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 risk associated with various HAIs such as: bloodstream infections; post-surgical infections; urinary tract infections; and pneumonia related to the use of a ventilator, can impact morbidity and mortality, length of hospital admissions/readmissions and healthcare spending. 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.

Ranking/ratings

  • Likelihood – average score 2.62
  • Impact – average score 3.13

The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key controls/mitigation strategies

 

  • Education and Communication
    • Hand Hygiene training and education for all staff, volunteers and physicians as per job category upon hire/entry to organization and annually
    • Training/education/certification/competency evaluation of all staff evaluated on an annual basis as per job category for all relevant equipment, resources and processes upon entry to organization and with new equipment, care products
      • Use of simulation
      • Vendor engagement and accountability to provide necessary training
      • Ensure all required resources and equipment are available
    • 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 team
    • Focus on high reliability with application of evidence informed prevention bundles
    • Application of Incident Management System to high impact and sustained risk from communicable diseases exposure
    • 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
    • Discussion with patients/clients and their families relating to care options and transitions between points of care
      • Ensuring safe transitions to community and other levels of care by communicating plan of care appropriately
    • Communications/alerts shared with frontline staff appropriately e.g. Middle East Respiratory Syndrome (MERS)
  • Internal Policies/Procedure and Processes
    • Governance structure in place to ensure support, guidance and accountability at all levels
      • Integration of infection prevention focus into roles outside of designated Infection Prevention and Control (IPAC) team (e.g. Reprocessing Department supervisors, Unit based Quality Leaders, Housekeeping Supervisors, Educators, front line staff)
      • IPAC reporting structure alignment with organizational Quality and Safety agenda
    • Standardization of documentation for all care providers
    • Outcome and process surveillance program
    • Data collection tools and resources developed and utilized
    • Routine auditing, assessments, quality assurance process, checks and reconciliations conducted utilizing a variety of methods:
      • Direct observation
      • Self-auditing / reporting
      • Patient/Client/Family surveys
      • Chart audits
      • External review
    • Robust preventative maintenance (PM) processes in place and evaluated on a routine basis
    • Ensure policies & procedures are in place and are reviewed and evaluated against current best practices and revised accordingly
    • Development and routine review of communicable diseases prevention plan/pandemic plan
    • Development and required use of checklists
    • Standardize and automate processes and procedures where appropriate
    • Review of physical space/environment e.g. airborne isolation rooms (negative pressure); positive pressure rooms
    • Ensure all required equipment and supplies are readily available and accessible
    • Food borne illness:
      • Public Health inspections
      • Use of only Hazard Analysis Critical Control Point (HACCP) approved vendors
      • Staff training on safe food handling, HACCP, Workplace Hazardous Materials Information System (WHIMIS)
      • Quality Assurance(QA) monitoring; daily follow-up with Hazard Alert database
    • Ongoing projects and initiatives based on HAIs
  • Reprocessing Specific
    • Vendor education and sign-off (annually)
    • Staff attend an original equipment manufacturer (OEM) “train the trainer” program
    • Reprocessing Department staff:
      • Are qualified and aware of departmental reprocessing policies and procedures, quality control measures, departmental design
      • Receive ongoing staff training and supervision
      • Adhere to best practice guidelines (single use) where possible
    • All Reprocessing Department staff and coordinator possess current Canadian Standards Association (CSA) certification
    • Training/education/competency/evaluation process in place for reprocessing staff
    • Review of physical space/environment and ensure Capital Plan resources
    • Policies for reprocessing in decentralized areas are developed and in place
    • Technicians who reprocess endoscopes are Medical Device Reprocessing Association of Ontario (MDRAO) certified
    • Reprocessing Department committee in place and managed by Reprocessing Department/IPAC
    • Preventative Maintenance program in place
    • Annual endoscopy audits completed, assessed and action plans developed
      • Annual audit of decentralized preprocessing areas
    • Standardization of all documentation/test logs
    • Standardized work developed for decentralized processing locations
    • Completion of daily chemical and mechanical biological testing on all reprocessing equipment
    • Development of web-based site for reprocessing resources
    • Risk Assessment Checklist (RAC) for inadequate sterility followed
    • Instrument tracking system to facilitate exposure management and Recall system
    • Loaner equipment policy
    • Automated Alarms and Alerts in place for Mechanical Sterilization and Disinfection Failures

Monitoring/indicators

  • Audits and surveys:
    • Percentage of staff in compliance with established practices and protocols; training and education (modules)
    • Number of audits and timing (monthly/annual)
    • Method of survey e.g. direct observation, patient/client/family feedback, self-reporting
    • Use of technology e.g. Radio-frequency Identification (RFID) badge scans
    • Standardized audit tool and reporting process
    • Periodic audits of practice against best practice infection prevention guidelines
  • Surveillance processes to monitor baseline infection rates and to identify trends and issues
  • Monitor line infection days; infection control rates
  • Ongoing monitoring of environmental cleaning, equipment reprocessing and safe food handling practices using appropriate internal and external processes
    • Cleaning protocols in place
  • Daily Safety Briefing to enhance situational awareness
  • External reviews conducted
  • Leadership presence and accountability at direct care levels to ensure audits completed
  • Monitor bulletins from external agencies and industry specific sources e.g. Respiratory Viral Watch
  • Sources of data:
    • Environmental services data
    • Staff influenza vaccination rate
    • HAI rates/# of patients with HAI (CDI, CLI, SSI, VAP, MRSA, VRE)
  • Number of staff compliance with use of checklists and other sources of data collection e.g. audits and surveys
    • Evaluation of compliance with various stages of Hand Hygiene
    • Environmental cleaning compliance
  • Pharmacy holds compounded products in quarantine until lab testing clear
  • Data collected through Incident reporting mechanisms/systems
  • Number of staff compliance with use of checklists
  • Ongoing staff educational programming including integration of IPAC content into other curricula
    • Educational program compliance numbers and attendance data
  • Number of staff who hold required qualifications/certifications
    • Review and tracking of ongoing maintenance of required certifications
  • Number of professional development opportunities
  • Routine review and comparison of practice vs. best practice guidelines; current policies and procedures
  • Monitor external sources of information
  • Protocols, policy and procedures in place and reviewed as per organizational policy and with new best practice/standards changes
  • Reprocessing Specific:
    • 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 as a Quality Board metric
    • 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
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.