Care – Infection Control

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