Frame Work For Annual Infection Control Plan
 
The infection control process is integrated throughout the organization.  There is ongoing activity to improve 
prevention, control activities, and keep health care associated infections (HAIs) rates at the lowest possible 
level.  
 
This plan is subject to change based on the needs of the 

patient and changes in the environment of care, and will be 
reviewed annually or more frequently if significant changes 
occur in services provided, characteristics of the population 
served, or results of analysis of the practice's infection 
prevention and control data reveal a negative trend. 
 
A multitude of control measures for the surveillance and 
prevention of infection exists throughout the facility and 
can be seen in the various policies, procedures, and methods 
found in the facility's manual.
 
Risks: 
 
The organization identifies specific risks or areas that 
could affect the transmission and acquisition of infectious 
agents throughout the practice based on the following 
factors: characteristics of the population served, the care, 
treatment, and services provided by the organization, 
statistics on infection rates, geographic location/community 
environment.  Additionally, this organization accesses the 
CDC website, http://www.cdc.gov/mmwr/ and OSHA 
http://www.osha.gov/ as well as our local Department of 
Health's website annually.  Any pertinent findings are 
reported to the Medical Director.  Appropriate actions will 
be taken based on these findings, i.e. policy changes, 
process and system changes, and in-services.  Risks must and 
are prioritized.
  
 
Additionally, this organization performs procedures on 
patients classified as ASA level 1 or 2 only. Internal 
infection rates are recorded in the Sequella monitoring 
record and discussed at team meetings


This organization's specific risks in priority order are as 
follows:  

PROCEDURES THAT ARE PERFORMED IN A 'DIRTY FIELD' HAVE A 
HIGHER RISK THAN A STERILE PROCEDURE, AS AN EXAMPLE: POLYPECTOMY IN A DIRTY COLON.

EQUIPMENT OR INSTRUMENTS WITH MULTIPLE CHANNELS SUCH AS ENDO 
SCOPES, OR SURGICAL EQUIPMENT/INSTRUMENTS THAT ARE DIFFICULT 
TO CLEAN

BLOOD BORNE PATHOGENS, I.E. HIV, HEP B HEP C
 
SURGICAL SITE INFECTION: Surgical site infection is considered when the patient presents with symptoms up to 2 weeks after a sterile procedure. Surgical Site infections do not apply to the procedures we perform at this office 
 

RECENTLY HOSPITALIZED PATIENTS OR THOSE ON RECENT 
ANTIBIOTICS(IE. MRSA (Methicillin-resistant
taphylococcus Aureus) , VISA (Vancomycin 
intermediate Staphylococcus aureus), VRE (Vanomycin
resistant Enterococci)OR Clostridium Difficile)
 


STERILE PROCEDURES THAT ARE PERFORMED WHERE BREAKS OF STERILE 
TECHNIQUE CAN OCCUR BASED ON ANATOMICAL LOCATION, ie
IV CATHETER PROCEDURES.
 
SERVICES PROVIDED TO  IMMUNOSUPRESSED INDIVIDUALS.
 
COMMUNITIES WITH HISTORY OF TB
 
ANY REPORTED OUTBREAKS IN THE COMMUNITY; I.E.
COMMUNICABLE DISEASES
 
NEW PROCEDURES WILL BE EVALUATED FOR RISK 
 
NEW EQUIPMENT WILL BE EVALUATED FOR RISK 

See the organization's Risk Table, Risk Column
Reducing Risk
 
Risks are minimized or eliminated by the following policies : 
 
1.    Aseptic technique for prevention of IV Site 
        infection

2.    High level disinfection, to prevent the transmission 
        of infection associated with blood borne pathogens
        via semi-critical devices
3.    Cleaning and Sanitation of the Procedure area, to 
        prevent the transmission of infection by pathogens 
        that live on hard surfaces
4.    Handling and Storage of Sterile supplies to prevent 
        the contamination of sterile supplies, which if 
        contaminated can cause infection.
5.    CDC Hand hygiene guidelines, to assure proper hand 
        cleansing and reduce the risk of spreading 
        infections via the Health Care worker's hands
6.    Personal protective equipment, to prevent infection 
        from transmission of blood borne pathogens from the
        patient to the Health Care worker.
7.    Proper disposal of contaminated sharps, to prevent 
        infection from transmission of blood borne pathogens 
        from the patient to the Health Care worker
8.    Proper care of regulated waste and laundry, to 
        prevent infection from transmission of blood borne 
        pathogens from the patient to the Health Care worker
9.    Proper spill handling, to prevent infection from 
        transmission of blood borne pathogens from the 
        patient to the Health Care worker
10.     Staff competency in any infection control related 
        procedure; instrument processing, high level 
        decontamination, duties related to being the IC
        officer, etc.
 
See the organization's Risk Table, Plan for Risk Reduction
 
Additionally various staff trainings, and in-services and 
maintaining an active infection control committee contributes 
to risk minimization and elimination. 
 
The organization also utilizes various resources, i.e., 
  publications regarding infection control 
from  the CDC and Public Health Department.
 
Additional risk reduction is accomplished by: 
 
1.    Offering Hepatitis B immunizations to employees
2.    Offering the influenza vaccine on an annual basis
 
3.    Reporting of communicable disease (disease for which 
      there are immunizations, i.e. chicken pox, mumps) to 
      appropriate authorities, (local Department of Health),
      this includes patients as well as staff, physicians, etc.
 
4.    Following and adhering to Standard Precautions as 
      outlined in the OSHA manual (use of Personal 
      Protective Equipment)  Reporting all needle sticks,
      or like incidents and providing referral to
    appropriate clinicians should an incident 
      occur.
 
5.    Anti-microbial soap or other methods determined to be 
      effective by the CDC  is used by employees before 
      participating in invasive procedures.  Alcohol based 
      hand gels are utilized for hand sanitation between
      patients when the hands are visibly free of bio-
      burden. 
 
6.    Works closely with Cleaning company regarding 
      checklist for terminal cleaning of procedure room
 
 
Surveillance and Evaluation:
 
Various areas are monitored including the area of Infections 
which are monitored utilizing the sequela-spread sheet.  All post procedural infections 
as defined by the organization that are found are reported in 
written form, in detail.  Should there appear a cluster of 
infections, any trend, or an infection that is reportable to 
the local Department of Health, assigned individuals from the 
infection control committee will undertake a root cause 
analysis. Intensive monitoring and surveillance continue 
until follow up analysis indicates that the problem has been 
resolved.   At this time, the collection of this data, 
recording, and reporting to committees and proper authorities 
is the responsibility of the Medical Director. 
 
This surveillance also applies to illness of epidemiological 
significance for employees, licensed independent 
practitioners, students, etc.  If illness is found that could
put the patient's at risk, referral for assessment by an 
appropriate clinician will be enacted.  
 
The Infection Control Officer receives training on areas of 
infection control so that he/she may be effective in their 
role. SEE BELOW 
 
Any infection resulting in the loss of a limb, use of a limb, 
permanently affects a patient's quality of life or results in 
death shall be investigated as a sentinel or adverse event.
 
However, each prioritized Risk listed in the organization's 
Risk Table is monitored and evaluated with action taken as 
indicated in the Risk Table.  See the organization's Risk 
Table, Surveillance and Evaluation columns
 
Goals:
 
The goals for this organization are to educate the staff in 
limiting unprotected exposure to pathogens throughout the 
practice, prevent HAI transmission/infection, prevent 
infection/transmission from staff to staff, competency when 
processing instruments and/or equipment used in patient care, 
 enhance hand hygiene compliance, and increase influenza vaccination rates within the 
organization; as appropriate.

Based on infection control analysis and meetings with the medical director, the following has been identified. 

Due to the limited scope of our practice, there are few avenues for infection in comparison to a large multidisciplinary practice. Furthermore, due to the fact that we do not treat in-patients, the financial impact of breaches in policy are not as well realized in comparison to a large center. However, management has agreed upon a few key areas where policy could use improvement to meet infection control challenges. We have organized it based on priority and financial risk.

1. Needle stick injuries. Based on national guidelines, blood borne products are considered infected until proven otherwise. We therefore identify that the anesthesiologist intravenous puncture for medication delivery to be the most critical moment of infection control in our practice. Improper technique has recently lead to hepatitis outbreaks in GI practices in the mid west. Our office has a policy of using the latest technology to benefit our staff and patients. We therefore will implement self retracting angiocathers to minimize the risk of needle stick starting in 2015.

2. Scope reprocessing. Scope reprocessing is a high priority at our organization. There have been reports of bacteremia following ERCP procedures in hospitals. These outbreaks have been linked to cultures from "cleaned" endoscopes. Even though we do not use duodenoscopes or perform ERCP, we have taken this mater seriously. We have re qualified our staff, reviewed their practices and have performed the following

1. Re-processors will now measure enzyme solutions precisely. Signs will be posted to facilitate calculation.

This will also facilitate improper wastage of enzyme detergent as well as minimize potential damage to scopes

2. To minimize entrance by unauthorized personnel, self closing hinges will be installed on all doors to reprocessing areas. This will also minimize airflow and the potential airborne contamination of our scopes.

3. Biopsy Site infection/Post polypectomy Syndrome: Post polypectomy syndrome is characterized by abdominal pain, low grade fever and an elevated white cell count. Treatment usually consists of PO antibiotics. Although prevelent at large institutions. Our surveillance systems have failed to detect the presence of this entity in our population. We attribute this to the fact that only one member is responsible for procedures and their standard technique prevents this. Nonetheless, we take this risk seriously and have based our recommendations on the endoscopists needs.

1. Invest in new polypectomy snares

2. Invest in the newest affordable cautery machines for the needs of our patients

3. Continue the technique, whereby the endoscopist only resects the upper stalk of polyp

4. Influenza Vaccination compliance: Influenza vaccination compliance is not favorable in respect to national standards. We therefore propose the following

1. Mandate the use of face masks for those who do not vaccinate during influenza season. This is to protect our patients. 

2. Involve staff in education sessions where we train them on the importance of vaccination.

5. Hand Hygiene. Hand hygiene continues to be an important topic in health care organizations. Staff have complained about excessive dryness with our alcohol hand rub dispensers. We therefore suggest the following improvements to our program

1) Invest in newest, latest hand rubs. These hand rubs, based on focused studies with our staff, have shown to be favorable. 

2) Invest in automatic dispensers and install in high traffic areas including all entrances to procedure room.

 



 

Approved By Governing Board    
SE.02.1    
Control #295.16
GUPTA GASTRO