Road Map to a Comprehensive Healthare-Assoiated Infetion (HAI) Prevention Program 2.0
The HAI Road Map provides evidene-based reommendations/standards for Minnesota hospitals in the development of a omprehensive Healthare-Assoiated Infetion Prevention Program whih inludes atheterassoiated urinary trat infetions (CAUTI), entral line assoiated bloodstream infetions (CLABSI), ventilatorassoiated pneumonia (VAP), surgial site infetion (SSI), and lostridium diffiile infetion (CDI). The Road Map and aompanying tool kit were developed as part of the Minnesota HAI Prevention Collaborative, whih was made possible with funding through the Centers for Disease Control and Prevention (CDC) Epidemiology and Laboratory Capaity Program (ELC) Amerian Reinvestment and Reovery At (ARRA) and CMS Partnership for Patients (P4P) Initiative. We would like to thank the following individuals for sharing their time, expertise and stories whih made the road map and tool kit possible. Danielle Abel, CHI Lakewood Health, Baudette Julie Apold, Minnesota Hospital Assoiation, St. Paul Mary Ellen Bennett, Hennepin County Medial Center, Minneapolis Tania Daniels, Minnesota Hospital Assoiation, St. Paul Jane Harper, Minnesota Department of Health, St. Paul Jane Hirst, LifeCare Medial Center, Roseau Lindsey Lesher, Minnesota Department of Health, St. Paul Viki Olson, Stratis Health, Bloomington Kate Peterson, Stratis Health, Bloomington Jean Rainbow, Minnesota Department of Health, St. Paul Mikey Reid, Minnesota Hospital Assoiation, St. Paul Linell Santella, Park Niollet Methodist Hospital, St Louis Park Boyd Wilson, HealthEast Care System, St. Paul Cindi Welh, Essentia Health, Duluth Jill Kieser, Stratis Health, Bloomington Jessia Nerby, Allina Health Cindy Teihroew, FirstLight Health System, Mora Dawn Twenge, HealthPartners, In., Minneapolis Tiana Wells, Fairview Southdale Hospital, Edina Lisa Hesse, Fairview Range Medial Center, Hibbing Janet Lilleberg, Minnesota Department of Health, St. Paul Catriona MaBean Mann, HealthPartners, In., St. Paul Jane Hindersheid, HealthEast Care System, St. Paul Jennifer Heath, Minnesota Department of Health, St. Paul Tammy Suhy, Tri-County Health Care, Wadena Denise Herrmann, HealthPartners, In., Minneapolis Margaret Nielsen, HealthPartners, In., Minneapolis Mary Houle, Tri-County Health Care, Wadena Kathy Tusken, Essentia Health, Duluth Marilyn Grafstrom, Minnesota Hospital Assoiation, St. Paul Marie Dotseth, Minneaposa Alliane for Patient Safety Jan Deane, End Stage Renal Disease, Network, St. Paul Stephanie Tismer, HealthPartners, In., Minneapolis
SSI (original version): Sheila Higbe, Olmsted Medial Center, Rohester Gail Pries, Gillette Children s Speialty Healthare, St Paul We would also like to thank the following hospitals for ontributions to the SSI, VAE, CLABSI, CAUTI, and CDI gap analyses: Allina Health, Minneapolis CentraCare Health, Melrose CHI LakeWood Health, Baudette Cuyuna Regional Medial Center, Crosby Distrit One Hospital, Faribault Essentia Health, Duluth Essentia Health-Fosston Glaial Ridge Health System, Glenwood Glenoe Regional Health Servies Grand Itasa Hospital Grand Itasa Clini and Hospital Hennepin County Medial Center, Minneapolis Mayo Clini, Rohester North Memorial Medial Center, Robbinsdale Park Niollet Methodist Hospital, St. Louis Park Regions Hospital, St. Paul St. Cloud Hospital Sanford Bemidji Medial Center United Hospital, St. Paul University of Minnesota Medial Center, Fairview, Minneapolis Windom Area Hospital Definitions Health are personnel (HCP): All persons, paid and unpaid, working in an aute are faility who have potential for exposure to patients and/or infetious materials, inluding body substanes, ontaminated medial supplies and equipment, ontaminated environmental surfaes, or ontaminated air. This inludes persons not diretly involved in patient are (e.g. leadership, lerial, housekeeping, and volunteers) but potentially exposed to infetious agents that an be transmitted to and from HCP and patients. This term inludes, but is not limited to, physiians, physiian assistants, nurse pratitioners, nurses, nursing assistants, therapists, tehniians, emergeny medial servie personnel, dental personnel, pharmaists, laboratory personnel, autopsy personnel, students and trainees, and ontratual personnel. Presriber: Health are personnel who are liensed to presribe mediations, inluding antimirobial agents.
Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0 Safe from HAI Speifi Ations(s) Audit Questions Yes No Team members 1) Promote HAI prevention representation/ hampions throughout the faility HAI prevention hampions/team members/liaisons with lear roles and expetations have been designated from: 1a) Physiian/provider knowledgeable in infetious diseases 1b) Infetion prevention 1) Diret are 1d) Safety/quality 1e) Pharmay 1f) Laboratory 1g) Environmental servies 1h) Operating room N/A: 1i) Other physiians as appropriate for speifi HAI fous areas (e.g.surgery, pulmonary mediine, hospitalist) 1j) The faility has a proess in plae to engage other team members as regular or ad-ho members as appropriate (e.g., purhasing, eduation, IV team, human resoures, patient/family). Performane improvement 2) Trak progress on proess and outome measures Data olletion A proess is in plae to ollet HAI prevention bundle/proess data for the following as appliable: 2a) Hand hygiene ompliane 2b) Healthare personnel influenza vaination ompliane 2) Hospital patient influenza vaination ompliane 2d) VAE N/A: 2e) SSI N/A: 2f) CAUTI 2g) CDI 2h CLABSI 2i) MDRO 2j) Environmental leaning general 2k) Environmental leaning OR N/A: A proess is in plae to ollet HAI outome measures using NHSN definitions for the following as appliable: 2l) CAUTI rate 2m) CLABSI rate 2n) VAE rate N/A: 2o) SSI rate N/A: 2p) CDI rate 2q) MDRO rates 2r) Outome data is traked on a regular basis for other surgial areas as identified as high-risk for infetions by the hospital. 2s) A proess is in plae to routinely review and analyze eah HAI for improvement opportunities/defets. HCP HAI eduation 3) Provide HAI eduation for health are personnel (HCP) and presribers Expetations and supporting HAI prevention eduation, inluding speifi roles in preventing transmission of infetions for identified patients, have been inorporated into new employee orientation for: 3a) HCP and presribers Expetations and supporting HAI prevention eduation have been inorporated into employee orientation for personnel employed by outside agenies and ontrated personnel. 3b) Ongoing HAI prevention eduation is provided for HCP, presribers annually. 3) Expetations and supporting HAI prevention eduation have been inorporated into new physiian orientation. Page 1 Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0
Building bloks for HAI prevention Hand hygiene Audit Questions Yes No The faility has instituted an infrastruture, based on CDC or WHO guidelines, to reinfore and sustain hand hygiene praties using the following strategies, at minimum: 1a) Set lear expetations for hand hygiene praties to all health are personnel (HCP) and presribers. 1b) Consider inorporating a human fators approah to hand hygiene ompliane (www.mnhospitals.org.ontrollingdi) 1) Provide visible reminders of hand hygiene expetations, e.g., omputer sreen savers, posters. 1d) Provide on-going oahing and just-in-time training to reinfore effetive hand hygiene expetations. 1e) Provide real time performane feedbak to HCP, presribers. 1f) Tailor eduation in proper hand hygiene for speifi disiplines. 1g) Make soap/waterless hand sanitizer readily available to HCP, presribers, patients and visitors. 1h) Struture the hand hygiene environment to support hand hygiene, e.g., dediated spae to plae items while leaning hands. 1i) Limit the need to frequently enter or exit patient room, e.g., bedside omputer, portable phone, adequate/dediated supplies in room. 1j) Consider tehnologies to make it easy for HCP, presribers to remember to lean hands, e.g., radio frequeny identifiation, automati reminders, warning systems. 1k) A Justie, Learning and Aountability model is applied when HCP, presribers are observed not following faility expetations for appropriate hand hygiene. 1l) Celebrate improvements in hand hygiene praties. 2a) A proess is in plae to provide hand hygiene eduation for all HCP, presribers at orientation and on an on-going basis. 3a) A proess is in plae to provide on-going eduation to patients, families and visitors on the importane of proper hand hygiene, e.g., signage, fat sheets, easily aessible hand sanitizer dispensers for patients/families. The faility has lear expetations that all HCP, presribers may lean hands with either soap and water or an aloholbased hand rub: 4a) When hands are not visibly dirty or ontaminated. 4b) Before having diret ontat with patients. 4) After removing gloves. The faility has lear expetations that all HCP, presribers must lean hands with soap and water: 4d) When hands are visibly dirty or ontaminated. 4e) Before eating or handling food. 4f) After using a restroom. 4g) After aring for a patient with potentially infetious diarrhea. 4h) The faility s hand hygiene and surgial hand srub produts are FDA- approved. 4i) The faility follows AORN, CDC, and/or WHO guidelines as well as manufaturer s diretions when using hand hygiene and surgial hand srub produts. In any setting where sterile tehnique is used, the faility has lear expetations for hand hygiene praties: 4j) Fingernails are short, lean, and without hipped nail polish. 4k) Artifiial nails (any enhanement or resin bonding produt inluding gel), are not worn. 4l) Rings, wathes, and braelets are removed prior to hand hygiene. 4m) Cutiles, hands and exposed skin are free of uts, abrasions, open lesions, and new tattoos. 4n) A surgial hand srub is performed by health are personnel before donning sterile gloves for surgial proedures as outlined by AORN guidelines. The faility onduts hand hygiene audits: 5a) The faility has a method in plae to audit ompliane with hand hygiene in all departments, inluding outpatient/lini/ ambulatory are settings., e.g., no. of hand hygiene episodes/no. of hand hygiene opportunities, appropriate hand hygiene tehnique, when outbreaks of infetion our, artifiial nail wearing praties, monitoring the volume of alohol-based hand rub (or detergent used for hand leaning or hand antisepsis) used per 1,000 patient-days. 5b) The faility uses trained observers to monitor appropriateness of hand hygiene (Consider nursing students). 5) The faility has a proess to identify hand hygiene system issues and target solutions, e.g., supplies not readily available, faulty/empty hand sanitizer dispenser. 5d) The faility has a proess to assess patient/family perspetive on HCP/presriber hand hygiene ompliane (e.g. patient satisfation survey post visit survey or use of survey ards for patient-as-observer during a visit). Page 2 Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0
Audit Questions Yes No The faility provides feedbak on hand hygiene adherene: 5e) Within units 5f) Aross units 5g) Aross departments 5h) With leadership 5i) With medial staff 5j) With the board(s) Continually improve hand hygiene: 6a) Establish goals for improving ompliane with hand hygiene guidelines. 6b) Improve ompliane with hand hygiene guidelines based on established goals using evidene based strategies. Transmission-based preautions 1a) The faility has a proess in plae to apply standard infetion prevention praties for all patients, regardless of suspeted or onfirmed infetion status whih inludes, at a minimum: Hand hygiene Use of gloves Gown Mask Eye protetion or fae shield, depending on the antiipated exposure Safe injetion praties Respiratory hygiene/ough etiquette Use of masks for insertion of atheters or injetion of material into spinal or epidural spaes via lumbar punture proedures 2a) The faility s infetion prevention program addresses the use of transmission-based isolation preautions based on urrent publi health and other evidene-based guidelines whih addresses, at a minimum Contat Preautions Droplet Preautions Airborne Preautions 2b) Have a proess in plae to respond to CDC reommendations for emerging pathogens. The faility s proess for patient plaement/room seletion inludes: 3a) Private/single-patient room preferred for patients requiring isolation preautions when available. 3b) If private room availability is limited, ohort patients aording to CDC guideline. 3) Patients with disordant status of infetion or olonization with other epidemiologially important organisms (e.g., VRE, MRSA) are not ohorted. 3d) Airborne isolation infetion room (AIIR) aording to CDC guideline for patients with infetious agents requiring Airborne Preautions or a proess to transfer patients requiring airborne isolation to another faility. Communiate preaution status: 4a) The faility has a proess is in plae to immediately post Isolation Preautions signage in visible loation outside suspeted and positive patient rooms. 4b) The faility has a proess in plae to ommuniate isolation preaution status to reeiving departments/failities when isolation patients are transferred. Ensure effetive use of personal protetive equipment (PPE): 5a) Adequate supplies for ompliane with Isolation Preautions (e.g., gowns, gloves) are readily aessible outside of the patient room. 5b) HCP, presribers wear PPE aording to Standard Preautions and Transmission-based preautions. 5) Gloves are hanged immediately if visibly soiled and after touhing or handling ontaminated surfaes/materials. 5d) HCP, presribers hange gown and gloves and perform hand hygiene when moving between ohorted patients. 5e) Respiratory protetion is worn aording to CDC guidelines for patients with infetious agents requiring airborne preautions and for performane of aerosol-generating proedures. 5f) PPE is removed before exiting the patient room (exeption: N95 respirator is removed after exiting patient room). 5g) The CDC Guideline instrutions on donning and removal of PPE are followed. 5h) Staff training is provided on donning and doffing PPE on orientation and regularly, inluding ompeteny assessments. Patient transport: 6a) The faility provides lear expetations that patient transport or movement for patients with infetions, outside of the room is avoided unless medially neessary. 6b) When transport is neessary, a proess is in plae to ensure that infeted or olonized areas of the patient s body are ontained and overed. Page 3 Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0
Audit Questions Yes No Environmental leaning and disinfetion: 7a) The faility has proesses in plae for routine and targeted leaning and disinfetion of environmental surfaes as indiated by level of patient ontat and degree of soiling whih inludes emphasis on high-touh surfaes in the patient are environment. 7b) The faility uses EPA-registered disinfetant produts that have mirobioidal ativity against the pathogens most likely to ontaminate the patient are environment. 7) The faility has a proess in plae to use disinfetant produts in aordane with manufaturer instrutions for use and ontat time. Linen and waste management: 8a) The faility has a proess in plae to follow Standard Preautions for the handling of soiled linen and waste materials. 8b) The faility has a proess in plae to dispose of infetious/biohazard waste aording to the OSHA Bloodborne Pathogen Standard. Patient are supply/equipment management: 9a) Patient are equipment and instruments are handled aording to Standard Preautions. 9b) Single-use or dediated patient are equipment is utilized when possible (e.g. blood pressure uff). 9) Reusable patient-are equipment is leaned and disinfeted between patients. 9d) The amount of supplies stoked in the patient room is limited to what will be needed for are. 9e) Responsibility is assigned for regularly heking and restoking supplies. 9f) A defined proess is in plae for handling supplies remaining in the patient room after disharge. 9g) Responsibility is defined for who is assigned to lean patient are supplies/equipment and surfaes, eg., nursing, EVS. 9h) A defined proess is in plae for separating and identifying lean and dirty equipment, eg., ommodes, IV pumps. Communiate lear expetations for patient and visitors: 10a)The faility has a proess in plae to eduate patients/families on reommended hand hygiene, respiratory hygiene and transmission- based preautions as well as infetious agent speifi information as appropriate. 10b)The faility has a proess to learly o mmuniate and enfore requirements for visitors to enter isolation rooms, e.g., hand hygiene, PPE requirement. 10)The faility has established a proess to learly ommuniate and enfore restritions for visitors based on potential for their exposure as well as if they have signs/symptoms of infetion, e.g., fever, aute respiratory symptoms, gastrointestinal symptoms. Establish parameters for disontinuation of preautions: 11a) The faility has a proess in plae to disontinue preautions based on CDC reommendations, suh as: after signs and symptoms of infetion have resolved and patient is no longer ontagious aording to pathogen-speifi reommendations if infetious agents that require isolation preautions have been ruled out Antimirobial Stewardship Program (ASP) 1a) A physiian who is knowledgeable about antimirobials and is respeted by peers has been appointed to serve as a hampion for the ASP. 1b) The faility has established an ASP team that inludes, at a minimum, the physiian hampion and a pharmay hampion. 1) Senior leadership supports the ASP by providing ompensation and/or time for team members to work on the ASP. 1d) The ASP team is familiar with the key published ASP literature. 1e) The pharmay provides antimirobial use data to the ASP team. 1f) The ASP Team (or pharmay or Pharmay and Therapeutis Committee) has reviewed and updated the formulary to promote optimal, non-dupliative availability of antimirobials. 1g) The faility s laboratory produes a faility-speifi antibiogram or has aess to a region-speifi antibiogram that is updated annually. 1h) A baseline assessment of resoures and barriers for an ASP has been onduted. 1i) The ASP Team utilizes antimirobial use data and mirobiology data (e.g., antibiogram) to prioritize ASP strategies. 1j) The ASP Team onsiders adopting poliies requiring the use of minimal linial riteria for presribing antibiotis to treat urinary trat infetions. Injetion praties The faility has established injetion praties poliies/protools with lear expetations that the praties below are followed: 1a) Asepti tehnique is used to avoid ontamination of sterile injetion equipment. 1b) Used syringes, needles and annulas are disarded at the point of use in an approved Sharps ontainer immediately after use. Page 4 Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0
Audit Questions Yes No 1) Single-dose vials are used whenever possible and disarded immediately after use on a single patient. 1d) Mediations are not administered from a syringe to multiple patients, even if the needle or annula on the syringe is hanged. 1e) Needles, annulae, and syringes are sterile, single-use items andshould not be reused for another patient or to aess a mediation or solution that might be used for a subsequent patient. 1f) A syringe or needle/annula is onsidered ontaminated one it has been used to enter or onnet to a patient s intravenous infusion bag or administration set. 1g) Mediation is not prepared in one syringe to transfer to another syringe. 1h) A sterile syringe and needle/annula is always used when entering vial never one that has been used on another patient. 1i) Multidose vials are disarded 28 days after opening, unless speified by the manufaturer, or sooner if sterility is questioned or ompromised. 1j) Multi-dose vials are not kept in the immediate patient treatment area and are stored in aordane with the manufaturer s reommendations. 1k) A needle, annula, or spike devie is never left inserted into a mediation vial rubber stopper beause it leaves the vial vulnerable to ontamination. 1l) Fluid infusion and administration sets (eg., intravenous bags, tubing, and onnetors) are used for one patient only and disarded appropriately after use. 1m) Bags or bottles of intravenous solution are not used as a ommon soure of supply for multiple patients. 1n) One IV solution bags have been spiked; administration must begin within 1 hour. 1o) All opened vials, IV solutions and prepared or opened syringes that were used in an emergeny situation are disarded. 1p) Insulin pens are never shared between patients. 1q) Only single-use, disposable lanets are used for fingerstiks. 1r) Gluometers are not shared between patients unless the manufaturer indiates they are proved for multi-use and disinfetion instrutions are arefully followed. 1s) Equipment that minimizes reapping needlestik injuries is utilized. 1t) Faility follows reommendations outlined by the One & Only Campaign (http://oneandonlyampaign.org/ontent/what-arethey-why-follow-them). System-wide environmental leaning CORE Prevention Strategies = Strategies that should always be in plae. ENHANCED Prevention Strategies = Strategies to be onsidered in addition to ore strate-gies when: a) There is evidene that the ore strategies are being implemented and ad-hered to onsistently. b) There is evidene of on-going transmission as appropriate. ) There is evidene that rates are not dereasing. d) There is evidene of hange in pathogenesis as appropriate (e.g. inreased morbidity/mortality among patients). CORE PREVENTION 1a) Patient rooms and patient are equipment are appropriately leaned and disinfeted. The faility has a standardized environmental leaning and disinfetion protool that inludes: 1b) Hospital grade EPA-registered germiide is used for routine disinfetion and in aordane with the manufaturers instrutions. 1) Manufaturer produt reommendations are followed for use, inluding ontat time and dilution. Provide leaning/ disinfetion eduation for nursing/support staff: 2a) The faility has a proess in plae to provide leaning and disinfetion eduation for nursing and support staff. Provide eduation and ompeteny testing for environmental servies trainers the faility has a proess in plae to require person(s) responsible for environmental servies training to: 3a) Reeive eduation on urrent environmental leaning/disinfetion praties at least annually. 3b) Complete a ompeteny evaluation of leaning/disinfetion pratiesat least annually. Page 5 Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0
Audit Questions Yes No Provide leaning/ disinfetion training and evaluation for environmental servies staff: 4a) Training materials are provided in HCP, presribers native language (or ensure ommuniation of the information through other means). 4b) Environmental servies staff training inludes return demonstration. 4) A systemati proess is in plae to periodially evaluate terminally leaned rooms. 4d) Proesses are in plae to address issues identified through evaluations. Provide ompeteny testing to environmental servies staff: 5a) Environmental servies staff training inludes written or verbal ompeteny testing whih inludes demonstrated understanding of the rationale for leaning/disinfetion omponents. 5b) Expetations are in plae for environmental servies staff to pass a ompeteny test prior to assignment to patient are areas. 5) Expetations are in plae for environmental servies staff that do not pass the ompeteny test to reeive additional training or be assigned to non-patient are areas. ENHANCED PREVENTION Establish enhaned leaning & disinfetion praties: 6a) The faility has a proess to onsider tehnology to monitor for room leanliness, e.g., ATP, bioluminesene, fluoresent dye/marker, as appropriate. 6b) The faility has a proess to onsider other tehnologies for environmental disinfetion, e.g., UV light, hydrogen peroxide vapor. Patient influenza immunizations The faility has a proess to sreen and administer influenza vainations to hospitalized persons 6 months or older aording to National Hospital Inpatient Quality Measures and ACIP guidelines that inludes: 1a) Inorporation of influenza immunization status into initial patient assessment. 1b) Consideration of nursing standing orders for influenza vainations aording to ACIP guidelines. 1) Establishment of protool for influenza immunizations for obstetri patients. 1d) A review of influenza vaination status inluded in the disharge proess with administration of vaine if indiated 1e) Consider the promotion of patient influenza vainations in outpatient settings. Immunization of healthare personnel 1a) The faility has poliies and proedures in plae based on the Advisory Committee on Immunization Pratie (ACIP) reommendations that ensure employees are proteted against vaine-preventable diseases that pose a threat to the HCP s or patient s wellbeing within the institutional setting. 1b) Poliy and proedure has been established for eah HCP-reommended vaine that inludes the following: Category of HCP indiated for vaination Presumptive immunity for eah vaine-preventable disease The ACIP reommended shedule Annual review of these poliies and updates as neessary (See Appendix A for summary of urrent guidelines) Poliy to implement new HCP-related ACIP reommendations: 2a) Faility has proedure to ensure that all urrent employees are vainated within 1 year of new reommendation. Poliy and appropriate follow-up for non-vainated employees without evidene of immunity: 3a) Faility has taken steps to minimize/redue potential for spread of vaine preventable disease by unvainated employees who have not met the riteria for presumptive immunity. 3b) Reasons for non-reeipt of a reommended vaine are doumented. 3) Employee has reeived appropriate follow-up Contraindiations: advise HCP on post-exposure protools and any need to restrit or modify normal work duties Delination/Refusal: onsider poliy for a follow-up onversation to provide resoures to ounter misinformation (if indiated) and advise employee on post-exposure protools and any need to restrit or modify work duties Page 6 Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0
Audit Questions Yes No Immunization Reords Immunizations reords follow regulations and best praties: 4a) Federal requirements Date vaine administered Date of publiation of the Vaine Information Statement (VIS) Date that VIS was provided Manufaturer and lot number of the vaine Name, title, and lini address of the individual who administered vaine 4b) Best pratie Vaine type Route and site of administration Dosage History of vaine reation Contraindiations Patient s date of birth Other data that may be required by institution 4) Doumented in the Minnesota Immunization Information Connetion (MIIC) Vaine is stored and handled aording to best pratie guidelines. Poliies and proedures for proper storage and handling of vaine are in plae: 5a) Praties reflet reommendations of vaine manufaturer and reommendations found in the General Reommendations for Immunizations of the Advisory Committee on Immunization Praties. 5b) An emergeny plan to manage vaine in a power outage is in plae. 5) Institution has identified speifi staff (minimum 2) responsible for ensuring adherene to storage and handling poliies. 5d) Poliy and proedure is reviewed annually. Vaine is administered aording to best-pratie reommendations. Poliies and proedures reflet best praties on providing immunizations as desribed in the General Reommendations for Immunizations of the Advisory Committee on Immunization Praties: 6a) Vainees are sreened for ontraindiations and preautions 6b) The five rights for mediation administration are followed 6) Emergeny protools for anaphylaxis are in plae 6d) Clear proess for proper doumentation internally and to MIIC is in plae 6e) Adverse events are reported for internal analysis and to the Vaine Adverse Event Reporting System (VAERS) https:// vaers.hhs.gov/index 6f) Poliy and proedure is reviewed annually and as needed. Outbreak poliies Poliies reflet hanges to routine immunization praties that our in an outbreak situation. Examples may inlude but are not limited to: 7a) Measles: vaination of persons born before 1957 7b) Variella 7) Influenza: pandemi flu plan and mass vaination plans updated and pratied periodially Poliies speifi to influenza 8a) The institution has a written seasonal influenza vaination poliy that align with regulatory guidelines: http://www.health.state.mn.us/divs/idep/diseases/flu/vaine/vaxhw/index.html Other immunization poliies 9a) Health are failities should strongly onsider administering/offering all reommended adult immunizations. (See Appendix A) Page 7 Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0
HAI speifi topis Implement CAUTI Roadmap praties Audit Questions Yes No 1a) The faility provides are for patients with Foley atheters. 1b) The faility has performed a gap analysis of urrent poliies and praties against the CAUTI reommendations. 1) An implementation plan has been developed to address relevant gaps. 1d) The plan to address relevant gaps has been implemented to ahieve at least 90% of the reommended praties. Implement CLABSI Roadmap praties and/or Cheking CLABSI bundle 2a) The faility provides are for patients with entral lines. 2b) The faility has performed a gap analysis of urrent poliies and praties against the CLABSI reommendations. 2) An implementation plan has been developed to address relevant gaps. Implement SSI Roadmap praties and/or Slashing SSI bundle 3a) The faility has an OR and does surgeries. 3b) The plan to address relevant gaps has been implemented to ahieve at least 90% of the reommended praties. 3) The faility has performed a gap analysis of urrent poliies and praties against the SSI reommendations. 3d) An implementation plan has been developed to address relevant gaps. 3e) The plan to address relevant gaps has been implemented to ahieve at least 90% of the reommended praties. Implement VAE Roadmap praties and/or Vanishing VAE bundle 4a) The faility provides are for patients on ventilators. 4b) The faility has performed a gap analysis of urrent poliies and praties against the VAP reommendations. 4) An implementation plan has been developed to address relevant gaps. 4d) The plan to address relevant gaps has been implemented to ahieve at least 90% of the reommended praties. Implement CDI Roadmap praties and/or Cheking CDI bundles 5a) The faility has a proess in plae to manage patients with CDI. 5b) The faility has performed a gap analysis of urrent poliies andpraties against the CDI reommendations. 5) An implementation plan has been developed to address relevantgaps. 5d) The plan to address relevant gaps has been implemented to ahieveat least 90% of the reommended praties. Page 8 Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0
Appendix A: Guidelines for Vaination of HCP (adapted from ACIP Reommendations) Vaination Indiated Population Presumptive Immunity Primary Vaine Shedule and Boosters Hepatitis B HCP at risk for exposure to blood or body fluids 3 valid doses of Hep B vaine or Anti-HBs titer of 10 miu/ml 3 doses given at 0, 1-2, 4-6 month intervals; booster doses not neessary Influenza All HCP N/A Annual vaination with urrent seasonal vaine. Measles Mumps Rubella All HCP who lak presumptive immunity All HCP who lak presumptive immunity All HCP who lak presumptive immunity 2 valid doses of measles or MMR vaine Laboratory evidene of immunity gained through either vaination or disease Birth before 1957 2 valid doses of mumps or MMR vaine Laboratory evidene of immunity gained through either vaination or disease Birth before 1957 1 valid dose of rubella or MMR vaine Laboratory evidene of immunity gained through either vaination or disease Birth before 1957 2 doses at least 28 days apart 2 doses at least 28 days apart 1 dose (However, due to the two dose requirements of measles and mumps, most HCP will have 2 doses of rubella-ontaining vaine) Pertussis All HCP, regardless of age N/A 1 dose of Tdap, as soon as feasible if Tdap not already reeived and regardless of interval from last Td Variella All HCP who lak presumptive immunity Non Routine Vaines (for at-risk HCP ategories) Meningooal Clinial and researh mirobiologists who might routinely be exposed to isolates of Neisseria meningitides 2 valid doses of variella vaine Laboratory evidene of immunity Diagnosis or verifiation of either variella or herpes zoster disease by a health are provider 2 doses at least 28 days apart 1 dose; booster dose every 5 years if person remains in indiated population Speial Considerations When there is a ommunity outbreak, inluding an identified ase within the health are faility, vaination should be onsidered for those born before 1957. When there is a ommunity outbreak, inluding an identified ase within the health are faility, vaination should be onsidered for those born before 1957. Meningooal onjugate vaine, 4-valent (MenACYW) is preferred for persons through age 55 years and ACIP reommends off-label MenACYW for persons over 55 years who will need booster doses every 5 years Page 9 Road Map to a Comprehensive Healthare Assoiated Infetion (HAI) Prevention Program 2.0
Typhoid Workers in mirobiology laboratories who frequently work with Salmonella typhi. Oral: 4 apsules every 48 hours; booster on same shedule every 5 years Injetable: One-time dose; booster every 2 years Polio HCP who have lose ontat with patients who might be exreting polioviruses; or work in a lab with poliovirus. Routine Adult Immunizations (reommendation not based on oupational risk) Zoster Pneumooal Conjugate (PCV13) Pneumooal Polysaharide (PPSV23) Human Papillomavirus (HPV) Consider offering to: All persons 60 years and older Persons 19-64 with who are immunoompromised, have hroni renal failure, nephroti syndrome, asplenia, CSF leak, or ohlear implants and all persons 65 and older Persons 19-64 who are eligible for PCV13, and those who have heart disease, lung disease, liver disease, diabetes, aloholism, or a smoker or resident of long term are and all persons 65 and older Females through age 26 Males through age 21, additionally males 22-26 at high risk* or who simply want to be proteted Vaine Shedule and Booster Doses Adults who have previously reeived a omplete series of polio vaine may reeive one lifetime booster. Primary series for unvainated adults: 3 doses at 0, 1-2, 6 month intervals. Speial Considerations 1 dose Give vaine regardless of history of shingles disease 1 dose, no booster When both pneumooal vaines are indiated PCV13 should be administered first, PCV13 and PPSV23 should not be administered at the same visit Whenever possible, the onjugate vaine should be given before the polysaharide vaine. 2 doses in ertain situations, most ommonly, 1 dose 3 doses at 0, 2 and 6 months Meningooal All adults at risk* 2 doses at least 2 months apart Hepatitis A Hepatitis B Tetanus, Diphtheria, and Pertussis (Tdap, Td) All adults at risk* or those who simply want to be proteted All adults at risk* or those who simply want to be proteted All adults not previously vainated, women need 1 dose in eah pregnany 2 doses, usually at 0 and 6-18 months depending on vaine brand 3 doses at 0, 1-2, and 4-6 months, booster not neessary 1 dose if have reeived hildhood series The timing and sequene of the pneumooal vaines is important to attaining an appropriate immune response, please see http://eziz.org/assets/dos/imm-1152.pdf for detailed guidane. All adults also need a Td-only booster every 10 years The above table is for onveniene purposes, more omplete and detailed information should be sought out when providing these vainations. http://www.health.state.mn.us/divs/idep/immunize/adult/ *see full Adult Immunization Shedule for risk ategories