b Infection Prevention Plan 20 Facility Name b

b Infection Prevention Plan 20__ Facility Name

b Table of Contents Infection Prevention Program 3 Objectives 4 Authority and Scope 4 Surveillance and Prevention Activities 5 Infection Prevention Collaboration Teams 6 Reporting and Accountabilities 7 Program Evaluation 8 Assessments 9 Community 10 Facility 11 Construction 11 Multi Drug Resistant Organisms 12 Tuberculosis 12 Infection Prevention Goals and Plan 13 Hand Hygiene Compliance 14 Multidrug Resistant Organism 15 Central Line Associated Blood Stream Infections 16 Catheter Associated Urinary Tract Infections 18 Surgical Site Infections 20 Influenza Vaccination 22 Appendices: 23 A. Hospital Risk Assessment 24 B. Tuberculosis Risk Assessment 28 2

b Infection Prevention Program 3

b Infection Prevention Program Objectives The objective of the infection prevention program is to monitor, prevent and reduce the incidence of healthcare associated infections experienced by patients, visitors, volunteers, and staff members. To meet this objective, the program emphasizes prevention through implementation of evidence-based practices, surveillance programs, data analysis, the provision of consultative and educational opportunities for patients, and staff, as well as appropriate follow up activities. Program goals are reviewed annually and are determined by ongoing risk assessments. Evaluation of the progress towards infection prevention goals is evaluated throughout the year. The infection prevention program is founded upon guidelines and standards from nationally recognized associations, which include but are not limited to: • Association for Professionals in Infection Control and Epidemiology (APIC) • Centers for Disease Control and Prevention (CDC) • Healthcare Infection Control Practices Advisory Committee (HICPAC) • Society for Healthcare Epidemiology of America (SHEA) • The Joint Commission (TJC) Authority and Scope (Hospital) recognizes that the infection prevention program plays an important role in its efforts to improve patient safety and quality of care. Therefore, this program functions under the authority of the Quality Department as part of the Quality Assessment and Performance Improvement (QAPI) efforts. The infection prevention program encompasses all hospital-licensed patient care and support services, which include both hospital-based and outpatient services. Infection prevention functions are vested in the Infection Preventionist (IP), who oversees day-to-day surveillance activities and coordinates infection prevention duties and responsibilities. The IP has the authority to institute focused surveillance practices, prevention and control measures, isolation precautions and/or restrictions when deemed necessary to prevent actual or potential harm from occurring due to medical devices, medical procedures, infectious organisms, or infections. The IP chairs the Infection Prevention and Control Committee (IPCC) and oversees the implementation and evaluation of the committee’s plans and ideas. The physician assigned by the Chief of Staff oversees and shares the responsibility for coordinating infection prevention activities as defined by the Medical Staff bylaws. The physician has a primary role in assisting with physician intervention. Infection Prevention program responsibilities include: aiding in disseminating information to the medical staff and employees; suggesting patient care protocol changes; overseeing process improvement activities; co-chairing the Infection Prevention and Control Committee (IPCC); and directly reporting to, or obtaining approval from, the Medical Executive Committee (MEC). 4

b Surveillance and Prevention Activities Surveillance is an ongoing program to effectively identify infection risks and infections among patients and personnel. Appropriate mechanisms are in place to prevent, reduce, and control such risks. The Centers for Disease Control and Prevention (CDC) provide definitions used for determining hospital associated infections via the National Health Safety Network (NHSN). Surveillance activities include the following: • • Review of computer-identified data to assist in the identification of healthcare-associated infections, potentially transmissible organisms, and reportable diseases Concurrent and retrospective review of medical records as well as written and/or verbal communication with healthcare workers Quality Management Consultants and individuals within patient care departments or clinics perform concurrent monitoring of infection prevention activities. Staff are encouraged to report any potential hospital or device related infections, breaches during patient care activities, or any identified risks within the immediate environment Targeted surveillance focused on high risk areas such as: high acuity units, medical devices, invasive procedures, and organisms of epidemiological significance Special focused reviews or studies may be completed for significant negative patient outcomes Identification of reportable communicable diseases and reporting to required agencies Responding appropriately to identified communicable diseases in patients, and employees, as well as children within the Child Development Center Investigate and manage outbreaks per the Intermountain Healthcare Outbreak Investigation Guideline Prevention Programs to reduce the risk of infection include the following: • • Employee education programs include orientation for all new employees, annual updates for all employees, department-specific education, individual consultation, and in-services as needed Implementation of infection prevention bundles as appropriate (e. g. , central line placement and care, ventilator related care, foley catheter insertion and care, C. difficile, etc. ) Ongoing evaluation, review, and revision of infection prevention guidelines to be consistent with current literature, evidence based practices, and regulatory or accrediting agency standards Reference to the annual antibiogram in identifying organisms’ antibiotic sensitivity and resistance patterns or trends Appropriate handling of regulated medical waste Active participation in products review and processes for cleaning, disinfection, and sterilization of patient care instrumentation and equipment, including patient-owned equipment (see corporate Clinical Engineering policy) Providing consultation for Facilities Management Community educational programs and consultation through the Live Well Library 5

b Infection Prevention Collaboration Teams The Infection Prevention Team understands the importance of communication and collaboration, and recognizes that all hospital staff play a role in the prevention of hospital associated infections. Therefore, we believe that it is Integral to the program’s success to partner with various teams and committees in order to achieve the program’s goals and desired outcomes. The infection Prevention Team coordinates with appropriate hospital and medical staff to promote infection prevention practices. Leadership efforts to achieve this include: o Chairing the Infection Prevention Committee o Interface with the hospital Antibiotic Stewardship Committee regarding utilization of antibiotics o Interact with shared governance councils and committees for practice, education, and quality functions related to improving care o Participate in review and monitoring of safety functions pertaining to infection prevention principles through participation with the Environment of Care Committee and the Emergency Management Committee As chairs of the Infection Prevention Committee (IPC), the Infection Preventionist are charged with the oversight of infection prevention related education, implementation and monitoring of prevention strategies, and quality improvement measures of this team. The IPPC has the direct responsibility to plan, implement, and evaluate the effectiveness of the infection prevention program and any associated activities. This committee includes front line staff as well as hospital leadership and as such is required to mentor staff members within their immediate departments or service lines. Members include: frontline nursing staff, nursing leadership, surgical services, central processing, environmental services, employee health, pharmacy, education, safety and security, risk management, and other ad hoc members as needed. The Infection Prevention Team maintains a working relationship with the Employee Health Team. Employee Health is an integral part of the infection prevention program, and efforts are made to overlap appropriate activities to meet the objectives of both programs. The Employee Health Team consists of a Registered Nurse and Medical Assistant ; this team has the sole responsibility to report employee health problems, maintain health status files, and coordinate appropriate immunization files and programs (such as Hepatitis A and B vaccinations, flu immunizations, and others). The Employee Health Team also handles and coordinates employee injury and occupational exposures from the first reporting, through the counseling phase, and to the return back to work or the resolution of a conflict. 6

b Reporting and Accountabilities The Infection Preventionist compiles , organizes, and analyzes infection prevention data. Data is presented to, and further reviewed or analyzed by, the Infectious Disease Physician. Based on the analysis of data and outcomes, the IP and physician institutes appropriate infection prevention actions or recommendations. Reporting of hospital-associated infections is completed monthly via the CDC’s NHSN program, as directed by the Centers for Medicare and Medicaid Services. The IP reports information quarterly to the IPC, the CNO, the CMO, the Medical Executive Committee, and the Board of Trustees. Any infection prevention issue requiring emergent action is reported to any of the above by the IP or physician. Recommended actions may include the following: o In-service, focused education, and providing resources for knowledge deficiencies o Revising policy and procedures, changing equipment, and altering staffing patterns or equipment as possible solutions for system deficiencies o Individual counseling and goal setting for behavioral or performance deficiencies Various hospital leadership members or teams have additional accountabilities related to the IP program. • Individual Patient Care Departments reporting QAPI activities include infection prevention monitoring and specific actions as a major component of that report. Administrative directors are accountable for outcomes and follow-up to appropriate resolutions. • The Patient Care Council aids in reporting and integrating infection control by addressing infection controlrelated issues with education, policy and procedure review and revisions, and overall issues of compliance with patient care standards. • The Environment of Care Committee has responsibility for oversight and advisory functions, providing direction and strengthening clinical aspects, and evaluating program effectiveness. The committee assures that appropriate and timely action is taken through review of collected data on healthcare-associated infections, and through evaluation of quality and appropriateness of care rendered to a patient or group of patients with an infection. This committee may recommend corrective action for protection of employees and patients, or educational programs for employees based on the findings of the infection control surveillance activities. • The Medical Executive Committee (MEC) is responsible to determine and review, at least annually, the type of surveillance programs and activities that best impact patient care management. The MEC: 1) reviews and approves proposals and protocols for special infection prevention studies conducted throughout the hospital and region; 2) reviews and approves proposals relating to infection prevention and patient care management; and 3) may recommend educational programs for physicians and health care personnel based on the findings of any of the infection prevention activities. 7

b Evaluation of Infection Prevention Program The IP and physician assess the infection prevention program by using an approach that consists of, but is not limited to, the following: data collection and analysis; examination of the outcomes of corrective actions taken; and the resolution of identified problems or trends. Specific healthcare infection prevention teams, as well as the Infection Prevention Committee and hospital leadership teams, review process and outcome data to determine the effectiveness of implemented infection prevention measures. With the input of the IP, these teams have the ability to modify or implement infection prevention activities based on outcomes of such actions. The program’s effectiveness is also correlated with patient outcomes. Hospital infection rates are compared to both internal and external benchmark data. Modification of goals or programs occur on an ongoing basis as needs are identified during the review of data. 8

b Assessments 9

b Community Assessment (Hospital’s location and where services are provided) Description of population served (state census website) According to the Health Department, the top five communicable reported diseases in the county during 2016 were: 1. Chlamydia Trachomatis Infection (873 reported 871 cases) 2. Hepatitis C Virus Infection, Past or Present (250 reported 183 cases) 3. Gonorrhea (212 Reported 212 cases) 4. Influenza-associated Hospitalizations (141 Reported 138 cases) 5. Influenza Activity (125 Reported 102 cases) Potential Risk Factors Population risks include immunization preventable communicable diseases due to low immunization rate (≈75%) of children; enteric diseases related to drinking raw milk; and immunocompromised states associated with advanced age; and co-morbidities of obesity, cancer, and diabetes. 10

b Facility Assessment Facility Description Hospital is a nonprofit, community hospital. Services Provided Hospital provides a variety of services across the continuum of care, Including, but not limited to, the following: • Emergency and Critical Care Services • Women & Children Services • Medical / Surgical Services (which include an Intensive Care Unit) • Cancer Services • Imaging Services • Rehabilitation Services • Wound Care • Infusion Services • Sleep Center Construction Risk Assessment The IP helps in assessing construction risks to patients, staff, and visitors by assisting in the completion of Infection Control Risk Assessments for each project. The IP meets regularly with the Director of Engineering, Construction Manager, and Engineering Team Leads. The IP assists the Construction Management team and/or Engineering staff in monitoring compliance to measures that mitigate risks during construction projects. Risk assessment documents for each project are kept on file by the IP. Projects anticipated during the current year include: • OR Integrated Rooms • ICU Med gas integration • Maintenance Projects 11

b Multidrug Resistant Organism (MDRO) Assessment Hospital complies with CDC’s recommendations. Adherence to hand hygiene guidelines and Standard Precautions are encouraged, in addition to appropriate utilization of isolation precautions as indicated. The IP program monitors the rate of hospital associated MDROs infections throughout the facility via routine surveillance methodology. The prevalence of targeted MDROs is identified through lab data, and is reported as the total number of positive cultures each month. Facility Assessment During 2016, had a MDRO rate of). Tuberculosis (TB) Risk Assessment The TB risk assessment is completed each spring when information for the previous year has been made available from the state and local health departments. The yearly assessment is found within this document as Appendix B. Facility Summary During 2016, Hospital had XX suspected TB patients, with X confirmed active case. Our facility had XX associated exposures and X employee conversions with a positive Quantiferon Gold. Therefore, our facility is considered as “Low Risk. ” Community Summary During 2016, XX Counties combined had X case of active TB diagnosed and treated via DOT (direct observation therapy). The patient received half his treatment prior to moving to another county in the state. The State of Idaho had a total of X cases of active TB during 2016. 12

b Infection Prevention Goals and Plan Goals are based on the prioritized risks identified during the completion of facility risk assessments. The purpose of the program goals and plan are to focus on limiting unprotected exposures to pathogens as well as minimizing the risks associated with medical procedures, medical equipment and invasive devices. 13

b Hand Hygiene Compliance Goal Measurements Action Plan or Method Evaluation 1 st Qtr. 2 nd Qtr. 3 rd Qtr. 4 th Qtr. Physician Nursing Ancillary Outpatient Overall Goal Met 14

b Multi-drug Resistant Organisms Goal Measurements Action Plan or Method Evaluation Goal Met Number of infections Rates & SIRs Comments 1 st Qtr. 2 nd Qtr. 3 rd Qtr. 4 th Qtr. 15

b Name of Goal Measurements Action Plan or Method Evaluation Goal Met Number of infections Rates & SIRs Comments 1 st Qtr. 2 nd Qtr. 3 rd Qtr. 4 th Qtr. 16

b Influenza Vaccination Goal Measurements Action Plan or Method Evaluation 1 st Qtr. 2 nd Qtr. 3 rd Qtr. 4 th Qtr. 17

b Appendices: A. Hospital Risk Assessment B. Tuberculosis Risk Assessment 18

b Hospital Risk Assessment: Appendix A 19

b Tuberculosis Risk Assessment: Appendix B 29