Tab_15_-_Attachment_2_-_MDGI_44-113.pdf

BY ORDER OF THE COMMANDER 48 MDG INSTRUCTION 44-113

48TH MEDICAL GROUP 15 September 2016

Medical

INFECTION PREVENTION AND CONTROL PROGRAM

COMPLIANCE WITH THIS PUBLICATION IS MANDATORY

ACCESSIBILITY: This publication is available digitally on the 48th Medical Group (48 MDG) Intranet site “Medweb”:

https://ice.usafe.af.mil/sites/48MDG/Topics/MDGI/MDGI/Forms/AllItems.aspx

RELEASABILITY: There are no releasability restrictions on this publication.

OPR: 48 MDG/SGHI Certified by: 48 MDG/SGH (Col Peter H. Kim) Supersedes: 48 MDGI 44-113, 28 March 2013 Pages: 23

This Medical Group Instruction (MDGI) implements Air Force Policy Directive (AFPD) 44-1, Medical Operations and Air Force Instruction (AFI) 44-108, Infection Prevention and Control Program, and applies to all 48 MDG personnel. It establishes and defines responsibilities, identifies areas of concern to the Infection Prevention and Control Program, implements The Joint Commission (TJC) and Occupational Safety and Health Administration (OSHA) standards, and provides a program for the prevention, surveillance, and control of hospital and clinic-acquired infections. It is the responsibility of all personnel assigned to the 48 MDG to comply with this regulation. Refer recommended changes and questions about this publication to the Office of Primary Responsibility (OPR) using AF Form 847, Recommendation for Change of Publication prescribed by AFI 11-215, USAF Flight Manuals Program; route AF 847s from the field through publications/forms manager. 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 Information Management System (AFRIMS) Records Disposition Schedule (RDS).

This publication requires the collection and or maintenance of information protected by the Privacy Act of 1974 authorized by 10 U.S.C. 55, Medical and Dental Care; 10 U.S.C. 8013, Secretary of the Air Force; 29 CFR 1960, Occupational illness/Injury Reporting Guidelines for Federal Agencies; Air Force instruction 105, Surveillance, Prevention, and Control of Diseases and Conditions of Public Health or Military Significance, E.O. 9398 (SSN) and the Department of Defense (DoD) Health Information Privacy Regulation (DoD 6025.18-R). The applicable Privacy Act SORN F044 AF SG R, Reporting of Medical Conditions of Public Health and https://ice.usafe.af.mil/sites/48MDG/Topics/MDGI/MDGI/Forms/AllItems.aspx

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Military Significance (June 16, 2003, 68 FR 35646) is available at:

http://privacy.defense.gov/notices/usaf/.

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 revision updates the changes in Air Force (AF), DoD, and other regulatory agency policies and regulations in the rapid, dynamic changing pace of the infection prevention and control arena. This instruction has been substantially revised and must be reviewed in its entirety

1. General: The methods and processes of the Infection Prevention and Control Program are consistent with current TJC standards, OSHA and the Association of Professionals in Infection Control and Epidemiology (APIC) standards, the Association for the Advancement of Medical Instrumentation (AAMI), the Centers for Disease Control and Prevention (CDC) guidelines, the Association of Perioperative Registered Nurses (AORN), the Society for Healthcare Epidemiology of America, Inc. (SHEA), and AFI 44-108, Infection Prevention and Control. Per TJC, all hospital components and functions are integrated into infection prevention and control activities.

2. Scope and Responsibilities: The Infection Prevention Office works closely with Public Health, Microbiology, and 48 MDG leadership, in addition to local community hospitals. The Infection Prevention Office actively provides education, evaluation and consultation to all 48 MDG employees and throughout the RAF Lakenheath community. Infection Prevention and Control is the responsibility of all personnel assigned to the 48 MDG. The goal of the Infection Prevention and Control Program is to prevent, reduce, and control the transmission and occurrence of infections.

3. Infection Prevention and Control Function (ICF): The ICF meets quarterly with members appointed as described in 48 MDGI 44-134, Committees, Council and Function. Problems that cannot be solved within the scope of the committee are referred to the Executive Committee of the Medical Staff (ECOMS).

4. ICF Chairperson:

4.1. In conjunction with Infection Preventionist (IP), performs annual risk assessment, develops annual Infection Prevention and Control Program Plan (ICPP) and compiles annual summary.

4.2. Reviews ICF agenda with the IP.

4.3. Reviews ICF minutes with the IP

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5. Infection Preventionist:

5.1. Performs surveillance of infections; initiates appropriate isolation precautions;

investigates suspected outbreaks in concert with Public Health; observes patient care practices to provide ICF with recommendations for improved Infection Prevention and Control policies and procedures; assesses educational needs; and develops and presents in-service programs.

5.2. Informs personnel of decisions and actions made by the ICF and the corresponding responsibilities.

5.3. Provides infection prevention consultation to the 48 MDG and Limited Scope Military Treatment Facilities (LSMTF) staff.

5.4. Analyzes and reports Healthcare Associated Infection (HAI) occurrence trends and evaluates all surgical site infection (SSI) occurrences or findings to the ICF and inputs data into the National Healthcare and Safety Network (NHSN) or other databases as required by the Military Health System (MHS) or DoD.

5.5. Conducts formal Infection Prevention and Control orientation for all new employees at newcomers and ensures in-service training occurs for all 48 MDG personnel covering principals and aspects of Infection Prevention and Control, Bloodborne Pathogens, Multi-drug Resistant Organisms (MDRO), and tuberculosis exposure control.

5.6. Maintains Infection Prevention and Control files on each activity pertinent to the ICPP.

Surveillance compliance monitoring activities are reported to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians. The results will be presented at the ICF, the Nurse Executive Council (NEC) meetings, and other committees as requested. The ICF reports findings to leadership via ECOMS quarterly or in real time as needed. Trends will be investigated as needed.

5.7. In conjunction with the Contracting Officer’s Representative (COR), monitors compliance of housekeeping, laundry, and waste disposal services and conducts at least an annual inspection of the contracted laundry facility IAWAFI 44-108, Infection Prevention and Control Program.

5.8. Provides infection prevention consultation on the purchase of supplies and equipment, facility moves, construction or structural changes.

5.9. Plans and coordinates the ICF agenda with the chairperson.

5.10. Has access to all records and areas for surveillance activities.

5.11. In conjunction with ICF Chairperson, performs annual risk assessment, develops annual ICPP and compiles annual summary.

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6. Health Care Providers and Nurses: Will order and/or collect body site cultures of suspected infections. Report any suspected HAIs to the IP. Examples include, but are not limited to: SSIs; catheter-related urinary tract infections (CAUTIs); Central Line Blood Stream Infection (CLBSI); and MDROs. These can be reported in person, via telephone/e-mail.

7. Flight Chiefs/NCOICs and Infection Control Coordinators:

7.1. Develop unit Infection Prevention and Control Operating Instructions (OI) and procedures as needed to meet facility needs. Unit-Specific Infection Prevention and Control OIs are no longer required in all patient care areas or where patient care items are stored.

Only those areas needing additional and specific guidance may need a unit-specific OI. All section-specific OIs will be reviewed and approved by the ICF prior to implementation and reviewed and/or revised every 2 years. (Note: Anything written in this document or in AFI 44-108 need not be repeated in unit-specific instructions).

7.2. Ensure personnel know and comply with Infection Prevention and Control policies and procedures. Report patients with suspected or known HAIs to the IP.

7.3. Assist the IP with surveillance in their areas.

7.4. Notify the ICF, through the IP, of any changes or new procedures, which may affect Infection Prevention and Control policies.

7.5. Consult with the IP on any Infection Prevention and Control concerns.

7.6. Assign a primary and an alternate Infection Prevention Monitor (IPM) to focus on unit Infection Prevention and Control issues and act as a liaison with the IP. The Element Chief or NCOIC will provide the IP with the names of the IC Coordinator on the approved template (available upon request to the IP). IC Coordinators will meet with the IP throughout the year as needed for updates, in-services, and other necessary communications.

7.7. Ensure personnel (military, civilian personnel, and volunteers) in their section have received the required initial training with Infection Prevention within 30 days of arrival to MTF and initial brief within 10 days from Public Health (PH) on Bloodborne Pathogen (BBP) Control Plan and Tuberculosis.

7.8. Ensure their unit personnel are in compliance with current TJC infection prevention guidelines. All personnel have initial unit specific and annual infection prevention training and reusable medical equipment training before beginning clinical care.

7.9. Ensure all infection prevention related in-services are reviewed prior to presentation by the IP. All Infection Prevention and Control educational programs offered will have a lesson plan and attendance roster on file for TJC, OSHA, and internal reviews.

7.10. Ensure self-inspection surveillance checklists are performed monthly until three consecutive months of achieving a score of 90% or greater, at which time the self-inspections

5 48 MDGI 44-113 16 June 2016 may decrease to quarterly. Upon completion, a visual surveillance checklist will be forwarded to the IP showing discrepancies and will include plans of action as well as estimated dates of completion. Gross violations will be reported to the IP immediately.

Hand-hygiene surveillance will be conducted monthly for at least 20% of the staff or 20 personnel (whichever is greater). This data will be presented during monitor meetings.

7.11. For any bloodborne pathogen exposure, supervisors will electronically file AF 978, Electronic Supervisor's Report of Mishap, IAW AFI 91-202, The US Air Force Mishap Prevention Program to MDG safety. If there is an exchange of bodily fluids which exposes a hospital patient, a Patient Safety Event Review Form must be completed.

8. 48 MDG Personnel:

8.1. Receive facility-specific Infection Prevention and Control at Newcomers’ Orientation if attending within 30 days of arrival or at alternate class arranged by IP.

8.2. Comply with 48 MDG and duty section Infection Prevention and Control policies and procedures.

8.3. Identify and report any deviation from Infection Prevention and Control procedures to supervisory personnel or the IP.

8.4. Direct any questions regarding the Infection Prevention and Control Program to the IP.

8.5. Notify the IP of any patient with the following: on a ventilator over 4 hours, acquires a CAUTI, has a central line, has a known or suspected MDRO infection, other bloodstream infection, HAI, or SSI. Patients and/or their family will be educated regarding infections and provided printed education materials regarding the topic’s Frequently Asked Questions (FAQs).

8.6. Complete monitoring tools as directed for: indwelling catheters, central line use, or vancomycin use, see attachments 2 to 5 for copies of the forms. These form are also kept in:

T:\MDG\INFECTION PREVENTION- SGHI\IP MONITORING.

8.7. Unless directed by IP or the ICF, no random or routine environmental cultures are to be obtained.

9. Public Health (PH): Reports to the ICF on health status and disease monitoring in the Medical Employee Health Program, occupational exposures to blood and body fluids, immunization status of 48 MDG employees, reportable diseases or conditions, outbreak investigations within the 48 MDG, and any other pertinent findings.

10. Bioenvironmental Engineering (BE):

10.1. Manages and reports the respiratory protection fit-testing for the N-95 respirator IAW MDGI 48-105, Communicable and other Reportable Disease and Conditions, AFI 48-137, 48 MDGI 44-113 15 September 2016 6

Respiratory Protection Program. BE performs ventilation surveys semiannually IAW AFI 44-108 and submits reports to the Facility Manager.

10.2. Ventilation studies: BE, in conjunction with the Facility Manager or representative, will report on studies conducted by BE semi-annually, after major construction, and/or significant work on the Heating, Ventilation, and Air Conditioning (HVAC) system. Rooms identified in AFI 44-108 are monitored and include, but are not limited to: Histopathology (autopsy) and Histopathology (grossing room); Dermatology Clinic Room 361; Emergency Services (ES) Trauma Room; Family Health Clinic Treatment Rooms 153 and 154; General Surgery Clinic Room 362; Urology General Surgical Rooms 301A and 303; Labor and Delivery Rooms 2072, 2074, 2081, 2082, 2083, 2085, and 2087; Nursery Room, 2096a and C-section Room 2004. In Central Sterile Supply (CSS) and the Operating Room (OR):

Clean Side Room 202; CSS Decontamination Room; OR #1 Room 232; OR #2 Room 229;

OR #3 Room 228; Post-Anesthesia Care Unit (PACU); and Rooms 222, 223 234, 235, and

236. Lakenheath Dental Instrument Processing Center (DIPC) Clean Side; Lakenheath DIPC Dirty Side; Mildenhall Dental Clinic DIPC Dirty Side/Clean Side; and Oral Surgery Rooms.

10.3. Conducts studies on the three negative airflow rooms, also termed as Airborne Isolation Infection Rooms (AIIR) in the MTF. These three rooms are located in Multiservice Unit (MSU) Room 460, Pediatrics Clinic Room 77, and ES. Every 6 months, BE conducts study of negative pressure patterns and total air exchange rates/hour. The unit staff will perform a paper test on the room monthly when the room is not in use as an AIIR room. If a patient is in the room for airborne precautions, the flow test must be done prior to use as an AIIR room and every shift while patient is in room. To test for negative air flow: with the door closed, place tissue paper against the outside space underneath the door and if the paper moves towards the space there is negative flow (alternately, if the room has an indicator, checking the airflow indicator is sufficient). Each unit will maintain documentation of this test. The room may not be utilized as an AIIR if it does not pass, personnel must notify facility management.

11. Annual reviews: The ICF will review all Infection Prevention and Control policies, procedures, and regulations for each MTF area.

11.1. The approved lists of disinfectant and antiseptic agents will be reviewed annually and included in the ICPP. A separate lists will be maintained for housekeeping personnel specifically.

11.2. Contracts/Agreements: The Facility Manager (FM) reports on contractual compliance of the housekeeping contractor and will review the contract annually in conjunction with the IP and as needed.

11.2.1. Fly traps with ultraviolet lights are in place in select clinical areas. These devices are cleaned by contractors and managed by FM. Any questions related to the contract should be addressed with FM. If the fly traps become an infection control risk (e.g.

bioburden is not contained), 48 MDG personnel will immediately notify the IP.

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11.2.2. Ice machines are maintained by contractors and managed by FM. Each unit ensures that weekly exterior cleaning is completed.

11.3. FM or Medical Logistics will report on compliance to the agreements for laundry services and waste management, and will review the agreement and perform a site inspection annually in conjunction with the IP.

11.4. All construction projects will require an Infection Control Risk Assessment (ICRA) approved by the IP prior to initiation of work.

12. Respiratory Hygiene Program:

12.1. The CDC’s respiratory hygiene/cough etiquette guidelines will be used in all areas of the MDG. These guidelines include providing no-touch waste receptacles in the waiting rooms for disposal of used tissues. Appropriate supplies or stocked respiratory hygiene stations will be available at clinic entry points.

12.2. Appropriate signage explaining respiratory hygiene/cough etiquette will be displayed at the front check-in desk and in the main lobby of the facility. These signs direct all individuals with signs and symptoms of a respiratory infection to cover their nose and mouth when coughing and/or sneezing with either a tissue or face mask for containment of respiratory secretions; and to use proper hand hygiene upon entering the facility and after contact with either mucous and/or contaminated objects.

13. Standard Precautions:

13.1. Definition: The minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. Standard Precautions (SP) apply to the handling of all blood, body fluids, secretions, excretions (regardless of whether or not they contain visible blood), non-intact skin, and mucous membranes. SPs are used at the 48 MDG and all adjoining clinics.

SPs are to be used with every patient, every time they receive care, inpatient or outpatient, regardless of their diagnosis or presumed infection status. SP also includes respiratory hygiene/cough etiquette. There are three respiratory kiosks located in the medical treatment facility; one in the hospital annex, one in the radiology/laboratory/pharmacy waiting area, and one at the Family Health Clinic entrance.

13.2. All staff will follow the CDC hand-hygiene guidelines as published in MMWR, Guideline for Hand Hygien in Health-Care Settings, 2002.

13.2.1. Hand-washing procedure with soap and water: wet hands with running water, apply soap and use friction over all surfaces of the hands, ensuring to include wrists, around fingernails, and between fingers for at least 15 seconds. Rinse thoroughly and avoid splashing. Dry hands with paper towels. Use clean, dry paper towel to turn off water. Avoid using hot water, to prevent dying of skin.

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13.2.2. Procedure with alcohol-based hand sanitizer: apply product to hands; ensure coverage of all hand surfaces, including wrists, around fingernails, and between fingers.

Continue to rub in until product is dry. This should take around 20 seconds.

13.3. Liquid soap dispensers will be filled with an approved general-purpose soap. A general purpose hand-washing agent will be used between patients. Alcohol hand rubs can be used when hands are not visibly soiled. The exception of using alcohol rub includes when a patient has diarrheal illness caused by spore forming bacteria (e.g. Clostridium difficile) where the general purpose hand-washing agent should be used. Bar soap will be used for patient bathing/showering only.

13.4. Personnel working in direct patient care areas must have fingernails that do not exceed 1/4 inch in length beyond the tip of the finger, artificial nails are prohibited, and nail polish is discouraged, but when worn may not be cracked or chipped.

13.5. Non-oil based hand lotion may be used to restore moisture depleted from hands by hand washing. Products containing oils/lanolin/petroleum can compromise the integrity of latex gloves, and will not to be used to restore moisture to hands. Only “personal use” lotion containers will be acceptable, and should be labeled with the staff member’s name.

13.6. Jewelry should be minimal and not interfere in proper hand-washing technique. When rings are worn, special attention will be made to move rings around and wash area under the rings.

14. Transmission-Based Isolation Precautions:

14.1. In addition to standard precautions, isolation precautions will be implemented in accordance with current CDC Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings available online at:

http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007appendixA.pdf.

14.2. All staff will screen and restrict visitors with obvious or reported signs or symptoms of transmissible infections (e.g. cough, fever or exudative lesions). Information from the CDC will be made available to patients, family, and visitors when appropriate.

14.3. Notify the IP (via e-mail or phone) for all patients placed on precautions.

14.4. Communicate any precautions instituted. Immediately place sign on door with appropriate precautions. Provide appropriate PPE easily in reach by door to room.

14.5. Inform auxiliary personnel of precautions. Nutritional medicine will provide inpatients with disposable food containers. If a regular tray is brought up, the unit staff must empty all disposable items from tray before leaving room. The tray and non-disposable items will be placed in a plastic bag before taken to the collection cart.

14.6. Visitors for any patient on precautions will be briefed on isolation procedures and must comply. Visitors must be given specific instructions regarding limitations, PPE and hand hygiene. This instruction will be documented in the progress note.

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15. Contact Precautions:

15.1. Patients suspected or confirmed with having MDRO such as Methicillin Resistant Staphylococcus Aureus (MRSA), Vancomycin Resistant Enterococcus (VRE), or Clostridium difficile (C-DIFF) will be put on appropriate precautions per CDC.

15.2. In the clinic setting (following CDC guidelines), patients who have possible MDRO infectious processes (such as MRSA or VRE) may remain on standard precautions unless wounds are not contained by dressing. If not isolated to a contained site, contact precautions will be initiated in the clinic. Staff will perform a thorough wipe down of all surfaces with Caviwipes.

15.3. Inpatients will be placed on appropriate precautions and managed on the unit. All staff are educated on proper PPE.

15.4. If a patient is placed on precautions for a suspected or known infection, appropriate PPE and signs will be clearly displayed outside the patient room.

15.5. Staff will don PPE prior to entry into room and doff PPE prior to exiting. All of the trash bins in the room will be considered infectious and be placed in the yellow infectious waste bags. The large bin will be placed inside the door so the required PPE can be removed prior to leaving the room.

15.6. All patient personal items, designated medical equipment, and medical supplies will remain in the patient room until the patient is discharged. Upon patient discharge, the patient room will be terminally cleaned by housekeeping, disposable medical supplies will be discarded, and reusable medical equipment will be cleaned with a quaternary ammonium solution.

15.7. Eating Utensils: Per CDC Isolation Guidelines, no special precautions are needed for dishes, glasses or eating utensils. The combination of hot water, bleach, and detergents used in institutional dishwashers is sufficient to decontaminate these items. For patients who require Transmission-Based Precautions, all reusable eating utensils will be bagged after use and prior to placing on the dietary cart to prevent cross contamination.

15.8. In the case of Clostridium difficile, hand hygiene must be done with soap and water for at least 15 seconds before leaving room. Housekeeping for undetermined diarrheal illnesses or suspected Clostridium difficile patients requires that a 1:10 dilution of bleach (~5,000 parts per million) be used to disinfect surfaces when Clostridium difficile spore contamination is a concern.

15.9. All patients transferred within 24 hours of inpatient stay from a local facility will be placed on Contact Isolation on arrival. The patient will be cultured with one swab from each location for possible MRSA colonization/infection at the following sites: nares, axilla, groin, and wound or incision (if one is present). The patient may be removed from isolation by the inpatient unit staff when the results of the sensitivity report (usually in 48 to 72 hours) have been certified by the lab.

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15.10. Operating Rooms (OR) scheduled to receive a known MDRO patient are cleared of all furniture, supplies and equipment that will not be used for the case. Suture racks and computers will be covered. A MDRO precautions sign will be posted on the OR main door and the door leading to it from the sub-sterile. An extra OR member will be assigned as a runner for that room and will be available to obtain supplies during the case. A MDRO case should be scheduled as the last case of the day for that particular room, whenever possible.

The patient will be taken from their inpatient room directly into the OR to avoid extra patient movement. Recovery will take place in the OR if at all possible. After a MDRO case is completed, housekeeping will be notified and informed the case was a known or suspected MRSA/MDRO patient. All staff members will change their scrubs upon completion of the case.

15.11. Vancomycin use has consistently been reported as a risk factor for infection and colonization with VRE. Key parameters of Vancomycin use will be monitored by the IP and reported through the ICF. The LAK-Vancomycin Pre-Authorized Note will be completed in Essentris by the prescriber at the time of Vancomycin use for all patients. When using paper chart in case of computer outage, the Vancomycin Pre-Authorization Worksheet (Attachment

2) will be filled out by the prescriber. The Worksheet must be turned in to the IP upon Vancomycin order.

16. Droplet Precautions: A simple mask is required at all times in these rooms. Doors will remain closed and signs posted with necessary PPE available. Staff and visitors must wear simple masks. If the patient must leave room, the patient must wear a simple mask. Terminal cleaning will be done by housekeeping.

17. Airborne Precautions:

17.1. If the patient was seen for suspected or diagnosed conditions transmitted by airborne droplet nuclei (e.g., Measles, Chickenpox, Disseminated Varicella Zoster, Tuberculosis, Severe Acute Respiratory Syndrome, Smallpox, or Vaccinia) the patient will be placed in an exam room as close to an exit as possible with the door closed. Airborne Precaution signs will be immediately posted by staff. The patient will be instructed to wear a simple mask until placed in one of the AIIR/negative airflow rooms in Peds, MSU, or ES as appropriate.

17.2. Only staff who have been properly fit tested with N-95 respirators should care for patient in negative flow room if the patient is unmasked. Only parents and visitors with confirmed immunity to the patient’s known or suspected illness will be allowed in airborne isolation rooms.

17.3. IAW CDC Airborne Isolation Guidelines, the room will be sealed for the time needed to allow for at least 99% of the airborne contaminants to be removed prior to being cleaned by housekeeping or placement of another patient in that room. The 48 MDG AIIR require 60 minutes before entry is allowed.

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17.4. Susceptible healthcare personnel (e.g. pregnant, or without proven immunity) will be restricted from entering the rooms of patients known or suspected to have airborne transmitted diseases such as: measles (rubeola), varicella (chickenpox), disseminated zoster, or smallpox.

17.5. Inpatients with potentially infectious or epidemiologically/clinically important organisms that may be considered virulent may leave their room only for medically essential procedures, such as laboratory studies and X-rays. The area to which the patient is being transported will be notified of the patient's impending arrival and advised on appropriate precautions. Timing of the transport will be planned so the procedure is performed rapidly and the patient does not have to wait in a waiting room with other patients or crowded area.

Consider using the service elevator if appropriate. Patients with diseases that are transmitted through the respiratory route will wear a surgical mask whenever they are outside of the isolation room. If the patient is producing sputum when coughing, tissues and a bag to dispose of the tissues will be supplied to the patient.

18. Housekeeping of precaution rooms: Rooms of patients on isolation precautions will receive at a minimum the same cleaning schedule as non-isolation rooms. Housekeeping personnel will be advised of appropriate precautions by signs on the door. Cleaning equipment will be appropriately disposed of or disinfected before being used in another patient's room.

Mop heads and cleaning cloths will be changed and discarded in the appropriate manner.

19. Communication of MDROs:

19.1. Patients who have been identified as infected or colonized with an MDRO will be identified in AHLTA. The IP has access to AHLTA to add flag to chart.

19.2. Management of MDROs will also be consistent with National Patient Safety Goals.

Periodic risk assessments for multidrug-resistant organism acquisition and transmission will be ongoing in conjunction with the Microbiology Department. The Microbiology Department’s laboratory-based alert system identifies new patients with MDROs as a critical value and notification will be made to the provider and the IP. The alert system is a combination of manual and electronic (phone, e-mail, CHCS, and AHLTA). A note is placed in AHLTA by the Microbiology Department when the notification to the provider is made.

19.3. Reporting of HAI MDROs will be made through the NHSN IAW AFI 44-108. The IP will provide multidrug-resistant organism surveillance data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians. This is typically communicated via the Nursing Practice Work Group, Nurse Executive Council (NEC), Invasive Procedures, Environment of Care and ECOMS.

19.4. If a patient with a MDRO is transferred outside of 48 MDG, information on the patient’s MDRO status must be communicated to the receiving facility by the transferring physician or registered nurse. If the MDRO cultures come back positive after patient transfer, the Utilization Manager will notify the receiving facility.

19.5. If a patient transferred from an outside facility becomes symptomatic or has a positive culture for MDRO within the first 48 hours after admission to this facility, the losing facility will be notified by the Utilization Manager.

19.6. Discharge home of colonized or infected MDRO patients may present little risk to other healthy persons living in the household. Other persons in the home should be educated about the risks associated with the specific MDRO and the need for good hand hygiene. No special precautions need to be taken unless there are open wounds or other sources for potential splash or exposures to blood, feces and body fluids. Key family members will need to be taught the basics of standard precautions and the correct use of PPE.

20. Outbreaks: The process for investigating outbreaks of infectious disease is done in concert with Public Health and will be delineated in the annual plan. Principles of the investigation will include routine surveillance programs and recognizing if a cluster or outbreak exists. Findings will be reported by PH to leadership, ICF, and key stakeholders as indicated. In general, use epidemiologic principles to investigate the outbreak; steps include: 1) establish case definition(s); 2) confirm that cases are "real;" 3) establish the background rate of disease; 4) find cases, decide if there is an outbreak; 5) define scope of the outbreak; 6) examine the descriptive epidemiologic features of the cases; 7) generate hypotheses; 8) test hypotheses; 9) collect and test environmental samples; conduct a literature search as needed; 10) implement control measures; and 11) interact with the press and inform the public as indicated. Another resource will include (but is not limited to) the current copy of the APIC text. Expert consensus will be sought and used as needed.

21. Animals: TJC has recommended medical facilities reduce the risks associated with animals brought into the hospital (such as, management of animal waste). There are no pet therapy programs in the MTF. On rare occasions, military working dogs or service animals (e.g. Seeing Eye dogs) may enter the MTF. This facility follows the CDC Guidelines for Environmental Infection Control in Health Care Control Measures for Animal Encounters, as well as guidelines established by the APIC text of Infection Control and Epidemiology. Although animals potentially carry zoonotic pathogens transmissible to humans, the risk is minimal with a healthy, clean, vaccinated, well-behaved, and trained working or service animal. Housekeeping staff is trained to handle animal waste following guidelines in the British Veterinary Association, Good Practice Guide to Handling Veterinary Waste in England and Wales, December 2011. In addition APIC “State-of-the-Art Report: The implications of service animals in health care” states no special housekeeping methods are needed, provided there is no contamination with animal urine, feces, vomit, or blood (organic debris). If the animal contaminated the area, the cleanup procedures should be performed to include the use of appropriate PPE. Gloves are the minimum protection that will be used. The spill should be removed with paper towels, which should be placed in a plastic bag in a clinical waste container, similar to the disposal of diapers.

If there is a need to clean animal feces, after removal of the organic debris, the area of the spill should be cleaned with a facility-approved disinfectant following label instructions for adequate contact time to ensure disinfection. In general, contact with animal saliva, dander, urine, and feces should be minimized and appropriate hand hygiene must occur after any animal contact.

22. Linen:

13 48 MDGI 44-113 16 June 2016

22.1. Clean linen that arrives in the 48 MDG is transported and stored IAW AFI 44-108.

In addition, clean linen is to remain stored in clean storage areas (e.g., dedicated linen rooms with closing door, covered carts or enclosed drawers, or cabinets). At the time of being placed in clean storage areas, clean linens will be removed from the plastic wrap they arrived in. Clean linen remains protected until the point of use. Therefore, clean linen should not be placed on the floor, be mixed with dirty linen, or left in plastic wrap when placed in clean storage areas.

22.2. All used linen is handled as potentially infectious. Handle linen as little as possible to prevent the spread of contamination. Regular linen is placed in Yellow moisture-resistant laundry bags. Linen from patients in isolation, or patients having a known bloodborne disease, or linen that is grossly contaminated with blood and/or body fluids is placed in a Red alginate (water soluble) laundry bag and then in Green water-proof bag.

Linen is to be placed in a hamper at the point of use and is not to be carried by hand through the work center. Full bags are taken to the accumulation point on the rolling hampers; the top of the bag is closed, and placed in the large bin provided for this purpose.

Linen bags will never be dragged on the floor or be allowed to come in contact with personal clothing.

22.3. Linen Warmer. The temperature range of the linen warming cabinets should not exceed 54.4°C (130°F). Post the temperature parameters on the cabinet for ready reference. The temperature of the warming cabinet should be checked daily and documented.

23. Medical Equipment, Instruments, and Supplies:

23.1. Disposable Equipment.

23.1.1. Disposable supplies should be used as much as possible in respiratory therapy.

These include the following items: nasal cannulas, simple oxygen masks, venturi masks, non-rebreathing and rebreathing masks, bubble humidifiers, aerosol masks, tracheostomy masks, face tents, nebulizer bottles, corrugated tubing, hand-held nebulizers (HHN), mist tents, and breathing circuits for ventilators.

23.1.2. All fluid in humidifiers or nebulizer bottles will be changed whenever there is suspicion of contamination, retrograde flow of humidity from the patient to the reservoir, when used on a known or suspected infectious patient, or at a minimum of every 24 hours.

23.1.3. All masks, oxygen (O2) tubing and cannulas will be changed upon patient discharge and if equipment becomes contaminated. Corrugated tubing will be changed at least every 24 hours. Breathing circuits will be changed every 7 days or if contaminated.

23.1.4. HHN equipment will be rinsed with sterile water and air dried after each use and may be used for the duration of the patient’s hospital stay.

23.1.5. Single-use items will be disposed of or given to patient. Reusable peak-flow meters must have a disposable mouthpiece attached when used. Any peak-flow meter that is labeled for single patient use will be given to the patient upon discharge or discarded in a designated biohazard bag.

23.2. Re-usable Medical Equipment (RME) and Instruments.

23.2.1. All equipment will be treated and processed according to Spaulding’s classification scheme as follows: Critical items - items generally designed to penetrate body tissue (e.g., surgical instruments and most dental instruments) - will be sterilized prior to use. Semi-critical items not designed to penetrate tissues, but come in contact with non-intact skin or mucous membranes (e.g., otoscopes, endoscopes, optometry instruments) may be sterilized, but must be at least high-level disinfected prior to use.

23.2.2. Non-critical equipment such as sphygmomanometers, stethoscopes, and other similar equipment will be disinfected between patients and when equipment is contaminated. All equipment will be disinfected according to the manufacturer’s recommended cleaning instructions – most often this is a quaternary ammonium solution (i.e., Caviwipe).

23.2.3. Examination Rooms: Exam tables will be cleaned with a disinfecting solution (e.g. quaternary ammonium impregnated wipes, Caviwipes) after each patient. The linen or paper and pillows on the examination tables will either be changed or discarded. Walls and floors should be spot cleaned as needed. At the end of the day, all horizontal surfaces (examination tables and exam lights) will be thoroughly cleaned with a disinfectant. Floors will be cleaned once daily. Used suction containers will be changed, and all waste containers emptied. At a minimum, exam rooms, including open supply shelves, are to be cleaned daily. Torn furniture will be removed from service until it is repaired/replaced. All listed tasks are the responsibility of the clinical staff.

23.2.4. Glutaraldehyde is not authorized for use at the 48 MDG.

23.2.5. Equipment not in use should be in closed drawers, storage bins, or covered in plastic covers to prevent exposure to dust or other contaminants.

23.2.6. Any worker who processes RME must have training in care and transport or contaminated instruments by their units before performing those duties. PPE will be worn when handling contaminated instruments.

23.2.7. RME must always be stored and moved in a puncture-resistant covered container with a biohazard label affixed. While using appropriate PPE, instruments used in the outpatient units will be soaked in an approved enzymatic cleaner for designated amount of time prior to rinsing and placing in dirty instrument bin. Clinics should not scrub instruments. These steps will occur in designated areas and not in patient care areas. Additional information is located in MDGI 44-175, Central Sterile

15 48 MDGI 44-113 16 June 2016

Supply (CSS).

23.2.8. Processing and Sterilization. CSS and DIPC are responsible for decontaminating, terminally cleaning, processing and sterilizing instruments/sets IAW

MDGI 44-175.

23.3. Sterile Supplies and Instruments.

23.3.1. The 48 MDG uses event-related packaging for all sterile items IAW MDGI 44-175. Some disposable items have expiration dates directed by the manufacturer.

These expiration dates should be adhered to and may only be extended by the manufacturer or by an approved source coordinated through the IP. Reprocessing of items designated by the manufacturer as a single-use item is not authorized at the 48

MDG.

23.3.2. Before using a sterile item, it is the responsibility of the individual opening the item to:

23.3.2.1. Check the package to determine the integrity of the wrap has not been compromised. Items are considered sterile unless the package has been compromised in some manner (e.g., torn, moisture damage, stains, holes, or instruments poking through the wrap). If the instrument pack is wet or looks as if it has been wet, the instruments are considered contaminated.

23.3.2.2. Check for expiration dates on all packs and ensure the date has not passed.

23.3.3. Should the integrity of the package be compromised or the expiration date reached, the item will be considered contaminated and must be sent back to CSS for reprocessing. Expired disposable items are discarded as regular trash.

23.3.4. Warehouse boxes/shipping cartons (as evidenced by the shipping label and postal marking) must remain in the warehouse. Units of issue (contents of box) will be stored at the user level in a clean storage area. In the event it becomes absolutely necessary to deliver supplies to the users in a shipping box, the box will be emptied and removed from the area immediately. Shipping boxes frequently carry dust, parasites or insect larvae which are very difficult to eliminate from cabinetry and storage facilities.

23.3.5. Storage of Sterile Supplies will be accomplished IAW AFI 44-108:

23.3.5.1. All sterile supplies will be stored in an enclosed storage area.

Drawers or cabinets should be used wherever possible. The door will be kept closed at all times.

23.3.5.2. Sterile supplies will be physically separated from non-sterile supplies to prevent use of non-sterile item for a sterile procedure.

23.3.5.3. Sterile supplies will be at least 6-8 inches above the floor, 18 inches below the ceiling, and 2 inches away from a wall that connects directly to the outside of the building. No sterile supplies will be placed on the floor.

23.3.5.4. Sterile supplies should be rotated to assure the oldest stock is used first.

23.3.5.5. Sterile storage areas will be cleaned at least monthly by clinical staff. This activity must be documented on a monthly checklist.

23.3.5.6. Nothing will be stored underneath sinks, except cleaning supplies.

23.3.5.7. Sterile supply rooms and regular supply rooms housing sterile items must be environmentally controlled. Components such as proper temperature, humidity, air quality, air exchange and airflow direction are monitored to maintain the integrity of sterile packages and minimize the risk of fire. At a minimum, temperature and humidity readings must be taken daily and recorded on the 48 MDG Form 120 (Attachment 8). Discrepancies are brought to the attention of the IP, the FM, and the OIC or NCOIC for corrective actions.

24. Handling of Potentially Infectious Materials:

24.1. In the United Kingdom, Yellow rather than Red is the color recognized for identification of Biohazardous/Clinical/Offensive Waste disposal bags. Any item that has come into contact with a patient, and has been soiled by any amount of blood or body fluids is, under British regulations, classified as offensive waste. As such, it must be disposed of in the designated Yellow and Black (“tiger”) biohazard waste bags. If in doubt, place it into the tiger bag. This includes gloves, masks, bandages, diapers, swabs, tongue depressors, catheters (of any kind), soiled gauze pads, tissues, IV tubing, etc., that in the United States is not necessarily considered medically regulated infectious waste. Syringes (even without needles), will be placed in sharps containers IAW 48 MDGI 41-225, Regulated Medical Waste Management Program. Waste from a patient with a known infectious process is considered “clinical” waste and must be placed within a solid yellow waste bag.

24.2. Laboratory Specimens. ALL specimens are treated as potentially infectious. Place specimens in a secured, leak-proof container then place in a secondary bag (ziplock bag) before transporting to the laboratory. External contamination is cleaned off with 1:10 bleach and water solution (1 part of 5.25-6% bleach mixed with 10 parts water) or an approved disinfectant wipe (Caviwipe). If lab slips are used, lab slips will be maintained on the outside of the bag.

24.3. Needle disposal for self-administered medications: Patients requiring needles, syringes, or sharps at home for medication administration will have a sharps container ordered through a durable medical equipment referral. The container may be brought to any

17 48 MDGI 44-113 16 June 2016 local British hospital or the 48 MTF (laboratory or facilities) for disposal.

24.4. All areas in the 48 MDG will be compliant with OSHA Standards (29CFR 1910.1030, OSHA Bloodborne Pathogens Standard) and 48 MDGI 48-120, Bloodborne Pathogen and Tuberculosis Exposure Control Procedures. Safety devices or sharps with engineered sharps injury protections are required unless a waiver has been granted by the ICF. It is the responsibility of the requesting duty section to maintain proof of this waiver. Whenever possible, supply custodians will remove sharps without engineered sharps injury protections and replace with safety devices. Product preference will be given to items on the Regional Incentive Agreement (RIA). Work Practice Controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique) must be followed.

24.5. Sharps collection containers will be changed when ¾ full. The top will be sealed and taped closed and the date/initials/clinic will be written on the tape. Full, sealed sharps containers will be removed from the patient care area and placed in designated location for housekeeping’s removal.

25. Intravenous (IV) Fluids, Medications and Multi-dose Products: Refer to 48 MDGI 44- 126, Medication Management for full guidance.

25.1. IV fluids will be labeled with the date and time at the point of use. Do not write directly on the IV bag.

25.2. IV fluids will be discarded no later than 24 hours after the bag has been spiked and will not be re-spiked.

25.3. All indwelling IV catheters (except central lines) will be changed within 96 hours and IV administration kits will be changed every 72 hours. Both must be labeled with date and time of initial set-up. All IV tubing used for Total Parenteral Nutrition (TPN) and lipids will be changed every 24 hours.

25.4. Multi-patient use products (e.g., ultrasound gel) distribution nozzle will be handled without direct contact with patients, equipment, or healthcare workers. When feasible, single-patient use products will be used and labeled with the patient’s name and date. If using refillable containers, these must not be “topped off” but must be emptied, washed in hot, soapy water with approved disinfectant found in the annual plan, rinsed thoroughly and dried completely before refilling. Additionally, the containers need to be labeled with the contents and expiration date.

25.5. IV infusion bags will not be used for multiple IV flushes. These are single-use items and do not contain the necessary preservatives to support multiple entries.

26. Irrigation Fluids:

26.1. All irrigation fluids such as, sterile water or sterile normal saline, will be dated and timed when opened.

26.2. Irrigation fluids are single use only and will be discarded 24 hours after being opened.

26.3. Irrigation fluids placed in a warmer shall be used or discarded within 14 days of placement in the warmer with a temperature not to exceed 104°F. These bottles will be dated upon entry into the warmer.

27. Prevention of Central Line Blood Stream Infections: Prevention of Central Line Associated Bloodstream Infections (CLABSIs) will be consistent with National Patient Safety Goals, as well as CDC, SHEA and Institute for Healthcare Improvement (IHI) evidence-based guidelines. This requirement applies to short-term and long-term central venous catheters and peripherally-inserted central catheter (PICC) lines.

27.1. The IP will be notified when a central line is placed. Encrypted e-mail is acceptable.

27.2. There is a standardized supply cart in the Special Care Unit (SCU) for insertion of central lines. The staff will complete the insertion worksheet (Attachment 3 - adult or attachment 4 - infant) which reminds the insertion team the following items must be accomplished/used: hand hygiene, mask, hat, sterile gown worn during insertion, sterile gloves worn during insertion, maximal barrier precautions, chlorhexidine skin antisepsis (for patients over 2 months of age or unless contraindicated), and a reminder about the optimal catheter site selection (i.e. the subclavian vein as the preferred site for non-tunneled catheters; no catheters will be placed into the femoral vein unless other sites are unavailable). During insertion, any member may call a time out if a breach in technique is perceived.

27.3. Central lines will be reviewed daily to assess line necessity, with prompt removal of unnecessary lines. Specialized Chlorhexidine impregnated dressings are encouraged.

Supplies will be on the cart to facilitate compliance with the worksheet items.