ATrain Education

 

Continuing Education for Health Professionals

NY: Infection Control and Prevention, including Sepsis

Module 3

Element I: Scientifically Accepted Principles

The responsibility to adhere to scientifically accepted principles and practices of infection control and to monitor the performance of those for whom the professional is responsible.

Scientific evidence is the primary source of guidance for infection control practice and, as the science has evolved, practices have been updated to reflect new findings. A number of factors contribute to this changing landscape; for example, germs evolve and mutate, and new diseases emerge. The H1N1 influenza outbreak of 2009 is an example of a potentially deadly virus that emerged as a mix of human, swine, and bird viruses. Human immunodeficiency virus (HIV) is a well-known example of an infection that emerged in the late 1970s, prompting widespread and rapid changes in IC practices.

The transition of healthcare delivery from acute care hospitals to other settings (home, ambulatory, free-standing specialty, and long-term care sites) has created a need for IC guidelines that can be applied in all settings. These guidelines must follow common principles, yet be modified to reflect setting-specific needs. The emergence of new pathogens, concern for evolving pathogens, development of new therapies, and increasing concern for the threat of biological weapons has led to broader guidelines for infection control and prevention.

Until recently, infections were an expected consequence of hospitalization, and reliance on scientifically accepted information for infection prevention had not penetrated all corners of the healthcare system. However, as healthcare moves rapidly toward practices based on evidence-based principles, we are seeing a cultural shift in the prevention of HAIs.

In the past it was accepted practice for hospitals to compare the success of their IC activities to national averages called benchmarks—if the hospital’s infection rates were comparable to these benchmarks their performance was acceptable. Zero tolerance has now emerged as a guiding concept in the management of HAIs. The goal for all healthcare organizations—from hospitals to home care—is to reduce the number of HAIs to zero.

In 2005 the Legislature passed Public Health Law 2819, requiring hospitals to report certain selected hospital-acquired infections (HAIs) to the New York State Department of Health. The legislation provided an initial pilot phase year (2007) to:

  • Develop the reporting system
  • Train hospitals on its use
  • Standardize definitions, methods of surveillance and reporting
  • Audit and validate the hospitals’ infection data
  • Modify the system to ensure that the hospital-identified infection rates would be fair, accurate, and reliable

In June 2008 the Department issued the pilot year report for 2007. Subsequent annual reports have followed. The sixth annual report, entitled Hospital-Acquired Infections, New York State 2012, provides hospital-acquired infection rates statewide and by individual hospital for 2012 (NYSDOH, 2013). Annual hospital-specific infection data are available at this link.

The infections selected for reporting in 2012 include colon surgical site infections, hip replacement surgical site infections, coronary artery bypass graft surgical site infections, abdominal hysterectomy surgical site infections, central line-associated bloodstream infections in intensive care units (adult, pediatric and neonatal intensive care units), and Clostridium difficile infection rates occurring on admission and during a patient’s hospital stay. The report also contains updated information on infection control resources in NYS hospitals and describes progress of HAI prevention projects supported by the Department (NYSDOH, 2013).

Hospitals report to NYS using the CDC’s National Healthcare Safety Network (NHSN). This secure web-based system allows hospitals, NYS, and federal agencies to monitor the same data concurrently. NHSN is used by almost all hospitals in the United States. All participants use the same surveillance definitions. In 2012, all 175 NYS acute care hospitals (excluding Veterans Affairs, critical access, psychiatric, and long-term acute care hospitals) reported HAI data. The following table summarizes the types of HAIs that NYS hospitals were required to report in 2012, along with the total number of infections reported and the infection rates (NYSDOH, 2013).

Source: NYSDOH, 2013.

Hospital-Acquired Infections, New York State Hospitals, 2012

Type of infection

Number

Rate

Hospital-onset Clostridium difficile infections (CDIs) among inpatients

9,945

8.3 per 10,000 patient days

Surgical site infections (SSI) following

  • Colon surgery
  • Abdominal hysterectomy surgery
  • Hip replacement or revision surgery
  • Coronary artery bypass graft (CABG) -
    chest site
  • CABG - donor site

 

836

415

311

223

 

58

 

5.1 per 100 procedures

2.2 per 100 procedures

1.1 per 100 procedures

2.1 per 100 procedures

 

0.6 per 100 procedures

Central line-associated blood stream infections (CLABSI) among patients in intensive care units

735

1.2 per 1,000 line days

Total

12,523

 

Hospitals have continuous access to their own data and can compare their rates to national levels and monitor trends over time. In addition, the NYSDOH has continuous access to the data reported by the hospitals for consistent real-time surveillance, identification of trends, and provision of technical assistance as needed. The collected data are made available to the public annually, giving the public the ability to review hospitals’ performance for these particular procedures and helping to guide their medical decisions (NYSDOH, 2010).

Currently, HAI reports rates are identified by hospital and by region for the following:

Surgical site infections (SSIs)

  • Colon
  • Coronary artery bypass graft (CABG)
  • Hip replacement/revision
  • Abdominal hysterectomy

Central line-associated bloodstream infections (CLABSIs)

  • Adult
  • Pediatric
  • Neonatal intensive care units (NICUs)

Clostridium difficile (C. Difficile) (NYSDOH, 2013)

 

NYSDOH entered into a data use agreement with CDC beginning in July 2013. This agreement gives NYSDOH the ability to use non-mandated NHSN data for quality improvement purposes. Examples of these data include catheter-associated urinary tract infections (CAUTI) and methicillin-resistant Staphylococcus aureus infections, which are reported to NHSN by almost all NYS hospitals as part of the CMS Hospital Inpatient Quality Reporting Program. As staffing levels allow, NYSDOH will evaluate the burden of other non-mandated HAIs (NYSDOH, 2013).

NYSDOH will continue to conduct medical record audits to verify appropriate use of surveillance definitions and accurate reporting by hospitals. Variation in audit coverage and thoroughness across the states currently results in inequitable comparison of hospital and state average rates. NYSDOH will continue to discuss audit methodology with CDC and CMS, as the stakeholders hopefully converge on a fair and efficient audit process (NYSDOH, 2013).

Laws and Regulations

Both regulations and science impact infection control practice. Whichever is stricter must be followed. Regulation is often more specific than science.

Law is a broad term that refers to legally binding rules of conduct adopted by a legislative or other government body at the international, federal, state, or local level. The most common laws are statutes enacted by a legislature. A regulation is an official policy issued by an agency of the executive branch in response to statutory authority. Regulations have binding legal force and are intended to implement the administrative policies of an agency. Regulations govern professional conduct and establish acceptable conduct for those regulated by the agency.

Legal issues first began to impact IC practices at the beginning of the AIDS epidemic in the early 1980s. The need to protect healthcare workers from bloodborne exposures resulted in the publication of the Bloodborne Pathogens Standard by the Occupational Safety and Health Administration (OSHA) in 1991. The OSHA Standard requires employers whose employees have exposure to blood to provide safe work practices, education, and barriers to exposure. The standards were later amended to cover the safe use of sharps.

The OSHA Bloodborne Pathogens Standard requires that every healthcare worker who may have contact with body fluids on the job must receive specific annual education. This education includes instruction in the basics of infection control and prevention, bloodborne pathogens training, and instruction in modes of transmission (OSHA, 2012).

Since 1991 other laws and regulations have been enacted, some at the federal and some at the state level. The Conditions of Participation, published by the CMS, is an important source of legal guidance for the infection control community. The Conditions of Participation must be met for a hospital to receive Medicare funding, which is typically about half their income for most facilities. Inspection for compliance with the Conditions of Participation is generally carried out by survey teams from either the Joint Commission or the American Osteopathic Association (AOA). Validation surveys may also be made by state health department staff.

Infection Control Policies and Procedures

[The information in this section is derived from OSHA, 2012 and NYSDOH, 2010, 2013.]

Key practices for infection control and prevention include establishing infection control policies and procedures; proper handling of sharps, medications, and solutions; use of aseptic technique; fulfilling infection prevention training requirements; and correct reprocessing of medical equipment.

Healthcare facilities are responsible for establishing and maintaining written infection control policies and procedures and implementing them according to published guidelines. They must ensure that these policies and procedures are reviewed and updated regularly and that staff members are familiar with them.

Standards of Professional Conduct

In New York State it is a violation of professional conduct to fail to use scientifically accepted infection prevention techniques appropriate to each profession. This includes techniques for the cleaning and sterilization or disinfection of instruments, devices, materials, and work surfaces; utilization of protective garb; use of covers for contamination-prone equipment; and the handling of sharp instruments. Title 10 of the Rules and Regulations of New York also mandates that health professionals are responsible for monitoring the IC practices of all licensed and unlicensed workers for whom they are responsible.

Under New York State’s standards, unprofessional conduct applies to the professions of: acupuncture, athletic training, audiology, certified dental assisting, chiropractic, creative arts therapy, dental hygiene, dentistry, dietetics/nutrition, licensed practical nursing, marriage and family therapy, massage therapy, medicine, mental health counseling, midwifery, occupational therapy, ophthalmic dispensing, optometry, pharmacy, physical therapist assistant, physical therapy, physician assistant, podiatry, psychoanalysis, psychology, registered professional nursing, respiratory therapy, respiratory therapy technician, social work, specialist assistant, occupational therapy assistant, and speech-language pathology.

There are exceptions for cases involving those professions licensed, certified, or registered pursuant to the provisions of Article 131 or 131-B of the Education Law, in which a statement of charges of professional misconduct was not served on or before July 26, 1991, the effective date of Chapter 606 of the Laws of 1991.

All licensed healthcare professionals in New York State are required to receive training on infection control and barrier precautions every four years through an NYS-approved provider. Documentation of appropriate training must be maintained both by the course provider and course participant.

Scientifically accepted prevention techniques include:

  • Wear appropriate protective gloves at all times when touching blood, saliva, other body fluids or secretions, mucous membranes, non-intact skin, blood-soiled items or bodily fluid-soiled items, contaminated surfaces, and sterile body areas, and during instrument cleaning and decontamination procedures
  • Discard gloves used following treatment of a patient and change to new gloves if torn or damaged during treatment of a patient; wash hands and don new gloves prior to performing services for another patient; and wash hands and other skin surfaces immediately if contaminated with blood or other body fluids
  • Wear appropriate masks, gowns, or aprons, and protective eyewear or chin-length plastic face shields whenever splashing or spattering of blood or other body fluids is likely to occur
  • Sterilize equipment and devices that enter the patient’s vascular system or other normally sterile areas of the body
  • Sterilize equipment and devices that touch intact mucous membranes but do not penetrate the patient’s body, or use high-level disinfection for equipment and devices that cannot be sterilized prior to use for a patient
  • Use appropriate agents, including but not limited to detergents, for cleaning all equipment and devices prior a sterilization or disinfection
  • Clean, by the use of appropriate agents, including but not limited to detergents, equipment and devices which do not touch the patient or that only touch the intact skin of the patient
  • Maintain equipment and devices used for sterilization according to the manufacturer’s instructions
  • Adequately monitor the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques
  • Place disposable used syringes, needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers for disposal; and place reusable needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers until appropriately cleaned and sterilized
  • Maintain appropriate ventilation devices to minimize the need for emergency mouth-to-mouth resuscitation
  • Refrain from all direct patient care and handling of patient care equipment when you have exudative lesions or weeping dermatitis and the condition has not been medically evaluated and determined to be safe or capable of being safely protected against in providing direct patient care or in handling patient care equipment
  • Place all specimens of blood and bodily fluids in well-constructed containers with secure lids to prevent leaking; and clean any spill of blood or other bodily fluid with an appropriate detergent and appropriate chemical germicide (NYSED, 2011)

Reporting of suspected or confirmed communicable diseases is mandated under the New York State Sanitary Code (10NYCRR 2.10). Although physicians have primary responsibility for reporting, school nurses, laboratory directors, IC practitioners, daycare center directors, healthcare facilities, state institutions, and any others providing healthcare services are also required to report communicable diseases.

Reports should be made to the local health department in the county in which the patient resides and need to be submitted within 24 hours of diagnosis. However, some diseases require prompt action and should be reported immediately to local health departments by phone. A list of diseases and information on proper reporting can be found under Communicable Disease Reporting Requirements on the New York State Department of Health (NYSDOH) website.

Any single case of a reportable condition or an increase over baseline incidence of any condition is required to be reported by a facility licensed under Article 28 of the Public Health Law (10NYCRR 702.4). The facility should report the case to the NYSDOH electronically through the Nosocomial Outbreak Reporting Application (NORA), by fax to the Regional Epidemiology Program central office, or by phone to the regional epidemiologist in the facility’s region. Urgent matters should be directed by phone to the regional epidemiologist. General questions and IC guidance may be directed to the regional epidemiologist or to the regional epidemiology program central office.

Professional Misconduct

In 2011 New York passed legislation that enhances the state’s ability to investigate potential cases of physician misconduct and increases medical student and medical resident training in infection control. The legislation also requires the reporting of suspected disease transmission in office-based surgery practices. The bill requires the state to publicize charges served on a physician in any discipline proceeding and authorizes the state to release information about any public health threat revealed during an investigation (NYSED, 2012).

The legislation provides that a physician’s failure to respond to records requests from state or local health departments constitutes “professional medical misconduct.” It requires that medical students take the same courses in IC practices as those offered for physicians, physicians’ assistants, and specialist assistants (NYSED, 2012).

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