Care – Infection Control

Service: Risk Management
Subject: Care
Setting: Infection
Type: Risk Profiles

Infection control and its associated risks relating to Healthcare Associated Infections (HAIs) in a healthcare organization can have significant patient safety implications and adverse event outcomes. This document contains information entered by HIROC subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Key controls/Mitigation strategies

Education and Training

  • Training/education/certification/competency/evaluation for all staff, volunteers, and physicians as per job category and public health directives upon hire/entry to the organization and ongoing for:
    • Hand hygiene 
    • Personal protective equipment (PPE) 
    • Isolation precautions 
    • Respiratory mask fit testing
    • Safe food handling
    • Workplace Hazardous Materials Information System 
  • Vendor engagement and accountability including sign-off (annually) to provide training, as necessary 
  • Staff attend an original equipment manufacturer “train the trainer” program
  • Reprocessing certifications (e.g., Canadian Standards Association, Medical Device Reprocessing Association of Ontario) for reprocessing department staff
  • Use of simulation

Communication and Collaboration

  • Interprofessional collaboration internally and externally with key stakeholders to ensure best practice guidelines/processes and standardization is followed
    • Focus on Outcome Based Pathways and Service Pathways
    • Ensure assessments and re-evaluations are conducted and communicated to members of the care teams
  • Collaboration with Infection Prevention and Control (IPAC) and Environmental Services related to the selection of appropriate cleaning and disinfection products 
  • Consult IPAC professional for practice specific consultation/queries 
  • Access to IPAC site lead
  • Focus on high reliability with application of evidence informed prevention bundles (e.g. ventilator associated pneumonia/central line bundles) 
  • Daily safety briefing to enhance situational awareness

Internal Policies, Procedures and Programs

  • Ensure policies and procedures are in place and are regularly reviewed and evaluated against current best practices and revised accordingly
  • Governance structure in place to ensure support, guidance and accountability at all organization levels
    • Integration of infection prevention into roles outside of designated IPAC team (e.g. Reprocessing Department Supervisors, unit based Quality Leaders, Housekeeping Supervisors, Educators, front line staff)
    • IPAC reporting structure aligned with organizational Quality and Safety
  • Policy/Standard Operating Procedure for: 
    • Regular environmental cleaning, enhanced cleaning during outbreaks and pandemics, cleaning of shared patient equipment and frequent cleaning of high touch surfaces
    • Toys and reading material in clinics and waiting rooms, non-sterile medical gel, purchasing and cleaning of home visit equipment 
    • Point of care risk assessment, routine practices and additional precautions 
    • Outbreak management 
    • Surgeons bringing in office instrumentation for use in operating room; equipment transport policy
    • Reprocessing in decentralized areas are developed and in place (e.g. flash sterilization)
    • Loaner equipment 
  • Policies and procedures for management of infection prevention & control standards for new equipment, care products , renovations and new construction on entry to organization 
  • Standardize and automate processes and procedures, where appropriate
  • Standardization of documentation/test logs for all care providers
  • Operating Room staff follow Operating Room Nurses Association of Canada standards related to instrumentation
  • Ongoing projects and initiatives based on healthcare acquired infections 
  • Antimicrobial stewardship program
  • Vaccination programs for inpatients and residents

Prevention Processes 

  • Ensure required resources, equipment and supplies are available and accessible 
  • Robust preventative maintenance processes in place and evaluated on a routine basis, including: 
    • Heating 
    • Ventilation 
    • Air conditioning filter changes/air purifying
    • Reprocessing areas meet current standards
  • Development and required use of cleaning checklists
  • Review of physical space/environment (e.g. airborne isolation rooms (negative pressure); positive pressure rooms)
  • Food-borne illness:
    • Public Health inspections 
    • Use of only Hazard Analysis Critical Control Point (HACCP) approved vendors
  • Sufficient point of care sharps containers and hand sanitizer dispensers 
  • Pharmacy holds compounded products in quarantine until lab testing clear

Medical Device Reprocessing (MDR)

  • Adhere to best practice guidelines (single use) where possible
  • Any instrumentation found with biological or foreign body debris on instrumentation should immediately be removed and replaced 
  • Issues related to instrumentation reported using organizational reporting mechanism, tracking of issue frequency analyzed for cause and improvement strategies, shared at departmental meetings/huddles
  • Development of web-based site for reprocessing resources
  • Review of physical space/environment and ensure soiled to clean to sterile workflow
  • Standardized work developed for decentralized processing locations
  • Reprocessing department committee in place and managed by Reprocessing department/IPAC
  • Automated alarms and alerts in place for mechanical sterilization and disinfection failures
  • Instrument tracking system to facilitate exposure management and recall system
  • Completion of daily chemical and mechanical biological testing on all reprocessing equipment
  • Routine monitoring of age and end of life of equipment to ensure replacement in timely fashion

Pandemic-Specific

  • Implementation of Incident Management System during an incident response of high impact and sustained risk from communicable diseases exposure
    • Open and operate Emergency Operations Center
    • Monitor Personal Protective Equipment (PPE) inventory, shields, hand sanitizer, paper towels usage and available critical supply stock; consider burn rate formula
    • Monitor ongoing availability of ventilators by categories
    • Monitor staff wellness, offer mental health wellness resources
    • Business continuity plans
  • Health human resource contingency planning for all departments
  • Provide for process of communicable disease testing via occupational health & safety processes 
  • Provide guidance based on symptoms and test results 
    • Assess need for contact tracing of confirmed cases and testing protocols
    • Active screening protocols at all healthcare facility entrances, minimize entrances available
    • Review pertinent reports, dashboards related to infection rates, hospitalization and Intensive care admission rates, isolated patients, patient transfers 
    • Use of analytic software (such as Epic) to identify patients with suspected or confirmed infection, consider patient co-horting
    • Use of algorithm for bed flow, active bed management 
  • Risk self-assessment tool for all employees and visitors
  • Universal masking policy for all employees and visitors
  • Frequent infection surveillance reporting
  • Closure, suspension or decrease of non-essential services and clinics 
    • Re-engineer service delivery models to ensure staff and patients are able to adhere to public health guidelines and government-mandated directives
  • Virtual methods of providing applicable care services
  • Mandatory work from home for non-essential personnel, reducing need for PPE
  • Visitor restrictions based on risk assessment, public health directives and PPE supply
  • Communications/alerts shared with frontline staff as appropriate
  • Communication process using electronic platforms to ensure frontline staff are aware of current  measures (e.g., pandemic)
  • Distribution of Provincial Infectious Diseases Advisory Committee (PIDAC) updates to staff and decision makers
  • Weekly quality board rounding with staff involvement
  • Clients/Patients/Families provided with education in various formats
    • Partnering with patients for their observations, feedback and recommendations
    • Guidelines for visitor expectations (e.g. physical distancing, no eating/drinking, no use of washroom in patient room, no wandering around unit or visiting others)
    • Development of frequently asked questions for visitors
    • Establish visitor times around Aerosol Generating Medical procedures, therapy and supplies
  • Discussion with patients/clients and their families relating to care options and transitions between points of care

Monitoring/indicators

Audits and surveys:

  • Ongoing monitoring of: 
    • Baseline infection rates and hand hygiene to identify trends and issues
    • Line infection days; infection control rates
    • Compliance rate with Hand Hygiene and Point of Care risk assessment
    • Environmental cleaning, equipment reprocessing and safe food handling practices using appropriate internal and external processes
      • Cleaning protocols in place
      • Environmental cleaning audits 
    • Bulletins/information from external agencies and industry specific sources (e.g. Respiratory Viral Watch)
    • Staff influenza vaccination rate
    • Healthcare Acquired Infection rates/# of patients
    • IPAC inspections 
    • Data collected through Incident reporting mechanisms/systems
    • Number of staff who hold required qualifications/certification
    • Routine review and comparison of practice vs. best practice guidelines; current policies and procedures
    • Number of consults to IPAC professional
    • Percentage of staff in compliance with established practices and protocols; training and education (modules)
    • Number of staff compliance with use of checklists and other sources of data collection (e.g. audits and surveys)
    • Number of audits and timing (monthly/annual)
    • Vaccination rates
    • Number of staff fitted for respiratory masks
    • Method of survey (e.g. direct observation, patient/client/family feedback, self-reporting, chart audits)
    • Audits: 
      • Audits of practice against best practice infection prevention guidelines 
      • Endoscopy audits , and action plans developed
      • Audit of decentralized preprocessing areas
    • Audit/peer observation of adherence and breaches for donning and doffing Personal Protective Equipment
    • External reviews
    • Educational program compliance numbers and attendance data

Quality Control 

  • Daily biological validation testing and chemical indicator testing
  • Monthly Adenosine Triphosphate (ATP) testing based on industry benchmarks
  • Maintain logs of daily diagnostic testing on all equipment, monthly audits, daily/weekly maintenance on all reprocessing equipment
  • Reprocessing Department reprocessing indicator monitoring, audits and QA for sterilization
  • Biochemical indicators for reprocessing equipment are documented
  • Endo/Channel results recorded (if positive, reprocessing repeated until negative)
  • Monitoring of packaging and disposable items to ensure cleanliness
  • All sterilization parameters are audited, checked and recorded in Reprocessing Department
    • Consider a Quality Board 
  • Recall policy (equipment numbered) followed for any instruments that did not meet sterilization parameters
  • Patient self-reporting of outcomes
  • Quality/Patient Safety reporting system
  • Hospital wide survey to monitor inappropriate decentralized sterilization and/or high level disinfection processes in use
  • Food-borne illness: Quality Assurance (QA) monitoring; daily follow-up with Hazard Alert database
  • Leadership presence and accountability at direct care levels to ensure audits completed
Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.