort to eliminate unsafe medical injections. To learn more about safe injection practices, please visit www.cdc.gov/injectionsafety/1anonly.html.
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Safe Injection Practices CoalitionThe Safe Injection Practices Coalition (SIPC) is a partnership of healthcare-related organizations led by the Centers for Disease Control and Prevention that was formed to promote safe injection practices in all U.S. healthcare settings. The SIPC has developed the One & Only Campaign – a public health education and awareness campaign – aimed at both healthcare providers and patients to advance and promote safe injection practices.
Become an active partner in your health care.
Glossary healthcare providers – doctors, nurses and other trained healthcare professionals
hepatitis B – a liver disease caused by the hepatitis B virus (HBV)
hepatitis C – a liver disease caused by the hepatitis C virus (HCV)
HIV – the virus that can lead to acquired immune deficiency syndrome, or AIDS
injection – forcing a fluid into the body by means of a syringe
IV – intravenous, or “within a vein”
needle – a sharp pointed object used for injection or removal of fluid from the body
syringe – an instrument used to inject fluids into the body or draw them from it
transmission – spread, as of an infection from one patient to another
vial – a small container or bottle that holds medicine
3.12
115
Here is what you should know about safe injection practices:
What are safe injection practices?Safe injection practices are a set of practices that healthcare providers should follow when they give injections. For example, healthcare providers should not use the same syringe on more than one patient, even if the needle is changed. A good rule to remember is One Needle, One Syringe, only One Time.
Why are safe injection practices so important?These practices will prevent the spread of diseases like hepatitis B, hepatitis C, or HIV.
Who should be aware of safe injection practices?Anyone who receives an injection or IV therapy should be aware of these practices. Anyone who gives an injection or IV therapy (like a healthcare provider) should understand and follow safe injection practices.
What can patients do to find information about safe injection practices?Patients can take the following steps to learn more about safe injection practices:
• Talkwithyourhealthcareprovideraboutsafe injection practices.
• Gotowww.cdc.gov/injectionsafety/1anonly.html for more information.
Did you know?Most healthcare providers follow safe injection practices. Though not common, unsafe practices sometimes occur. Healthcare providers can spread diseases like hepatitis B, hepatitis C, or HIV if they reuse injection equipment like needles or syringes on more than one patient or to access vials that are shared between patients.
For more information, please visit: www.cdc.gov/injectionsafety/1anonly.html.
SyringeNeedle
Vial
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Module 4
Epidemiology & Infectious Diseases
Resources
Principles of EpidemiologyCenters for Disease Control and Prevention (CDC)https://www .cdc .gov/csels/dsepd/ss1978/lesson1/section10 .html
Chart of Clinical Syndromes or Conditions Warranting Empiric Transmission-Based Precautions in Addition to Standard PrecautionsCDChttps://www .cdc .gov/infectioncontrol/guidelines/isolation/appendix/ transmission-precautions .html
Measles outbreak toolkit CDChttps://www .cdc .gov/measles/toolkit/state-health-departments .html
MeaslesCDChttps://www .cdc .gov/measles/hcp/index .html
Chicken PoxCDChttps://www .cdc .gov/chickenpox/hcp/index .html
ShinglesCDChttps://www .cdc .gov/shingles/hcp/index .html
Respiratory Synctial Virus InfectionCDChttps://www .cdc .gov/rsv/clinical/index .html
MeningitisCDChttps://www .cdc .gov/meningitis/clinical-resources .html
Multidrug Resistant Organisms ManagementCDChttps://www .cdc .gov/infectioncontrol/guidelines/mdro/index .html
Red Book 2018American Academy of Pediatricshttps://redbook .solutions .aap .org/Book .aspx?bookid=2205
117
Module 5
Occupational/Employee Health
Contents
5.1 Recommended vaccines for healthcare workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120Immunization Action Coalition https://www .immunize .org/catg .d/p2017 .pdf
5.2 Checklist for Bloodborne Pathogens Content Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122Forms & Checklists for Infection Control, Volume 2
5.3 Sharps Injury Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Forms & Checklists for Infection Control, Volume 2
5.4 Employee Training Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124Forms & Checklists for Infection Control, Volume 2
5.5 Injection Safety Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Forms & Checklists for Infection Control, Volume 1
Resources
Healthcare Worker GuidelinesCenters for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC)https://www .cdc .gov/hicpac/pdf/infectcontrol98 .pdf
Vaccine guidelines for healthcare providers/professionalsCDChttps://www .cdc .gov/vaccines/hcp/index .html
Standards for Adult immunization PracticeCDChttps://www .cdc .gov/vaccines/hcp/adults/for-practice/standards/index .html
Bloodborne Pathogens Quick Reference GuideOccupational Safety and Health Administration (OSHA)https://www .osha .gov/SLTC/bloodbornepathogens/bloodborne_quickref .html
Immunization Action Coalitionhttps://www .immunize .org/
InfluenzaSociety for Healthcare Epidemiology of America (SHEA)https://www .shea-online .org/index .php/practice-resources/priority-topics/influenza
118
MeaslesCDChttps://www .cdc .gov/infectioncontrol/guidelines/measles/index .html
Red Book 2018American Academy of Pediatricshttps://redbook .solutions .aap .org/Book .aspx?bookid=2205
Control of Communicable Diseases ManualAmerican Public Health Associationhttps://www .apha .org/ccdm
119
Hepatitis BUnvaccinated healthcare personnel (HCP) and/or those who cannot document previous vac-cination should receive either a 2-dose series of Heplisav-B at 0 and 1 month or a 3-dose series of either Engerix-B or Recombivax HB at 0, 1, and 6 months. HCP who perform tasks that may involve exposure to blood or body fluids should be tested for hepatitis B surface anti-body (anti-HBs) 1–2 months after dose #2 of Heplisav-B or dose #3 of Engerix-B or Recom-bivax HB to document immunity.
• If anti-HBs is at least 10 mIU/mL (positive), the vaccinee is immune. No further serologic testing or vaccination is recommended.
• If anti-HBs is less than 10 mIU/mL (negative), the vaccinee is not protected from hepatitis B virus (HBV) infection, and should receive another 2-dose or 3-dose series of HepB vaccine on the routine schedule, followed by anti-HBs testing 1–2 months later. A vaccinee whose anti-HBs remains less than 10 mIU/mL after 2 complete series is considered a “non-responder.”
For non-responders: HCP who are non-responders should be considered susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-positive blood or blood with unknown HBsAg status. It is also possible that non-responders are people who are HBsAg positive. HBsAg testing is recommended. HCP found
to be HBsAg positive should be counseled and medically evaluated.
For HCP with documentation of a complete 2-dose (Heplisav-B) or 3-dose (Engerix-B or Re-combivax HB) vaccine series but no documen-tation of anti-HBs of at least 10 mIU/mL (e.g., those vaccinated in childhood): HCP who are at risk for occupational blood or body fluid expo- sure might undergo anti-HBs testing upon hire or matriculation. See references 2 and 3 for details.
Influenza All HCP, including physicians, nurses, paramedics, emergency medical technicians, employees of nursing homes and chronic care facilities, students in these professions, and volunteers, should receive annual vaccination against influ-enza. Live attenuated influenza vaccine (LAIV) may be given only to non-pregnant healthy HCP age 49 years and younger. Inactivated injectable influenza vaccine (IIV) is preferred over LAIV for HCP who are in close contact with severely immunosuppressed patients (e.g., stem cell transplant recipients) when they require protec-tive isolation.
Measles, Mumps, Rubella (MMR)HCP who work in medical facilities should be immune to measles, mumps, and rubella.
• HCP born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation of disease or immunity or (b) appropriate vaccination against measles, mumps, and rubella (i.e., 2 doses of live
measles and mumps vaccines given on or after the first birthday and separated by 28 days or more, and at least 1 dose of live rubella vaccine). HCP with 2 documented doses of MMR are not recommended to be serologically tested for immunity; but if they are tested and results are negative or equivocal for measles, mumps, and/or rubella, these HCP should be considered to have presumptive evidence of immunity to measles, mumps, and/or rubella and are not in need of additional MMR doses.
• Although birth before 1957 generally is con- sidered acceptable evidence of measles, mumps, and rubella immunity, 2 doses of MMR vaccine should be considered for unvacci-nated HCP born before 1957 who do not have laboratory evidence of disease or immunity to measles and/or mumps. One dose of MMR vaccine should be considered for HCP with no laboratory evidence of disease or immunity to rubella. For these same HCP who do not have evidence of immunity, 2 doses of MMR vaccine are recommended during an outbreak of measles or mumps and 1 dose during an outbreak of rubella.
Varicella It is recommended that all HCP be immune to varicella. Evidence of immunity in HCP includes documentation of 2 doses of varicella vaccine given at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or diagnosis or verification of a history of vari-cella or herpes zoster (shingles) by a healthcare provider.
Tetanus/Diphtheria/Pertussis (Td/Tdap)All HCPs who have not or are unsure if they have previously received a dose of Tdap should receive a dose of Tdap as soon as feasible, with- out regard to the interval since the previous dose of Td. Pregnant HCP should be revaccinated during each pregnancy. All HCPs should then receive Td boosters every 10 years thereafter.
MeningococcalVaccination with MenACWY and MenB is recommended for microbiologists who are routinely exposed to isolates of N. meningitidis. The two vaccines may be given concomitantly but at different anatomic sites, if feasible.
references1 CDC. Immunization of Health-Care Personnel: Recom-
mendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).
2 CDC. Prevention of Hepatitis B Virus Infection in the Unit-ed States. Recommendations of the Advisory Committee on Immunization Practices. MMWR, 2018; 67(RR1):1–30.
3 IAC. Pre-exposure Management for Healthcare Personnel with a Documented Hepatitis B Vaccine Series Who Have Not Had Post-vaccination Serologic Testing. Accessed at www.immunize.org/catg.d/p2108.pdf.
For additional specific ACIP recommendations, visit CDC’s website at www.cdc.gov/vaccines/hcp/acip-recs/index.html or visit IAC’s website at www.immunize.org/acip.
Healthcare Personnel Vaccination Recommendationsvaccines and recommendations in brief
Hepatitis B – If previously unvaccinated, give a 2-dose (Heplisav-B) or 3-dose (Engerix-B or Recombivax HB) series. Give intramuscularly (IM). For HCP who perform tasks that may involve exposure to blood or body fluids, obtain anti-HBs serologic testing 1–2 months after dose #2 (for Heplisav-B) or dose #3 (for Engerix-B or Recombivax HB).
Influenza – Give 1 dose of influenza vaccine annually. Inactivated injectable vaccine is given IM, except when using the intradermal influenza vaccine. Live attenuated influenza vaccine (LAIV) is given intranasally.
MMR – For healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP born prior to 1957, see below. Give subcutaneously (Subcut).
Varicella (chickenpox) – For HCP who have no serologic proof of immunity, prior vaccination, or diagnosis or verification of a history of varicella or herpes zoster (shingles) by a healthcare provider, give 2 doses of varicella vaccine, 4 weeks apart. Give Subcut.
Tetanus, diphtheria, pertussis – Give 1 dose of Tdap as soon as feasible to all HCP who have not received Tdap previously and to pregnant HCP with each pregnancy (see below). Give Td boosters every 10 years thereafter. Give IM.
Meningococcal – Give both MenACWY and MenB to microbiologists who are routine-ly exposed to isolates of Neisseria meningitidis. Every 5 years boost with MenACWY if risk continues. Give MenACWY and MenB IM.
Hepatitis A, typhoid, and polio vaccines are not routinely recommended for HCP who may have on-the-job exposure to fecal material.
Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.orgTechnical content reviewed by the Centers for Disease Control and Prevention
www.immunize.org/catg.d/p2017.pdf • Item #P2017 (3/18)
5.1
Hepatitis BUnvaccinated healthcare personnel (HCP) and/or those who cannot document previous vac-cination should receive either a 2-dose series of Heplisav-B at 0 and 1 month or a 3-dose series of either Engerix-B or Recombivax HB at 0, 1, and 6 months. HCP who perform tasks that may involve exposure to blood or body fluids should be tested for hepatitis B surface anti-body (anti-HBs) 1–2 months after dose #2 of Heplisav-B or dose #3 of Engerix-B or Recom-bivax HB to document immunity.
• If anti-HBs is at least 10 mIU/mL (positive), the vaccinee is immune. No further serologic testing or vaccination is recommended.
• If anti-HBs is less than 10 mIU/mL (negative), the vaccinee is not protected from hepatitis B virus (HBV) infection, and should receive another 2-dose or 3-dose series of HepB vaccine on the routine schedule, followed by anti-HBs testing 1–2 months later. A vaccinee whose anti-HBs remains less than 10 mIU/mL after 2 complete series is considered a “non-responder.”
For non-responders: HCP who are non-responders should be considered susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-positive blood or blood with unknown HBsAg status. It is also possible that non-responders are people who are HBsAg positive. HBsAg testing is recommended. HCP found
to be HBsAg positive should be counseled and medically evaluated.
For HCP with documentation of a complete 2-dose (Heplisav-B) or 3-dose (Engerix-B or Re-combivax HB) vaccine series but no documen-tation of anti-HBs of at least 10 mIU/mL (e.g., those vaccinated in childhood): HCP who are at risk for occupational blood or body fluid expo- sure might undergo anti-HBs testing upon hire or matriculation. See references 2 and 3 for details.
Influenza All HCP, including physicians, nurses, paramedics, emergency medical technicians, employees of nursing homes and chronic care facilities, students in these professions, and volunteers, should receive annual vaccination against influ-enza. Live attenuated influenza vaccine (LAIV) may be given only to non-pregnant healthy HCP age 49 years and younger. Inactivated injectable influenza vaccine (IIV) is preferred over LAIV for HCP who are in close contact with severely immunosuppressed patients (e.g., stem cell transplant recipients) when they require protec-tive isolation.
Measles, Mumps, Rubella (MMR)HCP who work in medical facilities should be immune to measles, mumps, and rubella.
• HCP born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation of disease or immunity or (b) appropriate vaccination against measles, mumps, and rubella (i.e., 2 doses of live
measles and mumps vaccines given on or after the first birthday and separated by 28 days or more, and at least 1 dose of live rubella vaccine). HCP with 2 documented doses of MMR are not recommended to be serologically tested for immunity; but if they are tested and results are negative or equivocal for measles, mumps, and/or rubella, these HCP should be considered to have presumptive evidence of immunity to measles, mumps, and/or rubella and are not in need of additional MMR doses.
• Although birth before 1957 generally is con- sidered acceptable evidence of measles, mumps, and rubella immunity, 2 doses of MMR vaccine should be considered for unvacci-nated HCP born before 1957 who do not have laboratory evidence of disease or immunity to measles and/or mumps. One dose of MMR vaccine should be considered for HCP with no laboratory evidence of disease or immunity to rubella. For these same HCP who do not have evidence of immunity, 2 doses of MMR vaccine are recommended during an outbreak of measles or mumps and 1 dose during an outbreak of rubella.
Varicella It is recommended that all HCP be immune to varicella. Evidence of immunity in HCP includes documentation of 2 doses of varicella vaccine given at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or diagnosis or verification of a history of vari-cella or herpes zoster (shingles) by a healthcare provider.
Tetanus/Diphtheria/Pertussis (Td/Tdap)All HCPs who have not or are unsure if they have previously received a dose of Tdap should receive a dose of Tdap as soon as feasible, with- out regard to the interval since the previous dose of Td. Pregnant HCP should be revaccinated during each pregnancy. All HCPs should then receive Td boosters every 10 years thereafter.
MeningococcalVaccination with MenACWY and MenB is recommended for microbiologists who are routinely exposed to isolates of N. meningitidis. The two vaccines may be given concomitantly but at different anatomic sites, if feasible.
references1 CDC. Immunization of Health-Care Personnel: Recom-
mendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).
2 CDC. Prevention of Hepatitis B Virus Infection in the Unit-ed States. Recommendations of the Advisory Committee on Immunization Practices. MMWR, 2018; 67(RR1):1–30.
3 IAC. Pre-exposure Management for Healthcare Personnel with a Documented Hepatitis B Vaccine Series Who Have Not Had Post-vaccination Serologic Testing. Accessed at www.immunize.org/catg.d/p2108.pdf.
For additional specific ACIP recommendations, visit CDC’s website at www.cdc.gov/vaccines/hcp/acip-recs/index.html or visit IAC’s website at www.immunize.org/acip.
Healthcare Personnel Vaccination Recommendationsvaccines and recommendations in brief
Hepatitis B – If previously unvaccinated, give a 2-dose (Heplisav-B) or 3-dose (Engerix-B or Recombivax HB) series. Give intramuscularly (IM). For HCP who perform tasks that may involve exposure to blood or body fluids, obtain anti-HBs serologic testing 1–2 months after dose #2 (for Heplisav-B) or dose #3 (for Engerix-B or Recombivax HB).
Influenza – Give 1 dose of influenza vaccine annually. Inactivated injectable vaccine is given IM, except when using the intradermal influenza vaccine. Live attenuated influenza vaccine (LAIV) is given intranasally.
MMR – For healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP born prior to 1957, see below. Give subcutaneously (Subcut).
Varicella (chickenpox) – For HCP who have no serologic proof of immunity, prior vaccination, or diagnosis or verification of a history of varicella or herpes zoster (shingles) by a healthcare provider, give 2 doses of varicella vaccine, 4 weeks apart. Give Subcut.
Tetanus, diphtheria, pertussis – Give 1 dose of Tdap as soon as feasible to all HCP who have not received Tdap previously and to pregnant HCP with each pregnancy (see below). Give Td boosters every 10 years thereafter. Give IM.
Meningococcal – Give both MenACWY and MenB to microbiologists who are routine-ly exposed to isolates of Neisseria meningitidis. Every 5 years boost with MenACWY if risk continues. Give MenACWY and MenB IM.
Hepatitis A, typhoid, and polio vaccines are not routinely recommended for HCP who may have on-the-job exposure to fecal material.
Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.orgTechnical content reviewed by the Centers for Disease Control and Prevention
www.immunize.org/catg.d/p2017.pdf • Item #P2017 (3/18)
120
Hepatitis BUnvaccinated healthcare personnel (HCP) and/or those who cannot document previous vac-cination should receive either a 2-dose series of Heplisav-B at 0 and 1 month or a 3-dose series of either Engerix-B or Recombivax HB at 0, 1, and 6 months. HCP who perform tasks that may involve exposure to blood or body fluids should be tested for hepatitis B surface anti-body (anti-HBs) 1–2 months after dose #2 of Heplisav-B or dose #3 of Engerix-B or Recom-bivax HB to document immunity.
• If anti-HBs is at least 10 mIU/mL (positive), the vaccinee is immune. No further serologic testing or vaccination is recommended.
• If anti-HBs is less than 10 mIU/mL (negative), the vaccinee is not protected from hepatitis B virus (HBV) infection, and should receive another 2-dose or 3-dose series of HepB vaccine on the routine schedule, followed by anti-HBs testing 1–2 months later. A vaccinee whose anti-HBs remains less than 10 mIU/mL after 2 complete series is considered a “non-responder.”
For non-responders: HCP who are non-responders should be considered susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-positive blood or blood with unknown HBsAg status. It is also possible that non-responders are people who are HBsAg positive. HBsAg testing is recommended. HCP found
to be HBsAg positive should be counseled and medically evaluated.
For HCP with documentation of a complete 2-dose (Heplisav-B) or 3-dose (Engerix-B or Re-combivax HB) vaccine series but no documen-tation of anti-HBs of at least 10 mIU/mL (e.g., those vaccinated in childhood): HCP who are at risk for occupational blood or body fluid expo- sure might undergo anti-HBs testing upon hire or matriculation. See references 2 and 3 for details.
Influenza All HCP, including physicians, nurses, paramedics, emergency medical technicians, employees of nursing homes and chronic care facilities, students in these professions, and volunteers, should receive annual vaccination against influ-enza. Live attenuated influenza vaccine (LAIV) may be given only to non-pregnant healthy HCP age 49 years and younger. Inactivated injectable influenza vaccine (IIV) is preferred over LAIV for HCP who are in close contact with severely immunosuppressed patients (e.g., stem cell transplant recipients) when they require protec-tive isolation.
Measles, Mumps, Rubella (MMR)HCP who work in medical facilities should be immune to measles, mumps, and rubella.
• HCP born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation of disease or immunity or (b) appropriate vaccination against measles, mumps, and rubella (i.e., 2 doses of live
measles and mumps vaccines given on or after the first birthday and separated by 28 days or more, and at least 1 dose of live rubella vaccine). HCP with 2 documented doses of MMR are not recommended to be serologically tested for immunity; but if they are tested and results are negative or equivocal for measles, mumps, and/or rubella, these HCP should be considered to have presumptive evidence of immunity to measles, mumps, and/or rubella and are not in need of additional MMR doses.
• Although birth before 1957 generally is con- sidered acceptable evidence of measles, mumps, and rubella immunity, 2 doses of MMR vaccine should be considered for unvacci-nated HCP born before 1957 who do not have laboratory evidence of disease or immunity to measles and/or mumps. One dose of MMR vaccine should be considered for HCP with no laboratory evidence of disease or immunity to rubella. For these same HCP who do not have evidence of immunity, 2 doses of MMR vaccine are recommended during an outbreak of measles or mumps and 1 dose during an outbreak of rubella.
Varicella It is recommended that all HCP be immune to varicella. Evidence of immunity in HCP includes documentation of 2 doses of varicella vaccine given at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or diagnosis or verification of a history of vari-cella or herpes zoster (shingles) by a healthcare provider.
Tetanus/Diphtheria/Pertussis (Td/Tdap)All HCPs who have not or are unsure if they have previously received a dose of Tdap should receive a dose of Tdap as soon as feasible, with- out regard to the interval since the previous dose of Td. Pregnant HCP should be revaccinated during each pregnancy. All HCPs should then receive Td boosters every 10 years thereafter.
MeningococcalVaccination with MenACWY and MenB is recommended for microbiologists who are routinely exposed to isolates of N. meningitidis. The two vaccines may be given concomitantly but at different anatomic sites, if feasible.
references1 CDC. Immunization of Health-Care Personnel: Recom-
mendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).
2 CDC. Prevention of Hepatitis B Virus Infection in the Unit-ed States. Recommendations of the Advisory Committee on Immunization Practices. MMWR, 2018; 67(RR1):1–30.
3 IAC. Pre-exposure Management for Healthcare Personnel with a Documented Hepatitis B Vaccine Series Who Have Not Had Post-vaccination Serologic Testing. Accessed at www.immunize.org/catg.d/p2108.pdf.
For additional specific ACIP recommendations, visit CDC’s website at www.cdc.gov/vaccines/hcp/acip-recs/index.html or visit IAC’s website at www.immunize.org/acip.
Healthcare Personnel Vaccination Recommendationsvaccines and recommendations in brief
Hepatitis B – If previously unvaccinated, give a 2-dose (Heplisav-B) or 3-dose (Engerix-B or Recombivax HB) series. Give intramuscularly (IM). For HCP who perform tasks that may involve exposure to blood or body fluids, obtain anti-HBs serologic testing 1–2 months after dose #2 (for Heplisav-B) or dose #3 (for Engerix-B or Recombivax HB).
Influenza – Give 1 dose of influenza vaccine annually. Inactivated injectable vaccine is given IM, except when using the intradermal influenza vaccine. Live attenuated influenza vaccine (LAIV) is given intranasally.
MMR – For healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP born prior to 1957, see below. Give subcutaneously (Subcut).
Varicella (chickenpox) – For HCP who have no serologic proof of immunity, prior vaccination, or diagnosis or verification of a history of varicella or herpes zoster (shingles) by a healthcare provider, give 2 doses of varicella vaccine, 4 weeks apart. Give Subcut.
Tetanus, diphtheria, pertussis – Give 1 dose of Tdap as soon as feasible to all HCP who have not received Tdap previously and to pregnant HCP with each pregnancy (see below). Give Td boosters every 10 years thereafter. Give IM.
Meningococcal – Give both MenACWY and MenB to microbiologists who are routine-ly exposed to isolates of Neisseria meningitidis. Every 5 years boost with MenACWY if risk continues. Give MenACWY and MenB IM.
Hepatitis A, typhoid, and polio vaccines are not routinely recommended for HCP who may have on-the-job exposure to fecal material.
Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.orgTechnical content reviewed by the Centers for Disease Control and Prevention
www.immunize.org/catg.d/p2017.pdf • Item #P2017 (3/18)
Hepatitis BUnvaccinated healthcare personnel (HCP) and/or those who cannot document previous vac-cination should receive either a 2-dose series of Heplisav-B at 0 and 1 month or a 3-dose series of either Engerix-B or Recombivax HB at 0, 1, and 6 months. HCP who perform tasks that may involve exposure to blood or body fluids should be tested for hepatitis B surface anti-body (anti-HBs) 1–2 months after dose #2 of Heplisav-B or dose #3 of Engerix-B or Recom-bivax HB to document immunity.
• If anti-HBs is at least 10 mIU/mL (positive), the vaccinee is immune. No further serologic testing or vaccination is recommended.
• If anti-HBs is less than 10 mIU/mL (negative), the vaccinee is not protected from hepatitis B virus (HBV) infection, and should receive another 2-dose or 3-dose series of HepB vaccine on the routine schedule, followed by anti-HBs testing 1–2 months later. A vaccinee whose anti-HBs remains less than 10 mIU/mL after 2 complete series is considered a “non-responder.”
For non-responders: HCP who are non-responders should be considered susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-positive blood or blood with unknown HBsAg status. It is also possible that non-responders are people who are HBsAg positive. HBsAg testing is recommended. HCP found
to be HBsAg positive should be counseled and medically evaluated.
For HCP with documentation of a complete 2-dose (Heplisav-B) or 3-dose (Engerix-B or Re-combivax HB) vaccine series but no documen-tation of anti-HBs of at least 10 mIU/mL (e.g., those vaccinated in childhood): HCP who are at risk for occupational blood or body fluid expo- sure might undergo anti-HBs testing upon hire or matriculation. See references 2 and 3 for details.
Influenza All HCP, including physicians, nurses, paramedics, emergency medical technicians, employees of nursing homes and chronic care facilities, students in these professions, and volunteers, should receive annual vaccination against influ-enza. Live attenuated influenza vaccine (LAIV) may be given only to non-pregnant healthy HCP age 49 years and younger. Inactivated injectable influenza vaccine (IIV) is preferred over LAIV for HCP who are in close contact with severely immunosuppressed patients (e.g., stem cell transplant recipients) when they require protec-tive isolation.
Measles, Mumps, Rubella (MMR)HCP who work in medical facilities should be immune to measles, mumps, and rubella.
• HCP born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation of disease or immunity or (b) appropriate vaccination against measles, mumps, and rubella (i.e., 2 doses of live
measles and mumps vaccines given on or after the first birthday and separated by 28 days or more, and at least 1 dose of live rubella vaccine). HCP with 2 documented doses of MMR are not recommended to be serologically tested for immunity; but if they are tested and results are negative or equivocal for measles, mumps, and/or rubella, these HCP should be considered to have presumptive evidence of immunity to measles, mumps, and/or rubella and are not in need of additional MMR doses.
• Although birth before 1957 generally is con- sidered acceptable evidence of measles, mumps, and rubella immunity, 2 doses of MMR vaccine should be considered for unvacci-nated HCP born before 1957 who do not have laboratory evidence of disease or immunity to measles and/or mumps. One dose of MMR vaccine should be considered for HCP with no laboratory evidence of disease or immunity to rubella. For these same HCP who do not have evidence of immunity, 2 doses of MMR vaccine are recommended during an outbreak of measles or mumps and 1 dose during an outbreak of rubella.
Varicella It is recommended that all HCP be immune to varicella. Evidence of immunity in HCP includes documentation of 2 doses of varicella vaccine given at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or diagnosis or verification of a history of vari-cella or herpes zoster (shingles) by a healthcare provider.
Tetanus/Diphtheria/Pertussis (Td/Tdap)All HCPs who have not or are unsure if they have previously received a dose of Tdap should receive a dose of Tdap as soon as feasible, with- out regard to the interval since the previous dose of Td. Pregnant HCP should be revaccinated during each pregnancy. All HCPs should then receive Td boosters every 10 years thereafter.
MeningococcalVaccination with MenACWY and MenB is recommended for microbiologists who are routinely exposed to isolates of N. meningitidis. The two vaccines may be given concomitantly but at different anatomic sites, if feasible.
references1 CDC. Immunization of Health-Care Personnel: Recom-
mendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).
2 CDC. Prevention of Hepatitis B Virus Infection in the Unit-ed States. Recommendations of the Advisory Committee on Immunization Practices. MMWR, 2018; 67(RR1):1–30.
3 IAC. Pre-exposure Management for Healthcare Personnel with a Documented Hepatitis B Vaccine Series Who Have Not Had Post-vaccination Serologic Testing. Accessed at www.immunize.org/catg.d/p2108.pdf.
For additional specific ACIP recommendations, visit CDC’s website at www.cdc.gov/vaccines/hcp/acip-recs/index.html or visit IAC’s website at www.immunize.org/acip.
Healthcare Personnel Vaccination Recommendationsvaccines and recommendations in brief
Hepatitis B – If previously unvaccinated, give a 2-dose (Heplisav-B) or 3-dose (Engerix-B or Recombivax HB) series. Give intramuscularly (IM). For HCP who perform tasks that may involve exposure to blood or body fluids, obtain anti-HBs serologic testing 1–2 months after dose #2 (for Heplisav-B) or dose #3 (for Engerix-B or Recombivax HB).
Influenza – Give 1 dose of influenza vaccine annually. Inactivated injectable vaccine is given IM, except when using the intradermal influenza vaccine. Live attenuated influenza vaccine (LAIV) is given intranasally.
MMR – For healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP born prior to 1957, see below. Give subcutaneously (Subcut).
Varicella (chickenpox) – For HCP who have no serologic proof of immunity, prior vaccination, or diagnosis or verification of a history of varicella or herpes zoster (shingles) by a healthcare provider, give 2 doses of varicella vaccine, 4 weeks apart. Give Subcut.
Tetanus, diphtheria, pertussis – Give 1 dose of Tdap as soon as feasible to all HCP who have not received Tdap previously and to pregnant HCP with each pregnancy (see below). Give Td boosters every 10 years thereafter. Give IM.
Meningococcal – Give both MenACWY and MenB to microbiologists who are routine-ly exposed to isolates of Neisseria meningitidis. Every 5 years boost with MenACWY if risk continues. Give MenACWY and MenB IM.
Hepatitis A, typhoid, and polio vaccines are not routinely recommended for HCP who may have on-the-job exposure to fecal material.
Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.orgTechnical content reviewed by the Centers for Disease Control and Prevention
www.immunize.org/catg.d/p2017.pdf • Item #P2017 (3/18)
Hepatitis BUnvaccinated healthcare personnel (HCP) and/or those who cannot document previous vac-cination should receive either a 2-dose series of Heplisav-B at 0 and 1 month or a 3-dose series of either Engerix-B or Recombivax HB at 0, 1, and 6 months. HCP who perform tasks that may involve exposure to blood or body fluids should be tested for hepatitis B surface anti-body (anti-HBs) 1–2 months after dose #2 of Heplisav-B or dose #3 of Engerix-B or Recom-bivax HB to document immunity.
• If anti-HBs is at least 10 mIU/mL (positive), the vaccinee is immune. No further serologic testing or vaccination is recommended.
• If anti-HBs is less than 10 mIU/mL (negative), the vaccinee is not protected from hepatitis B virus (HBV) infection, and should receive another 2-dose or 3-dose series of HepB vaccine on the routine schedule, followed by anti-HBs testing 1–2 months later. A vaccinee whose anti-HBs remains less than 10 mIU/mL after 2 complete series is considered a “non-responder.”
For non-responders: HCP who are non-responders should be considered susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-positive blood or blood with unknown HBsAg status. It is also possible that non-responders are people who are HBsAg positive. HBsAg testing is recommended. HCP found
to be HBsAg positive should be counseled and medically evaluated.
For HCP with documentation of a complete 2-dose (Heplisav-B) or 3-dose (Engerix-B or Re-combivax HB) vaccine series but no documen-tation of anti-HBs of at least 10 mIU/mL (e.g., those vaccinated in childhood): HCP who are at risk for occupational blood or body fluid expo- sure might undergo anti-HBs testing upon hire or matriculation. See references 2 and 3 for details.
Influenza All HCP, including physicians, nurses, paramedics, emergency medical technicians, employees of nursing homes and chronic care facilities, students in these professions, and volunteers, should receive annual vaccination against influ-enza. Live attenuated influenza vaccine (LAIV) may be given only to non-pregnant healthy HCP age 49 years and younger. Inactivated injectable influenza vaccine (IIV) is preferred over LAIV for HCP who are in close contact with severely immunosuppressed patients (e.g., stem cell transplant recipients) when they require protec-tive isolation.
Measles, Mumps, Rubella (MMR)HCP who work in medical facilities should be immune to measles, mumps, and rubella.
• HCP born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation of disease or immunity or (b) appropriate vaccination against measles, mumps, and rubella (i.e., 2 doses of live
measles and mumps vaccines given on or after the first birthday and separated by 28 days or more, and at least 1 dose of live rubella vaccine). HCP with 2 documented doses of MMR are not recommended to be serologically tested for immunity; but if they are tested and results are negative or equivocal for measles, mumps, and/or rubella, these HCP should be considered to have presumptive evidence of immunity to measles, mumps, and/or rubella and are not in need of additional MMR doses.
• Although birth before 1957 generally is con- sidered acceptable evidence of measles, mumps, and rubella immunity, 2 doses of MMR vaccine should be considered for unvacci-nated HCP born before 1957 who do not have laboratory evidence of disease or immunity to measles and/or mumps. One dose of MMR vaccine should be considered for HCP with no laboratory evidence of disease or immunity to rubella. For these same HCP who do not have evidence of immunity, 2 doses of MMR vaccine are recommended during an outbreak of measles or mumps and 1 dose during an outbreak of rubella.
Varicella It is recommended that all HCP be immune to varicella. Evidence of immunity in HCP includes documentation of 2 doses of varicella vaccine given at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or diagnosis or verification of a history of vari-cella or herpes zoster (shingles) by a healthcare provider.
Tetanus/Diphtheria/Pertussis (Td/Tdap)All HCPs who have not or are unsure if they have previously received a dose of Tdap should receive a dose of Tdap as soon as feasible, with- out regard to the interval since the previous dose of Td. Pregnant HCP should be revaccinated during each pregnancy. All HCPs should then receive Td boosters every 10 years thereafter.
MeningococcalVaccination with MenACWY and MenB is recommended for microbiologists who are routinely exposed to isolates of N. meningitidis. The two vaccines may be given concomitantly but at different anatomic sites, if feasible.
references1 CDC. Immunization of Health-Care Personnel: Recom-
mendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).
2 CDC. Prevention of Hepatitis B Virus Infection in the Unit-ed States. Recommendations of the Advisory Committee on Immunization Practices. MMWR, 2018; 67(RR1):1–30.
3 IAC. Pre-exposure Management for Healthcare Personnel with a Documented Hepatitis B Vaccine Series Who Have Not Had Post-vaccination Serologic Testing. Accessed at www.immunize.org/catg.d/p2108.pdf.
For additional specific ACIP recommendations, visit CDC’s website at www.cdc.gov/vaccines/hcp/acip-recs/index.html or visit IAC’s website at www.immunize.org/acip.
Healthcare Personnel Vaccination Recommendationsvaccines and recommendations in brief
Hepatitis B – If previously unvaccinated, give a 2-dose (Heplisav-B) or 3-dose (Engerix-B or Recombivax HB) series. Give intramuscularly (IM). For HCP who perform tasks that may involve exposure to blood or body fluids, obtain anti-HBs serologic testing 1–2 months after dose #2 (for Heplisav-B) or dose #3 (for Engerix-B or Recombivax HB).
Influenza – Give 1 dose of influenza vaccine annually. Inactivated injectable vaccine is given IM, except when using the intradermal influenza vaccine. Live attenuated influenza vaccine (LAIV) is given intranasally.
MMR – For healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP born prior to 1957, see below. Give subcutaneously (Subcut).
Varicella (chickenpox) – For HCP who have no serologic proof of immunity, prior vaccination, or diagnosis or verification of a history of varicella or herpes zoster (shingles) by a healthcare provider, give 2 doses of varicella vaccine, 4 weeks apart. Give Subcut.
Tetanus, diphtheria, pertussis – Give 1 dose of Tdap as soon as feasible to all HCP who have not received Tdap previously and to pregnant HCP with each pregnancy (see below). Give Td boosters every 10 years thereafter. Give IM.
Meningococcal – Give both MenACWY and MenB to microbiologists who are routine-ly exposed to isolates of Neisseria meningitidis. Every 5 years boost with MenACWY if risk continues. Give MenACWY and MenB IM.
Hepatitis A, typhoid, and polio vaccines are not routinely recommended for HCP who may have on-the-job exposure to fecal material.
Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.orgTechnical content reviewed by the Centers for Disease Control and Prevention
www.immunize.org/catg.d/p2017.pdf • Item #P2017 (3/18)
121
5.2 113Forms & Checklists for Infection Prevention, Volume 2
3-5. Checklist for Bloodborne Pathogens Training Content
Date: Reviewer:
Note “Yes” or “No” as to if required content is included in training
Subject matter to include:
Epidemiology, symptoms, and transmission of bloodborne pathogen diseases
A copy and explanation of the OSHA bloodborne pathogen standard
An explanation of our ECP and how to obtain a copy
An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident
An explanation of the use and limitations of engineering controls, work practices, and PPE
An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE
An explanation of the basis for PPE selection
Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge
Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM
An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available
Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident
An explanation of the signs and labels and/or color coding required by the standard and used at this facility
An opportunity for interactive questions and answers with the person conducting the training session.
Comments:
Reference
Debbie Hurst, RN, BSN, CIC
113Forms & Checklists for Infection Prevention, Volume 2
3-5. Checklist for Bloodborne Pathogens Training Content
Date: Reviewer:
Note “Yes” or “No” as to if required content is included in training
Subject matter to include:
Epidemiology, symptoms, and transmission of bloodborne pathogen diseases
A copy and explanation of the OSHA bloodborne pathogen standard
An explanation of our ECP and how to obtain a copy
An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident
An explanation of the use and limitations of engineering controls, work practices, and PPE
An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE
An explanation of the basis for PPE selection
Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge
Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM
An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available
Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident
An explanation of the signs and labels and/or color coding required by the standard and used at this facility
An opportunity for interactive questions and answers with the person conducting the training session.
Comments:
Reference
Debbie Hurst, RN, BSN, CIC
113Forms & Checklists for Infection Prevention, Volume 2
3-5. Checklist for Bloodborne Pathogens Training Content
Date: Reviewer:
Note “Yes” or “No” as to if required content is included in training
Subject matter to include:
Epidemiology, symptoms, and transmission of bloodborne pathogen diseases
A copy and explanation of the OSHA bloodborne pathogen standard
An explanation of our ECP and how to obtain a copy
An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident
An explanation of the use and limitations of engineering controls, work practices, and PPE
An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE
An explanation of the basis for PPE selection
Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge
Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM
An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available
Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident
An explanation of the signs and labels and/or color coding required by the standard and used at this facility
An opportunity for interactive questions and answers with the person conducting the training session.
Comments:
Reference
Debbie Hurst, RN, BSN, CIC
113Forms & Checklists for Infection Prevention, Volume 2
3-5. Checklist for Bloodborne Pathogens Training Content
Date: Reviewer:
Note “Yes” or “No” as to if required content is included in training
Subject matter to include:
Epidemiology, symptoms, and transmission of bloodborne pathogen diseases
A copy and explanation of the OSHA bloodborne pathogen standard
An explanation of our ECP and how to obtain a copy
An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident
An explanation of the use and limitations of engineering controls, work practices, and PPE
An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE
An explanation of the basis for PPE selection
Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge
Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM
An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available
Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident
An explanation of the signs and labels and/or color coding required by the standard and used at this facility
An opportunity for interactive questions and answers with the person conducting the training session.
Comments:
Reference
Debbie Hurst, RN, BSN, CIC 122
5.3 115Forms & Checklists for Infection Prevention, Volume 2
3-7. Sharps Injury Log
Incident Date Incident ID # Device Type Device Brand Incident Location
Brief Description of Incident
29 CFR 1910.1030, OSHA’s Bloodborne Pathogens Standard, in paragraph (h)(5), requires an employer to establish and maintain a Sharps Injury Log for recording all percutaneous injuries in a facility occurring from contaminated sharps. The purpose of the Log is to aid in the evaluation of devices being used in healthcare and other facilities and to identify problem devices or procedures requiring additional attention or review. This log must be kept in addition to the injury and illness log required by 29 CFR 1904.The Sharps Injury Log should include all sharps injuries occurring in a calendar year. The log must be retained for five years following the end of the year to which it relates. The Log must be kept in a manner that preserves the confidentiality of the affected employee.
Reference
George Allen, RN, PhD, FAPIC, CIC, CNOR
Year:
115Forms & Checklists for Infection Prevention, Volume 2
3-7. Sharps Injury Log
Incident Date Incident ID # Device Type Device Brand Incident Location
Brief Description of Incident
29 CFR 1910.1030, OSHA’s Bloodborne Pathogens Standard, in paragraph (h)(5), requires an employer to establish and maintain a Sharps Injury Log for recording all percutaneous injuries in a facility occurring from contaminated sharps. The purpose of the Log is to aid in the evaluation of devices being used in healthcare and other facilities and to identify problem devices or procedures requiring additional attention or review. This log must be kept in addition to the injury and illness log required by 29 CFR 1904.The Sharps Injury Log should include all sharps injuries occurring in a calendar year. The log must be retained for five years following the end of the year to which it relates. The Log must be kept in a manner that preserves the confidentiality of the affected employee.
Reference
George Allen, RN, PhD, FAPIC, CIC, CNOR
Year:
115Forms & Checklists for Infection Prevention, Volume 2
3-7. Sharps Injury Log
Incident Date Incident ID # Device Type Device Brand Incident Location
Brief Description of Incident
29 CFR 1910.1030, OSHA’s Bloodborne Pathogens Standard, in paragraph (h)(5), requires an employer to establish and maintain a Sharps Injury Log for recording all percutaneous injuries in a facility occurring from contaminated sharps. The purpose of the Log is to aid in the evaluation of devices being used in healthcare and other facilities and to identify problem devices or procedures requiring additional attention or review. This log must be kept in addition to the injury and illness log required by 29 CFR 1904.The Sharps Injury Log should include all sharps injuries occurring in a calendar year. The log must be retained for five years following the end of the year to which it relates. The Log must be kept in a manner that preserves the confidentiality of the affected employee.
Reference
George Allen, RN, PhD, FAPIC, CIC, CNOR
Year:
115Forms & Checklists for Infection Prevention, Volume 2
3-7. Sharps Injury Log
Incident Date Incident ID # Device Type Device Brand Incident Location
Brief Description of Incident
29 CFR 1910.1030, OSHA’s Bloodborne Pathogens Standard, in paragraph (h)(5), requires an employer to establish and maintain a Sharps Injury Log for recording all percutaneous injuries in a facility occurring from contaminated sharps. The purpose of the Log is to aid in the evaluation of devices being used in healthcare and other facilities and to identify problem devices or procedures requiring additional attention or review. This log must be kept in addition to the injury and illness log required by 29 CFR 1904.The Sharps Injury Log should include all sharps injuries occurring in a calendar year. The log must be retained for five years following the end of the year to which it relates. The Log must be kept in a manner that preserves the confidentiality of the affected employee.
Reference
George Allen, RN, PhD, FAPIC, CIC, CNOR
Year:
123
5.4Forms & Checklists for Infection Prevention, Volume 2116
3-8. Employee Training Record
Training SubjectDate
CommentsTrained Retrained
Employee’s Signature Date Supervisor’s Signature Date
Reference
OSHA, https://www.osha.gov/SLTC/etools/safetyhealth/employeetrainingrec.pdf
Name of employee:
Employee number:
Department:
Job title:
I have received and understood the safety and health training listed above and acknowledge that it has
been given to me.
Forms & Checklists for Infection Prevention, Volume 2116
3-8. Employee Training Record
Training SubjectDate
CommentsTrained Retrained
Employee’s Signature Date Supervisor’s Signature Date
Reference
OSHA, https://www.osha.gov/SLTC/etools/safetyhealth/employeetrainingrec.pdf
Name of employee:
Employee number:
Department:
Job title:
I have received and understood the safety and health training listed above and acknowledge that it has
been given to me.
Forms & Checklists for Infection Prevention, Volume 2116
3-8. Employee Training Record
Training SubjectDate
CommentsTrained Retrained
Employee’s Signature Date Supervisor’s Signature Date
Reference
OSHA, https://www.osha.gov/SLTC/etools/safetyhealth/employeetrainingrec.pdf
Name of employee:
Employee number:
Department:
Job title:
I have received and understood the safety and health training listed above and acknowledge that it has
been given to me.
Forms & Checklists for Infection Prevention, Volume 2116
3-8. Employee Training Record
Training SubjectDate
CommentsTrained Retrained
Employee’s Signature Date Supervisor’s Signature Date
Reference
OSHA, https://www.osha.gov/SLTC/etools/safetyhealth/employeetrainingrec.pdf
Name of employee:
Employee number:
Department:
Job title:
I have received and understood the safety and health training listed above and acknowledge that it has
been given to me.
124
5.52-6. Injection Safety Competency
Injection Safety Competency Validation
PointofCareTesting
Typeofvalidation:Returndemonstration
Orientation
Annual
Other
EmployeeName: JobTitle:
Medication PreparationCompetent
N/AYES NO
1. Performhandhygienepriortopreparingoradministering
medications
2. Injectionsarepreparedusingaseptictechniqueinacleararea
freefromcontaminationorcontactwithblood,bodyfluids,or
contaminatedequipment
3. Needlesandsyringesareusedforonlyonepatient(this
includesmanufacturedprefilledsyringesandcartridge
devices)
4. Rubberseptumonmedicationvialisdisinfectedwithalcohol
priortopiercing
5. Medicationvialsareenteredwithanewneedleandnew
syringe,evenwhenobtainingadditionaldosesforsame
patient
6. Single-doseorsingle-usemedicationvials,ampules,and
bags/bottlesofintravenoussolutionareusedforonlyone
patient
7. Medicationadministrationtubingandconnectorsareusedfor
onlyonepatient
8. Multi-dosevialsaredatedwhenfirstopenedanddiscarded
within28daysunlessmanufacturerspecifiesadifferent
(shorterorlonger)dateforthatopenedvial
9. Multi-dosevialsarededicatedtoindividualpatientswhenever
possible(e.g.,insulinvials,lidocaine,etc.)
10.Multi-dosevialstobeusedformorethanonepatientare
keptinacentralizedmedicationareaanddonotenterthe
immediatepatienttreatmentarea(e.g.,operatingroom,
patientroom/cubicle)
11. Insulinpensdedicatedtoonlyonepatient
12.Medicationisadministeredwithin1hourofpreparation
Forms & Checklists for Infection Prevention, Volume 1 69
2-6. Injection Safety Competency
Injection Safety Competency Validation
PointofCareTesting
Typeofvalidation:Returndemonstration
Orientation
Annual
Other
EmployeeName: JobTitle:
Medication PreparationCompetent
N/AYES NO
1. Performhandhygienepriortopreparingoradministering
medications
2. Injectionsarepreparedusingaseptictechniqueinacleararea
freefromcontaminationorcontactwithblood,bodyfluids,or
contaminatedequipment
3. Needlesandsyringesareusedforonlyonepatient(this
includesmanufacturedprefilledsyringesandcartridge
devices)
4. Rubberseptumonmedicationvialisdisinfectedwithalcohol
priortopiercing
5. Medicationvialsareenteredwithanewneedleandnew
syringe,evenwhenobtainingadditionaldosesforsame
patient
6. Single-doseorsingle-usemedicationvials,ampules,and
bags/bottlesofintravenoussolutionareusedforonlyone
patient
7. Medicationadministrationtubingandconnectorsareusedfor
onlyonepatient
8. Multi-dosevialsaredatedwhenfirstopenedanddiscarded
within28daysunlessmanufacturerspecifiesadifferent
(shorterorlonger)dateforthatopenedvial
9. Multi-dosevialsarededicatedtoindividualpatientswhenever
possible(e.g.,insulinvials,lidocaine,etc.)
10.Multi-dosevialstobeusedformorethanonepatientare
keptinacentralizedmedicationareaanddonotenterthe
immediatepatienttreatmentarea(e.g.,operatingroom,
patientroom/cubicle)
11. Insulinpensdedicatedtoonlyonepatient
12.Medicationisadministeredwithin1hourofpreparation
Forms & Checklists for Infection Prevention, Volume 1 69
125
Point of Care Testing (e.g., glucometer, PT/INR)Competent
N/AYES NO
13.Performhandhygiene
14.Dongloves
15.Single-use,auto-disablingfingerstickdeviceusedforone
patientonly&discardedintosharpscontainer
16.Individualpatientdedicatedglucometer(preferred)is
storedtoavoidcross-contaminationandinadvertentuseon
additionalpatients(ideally,inthepatientroom)—bestpractice
istoclean/disinfectpriortostoragepermanufacturer’s
instructions
17.Sharedglucometers/equipmentmustbecleanedand
disinfectedaftereveryusepermanufacturer’sinstructions
(ifthemanufacturerdoesnotspecifyhowthedeviceshould
becleanedanddisinfected,thenitshouldnotbeshared)
18.Glovesremoved
19.Handhygieneperformed
Comments or follow up actions:
EmployeeSignature
ValidatorSignature /Date
References CDCathttp://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html
OneandOnlyCampaignathttp://www.oneandonlycampaign.org/ NCSPICE;9-2016
Forms & Checklists for Infection Prevention, Volume 170
126
Module 6
Construction and Water Management
Contents
6.1 Infection Control Risk Assessment (ICRA) Matrix of Precautions for Construction & Renovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128https://apic .org/Resource_/TinyMceFileManager/Education/ASC_Intensive/Resources_Page/ICRA_Risk_Assessment_for_Construction_and_Renovation .pdf
6.2 What Clinicians need to know about Legionnaires disease . . . . . . . . . . . . . . . . . . . . . . . . . 134Centers for Disease Control (CDC)https://www .cdc .gov/legionella/downloads/fs-legionella-clinicians .pdf
6.3 Healthcare Facility Water Management Program Checklist . . . . . . . . . . . . . . . . . . . . . . . . . 135CDChttps://www .cdc .gov/HAI/pdfs/Water-Management-Checklist-P .pdf
Resources
Environmental Infection Control guidelinesCDChttps://www .cdc .gov/infectioncontrol/guidelines/environmental/index .html#anchor_ 1556902049
Infection Prevention Manual for Construction & Renovation Association for Professionals in Infection Control and Epidemiology (APIC)https://rise .apic .org/WEB/ItemDetail?iProductCode=SLS9808&Category=BOOKS
Guidelines for Design and Construction of Outpatient FacilitiesFacility Guidelines Institutehttps://www .fgiguidelines .org/guidelines/2018-fgi-guidelines/
ANSI/ASHRAE Standard 188:2018, Legionellosis: Risk Management for Building Water SystemsAmerican Society of Heating, Refrigerating, and Air Conditioning Engineershttps://www .ashrae .org/technical-resources/bookstore/ansi-ashrae-standard-188-2018-legio-nellosis-risk-management-for-building-water-systems
ANSI/ASHRAE Standard 188-2018 for Legionnaires’ Disease Risk ManagementAmerican National Standards Institute (ANSI) bloghttps://blog .ansi .org/2018/09/ansi-ashrae-standard-188-2018-legionnaires/#gref
Legionella CDChttps://www .cdc .gov/legionella/clinicians .html
127
Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. [email protected] Updated, 2009.
Infection Control Risk AssessmentMatrix of Precautions for Construction & Renovation
Step One:Using the following table, identify the Type of Construction Project Activity (Type A-D)
TYPE A
Inspection and Non-Invasive Activities.Includes, but is not limited to:
removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feetpainting (but not sanding) wallcovering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.
TYPE B
Small scale, short duration activities which create minimal dustIncludes, but is not limited to:
installation of telephone and computer cabling access to chase spaces cutting of walls or ceiling where dust migration can be controlled.
TYPE C
Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies Includes, but is not limited to:
sanding of walls for painting or wall covering removal of floorcoverings, ceiling tiles and casework new wall construction minor duct work or electrical work above ceilings major cabling activities any activity which cannot be completed within a single workshift.
TYPE D
Major demolition and construction projectsIncludes, but is not limited to:
activities which require consecutive work shifts requires heavy demolition or removal of a complete cabling system new construction.
Step 1: _________________________________________________________
6.1
Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. [email protected] Updated, 2009.
Infection Control Risk AssessmentMatrix of Precautions for Construction & Renovation
Step One:Using the following table, identify the Type of Construction Project Activity (Type A-D)
TYPE A
Inspection and Non-Invasive Activities.Includes, but is not limited to:
removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feetpainting (but not sanding) wallcovering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.
TYPE B
Small scale, short duration activities which create minimal dustIncludes, but is not limited to:
installation of telephone and computer cabling access to chase spaces cutting of walls or ceiling where dust migration can be controlled.
TYPE C
Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies Includes, but is not limited to:
sanding of walls for painting or wall covering removal of floorcoverings, ceiling tiles and casework new wall construction minor duct work or electrical work above ceilings major cabling activities any activity which cannot be completed within a single workshift.
TYPE D
Major demolition and construction projectsIncludes, but is not limited to:
activities which require consecutive work shifts requires heavy demolition or removal of a complete cabling system new construction.
Step 1: _________________________________________________________
128
Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. [email protected] Updated, 2009.
Step Two: Using the following table, identify the Patient Risk Groups that will be affected.If more than one risk group will be affected, select the higher risk group:
Low Risk Medium Risk High Risk Highest Risk Officeareas
CardiologyEchocardiographyEndoscopyNuclear Medicine Physical Therapy Radiology/MRIRespiratoryTherapy
CCUEmergency Room Labor & Delivery Laboratories(specimen) Medical Units Newborn Nursery Outpatient Surgery PediatricsPharmacy Post Anesthesia Care UnitSurgical Units
Any area caring for immunocompromised patients Burn Unit Cardiac Cath Lab Central Sterile Supply Intensive Care Units Negative pressure isolation rooms OncologyOperating rooms including C-section rooms
Step 2__________________________________________________________Step Three: Match the
Patient Risk Group (Low, Medium, High, Highest) with the planned … Construction Project Type (A, B, C, D) on the following matrix, to find the …Class of Precautions (I, II, III or IV) or level of infection control activities required.Class I-IV or Color-Coded Precautions are delineated on the following page.
IC Matrix - Class of Precautions: Construction Project by Patient Risk
Construction Project Type Patient Risk Group TTYYPPEE AA TTYYPPEE BB TTYYPPEE CC TTYYPPEE DD
LLOOWW Risk Group II IIII IIII IIIIII//IIVVMMEEDDIIUUMM Risk Group II IIII IIIIII IIVVHHIIGGHH Risk Group II IIII IIIIII//IIVV IIVVHHIIGGHHEESSTT Risk Group IIII IIIIII//IIVV IIIIII//IIVV IIVVNote: Infection Control approval will be required when the Construction Activity and Risk Level indicate that CCllaassss IIIIII or CCllaassss IIVV control procedures are necessary.
Step 3 ______________________________________________________
Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. [email protected] Updated, 2009.
Infection Control Risk AssessmentMatrix of Precautions for Construction & Renovation
Step One:Using the following table, identify the Type of Construction Project Activity (Type A-D)
TYPE A
Inspection and Non-Invasive Activities.Includes, but is not limited to:
removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feetpainting (but not sanding) wallcovering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.
TYPE B
Small scale, short duration activities which create minimal dustIncludes, but is not limited to:
installation of telephone and computer cabling access to chase spaces cutting of walls or ceiling where dust migration can be controlled.
TYPE C
Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies Includes, but is not limited to:
sanding of walls for painting or wall covering removal of floorcoverings, ceiling tiles and casework new wall construction minor duct work or electrical work above ceilings major cabling activities any activity which cannot be completed within a single workshift.
TYPE D
Major demolition and construction projectsIncludes, but is not limited to:
activities which require consecutive work shifts requires heavy demolition or removal of a complete cabling system new construction.
Step 1: _________________________________________________________
129
Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. [email protected] Updated, 2009.
Description of Required Infection Control Precautions by ClassDuring Construction Project Upon Completion of Project
CLA
SS I 1. Execute work by methods to minimize raising dust
from construction operations. 2. Immediately replace a ceiling tile displaced for
visual inspection
1. Clean work area upon completion of task.
CLA
SS II
1. Provide active means to prevent airborne dust from dispersing into atmosphere.
2. Water mist work surfaces to control dust while cutting.
3. Seal unused doors with duct tape. 4. Block off and seal air vents. 5. Place dust mat at entrance and exit of work area 6. Remove or isolate HVAC system in areas where
work is being performed.
1. Wipe work surfaces with cleaner/disinfectant. 2. Contain construction waste before transport in
tightly covered containers. 3. Wet mop and/or vacuum with HEPA filtered
vacuum before leaving work area. 4. Upon completion, restore HVAC system
where work was performed.
CLA
SS II
I
1. Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system.
2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.
3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.
4. Contain construction waste before transport in tightly covered containers.
5. Cover transport receptacles or carts. Tape covering unless solid lid.
1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Prevention & Control Department and thoroughly cleaned by the owner’s Environmental Services Department.
2. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.
3. Vacuum work area with HEPA filtered vacuums.
4. Wet mop area with cleaner/disinfectant. 5. Upon completion, restore HVAC system
where work was performed.
CLA
SS IV
1. Isolate HVAC system in area where work is being done to prevent contamination of duct system.
2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.
3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.
4. Seal holes, pipes, conduits, and punctures. 5. Construct anteroom and require all personnel to
pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave work site.
6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area.
1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Prevention & Control Department and thoroughly cleaned by the owner’s Environmental Services Dept.
2. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.
3. Contain construction waste before transport in tightly covered containers.
4. Cover transport receptacles or carts. Tape covering unless solid lid.
5. Vacuum work area with HEPA filtered vacuums.
6. Wet mop area with cleaner/disinfectant. 7. Upon completion, restore HVAC system
where work was performed.
Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. [email protected] Updated, 2009.
Infection Control Risk AssessmentMatrix of Precautions for Construction & Renovation
Step One:Using the following table, identify the Type of Construction Project Activity (Type A-D)
TYPE A
Inspection and Non-Invasive Activities.Includes, but is not limited to:
removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feetpainting (but not sanding) wallcovering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.
TYPE B
Small scale, short duration activities which create minimal dustIncludes, but is not limited to:
installation of telephone and computer cabling access to chase spaces cutting of walls or ceiling where dust migration can be controlled.
TYPE C
Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies Includes, but is not limited to:
sanding of walls for painting or wall covering removal of floorcoverings, ceiling tiles and casework new wall construction minor duct work or electrical work above ceilings major cabling activities any activity which cannot be completed within a single workshift.
TYPE D
Major demolition and construction projectsIncludes, but is not limited to:
activities which require consecutive work shifts requires heavy demolition or removal of a complete cabling system new construction.
Step 1: _________________________________________________________
130
Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. [email protected] Updated, 2009.
Step 4. Identify the areas surrounding the project area, assessing potential impact
Unit Below Unit Above Lateral Lateral Behind Front
Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group
Step 5. Identify specific site of activity e.g., patient rooms, medication room, etc. __________________________________________________________________
Step 6. Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages.__________________________________________________________________
Step 7. Identify containment measures, using prior assessment. What types of barriers? (E.g., solids wall barriers); Will HEPA filtration be required?
_________________________________________________________________(Note: Renovation/construction area shall be isolated from the occupied areas during construction and shall be
negative with respect to surrounding areas)
Step 8. Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (e.g., wall, ceiling, roof)
Step 9. Work hours: Can or will the work be done during non-patient care hours?
Step 10. Do plans allow for adequate number of isolation/negative airflow rooms?
Step 11. Do the plans allow for the required number & type of handwashing sinks?
Step 12. Does the infection prevention & control staff agree with the minimum number of sinks for this project? (Verify against FGI Design and Construction Guidelines for types and area)
Step 13. Does the infection prevention & control staff agree with the plans relative to clean and soiled utility rooms?
Step 14. Plan to discuss the following containment issues with the project team. E.g., traffic flow, housekeeping, debris removal (how and when),
___________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Identify and communicate the responsibility for project monitoring that includes infection prevention & control concerns and risks. The ICRA may be modified throughout the project.
Revisions must be communicated to the Project Manager.
131
Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX. Form modified /updated & provided courtesy of Judene Bartley, ECSI Inc Beverly Hills MI 2002. [email protected], 2009
5
Infection Control Construction Permit Permit No:
Location of Construction: Project Start Date: Project Coordinator: Estimated Duration: Contractor Performing Work Permit Expiration Date: Supervisor: Telephone:YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP
TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk TYPE B: Small scale, short duration, moderate to high levels
GROUP 2: Medium Risk
TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion
GROUP 3: Medium/High Risk
TYPE D: Major duration and construction activities Requiring consecutive work shifts
GROUP 4: Highest Risk
CLASS I 1. Execute work by methods to minimize raising dust from construction operations.
2. Immediately replace any ceiling tile displaced for visual inspection.
3. Minor Demolition for Remodeling
CLASS II 1. Provides active means to prevent air-borne dust from dispersing into atmosphere
2. Water mist work surfaces to control dust while cutting. 3. Seal unused doors with duct tape. 4. Block off and seal air vents. 5. Wipe surfaces with cleaner/disinfectant.
6. Contain construction waste before transport in tightly covered containers.
7. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.
8. Place dust mat at entrance and exit of work area. 9. Isolate HVAC system in areas where work is being
performed; restore when work completed.
CLASS III 1. Obtain infection control permit before construction begins. 2. Isolate HVAC system in area where work is being done to
prevent contamination of the duct system. 3. Complete all critical barriers or implement control cube
method before construction begins.
6. Vacuum work with HEPA filtered vacuums. 7. Wet mop with cleaner/disinfectant 8. Remove barrier materials carefully to minimize
spreading of dirt and debris associated with construction.
9. Contain construction waste before transport in Date
Initial
4. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.
5. Do not remove barriers from work area until complete project is checked by Infection Prevention & Control and thoroughly cleaned by Environmental Services.
tightly covered containers. 10. Cover transport receptacles or carts. Tape covering. 11. Upon completion, restore HVAC system where work
was performed.
CLASS IV
Date
Initial
1. Obtain infection control permit before construction begins. 2. Isolate HVAC system in area where work is being done to
prevent contamination of duct system. 3. Complete all critical barriers or implement control cube
method before construction begins. 4. Maintain negative air pressure within work site utilizing
HEPA equipped air filtration units. 5. Seal holes, pipes, conduits, and punctures appropriately. 6. Construct anteroom and require all personnel to pass
through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave the work site.
7. All personnel entering work site are required to wear shoe covers.
8. Do not remove barriers from work area until completed project is checked by Infection Prevention & Control and thoroughly cleaned by Environmental. Services.
9. Vacuum work area with HEPA filtered vacuums. 10. Wet mop with disinfectant. 11. Remove barrier materials carefully to minimize
spreading of dirt and debris associated with construction.
12. Contain construction waste before transport in tightly covered containers.
13. Cover transport receptacles or carts. Tape covering. 14. Upon completion, restore HVAC system where work
was performed.
Additional Requirements:
___________Date Initials
___________ Exceptions/Additions to this permit Date Initials are noted by attached memoranda
Permit Request By: Permit Authorized By:
Date: Date:
132
What Clinicians Need to Know about
LEGIONNAIRES’ DISEASE
Legionnaires’ disease is a sometimes fatal form of pneumonia that is on the rise in the United States. Unfortunately, this disease is also underrecognized and underdiagnosed. Clinicians are in a unique position to make sure cases are detected, allowing rapid investigation by public health officials and prevention of additional cases.
Diagnosis and TestingClinical features of Legionnaires’ disease include cough, fever, and radiographic pneumonia. Signs and symptoms for Legionnaires’ disease are similar to pneumonia caused by other pathogens; the only way to tell if a pneumonia patient has Legionnaires’ disease is by getting a specific diagnostic test. Indications that warrant testing include:
• Patients who have failed outpatient antibiotic therapy for community-acquired pneumonia
• Patients with severe pneumonia, in particular those requiring intensive care
• Immunocompromised patients with pneumonia*
• Patients with a travel history (patients who have traveled away from their home within 10 days before the onset of illness)
• All patients with pneumonia in the setting of a Legionnaires’ disease outbreak
• Patients at risk for Legionnaires’ disease with healthcare-associated pneumonia (pneumonia with onset ≥48 hours after admission)
* Clinicians may also consider testing for Legionnaires’ disease in patients with other risk factors for this infection (see page 2).
Testing for healthcare-associated Legionnaires’ disease is especially important if any of the following are identified in your facility:
• Other patients with healthcare-associated Legionnaires’ disease diagnosed in the past 12 months
• Positive environmental tests for Legionella in the past 2 months
• Current changes in water quality that may lead to Legionella growth (such as low chlorine levels)
Infection control staff may have more information about these situations in your facility.
The preferred diagnostic tests for Legionnaires’ disease are culture of lower respiratory secretions (e.g., sputum, bronchoalveolar lavage) on selective media and the Legionella urinary antigen test. Serological assays can be nonspecific and are not recommended in most situations. Best practice is to obtain both sputum culture and a urinary antigen test concurrently. Sputum should ideally be obtained prior to antibiotic administration, but antibiotic treatment should not be delayed to facilitate this process. The urinary antigen test can detect Legionella infections in some cases for days to weeks after treatment. The urinary antigen test detects Legionella pneumophila serogroup 1, the most common cause of Legionnaires’ disease; isolation of Legionella by culture is important for detection of other species and serogroups and for public health investigation. Molecular techniques can be used to compare clinical isolates to environmental isolates and confirm the outbreak source.
Order both a culture of a lower respiratory specimen and a urinary antigen test when testing patients for Legionella.
In the United States, reported cases of Legionnaires’ disease have grown by nearly four and a half times since 2000. More than 6,000 cases of Legionnaires’ disease were reported in 2015, but this number is likely an underestimate as the illness is thought to be underdiagnosed.
More illness occurs in the summer and early fall, but Legionnaires’ disease can happen any time of year.
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
Inci
den
ce (c
ases
/100
,000
po
pul
atio
n)
Year
0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
*National Notifiable Diseases Surveillance System
Legionnaires’ Disease Is On the Rise2000–2015*
6.2
133
TreatmentIf your patient has Legionnaires’ disease, see the most recent guidelines for treatment of community-acquired pneumonia (http://bit.ly/CommunityPneumonia) and hospital-acquired pneumonia (http://bit.ly/HospitalPneumonia). Macrolides and respiratory fluoroquinolones are currently the preferred agents for treating Legionnaires’ disease.
ReportingMake sure your infection control department or lab are promptly reporting cases of Legionnaires’ disease to your local health department. Timely identification and reporting of cases is important, as this allows public health officials to quickly identify and stop potential clusters and outbreaks by linking new cases to previously reported ones.
EtiologyLegionnaires’ disease is a severe form of pneumonia that often requires hospitalization and is fatal in about 10% of cases overall, and in 25% of healthcare-associated cases. Legionnaires’ disease is caused by Legionella bacteria. There are at least 60 different species of Legionella, and most are considered capable of causing disease. However, most disease is caused by L. pneumophila, particularly serogroup 1.
TransmissionWhile Legionella is found in natural, freshwater environments, it can become a health concern in human-made water systems (e.g., plumbing system of large buildings, cooling towers, certain medical devices, decorative fountains, hot tubs) where conditions allow it to multiply and come in contact with vulnerable persons. People contract Legionella by inhaling aerosolized water droplets containing the bacteria, or, less commonly, by aspiration of contaminated drinking water. Legionella is usually not transmitted from person to person; however, a single episode of person-to-person transmission has been reported. Fortunately, most people exposed to the bacteria do not become ill.
Risk FactorsRisk factors for developing Legionnaires’ disease include:
• Age ≥50 years
• Smoking (current or historical)
• Chronic lung disease, such as emphysema or COPD
• Immune system disorders due to disease or medication
• Systemic malignancy
• Underlying illness, such as diabetes, renal failure, or hepatic failure
PreventionThe key to preventing Legionnaires’ disease is maintenance of the water systems in which Legionella may grow. If Legionella is found in a healthcare facility’s water system, the facility should work to eliminate the bacteria. CDC encourages all building owners, and especially those in healthcare facilities, to develop comprehensive water management programs to reduce the risk of Legionella growth and spread. Learn more about how to develop a water management program at www.cdc.gov/legionella/WMPtoolkit.
Timely reporting of Legionnaires’ disease cases is important for controlling clusters and outbreaks.
Commons Sources of InfectionOutbreaks of Legionnaires’ disease are most often associated with large or complex water systems, like those found in hospitals, long-term care facilities, hotels, and cruise ships.
The most likely sources of infection include:
Water used for showering (potable water)
Cooling towers (parts of large air conditioning systems)
Decorative fountains
Hot tubs
cdc.gov/legionella | CS278126-A 05/15/2017134
Updated: 12/11/2018 Page 1 of 4
Healthcare Facility Water Management Program Checklist Available from: www.cdc.gov/hai/prevent/water-management.html
This checklist is intended to assist in the development of an all-hazards approach to water management in a healthcare facility, and may be used to:
• Evaluate a comprehensive water management program. • Identify individuals to participate in the water management program. • Assist in conducting assessments, including hazard analyses, environmental risk assessments,
and infection control risk assessments. • Inform water monitoring practices guided by the management program.
Depending on complexity of the building plumbing systems, a comprehensive program may include several water management plans. These plans should include areas within the system where control points are identified as well as monitoring methods and procedures.
Establish a Water Management Program Team For all facility types, establish clear lines of communication to facilitate dialogue with representatives from the water utility/drinking water provider, as well as the local health department, on an as needed basis.
☐ Define membership (at a minimum, the following ‘roles’ should be represented; may include others depending on facility size, type • facility administration/ownership or C-Suite • facilities management • facilities engineer • infection prevention
☐ Develop a charter that defines roles and responsibilities of members, chair, meeting schedule, etc.
☐ Have you identified team members who should:
☐ Y ☐ N Be familiar with the facility water system(s) ☐ Y ☐ N Identify control locations and control limits ☐ Y ☐ N Identify and take corrective actions ☐ Y ☐ N Monitor and document program performance ☐ Y ☐ N Communicate to the C-suite, staff, health department, and representatives of the
drinking water supplier (if needed) ☐ Y ☐ N Oversee the program ☐ Y ☐ N Access necessary resources to implement changes
☐ Develop the Water Management Policies and Procedures, Plans, and Protocols
Describe your building water systems
☐ Text description of the building water systems, campus water systems, etc.
☐ Develop flow diagrams that describes these systems
For nursing homes, the group may consist of three or more individuals representing management, nursing (someone filling the role of infection control), and the facilities engineer; ad hoc members with subject matter expertise (to provide advice) may be water consultants.
Larger facilities representation may include a designee from the C-suite, risk management, infection prevention, facilities engineers, central services, laboratory, and ad hoc members from clinical departments or water consultants.
Updated: 12/11/2018 Page 1 of 4
Healthcare Facility Water Management Program Checklist Available from: www.cdc.gov/hai/prevent/water-management.html
This checklist is intended to assist in the development of an all-hazards approach to water management in a healthcare facility, and may be used to:
• Evaluate a comprehensive water management program. • Identify individuals to participate in the water management program. • Assist in conducting assessments, including hazard analyses, environmental risk assessments,
and infection control risk assessments. • Inform water monitoring practices guided by the management program.
Depending on complexity of the building plumbing systems, a comprehensive program may include several water management plans. These plans should include areas within the system where control points are identified as well as monitoring methods and procedures.
Establish a Water Management Program Team For all facility types, establish clear lines of communication to facilitate dialogue with representatives from the water utility/drinking water provider, as well as the local health department, on an as needed basis.
☐ Define membership (at a minimum, the following ‘roles’ should be represented; may include others depending on facility size, type • facility administration/ownership or C-Suite • facilities management • facilities engineer • infection prevention
☐ Develop a charter that defines roles and responsibilities of members, chair, meeting schedule, etc.
☐ Have you identified team members who should:
☐ Y ☐ N Be familiar with the facility water system(s) ☐ Y ☐ N Identify control locations and control limits ☐ Y ☐ N Identify and take corrective actions ☐ Y ☐ N Monitor and document program performance ☐ Y ☐ N Communicate to the C-suite, staff, health department, and representatives of the
drinking water supplier (if needed) ☐ Y ☐ N Oversee the program ☐ Y ☐ N Access necessary resources to implement changes
☐ Develop the Water Management Policies and Procedures, Plans, and Protocols
Describe your building water systems
☐ Text description of the building water systems, campus water systems, etc.
☐ Develop flow diagrams that describes these systems
For nursing homes, the group may consist of three or more individuals representing management, nursing (someone filling the role of infection control), and the facilities engineer; ad hoc members with subject matter expertise (to provide advice) may be water consultants.
Larger facilities representation may include a designee from the C-suite, risk management, infection prevention, facilities engineers, central services, laboratory, and ad hoc members from clinical departments or water consultants.
6.3
Updated: 12/11/2018 Page 1 of 4
Healthcare Facility Water Management Program Checklist Available from: www.cdc.gov/hai/prevent/water-management.html
This checklist is intended to assist in the development of an all-hazards approach to water management in a healthcare facility, and may be used to:
• Evaluate a comprehensive water management program. • Identify individuals to participate in the water management program. • Assist in conducting assessments, including hazard analyses, environmental risk assessments,
and infection control risk assessments. • Inform water monitoring practices guided by the management program.
Depending on complexity of the building plumbing systems, a comprehensive program may include several water management plans. These plans should include areas within the system where control points are identified as well as monitoring methods and procedures.
Establish a Water Management Program Team For all facility types, establish clear lines of communication to facilitate dialogue with representatives from the water utility/drinking water provider, as well as the local health department, on an as needed basis.
☐ Define membership (at a minimum, the following ‘roles’ should be represented; may include others depending on facility size, type • facility administration/ownership or C-Suite • facilities management • facilities engineer • infection prevention
☐ Develop a charter that defines roles and responsibilities of members, chair, meeting schedule, etc.
☐ Have you identified team members who should:
☐ Y ☐ N Be familiar with the facility water system(s) ☐ Y ☐ N Identify control locations and control limits ☐ Y ☐ N Identify and take corrective actions ☐ Y ☐ N Monitor and document program performance ☐ Y ☐ N Communicate to the C-suite, staff, health department, and representatives of the
drinking water supplier (if needed) ☐ Y ☐ N Oversee the program ☐ Y ☐ N Access necessary resources to implement changes
☐ Develop the Water Management Policies and Procedures, Plans, and Protocols
Describe your building water systems
☐ Text description of the building water systems, campus water systems, etc.
☐ Develop flow diagrams that describes these systems
For nursing homes, the group may consist of three or more individuals representing management, nursing (someone filling the role of infection control), and the facilities engineer; ad hoc members with subject matter expertise (to provide advice) may be water consultants.
Larger facilities representation may include a designee from the C-suite, risk management, infection prevention, facilities engineers, central services, laboratory, and ad hoc members from clinical departments or water consultants.
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Identify external hazards (i.e., compromised supply) and describe plans for mitigating or managing these events:
☐ Trace or no disinfectant residual upon entry into the building
☐ Water main breaks
☐ Low pressure events
☐ Flushing hydrants
☐ Boil Water Advisory
☐ Nearby construction ☐ Other (specify):
Identify areas where biofilms may be present and areas where opportunistic pathogens of premise plumbing may grow and spread
☐ Identify storage tanks and describe (water turnover rates, residence times, etc.)
☐ Identify areas of stagnation (dead legs, vacant units/rooms, etc.)
☐ Identify areas with hand-held showers, faucets with aerators/flow restrictors,
☐ Identify areas with no residual disinfectant
☐ Identify areas where temperatures can support microbial growth
☐ Identify locations of commodes and hoppers
☐ Y ☐ N Do all commodes and hoppers have covers that can be closed when flushing?
☐ Y ☐ N If no cover present, are they located in a separate room with a door that can closed?
☐ Identify sinks and sink locations
☐ Y ☐ N Do sinks in patient care areas have aerators and flow restrictors?
☐ Y ☐ N Identify electronic sinks/faucets and temperature setting for mixing valve
☐ Y ☐ N Do all sinks in patient care areas have drains that are offset from faucet flow stream?
☐ Y ☐ N Are there barriers (splash guards) between sinks and adjacent medication preparation areas and patient supplies?
☐ Y ☐ N If splash guards are present, is medication prep and clean supply storage > 3 feet from sinks?
Conduct an Infection Control Risk Assessment (ICRA Adapt for potential water exposures both direct and indirect)
☐ Identify patients at increased risk (e.g., burn patients, patients with immune suppression, patients with lung disease/injury, patients with indwelling devices (e.g., central venous catheters, peritoneal dialysis catheters, etc.), patients with open wounds, patients undergoing endoscopy, etc.)
☐ Risk stratify procedures and processes
☐ Identify potential exposures to water
See From Plumbing to Patients: Water Management Programs for Healthcare Facilities (https://www.cdc.gov/hai/prevent/water-management.html)
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Identify control point locations and determine how control measures will be applied using both the environmental assessment and ICRA Decide how to monitor control measures (some examples) ☐ Water temperature
See: Guidelines for Environmental Infection Control in Healthcare Facilities (https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html)
☐ Residual disinfectant
☐ Heterotrophic plate count (HPC)
☐ Total Organic Carbon
☐ Review trend data and report out of control results
☐ Determine frequency for monitoring
☐ Other (specify):
Set control limits for control measures that will be monitored (water temperature, residual disinfectant, HPC, and/or total organic carbon). Corrective Actions (some examples)
☐ Eliminate dead legs, unused branches
☐ Remove or repurpose high risk features (e.g., water features, decorative fountains)
☐ Flush taps/fixtures in vacant rooms
☐ Decontamination (shock treatment or remediation using supplemental treatment for short period of time)
☐ Change fixtures/hand held showers
☐ Point of use filtration; supplemental building disinfection systems Routine and intermittent supplemental disinfection (requires registration with State drinking water program); once one starts to treat water facility is now a small drinking water utility subject to drinking water regulations
☐ Raise hot water temperature if in tepid zone (16°C - 38°C)
☐ Other (specify):
Outbreak and Contingency Response Plans
☐ Ability to detect, investigate, and respond to a sentinel infection or cluster that is potentially linked to a water source
☐ Collect epidemiologically linked samples
☐ Notify Health Department
☐ Arrange for molecular typing or relatedness testing
☐ Reassess water control measures and apply corrective actions
See also HAI Outbreak Investigation Toolkit (https://www.cdc.gov/hai/outbreaks/ outbreaktoolkit.html) Tap Water Quality and Infrastructure Discussion Guide for Investigation of Potential Water-Associated Infections in Healthcare Facilities [PDF - 5 pages] (https://www.cdc.gov/hai/pdfs/Water-Quality-Discussion-Guide-P.pdf)
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Verification: has the plan been implemented as designed and are you following it?
Validation: Determine what conditions, outcomes inform you that your program is effective
☐ Perform clinical surveillance for infections due to opportunistic pathogens of premise plumbing See: From Plumbing to Patients: Water Management Programs for Healthcare Facilities (https://www.cdc.gov/hai/prevent/water-management.html)
☐ Identify clusters and conduct an epidemiologic investigation
☐ Routine environmental sampling for Legionella (optional consideration) Base decisions on building environmental assessment, water quality data, and context of whether disease is present or absent: Legionella Routine Environmental Sampling (https://www.cdc.gov/legionella/wmp/monitor-water.html#env-sampling).
Documentation
☐ Team Roster: Names, titles, contact info, team responsibility, member roles
☐ Building Description: Location, building age, use, occupants, visitors, bed occupancy rate, additions or renovations, etc.
☐ Water system description: both text and process diagrams, location of attached equipment
☐ Control Measures: identify control measures, locations in the system where critical limits can be monitored and where controls can be monitored and applied
☐ Confirmatory procedures: verification steps, and validation to show effectiveness of the water management plan as designed
☐ Sampling and testing: document collection and transport methods, chain of custody, and laboratory identified performing assays if environmental testing is conducted, results
Communication Plan
☐ Notification to building staff/occupants that a plan is in place and provide team’s contact info; issue regular updates as plan is implemented or modified
☐ Reports to team, infection control, hospital administration, other affected parties if control limits are exceeded, and corrective actions to be applied
☐ Consider quarterly and annual reports: reports to management and occupants, consider part of facility quality review; since activity is part of Continuous Quality Improvement (CQI).
☐ Notification protocols with public health points of contact for when a sentinel infection or cluster is detected.
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Module 7
Environmental Cleaning
Contents
7.1 Environmental Checklist for Monitoring Terminal Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . 140CDC
7.2 Options for Evaluating Environmental Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141CDC
Resources
Guidelines for Environmental Infection Control in Health-Care FacilitiesCDChttps://www .cdc .gov/infectioncontrol/guidelines/environmental/index .html
Pesticide Product and Label SystemEnvironmental Protection Agencyhttps://iaspub .epa .gov/apex/pesticides/f?p=PPLS:1
Disinfection and Sterilization CDChttps://www .cdc .gov/infectioncontrol/guidelines/disinfection/index .html
Chemical DisinfectantsCDChttps://www .cdc .gov/infectioncontrol/guidelines/disinfection/disinfection-methods/ chemical .html
Bed BugsCDChttps://www .cdc .gov/parasites/bedbugs/faqs .html
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7.1
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CDC Environmental Checklist for Monitoring Terminal Cleaning1
Date: Unit: Room Number: Initials of ES staff (optional):2 Evaluate the following priority sites for each patient room: High-touch Room Surfaces3 Cleaned Not Cleaned Not Present in Room Bed rails / controls Tray table IV pole (grab area) Call box / button Telephone Bedside table handle Chair Room sink Room light switch Room inner door knob Bathroom inner door knob / plate Bathroom light switch Bathroom handrails by toilet Bathroom sink Toilet seat Toilet flush handle Toilet bedpan cleaner Evaluate the following additional sites if these equipment are present in the room: High-touch Room Surfaces3 Cleaned Not Cleaned Not Present in Room IV pump control Multi-module monitor controls Multi-module monitor touch screen Multi-module monitor cables Ventilator control panel Mark the monitoring method used: Direct observation Fluorescent gel Swab cultures ATP system Agar slide cultures ____________________________ 1Selection of detergents and disinfectants should be according to institutional policies and procedures 2Hospitals may choose to include identifiers of individual environmental services staff for feedback purposes. 3Sites most frequently contaminated and touched by patients and/or healthcare workers
CDC Environmental Checklist for Monitoring Terminal Cleaning1
Date: Unit: Room Number: Initials of ES staff (optional):2 Evaluate the following priority sites for each patient room: High-touch Room Surfaces3 Cleaned Not Cleaned Not Present in Room Bed rails / controls Tray table IV pole (grab area) Call box / button Telephone Bedside table handle Chair Room sink Room light switch Room inner door knob Bathroom inner door knob / plate Bathroom light switch Bathroom handrails by toilet Bathroom sink Toilet seat Toilet flush handle Toilet bedpan cleaner Evaluate the following additional sites if these equipment are present in the room: High-touch Room Surfaces3 Cleaned Not Cleaned Not Present in Room IV pump control Multi-module monitor controls Multi-module monitor touch screen Multi-module monitor cables Ventilator control panel Mark the monitoring method used: Direct observation Fluorescent gel Swab cultures ATP system Agar slide cultures ____________________________ 1Selection of detergents and disinfectants should be according to institutional policies and procedures 2Hospitals may choose to include identifiers of individual environmental services staff for feedback purposes. 3Sites most frequently contaminated and touched by patients and/or healthcare workers
Options for Evaluating Environmental Cleaning
Prepared by: Alice Guh, MD, MPH1
Philip Carling, MD2
Environmental Evaluation Workgroup3
December 2010
1Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia 2Carney Hospital and Boston University School of Medicine, Boston, MA; Dr. Philip Carling has been compensated as a consultant of Ecolab and Steris. He owns a patent for the fluorescent targeting evaluation system described in this document (DAZO Fluorescent Marking Gel). 3Brian Koll, Beth Israel Medical Center, New York, NY; Marion Kainer and Ellen Borchers, Tennessee Department of Health, Nashville, TN; and Brandi Jordan, Illinois Department of Public Health, Chicago, IL
7.2
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Introduction: In view of the evidence that transmission of many healthcare acquired pathogens (HAPs) is related to contamination of near-patient surfaces and equipment, all hospitals are encouraged to develop programs to optimize the thoroughness of high touch surface cleaning as part of terminal room cleaning at the time of discharge or transfer of patients. Since dedicated resources to implement objective monitoring programs may need to be developed, hospitals can initially implement a basic or Level I program, the elements of which are outlined below. Some hospitals should consider implementing the advanced or Level II program from the start, particularly those with increased rates of infection caused by healthcare acquired pathogens (e.g., high Clostridium difficile infection rate). All hospitals that have successfully achieved a Level I program should advance to Level II. At present, the objective monitoring of the cleaning process of certain high touch surfaces (e.g., the curtain that separates patient beds) beyond those outlined in the attached checklist is not well defined. Additionally, there is no standard method for measuring actual cleanliness of surfaces or the achievement of certain cleaning parameters (e.g., adequate contact time of disinfectant) or for defining the level of microbial contamination that correlates with good or poor environmental hygienic practices. As our understanding of these issues evolve and a standardization of assessment in these respective areas can be developed and practically implemented, hospitals that have obtained a high compliance rate with surface cleaning as outlined in the Level II program are encouraged to advance their efforts in optimizing environmental hygienic practices. Level I Program Elements of the program:
1. The program will be an infection preventionist/hospital epidemiologist infection prevention & control (IPC) based program internally coordinated and maintained through environmental services (ES) management level participation. The goal should be seen as a joint (IPC/ES), team effort during planning implementation and ongoing follow-up phases.
2. Each program will be hospital-specific and based on a joint (IC/ES) definition
of institutional expectations consistent with the CDC standards1,2 and the attached check list. The responsibilities of ES staff and other hospital personnel for cleaning high touch surfaces (e.g., equipment in ICU rooms) will be clearly defined.
3. Structured education of the ES staff to define programmatic and institutional
expectations will be carried out and the proportion of ES staff who participate
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will be monitored (see Elements of the Educational Intervention – Appendix A).
4. Development of measures for monitoring along with methods and identified
staff for carrying out monitoring will be undertaken by the IPC/ES team. Monitoring measures may include competency evaluation of ES staff by ES management, IPC staff or, preferably, both. Teams are also encouraged to utilize patient satisfaction survey results in developing measures. Regular ongoing structured monitoring of the program will be performed and documented.
5 Interventions to optimize the thoroughness of terminal room cleaning and
disinfection will be a standing agenda item for the Infection Control Committee (ICC) or Quality Committee as appropriate for the facility.
6. Consideration of the feasibility of moving to the Level II program will be
discussed by the ICC and documented in the committee minutes.
Reporting:
Results should be reported to the ICC and facility leadership.
Level II Program Elements of the Program 1. The program will be an infection preventionist/hospital epidemiologist infection
prevention & control (IPC) based program internally coordinated and maintained through environmental services (ES) management level participation. The goal should be seen as a joint (IPC/ES), team effort during planning implementation and ongoing follow-up phases.
2. Each program will be hospital-specific and based on a joint (IC/ES) definition of
institutional expectations consistent with the CDC standards1,2 and the attached check list. The responsibilities of ES staff and other hospital personnel for cleaning high touch surfaces (e.g., equipment in ICU rooms) will be clearly defined.
3. Either covertly or in conjunction with ES staff, an objective assessment of the
terminal room thoroughness of surface disinfection cleaning will be done using one or more of the methods discussed below (see Objective Methods for
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Evaluating Environmental Hygiene - Appendix B) to document the pre-intervention thoroughness of disinfection cleaning (generally referred to as the “TDC Score” calculated as # of objects cleaned / total # of objects evaluated X 100). Such results will be maintained by the institution and used internally to optimize programmatic and educational interventions.
4. Structured education of the ES staff to define programmatic and institutional
expectations will be carried out and the proportion of ES staff who participate will be monitored. It would be expected that the results of the pre-intervention objective evaluation of disinfection cleaning be incorporated into the ES educational activity in a non-punitive manner (see Elements of the Educational Intervention – Appendix A).
5. Scheduled ongoing monitoring of the TDC cleaning using one or more of the
objective monitoring approaches discussed in Appendix B will be performed at least three times a year. The monitoring will use a projected sample size based on the previous level of TDC in order to detect a 10-20% change in performance (see Sample Size Determination – Appendix C). The results will be recorded in an excel spreadsheet to calculate aggregate TDC scores (see Appendix D).
6. The results of the objective monitoring program and the objectively developed
TDC scores will be used in ongoing educational activity and feedback to the ES staff following each cycle of evaluation. It is recommended that such results be shared more widely within and beyond the institution as useful and appropriate.
7. Results of the objective monitoring program and interventions to optimize the
thoroughness of terminal room cleaning and disinfection will be a standing agenda item for the Infection Control Committee (ICC).
Reporting: Results should be reported to the ICC and facility leadership and could be reported to the state health department through the state prevention collaborative coordinator by various mechanisms (e.g., NHSN template), depending on infrastructure. ________________ 1 Guidelines for Environmental Infection Control in Healthcare Facilities, 2003 (http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf) 2 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf)
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Appendices to the Conceptual Program Model for Environmental Evaluation
APPENDIX A Elements of the Educational Intervention Environmental Services Line Personnel – A presentation should be developed for all line staff involved in terminal room cleaning and should: A. Provide an overview of the importance of HAIs in a manner commensurate with their
educational level using as many pictorial illustrations as is feasible. B. Explain their role in improving patient safety through optimized hygienic practice. C. Review specific terminal room cleaning practice expectations. D. Discuss the manner in which their practice will be evaluated. For Level II programs,
a participatory demonstration of the monitoring method is very useful. E. Provide them with information from the baseline evaluation emphasizing or possibly
exclusively showing them results for those objects which have been most thoroughly cleaned (Level II).
F. Stress the non-punitive nature of the program. G. Inform them that their good performance will be broadly recognized (i.e., beyond
their department) and highlighted within their department for others to emulate. (Level II)
H. Repeatedly reinforce the importance of their work, and how it directly relates to the hospital’s goals and mission and how it is appreciated by patients and plays a major role in a patient’s satisfaction with the hospital.
Many hospitals have provided a small (possibly ES staff-language specific) pictorial booklet to the environmental services personnel at the conclusion of the presentation which is often developed to be language skill appropriate. ES managers – As senior managers will be actively involved in the design and implementation of either Level I or Level II programs, educational interventions for them will need to be customized. While many of these individuals have an excellent understanding of the basic policies and procedures involved in terminal room cleaning, most will benefit from focused educational interventions related to our evolving understanding of the role of the environment in healthcare-associated pathogen (HAP) transmission. Evaluation of mid-level managers also needs to be customized. Most importantly, the impact of the program on mid-level ES managers needs to be monitored since additional formal and informal education is frequently needed for those individuals who are somewhat unsure of the importance of developing programmatic approaches to optimize terminal room cleaning.
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Other groups – Given the overall importance of optimizing the thoroughness of hygienic practice in healthcare settings, hospital specific educational interventions graphically illustrating the impact of the program should be considered for both Level I and Level II programs. Such communications should be developed for a range of audiences within the hospital including the senior hospital administration, the medical staff, nursing personnel on the units, executive nursing and medical staff committees and the hospital’s board of managers or directors. APPENDIX B Objective Methods for Evaluating Environmental Hygiene In considering implementation of a Level II program, the advantages and limitations of various monitoring approaches must be considered carefully. The factors which distinguish each approach to Level II monitoring are discussed below and summarized in Fig.1. With any method or methods used it is important that neither the system itself (fluorescent marker) nor its use (precleaning cultures or ATP measurements) induce a Hawthorne type effect. Direct Practice Observation – Covert monitoring of disinfection cleaning can provide an objective assessment of individual ES staff performance and compliance with cleaning protocols. This approach has been used to objectively evaluate and improve ICU environmental hygiene in one hospital.1 While conceptually feasible, logistical issues related to maintaining such a program outside a research setting may limit adaptation of this form of Level II monitoring. Furthermore, the complexity of monitoring cleaning practice in individual patient rooms without the evaluator being recognized as such might represent a difficult confounding issue. Swab Cultures – While several outbreak intervention studies have associated decreased environmental contamination by target organisms as a result of modified cleaning practice leading to decreased acquisition of targeted pathogens, none of the reports specifically note if serial environmental culture results were actually used to provide practice feedback to the ES staff. Although swab cultures are easy to use, the cost of processing, including isolate identification, the delay in analyzing results, the need to determine pre-cleaning levels of contamination for each object evaluated in order to accurately assess cleaning practice, and the limited feasibility of monitoring multiple surfaces in multiple patient rooms as part of an ongoing Level II monitoring program represent issues which could limit the broad application of this system. Agar Slide Cultures – Agar coated glass slides with finger holds were developed to simplify quantitative cultures of liquids. The slides have been adopted for use in environmental surface monitoring in healthcare settings.2 These studies have used agar
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coated slide systems to evaluate cleaning practice by quantifying aerobic colony counts (ACCs) per cm.2,3 While studies have measured aggregate ACCs before and after cleaning, no studies to date have evaluated the actual thoroughness of cleaning of the same objects to determine if objects with relatively high ACCs were either poorly cleaned or actually overlooked by the ES staff. Although some difficulties have been encountered in utilizing the agar slide cultures on other than large, flat surfaces, they potentially provide an easy method for quantifying viable microbial surface contamination. There is a need, similar to that noted above for swab cultures, to determine pre-cleaning levels of contamination for each object evaluated in order to accurately assess cleaning practice. Fluorescent Markers – Fluorescent gel, powder, and lotion have all been developed for the purpose of marking high touch objects prior to room cleaning. While the powder and lotion have been used as part of educational interventions, their overt visibility (lotions and powder), ease with which they can be disturbed (powder), and difficulty with easy removal (lotion if allowed to air dry) may limit their use in a monitoring system and there is little or no published experience in their use for this purpose. In contrast, the fluorescent gel dries transparent on surfaces, resists abrasion, and there are several studies demonstrating the accuracy of the system in objectively evaluating cleaning practice and quantifying the impact of educational interventions on such cleaning.4,5 Because these fluorescent markers are all designed to indicate physical removal of an applied substance, surfaces that are effectively disinfected but less effectively cleaned may be more likely flagged as failing to meet a quality standard using one of these markers than one of the culture techniques.
ATP Bioluminesence – The measurement of organic ATP on surfaces using a luciferase assay and luminometer has been used to evaluate cleanliness of food preparation surfaces for more than thirty years. A specialized swab is used to sample a standardized surface area which is then analyzed using a portable handheld luminometer. The total amount of ATP, both microbial and non-microbial, is quantified and expressed as relative light units. Although readout scales vary more than 10 fold and sensitivity varies between commercially available systems, very low readings are typically associated with low aerobic colony counts (ACCs).6 Very high readings may represent either a viable bioburden, organic debris including dead bacteria or a combination of both. An independent study in 2007 by the U.K. National Health Service evaluating the potential role of the ATP tool in assessing cleaning practice concluded that the tool could potentially be used effectively for ES education.7 Although it is likely that part of the lack of correlation between ATP readings and ACCs noted in the preceding studies relates to the fact that ATP systems measure organic debris as well as viable bacterial counts, several studies have noted additional environmental factors which may increase or decrease ATP readings. Because a large proportion of surface contamination with ATP is non-microbial in origin, surfaces that are effectively disinfected but less effectively cleaned may be more likely flagged as failing to meet a quality standard
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using the ATP tool than one of the culture techniques. Additionally, high concentrations of bleach may potentially quench the ATP bioluminescence reaction and result in a signal reduction, but further research is needed to better understand the impact of bleach-based disinfectants on the use of the ATP system. If a bleach-based disinfectant is used, it is important that the surface is dry before using the ATP tool. Similar to the culture methods described above, it is unclear whether “threshold values” for a clean hospital surface can be established using existing methods, suggesting use of the ATP tool is likely to require pre-cleaning levels of contamination for each object evaluated in order to accurately assess cleaning practice. Despite these limitations, the ATP system has been used to broadly document significant improvement in daily cleaning as well as provide quantitative measurement to indicate the level of cleanliness of high touch surfaces.8,9 Final Points No matter which of the Level II monitoring approaches is chosen by the hospital, it is important that the monitoring be performed by hospital epidemiologists, infection preventionists or their designees who are not part of the actual ES cleaning program. Such an approach assures the validity of the information collected and provides an opportunity for the Infection Control and Prevention Department to independently champion the value of well performed disinfection cleaning.
A more detailed and fully referenced discussion of the above noted approaches to Level II monitoring of terminal room cleaning, may be found in the article Evaluating Hygienic Cleaning in Healthcare Settings: What You Don’t Know Can Harm Your Patients by P.C. Carling and J.M. Bartley in the June, 2010 supplement to the American Journal of Infection Control http://www.ajicjournal.org/issues/contents?issue_key=S0196-6553(10)X0005-0 . APPENDIX C Sample Size Determination Logistical issues must also be considered as part of planning for the implementation of an enhanced program. Before a decision has been made to use one of the Level II methods to objectively monitor cleaning practice, it is important to determine the number of surfaces to be evaluated for establishing baseline level of thoroughness of cleaning and the number of data points which must be monitored on a regular basis to accurately assess improvement or deterioration in practice. While it would be ideal to be able to identify small fluctuations in practice accurately (e.g., 10% relative change), such an approach would be highly labor intensive. Instead, a meaningful change in cleaning practice (e.g., 20% relative change) can be detected without having to evaluate a substantial number of surfaces. Previous experience suggests that conducting a baseline
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evaluation of all available surfaces (listed in the checklist) in a 10-15% sample of representative patient rooms is reasonable in a hospital with ≥150 beds. When hospitals have achieved a thoroughness of cleaning rate of >80%, the number of surfaces to be monitored can be decreased to those available in a 5% sample of rooms per evaluation cycle unless there is a deterioration in practice. In hospitals with less than 150 beds, all available surfaces (listed in the checklist) in a minimum of 15 rooms may be monitored for baseline and ongoing evaluation.
APPENDIX D Calculation of Aggregate Thoroughness of Disinfection Cleaning (TDC) Score The results of the evaluation of each object listed on the check list can be recorded in the attached excel spreadsheet template. The percentage of individual surfaces cleaned across multiple patient rooms will be automatically calculated by the excel spreadsheet. Because it has been found that cleaning practice within an institution is more likely to vary between types of objects than by patient units, the high touch surfaces listed in the check list have been grouped into 5 categories for calculating aggregate TDC scores: High Touch I, High Touch II, High Touch III, Bathroom Surfaces, and Equipment Surfaces. The aggregate TDC scores for each category of objects can be reported to the HAI prevention collaborative coordinator by various mechanisms (e.g., NHSN), depending on infrastructure.
References: 1. Hayden MK, Bonten MJ, Blom DW, Lyle EA. Reduction in acquisition of vancomycin-
resistant enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Disease 2006;42:11,1552-60.
2. Dancer SJ, White LF, Lamb J, Girvan EK, Robertson C. Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study. BMC Med 2009;June8:7-28.
3. Griffith CJ, Cooper RA, Gilmore J, Davies C, Lewis M. An evaluation of hospital cleaning regimes and standards. J Hosp Infect 2000;45:19-28.
4. Carling PC, Parry MM, Rupp ME, Po JL, Dick BL, Von Beheren S. for the Healthcare Environmental Hygiene Study Group. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Inf Control Hosp Epidem 2008; 29:11,1035-1041.
5. Goodman ER, Platt R, Bass R, Onderdonk AB, Yokoe DS, Huang SS. Impact of an environmental cleaning intervention on the presence of methicillin-resistant
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Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms. Infect Control Hosp Epi Demiol 2008; 29:593-599.
6. Aycicek H, Oguz U, Karci K. Comparison of results of ATP bioluminescence and traditional hygiene swabbing methods for the determination of surface cleanliness at a hospital kitchen. Int J Hyg Environ Health 2006;209:203-6.
7. Willis C, Morley J,Westbury J, Greenwood M, Pallett A. Evaluation of ATP bioluminescence swabbing as a monitoring and training tool for effective hospital cleaning. Br J of Infect Control 2007 8:17-21.
8. Boyce JM, Havill NL, Dumigan DG, Golebiewski M, Balogun O, Rizvani R. Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay. Infect Control Hosp Epidemiol 2009;30,7:678-84.
9. Boyce JM, Havill NL, Lipka A, Havill H, Rizvani R. Variations in hospital daily cleaning practices. Infect Control Hosp Epidemiol 2010;31,1:99-101.
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Figure 1
Evaluating Patient Zone Environmental Hygiene
Method Ease of Use
Identifies Pathogens
Useful for Individual Teaching
Directly Evaluates Cleaning
Published Use in Programmatic Improvement
Direct Practice Low No Yes Yes 1 Hospital
Observation
Swab cultures High Yes Not Studied Potentially 1 Hospital
Agar slide cultures Good Limited Not Studied Potentially 1 Hospital Fluorescent gel High No Yes Yes 49 Hospitals ATP system High No Yes Potentially 2 Hospitals
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INSTRUCTIONS FOR EVALUATING THE CLEANING OF OBJECTS IN THE PATIENT ZONE
The group of objects on the checklist was chosen on the basis of information regarding the contamination of these surfaces with healthcare-associated pathogens (HAPs) as well as a consideration of the likelihood they would be touched during routine care by healthcare personnel without changing gloves or performing hand hygiene prior to using these items. The following descriptions and suggestions should be used to standardize, to the degree feasible, the manner in which the thoroughness of cleaning can be most consistently evaluated. If the evaluation system utilizes a fluorescent gel targeting system, the targets should generally be placed very near but not in/on the area of the object touched in routine use (as noted in the outline below) in order to avoid disturbing the target during actual use of the object. If one of the direct evaluation systems (one of the two culture methods or the ATP method as described in the Appendix) is being used, the primary hand touch area of each object should be evaluated as noted in the outline below, taking particular care to evaluate exactly the same area of the object before and after cleaning. All available objects noted below should be marked in each room. Patient Area Bed rails – If the bed rail incorporates bed controls, evaluate the control area (on the patient side) slightly away from the control buttons. If the rails do not contain the new style control areas, the rails are best evaluated on the smooth inner surface in an area easily accessible to cleaning. Tray table - The top of the tray table should be evaluated in one corner. Call boxes – Evaluation is done on the back mid portion of the call box in an area easily accessible to cleaning. If tiny call buttons are used, mark the separate TV control box instead if feasible. Telephones – Evaluation is best done on the back side of the hand-held portion of the telephone near the top of the phone, away from the end that is attached to the phone wire. Bedside tables – The drawer pull is evaluated. Patient chair – Evaluation is done in the center of the seat of the chair close to the rear of the cushion. If the cushion is covered in textured fabric, evaluate the arm of the chair.
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IV pole – For hanging IV poles, the shaft of the pole just above the textured grab area should be evaluated. For standing IV poles, the chest-high portion where hand contact is most common should be evaluated. Toilet Area Sinks – If using a targeting system, the best place to mark the sink rim is towards the rear in order to avoid water splash interference with evaluation of the target. If direct evaluation is used, the faucet handle should be evaluated. Bathroom and patient room light switches – When using a targeting method, a target is placed on the plate portion of the light switch. When using a direct evaluation system, the switch or plate should be evaluated because of its relatively large surface area. Door knobs and door levers – The inside door knob or lever is marked for each bathroom door and each patient room door. If using a targeting system on a round door knob, the mark is best placed as close to the middle of the face of the door knob as possible. If the knob has a locking mechanism, place the target on the circular door plate that surrounds the handle. Lever-type handles are marked on any easily cleanable surface somewhat away from the end of the lever where direct hand contact would be most frequent. Similarly, when using a fluorescent system, door push plates are marked in the middle of the smooth part of the plate. When using direct evaluation systems, the most frequently contacted portion of the door knob, lever or push plate should be evaluated. Toilet area hand holds (bathroom handrails) – Evaluate the most accessible surface of the hand hold just off the edge of the textured surface at the curve where the hand hold goes towards the wall. If there are two hand holds, mark the one most likely to be touched by a patient using the toilet. Toilet seats – When using a targeting method, the target is placed on the back of the toilet seat just below the outside edge of the seat in an area readily accessible to cleaning activities. When using a direct evaluation method, the surface of the toilet seat should be evaluated, being sure to evaluate the same area before and after cleaning. Toilet handles – When using a targeting method, the target is placed on top of the handle approximately two thirds away from the end of the handle. Bed pan cleaning equipment – Two types of bed pan cleaning equipment designed as part of toilet units are in general use in hospitals.
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Hinged pipe type cleaner - The most commonly used bed pan cleaner consists of a pipe with a small shower head type device that is lowered over the toilet bowl by the user. When the arm is lowered, the toilet flush water is sprayed in a stream through the cleaner head. This device is best targeted by marking the spray head (the most common area which would be touched by users).
Spray hoses – Some toilets have a spray hose with a lever-type trigger on the handle which is depressed to activate the spray head. Evaluate the handle itself.
Where Applicable IV Pump control panel – Evaluate an area that is just adjacent to the portion of the panel that is most frequently touched by healthcare providers. Monitor control panel – When using a targeting method, the control panel should be evaluated in an area immediately adjacent to a part of the panel which is directly contacted by caregivers’ hands. When using a direct method, the control area itself is evaluated. Monitor touch screen – The touch screen should be evaluated in the lower right hand corner in an area easily accessible to cleaning. Monitor cables – Evaluate the junction box area. Ventilator control panel – Evaluate an area immediately adjacent to a part of the panel which is most frequently touched by healthcare provider.
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Module 8
Cleaning, Disinfection, Sterilization
Contents
8.1 Essential Elements of a Reprocessing Program for Flexible Endoscopes—Recommendations of the Healthcare Infection Control Practices Advisory Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC)https://www .cdc .gov/hicpac/recommendations/flexible-endoscope-reprocessing .html
8.2 HICPAC Sample Policy Template: Reprocessing Flexible Endoscopes . . . . . . . . . . . . . . . 171CDC/HICPAChttps://www .cdc .gov/hicpac/pdf/FlexEndoReprocessing-Policy .docx
8.3 HICPAC Sample Competency Verification Tool: Reprocessing Flexible Endoscopes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176CDC/HICPAChttps://www .cdc .gov/hicpac/pdf/FlexEndoReprocessing-Competency .docx
8.4 HICPAC Sample Audit Tool: Reprocessing Flexible Endoscopes . . . . . . . . . . . . . . . . . . . . 194CDC/HICPAChttps://www .cdc .gov/hicpac/pdf/FlexEndoReprocessing-AuditTool .docx
8.5 Autoclave Biological Indicator (BI) Test Results Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
8.6 Reported Gastrointestinal Endoscope Reprocessing Lapses: The Tip of the Iceberg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198Alexandra M . Dirlam Langlay, PhD; Cori L . Ofstead, MSPH; Natalie J . Mueller, MPH; et al . American Journal of Infection ControlDecember 2013, Vol 41, Issue 12, p . 1188-1194https://www .ajicjournal .org/article/S0196-6553(13)00974-7/fulltext
8.7 Special problems associated with reprocessing instruments in outpatient care facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205Judie Bringhurst MSN, RN, CICAmerican Journal of Infection ControlJune 2019, Vol 47, Supplement, p . A58-A61https://www .ajicjournal .org/article/S0196-6553(19)30155-5/fulltext
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Resources
Association for the Advancement of Medical Instrumentationwww .aami .org
The Joint Commissionwww .jointcommission .org
Accreditation Association for Ambulatory Health Carewww .aaahc .org
Centers for Medicare & Medicaid Serviceswww .cms .gov
Disinfection and Sterilization GuidelinesCDChttps://www .cdc .gov/infectioncontrol/guidelines/disinfection/index .html
SterilizationAssociation of periOperative Registered Nurses (AORN) guidelineshttps://aornguidelines .org/tool/filter?categoryid=42865
High Level DisinfectionAORN guidelineshttps://aornguidelines .org/tool/filter?categoryid=42845
High Level DisinfectionFood & Drug Administration (FDA)https://www .fda .gov/medical-devices/reprocessing-reusable-medical-devices-informa-tion-manufacturers/fda-cleared-sterilants-and-high-level-disinfectants-general-claims-process-ing-reusable-medical-and
Instrument CleaningAORN guidelineshttps://aornguidelines .org/tool/filter?categoryid=42841
Flexible EndoscopeAssociation of periOperative Registered Nurses (AORN) guidelineshttps://aornguidelines .org/tool/filter?categoryid=42855
The FDA Continues to Remind Facilities of the Importance of Following Duodenoscope Reprocessing InstructionsFDA Safety Communicationhttps://www .fda .gov/medical-devices/safety-communications/fda-continues-remind-facili-ties-importance-following-duodenoscope-reprocessing-instructions-fda
Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal Endoscopeshttps://www .sgna .org/Portals/0/SGNA%20Standards%20of%20infection%20prevention%20in%20reprocessing_FINAL .pdf?ver=2018-11-16-084835-387
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Spaulding Classification Systemhttps://cdn .hpnonline .com/inside/2014-06/1406-PnP .html
Multisociety Guideline on Reprocessing Flexible GI Endoscopes: 2016 updatePrepared by: Reprocessing Guideline Task Force, Bret T . Petersen, MD, FASGE (Chair); Jonathan Cohen, MD, FASGE; Ralph David Hambrick III, RN; Navtej Buttar, MD; David A . Green-wald, MD, FASGE; Jonathan M . Buscaglia, MD, FASGE; James Collins, RN; Glenn Eisen, MD, MPH, FASGEGastrointestinal Endoscopy February 2017, Vol 85, Issue 2, p . 282-294 .e1https://www .giejournal .org/article/S0016-5107(16)30647-2/fulltext
ANSI/AAMI ST58:2013 (R2018)Chemical and High-Level Disinfection in Health Care Facilitieshttps://webstore .ansi .org/Standards/AAMI/ANSIAAMIST582013R2018
ANSI/AAMI ST79:2017Comprehensive guide to steam sterilization and sterility assurance in health care facilitieshttps://my .aami .org/store/detail .aspx?id=ST79
ANSI/AAMI ST91:2015Comprehensive guide to flexible and semi-rigid endoscope processing in health care facilitieshttps://www .aami .org/productspublications/ProductDetail .aspx?ItemNumber=2477
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Last update: January 25, 2017 Page 1 of 12 From: https://www.cdc.gov/hicpac/recommendations/flexible-endoscope-reprocessing.html
Essential Elements of a Reprocessing Program for Flexible Endoscopes – Recommendations of the Healthcare Infection Control Practices Advisory Committee
Preface The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee chartered to provide advice and guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services (HHS) regarding the practice of infection control and strategies for surveillance, prevention, and control of healthcare-associated infections, antimicrobial resistance and related events in United States healthcare settings. At the July 2015 HICPAC Meeting, CDC asked HICPAC for guidance on ways to improve facility-level training and ensuring competency for reprocessing endoscopes. To develop recommendations for HICPAC to consider, a HICPAC workgroup was formed that contained the following key stakeholder organizations: Accreditation Association for Ambulatory Health Care (AAAHC), Association for the Advancement of Medical Instrumentation (AAMI), American Gastroenterological Association (AGA), American Society for Gastrointestinal Endoscopy (ASGE), Association of periOperative Registered Nurses (AORN), Association for Professionals in Infection Control and Epidemiology (APIC), Centers for Medicare & Medicaid (CMS), Council of State and Territorial Epidemiologists (CSTE), DNVGL Healthcare, Food and Drug Administration (FDA), International Association of Healthcare Central Service Material Management (IAHCSMM), Public Health Agency of Canada (PHAC), Society of Gastroenterology Nurses and Associates (SGNA), Society for Healthcare Epidemiology of America (SHEA), and The Joint Commission (TJC). The Workgroup provided updates and obtained HICPAC input at the November 2015, March 2016, and July 2016 HICPAC Meetings. HICPAC voted to finalize the recommendations at the July 2016 meeting. Additional information about HICPAC is available on the HICPAC Website (https://www.cdc.gov/hicpac/).
Introduction Healthcare facilities should have a reliable, high-quality system for endoscope reprocessing which minimizes infection risks. To achieve this goal, all reprocessing programs must have an infrastructure that supports training and competencies, quality measurement, and management. The following guidance is provided to assist healthcare facilities, including clinical and administrative staff, to achieve a reliable, high-quality reprocessing program. A toolkit of sample documents accompanies this guidance to help facilities create and maintain the infrastructure to support their flexible endoscope reprocessing program (available from: https://www.cdc.gov/hicpac/recommendations/flexible-endoscope-reprocessing.html).
8.1
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Recommendations
Essential Steps for Flexible Endoscope Reprocessing To ensure flexible endoscopes are safe for patient use, all staff involved in reprocessing this equipment must understand and consistently follow a number of steps which have been distilled down to seven essential steps. Ensuring adherence to these steps requires a complete and effective reprocessing program. These recommendations apply to all settings where endoscopic procedures are performed and where endoscopes are reprocessed.
1. Pre-cleaning a. Pre-clean flexible endoscopes and reusable accessories by following the device manufacturer’s
instructions for use (IFU). Perform pre-cleaning immediately following completion of the endoscope procedure to help prevent the formation of biofilm.
2. Leak Testing a. For endoscopes that require leak testing, perform the leak test using manufacturer’s IFU after
each use and prior to manual cleaning. Leak testing detects damage to the external surfaces and internal channels of the endoscope that can lead to inadequate disinfection and further damage of the endoscope.
3. Manual Cleaning a. Perform meticulous manual cleaning including brushing and flushing channels and ports
consistent with the manufacturer’s IFU before performing high-level disinfection (HLD) or sterilization. Perform manual cleaning within the timeframe specified in the manufacturer’s IFU. Manual cleaning is the most critical step in the disinfection process since residual organic material can reduce the effectiveness of HLD and sterilization.
4. Visual Inspection a. After manual cleaning, visually inspect the endoscope and its accessories. Visual inspection
provides additional assurance that the endoscope and its accessories are clean and free of defects. Complex devices such as flexible endoscopes may require the use of lighted magnification or additional methods to assist with the inspection process.
5. Disinfection or Sterilization a. Following cleaning and visual inspection perform HLD or sterilization in accordance with the
manufacturer’s IFU. Carefully review and adhere to the endoscope manufacturer’s reprocessing instructions and to the IFU for chemicals or sterilants and any equipment (e.g., automated endoscope reprocessors) used for reprocessing to help ensure that effective disinfection occurs.
6. Storage a. After reprocessing is complete, store endoscopes and accessories in a manner that prevents
recontamination, protects the equipment from damage, and promotes drying. Store processed flexible endoscopes in a cabinet that is either: 1. of sufficient height, width, and depth to allow flexible endoscopes to hang vertically
without coiling and without touching the bottom of the cabinet OR
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2. designed and intended by the manufacturer for horizontal storage of flexible endoscopes 7. Documentation
a. Maintain documentation of adherence to these essential steps each time an endoscope is reprocessed. Documentation is essential for quality assurance purposes and for patient tracing in the event a look back is necessary.
Essential Elements of a Reprocessing Program for Flexible Endoscopes Administrative
1. Leadership of the healthcare organization or practice setting where flexible endoscopes are used and/or reprocessed is accountable for: a. Allocating sufficient human and material resources to ensure that the selection, use, and
reprocessing of endoscopes and related accessories are managed in a manner that minimizes infection risk and supports patient and healthcare worker safety.
b. Supporting and empowering the authority of those responsible for managing infection prevention practices to ensure effectiveness of the program.
c. Ensuring that the essential elements of an endoscope reprocessing program are followed and that endoscopes are reprocessed according to manufacturers’ IFU.
2. Policies a. In all practice settings where endoscopy is performed, policies related to the reprocessing of
endoscopes should be developed by a multidisciplinary team that includes physicians, nurses, endoscope reprocessing personnel, infection preventionists, and other personnel who are involved in the use and reprocessing of endoscopes. For facilities with limited personnel where formation of a multidisciplinary team is not possible, consider seeking external expertise to obtain multidisciplinary input.
b. Policies should address the selection, use, transport, reprocessing, and storage of endoscopes and accessory devices to ensure compliance with endoscope and reprocessing equipment manufacturers’ IFUs. In addition, policies should clearly include requirements for documentation of adherence to essential reprocessing steps, parameters regarding the physical setting where endoscope reprocessing occurs, staff education, training, and assessment of competency, ongoing quality assurance procedures, and protocols for responding to equipment and HLD/sterilization failures or breaches (see sections below).
c. Policies should include the management of “loaner” endoscopes (i.e., endoscopes that are not owned by the healthcare facility but are provided for temporary use by manufacturers, equipment suppliers or other healthcare facilities) to ensure adherence to the same reprocessing standards described above required for facility-owned equipment. This includes: 1. Assessing the condition (i.e., visual inspection, leak testing) of loaner endoscopes prior to use. 2. Cleaning and high level disinfection or sterilization of loaner endoscopes supplied by the
manufacturer or another healthcare facility prior to use. d. Policies must be in compliance with all federal and local regulatory (e.g., FDA, CMS, OSHA, state
health departments) and relevant accrediting organization (e.g. AAAASF, AAAHC, DNVGL Healthcare, TJC) standards and requirements. Policies should also take into consideration the
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standards and recommendations from professional organizations (e.g., AAMI, AGA, AORN, ASGE, SGNA).
3. Management should ensure that: a. Policies related to the reprocessing of endoscopes are in place and are reviewed on a regular basis
as required by the facility governing body and any applicable regulatory organization. In addition, policies should be updated regularly when new equipment/products are purchased and when new information is published.
b. Single-use devices should not be reprocessed. If a facility chooses to reprocess a single use device, FDA regulations for reprocessing of single use devices must be followed.
c. Occupational health needs are addressed that include but are not be limited to the provision of hepatitis B vaccine, prevention of exposure to infectious agents (e.g., bloodborne pathogens, enteric pathogens) and availability of post-exposure prophylaxis when indicated, convenient access to and appropriate use of personal protective equipment (PPE), and monitoring for exposure to chemicals used for reprocessing when applicable. The CDC provides multiple resources related to occupational health.1,2
d. Patient scheduling and staffing levels are adequate to allow for enough time to consistently perform adequate reprocessing of endoscopes and to avoid delays between completion of an endoscopic procedure and initiation of reprocessing of the endoscope used for that procedure. Management should be knowledgeable about the manufacturer’s IFUs related to delayed reprocessing to ensure that appropriate steps are taken if a reprocessing delay occurs.
e. Staff has access to personnel with infection prevention knowledge and training to support the development and implementation of infection prevention policies and procedures.
f. All personnel involved in the reprocessing of endoscopes, including the supervisors and managers of reprocessing personnel, receive ongoing education, training and assessment of competency as outlined in the Education, Training and Competencies section. 1. If personnel are responsible for reprocessing more than one type of endoscope, verify
reprocessing competency for each type of endoscope, including the appropriate use of all equipment required for reprocessing.
2. Endoscope reprocessing certification is encouraged but does not negate the need for ongoing assessments of competency.
g. At minimum, water used for reprocessing of endoscopes meets the specifications that are recommended by the device and reprocessing equipment manufacturers.3,4 Professional society guidelines that recommend more stringent water specifications should be considered.5
h. All the essential elements of an effective endoscope reprocessing program are met and maintained.
Documentation 1. Documentation requirements vary depending upon the methods and the products that are used for
HLD or sterilization. 2. For all methods of reprocessing using HLD or sterilization, document endoscope and patient
identifiers. Tracking is essential in the event of a disinfection failure and for responding to device or product recalls.
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3. Ensure that there is a process in place to record the procedure end time and the start time for manual cleaning. Recording these times enables reprocessing personnel to ascertain how long the endoscope has been awaiting reprocessing, to prioritize reprocessing of specific endoscopes, and to determine whether routine reprocessing within the manufacturer’s recommended time to cleaning is achievable, and if not, to implement the manufacturer’s procedures for delayed processing.
4. Maintain documentation of the effectiveness of the products used for cleaning and disinfection (e.g., document the results of testing for effective concentrations of the chemical disinfectant, expiration dates for test strips and chemical disinfectants).
5. Maintain records of preventive maintenance and repair of endoscopes and reprocessing equipment (e.g., leak testers, automated endoscope reprocessors [AERs], sterilizers).
6. Documentation should include the investigation of critical or potential critical events such as HLD or sterilization process failures or equipment failures.
7. Retain documentation as designated by the facility record retention policy. This includes documentation for AERs and retired endoscopes.
Inventory 1. Conduct an endoscope inventory to identify all endoscopes and method of reprocessing in use by the
facility. Information reviewed for each endoscope should include but is not limited to the: a. Endoscope manufacturer and model b. Location of use c. Number of procedures performed d. Location of the endoscope manufacturer’s IFUs e. Location for reprocessing f. Equipment used for HLD and/or sterilization g. Status of the endoscope (i.e., retired, out for repair, in use)
2. Ensure that each endoscope has a unique identifier to facilitate tracking. Tracking should include the ability to determine when specific endoscopes were used for specific patients, loaned to other units or facilities, reprocessed, or repaired. Tracking is also essential for responding to device or product recalls.
Physical Setting 1. The reprocessing area should be in a space that is separate from the patient procedural area. 2. Review the physical setting to ensure a “one way” work flow that separates contaminated work spaces
from clean work spaces. 3. If a separate room is used for manual cleaning of endoscopes, ensure a directional airflow that
maintains negative pressure within that room relative to adjoining spaces. 4. Ensure that heating, ventilation, and air conditioning parameters are appropriate for the chemicals and
equipment in use. 5. Staff should have access to a handwashing sink that is separate from the reprocessing sink(s). 6. Install eyewash stations, either plumbed or self-contained, within the endoscopy reprocessing room
where chemicals that are hazardous to the eyes are used. Eyewash stations should not be installed in a location that requires flushing of the eyes in the decontamination sink.
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7. Ensure that manufacturer’s IFUs for reprocessing of the endoscopes and for use of the AERs and associated chemicals are readily available.
8. Provide designated space to enable access to files electronically (e.g., computer) or hard copy (e.g., in binders for IFUs and Safety Data Sheets for chemicals used to reprocess flexible endoscopes.
Education, Training, and Competencies 1. Education and training should include the rationale for each of the seven essential steps of
reprocessing outlined in this document. Training and competency assessments should be based upon the endoscope manufacturer’s IFUs as well as the reprocessing equipment and chemicals used. If more than one type/model of endoscope is used, staff should be able to demonstrate they are competent to reprocess each specific type of endoscope.
a. Model-specific competency assessment check lists may be required. b. Post visual educational aids and standard operating procedures to reinforce best reprocessing
practices. 2. Education and training should also address decontamination, cleaning and sterilization of reusable
accessories that breach the mucosal barrier (e.g., biopsy forceps). 3. Ensure that trainers and managers are competent to reprocess endoscopes and are able to adequately
train and verify the competency of their staff. 4. Perform staff competencies:
a. Initially upon hire and periodically as required by facility policy. An educational update followed by direct observation of staff performing endoscope reprocessing is recommended.
b. Whenever a new model of endoscope, reprocessing equipment (e.g., AER, leak tester), or chemical is purchased.
c. Whenever there are updates to the manufacturer’s IFUs. d. That include essential steps of reprocessing from pre-clean to storage and documentation. e. That include a review of procedures to be followed in the case of equipment failure (e.g., use
of manual reprocessing methods as per manufacturer’s IFU or use of an alternative automated reprocessor that is validated for the endoscope).
f. That include how and when to perform supplemental testing or other assessments of endoscope cleaning (e.g., tests that measure residual organic material or adenosine triphosphate) when those tests are used by the facility.
5. Certification in reprocessing of endoscopes does not mitigate the need for orientation, ongoing education training/education and competency assessments.
Risk Assessment and Quality Assurance 1. A risk assessment or comprehensive gap analysis should be conducted to ensure that:
a. All essential steps of reprocessing and essential elements of an endoscope reprocessing program are met and maintained.
b. Flexible endoscopes are precleaned at the point of use and transported safely to the reprocessing area.
c. Staff competencies are verified d. Sufficient numbers of reprocessing personnel are available when routine and/or emergency
endoscopic procedures are performed
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e. Manufacturer’s IFUs are readily available and followed f. Necessary reprocessing equipment and supplies are available g. Physical space is adequate for reprocessing h. Heating, ventilation and air conditioning parameters are monitored and controlled i. Storage of endoscopes is appropriate j. Documentation providing complete traceability is maintained.
2. When conducting the risk assessment or gap analysis, if an AER is used, assess for documentation that AER has been validated for reprocessing the endoscope and endoscope components. Obtain the model-specific reprocessing protocols for both the endoscope and AER and verify compatibility.
3. Perform periodic audits of facility reprocessing protocols and the completeness of documentation to monitor compliance. Gap analyses and risk assessments should be conducted periodically and whenever new endoscopes are purchased, manufacturer’s IFUs change, and when changes occur in guidance from professional and regulatory organizations.
Disinfection/Sterilization Breach or Failure 1. Breaches in adherence to essential disinfection and sterilization steps can be a result of malfunctioning
of equipment and/or human error. Each breach is a result of unique circumstances and should be evaluated to determine the risk of disease transmission. A multi-disciplinary team that includes infection prevention, risk management, and endoscopy personnel should review each event carefully to determine the necessary corrective steps and the need for patient notification.
2. There are several resources available to assist in a breach evaluation. The multi-disciplinary team should use one or more of these documents to guide their investigation.5-7
3. When a breach involves a suspicion of patient exposure to an improperly reprocessed endoscope, the decision to notify patients of their potential exposure should be made in consultation with an infection preventionist and state and local health departments.
4. If a healthcare provider suspects persistent bacterial contamination of an endoscope following reprocessing, either because of an increase in infections after endoscopic procedures or because of the results of microbiological culturing of endoscopes, the healthcare provider should file a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program.8
Unresolved Issues 1. Supplemental measures for duodenoscope reprocessing following HLD
• Some healthcare facilities have chosen to use a supplemental method(s) following high level disinfection for reprocessing of duodenoscopes. Because there is currently insufficient evidence to adequately assess the balance between potential benefits and unintended consequences associated with these supplemental methods, these methods have not been included as essential elements of a reprocessing program9. Examples of supplemental measures as of July 2016 include but are not limited to: o Repeat high level disinfection o Microbiological culturing and quarantine until negative culture o Liquid chemical sterilant processing system o Ethylene oxide sterilization
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o FDA-cleared low-temperature sterilization 2. Endoscope Storage Interval
• The available data on the maximum interval of endoscope storage before reprocessing is required prior to use is inconclusive. The length of time may depend on multiple factors as identified on organizational risk assessment that may include endoscope usage/turnover of endoscopes used and manufacturer’s instructions-for-use.
3. Endoscope Storage Space • The storage cabinet features that are optimal for prevention of contamination have not been
determined (e.g., cabinet ventilation parameters, capacity to store accessories). 4. Replacement of Endoscopes
• While endoscopes should be serviced no less frequently than indicated in the FDA-cleared manufacturer’s IFUs, the optimal time interval for replacement of the endoscope and its associated parts is unknown.
References 1. Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee.
Bolyard EA, Tablan OC, Williams W, et. al., Guideline for infection control in health care personnel, 1998. Available at: https://stacks.cdc.gov/view/cdc/7250. Accessed August 3, 2015.
2. Healthcare Infection Control Practices Advisory Committee. Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings – The Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2017. Accessed August 3, 2016 prior to publication. Available at: https://www.cdc.gov/hicpac/pdf/core-practices.pdf.
3. Association for the Advancement of Medical Instrumentation. Technical Information Report 34: Water for the Reprocessing of Medical Devices. 2014.
4. Association for the Advancement of Medical Instrumentation. ST91 Flexible and semi-rigid endoscope processing in health care facilities 2015.
5. Van Wicklin SA, Spry C, Conner R. Guideline For Processing Flexible Endoscopes. In: Connor, R,. ed. AORN Guidelines for Perioperative Practice: AORN; 2016.
6. American Society for Gastrointestinal Endoscopy Standards of Practice Committee, Banerjee S, Nelson DB, et al. ASGE Standards of Practice Committee Statement: Reprocessing failure. Gastrointest Endosc. 2007;66(5):869-871.
7. Weber DJ, Rutala WA. Assessing the risk of disease transmission to patients when there is a failure to follow recommended disinfection and sterilization guidelines. Am J Infect Control. 2013;41(5 Suppl):S67-71.
8. US Food and Drug Administration. Infections Associated with Reprocessed Flexible Bronchoscopes: FDA Safety Communication; Issued September 17, 2015. 2015. Available at: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm462949.htm. Accessed June 14, 2016, 2016.
9. Rutala WA, Weber DJ. ERCP scopes: what can we do to prevent infections? Infect Control Hosp Epidemiol. 2015;36(6):643-648.
Additional Resources
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• American National Standards Institute Inc., and the Association for the Advancement of Medical Instrumentation. ST91:2015 Flexible and semi-rigid endoscope processing in health care facilities. Arlington, VA: AAMI, 2015. [Available from: http://my.aami.org/store/detail.aspx?id=ST91-PDF. Accessed 28 September 2016.]
• American Society for Gastrointestinal Endoscopy (ASGE), Quality Assurance in Endoscopy Committee, Petersen BT, Chennat J, et. al. Multisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2011. Gastrointest Endosc. 2011 Jun;73(6):1075-84 (under revision).
• American Society for Gastrointestinal Endoscopy Standards of Practice Committee, Banerjee S, Nelson DB, et al. ASGE Standards of Practice Committee Statement: Reprocessing failure. Gastrointest Endosc. 2007;66(5):869-871.
• Canadian Standards Association. CSA Z314.8-14 Decontamination of reusable medical devices. Chapter 11. Flexible endoscopes. [Available from: http://shop.csa.ca/search?q=Decontamination&categories=shop. Accessed 28 September 2016.]
• Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R, Fields B, McNeil MM, Whitney C, Wong S, Juranek D, Cleveland J. Guidelines for environmental infection control in health-care facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004. [Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf [PDF - 2.32 MB]. Accessed 28 September 2016.]
• Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings [Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf [PDF - 1.4 MB]. Accessed 28 September 2016.]
• Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities, Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee; 2008 [Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf [PDF - 1.3 MB]. Accessed 28 September 2016.]
• Rutala WA, and Weber DJ. SHEA Guideline for Disinfection and Sterilization of Prion-Contaminated Medical Instruments (2010). Infection Control and Hospital Epidemiology. Vol. 31, No. 2 (February 2010), pp. 107-117. [Available from: http://www.jstor.org/stable/10.1086/650197. Accessed 28 September 2016.]
• Public Health Agency of Canada. Infection Prevention and Control Guideline for Flexible Gastrointestinal Endoscopy and Flexible Bronchoscopy. 2011. [Available from: http://www.phac-aspc.gc.ca/nois-sinp/guide/endo/intro-eng.php. Accessed 28 September 2016.]
• Society of Gastroenterology Nurses and Associates, Inc. (SGNA). Guideline for Use of High Level Disinfectants & Sterilants for Reprocessing Flexible Gastrointestinal Endoscopes (2013). Published 1998. Revised 2003, 2006, 2007, 2010, and 2013. [Available from: http://www.sgna.org/Portals/0/Issues/PDF/Infection-Prevention/6_HLDGuideline_2013.pdf [PDF - 243 KB]. Accessed 28 September 2016.]
• Society of Gastroenterology Nurses and Associates, Inc. (SGNA). Infection Prevention Champion Program. [Available from: https://www.sgna.org/Issues/Infection-Prevention/Become-A-Champion. Accessed 28 September 2016.]
• Society of Gastroenterology Nurses and Associates, Inc. (SGNA). Infection Prevention Toolkit. [Available
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from: https://www.sgna.org/Issues/Infection-Prevention/Infection-Prevention-Toolkit. Accessed 28 September 2016.]
• Society of Gastroenterology Nurses and Associates, Inc. (SGNA). Position Statement: Reuse of Single-Use Critical Medical Devices (2015). Published February 1998. Revised May 2002, October 2005, August 2008, March 2012, and May 2013 [Available from: http://www.sgna.org/Portals/0/Issues/PDF/Infection-Prevention/8_SUDPositionStatement_2013.pdf [PDF - 118 KB]. Accessed 28 September 2016.]
• Society of Gastroenterology Nurses and Associates, Inc. (SGNA). Position Statement: Statement on Reprocessing of Endoscopic Accessories and Valves (2014). Published May 2002. Revised 2005, May 2009, September 2011, and September 2014 [Available from: https://www.sgna.org/Portals/0/Education/PDF/Position-Statements/Reprocessingvalvesdocument_FINAL.pdf [PDF - 123 KB]. Accessed 28 September 2016.]
• Society of Gastroenterology Nurses and Associates, Inc. (SGNA). Position Statement: Statement on Water and Irrigation Bottles Used During Endoscopy (2014). Published May 2002. Revised October 2005, August 2008, May 2009, September 2011, and September 2014. [Available from: https://www.sgna.org/Portals/0/Education/PDF/Position-Statements/WaterandIrrigationBottles_final.pdf [PDF - 126 KB]. Accessed 28 September 2016.]
• Society of Gastroenterology Nurses and Associates, Inc. (SGNA). Standards of Infection Prevention in Reprocessing of Flexible Gastrointestinal Endoscopes (2016). Published 1996. Revised 2000, 2005, 2007, 2008, 2011, 2012, 2015, and 2016. [Available from: https://www.sgna.org/Portals/0/Standards%20for%20reprocessing%20endoscopes_FINAL.pdf [PDF – 309 KB]. Accessed 28 September 2016.]
• Society of Gastroenterology Nurses and Associates, Inc. (SGNA). Standard of Infection Prevention in the Gastroenterology Setting (2015). Published 2015. [Available from: https://www.sgna.org/Portals/0/Standard%20of%20Infection%20Prevention_FINAL.pdf [PDF – 235 KB]. Accessed 28 September 2016.]
• The Joint Commission. High-Level Disinfection and Sterilization BoosterPak™. [Available from: https://www.jointcommission.org/standards_booster_paks/. Accessed 28 September 2016.]
• Van Wicklin SA, Spry C, Conner R. Guideline for Processing Flexible Endoscopes. In: Connor, R. ed. AORN Guidelines for Perioperative Practice: AORN; 2016. [Available from: http://www.aornstandards.org/. Accessed 28 September 2016.]
Suggested Citation Healthcare Infection Control Practices Advisory Committee. Essential Elements of a Reprocessing Program for Flexible Endoscopes – The Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2016. Available at: https://www.cdc.gov/hicpac/pdf/flexible-endoscope-reprocessing.pdf [PDF - 237 KB].
Contributors
HICPAC Workgroup Members Vickie Brown, RN, MPH; HICPAC Member (Workgroup Co-Chair); Lisa L. Maragakis, MD, MPH; HIPCAC Member (Workgroup Co-Chair); Elizabeth Claverie-Williams, MS; US Food and Drug Administration (FDA); Barbara
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Connell, CAE, CMP, American Society for Gastrointestinal Endoscopy (ASGE); Mary Ann Drosnock, MS, CIC, CFER, RM (NRCM), Association for the Advancement of Medical Instrumentation (AAMI); Glenn Eisen, MD, MPH, FASGE, American Society for Gastrointestinal Endoscopy (ASGE); Eden Essex, American Society for Gastrointestinal Endoscopy (ASGE); Karen Hoffmann, RN, BSN, MS, CIC, FSHEA, FAPIC, Centers for Medicare & Medicaid Services (CMS); Michael L. Kochman, MD, AGAF, FASGE, American Gastroenterological Association (AGA); Naomi Kuznets, PhD; Accreditation Association for Ambulatory Health Care (AAAHC); Natalie Lind, International Association of Healthcare Central Service Materiel Management (IAHCSMM); Betty McGinty, MSHSA, CGRN, BSHA, RN, Society of Gastroenterology Nurses and Associates (SGNA); Laurie O'Neil, RN BN; Public Health Agency of Canada; Michael Anne Preas RN, BSN, CIC; Association for Professionals in Infection Control and Epidemiology (APIC); Sharon Roberson, RN, Centers for Medicare & Medicaid Services (CMS); Zachary Rubin, MD, Society for Healthcare Epidemiology of America (SHEA); Linda L. Spaulding RN, BC, CIC; DNVGL Healthcare; Rachel Stricof, MPH, Council of State and Territorial Epidemiologists (CSTE); Michael Tapper, MD, HICPAC Member; Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC, Association of periOperative Registered Nurses (AORN); Lisa Waldowski MS, APRN, CIC, The Joint Commission; Deborah Yokoe, MD, MPH, HICPAC Co-Chair
HICPAC Members Daniel J. Diekema, MD, University of Iowa Carver College of Medicine (Co-Chair); Deborah S. Yokoe, MD, MPH, Brigham & Women's Hospital (Co-Chair); Hilary M. Babcock, MD, MPH, Washington University School of Medicine; Vickie M. Brown, RN, MPH, WakeMed Health & Hospitals; Sheri Chernetsky Tejedor, MD, Emory University School of Medicine; Susan Huang, MD, MPH; University of California Irvine School of Medicine; Loretta L. Fauerbach, MS, CIC, Fauerbach & Associates, LLC; Michael D. Howell, MD MPH, University of Chicago Medicine; W. Charles Huskins, MD, MSc, Mayo Clinic College of Medicine; Lynn Janssen MS, CIC, CPHQ, California Department of Public Health; Lisa L. Maragakis, MD, MPH, Johns Hopkins University School of Medicine; Jan Patterson, MD, MS, University of Texas Health Science Center San Antonio; Gina Pugliese, RN. MS, Premier healthcare alliance; Selwyn O. Rogers Jr., MD, MPH, FACS, The University of Texas Medical Branch; Tom Talbot, MD, MPH, Vanderbilt University Medical Center; Michael L. Tapper, MD, Lenox Hill Hospital
HICPAC Ex-officios William B. Baine, MD, Agency for Healthcare Research and Quality (AHRQ); David Henderson, MD, National Institutes of Health (NIH); Melissa Miller, MD, Agency for Healthcare Research and Quality (AHRQ); Paul D. Moore, PhD, Health Resources and Services Administration (HRSA); Elizabeth Claverie-Williams, MS, U.S. Food and Drug Administration (FDA); Gary Roselle, MD, Veterans Administration (VA); Daniel Schwartz, MD, MBA Center for Medicare & Medicaid Services; Jacqueline Taylor, Health Resources and Service Administration (HRSA); Judy Trawick, Health Resources and Service Administration (HRSA)
HICPAC Liaison Representatives David Banach, MD, MPH, Society for Healthcare Epidemiology of America (SHEA); Vineet Chopra, MBBS, Society of Hospital Medicine; Craig M. Coopersmith, MD, Society of Critical Care Medicine; Elaine Dekker, RN, BSN, CIC, America’s Essential Hospitals; Akin Demehin, American Hospital
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Association (AHA); Kathleen Dunn, BScN, MN, RN, Public Health Agency of Canada; Sandra Fitzler, RN, American Health Care Association (AHCA); Nancy Foster, American Hospital Association (AHA); Diana Gaviria, MD, MPH, National Association of County and City Health Officials (NACCHO); Jennifer Gutowski, MPH, BSN, RN, CIC, National Association of County and City Health Officials (NACCHO); Valerie Haley, PhD, Association of State and Territorial Health Officials (ASTHO)Holly Harmon, RN, MBA, American Health Care Association (AHCA); Patrick Horine, MHA, DNVGL Healthcare Inc.; Michael D. Howell, MD, MPH, Society of Critical Care Medicine (SCCM); Marion Kainer, MD, MPH, Council of State and Territorial Epidemiologists (CSTE); Emily Lutterloh, MD, MPH, Association of State and Territorial Health Officials (ASTHO); Sarah Matthews, MD, National Association of County and City Health Officials (NACCHO); Michael McElroy, MPH, CIC, America’s Essential Hospitals; Lisa McGiffert, Consumers Union; Jennifer Meddings, MD, Society of Hospital Medicine (SHM); Toju Ogunremi, Public Health Agency of Canada; Laurie O’Neil, RN, BN, Public Health Agency of Canada; Michael Anne Preas, RN CIC, Association of Professionals of Infection Control and Epidemiology, Inc. (APIC); Mark E. Rupp, MD, Society for Healthcare Epidemiology of America (SHEA); Mark Russi, MD, MPH, American College of Occupational and Environmental Medicine; Sanjay Saint, MD, MPH, Society of Hospital Medicine (SHM); Robert G. Sawyer, MD, FACS, FIDSA, FCCM, Surgical Infection Society (SIS); Kathryn Spates, the Joint Commission; Linda Spaulding RN, CIC, DNVGL Healthcare; Donna Tiberi, RN, MHA Healthcare Facilities Accreditation Program (HFAP); Margaret VanAmringe, MHS, the Joint Commission; Stephen Weber, MD, Infectious Disease Society of America (IDSA); Elizabeth Wick, MD, American College of Surgeons (ACS); Amber Wood, MSN, RN, CNOR, CIC, FAPIC, Association of periOperative Registered Nurses (AORN)
Acknowledgements Erin Stone, MA, Lynne Sehulster, PhD, Joseph Perz, DrPH, MA , and Jeffrey Hageman, MHS; the Division of Healthcare Quality Promotion (DHQP), the Centers for Disease Control and Prevention
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HICPACSamplePolicyTemplate:ReprocessingFlexibleEndoscopes
AdministrativeApprovalDateCreated: LastDateRevised: LastDateReviewed: DateofNextReview:
Approvalsignature(s)withtitleanddateofsignature:
Signature Title Date Signature Title Date Signature Title Date
Purpose:Facilitiescanuse this samplepolicy template todevelopa facility-specificpolicies that reflects theendoscopesandevidence-basedpracticesemployedbythefacility.Thepolicydocumentwillprovideguidancetopersonnelforprocessingalltypesofreusableflexibleendoscopesandaccessories.
PolicyItisthepolicyof[insertnameoffacility]that:• Allpersonnelinvolvedinthereprocessingofendoscopesreceiveongoingeducation,trainingand
assessmentofcompetency.• Ongoingperiodicauditsoffacilityreprocessingprotocolswillbeconductedtoensurequalityassurance,
monitorcompliance,andthecompletenessofdocumentation.• Flexibleendoscopesandaccessorieswillbeprecleanedatthepointofuse.• Flexibleendoscopesdesignedtobeleaktestedwillbeleaktestedaftereachuse,afteranyeventthatmay
havedamagedtheendoscope,andbeforeuseofanewlypurchased,repaired,orloanedendoscope.• Afterleaktestingandbeforehigh-leveldisinfection(HLD)orsterilization,flexibleendoscopeswillbe
manuallycleaned.• Flexibleendoscopes,accessories,andassociatedequipmentwillbevisuallyinspectedforcleanliness,
integrity,andfunctionbeforedisinfectionorsterilization.• Chemicalsandsolutionsusedforcleaningandreprocessingflexibleendoscopesandendoscope
accessorieswillbehandledinaccordancewithlocal,state,andfederalregulationsandthemanufacturer’sIFU.
• Flexibleendoscopesandaccessorieswillbestoredinamannerthatminimizescontaminationandprotectsthedeviceoritemfromdamage.
• Recordsofflexibleendoscopeprocessingandproceduresthatenabletraceabilityintheeventofaprocessingfailurewillbecompletedandmaintained.o Recordswillbemaintainedfor[insertfacility-specifictimeperiod].
HICPACSamplePolicyTemplate:ReprocessingFlexibleEndoscopes [Insertfacilitynameoraheader]
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HICPACSamplePolicyTemplate:ReprocessingFlexibleEndoscopes
AdministrativeApprovalDateCreated: LastDateRevised: LastDateReviewed: DateofNextReview:
Approvalsignature(s)withtitleanddateofsignature:
Signature Title Date Signature Title Date Signature Title Date
Purpose:Facilitiescanuse this samplepolicy template todevelopa facility-specificpolicies that reflects theendoscopesandevidence-basedpracticesemployedbythefacility.Thepolicydocumentwillprovideguidancetopersonnelforprocessingalltypesofreusableflexibleendoscopesandaccessories.
PolicyItisthepolicyof[insertnameoffacility]that:• Allpersonnelinvolvedinthereprocessingofendoscopesreceiveongoingeducation,trainingand
assessmentofcompetency.• Ongoingperiodicauditsoffacilityreprocessingprotocolswillbeconductedtoensurequalityassurance,
monitorcompliance,andthecompletenessofdocumentation.• Flexibleendoscopesandaccessorieswillbeprecleanedatthepointofuse.• Flexibleendoscopesdesignedtobeleaktestedwillbeleaktestedaftereachuse,afteranyeventthatmay
havedamagedtheendoscope,andbeforeuseofanewlypurchased,repaired,orloanedendoscope.• Afterleaktestingandbeforehigh-leveldisinfection(HLD)orsterilization,flexibleendoscopeswillbe
manuallycleaned.• Flexibleendoscopes,accessories,andassociatedequipmentwillbevisuallyinspectedforcleanliness,
integrity,andfunctionbeforedisinfectionorsterilization.• Chemicalsandsolutionsusedforcleaningandreprocessingflexibleendoscopesandendoscope
accessorieswillbehandledinaccordancewithlocal,state,andfederalregulationsandthemanufacturer’sIFU.
• Flexibleendoscopesandaccessorieswillbestoredinamannerthatminimizescontaminationandprotectsthedeviceoritemfromdamage.
• Recordsofflexibleendoscopeprocessingandproceduresthatenabletraceabilityintheeventofaprocessingfailurewillbecompletedandmaintained.o Recordswillbemaintainedfor[insertfacility-specifictimeperiod].
HICPACSamplePolicyTemplate:ReprocessingFlexibleEndoscopes [Insertfacilitynameoraheader]
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HICPACSamplePolicyTemplate:ReprocessingFlexibleEndoscopes
AdministrativeApprovalDateCreated: LastDateRevised: LastDateReviewed: DateofNextReview:
Approvalsignature(s)withtitleanddateofsignature:
Signature Title Date Signature Title Date Signature Title Date
Purpose:Facilitiescanuse this samplepolicy template todevelopa facility-specificpolicies that reflects theendoscopesandevidence-basedpracticesemployedbythefacility.Thepolicydocumentwillprovideguidancetopersonnelforprocessingalltypesofreusableflexibleendoscopesandaccessories.
PolicyItisthepolicyof[insertnameoffacility]that:• Allpersonnelinvolvedinthereprocessingofendoscopesreceiveongoingeducation,trainingand
assessmentofcompetency.• Ongoingperiodicauditsoffacilityreprocessingprotocolswillbeconductedtoensurequalityassurance,
monitorcompliance,andthecompletenessofdocumentation.• Flexibleendoscopesandaccessorieswillbeprecleanedatthepointofuse.• Flexibleendoscopesdesignedtobeleaktestedwillbeleaktestedaftereachuse,afteranyeventthatmay
havedamagedtheendoscope,andbeforeuseofanewlypurchased,repaired,orloanedendoscope.• Afterleaktestingandbeforehigh-leveldisinfection(HLD)orsterilization,flexibleendoscopeswillbe
manuallycleaned.• Flexibleendoscopes,accessories,andassociatedequipmentwillbevisuallyinspectedforcleanliness,
integrity,andfunctionbeforedisinfectionorsterilization.• Chemicalsandsolutionsusedforcleaningandreprocessingflexibleendoscopesandendoscope
accessorieswillbehandledinaccordancewithlocal,state,andfederalregulationsandthemanufacturer’sIFU.
• Flexibleendoscopesandaccessorieswillbestoredinamannerthatminimizescontaminationandprotectsthedeviceoritemfromdamage.
• Recordsofflexibleendoscopeprocessingandproceduresthatenabletraceabilityintheeventofaprocessingfailurewillbecompletedandmaintained.o Recordswillbemaintainedfor[insertfacility-specifictimeperiod].
8.2
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ProcedureInterventionsPrecleaning
• Precleanflexibleendoscopesandaccessoriesatthepointofuseassoonaspossibleaftertheendoscopeisremovedfromthepatient(ortheprocedureiscompleted)andbeforeorganicmaterialhasdriedonthesurfaceorinthechannelsoftheendoscope.
• Performprecleaninginaccordancewiththeendoscopemanufacturer’sIFUandbyo preparingafreshsolutionofthecleaningproductwithpropertiesrecommendedbythemanufacturer;o washingtheexteriorsurfacesoftheendoscopewithasoft,lint-freeclothorspongesaturatedwiththe
cleaningsolution;o suctioningthecleaningsolutionthroughthesuctionandbiopsychannels;o placingthedistalendoftheendoscopeinthecleaningsolutionandsuctioningthesolutionthrough
theendoscope;o flushingtheair,water,andotherchannelsoftheendoscopealternatelywiththecleaningsolutionand
air,finishingwithair;o visuallyinspectingtheendoscopefordamage;ando discardingthecleaningsolutionandcleaningclothorspongeafteruse.
Transporting
• Transportcontaminatedflexibleendoscopesandaccessoriestotheendoscopyprocessingroomassoonaspossibleafteruse.
• Keeptheendoscopewetordamp,butnotsubmergedinliquid,duringtransport.• Transportcontaminatedendoscopesandaccessoriestothedecontaminationareainaclosedcontaineror
closedtransportcart.o Useacontainerthatisleakproof,punctureresistant,andlargeenoughtocontainallcontents.o Useacontainerthatisofsufficientsizetoaccommodatetheendoscopewhentheendoscopeiscoiled
inlargeloops.• Labelthetransportcartorcontainerwithabiohazardlegend.
o Securelyaffixthebiohazardlabeltothecartorcontainer.• Transporttheaccessorieswiththeendoscopebutcontainthemseparatelyfromtheendoscope.• Beginprocessingflexibleendoscopesandaccessoriesassoonaspossibleaftertransporttotheendoscopy
processingroomorwithinthemanufacturer’srecommendedtimetoprocessing.o Whenitisnotpossibletoinitiatethecleaningprocesswithintheendoscopemanufacturer’s
recommendedtimetocleaning,followthemanufacturer’sIFUfordelayedprocessing.o Donotleaveflexibleendoscopessoakinginenzymaticcleaningsolutionsbeyondtheendoscope
manufacturer’sdesignatedcontacttimeunlessthisisrecommendedinthemanufacturer’sIFUfordelayedprocessing.
LeakTesting
• Performleaktestingbeforemanualcleaningandbeforetheendoscopeisplacedintocleaningsolutions.• Performleaktestinginaccordancewiththeendoscopeandleak-testingequipmentmanufacturers’IFU
andbyo removingallportcoversandfunctionvalves;o placingtheendoscopeinalooseconfiguration;o pressurizingtheendoscopetotherecommendedpressure;o manipulatingallmovingparts,includingtheelevator,andangulatingthebendingsectionofthedistal
end;o actuatingvideoswitches;ando maintainingpressureandinspectionforaminimumof30seconds.
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• Whenanendoscopefailsaleaktest,removeitfromserviceandsendforrepairorreplacementperfacilitypolicyandprocedure.
ManualCleaning
• Performmanualcleaninginaccordancewiththeendoscopemanufacturer’sIFU.• Performmanualcleaningusingthetypeofwaterandcleaningsolutionrecommendedbytheendoscope
manufacturer.• Performmanualcleaningusingafreshlypreparedcleaningsolution.• Followthecleaningsolutionmanufacturer’sIFUfor
o waterquality,hardness,andpH;o concentrationanddilution;o watertemperature;o contacttime;o conditionsofstorage;ando uselifeandshelflife.
• Completelysubmergetheendoscopeinthecleaningsolutionduringthecleaningprocess.o Detachremovableparts(e.g.,valves,buttons,caps)fromtheendoscopeandsubmergethemif
recommendedbytheendoscopemanufacturer’sIFU.• Cleanallexteriorsurfacesoftheendoscopewithasoft,lint-freeclothorspongesaturatedwiththe
cleaningsolution.• Cleanallaccessiblechannelsandthedistalendoftheendoscopewithacleaningbrushofthelength,
width,andmaterialrecommendedbytheendoscopemanufacturer.• Manuallyactuatetheendoscopevalveswhilecleaning.• Cleanandbrushtheelevatormechanism(ifpresent)andtherecessessurroundingitwithacleaningbrush
ofthelength,width,andmaterialrecommendedbytheendoscopemanufacturer.o Raiseandlowertheelevatorchannelthroughoutthemanualcleaningprocess.
• Useacleanbrushforeachendoscopecleaning.o Visuallyinspectbrushesandotheritemsusedtocleanendoscopechannelsbeforeuseanddonotuse
iftheintegrityofthebrushorothercleaningitemisinquestion.• Brushtheaccessiblechannelsoftheendoscopemultipletimesuntilnodebrisappearsonthebrush.
o Removedebrisfromthebrushbeforethebrushisretractedbackthroughthechannelandaftereachpassbyswirlingthebrushinthecleaningsolutionandrinsingit.
• Flushthechannelsoftheendoscopewithcleaningsolution.• Flushandrinsetheexteriorsurfacesandinternalchannelsoftheendoscopewithtapwateruntilall
cleaningsolutionandresidualdebrisisremoved.• Drytheexteriorsurfacesoftheendoscopewithasoft,lint-freeclothorspongeandpurgeallchannelswith
air.• Clean,brush,rinse,dry,andhigh-leveldisinfectorsterilizeallreusableparts(e.g.,valves,buttons,port
covers,tubing,waterbottles),accessories(e.g.,forceps)andcleaningimplements(e.g.,brushes,channelcleaningadapters).o High-leveldisinfectorsterilizewaterandirrigationbottlesatleastdaily.o Donotallowanyresidualwaterormoisturetoremaininthewaterbottleassembly.o Usesterilewatertofillwaterandirrigationbottles.
• Discardsingle-useparts,accessories,andcleaningimplementsaftereachuseanddonotreprocess.
Inspecting
• Visuallyinspectandevaluateendoscopes,accessories,andequipmentforo cleanliness,o missingparts,
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o clarityoflenses,o integrityofsealsandgaskets,o moisture,o physicalandchemicaldamage,ando function.
• Uselightedmagnificationtoinspectendoscopesandaccessoriesforcleanlinessanddamage,asneeded.• Removedefectiveendoscopes,accessories,andequipmentfromserviceandsendforrepairor
replacementperfacilitypolicyandprocedure.
High-LevelDisinfectionorSterilization
• ManuallycleantheendoscopeandaccessoriesbeforemechanicalormanualHLDorsterilization.
Mechanicalmethods
• Checktheexpirationdateofthehigh-leveldisinfectantorliquidchemicalsterilantbeforeeachuse.• UseateststriporotherUSFoodandDrugAdministration(FDA)-clearedtestingdevicespecifictothe
disinfectantorliquidchemicalsterilantandminimumeffectiveconcentrationoftheactiveingredientformonitoringsolutionpotencybeforeeachuse.
• Performmechanicalprocessinginaccordancewiththeendoscopemanufacturer’sIFUandthemechanicalprocessor’sIFU.o Verifycompatibilitybetweentheendoscopeandthemechanicalprocessorbeforeprocessing.o Positiontheendoscopeandaccessorieswithinthemechanicalprocessorinamannerthatensures
contactoftheprocessingsolutionswithallsurfacesoftheendoscope.o Ensureallconnectorsbetweentheendoscopeandthemechanicalprocessorareconnectedcorrectly.o Monitorthemechanicalprocessingcycletoverifyitiscompletedasprogrammed.
§ Ifamechanicalprocessingcycleisinterrupted,repeattheentirecycle.• Performmechanicalprocessingusingthecleaning,disinfectant,andsterilantsolutionsandchemicals
recommendedbytheendoscopemanufacturerandthemechanicalprocessormanufacturer.o Knowthelocationofthesafetydatasheetforeachchemicalused.o Knowthelocationofthechemicalspillkit.
Manualmethods
• Checktheexpirationdateofthehigh-leveldisinfectantbeforeeachuse.• UseateststriporotherUSFoodandDrugAdministration(FDA)-clearedtestingdevicespecifictothe
disinfectantandminimumeffectiveconcentrationoftheactiveingredientformonitoringsolutionpotencybeforeeachuse.
• Completelyimmersetheendoscopeinthehigh-leveldisinfectantsolutionforthedesignatedtimeaccordingtothedeviceandhigh-leveldisinfectantmanufacturer’sIFU.
• Flushandfilllumensandportswiththehigh-leveldisinfectantsolutionthencompletelyimmersetheitemsinthedisinfectantsolutionforthedesignatedtime.
• Followingdisinfection,thoroughlyrinsetheendoscopeandallofitschannelsandportswithwaterthatmeetsthemanufacturer’sspecificationorasrecommendedbyprofessionalorganizations.o Rinseallremovablepartsandendoscopeaccessories.
Mayberequiredforbothmechanicalandmanualmethods
• Flushendoscopelumenswith70%to90%ethylorisopropylalcoholaccordingtotheendoscopemanufacturer’sIFU.
• Drytheexteriorsurfacesoftheendoscopewithasoft,lint-freeclothorsponge.o Purgetheendoscopechannelswithair.o Dryallremovablepartsandendoscopeaccessories.
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Sterilization
• Packageandsterilizeendoscopesandendoscopeaccessoriesinaccordancewiththemanufacturers’IFU.
Storing• Storeflexibleendoscopesinaccordancewiththeendoscopeandstoragecabinetmanufacturers’IFU.
o Donotstoreflexibleendoscopesintheiroriginalshipmentcases.o Storeflexibleendoscopeswithallvalvesopenandremovablepartsdetached,butstoredwiththe
endoscope.• Wearclean,low-protein,powder-free,naturalrubberlatexglovesorlatex-freegloveswhenhandling
processedflexibleendoscopesandwhentransportingthemtoandfromthestoragecabinet.• Identifyprocessedendoscopeswiththefacility-specificvisualcue.• Visuallyinspectendoscopesandstoragecabinetsforcleanlinessbeforeplacingendoscopesintoor
removingthemfromthecabinet.• Storesterileitemsinasterilestorageareaperfacilitypolicyandprocedure.
Records• Recordsrelatedtoflexibleendoscopeprocessingwillincludethe
o dateandtime,o identityofendoscopeandendoscopeaccessories,o methodandverificationofcleaningandresultsofcleaningverificationtesting,o numberoridentifierofthemechanicalprocessororsterilizerandresultsofprocessefficacytesting,o identityofthepersonsperformingtheprocessing,o lotnumbersofprocessingsolutions,o dispositionofdefectiveitemsorequipment,ando maintenanceofwatersystems,endoscopesandendoscopeaccessories,andprocessingequipment.
• Recordsrelatedtoflexibleendoscopyprocedureswillincludetheo dateandtime,o identityofthepatient,o procedure,o identityofthelicensedindependentpractitionerperformingtheprocedure,ando identityoftheendoscopeandendoscopeaccessoriesusedduringtheprocedure.
• Recordsrelatedtoannualtrainingandcompetencyauditwillincludetheo dateandtimeoftrainingandcompetencyverificationo nameofpersonneltakingtraining/competencyverificationo resultsofcompetencyverificationo resultsofaudittool
• Recordsrelatedtofacilityauditsshouldincludetheo dateandtimeo facilitynameo completenessofinventoryandrepairlogo gapanalysis
§ actionstakeno riskassessment
§ actionstaken Availablefrom:https://www.cdc.gov/hicpac/recommendations/flexible-endoscope-reprocessing.html
175
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ram
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omm
enda
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te:
DE
M
=De
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=Di
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176
HICP
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Com
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Verif
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Met
hod
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]Not
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xpla
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Com
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Stat
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ia
Verif
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ion
Met
hod
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]Not
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xpla
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HICP
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mpe
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©2
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AORN
,Inc
.,21
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outh
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kerR
oad,
Sui
te4
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802
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Allr
ight
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erve
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3o
f18
Com
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ts/P
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T
7. T
rans
port
sthe
acc
esso
riesw
ithth
een
dosc
ope
butc
onta
ins
them
sepa
rate
lyfr
omth
een
dosc
ope.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
8. B
egin
sto
proc
essf
lexi
ble
endo
scop
esa
nda
cces
sorie
sas
soon
asp
ossib
lea
fter
tran
spor
tto
the
endo
scop
ypr
oces
sing
room
orw
ithin
the
man
ufac
ture
r’sre
com
men
ded
time
to
proc
essin
g.
a.
Whe
nit
isno
tpos
sible
toin
itiat
eth
ecl
eani
ngp
roce
ss
with
inth
een
dosc
ope
man
ufac
ture
r’sre
com
men
ded
time
toc
lean
ing,
follo
wst
hem
anuf
actu
rer’s
IFU
for
dela
yed
proc
essin
g.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
178
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
4o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
b.
Does
not
leav
efle
xibl
een
dosc
opes
soak
ing
ine
nzym
atic
cl
eani
ngso
lutio
nsb
eyon
dth
een
dosc
ope
man
ufac
ture
r’sd
esig
nate
dco
ntac
ttim
eun
less
this
isre
com
men
ded
inth
em
anuf
actu
rer’s
IFU
ford
elay
ed
proc
essin
g.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Leak
Testin
g9.
Per
form
slea
kte
stin
gbe
fore
man
ualc
lean
ing
and
befo
reth
een
dosc
ope
ispl
aced
into
cle
anin
gso
lutio
ns.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
10. P
erfo
rmsl
eak
test
ing
ina
ccor
danc
ew
ithth
een
dosc
ope
and
leak
-tes
ting
equi
pmen
tman
ufac
ture
rs’I
FUa
ndb
y
a.
rem
ovin
gal
lpor
tcov
ersa
ndfu
nctio
nva
lves
;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
plac
ing
the
endo
scop
ein
alo
ose
conf
igur
atio
n;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
c.
pres
suriz
ing
the
endo
scop
eto
the
reco
mm
ende
dpr
essu
re;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
d.
man
ipul
atin
gal
lmov
ing
part
s,in
clud
ing
the
elev
ator
,an
dan
gula
ting
the
bend
ing
sect
ion
ofth
edi
stal
end
;☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
4o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
b.
Does
not
leav
efle
xibl
een
dosc
opes
soak
ing
ine
nzym
atic
cl
eani
ngso
lutio
nsb
eyon
dth
een
dosc
ope
man
ufac
ture
r’sd
esig
nate
dco
ntac
ttim
eun
less
this
isre
com
men
ded
inth
em
anuf
actu
rer’s
IFU
ford
elay
ed
proc
essin
g.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Leak
Testin
g9.
Per
form
slea
kte
stin
gbe
fore
man
ualc
lean
ing
and
befo
reth
een
dosc
ope
ispl
aced
into
cle
anin
gso
lutio
ns.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
10. P
erfo
rmsl
eak
test
ing
ina
ccor
danc
ew
ithth
een
dosc
ope
and
leak
-tes
ting
equi
pmen
tman
ufac
ture
rs’I
FUa
ndb
y
a.
rem
ovin
gal
lpor
tcov
ersa
ndfu
nctio
nva
lves
;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
plac
ing
the
endo
scop
ein
alo
ose
conf
igur
atio
n;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
c.
pres
suriz
ing
the
endo
scop
eto
the
reco
mm
ende
dpr
essu
re;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
d.
man
ipul
atin
gal
lmov
ing
part
s,in
clud
ing
the
elev
ator
,an
dan
gula
ting
the
bend
ing
sect
ion
ofth
edi
stal
end
;☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
179
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
5o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
e.
actu
atin
gvi
deo
switc
hes;
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
f. m
aint
aini
ngp
ress
ure
and
insp
ectio
nfo
ram
inim
umo
f30
seco
nds.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
11. W
hen
ane
ndos
cope
fails
ale
akte
st,r
emov
esit
from
serv
ice
and
send
sfor
repa
iror
repl
acem
entp
erfa
cilit
ypo
licy
and
proc
edur
e.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Man
ualC
lean
ing
12. P
erfo
rmsm
anua
lcle
anin
gin
acc
orda
nce
with
the
endo
scop
em
anuf
actu
rer’s
IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
13. P
erfo
rmsm
anua
lcle
anin
gus
ing
the
type
ofw
ater
and
cl
eani
ngso
lutio
nre
com
men
ded
byth
een
dosc
ope
man
ufac
ture
r.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
14. P
erfo
rmsm
anua
lcle
anin
gus
ing
afr
eshl
ypr
epar
edc
lean
ing
solu
tion.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
5o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
e.
actu
atin
gvi
deo
switc
hes;
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
f. m
aint
aini
ngp
ress
ure
and
insp
ectio
nfo
ram
inim
umo
f30
seco
nds.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
11. W
hen
ane
ndos
cope
fails
ale
akte
st,r
emov
esit
from
serv
ice
and
send
sfor
repa
iror
repl
acem
entp
erfa
cilit
ypo
licy
and
proc
edur
e.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Man
ualC
lean
ing
12. P
erfo
rmsm
anua
lcle
anin
gin
acc
orda
nce
with
the
endo
scop
em
anuf
actu
rer’s
IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
13. P
erfo
rmsm
anua
lcle
anin
gus
ing
the
type
ofw
ater
and
cl
eani
ngso
lutio
nre
com
men
ded
byth
een
dosc
ope
man
ufac
ture
r.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
14. P
erfo
rmsm
anua
lcle
anin
gus
ing
afr
eshl
ypr
epar
edc
lean
ing
solu
tion.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
180
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
6o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
15. F
ollo
wst
hec
lean
ing
solu
tion
man
ufac
ture
r’sIF
Ufo
ra.
w
ater
qua
lity,
har
dnes
s,a
ndp
H;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
conc
entr
atio
nan
ddi
lutio
n;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
c.
wat
erte
mpe
ratu
re;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
d.
cont
actt
ime;
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
e.
cond
ition
sofs
tora
ge;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
f. us
elif
ean
dsh
elfl
ife.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
6o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
15. F
ollo
wst
hec
lean
ing
solu
tion
man
ufac
ture
r’sIF
Ufo
ra.
w
ater
qua
lity,
har
dnes
s,a
ndp
H;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
conc
entr
atio
nan
ddi
lutio
n;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
c.
wat
erte
mpe
ratu
re;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
d.
cont
actt
ime;
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
e.
cond
ition
sofs
tora
ge;
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
f. us
elif
ean
dsh
elfl
ife.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
181
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
7o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
16. C
ompl
etel
ysu
bmer
gest
hee
ndos
cope
inth
ecl
eani
ng
solu
tion
durin
gth
ecl
eani
ngp
roce
ss.
a.
Deta
ches
rem
ovab
lep
arts
(e.g
.,va
lves
,but
tons
,cap
s)
from
the
endo
scop
ean
dsu
bmer
gest
hem
if
reco
mm
ende
dby
the
endo
scop
em
anuf
actu
rer’s
IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
17. C
lean
sall
exte
riors
urfa
ceso
fthe
end
osco
pew
itha
soft
,lin
t-fr
eec
loth
ors
pong
esa
tura
ted
with
the
clea
ning
solu
tion.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
18. C
lean
sall
acce
ssib
lec
hann
elsa
ndth
edi
stal
end
oft
he
endo
scop
ew
itha
cle
anin
gbr
ush
ofth
ele
ngth
,wid
th,a
nd
mat
eria
lrec
omm
ende
dby
the
endo
scop
em
anuf
actu
rer.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
19. M
anua
llya
ctua
test
hee
ndos
cope
val
vesw
hile
cle
anin
g.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
20. C
lean
sand
bru
shes
the
elev
ator
mec
hani
sm(i
fpre
sent
)and
th
ere
cess
essu
rrou
ndin
git
with
ac
lean
ing
brus
hof
the
leng
th,w
idth
,and
mat
eria
lrec
omm
ende
dby
the
endo
scop
em
anuf
actu
rer.
a.
Raise
sand
low
erst
hee
leva
torm
echa
nism
thro
ugho
ut
the
man
ualc
lean
ing
proc
ess.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
21. U
sesa
cle
anb
rush
fore
ach
endo
scop
ecl
eani
ng.
a.
Visu
ally
insp
ects
bru
shes
and
oth
erit
emsu
sed
toc
lean
en
dosc
ope
chan
nels
befo
reu
sea
ndd
oesn
otu
seth
em
ifth
ein
tegr
ityo
fthe
bru
sho
roth
erc
lean
ing
item
isin
qu
estio
n.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
7o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
16. C
ompl
etel
ysu
bmer
gest
hee
ndos
cope
inth
ecl
eani
ng
solu
tion
durin
gth
ecl
eani
ngp
roce
ss.
a.
Deta
ches
rem
ovab
lep
arts
(e.g
.,va
lves
,but
tons
,cap
s)
from
the
endo
scop
ean
dsu
bmer
gest
hem
if
reco
mm
ende
dby
the
endo
scop
em
anuf
actu
rer’s
IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
17. C
lean
sall
exte
riors
urfa
ceso
fthe
end
osco
pew
itha
soft
,lin
t-fr
eec
loth
ors
pong
esa
tura
ted
with
the
clea
ning
solu
tion.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
18. C
lean
sall
acce
ssib
lec
hann
elsa
ndth
edi
stal
end
oft
he
endo
scop
ew
itha
cle
anin
gbr
ush
ofth
ele
ngth
,wid
th,a
nd
mat
eria
lrec
omm
ende
dby
the
endo
scop
em
anuf
actu
rer.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
19. M
anua
llya
ctua
test
hee
ndos
cope
val
vesw
hile
cle
anin
g.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
20. C
lean
sand
bru
shes
the
elev
ator
mec
hani
sm(i
fpre
sent
)and
th
ere
cess
essu
rrou
ndin
git
with
ac
lean
ing
brus
hof
the
leng
th,w
idth
,and
mat
eria
lrec
omm
ende
dby
the
endo
scop
em
anuf
actu
rer.
a.
Raise
sand
low
erst
hee
leva
torm
echa
nism
thro
ugho
ut
the
man
ualc
lean
ing
proc
ess.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
21. U
sesa
cle
anb
rush
fore
ach
endo
scop
ecl
eani
ng.
a.
Visu
ally
insp
ects
bru
shes
and
oth
erit
emsu
sed
toc
lean
en
dosc
ope
chan
nels
befo
reu
sea
ndd
oesn
otu
seth
em
ifth
ein
tegr
ityo
fthe
bru
sho
roth
erc
lean
ing
item
isin
qu
estio
n.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
182
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
8o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
22. B
rush
esth
eac
cess
ible
cha
nnel
soft
hee
ndos
cope
mul
tiple
tim
esu
ntil
nod
ebris
app
ears
on
the
brus
h.
a.
Rem
oves
deb
risfr
omth
ebr
ush
befo
reth
ebr
ush
isre
trac
ted
back
thro
ugh
the
chan
nela
nda
fter
eac
hpa
ss
bysw
irlin
gth
ebr
ush
inth
ecl
eani
ngso
lutio
nan
drin
sing
it.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
23. F
lush
esth
ech
anne
lsof
the
endo
scop
ew
ithc
lean
ing
solu
tion.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
24. F
lush
esa
ndri
nses
the
exte
riors
urfa
ceso
fthe
end
osco
pe
with
tap
wat
eru
ntil
allc
lean
ing
solu
tion
and
resid
uald
ebris
is
rem
oved
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
25. D
riest
hee
xter
iors
urfa
ceso
fthe
end
osco
pew
itha
soft
,lin
t-fr
eec
loth
ors
pong
ean
dpu
rges
all
chan
nels
with
air.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
26. C
lean
s,b
rush
es,r
inse
s,d
ries,
and
hig
h-le
veld
isinf
ects
or
ster
ilize
sall
reus
able
par
ts(e
.g.,
valv
es,b
utto
ns,p
ortc
over
s,
tubi
ng,w
ater
bot
tles)
,acc
esso
ries(
e.g.
,for
ceps
)and
cl
eani
ngim
plem
ents
(e.g
.,br
ushe
s,c
hann
elc
lean
ing
adap
ters
).a.
Hi
gh-le
veld
isinf
ects
ors
teril
izesw
ater
and
irrig
atio
nbo
ttle
satl
east
dai
ly.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
Does
not
allo
wa
nyre
sidua
lwat
ero
rmoi
stur
eto
rem
ain
inth
ew
ater
bot
tlea
ssem
bly.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
183
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
9o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
c.
Use
sste
rile
wat
erto
fill
wat
era
ndir
rigat
ion
bott
les.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
27. D
iscar
dssi
ngle
-use
par
ts,a
cces
sorie
s,a
ndc
lean
ing
impl
emen
tsa
fter
eac
hus
ean
ddo
esn
otre
proc
esst
hem
.☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Inspectin
g28
. Visu
ally
insp
ects
and
eva
luat
ese
ndos
cope
s,a
cces
sorie
s,a
nd
equi
pmen
tfor
a.
cl
eanl
ines
s,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
miss
ing
part
s,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
c.
clar
ityo
flen
ses,
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
d.
inte
grity
ofs
eals
and
gask
ets,
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
9o
f18
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
c.
Use
sste
rile
wat
erto
fill
wat
era
ndir
rigat
ion
bott
les.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
27. D
iscar
dssi
ngle
-use
par
ts,a
cces
sorie
s,a
ndc
lean
ing
impl
emen
tsa
fter
eac
hus
ean
ddo
esn
otre
proc
esst
hem
.☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Inspectin
g28
. Visu
ally
insp
ects
and
eva
luat
ese
ndos
cope
s,a
cces
sorie
s,a
nd
equi
pmen
tfor
a.
cl
eanl
ines
s,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
miss
ing
part
s,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
c.
clar
ityo
flen
ses,
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
d.
inte
grity
ofs
eals
and
gask
ets,
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
184
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
10
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
e.
moi
stur
e,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
f. ph
ysic
alo
rche
mic
ald
amag
e,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
g.
func
tion.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
29. U
sesl
ight
edm
agni
ficat
ion
toin
spec
tend
osco
pesa
nd
acce
ssor
iesf
orc
lean
lines
sand
dam
age,
asn
eede
d.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
30. R
emov
esd
efec
tive
endo
scop
es,a
cces
sorie
s,a
nde
quip
men
tfr
omse
rvic
ean
dse
ndsf
orre
pair
orre
plac
emen
tper
faci
lity
polic
yan
dpr
oced
ure.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
High
-Lev
elDisinfectio
norSteriliza
tion
31. C
ondu
ctsm
echa
nica
lorm
anua
lhig
h-le
veld
isinf
ectio
nor
st
erili
zatio
nfo
llow
ing
mec
hani
calc
lean
ing
asd
etai
led
in
item
s12-
27a
bove
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
10
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
e.
moi
stur
e,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
f. ph
ysic
alo
rche
mic
ald
amag
e,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
g.
func
tion.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
29. U
sesl
ight
edm
agni
ficat
ion
toin
spec
tend
osco
pesa
nd
acce
ssor
iesf
orc
lean
lines
sand
dam
age,
asn
eede
d.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
30. R
emov
esd
efec
tive
endo
scop
es,a
cces
sorie
s,a
nde
quip
men
tfr
omse
rvic
ean
dse
ndsf
orre
pair
orre
plac
emen
tper
faci
lity
polic
yan
dpr
oced
ure.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
High
-Lev
elDisinfectio
norSteriliza
tion
31. C
ondu
ctsm
echa
nica
lorm
anua
lhig
h-le
veld
isinf
ectio
nor
st
erili
zatio
nfo
llow
ing
mec
hani
calc
lean
ing
asd
etai
led
in
item
s12-
27a
bove
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
185
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
11
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
Mecha
nica
lmetho
ds
32. C
heck
sthe
exp
iratio
nda
teo
fthe
hig
h-le
veld
isinf
ecta
nto
rliq
uid
chem
ical
ster
ilant
bef
ore
each
use
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
33. U
sesa
test
strip
oro
ther
FDA
-cle
ared
test
ing
devi
cesp
ecifi
cto
the
disin
fect
anto
rliq
uid
chem
ical
ster
ilant
and
min
imum
ef
fect
ive
conc
entr
atio
nof
the
activ
ein
gred
ient
for
mon
itorin
gso
lutio
npo
tenc
ybe
fore
eac
hus
e.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
34. P
erfo
rmsm
echa
nica
lpro
cess
ing
ina
ccor
danc
ew
ithth
een
dosc
ope
man
ufac
ture
r’sIF
Ua
ndth
em
echa
nica
lpro
cess
or
man
ufac
ture
r’sIF
U.
a.
Verif
iesc
ompa
tibili
tyb
etw
een
the
endo
scop
ean
dth
em
echa
nica
lpro
cess
orb
efor
epr
oces
sing.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
Posit
ions
the
endo
scop
ean
dac
cess
orie
swith
inth
em
echa
nica
lpro
cess
orin
am
anne
rtha
tens
ures
con
tact
of
the
proc
essin
gso
lutio
nsw
itha
llsu
rfac
eso
fthe
en
dosc
ope.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
c.
Ensu
resa
llco
nnec
tors
bet
wee
nth
een
dosc
ope
and
the
mec
hani
calp
roce
ssor
are
con
nect
edc
orre
ctly
.☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
d.
Mon
itors
the
mec
hani
calp
roce
ssin
gcy
cle
tov
erify
itis
co
mpl
eted
asp
rogr
amm
ed.
• Re
peat
sthe
ent
irem
echa
nica
lcyc
leif
inte
rrup
ted
or
notc
ompl
eted
asp
rogr
amm
ed.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
11
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
Mecha
nica
lmetho
ds
32. C
heck
sthe
exp
iratio
nda
teo
fthe
hig
h-le
veld
isinf
ecta
nto
rliq
uid
chem
ical
ster
ilant
bef
ore
each
use
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
33. U
sesa
test
strip
oro
ther
FDA
-cle
ared
test
ing
devi
cesp
ecifi
cto
the
disin
fect
anto
rliq
uid
chem
ical
ster
ilant
and
min
imum
ef
fect
ive
conc
entr
atio
nof
the
activ
ein
gred
ient
for
mon
itorin
gso
lutio
npo
tenc
ybe
fore
eac
hus
e.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
34. P
erfo
rmsm
echa
nica
lpro
cess
ing
ina
ccor
danc
ew
ithth
een
dosc
ope
man
ufac
ture
r’sIF
Ua
ndth
em
echa
nica
lpro
cess
or
man
ufac
ture
r’sIF
U.
a.
Verif
iesc
ompa
tibili
tyb
etw
een
the
endo
scop
ean
dth
em
echa
nica
lpro
cess
orb
efor
epr
oces
sing.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
Posit
ions
the
endo
scop
ean
dac
cess
orie
swith
inth
em
echa
nica
lpro
cess
orin
am
anne
rtha
tens
ures
con
tact
of
the
proc
essin
gso
lutio
nsw
itha
llsu
rfac
eso
fthe
en
dosc
ope.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
c.
Ensu
resa
llco
nnec
tors
bet
wee
nth
een
dosc
ope
and
the
mec
hani
calp
roce
ssor
are
con
nect
edc
orre
ctly
.☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
d.
Mon
itors
the
mec
hani
calp
roce
ssin
gcy
cle
tov
erify
itis
co
mpl
eted
asp
rogr
amm
ed.
• Re
peat
sthe
ent
irem
echa
nica
lcyc
leif
inte
rrup
ted
or
notc
ompl
eted
asp
rogr
amm
ed.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
186
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
12
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
35. P
erfo
rmsm
echa
nica
lpro
cess
ing
usin
gth
ecl
eani
ng,
disin
fect
ant,
and
ster
ilant
solu
tions
and
che
mic
als
reco
mm
ende
dby
the
endo
scop
em
anuf
actu
rera
ndth
em
echa
nica
lpro
cess
orm
anuf
actu
rer.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
36. H
andl
esc
hem
ical
sand
solu
tions
use
dfo
rcle
anin
gan
dpr
oces
sing
flexi
ble
endo
scop
esa
nde
ndos
cope
acc
esso
riesi
nac
cord
ance
with
loca
l,st
ate,
and
fede
ralr
egul
atio
nsa
ndth
em
anuf
actu
rer’s
IFU
.a.
Ve
rbal
izest
helo
catio
nof
the
safe
tyd
ata
shee
tsfo
rch
emic
alsu
sed
forc
lean
ing
and
proc
essin
gfle
xibl
een
dosc
opes
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
Verb
alize
sthe
loca
tion
ofth
ech
emic
alsp
illk
it.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Man
ualm
etho
ds
37. C
heck
sthe
exp
iratio
nda
teo
fthe
hig
h-le
veld
isinf
ecta
nt
befo
ree
ach
use.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
38. U
sesa
test
strip
oro
ther
FDA
-cle
ared
test
ing
devi
cesp
ecifi
cto
the
disin
fect
anta
ndm
inim
ume
ffect
ive
conc
entr
atio
nof
th
eac
tive
ingr
edie
ntfo
rmon
itorin
gso
lutio
npo
tenc
ybe
fore
ea
chu
se.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
39. C
ompl
etel
yim
mer
sest
hee
ndos
cope
inth
ehi
gh-le
vel
disin
fect
ants
olut
ion
fort
hed
esig
nate
dtim
eac
cord
ing
toth
ede
vice
and
hig
h-le
veld
isinf
ecta
ntm
anuf
actu
rer’s
IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
12
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
35. P
erfo
rmsm
echa
nica
lpro
cess
ing
usin
gth
ecl
eani
ng,
disin
fect
ant,
and
ster
ilant
solu
tions
and
che
mic
als
reco
mm
ende
dby
the
endo
scop
em
anuf
actu
rera
ndth
em
echa
nica
lpro
cess
orm
anuf
actu
rer.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
36. H
andl
esc
hem
ical
sand
solu
tions
use
dfo
rcle
anin
gan
dpr
oces
sing
flexi
ble
endo
scop
esa
nde
ndos
cope
acc
esso
riesi
nac
cord
ance
with
loca
l,st
ate,
and
fede
ralr
egul
atio
nsa
ndth
em
anuf
actu
rer’s
IFU
.a.
Ve
rbal
izest
helo
catio
nof
the
safe
tyd
ata
shee
tsfo
rch
emic
alsu
sed
forc
lean
ing
and
proc
essin
gfle
xibl
een
dosc
opes
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
Verb
alize
sthe
loca
tion
ofth
ech
emic
alsp
illk
it.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Man
ualm
etho
ds
37. C
heck
sthe
exp
iratio
nda
teo
fthe
hig
h-le
veld
isinf
ecta
nt
befo
ree
ach
use.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
38. U
sesa
test
strip
oro
ther
FDA
-cle
ared
test
ing
devi
cesp
ecifi
cto
the
disin
fect
anta
ndm
inim
ume
ffect
ive
conc
entr
atio
nof
th
eac
tive
ingr
edie
ntfo
rmon
itorin
gso
lutio
npo
tenc
ybe
fore
ea
chu
se.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
39. C
ompl
etel
yim
mer
sest
hee
ndos
cope
inth
ehi
gh-le
vel
disin
fect
ants
olut
ion
fort
hed
esig
nate
dtim
eac
cord
ing
toth
ede
vice
and
hig
h-le
veld
isinf
ecta
ntm
anuf
actu
rer’s
IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
187
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
13
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
40. F
lush
esa
ndfi
llslu
men
sand
por
tsw
ithth
ehi
gh-le
vel
disin
fect
ant,
then
com
plet
ely
imm
erse
sthe
item
sin
the
disin
fect
ants
olut
ion
fort
hed
esig
nate
dtim
e.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
41. T
horo
ughl
yrin
sest
hee
ndos
cope
and
all
ofit
scha
nnel
sand
po
rtsw
ithw
ater
that
mee
tsth
em
anuf
actu
rer’s
sp
ecifi
catio
nso
rasr
ecom
men
ded
byp
rofe
ssio
nal
orga
niza
tions
aft
erd
isinf
ectio
n.
a.
Rins
esa
llre
mov
able
par
tsa
nde
ndos
cope
acc
esso
ries.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
May
berequ
iredforb
othmecha
nica
land
man
ual
metho
ds
42. F
lush
ese
ndos
cope
lum
ensw
ith7
0%to
90%
eth
ylo
riso
prop
yla
lcoh
ola
ccor
ding
toth
een
dosc
ope
man
ufac
ture
r’s
IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
43. D
riest
hee
xter
iors
urfa
ceso
fthe
end
osco
pew
itha
soft
,lin
t-fr
eec
loth
ors
pong
e.
a.
Purg
esth
een
dosc
ope
chan
nels
with
air.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
Drie
sall
rem
ovab
lep
arts
and
end
osco
pea
cces
sorie
s.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Sterilizatio
n44
. Pac
kage
sand
ster
ilize
send
osco
pesa
nde
ndos
cope
ac
cess
orie
sin
acco
rdan
cew
ithth
em
anuf
actu
rers
’IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
13
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
40. F
lush
esa
ndfi
llslu
men
sand
por
tsw
ithth
ehi
gh-le
vel
disin
fect
ant,
then
com
plet
ely
imm
erse
sthe
item
sin
the
disin
fect
ants
olut
ion
fort
hed
esig
nate
dtim
e.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
41. T
horo
ughl
yrin
sest
hee
ndos
cope
and
all
ofit
scha
nnel
sand
po
rtsw
ithw
ater
that
mee
tsth
em
anuf
actu
rer’s
sp
ecifi
catio
nso
rasr
ecom
men
ded
byp
rofe
ssio
nal
orga
niza
tions
aft
erd
isinf
ectio
n.
a.
Rins
esa
llre
mov
able
par
tsa
nde
ndos
cope
acc
esso
ries.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
May
berequ
iredforb
othmecha
nica
land
man
ual
metho
ds
42. F
lush
ese
ndos
cope
lum
ensw
ith7
0%to
90%
eth
ylo
riso
prop
yla
lcoh
ola
ccor
ding
toth
een
dosc
ope
man
ufac
ture
r’s
IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
43. D
riest
hee
xter
iors
urfa
ceso
fthe
end
osco
pew
itha
soft
,lin
t-fr
eec
loth
ors
pong
e.
a.
Purg
esth
een
dosc
ope
chan
nels
with
air.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
Drie
sall
rem
ovab
lep
arts
and
end
osco
pea
cces
sorie
s.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
Sterilizatio
n44
. Pac
kage
sand
ster
ilize
send
osco
pesa
nde
ndos
cope
ac
cess
orie
sin
acco
rdan
cew
ithth
em
anuf
actu
rers
’IFU
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
188
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
14
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
Storing
45. S
tore
sfle
xibl
een
dosc
opes
ina
ccor
danc
ew
ithth
een
dosc
ope
and
stor
age
cabi
netm
anuf
actu
rers
’IFU
.a.
Do
esn
otst
ore
flexi
ble
endo
scop
esin
thei
rorig
inal
sh
ipm
entc
ases
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
Stor
esfl
exib
lee
ndos
cope
swith
all
valv
eso
pen
and
rem
ovab
lep
arts
det
ache
d,b
utst
ored
with
the
endo
scop
e.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
46. W
ears
cle
an,l
ow-p
rote
in,p
owde
r-fr
ee,n
atur
alru
bber
late
xgl
oves
orl
atex
-free
glo
vesw
hen
hand
ling
proc
esse
den
dosc
opes
and
whe
ntr
ansp
ortin
gth
emto
and
from
the
stor
age
cabi
net.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
47. V
erba
lizes
faci
lity-
spec
ific
visu
alc
uefo
ride
ntify
ing
proc
esse
den
dosc
opes
.☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
48. V
isual
lyin
spec
tse
ndos
cope
sand
stor
age
cabi
nets
for
clea
nlin
essb
efor
epl
acin
gen
dosc
opes
into
orr
emov
ing
them
fr
omth
eca
bine
t.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
49. S
tore
sste
rile
item
sin
ast
erile
stor
age
area
per
faci
lity
polic
yan
dpr
oced
ure.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
14
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
Storing
45. S
tore
sfle
xibl
een
dosc
opes
ina
ccor
danc
ew
ithth
een
dosc
ope
and
stor
age
cabi
netm
anuf
actu
rers
’IFU
.a.
Do
esn
otst
ore
flexi
ble
endo
scop
esin
thei
rorig
inal
sh
ipm
entc
ases
.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
Stor
esfl
exib
lee
ndos
cope
swith
all
valv
eso
pen
and
rem
ovab
lep
arts
det
ache
d,b
utst
ored
with
the
endo
scop
e.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
46. W
ears
cle
an,l
ow-p
rote
in,p
owde
r-fr
ee,n
atur
alru
bber
late
xgl
oves
orl
atex
-free
glo
vesw
hen
hand
ling
proc
esse
den
dosc
opes
and
whe
ntr
ansp
ortin
gth
emto
and
from
the
stor
age
cabi
net.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
47. V
erba
lizes
faci
lity-
spec
ific
visu
alc
uefo
ride
ntify
ing
proc
esse
den
dosc
opes
.☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
48. V
isual
lyin
spec
tse
ndos
cope
sand
stor
age
cabi
nets
for
clea
nlin
essb
efor
epl
acin
gen
dosc
opes
into
orr
emov
ing
them
fr
omth
eca
bine
t.
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
49. S
tore
sste
rile
item
sin
ast
erile
stor
age
area
per
faci
lity
polic
yan
dpr
oced
ure.
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
189
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
15
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
Reco
rding
50. R
ecor
dsth
efo
llow
ing
proc
essin
gin
form
atio
n:
a.
date
and
tim
e,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
iden
tity
ofe
ndos
cope
and
end
osco
pea
cces
sorie
s,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
c.
met
hod
and
verif
icat
ion
ofc
lean
ing
and
resu
ltso
fcl
eani
ngv
erifi
catio
nte
stin
g,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
d.
num
bero
ride
ntifi
ero
fthe
mec
hani
calp
roce
ssor
or
ster
ilize
rand
resu
ltso
fpro
cess
effi
cacy
test
ing,
☐
DEM
☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
e.
iden
tity
ofth
epe
rson
sper
form
ing
the
proc
essin
g,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
f. lo
tnum
bers
oft
hep
roce
ssin
gso
lutio
ns,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
HICP
ACS
ampl
eCo
mpe
tenc
yVe
rificat
ion
Tool
:Rep
roce
ssin
gFl
exib
leE
ndos
cope
s Ad
apte
dw
ithp
erm
issio
nfr
om“
Perio
pera
tive
Com
pete
ncy
Verif
icat
ion
Tool
sand
Job
Desc
riptio
ns.C
opyr
ight
©2
016
AORN
,Inc
.,21
70S
outh
Par
kerR
oad,
Sui
te4
00,D
enve
r,CO
802
31.
Allr
ight
sres
erve
d.”
Page
15
of1
8
Com
pete
ncy
Stat
emen
ts/P
erfo
rman
ceC
riter
ia
Verif
icat
ion
Met
hod
[See
lege
nda
bove
]Not
Met
[E
xpla
inw
hy]
Reco
rding
50. R
ecor
dsth
efo
llow
ing
proc
essin
gin
form
atio
n:
a.
date
and
tim
e,
☐DE
M☐
S☐
RWM
☐
V☐
DO
☐SB
T☐
P&P
☐
Oth
er
☐DA
☐
CS
☐KA
T
b.
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193
HICPACSampleAuditTool:ReprocessingFlexibleEndoscopes
AdaptedwithpermissionfromGuidelineEssentials.Copyright©2016,AORN,Inc,2170S.ParkerRoad,Suite400,Denver,CO80231.Allrightsreserved. Page1of3
HICPACSampleAuditTool:ReprocessingFlexibleEndoscopes
Purpose:FacilitiescanusethissampleAuditTooldocumentasatemplatetodeveloptheirownaudittoolspecifictotheirendoscopesandevidence-basedreprocessingpractices.ThissampletoolisdesignedtobeusedinconjunctionwiththeCompetencyVerificationTool.Facilitiesareencouragedtousethesetoolstogethertoverifycompetencyandauditcurrentpracticeaswellastoensurethattheirpracticesareconsistentwith“EssentialElementsofaReprocessingProgramforFlexibleEndoscopes–RecommendationsoftheHealthcareInfectionControlPracticesAdvisoryCommittee.”
Auditor: Date:
AuditItem Yes No Comments/ActionPrecleaning Precleanstheflexibleendoscopeatthepointofuse. Discardsthecleaningsolutionandclothafteruse. Transporting Transportsthecontaminatedendoscopeandaccessoriestotheendoscopyprocessingroomassoonaspossibleafteruse.
Ensuresthecontainerorcartislabeledwithabiohazardlegend. LeakTesting Performsleaktestingbeforemanualcleaningifindicated. ManualCleaning Usesafreshlypreparedcleaningsolutionanddoesnotaddadditionalproductstothewaterunlessrecommendedbythemanufacturer.
Completelysubmergestheendoscopeandaccessories. Cleansexteriorsurfacesoftheendoscopewithasoft,lint-freeclothorsponge.
Cleansallaccessiblechannelsandtheendoftheendoscopewithacleaningbrushofthelength,width,andmaterialrecommendedbytheendoscopemanufacturer.
Usesacleanbrushforeachendoscopecleaning. Iftheendoscopehasanelevator,raisesandlowerstheelevatorthroughoutthemanualcleaningprocess.
Brushestheaccessiblechannelsuntilnodebrisappearsonthebrush.
Removesdebrisbeforeretractingthebrushbackthroughtheendoscope.
Flushesthechannelsoftheendoscopewiththecleaningsolution. Manuallyactuatesthevalvesduringthecleaningprocess. Flushesandrinsesexteriorsurfacesandinternalchannelswithwateruntilallcleaningsolutionandresidualdebrisisremoved.
Driesexteriorsurfacesandremovablepartsoftheendoscopeandpurgesallchannelswithair.
Reprocessesreusableparts,accessories,andcleaningimplementsaccordingtothemanufacturer’sinstructionsforuse(IFU).
Disposesofsingle-useparts,accessories,andcleaningimplements.
HICPACSampleAuditTool:ReprocessingFlexibleEndoscopes
AdaptedwithpermissionfromGuidelineEssentials.Copyright©2016,AORN,Inc,2170S.ParkerRoad,Suite400,Denver,CO80231.Allrightsreserved. Page1of3
HICPACSampleAuditTool:ReprocessingFlexibleEndoscopes
Purpose:FacilitiescanusethissampleAuditTooldocumentasatemplatetodeveloptheirownaudittoolspecifictotheirendoscopesandevidence-basedreprocessingpractices.ThissampletoolisdesignedtobeusedinconjunctionwiththeCompetencyVerificationTool.Facilitiesareencouragedtousethesetoolstogethertoverifycompetencyandauditcurrentpracticeaswellastoensurethattheirpracticesareconsistentwith“EssentialElementsofaReprocessingProgramforFlexibleEndoscopes–RecommendationsoftheHealthcareInfectionControlPracticesAdvisoryCommittee.”
Auditor: Date:
AuditItem Yes No Comments/ActionPrecleaning Precleanstheflexibleendoscopeatthepointofuse. Discardsthecleaningsolutionandclothafteruse. Transporting Transportsthecontaminatedendoscopeandaccessoriestotheendoscopyprocessingroomassoonaspossibleafteruse.
Ensuresthecontainerorcartislabeledwithabiohazardlegend. LeakTesting Performsleaktestingbeforemanualcleaningifindicated. ManualCleaning Usesafreshlypreparedcleaningsolutionanddoesnotaddadditionalproductstothewaterunlessrecommendedbythemanufacturer.
Completelysubmergestheendoscopeandaccessories. Cleansexteriorsurfacesoftheendoscopewithasoft,lint-freeclothorsponge.
Cleansallaccessiblechannelsandtheendoftheendoscopewithacleaningbrushofthelength,width,andmaterialrecommendedbytheendoscopemanufacturer.
Usesacleanbrushforeachendoscopecleaning. Iftheendoscopehasanelevator,raisesandlowerstheelevatorthroughoutthemanualcleaningprocess.
Brushestheaccessiblechannelsuntilnodebrisappearsonthebrush.
Removesdebrisbeforeretractingthebrushbackthroughtheendoscope.
Flushesthechannelsoftheendoscopewiththecleaningsolution. Manuallyactuatesthevalvesduringthecleaningprocess. Flushesandrinsesexteriorsurfacesandinternalchannelswithwateruntilallcleaningsolutionandresidualdebrisisremoved.
Driesexteriorsurfacesandremovablepartsoftheendoscopeandpurgesallchannelswithair.
Reprocessesreusableparts,accessories,andcleaningimplementsaccordingtothemanufacturer’sinstructionsforuse(IFU).
Disposesofsingle-useparts,accessories,andcleaningimplements.
HICPACSampleAuditTool:ReprocessingFlexibleEndoscopes
AdaptedwithpermissionfromGuidelineEssentials.Copyright©2016,AORN,Inc,2170S.ParkerRoad,Suite400,Denver,CO80231.Allrightsreserved. Page1of3
HICPACSampleAuditTool:ReprocessingFlexibleEndoscopes
Purpose:FacilitiescanusethissampleAuditTooldocumentasatemplatetodeveloptheirownaudittoolspecifictotheirendoscopesandevidence-basedreprocessingpractices.ThissampletoolisdesignedtobeusedinconjunctionwiththeCompetencyVerificationTool.Facilitiesareencouragedtousethesetoolstogethertoverifycompetencyandauditcurrentpracticeaswellastoensurethattheirpracticesareconsistentwith“EssentialElementsofaReprocessingProgramforFlexibleEndoscopes–RecommendationsoftheHealthcareInfectionControlPracticesAdvisoryCommittee.”
Auditor: Date:
AuditItem Yes No Comments/ActionPrecleaning Precleanstheflexibleendoscopeatthepointofuse. Discardsthecleaningsolutionandclothafteruse. Transporting Transportsthecontaminatedendoscopeandaccessoriestotheendoscopyprocessingroomassoonaspossibleafteruse.
Ensuresthecontainerorcartislabeledwithabiohazardlegend. LeakTesting Performsleaktestingbeforemanualcleaningifindicated. ManualCleaning Usesafreshlypreparedcleaningsolutionanddoesnotaddadditionalproductstothewaterunlessrecommendedbythemanufacturer.
Completelysubmergestheendoscopeandaccessories. Cleansexteriorsurfacesoftheendoscopewithasoft,lint-freeclothorsponge.
Cleansallaccessiblechannelsandtheendoftheendoscopewithacleaningbrushofthelength,width,andmaterialrecommendedbytheendoscopemanufacturer.
Usesacleanbrushforeachendoscopecleaning. Iftheendoscopehasanelevator,raisesandlowerstheelevatorthroughoutthemanualcleaningprocess.
Brushestheaccessiblechannelsuntilnodebrisappearsonthebrush.
Removesdebrisbeforeretractingthebrushbackthroughtheendoscope.
Flushesthechannelsoftheendoscopewiththecleaningsolution. Manuallyactuatesthevalvesduringthecleaningprocess. Flushesandrinsesexteriorsurfacesandinternalchannelswithwateruntilallcleaningsolutionandresidualdebrisisremoved.
Driesexteriorsurfacesandremovablepartsoftheendoscopeandpurgesallchannelswithair.
Reprocessesreusableparts,accessories,andcleaningimplementsaccordingtothemanufacturer’sinstructionsforuse(IFU).
Disposesofsingle-useparts,accessories,andcleaningimplements.
8.4
194
HICPACSampleAuditTool:ReprocessingFlexibleEndoscopes
AdaptedwithpermissionfromGuidelineEssentials.Copyright©2016,AORN,Inc,2170S.ParkerRoad,Suite400,Denver,CO80231.Allrightsreserved. Page2of3
AuditItem Yes No Comments/ActionInspection Inspectsandevaluatesendoscopesandaccessoriesfor• cleanliness
• missingparts • clarityoflenses • integrityofsealsandgaskets • physicalorchemicaldamage • moisture • function Usesadditionalilluminationandmagnificationforinspection,asneeded.
High-levelDisinfectionorSterilization Manuallycleanstheendoscopeandaccessoriesbeforemechanicalormanualhigh-leveldisinfectionorsterilization.
MechanicalmethodsCheckstheexpirationdateofthehigh-leveldisinfectantorliquidchemicalsterilantbeforeeachuse.
UsesateststriporotherFDA-clearedtestingdevicespecifictothedisinfectantorliquidchemicalsterilantandminimumeffectiveconcentrationoftheactiveingredientformonitoringsolutionpotencybeforeeachuse.
Positionsendoscopesandaccessorieswithinthemechanicalprocessortoensurecontactoftheprocessingsolutionswithallsurfacesoftheendoscope.
Connectstheendoscopetothemechanicalprocessorcorrectly. Verifiesmechanicalprocessingcyclesarecompletedasprogrammed.
ManualmethodsCheckstheexpirationdateofthehigh-leveldisinfectantbeforeeachuse.
UsesateststriporotherFDA-clearedtestingdevicespecifictothedisinfectantandminimumeffectiveconcentrationoftheactiveingredientformonitoringsolutionpotencybeforeeachuse.
Flushesandfillslumensandportswiththehigh-leveldisinfectant. Completelyimmersestheendoscopeinthehigh-leveldisinfectantsolutionforthedesignatedtimeaccordingtothedeviceandhigh-leveldisinfectantsolutionmanufacturer’sIFU.
Rinsestheendoscopewithwaterthatmeetsthemanufacturer’sspecificationorasrecommendedbyprofessionalorganizationsafterdisinfection.
MayberequiredforbothmechanicalandmanualmethodsFlusheslumensusing70%to90%ethylorisopropylalcoholaccordingtotheendoscopemanufacturer’sIFU.
Driesexteriorsurfacesandremovablepartsoftheendoscopeandpurgesallchannelswithair.
195
HICPACSampleAuditTool:ReprocessingFlexibleEndoscopes
AdaptedwithpermissionfromGuidelineEssentials.Copyright©2016,AORN,Inc,2170S.ParkerRoad,Suite400,Denver,CO80231.Allrightsreserved. Page3of3
AuditItem Yes No Comments/ActionSterilizationPackagesandsterilizesendoscopicaccessoriesthatentersteriletissueorthevascularsystemperthehealthcarefacility’spolicyandprocedure.
Storage Wearscleangloveswhentransportingtheendoscopetoandfromthestoragecabinet.
Basedonthecabinetdesign,storesflexibleendoscopeshorizontallyorhangsthemverticallysotheydonotcoilortouchthefloorofthecabinet.
Storestheflexibleendoscopewithallvalvesopenandremovablepartsdetached.
Storessterileitemsinasterilestoragearea. Records Processingrecordsinclude• dateandtime
• identityofendoscopeandendoscopeaccessories • methodandverificationofcleaningandresultsofcleaning
verificationtesting
• numberoridentifierofthemechanicalprocessororsterilizerandresultsofprocessefficacytesting
• identityofthepersonsperformingtheprocessing • lotnumbersoftheprocessingsolutions • dispositionofdefectiveitemsorequipment • maintenanceofwatersystems,endoscopesandendoscope
accessories,andprocessingequipment
Proceduralrecordsinclude• dateandtime
• identityofthepatient • procedure • identityofthelicensedindependentpractitionerperforming
theprocedure
• identityoftheendoscopeandendoscopeaccessoriesused
Availablefrom:https://www.cdc.gov/hicpac/recommendations/flexible-endoscope-reprocessing.html
196
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Major article
Reported gastrointestinal endoscope reprocessing lapses: The tip of the iceberg
Alexandra M. Dirlam Langlay PhD a, Cori L. Ofstead MSPH a,*, Natalie J. Mueller MPH a,Pritish K. Tosh MDb, Todd H. Baron MDc, Harry P. Wetzler MD, MSPH a
aOfstead & Associates, Inc, Saint Paul, MNbDivision of Infectious Diseases, Mayo Clinic, Rochester, MNcDivision of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
Key Words:Instrument cleaningGuideline adherenceHigh-level disinfectionEpidemiologyColonoscopyMultidrug-resistant organismsInfection
Background: Most cases of microbial transmission to patients via contaminated endoscopes haveresulted from nonadherence to reprocessing guidelines. We evaluated the occurrence, features, andimplications of reprocessing lapses to gauge the nature and breadth of the problem in the context ofwidely available and accepted practice guidelines.Methods: We examined peer-reviewed and non-peer-reviewed literature to identify lapses reported inNorth America during 2005 to 2012 resulting in patient exposure to potentially contaminated gastro-intestinal endoscopes.Results: Lapses occurred in various types of facilities and involved errors in all major steps of reproc-essing. Each lapse continued for several months or years until the problemwas discovered except for onethat was described as a single incident. There were significant implications for patients, includingnotification and testing, microbial transmission, and increased morbidity and mortality. Only 1 reproc-essing lapse was found in a peer-reviewed journal article, and other incidents were reported ingovernmental reports, legal documents, conference abstracts, and media reports.Conclusion: Reprocessing lapses are an ongoing and widespread problem despite the existence ofguidelines. Lack of publication in peer-reviewed literature contributes to the perception that lapses arerare and inconsequential. Reporting requirements and epidemiologic investigations are needed todevelop better evidence-based policies and practices.
Copyright � 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc.Published by Elsevier Inc. All rights reserved.
Gastrointestinal (GI) endoscopes are used in bodily cavities thatare heavily colonized with microorganisms.1 Proper endoscopereprocessing, including thorough cleaning and high-level disin-fection (HLD), is necessary between patients to minimize the riskof cross contamination.1 Reprocessing guidelines for fiberopticendoscopes were first published in 1978.2 Since then, governmentaland professional organizations have updated them and developednew guidelines for reprocessing specific types of endoscopes.1,3,4
Guideline nonadherence led to the use of improperly reproc-essed endoscopes at Veterans Affairs (VA) medical facilities inTennessee, Florida, and Georgia between 2003 and 2009, requiringnotification of over 10,000 patients.5,6 Other reprocessing lapses(“lapses”) have come to light following investigations into facilities’practices.5-8 In 2008, the United States Centers for Medicare andMedicaid Services (CMS) conducted unannounced inspections ofinfection control practices at 68 ambulatory surgical centers, overhalf of which performed endoscopies.7 Among these facilities, 39had deficiencies in infection control serious enough to warrantcitation, and 19 failed to properly reprocess instruments. In 2010,an observational, multisite study revealed that only 48% of 183 GIendoscopes were properly reprocessed, even though managers atall sites asserted institutional adherence to guidelines and reproc-essing personnel were aware of being observed.8 Nonadherencewas particularly high (99%) when manual methods were used toclean endoscopes.8
A study conducted at Beth Israel Deaconess Medical Center andHarvard Medical School found that GI endoscopy-associated
* Address correspondence to Cori L. Ofstead, MSPH, Ofstead & Associates, Inc, 400Selby Avenue, Suite V, Blair Arcade West, Saint Paul, MN 55102.
E-mail address: [email protected] (C.L. Ofstead).Ofstead & Associates, Inc. has received funding from Johnson & Johnson and 3M
Company for infection prevention studies. Research reported here was supportedwith internal resources from Ofstead and Mayo Clinic. Outside corporations did nothave access to data and were not involved in manuscript preparation.
Conflicts of interest: C.L.O. has received honoraria from Johnson & Johnsonand 3M Company for speaking engagements related to instrument reprocessing.A.M.D.L., C.L.O., N.J.M., and H.P.W. are employed by Ofstead & Associates, Inc. Theremaining authors disclose no conflicts.
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.aj ic journal .org
American Journal of Infection Control
0196-6553/$36.00 - Copyright � 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.ajic.2013.04.022
American Journal of Infection Control 41 (2013) 1188-948.6
198
complications resulting in an emergency department visit or hos-pitalization occurred after approximately 1% of 18,015 outpatientprocedures, including screening colonoscopies.9 Complicationsincluded fever and other potential signs of infection. Other res-earchers have reported numerous cases of postendoscopy infectionassociated with endoscope contamination, including transmissionof multidrug-resistant organisms (MDROs).2,10-12 Although the riskof infection following endoscopy is stated to be extremely remoteby nearly all major guidelines including the 2008 Centers forDisease Control and Prevention/Healthcare Infection Control Prac-tices Advisory Committee (CDC/HICPAC) Guideline for Disinfectionand Sterilization in Healthcare Facilities and the 2011 MultisocietyGuideline on Reprocessing Flexible GI Endoscopes,1,4 existing riskestimates were recently found to be outdated, inaccurate, based onflawed methods, and too low.13
Since the introduction of reprocessing guidelines, there havebeen increases in the volume of endoscopic procedures, thecomplexity of endoscope design, and the economic pressures oninstitutions. Given the current challenges, we evaluated theoccurrence, features, and implications of recently reported lapses.
METHODS
Searches for scientific, peer-reviewed journal articles describinglapses were conducted via PubMed. Internet searches were per-formed to identify lapses published in media reports, includingnewspapers, magazines, press releases, or other articles. Govern-ment Web sites and reports were also reviewed, including sourcesfrom state departments of health, the Department of VeteransAffairs Office of Inspector General (VAOIG), CDC’s Epidemic Intel-ligence Service, and the Food and Drug Administration (FDA).Whenever possible, multiple sources were obtained to compileinformation about a lapse because individual documents oftencontained incomplete information.
We sought to identify lapses reported between January 2005and June 2012 in North America. Reports that met these searchparameters and described a lapse resulting in patient exposureto a potentially contaminated GI endoscope were included. Lap-ses were defined as any incident involving 1 or more reprocessingerrors resulting in the exposure of 1 or more patients. Errorsincluded nonadherence to cleaning and disinfection guidelines,improper use of reprocessing equipment, or inadequate standardoperating procedures or staff competence records for reproces-sing. Endoscopes under consideration included colonoscopes,gastroscopes, duodenoscopes (eg, endoscopic retrograde chol-angiopancreatography endoscopes), and endoscopes not other-wise specified.
RESULTS
Geographic and facility spread
Reported lapses occurred with various GI endoscopes andprocedures at health care facilities throughout the United Statesand Canada (Tables 1 and 2). Public and private facilities, includinghospitals, medical centers from large health systems, outpatientendoscopy centers, and outpatient surgical centers were involved(Tables 1 and 2). In some cases, multiple facilities within the samehealth system were implicated.5,14,15
Sources of reports
Among the lapses identified, only 1 was published in a peer-reviewed journal,16 whereas all others were described in mediareports and related sources (Table 1) or government reports
(Table 2). Individual government documents and certain mediareports described lapses at multiple health care facilities, including4 reports published by state agencies (Table 2).17-20
Following the well-publicized lapses at 3 VA medical facilities,unannounced inspections of 36 VA medical facilities with 38reprocessing units for colonoscopes were conducted by the VAOIGin 2009.5 Among these units, 52.6% were found to have inadequatestandard operating procedures or documentation of demonstratedstaff competence for reprocessing (Table 2). Since then, the VAOIGhas continued tomonitor facilities and publish reviews that indicatewhether processes are in place to ensure effective reprocessing.These recent reviews described additional lapses in the reprocessingof reusable medical equipment, including GI endoscopes.
Lapses were also readily identifiable in the FDA’s Manufacturerand User Facility Device Experience (MAUDE) database, whichconsists of adverse event reports involving medical devices. Theseare voluntary reports or other reports submitted by device manu-facturers, distributors, and health care facilities, typically followingdevice malfunction or incidents resulting in serious patient injuryor death. Recent MAUDE reports described postendoscopy com-plications, including infections or chemical colitis, attributed toreprocessing errors or defective equipment that was undetectedprior to patient use. When the FDA reviewed MAUDE reports onendoscopes filed between January 1, 2007, and May 11, 2010, theagency found 80 reports of lapses and 28 reports of infectionpossibly because of inadequate reprocessing (Table 2).21 Supple-mental data and references documenting lapses described inMAUDE and VAOIG reports are available from the authors onrequest.
Duration and nature of errors
Reports described errors in each of themajor reprocessing steps,whereas general noncompliance with guidelines and manufacturerprotocols was also cited. Steps were skipped or done improperly forentire endoscopes as well as for certain channels (Tables 1 and 2).Only 1 lapse was described as a single incident,22 whereas multiplelapses continued for several years, exposing numerous patients topotentially contaminated endoscopes.23-27 In some cases, the lapseduration was unknown, either because it was not disclosed orbecause investigators were unable to determine when the prob-lems started.28,29
Many lapses were identified as a result of surveillance orinspections. The single lapse reported in a peer-reviewed journalwas discovered during surveillance for deviations from reprocess-ing protocols.16 Government reports also described improperreprocessing practices identified through inspections or mandatoryadverse event reports.17,18 Generally, states having multiple lapses,such as Pennsylvania, New Jersey, and California, had mandatorypatient safety reporting requirements, whereas other states maynot gather data or publicly report lapses.
Improper cleaning occurred on multiple occasions, andemployees detected visually apparent residual matter on endo-scopes during several of these lapses.18,30-34 At 3 hospitals, residueon duodenoscopes was associated with bacterial infections.31,34 Atone of the hospitals, guidelines were violated over a period of 20months when contaminated duodenoscopes were allowed to drybefore cleaning.30,35 MAUDE reports described multiple lapsesinvolving detection of debris or residue in various endoscopechannels or components. Other lapses described in MAUDE reportsinvolved broken cleaning brushes that were left in endoscopes andfound during subsequent procedures, occasionally after beingexpelled into patients.
Errors in disinfection often involved lack of HLD for entire endo-scopes or certain channels.16,18,19,23,36-39 For example, endoscopes at
A.M. Dirlam Langlay et al. / American Journal of Infection Control 41 (2013) 1188-94 1189
199
Table
1Lapsespublished
inmed
iareports
andrelatedsources:North
America,
January20
05-June20
12
Typeof
hea
lthcare
facility
Location
Pub.
Yea
rTy
peof
endosco
pe
Errors
Estimated
duration
oflapse
Estimated
patients
Microorga
nismsfound
Exposed
Notified
Tested
Tested
positive
Privatehospital
32,33
North
Carolina
2012
GIen
dosco
peNOS
Noclea
ningor
sterilization
for1ch
annel
5mon
ths
10Yes
Yes
(viral)
ND
ND
Outpatienten
doscop
yclinic
26,71-73
Ontario
2011
;20
12GIen
dosco
peNOS
Multiple
reprocessing
andch
emical
issu
es9ye
ars
6,80
0Yes
Yes
(viral)
408
Hep
atitis
B;
hep
atitis
CAcadem
icmed
ical
center3
6,74
Louisiana
2011
GIen
dosco
peNOS
NoHLD
8mon
ths
222
Yes
Yes
(viral)
ND
ND
Privatemed
ical
center3
8,75,76
Orego
n20
11Colon
osco
pe
NoHLD
ND
18Yes
Yes
(viral)
ND
ND
Academ
icmed
ical
center7
7-79
Louisiana
2011
GIen
dosco
peNOS
Inad
equateHLD
temperature
8wee
ks36
0Yes
Yes
(viral)
ND
ND
Public
hospital
30,31,35,80
British
Columbia
2010
;20
11Duod
enosco
pe
Improper
reprocessing;
Endosco
pes
allowed
todry
before
clea
ning
20mon
ths
536
Yes
Yes
(viral)
11Pseu
domon
as;
hep
atitis
C*;HIV*
Public
hospital
andacad
emic
med
ical
center2
3,81
Minnesota
2010
GIen
dosco
peNOS
Improper
HLD
of1ch
annel
3ye
ars
2,60
0Yes
No
ND
ND
Privatemed
ical
center,
hospital,a
ndou
tpatient
surgerycenter1
4,82,83
California
2010
Colon
osco
pe
Improper
HLD
;Ex
pired
disinfectan
t16
mon
ths
3,40
0Yes
Yes
(viral)
ND
ND
Privatehospital
24
Pennsylvan
ia20
10GIen
dosco
peNOS
Improper
HLD
of1ch
annel
5ye
ars
75Yes
Yes
ND
ND
Public
hospital
27,39,84
British
Columbia
2010
Colon
osco
pe;
Gastrosco
pe
NoHLD
for1ch
annel
28mon
ths
9,00
0Yes
No
ND
ND
Twoco
unty
hospitals
and
aregion
alcancertrea
tmen
tcenter3
4,54,56
Florida
2009
;20
10Duod
enosco
pe
Improper
clea
ningof
elev
ator
chan
nel
�8mon
ths
191
Yes
Yes
13Klebsiella
pneu
mon
iae
(carba
pen
emase-producing);
Esch
erichiacoli
(carba
pen
emase-producing);
Pseu
domon
asae
rugino
sa;
Proteu
smirab
ilis;
Serratia
Outpatientsu
rgery
center4
1,85,86
Geo
rgia
2009
;20
10Colon
osco
pe
Inad
equateHLD
time
17mon
ths
1,30
0Yes
Yes
ND
ND
Public
hospital
44,46
New
foundland
andLabrad
or20
09GIen
dosco
peNOS
Inad
equatedisinfectan
tam
ount;
AER
malfunction
17mon
ths
2,90
0ND
ND
ND
ND
Outpatientsu
rgerycenter4
2,87
Nev
ada
2008
;20
09GIen
dosco
peNOS
Inad
equateHLD
time
2ye
ars
ND
Yes
Yes
ND
ND
GIfacilityNOS2
2U.S.N
OS
2008
Colon
osco
pe
Improper
storag
eof
contaminated
,dam
aged
endosco
pe
Singleinciden
t1
ND
ND
ND
ND
Public
hospital
25,50,52,88,89
Alberta
2007
;20
08En
dosco
peNOS
Improper
clea
ningan
dHLD
;Nodisassembly
4ye
ars
2,87
2(300
dueto
endo-scop
es)
Yes
Yes
(viral)
ND
Stap
hylococcus
aureus
(methicillin-resistant)
Twopriva
tehospitals15,90,91
California
2006
Gastrosco
pe
Improper
reprocessing
>1ye
ar30
5Yes
Yes
ND
ND
Privatehospital
92
WestVirginia
2006
Endosco
peNOS
Improper
HLD
19mon
ths
“100
s”Yes
ND
ND
ND
Privatehospital
37,93
Pennsylvan
ia20
05Colon
osco
pe
NoHLD
ofau
xilia
rych
annels
4mon
ths
200
Yes
Yes
(viral)
ND
ND
Privatehospital
94
Virginia
2005
GIen
dosco
peNOS
Inad
equateHLD
time
10day
s14
4Yes
Yes
(viral)
ND
ND
Privatehospital
28,95
California
2005
GIen
dosco
peNOS
Multiple
equipmen
tan
dop
erator
issu
esND
2,11
6Yes
Yes
(viral)
ND
ND
AER
,automated
endosco
pereprocessor;GI,ga
strointestinal;HLD
,high-lev
eldisinfection;ND,n
otdisclosed
;NOS,
not
otherwisesp
ecified
.*Indicates
previou
slyiden
tified
casesthat
tested
positive.
A.M. Dirlam Langlay et al. / American Journal of Infection Control 41 (2013) 1188-941190
200
a large medical center received no HLD during an 8-monthperiod.36,40 At another large center, HLD was not performedon an endoscope channel for nearly 3 years because ofmisinformation from the manufacturer.23 MAUDE reports dis-cussed incorrect connectors used to attach endoscopes toautomated endoscope reprocessors (AERs) or flushing aids,resulting in no HLD of certain channels. Other failures involvedinadequate HLD time or temperature41-43 and errors in disin-fectant concentration or water quality during reprocess-ing.14,44,45 At 1 hospital, only 25% of the required amount ofdisinfectant was used over a period of 17 months.46 Expireddisinfectant was used for over 1 year at each of 4 otherfacilities.14,47 In addition, 1 MAUDE report described a lapsewhere water was used in place of disinfectant, and problemswith endoscope flushing or rinsing were found when residualchemicals caused chemical colitis.
Improper endoscope storage was also reported.22 One lapseinvolved patient exposure to a damaged, contaminated colono-scope that was hung unlabeled in a cabinet with clean endo-scopes.22 Other errors involved equipment problems, includingAER malfunction or incorrect programming.46,48 In some cases,inadequate staff training was recognized as an underlying prob-lem.5,49 VAOIG investigations revealed insufficient documentationof staff competency at several VA medical centers.5 One stateagency reported receiving 3 notifications when staff knowinglyused incompletely reprocessed endoscopes on patients.18
Certain individual lapses involved multiple reprocessingerrors.26,30,31,50 At 1 private endoscopy clinic, reprocessing errorsinvolved expired chemicals, inadequate cleaning and HLD, andcross contamination of clean and dirty endoscopes.26,51 At a largegeneral hospital, failure to preclean duodenoscopes contributed toproblems cleaning them.31,35 Multiple cleaning and HLD errors alsooccurred at another general hospital.25,50,52
Effects on patient safety
The impact of lapses on patient safety was a focus of mediareports, but not the peer-reviewed journal article or governmentreports, with the exception of MAUDE reports. Lapses discussed inthe media typically involved exposure and notification of hundredsof patients, and several lapses involved more than 1,000 patients(Table 1). Patient notification often recommended testing forinfection transmission; however, testing was typically done onlyfor viruses such as HIV, hepatitis B, and hepatitis C rather than forenteric pathogens. In 1 lapse at a single provider’s clinic, 6,800patients were exposed to potentially contaminated GI endoscopesand offered only viral testing.26 In 2 other lapses, thousands ofpatients treated at large medical facilities were notified about thelapse but not tested.23,53 In each instance, national health author-ities had asserted the risk of disease transmission was too low towarrant testing.23,53
Microorganisms were reported to have been transmitted bycontaminated endoscopes.31,34 Various types of microorganismsand occasionally multiple species were detected, including virusesand bacteria (Table 1). Pseudomonas spp was most common, andother bacterial pathogens included Serratia spp, Proteus mirabilis,and Clostridium difficile (Table 1). One MAUDE report described 9patients who acquired C difficile after undergoing procedures withan endoscope that was found to have retained debris. Multidrug-resistant bacteria, including methicillin-resistant Staphylococcusaureus (MRSA) and Klebsiella pneumoniae carbapanemase (KPC)-producing Klebsiella pneumoniae and Escherichia coli, were detectedfollowing 2 lapses.25,34 One of these lapses involving a contami-nated duodenoscope resulted in 13 cases of multidrug-resistant Kpneumoniae among 191 endoscopy patients, indicating a 7% attackTa
ble
2Lapsespublished
ingo
vern
men
treports:North
America,
January20
05-June20
12
Typeofhea
lthca
refacility
Hea
lthca
refacilities
Loca
tions
Rep
ortingag
ency
Pub.Y
ear
Typeofen
doscope
Erro
rsTo
talNo.
insp
ected
No.w
ithlapses
1ou
tpatientsu
rgerycenter;
1ou
tpatientclinic;
5hospitals2
0,96
NA
7lapses;
5facilities
Minnesota
MN
Dep
artm
entof
Hea
lth
2012
Colon
osco
pe;
Duod
enosco
pe;
Gastrosco
pe;
Upper
GIen
dosco
pe;
Non
-GIen
dosco
pes
Improper
clea
ningan
dHLD
;Rep
rocessingasingle-use
dev
ice;
Usedim
proper
AER
connector;
Inad
equatestafftraining
ND21
NA
80*
USNOS
FDA
2011
Endosco
peNOS
Inad
equatereprocessing
Outpatientsu
rgerycenters
andsu
rgical
practices
17
91�3
New
Jersey
NJHea
lthCareQualityInstitute
2011
Colon
osco
pe;
Endosco
peNOS
Improper
reprocessing;
Unch
ange
dwater
andclea
ningsolution
ND18
107*
62*
Pennsylvan
iaPA
Patien
tSa
fety
Authority
2010
Gastrosco
pe;
Endosco
peNOS;
Non
-GIen
dosco
pes
Improper
clea
ning,
HLD
,and
doc
umen
tation
;Know
inglyused
inco
mpletely
reprocessed
endosco
pe
Veteran
sAffairs
med
ical
facilities5
36facilities;
38units
20units
Multiple
USstates
VAOIG
2009
Colon
osco
pe
Inad
equatestan
dardop
erating
proceduresor
doc
umen
tation
ofstaff
competen
ceforreprocessing
Hospitals1
9NA
3California
CADep
artm
entof
Hea
lthSe
rvices
2007
GIen
dosco
peNOS
Improper
sterilization
andreassembly
AER
,automated
endosco
pereprocessor;GI,ga
strointestinal;NA,n
otap
plic
able;ND,n
otdisclosed
;NOS,
not
otherwisesp
ecified
;VAOIG,V
eteran
sAffairs
Office
ofInsp
ectorGen
eral.
NOTE
.Supplemen
taldataan
dreferencesdoc
umen
tinglapsesdescribed
inMAUDEan
dVAOIG
reports
areav
ailablefrom
theau
thorson
requ
est.
*Indicates
reports.
A.M. Dirlam Langlay et al. / American Journal of Infection Control 41 (2013) 1188-94 1191
201
rate.34,54 Two other lapses were associated with patients whotested positive for viruses. In 1 instance, 408 of 4,353 exposedpatients who underwent laboratory testing for bloodborne patho-gens tested positive for hepatitis B or C, including previouslyundiagnosed cases and 20 cases of active infection.26,55 Viraltransmissionwas attributed to patient lifestyles, yet reports did notprovide substantiating data to rule out transmission from con-taminated endoscopes.26 In the other instance, 10 patients testedpositive for hepatitis C and HIV after exposure to a contaminatedduodenoscope; however, these cases had been previously diag-nosed.55 Nonetheless, these reports revealed that numerouspatients were exposed to improperly reprocessed endoscopes thathad been previously used on patients with viral infections.
Several lapses were associated with serious patient injury.On multiple occasions, reprocessing chemicals remaining in endo-scopes caused colitis in exposed patients. MAUDE reports describeda variety of patient complications after exposure to contaminatedendoscopes, including abdominal pain, inflammation, and bacter-emia. In other instances, patients who tested positive for microor-ganisms after a lapse required treatment and hospitalization.31,56 At1 hospital, an ill patient who had undergone endoscopy witha contaminated duodenoscope was hospitalized with a Pseudo-monas infection.31 The patient died soon after acquiring the infec-tion as a result of the preexisting illness.31 Following another lapse,patients who underwent endoscopies and acquired multidrug-resistant K pneumoniae were found to have longer hospital staysand 5 times higher mortality than other patients.34,54,56
DISCUSSION
By looking beyond peer-reviewed literature for evidence, weidentified numerous recent reprocessing lapses in North America,including several that were associated with patient infection, injury,or death.21,31,34,56 Recent lapses have also been reported in othercountries,10,11,57-61 indicating that improper reprocessing is wide-spread and continues to occur despite the existence of reprocessingguidelines. Other researchers have acknowledged that most lapsesnever get publicly reported.2,6 Reluctance by institutions to reportlapses may contribute to the lack of peer-reviewed articlesdescribing them. In addition, some journals do not publish casereports.62,63 Lack of reporting in peer-reviewed journals contributesto the perception that lapses are rare and inconsequential.
Current endoscopy-associated infection (EAI) risk estimates areerroneously based on the number of infections reported in peer-reviewed articles.13 As a result, numerous experts and organiza-tions have asserted the risk of EAI is virtually nonexistent.1,3,4,12 Basedon existing estimates, fewer than a dozen EAIs would be expected tooccur each year in the United States. However, multiple cases of EAIresulting from individual lapses have exceeded these estimates,indicating current estimates are inaccurate and far too low.13
Researchers have identified retained debris in lumened instru-ments, including endoscopes, as a result of inadequate reprocessingand complex device design.64,65 A recent study found that proteinresidue and water remained on endoscope channels even afterthorough cleaning.66 Studies by Alfa et al found that 14% of patient-ready GI endoscopes had bacterial or fungal growth67 and that upto 19% of manually cleaned channels tested positive for protein,hemoglobin, or carbohydrates.68 Detailed outbreak investigationshave implicated endoscopes as likely sources of microbial trans-mission.10,11,31,34,64 Matching strains of MDROs were collected frompatients and endoscopes following several of these lapses, indi-cating that MDROs may be transmitted by contaminated endo-scopes.10,11,34,56 With the exception of methicillin-resistantStaphylococcus aureus, the vast majority of MDROs are harboredin the GI tract and can be clinically silent for months to years before
causing extraintestinal infection. Endoscopies with contaminateddevices may place patients at high risk for acquiring MDROsbecause bowel preparation alters colonic microflora,69,70 therebyreducing patient resistance to colonization with MDROs.
At present, there is no central repository for reports on lapsesand no requirement that local or federal officials maintain recordsor make them available to clinicians, researchers, or policy makers.Exposed patients are not routinely recalled for testing because thehealth risks are assumed to be very low.23,27 This leads to a viciouscycle whereby institutions do not notify or test patients whena lapse is discovered because decision makers rely on erroneousrisk estimates that have been propagated in the guidelines.Mandatory reporting of lapses to a national registry would supportepidemiologic review and investigation and the consideration ofnew policies based on sound data.
Adherence to reprocessing guidelines needs to be improved.8 Ina multisite study that revealed poor adherence, staff reported thatthey did not like to do various reprocessing tasks, felt pressure towork quickly, and attributed health problems to working withendoscopes.8 The link between reprocessing errors and factors thatmay influence health care worker behavior suggests that trainingand competency testing need to be supplemented with account-ability measures and active surveillance of reprocessing effective-ness so that contaminated endoscopes can be identified before theyare used on patients.
Limitations
Because of the lack of a central repository or peer-reviewedjournal articles describing lapses, ad hoc searches of media,government reports, and other online sources were used to identifythem. Even when multiple reports on individual lapses wereavailable, the information was frequently incomplete and difficultto interpret. Thus, the results of this review may not be generaliz-able. Furthermore, the information provided in media andgovernment reports was neither scrutinized by peer reviewers noredited for technical accuracy or clarity of communication. Datawere sometimes reported using potentially inaccurate terms (eg,sterilization rather than HLD).
Conclusion
Improper endoscope reprocessing is an ongoing and pervasiveproblem that has the potential to cause significant patient harm.Reprocessing guidelines should be revised to reflect the true risk oftransmitting infections, including enteric pathogens and MDROs,when lapses occur. These revisions will require additional researchbecause the magnitude of risk associated with particular types oflapses is unknown. As such, there is a need for a central repositoryof data pertaining to lapses and associated outcomes. Infectionpreventionists should recognize risks associated with improperreprocessing and continuously evaluate reprocessing effectivenessto ensure that endoscopes are clean and disinfected prior to use onevery patient.
Acknowledgment
The authors thank Jeremy Ward and Lisa Mattson for theresearch, editorial, and logistical assistance provided.
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8.7
State of the Science Review
Special problems associated with reprocessing instruments in outpatientcare facilities: Physical spaces, education, infection preventionists,industry, reflections
Judie Bringhurst MSN, RN, CIC *Department of Hospital Epidemiology, UNC Hospitals, Chapel Hill, NC
The infection preventionists’ (IPs’) presence and intervention in outpatient facilities continues to lag behindthe inpatient hospital IPs’ presence. Additionally, in an outpatient world that is heavy on instrument reproc-essing, IPs must be prepared to assess instrument reprocessing practices, including high-level disinfectionand sterilization to keep our patients and staffs safe. This paper presents 3 problems associated with instru-ment reprocessing practices in health care facilities, with a special emphasis on outpatient facilities: physicalspace problems, training and education problems, and lack of IPs’ presence. We offer solutions and mitigationstrategies for these 3 problems. We also give some reflections on the current state of IP presence and respon-sibilities, and industry responsibilities, and we call for robust partnerships between IPs and the instrumentreprocessing industry.© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.
Key Words:High-level disinfectionHLDSterilizationAmbulatory careClinicsCounter-top sterilizers
In the United States, more patients obtain health care in specialtyclinics, ambulatory surgery centers, and physicians’ offices than inhospitals. In 2008, there were 1.2 billion ambulatory care visits in theUnited States, including physicians’ offices, outpatient hospitals, andemergency departments. Nearly 61% of those visits were to primarycare physician offices.1
Although many outbreaks of infection associated with instrumentreprocessing in outpatient care facilities go unreported, multiple out-breaks have been reported. In 2003, Srinivasan et al2 reported an out-break of Pseudomonas aeruginosa associated with bronchoscopes in anoutpatient setting, apparently caused by loose biopsy ports on the bron-choscopes. Thirty-nine patients were infected, 67% of whom wereinfectedwith P aeruginosa. In 2012, a commentary byWeber and Rutala3
onbronchoscopies, for the 12-year period between2000 and2012, found25 outbreaks and pseudo-outbreaks in the literature. The outbreaksdescribed in their commentary resulted in 82 infections and 4 deaths.Notably, single use, disposable bronchoscopes are nowavailable.
In 2013, Kovaleva et al4 reported on transmission of infections viaendoscopy and found that, of the 98 outbreaks assessed, 1,113patients were contaminated and 249 patients were infected. Kovalevaet al noted that if deficiencies related to cleaning, disinfection, auto-mated endoscope reprocessors (AERs), contaminated water, and dry-ing were eliminated, approximately 85% of outbreaks would beeliminated. Importantly, neither the works by Weber and Rutala norby Kovaleva distinguished between outbreaks associated with inpa-tient and outpatient facilities. Additionally, underreporting of trans-mission of infection associated with endoscopy is ongoing.11
This article looks at the following 3 problems associated withinstrument reprocessing practices in outpatient care facilities: (1)physical space problems, (2) training and education problems relatedspecifically to high-level disinfection (HLD) practices, and (3) lack ofinfection prevention presence. This article offers solutions or mitiga-tion strategies to these 3 problems. In addition, it will present somereflections on the current state of infection preventionists’ (IPs’)presence in outpatient facilities and collaborations between theinstrument reprocessing industry and IPs.
PROBLEM 1: PHYSICAL SPACE PROBLEMS
Ideally, instrument reprocessing should not be performed inpatient care areas. Instrument reprocessing contaminates the area inwhich is it performed. This environmental contamination may lead to
* Address correspondence to Judie Bringhurst, MSN, RN, CIC, Department of HospitalEpidemiology, UNC Hospitals, 101 Manning Dr., Campus Box 7600, Chapel Hill, NC27514.
E-mail address: [email protected] (J. Bringhurst).This work was presented as a 2019 Supplement at the Association for Professionals
in Infection Control and Epidemiology 45th Annual Conference, Minneapolis, MN, June13-15, 2018.
Conflicts of interest: Ms. Bringhurst has received consultant fees from Cogentixand honorarium fromMedivator.
https://doi.org/10.1016/j.ajic.2019.03.0060196-6553/© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
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patient and/or staff infections. A space designated specifically forinstrument reprocessing should be utilized to control quality andensure safety. The reprocessing area should be divided into distinctwork areas whenever feasible as follows: receiving, cleaning, anddecontamination; preparation; HLD/sterilization; and storage. Stor-age of reprocessed instruments should be in a manner that preventsrecontamination. Many endoscopy centers employ ventilated scopestorage cabinets, whereas other types of health care facilities such asphysician practices and specialty clinics store their reprocessedinstruments in a clean storage room. An overriding goal of instrumentreprocessing areas is to establish a dirty-to-clean flow in the area forthe instrument stream, which, ideally, terminates in storage of thesereprocessed items in clean utility rooms and ventilated cabinets spe-cifically designed for endoscope storage, not the instrument reproc-essing area or room.
Double sinks with 1 goose neck faucet serving both sinks aresometimes found in instrument reprocessing areas. This is not anissue within itself; however, staff may believe that 1 of these sinks is“clean” and 1 is “dirty” when both of the bowls in a double bowl sinkshould be either 1 or the other. Ideally, if the installation of separateclean and dirty sinks is not feasible, the sinks should be used as eitherboth dirty or both clean. If it is unavoidable that both clean and dirtyactivities occur in this double sink, the sink should be thoroughlycleaned with a bleach-based, Environmental Protection Agency-regis-tered hospital-grade surface disinfectant after dirty activities andbefore being used for clean activities. However, it is noted that this isa less-than-ideal situation and that there may be associated cross-transmission risks in using the same sink for clean and dirty activitiessince faucets and drains (areas that are typically unreachable) arecontaminated.13 Additionally, the use of the same sink for clean anddirty activities likely may lead to biofilm formation in the dischargeplumbing that may not allow decontamination even with periodicbleach flushes. Also, a microbial aerosol associated with use of 1 sinkfor clean and dirty activities may contaminate the faucet and/or fau-cet aerators. All avenues for the installation of additional sinks shouldbe explored. Certainly, if more than 1 dirty or clean sink is required,as is often the case in endoscopy instrument reprocessing rooms,then double or even triple sinks may be installed with the under-standing that these multiple sink units are designated as either allclean or all dirty.
Infrequently, instrument reprocessing may occur in very smallspaces (eg, closets) with no sink at all. In these rare cases, and whenspace cannot be carved out or dollars found for installation of a sink,one should consider either single use, disposable instruments orallowing minimal instrument reprocessing that can include a vapormanagement/soaking station device in facilities that reprocesssmooth, nonlumened, nonchanneled items such as some endocavi-tary probes. Additionally, using a high-level disinfectant chemicalthat requires only 1 final rinse (and can thus be rinsed in the rinsingtube of the soaking station device) is helpful in these sinkless instru-ment reprocessing areas. This rinse water must be changed with eachdisinfection run and cannot be reused. One may also consider use ofan endocavitary ultrasound probe high-level disinfecting system thatuses a vaporized hydrogen peroxide as the high-level disinfectant.This type of system requires no rinsing of ultrasound devices such asvaginal ultrasound probes. It is stressed that this “sinkless” room isanother less-than-ideal situation and there may be associated cross-transmission risks, staff safety risks, and inconsistencies with andeven violations of Occupational Safety and Health Administration(OSHA) regulations in these rare rooms with no sinks. The importanceof ready access to a handwash sink in case of exposure to blood andbody fluids is underscored.
Inadequate space is 1 of the most frequent problems encounteredin outpatient care instrument reprocessing areas. Clutter should beeliminated. When cluttered instrument reprocessing areas are found,
it is recommended to clear the room/area of all items, discard unnec-essary items, terminally clean the room, and then resupply the room.This activity has been found to provide space that was previouslyexhausted by storage of unused supplies. When renovations are notplanned, a dirty-to-clean flow and clear separation between cleanand dirty activities and clean and dirty items is imperative. Thus, sig-nificant improvements to instrument reprocessing areas may beaccomplished without renovation. Decluttering, installing uppershelves to use vertical space, and removing equipment and items thatcan be moved to other spaces or rooms greatly increases the usablespace and safety of these areas.
When renovations are planned, infection prevention activelyengages key personnel in requiring these spaces be expanded and ele-vated to national standards and guidelines. When renovations to out-patient facilities are planned, and in the absence of state designguidelines for physician practices and specialty clinics, the instrumentreprocessing room should be designed to comply with (at least) FacilityGuidelines Institute (FGI) Guidelines for the Design and Construction ofHealth Care Facilities5 and OSHA Bloodborne Pathogen regulations,8
including but not limited to air changes per hour, pressure differentials,and the presence of an eyewash where appropriate. The Joint Commis-sion (Environment of Care chapter, 02.06.05, element of performance1) indicates that health care systems planning new or renovated facili-ties should use state rules and regulations for design guidance and/orreputable standards and guidelines such as the Guidelines for Designand Construction of Health Care Facilities, 2018 edition, administeredby the FGI. When these rules, regulations, and guidelines do not meetspecific design needs, health care facilities should use other reputablestandards and guidelines that provide equivalent design criteria. Acomplicating factor is that outpatient clinic design codes may varyfrom state to state or be absent altogether. IPs are encouraged to checktheir respective state regulations regarding outpatient clinic construc-tion design codes. For example, North Carolina exempts from statehealth care design oversight and regulation, outpatient facilities thatare classified as business occupancy and are more than 30 feet fromany hospital facility. Therefore, in North Carolina these outpatient facil-ities should be designed to meet the standards set forth in the FGI6 andthe regulations in OSHA Bloodborne pathogens standards as well asother standards and guidelines.
In addition to the design recommendations for outpatient facilitiesin the FGI, utility sinks (ie, clean and dirty instrument washing andrinsing sinks) in instrument reprocessing areas should be specified tobe stainless steel, at least 24 inches from side-to-side (inside bowlwidth) and sometimes larger according to the clinic’s specific needs,and at least 8 inches deep or deeper. Importantly, at least 2 utilitysinks should be installed to accommodate instrument washing andrinsing, 1 designated as dirty (washing) and 1 as clean (for rinsingafter HLD). Some gastrointestinal scope reprocessing rooms have 3 or4 dirty sinks to accommodate high volumes of lumened flexible endo-scopes and decrease delays between use on a patient and soaking.These sinks designated as dirty and clean should be installed at a sig-nificant distance from each other to avoid cross-contamination. Fur-thermore, a separate handwash sink is required in these rooms tomeet OSHA regulations and to keep staff safe. Manual control ofwater sources (vs motion detection) to these sinks is necessary and isachieved by installing goose neck faucets or spring-loaded pull-downfaucets with wrist blade controls or single lever controls. It is usuallynot helpful to install splashguards in instrument reprocessing roomssince there should be no clean or sterile patient supplies stored onthe counters in these areas, and splashguards interfere with the ergo-nomics of moving items from sinks to counters and vice versa. Whenhazardous chemicals are being used, an American National StandardsInstitute-approved eyewash should also be installed either on a cleansink or as a separate wall-mounted version to meet staff safety regu-lations consistent with OSHA. Correspondingly, new construction and
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renovations of outpatient facilities such as physicians’ practices,ambulatory surgery centers, and specialty clinics should be consistentwith state design codes, FGI guidelines, and OSHA regulations.
PROBLEM 2: EDUCATION, TRAINING, VALIDATION, ANDSTANDARDIZATION: FOUR REASONS OUTPATIENT AREASNEED IPS’ PRESENCE
Because of the large margin of safety inherent in steam steriliza-tion processes−there is a 1:100 quadrillion chance of the steam-ster-ilized item not being sterile−whereas there is no margin of safetyassociated with HLD of gastrointestinal endoscopes, this article willfocus mainly on HLD challenges and complications in this section.12
Per the Spaulding classification scheme, HLD, minimally, is requiredfor semicritical devices (ie, those that contact mucous membranes ornon-intact skin).7 HLD is a time-consuming, complex process thatrequires training, education, and competency. Outpatient facilitiesthat reprocess semicritical devices generally will reprocess them viaHLD unless sterilization is an option.
Education and training
Recently, Olympus published a 111-page reprocessing manual(manufacturer’s instructions for use [IFU]) for their Q180V duodeno-scope (Olympus America Inc, Center Valley, PA). It is unlikely thatscope room staff have the resources to adhere to 111 pages of clean-ing instructions for endoscopes. This gap exposes 1 of the major prob-lems with HLD, which is that the complexity of many lumenedflexible endoscopes, in particular, has outstripped our ability to meetcomplex and time-consuming HLD instructions. In an effort to medi-ate the effects of this gap, a 3-hour HLD workshop curriculum at theUniversity of North Carolina Hospitals was designed and is deliveredby infection prevention. Results from onsite infection preventioninstrument reprocessing surveys were used to guide the curriculum.Infection prevention partnered with colleagues in the environmentalhealth and safety department to produce an occupational health com-ponent in the workshop applicable to personal protective equipment(PPE) usage when performing HLD, a process that exposes staff toblood and body fluids as well as hazardous chemicals. All personnelwith HLD responsibilities are required to attend as clinic schedulespermit. The workshop is not a “train-the-trainer” class nor is it anonline module. The workshop is conducted by an IP, personally, face-to-face. The lecture portion of the workshop includes, among otherrelevant issues, a review of outbreaks associated with inadequateHLD, the rationale for HLD, negative outcomes resulting from re-useof single use items, medical-legal implications, an overview of theSpaulding classification scheme, as well as explanations of the neces-sity for leak-testing flexible scopes. Students are urged to assumeaccountability as health care personnel (HCP) in the instrumentreprocessing environment−what to report to their supervisors and/or hospital infection prevention−and they are educated on the medi-cal-legal ramifications of errors in the reprocessing environment. Theworkshop portion includes instruction and return demonstration ofdonning and doffing appropriate PPE for HLD and the proper tech-nique for testing minimum effective concentrations of HLD chemicalswith test strips. Students are given a laminated, enlarged algorithmof the steps in HLD, a laminated poster describing the appropriatePPE for HLD processes, their own safety glasses, and a large packet ofinformation, including relevant peer-reviewed literature to place intheir workspaces. More than 600 HCP have attended the workshopover the past 6 years. HCP effectiveness (ie, less likelihood of makingmistakes during HLD activities) has been variable based on subse-quent visits to HLD areas. Student comments and evaluations havebeen positive. Students comment positively on the information theyreceive on outbreaks and the workshop portion of the session.
Perhaps the most significant benefit of the workshop is the familiaritystudents establish with infection prevention. This may ease anxietyassociated with reporting of challenges in their facilities to their IP. In2018, a 1-hour refresher HLD class was established for those whohave attended the 3-hour workshop and made mandatory every365 days. There are infection prevention benefits in requiring theworkshop for clinic HCP who may need remediation in HLD practices.Class materials, revised at least yearly to reflect current issues, areused for up-to-date education of staff.
Validation
Validation studies and their associated documents are a necessaryelement of any instrument reprocessing activity. Are the HLD chemi-cals in use validated effective by the instrument manufacturer? Arethe automated endoscope reprocessors (AERs) in use validated by theinstrument manufacturer and vice versa? Do our instruments havelumens that are validated to be effectively high-level disinfected withspecific connectors or hook-ups? The length and diameter of lumensmust be assessed before any HLD or sterilization process is assumedto be effective and validated. Most HLD chemical manufacturers andAER manufacturers have online, easy-to-use validation matrices.IFUs, Centers for Disease Control and Prevention, facility policies, andprofessional organizations’ guidelines should always be consulted forcleaning instructions with any instrument, automated instrumentreprocessors such as AERs, and HLD chemicals. Adherence to nation-ally accepted standards, guidelines, and manufacturer’s IFUs must bemeticulous. These standards, guidelines and IFUs are generally spe-cific to the product with which they are associated. Most medicaldevices, instruments, and instrument reprocessors must be evaluatedby the Food and Drug Administration (FDA) and should have com-plete IFUs9; however, not all instruments found in outpatient care aresubject to FDA evaluation nor are all IFUs written in a manner that isdecipherable to clinic staffs. The IP’s input pertaining to appropriatecleaning, disinfection, and sterilization should include interpretationof manufacturer’s IFUs where necessary. Improper use and disinfec-tion of equipment and instruments may harm the equipment andexpose staff and patients to cross-contamination. Furthermore, theIP’s assistance to weave together various IFUs for HLD chemicals andthe instruments and equipment (eg, AERs) for which those chemicalsare validated is invaluable to clinical staff. For example, some HLDchemicals are contraindicated for use in certain patients (eg, ortho-phthalaldehyde in bladder cancer patients), certain reprocessingenvironments, temperatures and equipment, whereas some HLDchemicals can be heated during the HLD process and some cannot,per FDA approvals. Manufacturer’s IFUs for the chemicals should bereviewed and the FDA list of cleared sterilants and high-level disin-fectants checked for validation of choices of HLD chemicals.10
Standardization
There is no standardization across manufacturers of instrumentreprocessing devices and consumables. The infection prevention pro-fession urges our industry partners to learn more about the chal-lenges faced on the front lines of our HLD areas and begin to addressthese challenges in a useful and, as far as possible, simple way. Thereis a plethora of products, each with their own specific, individualinstructions, including enzymatic detergents and other detergentcleaners with differing water-to-detergent ratios, HLD chemicalswith different soak times and usage days, and HLD chemical teststrips with different wait times and color changes. HCP should beclearly instructed by the IP that, although these variances exist, it isonly critical for personnel to read and follow all instructions thatapply to their HLD, detergents, test strips, instruments, and devices.Another method to mitigate some of this potential confusion is to
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decrease as much as possible the variety of HLDs and their attendantconsumables available to clinics.
PROBLEM 3: LACK OF IPS’ PRESENCE
If not already educated, IPs should become educated on the HLDprocess and proficient in assessing these practices. Multiple resourcesspecific to HLD practices, processes, and environments exist for theinquiring IP’s mind.14-17 In tandemwith these resources is all productinformation and IFUs that are relevant to HLD processes. Also neces-sary for the IP’s education are the regulatory notices that emanatefrom the Centers for Disease Control and Prevention and the FDA.18
IPs can develop the skills to assess whether an endoscope is reproc-essed correctly, whether all reprocessed instruments and devices arebeing stored appropriately, whether it is clear that an item is clean ordirty, and how to assist clinics in mediating some less-than-idealphysical plant situations to make these situations safer.
DON’T LET WHAT YOU CAN’T DO INTERFEREWITHWHATYOU CAN DO
The present time is “our watch.” IPs must take action to amelioratethe well-publicized problems with HLD. There has never been a timein which infection prevention must partner with industry like theprofession must partner today. Infection prevention must be engagedat a level not seen before. Thousands of known human infections(and thousands more unknown) are associated with failures in HLD−either human or engineering. IPs are responsible for immediately giv-ing solvable issues our attention. Industry is responsible for immedi-ately creating engineering controls on devices that make it difficult toinfect a patient, such as single use, sterile devices and sheaths andstandardizing products that perform the same function, such as HLDchemical test strips for minimum effective concentrations. The infec-tion prevention profession as a whole and individual IPs are responsi-ble for continuing the pressure on industry to do so. Our first step asIPs, committed to keeping our patients safe, should be to tuck ANYHLD guideline under our arm, walk into our instrument/scope reproc-essing room, and start a conversation.
SUMMARY AND REFLECTIONS
Historically, outpatient facilities have been overlooked by infec-tion prevention departments perhaps due to an assumption thatmost high-risk procedures occurred in hospitals rather than outpa-tient facilities and therefore the infection risk to patients was not assignificant in outpatient facilities. Today, we know the risks for cross-transmission and patient infections in outpatient facilities is ever-present as more patients receive their health care in outpatient facili-ties than in hospitals and many procedures that once required inpa-tient hospital stays are performed on an outpatient basis. The result isincreasingly complex care in outpatient facilities that often involvesreusable semicritical and critical devices. Failures in instrumentreprocessing have the potential to infect many patients in a shortperiod of time, and frequent reports of instrument reprocessing fail-ures and near-misses with or without resultant patient infectionsdemonstrate the need to continue to focus infection prevention’s andindustry’s attention to safer, simpler instrument reprocessingpractices in outpatient facilities. Fundamental to patient and staffsafety is infection prevention’s oversight of any facility−inpatient oroutpatient−that reprocesses reusable instruments.
An IP’s reflections:
1. It was a mistake for me to assume that people who HLD everydayknow the right way to do it.
2. Your instrument reprocessing sites, outpatient and inpatient, needyour attention and help−they may not know that yet.
3. We CANNOT always make it perfect or even consistent with regu-lations and guidelines but we CAN ALWAYS make it better andsafer for our patients and our staffs.
4. Start with your first visit−challenges will be uncovered, opportu-nities for improvement will become clear. Address the challengesand opportunities that present a risk to patients and staff first.
5. Once we, IPs, are fully engaged, the myriad elements and complex-ities of HLD within our facilities will lead us where they need usto go.
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