36C24920Q0030-004.pdf

ROBLEY REX VA MEDICAL CENTER MEMORANDUM NO. 603-17-003I-004

LOUISVILLE, KENTUCKY November 29, 2017

INFECTION AND DISEASE PREVENTION PROGRAM

1. PURPOSE

To establish the policies, procedures, and responsibilities for a systematic and effective Medical Center Infection and Disease Prevention Program (I&DP).

2. POLICY

a. The I&DP at the Robley Rex VA Medical Center is designed to identify, prevent and control infections in patients, employees, visitors, volunteers, and students in all areas of the Medical Center, or transported into these areas from the community. The I&DP works with other program lines on bioterrorism, sharing information and assisting with in-services to educate staff. Infection prevention is an integral component of all services. Prevention and control of infection is a primary responsibility of all health care workers. The scope of the ID&P is broad, including activities at the direct patient care level and at the patient support level. The goal of the I&DP is to improve patient health outcomes by identifying and reducing the risk of health care acquired infections associated with patients, health care workers, volunteers, students, trainees, visitors, contract workers and the environment.

b. The Robley Rex Veterans Affair Medical Center is in a metropolitan area located in the Ohio River Valley which provides care to a diverse population of primary care, extended care, homeless, mental health, and respite patients. Because of this diversity, there are different but well defined risks of infections. Primary risk factors include a large percentage of elderly patients with multi-system problems and a high level of chronic illness.

3. RESPONSIBILITIES

a. The Infection Control Committee (ICC) is responsible for monitoring the effectiveness of the I&DP evaluation of the infection potential of the related environment, and development of measures for control of infection within the medical center.

b. The Infection Preventionist (IP) is under the supervision of the Director of Infection & Disease Prevention. The IP is responsible for overall management of the I&DP. The IP is involved with construction projects and will cover specific infectious disease issues, especially regarding dust. Air sampling by microbiology and /or a contractor will be conducted as needed.

The IP is responsible for the coordination of surveillance, reporting, education, training, and consultation, and is responsible for reporting diseases to local health departments. The IP assists in the selection of supplies, conducts focused reviews as necessary, and has the authority to act in the absence of the committee to implement control measures when a potential danger exists for patients and/or personnel. The IP will provide reports to the VISN 9 Director as needed.

c. The chief of each service of the Medical Center is required to have a service-specific I&DP policy. Service chiefs are responsible for reviewing and revising service policies, ensuring employee attendance at I&DP in-service training, and monitoring their service's role in infection control.

d. Pathology and Laboratory is responsible for notifying the IP of all positive acid fast bacilli specimens, hepatitis profiles, multi-resistant organisms, lab confirmed, reportable, communicable diseases, and unusual trends identified. Multi-Drug resistant organisms (MDRO) should be reported to the MDRO Prevention Coordinator (MPC).

e. Occupational Health is responsible for pre-employment screening for infections and evaluation of immune status (recommending and providing necessary immunizations as indicated), conducting voluntary annual staff physical evaluations, the screening of all staff for tuberculosis as indicated, and the screening and prophylaxis for exposures and potential exposures of staff to infectious diseases. They are no longer under I&DP but have input into this process.

f. Employees are responsible for being familiar with I&DP policies and procedures, reporting self-infections and exposures, reporting patient infections, and attending orientation and annual infection control in-service training. The I&DP staff will share information on I&DP activities and results of surveillance with staff (e.g., monthly dashboards on Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE), and hand-hygiene adherence).

g. The Patient Safety Program Manager is responsible for working with all aspects of the I&DP to ensure responsiveness to any relative patient safety goals (e.g., follow-up on health care associated infections) and any other patient safety issues.

4. PROCEDURES

a. The I&DP will conduct surveillance and compile data and reports for the ICC.

b. The I&DP will analyze the data, identify trends, effect actions and make recommendations for improvement in patient care to the Healthcare Delivery Board. After reviewing the information, it will be disseminated to the nurse managers, nursing care units, and support staff.

c. Specific policies concerning I&DP surveillance and practices are maintained in the IC manual via the Intranet.

d. All information will remain confidential and shall only be released outside the Medical Center at the discretion of the Medical Center Director.

e. Modifications to the I&DP Risk Assessment and Plan are made throughout the year result analysis of surveillance activities, development of outbreak situations, issuance of new rules and regulations from oversight authorities, or awareness of new information in the field of infection control. A program evaluation also occurs during the yearly preparation of the surveillance plans.

f. I&DP education is provided in New Employee Orientation, annual mandatory reviews, and service-specific in-services for all staff, volunteers, and trainees.

5. REFERENCES

Current Joint Commission Manual for Hospitals; and Medical Center Memorandum No.

00QM-003, Patient Safety Program.

6. RESCISSION

Medical Center Memorandum No. 603-14-003I-004, Infection Control and Prevention Program, dated December 18, 2014.

7. EXPIRATION/RESPONSIBILITY

This policy expires on November 29, 2022, and is the responsibility of Infection & Disease Prevention.

/s/ Martin J. Traxler Medical Center Director