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CMS Infection Control Standards Appendix What Hospitals Need to Know. Hospitals Need to Know About the Infection Control Interpretive. Speaker. Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD President Patient Safety and Education 5447 Fawnbrook Lane Dublin, Ohio 43017

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  1. CMSInfection Control StandardsAppendixWhat Hospitals Need to Know. Hospitals Need to Know About the Infection Control Interpretive

  2. Speaker Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD President Patient Safety and Education 5447 Fawnbrook Lane Dublin, Ohio 43017 614 791-1468 sdill1@columbus.rr.com Appendix with additional resources 2 2

  3. Injection Safety CDC

  4. Advancing ASC Quality • ASC Quality Collaboration has ASC tool kit for infection prevention • Includes one on hand hygiene and safe injection practices • Includes a basic and expanded version of the toolkit • These are available at http://www.ascquality.org/advancing_asc_quality.cfm

  5. Resources • TJC has Speak Up Initiatives including five things you can do to prevent infections at www.jointcommission.org/GeneralPublic/Speak+Up/about_speakup.htm • Options to Increase Isolation Surge Capacity, Slides at www.jcrinc.com/common/PDFs/document_collection/resources/collections/00032482/00032984-0001.pdf • Preparing for a Pandemic, EM Case Study, How the Health First Hosptial Developed a Pandemic Influenza Plan at www.jcrinc.com/common/pdfs/qualityandsafety/preparing_for_a_pandemic_brevard_county_FL.pdf

  6. Spice www.unc.edu/depts/spice/

  7. www.apic.org

  8. / 25

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  13. CDC has Dialysis Resources also

  14. / 32 www.apic.org/Content/NavigationMenu/PracticeGuidance/APICEliminationGuides/Hemodialysis_Resourc.htm

  15. / 36 Institute for Healthcare Improvement

  16. / 37 Source: www.shea-online.org

  17. www.who.int/en/

  18. http://www.his.org.uk/

  19. www.theific.org/

  20. / 42 Source: www.idsociety.org

  21. www.idsociety.org/

  22. / 46 PA Patient Safety Authority Source: http://www.patientsafetyauthority.org/Pages/Default.aspx

  23. / 47 IHI ICU Improvements • VHA united with IHI to improve ICU care • Better control of blood sugars with glucose monitoring protocols1 • Aggressive treatment of sepsis/blood stream infections (see central line bundle) • Prevention of ventilator associated pneumonia (see VAP bundle), surgical infections • Developed toolkits (order sets, protocols, daily goal sheets), report templates for monthly reporting of change 1www.ihi.org

  24. / 48 Ventilator Bundle • Head of bed (HOB) elevation > 30 degrees • Deep venous thrombosis (DVT) prophylaxis • Peptic ulcer disease (PUD) prophylaxis • Daily sedation vacations • Assessment of readiness of wean • Oral care • Use a checklist and document each!

  25. / 49 Central Line Bundle • Hand hygiene • Maximal barrier precautions upon insertion • Chlorhexidine skin antisepsis • Optimal catheter site selection with subclavian vein as the preferred site for non-tunneled catheters • Daily review of line necessity with prompt removal of unnecessary lines

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