This policy has been adopted by UNC Health Care for its use in infection control.

It is provided to you as information only.

Current Status: Active PolicyStat ID: 5252220

Origination: 08/2018
Effective: 08/2018
Last Approved: 08/2018
Last Revised: 08/2018
Next Review: 08/2021
Owner: Sherie Goldbach: Infection
Prevention Registrar
Policy Area: Infection Prevention
Policy Tag Groups:
Applicability: UNC Medical Center

Infection Control Plan FY 2019

I. Description
Outlines the annual infection prevention priorities of Hospital Epidemiology and UNC Health Care

II. Rationale
An organized, systematic plan based upon the annual infection control risk assessment that provides the foundation for an
effective infection prevention program.

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III. Policy
A. Goals
1. Overall

a. Reduce risk of healthcare-associated infections for all patients, employee, and visitors.

2. Targeted

a. Healthcare-associated infection reduction – 10% reduction overall across the infection types listed below. (Note:
these infection counts are based on CMS required reporting regulations, not necessarily all hospital-wide infections)

Infection Types - All CMS Reportable Count - CY17 Reduce % Reduce # for FY19
MRSA bacteremia, C. difficle; CLABSI;
308 10% 31
SSI Hyst; SSI-Colon surgery; CAUTI

b. Clean In, Clean Out hand hygiene compliance program

i. Incorporate Patients and Families in at least three areas - from pilot phase through full implementation.

ii. Consistently sustain ≥90% compliance across all inpatient units, outpatient areas, procedural areas,
operating locations and job classes.

▪ At least 90 percent of inpatient units and departments must sustain 90 percent compliance or higher

▪ At least 90 percent of participating outpatient/procedureal areas must sustain 90 percent compliance or

higher

▪ At least 85 percent of job classes must sustain 90 percent compliance or higher

▪ At least 75 percent of OR locations must sustain 90 percent compliance or higher

iii. Continue improving our culture of feedback.

▪ Achieve overall feedback >75 percent in inpatient and outpatient areas

iv. Promote engagement

▪ Increase monthly number of participants by 10%

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 ▪ Physician participation goal to be determine by Service Leaders

B. Risk Assessment
(see Attachment 1: Annual Unit Based Infection Risk Assessment)

1. Patient Populations at Increased Risk of Infection

a. All intensive care unit patients

b. Solid organ transplant patients

c. Burn patients

d. Hematopoietic Stem Cell Transplant (HSCT) patients

e. Immunosuppressed patients (e.g., absolute neutrophil count [ANC] <1000, agranulocytosis)

2. Procedures/Devices that Increase Infection Risk

a. Central venous catheters

b. Indwelling urinary catheters

c. Tubes, drains, other devices inserted percutaneously

d. Intubation and prolonged ventilator support

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e. Surgical procedures

f. ECMO

3. Epidemiologically Important Pathogens

a. Legionella

b. Aspergillus/Rhizopus/Mucor

c. MRSA

d. VRE

e. C. difficile

f. MDR Gram negative bacteria

g. Carbapenem-resistant Enterobacteriacae

h. Candida auris

4. Highly Communicable Diseases

a. Novel Influenza virus

b. SARS

c. MERS-coV

d. Viral hemorrhagic fevers (e.g., Lassa fever, Ebola viral disease)

C. Strategies to Reduce Infection Risk

1. Identify and control outbreaks

a. Review of microbiology, immunology, molecular microbiology reports

b. Prospective and syndromic surveillance

c. Pulsed field gel electrophoresis of outbreak pathogens

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 d. Epidemiologic assessment as indicated (e.g., timeline, epidemic curve, case-control study)

e. Institution of prevention and control measures as indicated (e.g., isolation, cohorting of patients and staff, improved
hand hygiene, active surveillance cultures, assessment of environmental cleaning)

f. Exposure follow-up (in conjunction with OHS)

2. Perform surveillance for healthcare-associated infections

a. Follow CDC National Healthcare Safety Network (NHSN) definitions

b. Prospective and targeted Retrospective

c. Comprehensive: inpatient-related and outpatient-detected

d. Calculation/distribution of monthly infection rates and line listing of infected patients for each inpatient unit/service line

e. Monthly and as needed analysis of potential for cross-transmission

f. Targeted surveillance for home health/hospice infections

g. Monitor incidence of healthcare-associated device-related or procedure-related infections

i. Central Line-Associated Bloodstream Infections

ii. Ventilator-Associated Events (VAE)

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iii. Surgical Site Infections (SSI)

iv. Catheter-Associated Urinary Tract Infections (CAUTI)

3. Conduct routine monitoring

a. Biological indicators for sterilizers

b. Endoscopes

c. Pharmaceuticals

d. Dental water lines

4. Improve Hand Hygiene Compliance

a. Routinely monitor compliance and provide feedback to staff

b. Routinely evaluate the availability and acceptability of hand hygiene products

c. Provide just-in-time peer coaching

d. Provide frequent and tailored education on when and how to perform hand hygiene along with frequent visible
reminders

e. Enlist organizational leaders to serve as role models

f. Ensure commitment of leadership to achieve and sustain compliance of ≥90%. Managers must hold everyone
accountable for proper hand hygiene.

5. Support Infection Control Liaison Program

a. Unit-based staff, outpatient care services clinical staff, and ancillary care staff (i.e., ES, FNS, Transport) with focused
infection control training provided by Hospital Epidemiology

b. Responsible for assessing their unit's compliance with infection control policies/procedures and conducting
performance improvement activities related to infection prevention (e.g., reducing device-associated infections,
monitoring and improving hand hygiene compliance)

c. Serves as the contact person to disseminate infection control information, updates, and answer staff questions

6. Ensure compliance with JC National Patient Safety Goals

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 a. Comply with WHO or CDC hand hygiene guidelines

b. Prevent HAIs due to multi-drug resistant organisms (MDROs)

i. Annual risk assessment for MDROs

ii. Implement and assess prevention strategies outlined in this plan and under NPSG 07.03.01

c. Assess compliance with evidence-based practices for prevention of central line-associated bloodstream infections

i. Compliance with Central Line Insertions, Access, and Maintenance Bundle

ii. Standardized insertion training for providers

iii. Chlorhexidine bathing in intensive care units, step down units, and oncology units

iv. Daily assessment for central line need

v. Appropriate maintenance of central venous access devices

vi. Provide Central Line-Associated Bloodstream Infection rate data and prevention outcome measures to key
stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.

d. Assess compliance with evidence-based practices for prevention of surgical site infections

i. Ensure patient education provided in Pre-op visit. Use LMS for staff education.

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ii. Ensure Peri-Operative Services and Anesthesia infection control policies support prevention strategies.

iii. Trend surgical procedure specific infection rates and unit rates and provide feedback to key stakeholders

e. Implement evidence-based strategies for prevention of catheter-associated urinary tract infections

i. Staff education regarding aseptic insertion of catheter

ii. Insertion order must include indication for catheter

iii. Daily assessment for urinary catheter need

iv. Appropriate maintenance of indwelling urinary catheters

7. Manage HAIs as Sentinel Events When Indicated

a. Review all HAIs for indications of an unanticipated death or permanent loss of function

b. Notify Risk Management of suspected sentinel event

c. Participate in root cause analysis and follow up as needed

8. Construction Rounds and Construction Risk Assessment Meetings

a. Walk-about rounds with Plant Engineering every 2 weeks and on an as needed basis

b. Attend bi-weekly and as needed construction meetings held by Plant Engineering and Contract Services

c. Review blueprints and risk assessments for all new construction and renovations in clinical areas

9. Infection Control Rounds

a. Evaluate compliance with infection control policies/practices

b. Written recommendations to manager with their follow-up documented

10. Policy Review and Revision

11. Committee Participation: Refer to Infection Control Program Policy for committee information

12. Periodic Comprehensive TB Risk Assessment

13. Consultation, Education/Training

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 a. In-services, presentations, educational material to staff, visitors/families, attending physicians, residents, contract
employees, students, and volunteers

b. Computer-based training modules

c. Educational videos

d. Newsletter articles

e. Educational materials (e.g., booklets/brochures)

f. Quality Improvement support from Epidemiology Quality Improvement Staff

g. On-Call availability 24/7 for Infection Prevention consultation

14. Additional Strategies to Reduce Infections for the Immunosuppressed Patient

a. Ideally a private positive pressure room, HEPA filtration for HSCT patients

b. No live plants or fresh flowers

c. Immunosuppressed diet per physician order

d. Patient must wear tight-fitting surgical mask when outside room

15. Additional Strategies for Home Health and Hospice

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a. Trend analysis of device-related infections (urinary catheter-associated UTIs and central catheter-associated
bloodstream infections)

b. Promote immunizations to prevent respiratory infections: influenza and pneumococcal pneumonia vaccines (as
recommended by ACIP)

16. Additional Strategies for Outpatient Care Services

a. Since most patient encounters with the healthcare system now take place in outpatient settings, UNC Health Care will
maintain infection control programs in Outpatient Care Services, and this will include

b. Training and monitoring of practices on:

i. the basic principles of disease transmission and the methods to prevent transmission

ii. safe injection practices and proper use of single use and single patient devices/medications

iii. principles of asepsis and hand hygiene

iv. OSHA Bloodborne Pathogen Standard

v. the principles of disinfection and sterilization

vi. TB and respiratory protection per OSHA

D. Evaluation of Plan Effectiveness

1. Statistical analysis of infections

2. Trend analysis of infection rates

3. Device-associated rates to include home health and hospice

4. Monthly infection reports to nurse managers, clinical directors, infection control liaisons

5. Monthly infection reports to Infection Control Committee

6. Infection Control rounds report and annual compliance assessment

7. Monitor compliance with required and recommended immunizations

8. Annual assessment of communicable disease exposures with trend analysis

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 9. Annual risk assessment for MDROs with trend analysis

10. Periodic assessment of process measures with staff feedback

a. Evidence based processes to prevent surgical site infections

b. Evidence based processes to prevent catheter associated bloodstream infections

c. Evidence based processes to prevent catheter associated urinary tract infections

d. Evidence based processes to prevent Clostridium difficile infections

e. Evidence based processes to prevent ventilator associated pneumonia

f. Hand hygiene compliance

g. Isolation precautions compliance

Attachment 1 - Annual Unit Based Infection Risk

Attachments: Assessment.docx

Approval Signatures

Step Description Approver Date

Policy Stat Administrator Patricia Ness: Nurse Educator 08/2018

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Thomas Ivester: CMO/VP Medical Affairs 08/2018
Emily Vavalle: Director, Epidemiology 08/2018
Sherie Goldbach: Infection Prevention Registrar 08/2018

Applicability
UNC Medical Center

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