A-5_AFI_44-108.pdf

BY ORDER OF THE

SECRETARY OF THE AIR FORCE

AIR FORCE INSTRUCTION 44-108

11 DECEMBER 2014

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/SGN

Supersedes: AFI44-108, 1 March 2012

Certified by: AF/SG3/5

(Maj Gen Dorothy A. Hogg)

Pages: 87

This instruction implements Air Force Policy Directive (AFPD) 44-1, Medical Operations. It describes procedures for preventing and controlling healthcare-associated infections (HAIs) in patients, visitors, volunteers and staff (military, civilian, and contract personnel) within any healthcare setting such as military treatment facilities (MTFs), Limited Scope Military Treatment

Facilities (LSMTFs), Aeromedical Evacuation Squadrons (AESs), Air Reserve Component

(ARC) Medical Units (comprised of Air Force Reserve Medical Units [RMUs] and Air National

Guard Medical Units [GMUs]) and Dental Clinics. It defines the organization, specific functions, and responsibilities of personnel key to the Infection Prevention and Control Program and is integral to support home station and expeditionary missions. This instruction applies to all

Air Force military (Active Component Air Force, Air Force Reserve, and Air National Guard) and Civil Service personnel, contractor personnel, volunteers, and other medical personnel attached to or assigned to a unit with a medical or aeromedical evacuation mission. The term

“employee” as used in this AFI does not apply to contractor personnel. The term “Healthcare worker” and the term “personnel” as used in this AFI are presumed to cover contractor personnel unless otherwise noted. The term “contractor personnel” as used in this AFI includes subcontractor personnel at any tier. Air Force medical personnel at any level (AF/SG, AFMOA, MAJCOM/SG, or installation-level) who draft performance work statements (PWSs) for contracts under which contractor personnel will perform duties within any of the aforementioned healthcare settings are responsible for ensuring that each such PWS contains provisions that specifically require the contractor and its personnel, including subcontractors and their personnel at any tier, to comply with the provisions of this AFI. In the event of a conflict between a requirement in a services contract and this AFI, the services contract requirement governs the

Certified Current 14 July 2015 http://www.e-publishing.af.mil./

2 AFI44-108 11 DECEMBER 2014

obligations of the contractor and its personnel. This AFI may be supplemented at any level, but all supplements that directly implement 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, Table 1.1 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 (AFMAN) 33-363, Management of Records, and disposed of IAW Air Force

Records Disposition Schedule (RDS) located in the Air Force Records Information Management

System (AFRIMS). The use of the name 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: Tiering of directive statements and the creation of a new self-inspection checklist.

Directive compliance statements are highlighted to assist in the self-inspection process. It updates and clarifies medical employee health program requirements IAW Centers for Disease

Control (CDC) and Advisory Committee on Immunization Practices (ACIP) recommendations.

In addition, it incorporates an administrative change in the location of the Prevention and

Infection Prevention and Control Air Reserve Component (IC-ARC) course. Multiple references have been updated throughout the document.

Chapter 1—GENERAL ROLES AND RESPONSIBILITIES 6

1.1. Air Force Surgeon General (USAF/SG)

1.2. Major Command Surgeons (MAJCOM/SG)

1.3. Air Force Medical Operations Agency, Provision of Medical Care Division

(AFMOA/SGHM)

1.4. Medical Inspection Directorate, Air Force Inspection Agency (HQ AFIA/SG). .. 6

1.5. The Epidemiology, Prevention and Infection Prevention and Control Course

(EPIC), Infection Prevention and Control Reserve Component (IC-ARC), and the

Epidemiology, Prevention and Infection Prevention and Control Committee

Chairperson Course (EPIC3)

1.6. Military Treatment Facility Commander (MTF/CC)

1.7. Regional Infection Preventionist (IP)

1.8. Infection Prevention and Control Function (ICF) Chair

AFI44-108 11 DECEMBER 2014 3

1.9. Infection Preventionist (IP)

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

(NCOIC of IC) (Optional)

1.11. Infection Prevention and Control (IC) Assistant, Active Component Officer

(Optional)

1.12. Infection Prevention and Control Coordinators (Optional)

1.13. Unit Managers/Supervisors

1.14. Military Treatment Facility (MTF)/Limited Scope Military Treatment Facilities

(LSMTF) Personnel

1.15. Commander, Aerospace Medicine Squadron (AMDS), or local equivalent

1.16. Public Health (PH)

1.17. Bioenvironmental Engineer (BE)

1.18. Facility Manager

1.19. Patient Safety Manager (PSM)

Chapter 2—POLICY FOR INITIATING AND SUSTAINING INFECTION

PREVENTION AND CONTROL PROGRAMS IN AD MTFS 21

2.1. Scope of the Program

2.2. Program Authority

2.3. Infection Prevention and Control Function (ICF)

2.4. ICF Chair Training

2.5. IP/Infection Prevention and Control Monitor (ICM) Training

2.6. NCOIC of IC Training

Chapter 3—INFECTION PREVENTION AND CONTROL PROCEDURES IN AD MTFS

3.1. Guidelines for the Health and Safety of MTF/LSMTF Personnel

3.2. Employee Health Program Elements

3.3. Authority Statements

3.4. Guidelines for the Prevention and Control of Infection in Patients

3.5. Antiseptics

3.6. Disinfectants

3.7. Cleaning, Disinfection, and Sterilization

3.8. Event Related Sterility

3.9. Reprocessing Single Patient Use Items

3.10. Storage of Clean and Sterile Supplies

4 AFI44-108 11 DECEMBER 2014

3.11. Linen

3.12. Regulated Medical Waste (RMW)

3.13. HAMS/Clinic Housekeeping Contracts

3.14. Ventilation

3.15. Medical Laser Use

Chapter 4—SURVEILLANCE POLICIES FOR AD MTFS 45

4.1. Requirements

4.2. Definition

4.3. Surveillance Appropriate to MTF

4.4. Surveillance Activities in Annual ICPP

4.5. Surveillance Reports

Chapter 5—OPERATIONAL AND SPECIAL ENVIRONMENTS 48

5.1. Purpose

5.2. Goal

5.3. General Roles and Responsibilities

5.4. Patient Care Practices

5.5. Patient Placement

5.6. Supplies and Equipment

5.7. Environmental Controls

5.8. Disinfectants

5.9. Miscellaneous Environmental Issues

Chapter 6—INFECTION PREVENTION AND CONTROL PROGRAM ROLES AND

RESPONSIBILITIES FOR AEROMEDICAL EVACUATION

SQUADRONS (AESS) AND AIR RESERVE COMPONENT (ARC)

MEDICAL UNITS WITHOUT AN AEROSPACE MEDICINE MISSION 53

6.1. General

6.2. Air Force Surgeon General (USAF/SG)

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

6.4. Air Force Medical Operations Agency, Provision of Medical Care Division

(AFMOA/SGHM)

6.5. Medical Inspection Directorate, Air Force Inspection Agency (HQ AFIA/SG). .. 53

6.6. Unit Responsibilities

6.7. Responsibilities

AFI44-108 11 DECEMBER 2014 5

Table 6.1. Infection Prevention and Control Risk Assessment (ICRA)

Chapter 7—INFECTION PREVENTION AND CONTROL PROGRAM ROLES AND

RESPONSIBILITIES FOR AIR RESERVE COMPONENT MEDICAL

UNITS WITH AN AEROSPACE MEDICINE MISSION 59

7.1. General

7.2. Air Force Surgeon General (USAF/SG)

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

7.4. Air Force Medical Operations Agency, Provision of Medical Care Division

(AFMOA/SGHM)

7.5. Medical Inspection Directorate, Air Force Inspection Agency (HQ AFIA/SG). .. 59

7.6. Co-located and Non-co-located Units with an Aerospace Medicine Mission

7.7. Air Reserve Component Medical Units where PH officers are not available

7.8. Responsibilities

Attachment 1—GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION 68

Attachment 2—MISCELLANEOUS ISSUES TO CONSIDER DURING DEPLOYMENTS

Attachment 3—INFECTION PREVENTION AND CONTROL RISK ASSESSMENT

(ICRA) WORKSHEET 80

Attachment 4—INFECTION PREVENTION AND CONTROL PROGRAM

DOCUMENTATION REQUIREMENTS FOR AEROMEDICAL

EVACUATION SQUADRONS AND AIR RESERVE COMPONENT

MEDICAL UNITS 82

Attachment 5—EXAMPLES OF COMPLIANCE AND PROCESS SURVEILLANCE FOR

LSMTFS, DENTAL CLINICS, AESS, AND AIR RESERVE COMPONENT

MEDICAL UNITS 84

Attachment 6—HEPATITIS B VACCINE DECLINATION (MANDATORY) APPENDIX

A TO 29 CFR 1910.1030 BLOODBORNE PATHOGEN STANDARD 87

6 AFI44-108 11 DECEMBER 2014

Chapter 1

GENERAL ROLES AND RESPONSIBILITIES

1.1. Air Force Surgeon General (USAF/SG). Develops policy and delegates broad oversight responsibility for the Infection Prevention and Control Programs in the Air Force Medical

Service (AFMS).

1.2. Major Command Surgeons (MAJCOM/SG). In conjunction with the Air Force Medical operations Agency (AFMOA), allocates appropriate resources to MTFs/RMUs/GMUs.

1.3. Air Force Medical Operations Agency, Provision of Medical Care Division

(AFMOA/SGHM).

1.3.1. Develops, updates, and disseminates Air Force infection prevention and control guidance and instructions via print and electronic media.

1.3.2. Provides clinical consultation, defining and/or clarifying standards of care and practice related to infection prevention and control.

1.3.3. Serves as a liaison with military consultants in infection prevention and control and related specialties to keep abreast of changes in the field.

1.3.4. Serves as the Air Force resource for information and regulations that influence the practice of infection prevention and control.

1.3.5. Disseminates information to appropriate MTF points of contact.

1.4. Medical Inspection Directorate, Air Force Inspection Agency (HQ

AFIA/SG). Validates and verifies the internal inspections process of the program described in this instruction within AF MTFs, AFRC (RMUs) and ANG (GMUs). Active Component MTFs are also inspected by The Joint Commission (TJC) for bedded MTFs or the Accreditation

Association for Ambulatory Health Care (AAAHC) for non-bedded medical facilities.

1.5. The Epidemiology, Prevention and Infection Prevention and Control Course (EPIC), Infection Prevention and Control Reserve Component (IC-ARC), and the Epidemiology, Prevention and Infection Prevention and Control Committee Chairperson Course

(EPIC3). Personnel duties include:

1.5.1. Developing curriculum using the current version of the Association for Professionals in Infection Control and Epidemiology APIC Text of Infection Control and Epidemiology as the primary reference for course content. Additional resources will be incorporated as appropriate to include published texts, professional standards, guidelines, Air Force

Instructions, journal references, etc. (T-0).

1.5.2. Updating the courses, as needed, to maintain currency. (T-0).

1.5.3. Assisting with the maintenance of the Infection Prevention and Control Knowledge

Exchange (Kx) Internet web page. (T-1).

1.5.4. Developing curriculum that is appropriate and relevant to ARC Medical Units. (T-0).

AFI44-108 11 DECEMBER 2014 7

1.6. Military Treatment Facility Commander (MTF/CC).

1.6.1. Establishes an Infection Prevention and Control Function (ICF) to oversee an effective facility or unit-wide Infection Prevention and Control Program. (T-2).

1.6.2. Appoints the Chief of the Medical Staff (SGH), or other qualified medical or dental provider, in writing to provide clinical authority over the Infection Prevention and Control

Program and act as the Chairperson of the ICF. (T-2).

1.6.2.1. LSMTF/small clinic Commanders may choose not to have an ICF. If they elect not to have one, the Commander must ensure the Infection Prevention and Control

Program items identified in the annual Infection Prevention and Control Program Plan

(ICPP) are addressed at least quarterly at the Executive Committee of the Medical Staff

(ECOMS), or equivalent. The Chairperson of ECOMS, or equivalent, will then provide clinical authority over the Infection Prevention and Control Program. (T-0).

1.6.2.1.1. LSMTFs are defined according to AFI 44-102, Medical Care Management, and the AFMS Flight Path.

1.6.3. Provides resources such as equipment, supplies, and staffing to perform an annual

Infection Prevention and Control Risk Assessment (ICRA) to be used to develop and implement the ICPP. The MTF/CC determines, in concert with the SGH and the ICF, the capabilities of the MTF according to the level of probability and potential for harm which will be considered in the ICRA process. For example, if the capabilities involve surgical incisions into a body cavity or joint space, the facility should be considered at an increased risk and should plan accordingly. Refer to paragraph 2.3.5.1.1. and Attachment 3 of this instruction. Attachment 3 is an example only, and each ICRA should be tailored to the needs and mission of the MTF. (T-0).

1.6.4. Ensures computer and systems support to include access to the appropriate software programs, INTERNET sites to include protected/secured https sites, and information needed to support the Infection Prevention and Control Program. (T-2).

1.6.5. Reviews and approves non-programmed resources for special contingencies, such as external regulatory agency mandates and outbreaks. (T-2).

1.6.6. Ensures all MTF personnel receive a facility-specific Infection Prevention and Control

Newcomer Orientation that satisfies regulated training requirements. (T-2).

1.6.6.1. All MTF employees and contractor personnel will receive a workplace-specific infection prevention and control orientation for those items not covered in the facility orientation and are specific to the workplace prior to the start of direct patient care, clinical or assigned duties. (T-0).

1.6.6.2. All MTF personnel, students, and volunteers will attend the facility’s Infection

Prevention and Control Newcomer Orientation, or a similar forum, within 30 days of arrival. First Term Airman (FTA) will attend within 30 days after reporting to work within the MTF (reporting to work may be impacted by First Term Airmen Center course attendance). (T-0).

1.6.7. Ensures all MTF personnel and volunteers receive annual work area specific continuing education on infection prevention and control. (T-1).

8 AFI44-108 11 DECEMBER 2014

1.6.8. Ensures all MTF personnel and volunteers working in specialty areas receive annual continuing education on infection prevention and control aspects of patient care pertinent to high risk populations (e.g., intensive care units, transplant units, neonatal intensive care unit, dialysis units, and perioperative areas). (T-2).

1.6.9. Ensures all MTF personnel and volunteers receive timely training regarding significant changes in external regulatory agency standards. (T-2).

1.6.10. Establishes or uses current facility-wide centralized record keeping system to document compliance to the regulated training requirements to include the time schedule requirements for facility’s Newcomer Orientation and annual IC briefings. (T-1).

1.6.11. Ensures the ICF Chairperson, the Infection Preventionist (IP), and the NCOIC of IC

(optional position) attend the EPIC course, as soon as possible, but no later than one year after being assigned to the position. Refer to paragraph 2.4 thru 2.6. of this instruction (T-

2).

1.6.12. Publishes an MTF/LSMTF Operating Instruction (OI) on the Infection Prevention and Control Program. (T-1).

1.6.13. Ensures reference materials specified in this instruction are obtained, maintained, and updated as appropriate for the MTF’s/LSMTF’s specific mission. (T-2).

1.6.14. Ensures access to information needed to support the Infection Prevention and Control

Program. (T-2).

1.6.15. Ensures that incidents of occupational exposure to blood and other potentially infectious materials (OPIM) are managed and documented IAW with Occupational Safety and Health Administration (OSHA) standards and CDC guidelines specified in this instruction. (T-0).

1.7. Regional Infection Preventionist (IP).

1.7.1. The Regional IP will operate in a ‘Hub and Spoke’ fashion with the Regional IP as the

‘Hub’ (here forward referred to as the “assigned MTF”) and designated MTFs as the

‘Spokes’ (here forward referred to as the “receiving MTF”). (T-1).

1.7.2. The Regional IP will oversee and guide all elements of the Infection Prevention and

Control Program (ICP) carried out within their receiving MTFs to include all buildings associated with the MTF. (T-1).

1.7.3. Advise the MAJCOM and MTFs’ senior leadership about the status of the ICPs and any infection prevention and control concerns. (T-1).

1.7.4. Work closely with the AFMS Infection Prevention and Control Consultant and the assigned and receiving MTF IPs to provide consultation and expertise. (T-1).

1.7.5. Initially and then annually review and approve each assigned and receiving MTF’s

Infection Prevention and Control Operating Instruction, to ensure exposure prevention plans for Infection Control, Employee Health, Bloodborne Pathogen Exposure Control, and

Tuberculosis Prevention and Control Plans contain the appropriate actions and that they are based on current regulations and standards. (T-1).

AFI44-108 11 DECEMBER 2014 9

1.7.6. Communicate and collaborate with their assigned and receiving MTFs to ensure compliance in all phases of the ICP, suggest modifications when needed and discuss infection prevention concerns. (T-1).

1.7.7. Provide consultation on all aspects of Infection Prevention for the assigned and receiving MTFs. (T-1).

1.7.8. Provide regulatory and survey/inspection guidance, assist their assigned and receiving

MTFs to increase outcome and process surveillance activities, implement data collection/analysis and intervention tools, and provide evidence based practice oversight. (T-

1).

1.7.9. Emphasize a reduction of adverse events/healthcare acquired infections (HAIs) across their region and compliance with National Patient Safety Goals (NPSGs). (T-1).

1.7.10. Compile, analyze and interpret regional and MTF specific HAI data for trends and source. Make appropriate recommendations for implementation of measures to prevent and control HAIs. (T-1).

1.7.11. Maintain and distribute quarterly and annual MTF specific and regional statistical

HAI reports to assigned and receiving MTFs’ IP, ICF, senior leadership and the AFMS IC

Consultant by the tenth (10th) day of the second month following each quarter. (T-1).

1.7.11.1. Develop databases, graphs, and reports, to store, track, trend, and monitor infectious processes across assigned and receiving MTFs. (T-1).

1.7.11.2. Use basic analytical and epidemiological skills to generate, interpret, and apply data for improving infection prevention efforts. (T-1).

1.7.11.3. Use regional approved criteria IAW CDC "Outline For Healthcare-Associated

Infections Surveillance”, National Healthcare Safety Network (NHSN) Manual “Patient

Safety Component Protocol”, AFI 44-108, Infection Prevention and Control Program, and AFI 44-119, Medical Quality Operations. (T-0).

1.7.11.4. Share significant HAI trends with assigned and receiving facilities for educational purposes and targeted solutions purposes. (T-1).

1.7.11.5. Follow CDC and APIC outbreak investigation steps. (T-0).

1.7.12. Use AHLTA, Essentris, Composite Healthcare Computer System (CHCS), Integrated

Clinical Data Base (ICDB) programs or replacement Military Health System (MHS) systems of record for patient surveillance and reporting for assigned and receiving MTFs. (T-0).

1.7.13. Conduct an initial visit to each receiving MTF utilizing TJC, AAAHC, AF Inspector

General Unit Effectiveness Inspection (UEI), OSHA, APIC, CDC and NPSGs checklist criteria to consult and advise on facilities’ ICP adherence to regulations and standards within the first six (6) months of assignment. (T-0).

1.7.13.1. Compose a schedule of planned visits to designated receiving MTFs NLT the

(1st) first day of the second month after assuming Regional IP duties and submit to the

AFMS IC Consultant. (T-1).

10 AFI44-108 11 DECEMBER 2014

1.7.13.2. Document each facility visit and provide a copy of the report to the MTF’s IP, ICF, senior leadership and the AFMS IC Consultant within ten (10) days of the visit. (T-

1).

1.7.13.3. Compose the report using the official After Action Report (AAR) format located in AFH 33-337, Tongue and Quill, page 198. (T-1).

1.7.13.4. Site surveys include, but are not limited to, central sterile processing, dental instrument processing, surgery, hemodialysis, invasive cardiology, interventional radiology, oncology, equipment processing, and any areas under construction for infection prevention compliance and report any concerns to the MTF IP, Facility

Manager, the ICF and senior leadership. (T-1).

1.7.13.5. The Regional IP will witness sterilizer testing to ensure the appropriate and correct use of biological indicators (spore test) IAW current guidelines and will review results reports that have been provided to the ICF. (T-1).

1.7.13.6. Review actions taken for recall or re-sterilization if autoclave results were positive. (T-1).

1.7.13.7. Coordinate prior to the visit, if possible, for the testing of negative/positive pressure rooms, isolation rooms and other high-risk areas’ ventilation testing with

Bioenvironmental Engineering and Facility Management while the Regional IP is at the healthcare facility. (T-1).

1.7.13.8. Observe practices during surveillance rounds and identify areas of noncompliance using the MTF’s ICF approved policies and procedures. (T-1).

1.7.14. Review the assigned and receiving MTFs’ microbiological culture and sensitivity reports, admission and discharge diagnoses, high-risk procedures, necropsy reports and nursing services reports for significant findings related to infections and analyze for regional trends. (T-1).

1.7.15. Review assigned and receiving MTFs’ Annual ICP and summary report before submission to the MTF leadership and AFMS IC Consultant. (T-1).

1.7.16. Complete the one-time requisite NHSN training modules to obtain an NHSN account. The modules include, but are not limited to, Introduction to the Device-Associated

Module, Catheter Associated Urinary Tract Infection (CAUTI), Central Line Associated

Bloodstream Infection (CLABSI), Central Line Insertion Practices (CLIP), and Ventilator

Associated Pneumonia/Events (VAP/VAE). (T-1).

1.7.17. Ensure assigned and receiving MTFs have conferred rights to the Regional IP so

NHSN data can be reviewed. (T-0).

1.7.17.1. Ensure assigned and receiving inpatient MTFs are entering monthly data into the NHSN database and are utilizing the NHSN reports to benchmark HAI rates for their respective MTF by the tenth (10th) day of the second month following the reporting period. (T-0).

1.7.18. Monitor NHSN data to understand the performance of the assigned and receiving

MTFs and be prepared to guide the MTF IPs towards improvement. (T-0).

AFI44-108 11 DECEMBER 2014 11

1.7.19. Conduct bi-monthly, at a minimum, or upon request, teleconferences with their assigned and receiving IPs. (T-1).

1.7.19.1. Compile, maintain and distribute accurate teleconference meeting notes to their assigned and receiving MTFs and the AFMS IC Consultant within ten (10) days after the teleconference. (T-1).

1.7.20. Attend and participate in monthly teleconferences hosted by AFMS IC Consultant.

(T-1).

1.7.21. Virtually attend the assigned and receiving MTFs’ ICF meetings, if not physically co-located. (T-1).

1.7.22. Ensure appraisal of product representative visits and the testing of new medical equipment and supplies for patient care use comply with CDC, TJC, AAAHC, and OSHA standards. (T-0).

1.7.22.1. Communicate with MTF IPs and TRICARE Regional Business Office (TRBO)

Director on product introduction and inquires at the assigned and receiving MTFs. (T-0).

1.7.22.2. Compile a quarterly list of new equipment and supplies being used at their assigned and receiving MTFs, and share the information with their assigned and receiving MTFs and the AFMS IC Consultant by the tenth (10th) day of the first month following the quarter. (T-1).

1.8. Infection Prevention and Control Function (ICF) Chair.

1.8.1. For AD MTFs, the Chair will be a Medical or Dental Corps officer who is privileged and provides clinical authority and assistance to the IP in the implementation of the Infection

Prevention and Control Program. For LSMTFs, the Chairperson for ECOMS, or equivalent, will provide clinical authority and assist the IP. (T-0).

1.8.2. Implements the Infection Prevention and Control Program along with the IP. (T-2).

1.8.3. Provides direction and support to the IP. (T-2).

1.8.4. Notifies the Chief of the Medical Staff, who then notifies the MDG/CC of situations posing an imminent hazard to patient care. They will ensure notification of other appropriate personnel such as the Risk Manager, Patient Safety Manager and the Chief Nurse (CN)/SGN.

(T-0).

1.8.5. Conducts ICF meetings and validates the ICF summary. LSMTFs will include standard ECOMS, or equivalent, agenda items for the Infection Prevention and Control

Program (as determined by the annual ICPP) at least quarterly. (T-0).

1.8.6. Approves the annual ICRA and the prioritized list according to the level of probability and potential for harm before writing the ICPP. (T-2).

1.8.6.1. Presents the approved ICRA and prioritized list to ECOMS, or equivalent, for final approval and before the ICPP is written and presented to ICF. (T-3).

1.8.6.2. ICPP is written based on the approved ICRA, presented for approval at ICF and provided for final approval by ECOMS, or equivalent.

12 AFI44-108 11 DECEMBER 2014

1.8.6.3. Must have the ICPP approved by ECOMS, or equivalent, before it is implemented. Refer to paragraphs 2.3.5. and 2.3.5.1.2. of this instruction. (T-0).

1.8.7. Consults with Public Health (PH) to determine occupational risk categories for employees. Ensures contractors and their personnel are updated and familiar with these occupational risk categories and ensures applicable bloodborne pathogen, medical employee health, or infection prevention and control plans are updated accordingly. (T-2).

1.8.8. Establishes additional measures to study, prevent, and control infectious diseases when patients, personnel, volunteers or visitors may be at risk.

1.8.9. Activates contingency plans based on engineering control failures (e.g., ventilation surveys). (T-2).

1.8.10. Acts to minimize risk to the extent possible and/or remove susceptible individuals from environments that pose a health risk. (T-2).

1.8.11. Ensures tuberculosis and bloodborne pathogen exposure control plans are reviewed and updated annually IAW with OSHA standards. (T-0).

1.9. Infection Preventionist (IP).

1.9.1. Will be appointed in writing by the Unit Commander. The IP will be an officer, or civilian equivalent qualified by training, a minimum of three years clinical experience in their clinical field (e.g., nursing, dental, lab, medical), with an interest in managing the Infection

Prevention and Control Program. Enlisted personnel cannot be selected as the MTF's full-time IP. (T-0).

1.9.2. Works for the Chief of the Medical Staff (SGH), or designee, in performing duties and responsibilities commensurate with the management of the Infection Prevention and Control

Program. (T-2).

1.9.2.1. In small MTFs where the SGH may not be the IP’s rater or civilian supervisor, the SGH will provide appropriate input to the rater or civilian supervisor for evaluation purposes. (T-3).

1.9.3. Implements the Infection Prevention and Control Program with assistance and support from the ICF Chair and the ICF members. (T-0).

1.9.4. Performs an annual self-inspection using this AFI (AFI 44-108) as well as AFI 90-

201, The Air Force Inspection System, AFI 44-119, Medical Quality Operations and any other pertinent guidance. The assessments determine if there is sufficient evidence of compliance or noncompliance with standards. (T-2).

1.9.4.1. Uses the most current TJC or AAAHC survey standards appropriate for facility type (e.g., hospital environments). Additionally, uses AFIA’s UEI Evaluation Criteria for

MTFs when performing the self-inspection. (T-0).

1.9.4.2. Uses self-inspection tool(s) as directed by command (e.g., Management Internal

Control Toolset [MICT], and Accreditation Manager Plus [AMP]). (T-2).

1.9.5. Coordinates the annual ICRA with the IC Chair along with Facility Management, Patient Safety (PS), PH and other consultants as appropriate. Prioritizes the list according to

AFI44-108 11 DECEMBER 2014 13

the level of probability and potential for harm, refer to Attachment 3 of this instruction. The

ICRA will be presented at the ICF and ECOMS, or equivalent, for final approval. (T-1).

1.9.5.1. Drafts the ICPP with the ICF chair using the approved ICRA prioritized list. (T-

2).

1.9.5.2. Obtains ICF and ECOMS, or equivalent, approval for the plan before it is implemented. The plan may be updated as needed throughout the year with ICF and

ECOMS, or equivalent, approval. (T-2).

1.9.6. Maintains an effective ICPP by performing or supervising infection surveillance, prevention, and control activities pertinent to the mission as defined by the annual ICRA, ICPP, and approved by the MTF ECOMS, or equivalent. (T-2).

1.9.7. Develops and maintains the MTF/LSMTF OI for infection prevention and control.

Does not repeat items already listed in this AFI into the local MTF/LSMTF Infection

Prevention and Control OI. (T-2).

1.9.8. Works jointly with Education and Training (ET), PS, and PH Flights to ensure a formal orientation and annual in-service training program on the principles and practices of the MTF/LSMTF’s Infection Prevention and Control Program for all personnel is accurate and appropriately documented. (T-2).

1.9.8.1. Facilitates Newcomer Orientation and annual in-service training for infection prevention and control and ensures it will contain at a minimum:

1.9.8.1.1. Required PH information. IP will collaborate with the PH Flight to ensure all requirements listed in the 29 Code of Federal Regulations (CFR) 1910.1030, Bloodborne Pathogens Standard, Final Rule and Tuberculosis Prevention and

Control Plan, are reflected in the MTF/LSMTF's programs. (T-0).

1.9.8.1.2. Overview of facility requirements; IP will ensure training is tailored to meet the needs of the MTF/LSMTF for size and scope of care. (T-0).

1.9.8.2. Training may be accomplished through a variety of educational media to include lecture, self-learning packets, videotapes and computer-assisted learning packages.

(NOTE: If an in-person lecture style format is not used, a knowledgeable person must be accessible during the training to answer questions between trainer and trainee in-person or via telephone). (T-0).

1.9.9. Maintains infection prevention and control files on each activity pertinent to the

Infection Prevention and Control Program. (T-2).

1.9.9.1. Maintains records created as a result of processes prescribed in this publication in accordance with AFMAN 33-363, Management of Records, and disposed of in accordance with Air Force Records Information Management System (AFRIMS)

Records Disposition Schedule (RDS). (T-1).

1.9.10. Plans the ICF agenda with the IC Chairperson, based on activities outlined in the

ICPP. A formal agenda is not required for an ICF; however, an ongoing documented plan of action with interventions and follow up is required. LSMTF's ECOMS, or equivalent, Chairperson will ensure the standard agenda items outlined in the ICPP is included in the agenda at least quarterly. (T-0).

14 AFI44-108 11 DECEMBER 2014

1.9.11. Maintains infection prevention and control references which at a minimum include:

(T-0).

1.9.11.1. Most current version (e.g., hard copy and/or electronic) of the APIC Text of

Infection Control and Epidemiology for MTFs.

1.9.11.2. The following subscriptions and references are recommended to assist AD

MTF personnel to remain current and obtain updates in infection prevention and control:

1.9.11.2.1. American Journal of Infection Control (AJIC); allows for automatic notifications and a complete published copy of changes in guidelines and regulations that impact the IP. May obtain a hard copy subscription and/or electronically through

AFMS Virtual Library.

1.9.11.2.2. Infection Control and Hospital Epidemiology; allows for automatic notifications and a complete published copy of changes in guidelines and regulations that impact the IP.

1.9.11.2.3. Free weekly Centers for Disease Control and Prevention’s (CDC)

Morbidity and Mortality Weekly Report (MMWR); provides updates on

CDC/Healthcare Infection Prevention and Control Practices Advisory Committee

(HICPAC) and OSHA guidelines and regulations. It is recommended that MTFs obtain the index version with attached links to the articles.

1.9.11.2.4. Consider subscribing to other free electronic magazines such as Infection

Prevention and Control Today and International Sharps Injury Prevention Society.

1.9.11.3. Kx Infection Prevention and Control website.

1.9.11.4. Attachment 1 of this AFI consists of a Glossary of References and Supporting

Information including key websites; provides source information on infection prevention and control standards.

1.9.11.5. Other infection prevention and control references appropriate for the mission of the MTF/LSMTF.

1.9.12. Coordinates and consults on the purchase of supplies and equipment used by

MTF/LSMTF personnel in the direct and indirect care of patients. (T-1).

1.9.13. Coordinates and consults on renovation, construction and repair projects, facility modifications, and relocations that have an impact on direct patient care and those areas providing support to patient care areas (e.g., pharmacy, laboratory, nutritional medicine) in the MTF prior to start. (T-1).

1.9.13.1. Uses a focused construction or renovation ICRA to preplan infection prevention and control efforts to be coordinated before any new construction, renovation, facility modification, and relocation projects within the MTF and any geographically separated units (GSU) begins. (T-2). An ICRA template to be used to access a construction or renovation project is easily obtained through an electronic internet search using the following words: ICRA, construction matrix, Construction ICRA.

1.9.13.2. Conducts a walkthrough of areas before any department, service or unit occupies a new space or changes the existing functional use prior to the start of any project. (T-2).

AFI44-108 11 DECEMBER 2014 15

1.9.13.3. IP will issue an IC Construction Permit which is included as part of the construction ICRA template at the end of the document. (T-0). Compliance with the IC

Construction Permit is required to ensure the safety and wellbeing of personnel, patients and visitors. (T-0).

1.9.13.4. After completion of any construction, renovation, facility modifications, and relocations the IP or IC Department will conduct an environmental round to ensure readiness for patients and staff prior to occupancy. (T-0).

1.9.14. Coordinates and consults on service contracts and plans that have infection prevention and control implications. At a minimum, this includes the Hospital Aseptic

Management System (HAMS) or an equivalent housekeeping contract, linen contract, and the waste management contract. (T-1).

1.9.15. Reviews infection prevention and control related host-tenant agreement/memorandum of understanding (MOU) prior to expiration. (T-2).

1.9.16. All IPs must have access to all information needed to support the surveillance activities of the infection prevention and control program (e.g., AHLTA, CHCS, Operating

Room (OR) schedules, paper records, applicable lab reports and data bases of all areas in order to perform surveillance activities). (T-0).

1.9.17. Acts as a consultant to the Aerospace Medicine Squadron on the development of the

MTF/LSMTF instructions for exposure control plans. (T-2). (NOTE: Due to the overlapping nature of these programs, the MTF Instruction for Infection Prevention and

Control, Employee Health, the Bloodborne Pathogen Exposure Control Plan [BBP-ECP], and the Tuberculosis Prevention and Control Plan may all be contained in one MTF instruction).

Appropriate coordination by the process owners is imperative (e.g., Aerospace Medicine coordinates the exposure control plans).

1.9.18. Maintains active membership in the following groups (if indicated): (T-2).

1.9.18.1. Safety or Environment of Care Committee, or equivalent.

1.9.18.2. Product Evaluation Committee, or equivalent.

1.9.18.3. Patient Safety Committee.

1.9.18.4. Space Utilization Committee, or equivalent.

1.9.18.5. Medical Readiness Staff Function, or equivalent, to consult on emergency management plans involving the sudden influx of infectious patients.

1.9.18.6. Nursing Executive Function, or equivalent.

1.9.18.7. Executive Committee of Medical Staff (ECOMS), or equivalent.

1.9.19. Collaborates with PS on tracking and trending of infection prevention and control near misses, events and/or issues relating to PS, the NPSGs, PS Alerts/Notices to Airmen

(NOTAMS) and other initiatives that pertain to infection prevention and control. (T-2).

Engages PS Manager in proactive and reactive analysis related to infection prevention and control (e.g., conduct a root cause analysis, failure mode and effect analysis or other PS

Initiative). (T-2).

16 AFI44-108 11 DECEMBER 2014

1.9.20. The Host MTF will provide the ground level support for tenant ARC Medical Units located on AD bases per AFI 25-201, Intra-Service, Intra-Agency, and Inter-Agency Support

Agreements Procedures. (T-2). As a result, the IP will assist the AES/ARC Medical Units'

Infection Prevention and Control Officer (ICO) to develop a Memorandum of Understanding or Agreement (MOU/MOA), or Host Tenant Agreement in order to participate and comply with the Host MTF's Infection Prevention and Control Program per the requirements outlined in AFI 25-201 and Attachment 4 of this AFI. (T-2). Refer to Chapter 6 and 7 of this instruction for additional information on required collaboration with ARC Medical Units.

The IP will communicate and collaborate with the ICO to ensure these units are kept abreast of applicable infection prevention and control concerns, and the IP will also serve as a conduit to elevate ARC Medical Units IC issues to the AD MTFs. (T-2).

1.10. Non-Commissioned Officer in Charge of Infection Prevention and Control (NCOIC of IC) (Optional).

1.10.1. The NCOIC of IC is an optional position, but if an MTF elects to appoint an NCOIC in IC, criteria for selection to this role include completion of the EPIC course, a minimum of

3-years clinical experience in the medical enlisted career field (e.g., nursing, dental, laboratory) and must have an interest in infection prevention and control. (T-2).

1.10.2. Works directly for the IP when performing infection prevention and control duties and will cover for the IP in the temporary absence (e.g., 3 months or less) of the IP with oversight of the SGH or designee. (T-3).

1.10.3. Assists the IP with the implementation of the Infection Prevention and Control

Program. (T-3).

1.11. Infection Prevention and Control (IC) Assistant, Active Component Officer

(Optional).

1.11.1. The IC Assistant, Active Component Officer is an optional position, but for MTFs which have employed a civilian IP, appointment of this position is recommended.

1.11.2. Requirements: AD officer in a clinical AFSC (e.g., NC, MC, BSC, DC officer) that will assist the IP with the implementation of the Infection Prevention and Control Program and in turn will be mentored by the IP on how to manage an MTF IC Program. It is recommended the AD officer be rotated no more frequently than every two years. (T-2).

1.11.3. Works directly for the IP when performing IC duties and may cover for the IP in their temporary absence. (T-2).

1.11.4. Formal IC training is recommended as referenced in paragraph 2.5. of this instruction.

1.12. Infection Prevention and Control Coordinators (Optional).

1.12.1. The Infection Prevention and Control Coordinator is an optional position, but if an

MTF elects to appoint this position, he/she assists the IP and the Unit Manager in the implementation of the Infection Prevention and Control Program in their assigned clinical area. The Infection Prevention and Control Coordinator will be either an officer, enlisted, civilian, or contractor personnel (if the contract allows performing the IC Coordinator duties). The IC Coordinator will be appointed by their Unit Manager. (T-3).

AFI44-108 11 DECEMBER 2014 17

1.12.1.1. Assists the Unit Manager in developing and updating the IC unit specific operating instructions if there are unique section specific practices that are not addressed in the MDGI and unit specific education (orientation and annual training). Unit specific orientation and training does not replace MDG orientation and annual training. (T-3).

1.12.1.2. Assists the IP with surveillance activities (e.g., visual surveillance, compliance to IC protocols like hand hygiene). (T-3).

1.12.1.3. Assists in testing new products (e.g., new hand hygiene antiseptics, safety designed device) and in the coordination of training their unit personnel about the new product. (T-3).

1.12.1.4. Provides IC training and guidance when performing the IC duties in their assigned units/area. (T-3).

1.13. Unit Managers/Supervisors.

1.13.1. Monitors personnel within their area of responsibility to ensure they understand and comply with all infection prevention and control policies and practices. (T-2).

1.13.2. Ensures the healthcare workers understand and comply with the basic principles and practices of infection prevention and control (e.g., hand hygiene, aseptic technique, standard precautions, isolation, and personal protective attire/equipment) as they apply in their day-to-day activities. (T-2).

1.13.3. Writes a unit specific operating instruction (OI), only if needed, to supplement the

MTF/LSMTF Infection Prevention and Control OI. (NOTE: Do not repeat items written in

AFI 44-108 or the MTF OI for Infection Prevention and Control). (T-2).

1.13.3.1. If applicable, reviews the unit specific IC OI annually and updates as needed based on changes to the MTF/LSMTF Infection Prevention and Control OI. (T-2).

1.13.3.2. Submits the OI to the ICF for review at least every two years. (T-2).

1.13.4. Ensures the completion of a unit-specific orientation, on-the-job-training, and ongoing in-service education, to include the appropriate documentation per regulations on infection prevention and control for assigned personnel. (T-2).

1.13.5. Evaluates work practices and in-place personal protective equipment (PPE)/controls to identify ways of improving employee practices and protection. (T-2).

1.13.5.1. Ensures respiratory protection program plans for the workplace exists if the workplace is on the respiratory protection program. (T-2).

1.13.6. Assists IP with surveillance in their respective areas.

1.13.7. Reports patients or healthcare workers with healthcare-associated infections (HAIs) to the IP. (T-2).

1.13.8. Ensures staff members, including contractor personnel, with infectious illnesses are evaluated by a healthcare provider and duty restrictions are enforced IAW current CDC

Infection Prevention and Control Guidelines. (T-2). In the event duty restrictions become necessary for a contractor personnel staff member due to an infectious illness, the Unit

Manager/Supervisor shall immediately notify the Contracting Officer, who will immediately

18 AFI44-108 11 DECEMBER 2014

bring the matter to the attention of the contractor’s management for action in accordance with this paragraph.

1.13.9. Ensures PH is notified of employees in their duty section who are on medical leave or confined to quarters due to a communicable illness. (T-2).

1.13.10. Appoints the Infection Prevention and Control Coordinator in writing if MTF elects to appoint this position (refer to paragraph 1.12. of this instruction). (T-2).

1.13.11. Informs the IP or IC department of any plans to occupy a new space or change existing functional use of a present space. Ensures plans are reviewed by the IC department during the planning phase before the start of the project. (T-2).

1.13.12. Notifies the ICF, through the IP, prior to the start of new procedures or changes in already established procedures, which may affect infection prevention and control practices.

1.14. Military Treatment Facility (MTF)/Limited Scope Military Treatment Facilities

(LSMTF) Personnel.

1.14.1. Comply with the MTF/LSMTF and unit Infection Prevention and Control OIs. (T-

2).

1.14.2. Comply with work practice and engineering controls such as the practice of good hand hygiene and use available PPE per MTF/LSMTF policies. (T-2).

1.14.3. Report occupational exposures and injuries IAW AFI 91-204 Safety Investigations and as specified in MTF/LSMTF unit policy. (T-2).

1.14.4. Seek prompt medical evaluation, treatment, and report suspected/actual healthcare-associated infections or a communicable disease per the mechanism identified by the

MTF/LSMTF organization. Notify the immediate supervisor and PH of any duty restrictions or limitations as a result of an infectious or communicable disease. (T-2).

1.14.5. Accomplish periodic health examinations, immunizations, and clinical laboratory studies as deemed necessary by appropriate medical authority or Department of Defense

(DoD) mandate to prevent, detect, or control infections or communicable diseases. (T-2).

1.15. Commander, Aerospace Medicine Squadron (AMDS), or local equivalent.

1.15.1. Executes the occupational health program in accordance with IAW AFI 48-145, Occupational and Environmental Health Program. (T-2).

1.15.2. Collaborates with IC Department in the development of the facility BBP-ECP and ensures it is reviewed annually, and updated as necessary. (T-2).

1.15.3. Ensures tuberculosis prevention program plan is developed, reviewed annually, and updated as necessary. (T-2).

1.16. Public Health (PH).

1.16.1. Reports regularly to the ICF on health status and disease monitoring in the Medical

Employee Health Program (MEHP) as required by instructions, the ICPP or as requested by the ICF. LSMTFs reports will be provided to ECOMS, or equivalent, and per the MOU with a larger MTF. (T-0).

AFI44-108 11 DECEMBER 2014 19

1.16.1.1. Reports on occupational exposures to blood and body fluids, and other infectious disease, as appropriate. (T-2).

1.16.1.2. Reports on medical employee health screening status of MTF/LSMTF employees to the ICF at least annually. LSMTFs reports will be provided to ECOMS, or equivalent, and per the MOU with a larger MTF. (T-0).

1.16.2. Reports any reportable diseases or conditions identified within the MTF/LSMTFs to designated authorities and/or agencies. (T-2).

1.16.3. Consults on the annual ICRA with the IP, IC Chair, Facility Management, and other consultants, and prioritizes the risk assessment list according to the level of probability and potential for harm to be presented at ICF and ECOMS, or equivalent, for final approval. (T-

2).

1.16.4. Assists IP as necessary with a sudden influx of potentially infectious patients, cluster and/or epidemic investigations within the MTF/LSMTF. (T-2).

1.16.5. Collaborates with IC Department in the development of the facility BBP-ECP, the annual review, and provide updates as necessary. (T-2).

1.16.6. Collaborates with IC Department in the development of the facility tuberculosis prevention and respiratory protection program plan, to include the annual review, and provide updates as necessary. (T-2).

1.17. Bioenvironmental Engineer (BE).

1.17.1. Conducts respiratory protection fit-testing for all respirators (to include N-95) as described in AFI 48-137. (T-0).

1.17.2. Performs ventilation surveys (air exchanges and air flow studies) as required by

MTF/LSMTF instruction or as requested by the ICF or ECOMS, or equivalent. MTFs may need to arrange for alternative ways to accomplish these surveys if the BE lacks the necessary qualifications and/or equipment. The BE will work in concert with the Facility

Manager (FM) to arrange the necessary testing. Refer to paragraph 3.14. of this instruction for locations and frequency. (T-0).

1.18. Facility Manager.

1.18.1. Cross-feeds information obtained from BE ventilation surveys to the ICF. (T-2).

1.18.2. Alerts the IP and recommends corrective action if the ventilation survey fails to meet the design criteria listed in the most current version of Unified Facilities Criteria/Medical

Military Facilities-UFC 4-510-01 (formerly Military Handbook 1191, Medical Military

Construction Program Facilities Design and Construction Criteria). If the building has not undergone replacement or any extensive repairs/renovations, then the organization is to comply with the codes and standards that were in force at the time the facilities construction plans were approved. (T-0).

1.18.3. Coordinates regular preventive maintenance of the ventilation system. (T-0).

1.18.4. Consults with personnel who provide oversight of linen, housekeeping, HAMS, and regulated medical waste contracts. (T-3).

20 AFI44-108 11 DECEMBER 2014

1.18.5. Coordinates contract changes with the ICF. At a minimum, this includes the HAMS or an equivalent housekeeping contract, linen contract, and the waste management contract.

(T-3).

1.18.6. Coordinates facility renovation, clinical services relocation, construction, facility…