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
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.
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
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
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
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.
NEW PROCEDURES WILL BE EVALUATED FOR RISK
NEW EQUIPMENT WILL BE EVALUATED FOR RISK
See the organization's Risk Table, Risk Column
Risks are minimized or eliminated by the following policies :
1. Aseptic technique for prevention of IV Site
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
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
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-
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
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