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Assessment tool to promote implementation of infection control standards for joint commission accreditation
AJIC Volume 27, Number 2
IMPLEMENTATION OF A PATIENT IMMUNIZATION PROGRAM. A. Schlimm, RN, BSN, CIC,* M. LourdesBrundige, BS, PharmD. Hamot Medical Center, Erie, PA.
Ninety percent (90%) of deaths caused by influenza and pneumococcal disease occur in the elderly population. Based on the recommendations of the CDC, a patient immunization program that utilizes hospitalization as an opportunity to vaccinate was initiated 10/97. Pre-printed orders for screening patients and ordering vaccine were developed and implemented. Information was recorded on the history of egg allergy, drug allergies and reaction type, previous reactions to vaccines, and dates of the last pneumococcal and influenza vaccine. Vaccine was administered to all consenting patients on the day of discharge. Total patient census was determined from 10/20/97 through 2/28/98 (1,252), as well as for the same period of the previous year (1,256). Chi square analysis, c~=.05, was used to compare vaccination rates before and after program implementation. Ten (10) patients received influenza vaccine before implementation compared with 160 patients after; 110 patients received pneumococcal vaccine before versus 105 after. A patient immunization program significantly increased the influenzae vaccination rate in hospitalized patients (p < .001).
A S S E S S M E N T TOOL TO PROMOTE IMPLEMENTATION OF INFECTION CONTROL STANDARDS FOR JOINT COMMISSION ACCREDITATION. S. Atherton, RN, MS,* R. Tjoelker, RN, MS, CIC, L. Strausbaugh, MD. Veterans Affairs Medical Center, Portland, OR.
A challenge faced by many infection control professionals (ICPs) is assuring system wide issues addressed in the infection control (IC) Joint Commission (JC) standards are resolved. ICPs must also strive to make key IC issues meaningful to individual employees. In preparation for the 1998 accreditation survey, the Portland Veteran Affairs Medical Center ICPs developed a checklist assessment tool addressing key components of JC IC standards. The ICPs designed the tool to educate employees regarding key IC issues, heighten awareness of standards, document standard deficiencies, and provide recommendations for improvement. The assessment tool contained questions in the following categories: handwashing, isolation, linen, sterile supplies, waste disposal, and environmental cleanliness. Questions were scored "met," "not met," or "nonapplicable." ICPs initiated use of the assessment tool 12 months before JC survey. ICPs conducted scheduled inspections in 54 clinical and nonclinical areas of the medical center. Initial inspections identified deficiencies in 2 or more categories of the assessment tool in 100% of departments. Findings were reported to supervisory staff. ICPs conducted repeat assessments at 3-month intervals until all deficiencies were corrected. Only 6 departments required greater than 2 inspections to correct deficiencies. On survey JC made no recommendations related to IC standards. Utilization of
Abstracts 2 2 3 the assessment tool was an effective, efficient mechanism to identify and resolve system wide IC deficiencies.
INFECTION CONTROL PROCESS COMMITTEE: A MODEL FOR AN INTEGRATED HEALTH SYSTEM. V. Bren, RN, MPH, CIC,* S. Hansen, MT, CIC, J. Hargreaves, DO, T. Watne, RN, MS. Altru Health System, Grand Forks, ND.
Altru Health System integrates a 250-bed acute care hospital, a 100 physician clinic, 13 rural satellite clinics, home care services and hospice including 7 branch offices, and a rehabilitation hospital. Branch facilities are physically separated from the main plant by up to 175 miles. Before integration, five separate infection control committees existed. The hospital's committee (medical staff, executive managers) was used mainly as a reporting depository for the infection control and employee health programs. Outcome indicators were emphasized. With an expanded vision and mission, along with a less prescriptive committee requirement from Joint Commission, a new plan emerged in 1997 for an integrated infection control committee. Middle managers and patient care staff were utilized for improvement and standardization of intra- and inter-facility processes. The infection control process committee meets six times per year and follows an agenda that emphasizes education. An executive manager and the infection control medical director provide authority for decision-making. Satellite clinic and home care subcommittees meet at least twice per year to review infection control issues, standardize processes, and network. Feedback has been positive and attendance faithful. System-wide goals have been reached. The new committee model provides for increased information distribution to staff. Ownership for the infection control program has increased and information is shared across the continuu m of care.
USE OF AN ALGORITHM TO ISOLATE SUSPECT TB PATIENTS IN A TERTIARY CARE FACILITY. J. PresselHaas, RN, BSN,* D. Fish, MD, J. Whitney, MD, J. Miller, RN, BSN, M. Kosier, RN, MS, E. Hanley, BA, R.A. Venezia, PhD. Albany Medical Center, Albany, N~.
Albany Medical Center, a 650-bed hospital in upstate NY, places approximately 240 patients per year on airborne precautions while ruling out tuberculosis (TB). Only six (6) patients with infectious TB were identified from 1995-1997. A multidisciplinary process improvement team (PIT) was formed to develop a more consistent approach to identify cases and reduce the n u m b e r of patients unnecessarily isolated for TB. The PIT developed an algorithm to assess the risk of TB among patients with respiratory illnesses. The algorithm was tested on a review of the 6 TB cases and 16 non-TB cases. The algo-
IMPLEMENTATION OF A PATIENT IMMUNIZATION PROGRAM. A. Schlimm, RN, BSN, CIC,* M. LourdesBrundige, BS, PharmD. Hamot Medical Center, Erie, PA.
Ninety percent (90%) of deaths caused by influenza and pneumococcal disease occur in the elderly population. Based on the recommendations of the CDC, a patient immunization program that utilizes hospitalization as an opportunity to vaccinate was initiated 10/97. Pre-printed orders for screening patients and ordering vaccine were developed and implemented. Information was recorded on the history of egg allergy, drug allergies and reaction type, previous reactions to vaccines, and dates of the last pneumococcal and influenza vaccine. Vaccine was administered to all consenting patients on the day of discharge. Total patient census was determined from 10/20/97 through 2/28/98 (1,252), as well as for the same period of the previous year (1,256). Chi square analysis, c~=.05, was used to compare vaccination rates before and after program implementation. Ten (10) patients received influenza vaccine before implementation compared with 160 patients after; 110 patients received pneumococcal vaccine before versus 105 after. A patient immunization program significantly increased the influenzae vaccination rate in hospitalized patients (p < .001).
A S S E S S M E N T TOOL TO PROMOTE IMPLEMENTATION OF INFECTION CONTROL STANDARDS FOR JOINT COMMISSION ACCREDITATION. S. Atherton, RN, MS,* R. Tjoelker, RN, MS, CIC, L. Strausbaugh, MD. Veterans Affairs Medical Center, Portland, OR.
A challenge faced by many infection control professionals (ICPs) is assuring system wide issues addressed in the infection control (IC) Joint Commission (JC) standards are resolved. ICPs must also strive to make key IC issues meaningful to individual employees. In preparation for the 1998 accreditation survey, the Portland Veteran Affairs Medical Center ICPs developed a checklist assessment tool addressing key components of JC IC standards. The ICPs designed the tool to educate employees regarding key IC issues, heighten awareness of standards, document standard deficiencies, and provide recommendations for improvement. The assessment tool contained questions in the following categories: handwashing, isolation, linen, sterile supplies, waste disposal, and environmental cleanliness. Questions were scored "met," "not met," or "nonapplicable." ICPs initiated use of the assessment tool 12 months before JC survey. ICPs conducted scheduled inspections in 54 clinical and nonclinical areas of the medical center. Initial inspections identified deficiencies in 2 or more categories of the assessment tool in 100% of departments. Findings were reported to supervisory staff. ICPs conducted repeat assessments at 3-month intervals until all deficiencies were corrected. Only 6 departments required greater than 2 inspections to correct deficiencies. On survey JC made no recommendations related to IC standards. Utilization of
Abstracts 2 2 3 the assessment tool was an effective, efficient mechanism to identify and resolve system wide IC deficiencies.
INFECTION CONTROL PROCESS COMMITTEE: A MODEL FOR AN INTEGRATED HEALTH SYSTEM. V. Bren, RN, MPH, CIC,* S. Hansen, MT, CIC, J. Hargreaves, DO, T. Watne, RN, MS. Altru Health System, Grand Forks, ND.
Altru Health System integrates a 250-bed acute care hospital, a 100 physician clinic, 13 rural satellite clinics, home care services and hospice including 7 branch offices, and a rehabilitation hospital. Branch facilities are physically separated from the main plant by up to 175 miles. Before integration, five separate infection control committees existed. The hospital's committee (medical staff, executive managers) was used mainly as a reporting depository for the infection control and employee health programs. Outcome indicators were emphasized. With an expanded vision and mission, along with a less prescriptive committee requirement from Joint Commission, a new plan emerged in 1997 for an integrated infection control committee. Middle managers and patient care staff were utilized for improvement and standardization of intra- and inter-facility processes. The infection control process committee meets six times per year and follows an agenda that emphasizes education. An executive manager and the infection control medical director provide authority for decision-making. Satellite clinic and home care subcommittees meet at least twice per year to review infection control issues, standardize processes, and network. Feedback has been positive and attendance faithful. System-wide goals have been reached. The new committee model provides for increased information distribution to staff. Ownership for the infection control program has increased and information is shared across the continuu m of care.
USE OF AN ALGORITHM TO ISOLATE SUSPECT TB PATIENTS IN A TERTIARY CARE FACILITY. J. PresselHaas, RN, BSN,* D. Fish, MD, J. Whitney, MD, J. Miller, RN, BSN, M. Kosier, RN, MS, E. Hanley, BA, R.A. Venezia, PhD. Albany Medical Center, Albany, N~.
Albany Medical Center, a 650-bed hospital in upstate NY, places approximately 240 patients per year on airborne precautions while ruling out tuberculosis (TB). Only six (6) patients with infectious TB were identified from 1995-1997. A multidisciplinary process improvement team (PIT) was formed to develop a more consistent approach to identify cases and reduce the n u m b e r of patients unnecessarily isolated for TB. The PIT developed an algorithm to assess the risk of TB among patients with respiratory illnesses. The algorithm was tested on a review of the 6 TB cases and 16 non-TB cases. The algo-