ATTACH_Attachment_3__AFI 44-108 InfectionControlProgram.pdf

BY ORDER OF THE

SECRETARY OF THE AIR FORCE

AIR FORCE INSTRUCTION 44-108

5 JUNE 2019

Medical

INFECTION PREVENTION AND

CONTROL PROGRAM

COMPLIANCE WITH THIS PUBLICATION IS MANDATORY

ACCESSIBILITY: Publications and forms are available for downloading or ordering on the e-Publishing website at http://www.e-publishing.af.mil.

RELEASABILITY: There are no releasability restrictions on this publication.

OPR: AFMOA/SGH

Supersedes: AFI 44-108, 11 December 2014

Certified by: AFMOA/CC

(Brig Gen James H. Dienst)

Pages: 45

This instruction supplements Air Force Policy Directive (AFPD) 44-1, Medical Operations. It defines personnel’s roles and responsibilities in efforts to mitigate the risks of healthcare-associated infections within all healthcare settings and reduce the spread of infections to patients, visitors, volunteers and personnel. This instruction applies to all Air Force military (Active

Component, Reserve, and Air National Guard) and Civil Service personnel and other medical personnel attached to or assigned to a unit with a medical or aeromedical evacuation mission. This

AFI may be supplemented at any level, but all supplements that directly implicate this publication must be routed to the Office of Primary Responsibility (OPR) for coordination prior to certification and approval. Refer recommended changes and questions about this publication to the OPR using the AF Form 847, Recommendation for Change of Publication; route AF Forms 847 from the field through the appropriate functional chain of command. The authorities to waive wing/unit level requirements in this publication are identified with a Tier (T-0, T-1, T-2, T-3) number following the compliance statement. See AFI 33-360, Publications and Forms Management, for a description of the authorities associated with the Tier numbers. Submit requests for waivers through the chain of command to the appropriate Tier waiver approval authority, or alternately, to the Publication OPR for non-tiered compliance items. Ensure that all records created as a result of processes prescribed in this publication are maintained in accordance with (IAW) Air Force

Manual 33-363, Management of Records, and disposed of IAW Air Force Records Disposition

Schedule located in the Air Force Records Information Management System. The use of the name http://www.e-publishing.af.mil/

2 AFI44-108 5 JUNE 2019

or mark of any specific manufacturer, commercial product, commodity, or service in this publication does not imply endorsement by the Air Force.

SUMMARY OF CHANGES

This document has been substantially revised and must be completely reviewed. Major changes include: The elimination of redundancies found throughout the publication; the inclusion of nationally recognized guidelines found in Attachment 1; the merging of Chapter 6 and Chapter

7 into one chapter; addition of a new chapter on reprocessing reusable medical devices; the deletion of Attachments 2, 4, 5, and 6; and the renaming of Chapters 2, 3, 4, 6, and 7.

Chapter 1— Overview. 6

1.1. Infection prevention and control (IPC):

1.2. The AFMS is dedicated to:

Chapter 2— General Roles and Responsibilities in Active Component Military Treatment

Facilities (MTF). 7

2.1. Air Force Surgeon General (AF/SG):

2.2. Chief, IPC Air Force Medical Operations Agency (AFMOA/SGHQ):

2.3. Medical Inspection Directorate, Air Force Inspection Agency (HQ AFIA/SG). .. 7

2.4. Surgeon General, Major Command (MAJCOM/SG)

2.5. Program Director of Epidemiology, Prevention and Infection Control (EPIC)

Courses

2.6. Commander or Director, Military Treatment Facility (MTF/CC)

2.7. Chairperson, Infection Prevention and Control Function

2.8. Infection Preventionist

2.9. Non-Commissioned Officer in Charge of Infection Prevention and Control

2.10. Infection Prevention and Control Assistant (Optional)

2.11. Infection Prevention and Control Coordinator (Optional)

2.12. Unit Manager/Supervisor/Dental Clinic IPC

2.13. MTF Personnel

2.14. Aerospace Medicine, or local equivalent

2.15. Public Health

2.16. Bioenvironmental Engineer (BE)

AFI44-108 5 JUNE 2019 3

2.17. Facility Manager

2.18. Patient Safety Manager

Chapter 3— Program Management. 14

3.1. Scope

3.2. Program Authority

3.3. Infection Prevention and Control Function (IPCF)

3.4. IP

3.5. MTF Infection Prevention and Control Operating Instruction

3.6. Infection Control Risk Assessment (ICRA)

3.7. Infection Prevention and Control Annual Plan

3.8. Infection Prevention and Control Annual Summary

Chapter 4— Infection Prevention and Control Guidelines. 18

4.1. Requirements

4.2. Infection Prevention and Control Program Authority Statements

4.3. Employee Health

4.4. Antiseptics

4.5. Disinfectants

4.6. Storage and Transportation of Clean and Sterile Supplies

4.7. Linen/Laundry

4.8. Regulated Medical Waste

4.9. Hospital Aseptic Management System (HAMS)/Clinic Housekeeping Contracts. 25

4.10. Ventilation

4.11. Smoke Biohazards

4.12. Service animals in healthcare environments

Chapter 5— Surveillance. 27

5.1. Definition

5.2. Requirements for Inpatient MTFs

5.3. Surveillance Plans for all MTFs

5.4. Surveillance Reports

4 AFI44-108 5 JUNE 2019

5.5. Outbreak Investigations

Chapter 6— Infection Prevention and Control in Operational and Special Environments. 29

6.1. Purpose

6.2. Transmission-based Precautions

6.3. Supplies and Equipment

6.4. Environmental Controls

6.5. Detergents and Disinfectants

6.6. Occupational Injuries

Chapter 7— Infection Prevention and Control Program Management in Aeromedical

Evacuation Squadrons, Air Force Reserve Command and Air National

Guard Medical Units. 32

7.1. General

7.2. Command Surgeon, Air Force Reserve Command and Office of the Air Surgeon, Air National Guard

7.3. Unit Commander

7.4. Executive Management Committee

7.5. IP

7.6. Infection Prevention and Control Non-commissioned Officer in Charge

7.7. Bioenvironmental Engineer

7.8. Unit Personnel

7.9. Management of Reusable Medical Devices

Chapter 8— Reprocessing Reusable Medical Devices. 35

8.1. General

8.2. Spaulding Classification

8.3. Manufacturers’ Instructions for Use (IFUs)

8.4. Pre-cleaning

8.5. Reprocessing Practices in Instrument Processing Areas

8.6. Training for Personnel Who Reprocess Reusable Medical Devices

8.7. Reprocessing Single-Use Devices

Attachment 1— GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION 39

AFI44-108 5 JUNE 2019 5

Attachment 2— Table A2.1. Infection Prevention and Control Risk Assessment (ICRA). 42

6 AFI44-108 5 JUNE 2019

Chapter 1

OVERVIEW.

1.1. Infection prevention and control (IPC): touches all facets of healthcare. It starts with the basic concept of hand hygiene, to the more complex practice of instrument sterilization and endoscope high level disinfection. IPC demands a basic understanding of the epidemiology of diseases; risk factors that increase patient susceptibility to infection, the practices, procedures and treatments that may result in infections. Support from all levels within the Air Force Medical

Service (AFMS) of infection prevention and control programs (IPCP) is necessary to prevent the transmission of communicable diseases and to reduce or eliminate healthcare associated infections in our military treatment facilities (MTF).

1.2. The AFMS is dedicated to: preventing and controlling the transmission of healthcare associated infections to patients, healthcare workers, visitors and others. This publication provides instruction and guidance, to help achieve and maintain an effective IPCP while embracing a culture of “Trusted Care” (the Air Force Medical Service’s brand for practicing High Reliability principles).

AFI44-108 5 JUNE 2019 7

Chapter 2

GENERAL ROLES AND RESPONSIBILITIES IN ACTIVE COMPONENT MILITARY

TREATMENT FACILITIES (MTF).

2.1. Air Force Surgeon General (AF/SG):

2.1.1. Establishes comprehensive IPC instructions, standards of care practices and interdisciplinary core competencies.

2.1.2. Appoints a headquarters-level Infection Preventionist (IP) to oversee the IPCP.

2.1.3. Monitors MTF infection prevention and control improvement action plans.

2.1.4. Reviews and updates current medical service doctrine and training plans to incorporate procedures in the Defense Health Agency Procedural Instruction 6200.01, Comprehensive

Infection Prevention and Control Program, Enclosure 3.

2.2. Chief, IPC Air Force Medical Operations Agency (AFMOA/SGHQ):

2.2.1. Provides evidence-based clinical consultation on standards of care and practices related to IPC. (T-1)

2.2.2. Liaises with the Defense Health Agency (DHA), military services, and other entities to develop policies, promote leading practices, and facilitate process improvements. (T-1)

2.2.3. Develops, updates, and disseminates Air Force IPC guidance and instructions via print, teleconferences, conferences, and electronic media. (T-1)

2.2.4. Maintains the Management Internal Control Toolset (MICT) and Self-Assessment

Communicators (SAC) for this instruction. (T-1)

2.2.5. Collaborates with the DHA, AF/SG1/8 and AFMOA/SGA to coordinate resources and support to military treatment facility IPCPs. (T-1)

2.3. Medical Inspection Directorate, Air Force Inspection Agency (HQ AFIA/SG). Assesses and verifies MTF, Air Force Reserve Command (AFRC) and Air National Guard (ANG) IPCPs, internal inspection processes. In addition, Active Component MTFs are inspected by The Joint

Commission.

2.4. Surgeon General, Major Command (MAJCOM/SG). In conjunction with AFMOA, allocates funds, equipment and personnel to MTFs, AFRC and ANG medical units.

2.5. Program Director of Epidemiology, Prevention and Infection Control (EPIC)

Courses (Medical Education and Training Campus / 59th Training Group):

2.5.1. Collaborates with AFMOA/SGHQ on development of IPCP guidance and deployment of allocated resources to support the program.

2.5.2. Assists with teleconferences, site visits and consultation requests. (T-1)

2.6. Commander or Director, Military Treatment Facility (MTF/CC).

2.6.1. Enhances the delivery of “Trusted Care”; establishes the Infection Prevention and

Control Function (IPCF), which will consist of a multidisciplinary functional area team. (T-

1)

8 AFI44-108 5 JUNE 2019

2.6.1.1. Commanders at limited-scope MTFs may choose to not have an IPCF. In such cases, the Commander must ensure the IPCP items identified in the Annual Plan are addressed at least quarterly at the Executive Committee of the Medical Staff (ECOMS), or

Executive Committee meeting.

2.6.1.2. Appoints in writing a credentialed and privileged provider to serve as the clinical authority and Chairperson of the IPCF (e.g. physician, dentist, nurse practitioner, or physician’s assistant). (T-1)

2.6.2. Appoints in writing the IP to manage the IPCP. When the primary IP is not available for periods greater than three months, MTFs will appoint an alternate IP per the qualifications listed in 2.8.1. (T-1)

2.6.3. Publishes an MTF-specific IPCP operating instruction. (T-1)

2.6.4. Provides resources and training to support the IPCP. (T-1)

2.7. Chairperson, Infection Prevention and Control Function.

2.7.1. Executes clinical authority over the IPCP. (T-1)

2.7.2. Oversees the development and implementation of policies governing control of infections and communicable diseases. (T-1)

2.7.3. Attends the EPIC Chairperson course within six months of being assigned to the position. Exception: if board certified in infectious diseases or infection control. (T-1)

2.8. Infection Preventionist.

2.8.1. The IP will be an officer, or a civilian equivalent, who has a minimum of three years of clinical experience in their specialty (e.g., nursing, dental, laboratory, medical) and will remain in position at least two years after attending IP formal training. (T-1)

2.8.2. Reports to the Chief Medical Officer (SGH), or designee, in performing IP duties. (T-

3)

2.8.3. Manages day-to-day IPC activities. (T-1)

NOTE: If IP role is an additional duty, selected member will devote a minimum of eight (8) hours a week to the IPCP. (T-3)

2.8.4. Performs an annual self-inspection using the MICT, SACs, The Joint Commission’s

Comprehensive Accreditation Manual, and other relevant guidance. (T-1)

2.8.5. Conducts a MTF infection control risk assessment (ICRA) annually and when significant change to risk occurs. Risks will be prioritized according to probability and the potential for harm. Attachment 2, Infection Prevention and Control Risk Assessment, may be used to develop the risk assessment. (T-1)

2.8.6. In collaboration with the Chairperson, develops the IPC Annual Plan and Annual

Summary. Uses the ICRA findings to draft the plan and updates as needed. (T-1)

2.8.7. Conducts surveillance as indicated in the Annual Plan or as required by the Air Force

Medical Service and the DHA. (T-1)

AFI44-108 5 JUNE 2019 9

2.8.7.1. Collects, manages, and analyzes surveillance data using standardized methodology and definitions per the Centers for Disease Control and Prevention’s (CDC) guidelines and National Healthcare Safety Network (NHSN). (T-1)

2.8.7.2. Utilizes various information systems for surveillance activities. This includes but is not limited to: Armed Forces Health Longitudinal Technology Application, Composite

Healthcare System, NHSN, Surgical Scheduling System, electronic healthcare records, and

Defense Medical Logistics Standard Support (DMLSS). (T-1)

2.8.8. Monitors infectious diseases and epidemiologically significant organisms occurring in the community via laboratory and public health reports. (T-1)

2.8.9. Identifies and evaluates clusters of infections and potential outbreaks. (T-1)

2.8.10. Institutes outbreak investigations and control measures as needed. (T-1)

2.8.11. Reviews and updates the MTF’s infection prevention and control program operating instruction every two years. (T-1)

2.8.12. Educates and trains personnel on infection prevention and control-related topics and

National Patient Safety Goals. (T-1)

2.8.12.1. Ensures IPC newcomers’ orientation and annual training is developed and includes all requirements listed in the Occupational Safety and Health Administration

(OSHA), Code of Federal Regulations (CFR), Title 29, Standard 1910.1030, Bloodborne

Pathogens (BBP), and Standard 1910.134, Respiratory Protection. (T-0)

2.8.12.1.1. Annual IPC training must be completed in-person, to allow for interactive questions and answers with the person conducting the training IAW OSHA, CFR, Title

29. (T-0)

2.8.12.1.2. A similar, in-person format for newcomers orientation will be followed if

BBP and the MTF Bloodborne Pathogens Exposure Control Plan (ECP) is not briefed by Public Health when the member in-processes to the MTF.

2.8.12.2. Other training modalities (e.g., Relias Learning) may be used to reinforce learning, but will not be used to substitute IPC newcomers’ orientation or annual training.

(T-1)

2.8.13. Maintains records IAW regulatory and accrediting agencies and local policy. (T-1)

2.8.14. Develops the IPCF meeting agenda and minutes. (T-3)

2.8.15. Evaluates products, devices, and equipment relating to IPC. (T-1)

2.8.16. Reviews all requests for new products and medical supplies in the DMLSS system, excluding pharmaceutical items and equipment requests IAW AFMAN 41-209, Medical

Logistics Support. New pharmaceutical items are approved by the Pharmacy and Therapeutics

Function IAW AFI 44-102, Medical Care Management. (T-1)

2.8.17. Collaborates with other departments to implement strategies to prevent healthcare-associated infections (HAIs), transmission of multidrug-resistant organisms and other epidemiologically important organisms, and to promote antimicrobial stewardship. (T-1)

2.8.18. Monitors and evaluates the efficacy of IPC strategies. (T-1)

10 AFI44-108 5 JUNE 2019

2.8.19. Provides consultation on all renovation, construction, repair projects, facility modifications, and relocations. (T-1)

2.8.19.1. Develops a focused construction/renovation ICRA during the construction planning phase. (T-1)

2.8.19.2. Posts an IPC construction permit at the entry way and/or exits of the construction area, to promote safety and awareness of personnel, patients, contractors and visitors. (T-

1)

2.8.19.3. Conducts on-site inspections throughout the project and documents observations, to ensure readiness for personnel and patients upon project completion. (T-1)

2.8.20. Reviews and consults on IPC related documents and service contracts. At a minimum, this includes the Hospital Aseptic Management System (HAMS) or an equivalent housekeeping contract, linen, waste management, the Individual Medical Facility Exhibit

(IMFE), Housekeeping Contract Adaptive Manual, and Housekeeping Performance Work

Statement. (T-1)

2.8.21. Reviews and updates infection prevention and control-related Memorandum of

Understanding (MOU) as needed. (T-1)

2.8.22. Provides consultation to Aerospace Medicine in developing the BBP-ECP and

Respiratory Protection/Tuberculosis Prevention ECP.

2.8.22.1. Aerospace Medicine reviews and provides updates to the plans at least annually.

(T-0) 2.8.22.2. Determines personnel who are at risk for exposure to airborne infectious diseases and notifies Bioenvironmental Engineering (BE) of respiratory protection requirements. (T-1)

2.8.23. Consults with Public Health to determine occupational risk categories for personnel.

Ensures the IPC Annual Plan reflects any updates on occupational risk categories, BBP, and medical employee health. (T-1)

2.8.24. Collaborates with Aerospace Medicine and Public Health for the management of an influx of infectious patients. (T-1

2.8.25. Maintains membership in the following committees or their equivalents: (T-1)

2.8.25.1. Environment of Care.

2.8.25.2. Product Evaluation.

2.8.25.3. Patient Safety.

2.8.25.4. Facility Utilization Board.

2.8.25.5. Medical Readiness.

2.8.25.6. Nurse Executive Function.

2.8.25.7. ECOMS.

2.8.26. Reports surveillance data, findings, and analyses to the committees listed above, patient care units, personnel, and external agencies. (T-1)

AFI44-108 5 JUNE 2019 11

2.8.27. Collaborates with the Patient Safety Manager on infection prevention and control-related events. Assists with event analyses and development of corrective actions. (T-1)

2.8.28. Consults with AFRC, ANG and Aeromedical Evacuation Units’ IPs in developing

MOUs, or Host-Tenant Agreements as applicable. (T-1)

2.8.28.1. The agreement will define how the visiting units must comply with the Host

MTF’s IPCP if providing services to active component beneficiaries. Refer to AFI 25-201, Intra-Service, Intra-Agency, and Inter-Agency Support Agreements Procedures for more information. (T-1)

2.8.28.2. Informs the tenant unit’s IP on infection prevention and control-related issues within the host MTF. (T-1)

2.8.29. Notifies leadership and other personnel of infection prevention and control-related problems or emergencies. (T-3)

2.8.30. The IP will attend the EPIC course no later than six months of assignment to the position. (T-1)

2.9. Non-Commissioned Officer in Charge of Infection Prevention and Control.

2.9.1. Assists the IP with the development, execution and evaluation of the IPCP. Substitutes for the IP during temporary absences (e.g., three months or less) with oversight from the SGH or designee. (T-3)

2.9.2. Works directly for the IP when performing IPC-related duties. (T-1)

2.9.3. At least eight (8) hours per week will be devoted to IPC duties, if this is an additional duty role. (T-3)

2.9.4. Requirements: must have a minimum of three years of experience in the medical enlisted career field (e.g., nursing, dental, laboratory), complete the EPIC course within six months of assignment, and will remain in the position at least two years after attending the formal training course. (T-1)

2.10. Infection Prevention and Control Assistant (Optional).

2.10.1. Works directly for the IP when performing IPC-related duties; may substitute for the

IP during temporary absences. (T-3)

2.10.2. Requirements: active duty officer in a clinical assignment who has an interest in IPC.

(T-3)

2.11. Infection Prevention and Control Coordinator (Optional).

2.11.1. Assists the IP and the Unit Manager in the implementation of the IPCP in their assigned clinical area. The coordinator will be appointed by the unit manager in writing and may be an officer, enlisted, or civilian personnel. (T-3)

2.11.2. Assists the IP with surveillance activities and new product evaluation. (T-3)

2.12. Unit Manager/Supervisor/Dental Clinic IPC.

2.12.1. Monitors IPC practices in their area of responsibility. (T-3)

12 AFI44-108 5 JUNE 2019

2.12.2. Develops a unit-specific operating instruction, if needed. The unit-specific instruction will be reviewed by the IPCF every two years. (T-3)

2.12.3. Ensures personnel receive initial, annual and ongoing IPC education and training specific to the unit. (T-1)

2.12.4. Validates training documentation per local policy. (T-1)

2.12.5. Assists the IP with unit-specific surveillance. Notifies the IP when a HAI is identified.

(T-3)

2.12.6. Ensures personnel with an infectious disease are restricted from duty and notifies

Public Health for awareness. Contractor personnel will notify the Contracting Officer’s

Representative (COR) of their illness. (T-1)

2.12.7. Appoints the unit’s IPC coordinator in writing. (T-3)

2.12.8. Informs the IP of any plans to occupy a new space or change existing functional use of a present space. Ensures plans are reviewed by the IPCF during the planning phase, prior to beginning the project. (T-1)

2.12.9. Notifies the IP of any process changes to already established practices which may have

IPC implications. (T-1)

2.13. MTF Personnel.

2.13.1. Complies with all IPC policies and MTF-directed training. (T-1)

2.13.2. Reports occupational exposures and injuries IAW local policy. (T-1)

2.13.3. Seeks prompt medical evaluation and treatment of infectious diseases. Notifies the immediate supervisor, IP and Public Health of any duty restrictions or limitations as a result of an infectious disease. (T-1)

2.13.4. Accomplishes periodic health examinations, immunizations, and clinical laboratory studies as deemed necessary by a medical authority or Department of Defense mandate to prevent, detect, or control infections or communicable diseases. (T-1)

2.14. Aerospace Medicine, or local equivalent.

2.14.1. Executes the Occupational and Environmental Health Program IAW AFI 48-145, Occupational and Environmental Health Program. (T-1)

2.14.2. Collaborates with the IP in the development of the BBP-ECP and Respiratory

Protection-Tuberculosis Prevention ECP. Ensures both are reviewed annually and updated as necessary. (T-3)

2.15. Public Health.

2.15.1. Provides updates on the Medical Employee Health Program (e.g. health status, disease monitoring) to the IPCF, or equivalent. At limited-scope MTFs, provides updates to the

Executive Committee, or equivalent, and per a MOU with a larger MTF. (T-1)

2.15.1.1. Reports on occupational exposures to blood and other potentially infectious materials, and other infectious disease. (T-0)

AFI44-108 5 JUNE 2019 13

2.15.1.2. Provides an annual report on medical employee health screening status of personnel. (T-1)

2.15.2. Reports to designated authorities on diseases or conditions that are reportable and relevant to the MTF’s IPCP. (T-0)

2.15.3. Consults with the IPCF on the annual ICRA. (T-3)

2.15.4. Collaborates with the IP as necessary when an influx of infectious patients occurs. (T-

1)

2.15.5. Collaborates with the IP in developing the ECP, which includes BBP and Respiratory

Protection/Tuberculosis Prevention. Reviews and provides updates annually. (T-0)

2.16. Bioenvironmental Engineer (BE).

2.16.1. Conducts respiratory protection fit-testing for medical personnel required to wear N95 particulate respirators or a similar device, while providing patient care IAW AFI 48-137, Respiratory Protection Program. (T-1)

2.16.2. Performs ventilation surveys as required by the facility or as requested. Refer to

Chapter 4 for locations and frequency. (T-1)

2.17. Facility Manager.

2.17.1. Provides ventilation survey reports to the IPCF. (T-3)

2.17.2. Notifies the IP and recommends corrective actions, when a ventilation survey fails to meet the criteria in the Unified Facilities Criteria (UFC), Design: Military Medical Facilities-

UFC 4-510-01. (T-1)

2.17.3. If the facility has not undergone replacement or any extensive repairs/renovations, then the organization must comply with the codes and standards that were established at the time the MTF’s construction plans were approved. (T-1)

2.17.4. Consults on issues concerning linen, housekeeping, HAMS, and regulated waste contracts. (T-3)

2.17.5. Coordinates linen, waste management, HAMS or equivalent housekeeping contract changes with the IPCF (T-3)

2.17.6. Coordinates with the IP on facility renovation, clinical services relocation, construction, facility modifications, projects and repairs. (T-3)

2.18. Patient Safety Manager. Collaborates with the IP on IPC related near misses, events, and provides assistance with analyses and corrective actions. (T-3)

14 AFI44-108 5 JUNE 2019

Chapter 3

PROGRAM MANAGEMENT.

3.1. Scope. The scope of the infection prevention and control program (IPCP) is based upon the risks and product line services found in each military treatment facility (MTF). The program will comply with applicable external agencies such as The Joint Commission, Occupational Safety and

Health Administration (OSHA) and other regulatory bodies. (T-0)

3.1.1. The primary goals of the program are to protect patients, personnel and visitors in the healthcare environment and reduce the risk and occurrence of healthcare associated infections

(HAI) across the continuum of care.

3.1.2. Guidelines developed by the Centers for Disease Control and Prevention (CDC), the

Society for Healthcare Epidemiology of America, and other professional organizations will be used to implement the program. (T-1)

3.2. Program Authority.

3.2.1. The Executive Committee of the Medical Staff (ECOMS), or equivalent, oversees the

IPCF. (T-3)

3.2.2. MTF leadership will place an emphasis on the healthcare worker’s health and safety.

3.2.3. MDG leadership will promote the importance of adhering to IPC principles in all facility settings, to foster a culture of “Trusted Care” and zero harm.

3.3. Infection Prevention and Control Function (IPCF).

3.3.1. The IPCF is a multidisciplinary team that coordinates program activities. If a limited-scope MTF elects to not have an IPCF, the Executive Committee or equivalent will assume this role as previously stated (Refer to Chapter 3). (T-1)

3.3.2. Membership includes but is not limited to the following personnel or department:

Chairperson, IP, Public Health, Facility Manager, Nursing, Dental, Perioperative, Sterile

Processing subject matter expert, Risk Manager, Patient Safety Manager, Housekeeper and other representatives as deemed necessary. (T-3)

3.3.3. Meets at least quarterly and submits minutes to the ECOMS, or equivalent. (T-1)

3.3.4. Agenda items and meeting minutes will reflect all of the components listed in the

Annual Plan. (T-1)

3.3.5. Reviews and coordinates approval of the IPC operating instruction, ICRA, Annual Plan and Annual Summary. (T-1)

3.3.6. All documents will be signed and in-place no later than the first day of the reporting period (e.g. calendar year or fiscal year). (T-1)

3.3.7. Reviews and consults on the HAMS contract and IMFE annually. (T-1)

3.4. IP. The IP will coordinate development of the following items with the IPCF, ECOMS, or equivalent: (T-1)

3.4.1. IPC operating instruction.

AFI44-108 5 JUNE 2019 15

3.4.2. Infection Control Risk Assessment.

3.4.3. Annual Plan.

3.4.4. Annual Summary.

3.5. MTF Infection Prevention and Control Operating Instruction.

3.5.1. The IPCF, ECOMS or equivalent will review and approve the IPC operating instruction every two years. (T-3)

3.5.1.1. If the instruction contains any aspect of BBP-ECP, or the Tuberculosis

Prevention-Respiratory Protection Program, it will be reviewed annually. (T-0)

3.5.1.2. Unit-specific instructions will be reviewed every two years. (T-3)

3.5.2. The MTF’s operating instruction will address the following: (T-1)

3.5.2.1. Identify the scope of the program relevant to the MTF’s mission.

3.5.2.2. Give authority to isolate infectious patients using transmission-based precautions.

3.5.2.3. Give authority to culture any drainage site.

3.5.2.4. Define policy and procedures for the prevention and control of infection that is consistent throughout the facility (e.g., antimicrobial stewardship, identification of /follow-up on multi-drug resistant organisms, linen, environmental cleaning; medical equipment, devices and supplies; surveillance procedures, and infectious waste disposal).

3.5.2.5. Define public reporting of HAIs through the CDC’s NHSN or other databases as required by the DHA.

3.5.2.6. Implement hand hygiene protocol IAW the CDC or the World Health

Organization (WHO).

3.5.2.7. Identify the procedures for investigating outbreaks or a sudden influx of infectious patients.

3.6. Infection Control Risk Assessment (ICRA).

3.6.1. The ICRA is a visual tool (Attachment 2 of this instruction) used to develop program priorities and stratify infection risks based on the following: (T-1)

3.6.1.1. Geographic location, community and population served.

3.6.1.2. Care, treatment, and clinical services provided.

3.6.1.3. Environmental issues and potential disaster situations.

3.6.1.4. Clinically significant microorganisms and multidrug-resistant organisms identified through mandated or planned surveillance.

3.6.1.5. Military mission.

3.6.1.6. Endemic diseases.

3.6.1.7. HAI data and conclusions from the previous year’s Annual Plan to address further action and follow-up.

3.6.1.8. Projected construction, renovations or repairs.

16 AFI44-108 5 JUNE 2019

3.6.1.9. Potential for sterile processing outages.

3.6.2. The IPCF and the ECOMS or equivalent will review and approve the ICRA annually.

(T-1)

3.7. Infection Prevention and Control Annual Plan.

3.7.1. The Annual Plan includes a written description of the activities to minimize, reduce, or eliminate the risk of infection. It will identify the following: (T-1)

3.7.1.1. The MTF’s mission and vision statement.

3.7.1.2. Scope of the program which includes: a snapshot of the patient population, type and level of care, treatment and services provided by the community, and environmental risks and issues.

3.7.1.3. Timeframe for which it is written (e.g., calendar year or fiscal year).

3.7.1.4. Surveillance strategies and reporting mechanisms.

3.7.1.5. Process for investigating outbreaks of infectious disease.

3.7.1.6. IPC training.

3.7.1.7. Quality initiatives and process improvement activities.

3.7.1.8. Influenza vaccination rates.

3.7.1.9. Resources required to implement the plan.

3.7.1.10. Contingency plans for sterile processing outages.

3.7.1.11. If applicable, Active Component Host facilities will include how they interface with Aeromedical Evacuation Squadrons, AFRC and ANG medical squadrons and reflect how the unit(s) interface with, and participate in, the MTF’s IPCP. (T-1)

3.7.2. The Annual Plan will measure progress in obtaining goals at least quarterly, based on the reporting schedule for each action plan initiative. Document accomplishments, deficiencies and amendments in the IPCF meeting minutes. (T-3)

3.7.3. The Annual Plan may be revised at any time in response to events or changes at the

MTF.

3.7.4. The Annual Plan is reviewed and approved each year by the IPCF and the ECOMS or equivalent. (T-1)

3.8. Infection Prevention and Control Annual Summary.

3.8.1. The IPCF and the ECOMS or equivalent will review and approve the IPC summary annually. (T-1)

3.8.2. The Annual Summary will describe all activities included in the Annual Plan. (T-1)

3.8.3. The format of the Annual Summary will include a general discussion of IPC concerns or elements of compliance, recommendations, actions taken, and follow-up actions.

Unresolved items will be carried over to the next Annual Plan. (T-1)

3.8.4. MTFs that host an Aeromedical Evacuation Squadron, AFRC or ANG unit may provide a copy of the Annual Summary to the tenant unit.

AFI44-108 5 JUNE 2019 17

18 AFI44-108 5 JUNE 2019

Chapter 4

INFECTION PREVENTION AND CONTROL GUIDELINES.

4.1. Requirements. A comprehensive list of IPC standards, guidelines and references are listed in Attachment 1 and on the IPC Kx. These references will be used to guide clinical practices. (T-

1)

4.1.2. Blood and other potentially infectious materials will be treated as if infectious.

Heightened awareness is required in environments where poor lighting makes visualization difficult (e.g., aircraft, medical transportation buses, austere ground conditions in operational settings). (T-0)

4.1.3. Standard Precautions are used in all healthcare environments. These precautions include: hand hygiene, PPE, respiratory hygiene/cough etiquette, safe injection practices, the wearing of a mask during lumbar puncture procedures, sterile instruments, and cleaned/disinfected environmental surfaces. (T-1)

4.1.3.1. Hand hygiene is performed IAW the Centers for Disease Control and Prevention

(CDC) and Healthcare Infection Control Practices Advisory Committee: Guideline for

Hand Hygiene in Health-Care Settings or the World Health Organization: Guidelines on

Hand Hygiene in Health Care. (T-1)

4.1.3.2. PPE is worn whenever exposure to blood and other potentially infectious materials is expected, or when there is a potential for such exposure. (T-0)

4.1.3.2.1. PPE includes head cover, face shield, face mask, goggles, impervious gown, gloves, and shoe covers. (T-0)

4.1.3.2.2. Personnel will wear PPE as required for the task to form a barrier of protection for associated exposure risk. (T-0)

NOTE: Powdered surgeon’s gloves, powdered patient examination gloves, and absorbable powder for lubricating surgeon’s gloves have been banned by the Food and Drug Administration (FDA), and will not be used.

4.1.3.2.3. Gloves will be worn when exposure to blood and other potentially infectious materials is possible or anticipated. Hypoallergenic gloves will be readily accessible to those personnel who are allergic to the gloves normally provided. (T-0)

4.1.3.2.4. Scrub suit attire and cloth surgical hats are not considered PPE. (T-0)

4.1.3.3. Respiratory hygiene/cough etiquette signage and supplies (e.g. masks, tissue and alcohol-based hand hygiene products) will be available to all who enter the healthcare facility. (T-1)

4.1.3.4. Safe Injection Practices. The CDC Guideline for Isolation Precautions:

Preventing Transmission of Infectious Agents in Healthcare Settings provides evidence-based recommendations for safe injection practices and reflects the minimum standards that personnel will follow to prevent transmission of infections in healthcare settings. (T-

0)

AFI44-108 5 JUNE 2019 19

4.1.3.4.1. Use aseptic technique to avoid contamination of sterile injection equipment.

(T-0)

4.1.3.4.2. Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (e.g., during myelograms, lumbar puncture and spinal or epidural anesthesia.) (T-0)

4.1.3.4.3. Irrigation and intravenous fluid bags are considered single-use. Surplus volume from any irrigation or intravenous fluid bag will not be used for more than one patient to avoid the risk of cross-contamination. (T-0)

4.1.3.4.4. Do not administer medications from a single syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulas and syringes are sterile, single-use items; they will not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient. (T-0)

4.1.3.4.5. Use fluid infusion and administration sets (e.g., intravenous bags, tubing and connectors) for one patient only and dispose of them IAW regulatory guidance after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set. (T-0)

4.1.3.4.6. Use single-dose vials for parenteral medications whenever possible. (T-0)

4.1.3.4.7. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use. (T-0)

4.1.3.4.8. If multi-dose vials must be used, both the needle or cannula and syringe used to access the multi-dose vial must be sterile. (T-0)

4.1.3.4.9. Label multi-dose medications (e.g., bottles, vials) with the expiration date, which is 28 days after initial entrance. (T-0)

4.1.3.4.9.1. Per AFI 44-102, , the United States Pharmacopeia 797 requires reconstituted multi-dose vials for injection purposes, to be disposed of after 28 days. However, the standard is solely intended for sterile injectable products and does not apply to pre-manufactured topical agents. NOTE: This does not apply to vaccines, which have separate requirements for when multi-dose vials will be discarded. (T-0)

4.1.3.4.9.2. Non-injectable multiple use containers, such as eye drops, rubbing alcohol and hydrogen peroxide, are designed to be administered safely until the manufacturer's expiration dates and will be disposed of when expired or contaminated as noted in the manufacturer's drug insert. (T-0)

4.1.3.4.10. Do not keep multi-dose vials in the immediate patient treatment area and ensure they are stored IAW the manufacturer's recommendations; discard if sterility is compromised or questionable. (T-0)

4.1.3.4.11. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients. (T-0)

4.1.3.4.12. Do not refill bottles of antiseptic solutions, ultrasound transducer gel, or any other medication unless specifically stated to do so per the manufacturers’

20 AFI44-108 5 JUNE 2019

instructions for use (IFU). Use single-use packets or bottles if available for purchase.

(T-0)

4.1.4. Transmission-based precautions will be used in all healthcare environments. They include airborne, contact, and droplet precautions. Refer to CDC Guideline for Isolation

Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings for detailed information. (T-0)

4.1.4.1. Protective environment precautions will be used in acute care hospitals that provide care to hematopoietic stem cell transplant patients.

4.1.4.2. These precautions are designed to prevent HAIs and consist of engineering and design interventions that decrease the risk of exposure to environmental fungi for severely immunocompromised allogeneic patients. (T-0)

4.1.5. Dental Infection Prevention and Control. Refer to the USAF Guidelines for Infection

Prevention and Control in Dentistry. (T-1)

4.1.6. Occupational exposure to blood or other potentially infectious materials. Personnel exposed to blood and other potentially infectious materials will be evaluated and managed

IAW the Occupational Health and Safety Administration, 29 CFR, § 1910.1030, the CDC, Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for

Administering Post-exposure Management and the most current U.S. Public Health Service, Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Post-exposure Prophylaxis. (T-0)

4.1.6.1. Injuries involving sharps, blood or other potentially infectious materials exposure will be promptly washed with soap and water. If the eye(s) or a mucous membrane is involved, flush the area with copious amounts of water. (T-0)

4.1.6.2. Report the exposure to the injured person’s supervisor. The supervisor will report needle sticks to Public Health for investigation and follow-up IAW AFI 91-204, Safety

Investigations and Reports. This is also done to ensure compliance with OSHA 29 CFR, §

1904. The injured person will seek post-exposure evaluation and treatment from a credentialed and privileged provider per MTF policy. (T-0)

4.1.6.3. The MTF’s ECP is used to ensure communication to a medical team trained to triage all exposures and assess the need for post-exposure prophylaxis. If prophylaxis is required, it must be administered as soon as possible, following the exposure incident IAW the CDC, Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Post-exposure Management and the most current U.S. Public Health

Service Guidelines for the Management of Occupational Exposures to Human

Immunodeficiency Virus and Recommendations for Post-exposure Prophylaxis, 2013. (T-

0)

4.1.7. The MTF will provide initial and annual in-person training on standard precautions, transmission-based precautions and BBP. This training will be documented per local policy.

(T-0)

4.2. Infection Prevention and Control Program Authority Statements.

AFI44-108 5 JUNE 2019 21

4.2.1. The IPCF Chair, or Executive Committee Chair for limited scope facilities, institutes surveillance, prevention, and control measures and notifies the Commander of any related problems. (T-1)

4.2.2. The IP, provider, nurse, or technician responsible for the patient has the authority to initiate isolation precautions and to culture suspected infected sites per established clinical protocols. (T-3)

4.2.2.1. Notify the provider when isolation precautions are instituted or when a culture is performed. (T-1)

4.2.2.2. Personnel will be trained in culturing techniques prior to performing any culture.

(T-1) 4.2.2.3. Sites that may be cultured include: urine, sputum, wound, stool, peripheral and central venous access sites, and other external drainage. The probing of a deep wound, to include intra-oral surgical sites, will be done by the provider. (T-1)

4.3. Employee Health.

4.3.1. All personnel must in-process through Public Health within 10 duty days of arrival to the MTF/unit or within three Unit Training Assemblies (UTA) after arrival for AFRC or ANG units and prior to patient care duties.(T-1)

4.3.2. Hepatitis B Virus Vaccine and Immunity: refer to CDC, Guidance for Evaluating

Health-Care Personnel for Hepatitis B Virus Protection and for Administering Post-exposure

Management, and Occupational Health and Safety Administration, 29 CFR, § 1910.1030). (T-

0)

4.3.3. Human Immunodeficiency Virus: refer to AFI 44-178, Human Immunodeficiency Virus

Program. (T-1)

4.3.4. Other vaccinations or immunity: refer to CDC, Immunization of Health-Care

Personnel, Recommendations of the Advisory Committee on Immunization Practices, 2011.

(T-1)

4.4. Antiseptics. The MTF’s IPC operating instruction will list antiseptics approved by the

IPCF, or Executive Committee in limited-scope MTFs. (T-0)

4.4.1. Include antimicrobial hand hygiene agents for use by personnel and antiseptics for use on patients.

4.4.2. All antiseptics must be registered with the FDA.

4.5. Disinfectants. The CDC, Guideline for Disinfection and Sterilization in Health-care

Facilities, and Guidelines for Environmental Infection Control in Health-Care Facilities, will be used as guides for decision making on disinfectant selection. All disinfectants must be registered with the Environmental Protection Agency. (T-1)

4.5.1. The MTF’s IPC operating instruction and Annual -Plan must have a list of disinfectants approved by the IPCF, or Executive Committee in limited-scope MTFs. (T-1)

4.5.2. Environmental disinfectants used by housekeeping will be maintained and approved on a separate list, to indicate which products are used by housekeeping and which products are used by healthcare personnel. (T-1)

22 AFI44-108 5 JUNE 2019

4.5.2.1. The housekeeping contractor will purchase environmental disinfectants IAW the established contract. (T-1)

4.5.2.2. Supplies acquired through the housekeeping contract (e.g., chemicals, disinfectants, cleaning utensils) will only be used by personnel during an emergency and only when a housekeeper is unavailable for emergency response. (T-1)

4.5.3. Liquid chemical sterilants and high-level disinfectants for processing reusable medical devices (e.g., flexible endoscopes, instruments) will be used according to manufacturers’ IFU and will not be used to disinfect environmental surfaces. (T-1)

4.5.4. Bleach (Sodium hypochlorite) will not be used as a primary disinfectant in the healthcare environment; it lacks detergent and may be corrosive to some surfaces. (T-1)

4.5.4.1. Disinfectants containing chlorine compounds may be used as a primary hospital-grade disinfectant.

4.5.4.2. Bleach may be used in Nutritional Medicine as a disinfectant.

4.5.4.3. Bleach may be used as an additional disinfection step if deemed necessary and approved by the IPCF (e.g., due to its highly effective kill of Enterovirus, and spore forming bacteria [e.g., Clostridium difficile, Bacillus anthracis]).

4.5.4.3.1. Clean surfaces with a detergent or a detergent/disinfectant first and allow to air dry, followed by the bleach disinfecting solution. (T-1)

4.5.4.3.2. Follow the bleach manufacturer’s instructions for use for correct dilution ratio. (T-1)

4.5.4.4. Consult the dental unit waterline manufacturer for correct methods and equipment to maintain the quality of dental unit waterlines. (T-1)

4.6. Storage and Transportation of Clean and Sterile Supplies. Storage areas will be kept clean, organized, and in an environment-controlled location. (T-1)

4.6.1. Store similar items together (e.g., sterile with sterile and clean with clean).

4.6.1.1. Store liquids on lower shelves or in containers that will hold the volume of the primary container, in the event it leaks, to prevent compromise to other supplies stored next to or below. (T-1)

4.6.1.2. Sterile and nonsterile patient treatment items may be stored in the same drawers or cabinets as long as there is no possibility of similar nonsterile items being used inadvertently when sterility (e.g., sterile 4x4s and clean 4x4s) is required and the items are kept separated by wipeable dividers or containers.

4.6.2. Supplies will be rotated using a first in, first out plan so that older items are used first, thus preventing waste due to expiration. (T-1)

4.6.3. Storage shelving must be six to eight inches above the floor, and 12 to 18 inches below the ceiling and away from vents, sprinklers and lights, and one to two inches from an outside wall. Open rack systems must have a solid bottom shelf or shelf liner. (T-1)

4.6.4. Do not store supplies on top of plastic covered racks, above cabinets, or in any other manner that is unsafe or impedes cleaning. (T-1)

AFI44-108 5 JUNE 2019 23

4.6.5. Sterile supplies will be stored in designated shelving or cabinets. (T-1)

4.6.6. Shipping boxes will be removed from patient care areas promptly after the supplies have been transferred to a clean storage bin. (T-1)

4.6.6.1. Interior boxes (boxes shipped within a shipping box) may be used to store supply items.

4.6.7. Do not use rubber bands to bundle soft packaged items (e.g., paper-plastic packages) together. (T-1)

4.6.8. Do not use towels or absorbent materials (e.g., bed underpad) to line drawers or shelves.

(T-1)

4.6.9. Supplies must be checked at the point-of-use for package integrity and expiration dates prior to use on a patient. (T-1)

4.6.10. Personnel will check medical supplies for expiration dates on a monthly basis.

Supplies without an expiration date are considered sterile until an event compromises package integrity. (T-1)

4.6.11. Do not store clean supplies in a contaminated area (e.g., decontamination area, soiled utility room). (T-1)

4.6.12. Contaminated devices/instruments must be transported in a puncture-resistant, covered container with leak-proof sides and bottom, or a cart. Transport devices must have a biohazard symbol on the exterior. Refer to Chapter 8 for additional information on transporting contaminated items. (T-0)

4.6.12.1. Contaminated devices/instruments will be transported as soon as possible following the procedure after pre-cleaning transport solution has been applied. Refer to

Chapter 8 for details on pre-cleaning. (T-1)

4.6.12.2. A government vehicle will be used when transporting clean or contaminated supplies between buildings that are not within walking distance (greater than 0.25 miles).

The vehicle will accommodate separation of contaminated items from clean to sterile items.

(T-0)

4.6.12.2.1. Follow applicable national and state Department of Transportation laws regarding the transport of biohazardous supplies. (T-0)

4.6.12.2.2. The government vehicle will be decontaminated between trips and in the event of spills. (T-1)

4.6.12.3. Personnel who transport sterile, clean and/or contaminated supplies/instruments will receive initial and annual training on these responsibilities. (T-1)

4.7. Linen/Laundry.

4.7.1. The IP will:

4.7.1.1. Review the Linen Contract Performance Work Statement (PWS) annually and address problems through the MTF’s linen Contracting Officer’s Representative (COR).

(T-1)

24 AFI44-108 5 JUNE 2019

4.7.1.2. Tour and evaluate the linen facility with the linen COR prior to contract award for locally purchased contracts, and annually thereafter. Use the Inspection of Laundry

Facilities Checklist on the AFMS Knowledge Exchange to assess the linen facility. (T-1) https://kx2.afms.mil/AFMOA/ClinicalQuality/IP/Shared%20Documents/Forms/AllItems.as px?RootFolder=%2fAFMOA%2fClinicalQuality%2fIP%2fShared%20Documents%2fLI

NEN%20FACILITY&FolderCTID=0x0120002203EF072EEFC04381B450E5C8524E54

4.7.1.2.1. Personnel will complete a Customer Complaint Record, located in the Linen

Performance Work Statement Appendices, whenever linen discrepancies are observed.

The completed form will be provided to the COR and IPCF. (T-1)

4.7.1.2.2. The COR will validate the customer complaint IAW PWS and collaborate with the contractor to correct the problem(s). (T-1)

4.7.2. Clean linen will be transported and stored in carts used exclusively for this purpose, or in linen carts that were cleaned and disinfected after being used to transport soiled linen. (T-

1)

4.7.3. Clean linen will be stored in clean storage areas (e.g., dedicated linen rooms with closing door, covered carts, closed drawers or cabinets). (T-1)

4.7.4. The MTF will treat all used or soiled linen as potentially infectious and also comply with applicable state or host nation requirements. (T-0)

4.7.4.1. Used or soiled linen will be handled in a manner that minimizes dispersal of particles into the air and surrounding area. Extremely soiled or wet linen may be wrapped loosely in clean linen or placed directly in a plastic bag then into the linen hamper. (T-0)

4.7.4.2. Double-bagging of soiled linen is not required unless the first bag has been damaged…