MTVA Infection Prevention Plan 2023.FINAL.pdf

Montana VA Healthcare System (MTVAHCS) Infection Prevention and Control Plan – FY

Purpose The purpose of this document is to describe the Montana VA Healthcare System (MTVAHCS), the Infection Prevention and Control Program (IPCP) and infection prevention processes. Additionally, this document identifies risk areas and priorities and outlines specific goals and objectives to address topics of concern.

System Overview MTVAHCS is part of the Veteran Integrated Service Network (VISN) 19, the VA Rocky Mountain Network. The system is made up of the following:

• 29 inpatient hospital beds, (23 medical/surgical beds, 6 ICU beds)

• Home Based Primary Care Program

• Behavioral health domiciliary

• Outpatient behavioral health treatment services

• 14 Community Based Outpatient Clinics (CBOC) dispersed across the state

• 25 bed Community Living Center located in Miles City, Montana

• Ambulatory surgery center located in Billings, MT

• Behavioral Health Outreach Program

• Chemotherapy infusion center

• Surgical outpatient clinic

• Dental services

• Ophthalmology services

• Radiology services

• Inpatient and outpatient surgical services

• Sleep Medicine Clinic

• Pain Clinic

• Physical/Occupational Therapy Services

• Emergency Department

• Occupational Health Services

• Whole Health Services

• Employee Wellness

• Audiology and Speech and Language Pathology Services

• Telehealth Services

• MOVE Program

Customers of the IPCP include patients/Veterans, medical staff, nursing staff, ancillary departments, families, visitors, students, volunteers, other hospitals, other health care providers, the Montana Department of Public Health and Human Services (DPHHS) and local county health departments.

All hospital components and functions are integrated into the IPCP. The Infection Preventionist (IP) coordinates all infection prevention and control activities within the system and facilitates ongoing monitoring of the effectiveness of prevention and/or control activities and interventions.

Mission The IPCP staff plan and implement a program to prevent, identify and control infections in patients, personnel and visitors in all areas of MTVAHCS.

Core Values The IPCP staff will apply the Veteran Health Administration (VHA) Core Values to the services it provides.

These values include the following: integrity, commitment, advocacy, respect, and excellence.

Clinical Authority for the IPCP MTVAHCS has assigned responsibility for the daily management of infection prevention and control activities to the following:

• Infection Preventionist (IP), Fort Harrison, MT

• Chair of the Infection Prevention and Control Committee

• Quality Management Specialist, Billings, MT

• VASQIP/Infection Prevention RN, Fort Harrison, MT

• Quality Management Officer (QMO), Fort Harrison, MT

MTVA currently employs one full time IP. The IP is a Bachelor of Science prepared registered nurse. She also has earned her Master of Public Health (MPH) degree and is board certified in infection prevention and control. One Quality Management Specialists also assist with the IPCP program. The Quality Management Specialist is located in Billings, MT and is Masters prepared. The VASQIP/Infection Prevention RN is a Bachelor prepared nurse. IPCP staff report to the Quality Management Department.

MTVAHCS consults with an Infectious Disease (ID) Physician employed by MTVAHCS and Salt Lake City VA. The ID physician is licensed in the state of Utah. She is certified by the American Board of Internal Medicine (ABIM) in the specialty of Internal Medicine and subspecialty of Infectious Diseases. This physician regularly attends Infection Prevention and Control Committee (IPCC) and Water Safety Committee and is invited to all infection prevention and control-related meetings as needed.

Responsibilities The individuals with clinical authority over the IPCP are responsible for the daily management of the IPCP;

routinely this is the IP. The following activities are responsibilities of the IPCP.

• Developing and implementing policies which promote prevention and control of infections and communicable diseases.

• Developing and implementing a system for identifying, reporting, investigating, and controlling infections and communicable diseases.

• Facilitating and leading the annual risk assessment process to identify risks.

• Developing the IPCP strategic plan based on the results of the annual risk assessments (see Attachment

A).

• Monitoring environmental cleanliness and reporting issues as needed.

• Developing and implementing infection control measures (in collaboration of Occupational Health) focused on hospital staff, students, compensated work therapy (CWT) workers, contract workers and volunteers.

• Working with stakeholders to mitigate risks associated with patient infections present upon admission.

• Working with stakeholders to mitigate risks contributing to healthcare associated infections.

• Conducting active surveillance to identify healthcare-associated infections.

• Monitoring for trends in infection-prevention related data and initiating workgroups to address issues.

• Monitoring compliance with all policies, procedures, protocols and other IPCP requirements.

• Reporting areas of success and areas needing improvement to appropriate management.

• Evaluating and revising the IPCP when indicated.

• Coordinating with federal, state, and local emergency preparedness and health authorities to address communicable disease threats, bioterrorism, and outbreaks.

• Complying with the reportable disease requirements of the local health authority.

Competencies The IP maintains competency by routinely completing continuing education and maintaining certification in Infection Prevention. The IP follows the Association for Professions in Infection Control and Epidemiology (APIC) Competency Model for the Infection Preventionists.

Professional Organization Membership The IP maintains membership with the Association for Professions in Infection Control and Epidemiology

(APIC).

Availability and Communication The IPCP has staffing capability five days a week between the hours of 6:00 am to 17:30 Monday through Friday, based on program needs. Tour adjustments are made to facilitate hospital unit in-services, conduct surveillance, attend meetings, conduct outbreak investigations and/or to perform exposure follow up. Staff is available by telephone with voicemail, e-mail, in-person and Teams messaging. Emergency situations which occur during non-administrative hours are forwarded to the Nurse on Duty (NOD).

Product/Equipment Selection The IP serves as a member of the Clinical Product Review Committee (CPRC). This committee reviews and approves or rejects any new requested medical supply before it is allowed on station. The IP serves as a voting member for new requests and provides infection control expertise and guidance in product selections.

Infection Prevention also consults with the Equipment Committee members to provide input on new equipment when necessary. Areas reviewed are cleanability, ability to use currently approved hospital cleaning/disinfectant products, durability, etc.

Program Resources Hospital leaders allocate needed resources for the IPCP. Adequate equipment and supplies are provided to support infection prevention and control activities.

Adequate laboratory support is provided to support the infection prevention and control activities:

• Montana VA Hospital Laboratory

• Lab Corp and ARUP Reference Laboratories

• Montana State Public Health Lab, Helena, MT

• Hyperion Biotechnology Laboratory (legionella water testing).

Adequate systems to access information are provided to support infection prevention and control activities:

• VISTA

• CPRS

• Essentris

• Inpatient Evaluation Center (IPEC) Database

• SAIL

• VA wide database for Hepatitis B, Hepatitis C & Human Immunodeficiency Virus (HIV)

• Microsoft Office

• Montana VA Library Electronic References

• HAI Events (VA surveillance tool)

• NHSN

• Internet access.

Infection Prevention and Control Committee The Infection Prevention and Control Committee (IPCC) functions as the central decision-making and policy-making body for the organization-wide IPCP. The committee acts as the advocate for prevention and control of infections in the facility and healthcare system. Prevention activities include formulating and monitoring patient care policies, educating staff, and providing political support that empowers the team. The committee members disseminate information discussed in the meeting and communicate responsibilities about preventing and controlling infection.

The IP prepares meeting agendas and presents content related to the activities of the program. Performance improvement projects/activities are discussed with committee members. The committee is multidisciplinary and includes various applicable services and personnel throughout the healthcare system as directed by VHA Directive 1131(5): Management of Infectious Diseases and Infection Prevention and Control Programs. These representatives participate in the following:

• Developing policies governing control of infections and communicable diseases.

• Implementing policies governing control of infections and communicable diseases.

• Developing a system for identifying, reporting, investigating, and controlling infections and communicable diseases.

• Informing the design and implementation of performance improvement and infection prevention projects.

The IPCC meets on the first Tuesday of even months from 1300 to 1400. In order to enhance attendance, this meeting can be rescheduled if needed. IPCC minutes are prepared by the IP and signed by the committee Chair, Chief of Staff and IP. Program activities and infection surveillance data is reported to the Health Care Delivery (HCD) Executive Board on a quarterly basis as requested.

Community Living Center (CLC) Infection Prevention

The CLC is located in Miles City, Montana. The IPCP provides support and infection prevention oversight remotely from Fort Harrison and Billings, Montana. IP staff are in regular contact with CLC staff. Additionally, CLC staff are members of the IPCC to ensure updates and issues are addressed. Infection Prevention and Control staff participate in Quality Assurance Process Improvement (QAPI) meetings with the CLC staff to track and promote progress on infection prevention and control goals. The IP conducts surveillance activities at the CLC by completing a review of possible HAIs. CLC staff notifies IP staff of possible infections via cosigned notes, e-mail, Teams messaging or phone. Cases meeting NHSN criteria and infection trends are reported during IPCC and to IPEC as required. As discussed in another section of this document, each year IP staff collaborates with the CLC staff to conduct an annual infection prevention risk assessment.

CBOC/Ambulatory Care Infection Prevention MTVAHCS has 14 CBOCs located in three geographic regions of the state (Northwest, Eastern, and Central).

The CBOCs are represented in IPCC by the Outpatient Associate Chief of Nursing Services (ACNS). Infection Prevention staff (or infection prevention designee) visit each CBOC twice per (as permissible with current travel restrictions) to engage staff, identify infection prevention concerns and provide onsite support.

Ambulatory Surgical Center The ambulatory surgery center, located in Billings, MT, performs minor-moderate complexity level procedures and has been in operation since April 2014. A Quality Specialist, located in Billings, is tasked with routine local IP duties and oversight. Overall guidance and support is provided by the IP at Fort Harrison. Infection Prevention staff monitor for surgical site infections using an electronic surveillance system and physician report. OR suite cleanliness is monitored using a fluorescent pen marking system.

Behavioral Health Outreach Program Infection Prevention The Behavioral Health Outreach Program includes job finding services, transition and recovery services and supported housing and healthcare services for homeless Veterans. Temporary housing options provide a mix of private apartments and shared living spaces. Outreach staff conduct shelter and home visits with Veterans enrolled in the program. Program participants receive pertinent infection prevention information via Behavioral Health Outreach Program staff. Additionally, a new facet of this program is being developed. This includes nurse visits to provide basic assessment, lab collection and medication administration. IP is working with staff to ensure adequate infection prevention practices.

Residential Behavioral Health Infection Prevention The 24 bed residential mental health facility serves patients requiring treatment for post-traumatic stress disorder (PTSD) and substance abuse. Patients in this unit receive basic infection prevention education on admission (i.e. hand hygiene, respiratory hygiene, etc.) and when needed. The admission process also includes screening for communicable infectious disease; this includes a tuberculosis skin test, COVID-19 testing and screening and referral to ID Clinic for clinical evaluation when applicable.

HBPC Infection Prevention The program provides primary care for Veterans in their own homes. The area covered through this program is 115 minute radius from Fort Harrison, Billings, Missoula and Great Falls locations. The population this program serves is considered relatively high risk for infection because of age and co-morbidities. Most of the home care services received are from VA contracted agencies in the community. Infection trends are reviewed on a regular basis and any issues are addressed as needed.

Surgical Services (Fort Harrison) Infection Prevention Surgical services at Fort Harrison includes an operating suite consisting of two functioning operating rooms.

The surgical service supports all surgical specialties of standard complexity with an orthopedic carveout. A new endoscopy suite opened on January 6, 2020. This suite contains two procedure rooms. Operating Suite (OR) suite cleanliness is monitored using a fluorescent pen marking system. Additionally, infection prevention tracers are completed to monitor other infection prevention concerns, such as, instrument cleanliness and hand hygiene.

Reporting/ Collaboration/ Functional Relationships/Communication Various hospital committees and departments interface with the IPCP for the purpose of performance improvement, prevention and reporting of infectious/communicable diseases. The IP is a member of the following committees/workgroups:

• Infection Prevention and Control Committee (IPCC)

• Clinical Product Review Committee (CPRC)

• Equipment Committee

• Environment of Care (EOC)/Safety Committee

• Construction Safety Committee

• Emergency Preparedness Committee

• Water Safety Committee

• Influenza Taskforce

• Antimicrobial Stewardship Committee

• VISN 19 Hospital Acquired Infection (HAI) Workgroup

• Reusable Medical Device (RMD) Committee

• VISN 19 SPS Management Board

• Quality, Safety, Value (QSV) Executive Committee.

The IP acts as liaison for county health departments and the Montana DPHHS to ensure required communicable diseases are reported. Additionally, the IP serves as a point of contact for receipt of and dissemination of public health information and alerts.

It is the practice of MTVAHCS to notify a receiving organization when a patient is transferred with an infection or colonization requiring monitoring, treatment, and/or isolation. Organizations are notified of patients with hospital acquired infection (HAI) from their facility so information can be included in their surveillance and infection prevention and control program. When MTVAHCS becomes aware that a patient is received from another organization with an infection requiring action and the infection was not communicated by the referring organization, MTVAHCS will inform the referring organization.

The IP reports healthcare acquired infections to IPEC each month. Starting January 1, 2020, MTVAHCS will begin reporting designated infections to the National Health and Safety Network (NHSN) database.

Risk Assessment MTVAHCS conducts an annual system-wide risk assessment to prioritize strategies to decrease infection risk.

The focus areas for the annual risk assessment are Medical Center services, ambulatory care, CLC, domiciliary, ambulatory surgery center, Behavioral Health Outreach Program and Home Based Primary Care. All hospital components and functions are integrated into the risk assessment process. Risk assessments are also conducted as needed and when new services and populations are added that introduce new risk or require a framework of prevention strategies. IPCP staff recognize that communicable diseases may be either internal or external to the hospital and this information is considered in the annual system risk assessment.

Risks are identified for the transmission and acquisition of infectious agents throughout the hospital based on the following factors:

• Geographic location and community environment of the hospital, the programs and services provided and the characteristics of the population served.

• Analysis of the system’s infection prevention and control data.

• The care, treatment, and services provided by the facility.

• Potential change in care, treatment and services posed by an infection prevention related item.

• Current system readiness for an infection prevention-related risk or item.

A prioritization matrix is used as the tool to identify focus areas that require priority and attention. Infection Prevention Staff prepare surveillance and outcome and process data to help inform this risk assessment process. The assessments are conducted by a multidisciplinary team of stakeholders which include members of the IPCC.

Annually, Legionella and Tuberculosis risk assessments are conducted using the process dictated by the VHA (Legionella) and industry standard (Tuberculosis). Those risk assessments and corresponding recommendations are presented to the IPCC and other necessary stakeholders.

Infection Prevention also conducts topic specific risk assessments as needed. The risk assessment process is interdisciplinary and risk assessments are retained for future reference.

Strategic Plan The infection prevention plan is reviewed and updated annually and as needed. This plan is based on the results of the annual system risk assessment process. The written plan will include the following: assessment of risk, assessment of services provided, assessment of the population served, prioritized strategies to decrease risk and surveillance plan based on analysis of previous data.

The IP will incorporate the priority areas identified from the risk assessment into an annual strategic plan that includes goals, objectives and evaluation of the infection prevention projects/strategies. IPCC and department/unit stakeholders approve the goals and objectives. These goals and objectives will guide the IPCP activities for the next year. Progress toward goals is evaluated at each IPCC meeting.

That strategic plan will be revised every year and added as an attachment to the Infection Prevention and Control Plan.

At a minimum the annual strategic goals shall address the following:

o Addressing any priorities identified by the risk assessments o Limiting transmission of pathogens between staff, volunteers, customers and visitors o Improving compliance with hand hygiene guidelines o Improving influenza vaccination in healthcare staff.

Program Evaluation Evaluating the effectiveness of goals, strategies and interventions helps identify which activities were successful and which activities need modification to improve outcomes. Progress, findings, discussion, recommendations, actions and resolutions related to goals are documented in the IPCC meeting minutes.

The IP conducts an annual program evaluation. The evaluation of the IPCP includes a review of the following:

• Changes in the scope of the program, if applicable.

• Changes in the results of the IPCP prioritized risks as a result of analysis of surveillance activities.

• Success rate in meeting infection prevention and control goals.

• Emerging and reemerging problems in the healthcare community that potentially affect the healthcare system such as the development of outbreak situations, if applicable.

• Responses to concerns raised by leadership and others within the hospital, if applicable.

The results of the evaluation are presented at the annual risk assessment session and/or to IPCC as issues/changes arise. In addition to the IPCC, the risk assessment and annual evaluation of the IPCP will be distributed to the interested stakeholders.

Surveillance and Analysis of Data Surveillance is an essential component of an effective IPCP. In order to prevent, control and investigate infections and communicable diseases, the healthcare system’s program must include an active surveillance component that covers both hospital patients and personnel working in the hospital. The surveillance program is based on epidemiological and statistical principles. Surveillance activities are conducted in accordance with the recognized surveillance practices of the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). Current CDC surveillance definitions of infection are used. Rates are risk adjusted within the IPEC system and compared to NHSN and IPEC data for national benchmarking.

Information on designated HAIs are stored in secure excel spreadsheet. Surveillance data is reported bimonthly or quarterly to the IPCC.

Surveillance is used for the following purposes:

• Determining baseline and endemic rates of occurrence of a disease or event

• Detecting and investigation of clusters or outbreaks

• Assessing the effectiveness of prevention and control measures

• Monitoring the occurrence of adverse outcomes to identify potential risk factors

• Providing information to target organizational performance improvement activities

• Measuring the effectiveness of performance improvement efforts

• Monitoring practices, such as hand hygiene, to promote compliance with recommendations and standards

• Detecting and reporting notifiable diseases to the health department

• Identifying and preventing transmission of organisms and diseases of epidemiological importance

• Ensuring compliance with federal regulations, state regulations and accrediting agencies

• Providing information for the education of healthcare personnel

• Detecting a bioterrorist event or an emerging infectious disease

• Providing data for the facility risk assessment.

Focused Surveillance as identified by the IP and the IPCC includes the ongoing review/analysis of microbiology culture results to detect the presence and clinical significance of:

• All positive blood cultures

• Central line associated bloodstream infections (CLABSI) in the Intensive Care Unit (ICU), Medical/Surgical Unit and CLC

• Ventilator associated events (VAE) infections in the ICU

• Catheter associated urinary tract infections (CAUTI) in the ICU, Medical/Surgical Unit, CLC and HBPC

• Surgical site infections (SSI) (including those identified by Veteran Affairs Quality Improvement

Program (VASQIP))

• Antibiotic resistant organisms: Vancomycin Resistant Enterococcus (VRE), Methicillin Resistant

Staphylococcus aureus (MRSA), Carbapenemase-producing Enterobacteriaceae (CPE)

• Clostridioides difficile (formerly known as Clostridium difficile infection (CDI))

• Aspergillus fumigatus opportunistic infections

• Legionella pneumophila infections, both community- and hospital-acquired

• Suspected and known active Tuberculosis

• Detection of clusters of organisms exceeding the threshold in all acute settings

• Sentinel events

• Organisms/disease conditions meeting criteria for communicable disease reporting to local and state departments of public health.

• Organisms of novel nature that pose a threat to public health.

Special Investigations of Outbreaks of Infectious Diseases When routine or special surveillance procedures identify a potential or existing infection control problem a special investigation is conducted to determine the magnitude of the problem and to establish prevention and control measures. Outbreak investigation and control methodologies may be implemented using evidence based guidelines. Investigation of an epidemic or cluster of infections is conducted in a standardized method in order to identify the sources, pathogens, hosts, and the mode of transmission with the aim of controlling and preventing any future epidemic or clusters of infections.

Investigation of a potential outbreak follows epidemiological methodology. Steps in an outbreak investigation are conducted as follows:

• Describe the Situation: An epidemic/outbreak is an excess over the expected level of disease within a geographic area. However, one case of an unusual organism or potential bioterrorism organism may constitute an epidemic. Epidemics may occur outside the facility in the community as in a foodborne illness, or inside the facility as a cluster of hospital associated infections, or increase in hospital associated infections above the mean level. Special investigations may be triggered as a result of data supplied by surveillance methodologies, other hospital personnel or by data from an outside source.

• Verify the Diagnosis: Determine what information is needed to verify that an outbreak is occurring.

Determine if the cases are healthcare-associated. Calculate the current incidence or infection rates and compare to baseline data, NHSN rates or rates in the literature if applicable or available.

• Define a Case (Who, What, Where & When): Develop criteria for a case definition to help determine who is at risk, identify clustering of cases, determine who should be included in further studies and to estimate the magnitude of the problem. The case definition may change as new information is gathered.

• Consult Resources: Notify and consult the Infection Prevention and Control Committee Chair, Employee Health, Executive Leadership Team, Departmental Leadership, Infectious Disease Physicians or Public Health as applicable. Conduct a literature search or consult with outside experts such as the CDC as applicable.

• Case Finding: Determine how additional cases will be identified. Review lab, radiologic and clinical signs and symptoms as applicable. Conduct interviews of personnel, patients and families as applicable. Collect epidemiological specimens as needed. It may be necessary to culture environment, products or personnel based on data. Advise microbiology to save specimens and isolates for antimicrobial susceptibility testing, molecular, and non-molecular typing if applicable. Encourage immediate reporting of new cases by laboratory, physicians, nursing staff and others as appropriate.

Search for other cases that may have occurred retrospectively or concurrently. Increase surveillance rounds as applicable.

• Collect data using form/line list: collect critical data, develop a line listing. Develop an epidemic curve as applicable.

• Initiate Control Measures: Take immediate control and preventive measures if indicated. Identify specific measures based on the nature of the agent, characteristics of the patients, and sources. These measures may include, increased attention to hand hygiene, additional environmental cleaning/disinfection, additional use of barriers (e.g., gloves, and gown), or confiscating of specific suspected products, cohorting of patients, closing of units or restricting admissions to units, cohorting of personnel, removal of personnel from work or restriction of their activities. Evaluate control and preventive measures.

• Employee Exposures: If exposure to a communicable disease involving employees occurs, a list will be generated of exposed employees. Notification of staff through direct means or phone calls will occur.

• Formulate a tentative hypothesis: Make a best guess to explain the observations. This should involve the possible etiological organism, method of transmission and possible source of infection.

• Test hypothesis: Once a hypothesis is made, it is compared to the standard literature on known microorganisms and its epidemiology. This will support or refute the hypothesis. The hypothesis should explain the majority of cases. If necessary, refine hypotheses and carry out additional studies. Many investigations do not reach this stage and may conclude with descriptive epidemiology. The most important part of the investigation is interpretation of the results.

• Long term interventions: Determine if additional long term interventions should be considered. The efficacy of the interventions can be measured by further surveillance to determine if cases cease to occur or return to endemic levels.

• Communicate Findings: An outbreak investigation report is completed. Findings are reported to the Infection Prevention and Control Committee, Executive Leadership Team and as applicable to departmental leadership, medical staff, individuals, other hospital units, departments, committees, Occupational Health, or Public Health.

Public Health Infection Prevention and Control acts as liaison with the 62 local public health departments and DPHHS to assure required communicable diseases are reported and to serve as a contact point for receipt of and dissemination of public health information and alerts. Reports to the health department are made via phone and fax. Laboratory personnel provide the initial report of a laboratory confirmed reportable disease per policy.

Standard and Transmission-Based Precautions Infection Prevention and Control policy limits unprotected exposures to pathogens throughout the hospital by appropriately identifying patients, visitors and personnel, who because of an actual or potential communicable disease, require monitoring or restriction to prevent further spread of that infection. Such methods include appropriate isolation of inpatients using transmission-based precautions, work restrictions for personnel, and visitation restrictions for visitors. The Infection Prevention follows the 2007 CDC Isolation Guideline (most recent). Additionally, MTVAHCS follow guidelines found in the VHA Directive 1131(5):

Management of Infectious Diseases and Infection Prevention and Control Programs. This document covers standard precautions and transmission-based precautions including contact, droplet and airborne precautions.

This information has been incorporated into a local standard and transmission-based precaution policy.

Personal Protective Equipment (PPE) is readily available in all patient care areas. Wall mounted PPE boxes are available in designated areas. These boxes are maintained by the unit in which they are located. When staff use items from the box, he or she contacts logistics for restocking.

Hand Hygiene The Infection Prevention and Control Hand Hygiene policy is based on guidelines from the Centers for Disease Control (CDC) and the Joint Commission. Hand hygiene education is included for all new employees via the annual infection control education offered through the Talent Management System (TMS). Hand hygiene performance monitoring is conducted regularly by assigned monitors, for each department/service and results are entered into a Joint Commission Tracer Tool. Data results are communicated quarterly to all departments and to IPCC. Hand hygiene is also monitored throughout the organization during regular rounds infection prevention rounds and EOC rounds.

MTVA reduces barriers to adequate hand hygiene whenever possible. MTVA provides hand hygiene supplies to staff and manages placement of hand sanitizer and soap dispensers to facilitate ease of use. Prior to any changes in hand hygiene products, end users shall have an opportunity to trial new products and provide input.

Multi-Drug Resistant Microorganisms (MDROs) Healthcare-associated MDRO cases are designated in the IPCP HAI line list. Trends in incidence are monitored.

Antibiotic resistance patterns of organisms are reviewed annually as part of the microbiology antibiogram.

Patients who culture positive with MDROs of interest are flagged in the CPRS Medical Record System. MDROs that require isolation for an inpatient and CLC setting are listed in the Standard and Transmission Based Precaution Policy, Appendix D.

The IP leads implementation of new initiatives and monitors compliance with infection prevention and control procedures and MDRO/CDI Initiative guidelines. The IP acts as a liaison between the national MDRO Program Office and MTVA.

IPCP staff are an educational resource for MDROs and the MDRO/CDI Prevention Initiative. MDRO education is provided to new employees upon hire and annually via TMS. Other methods of education, such as, flyers, e-mails and periodic live training sessions are provided when needed.

Clinical nursing staff provide basic MDRO education to patients and families. The IPCP staff provide additional information when needed.

COVID-19

MTVAHCS follows the most recent VHA and CDC guidance on COVID-19 mitigation. COVID-19 mitigation includes, but is not limited to, universal source control, visitor restrictions, COVID-19 risk and symptom screening, testing, enhanced cleaning/disinfection programs, transmission-based precautions, physical distancing, vaccination, etc.

Occupational Health IPCP staff work closely with the Occupational Health Program on issues such as development and implementation of the system’s vaccination program, annual employee influenza vaccination program, annual Tuberculosis (TB) risk assessment, sharps injury reduction efforts and employee/volunteer work restrictions.

Screening for exposure and/or immunity to infectious disease is provided to staff who may come in contact with infections in the workplace. Staff that are suspected of having an infectious disease that could place other employees or patients at risk are referred for assessment, testing, immunization, and prophylaxis/treatment or counseling. Staff that has been occupationally exposed to an infectious disease are referred for assessment, testing, immunization, prophylaxis/treatment, or counseling.

Sharps Injury Reduction Infection Prevention and Control participates in the sharps injury reduction process. Procedures for storing, handling and disposing of infectious waste in order to minimize the risk of infection are located in the Hazardous Material Management policy and the Bloodborne Pathogens Exposure Control Plan. Occupational Health distributes an annual sharps survey to frontline clinical staff seeking input regarding concerns about existing sharps devices or suggestions for new equipment. This information is reported to the IP.

Influenza Prevention An annual influenza vaccination program is in place for MTVAHCS. The Influenza Task Force implements the influenza vaccination program for both Veterans and health care personnel. The team is multidisciplinary and consists of representatives from Occupational Health, Infection Prevention, Primary Care (including the 14 CBOCs), specialty care and acute care. The influenza vaccine is provided at the various worksites across MTVAHCS. Rounds are conducted in the patient care units to provide the influenza vaccine for staff working day and night shifts. Education is provided to all hospital staff about the influenza vaccine including, non-vaccine control and prevention measures, diagnosis, transmission, and impact of influenza. This is accomplished via poster campaigns, TMS training, all employee e-mails. Vaccination rates and the reasons given for declining the influenza vaccination (medical and religious reasons) are evaluated annually and reported to the IP.

In the fall of 2020, VHA released Directive 1192.01 - Seasonal Influenza Prevention for VHA Health Care Personnel. This directive requires all health care personnel to either obtain the influenza vaccine or wear a mask for the duration of the influenza season. Influenza vaccine is offered free of charge to all patients, staff, and volunteers.

COVID Vaccination The COVID 19 vaccination is offered to eligible recipients free of charge. Medical and religious refusals for the vaccine are documented and tracked through Occupational health. Those choosing not to receive the vaccine are required to wear a mask when inside MTVAHCS buildings (with minimal exceptions) when universal source control is not mandated.

Quality Improvement IPCP staff work closely with team members in the Quality Management (QM) department to focus on improving outcomes and quality of care. The team seeks to reach a higher level of performance and eliminate problems through planning and defining expectations, goals, and desired outcomes. QM also collects and monitors performance data to help identify and correct faulty processes.

Safety The IPCP staff work closely with the Safety Management Program and attends monthly Safety Committee and Construction Safety Committee meetings. The IP regularly provides reports to these committees.

Additionally, the IP, or designee, participates in the weekly Environment of Care Rounds.

Education Facility and public health surveillance results, in addition to results of IP risk assessments, drive IPCP education efforts, especially when specific problems are identified. Education may occur in various formats; it is tailored to maximize effectiveness. In-person education may occur one-on-one, in informal small groups on particular unit, or as a presentation at regularly scheduled staff meetings. Additionally, IPCP staff may use review of established policies and memos, assignment of educational modules, distribution of pertinent references/handouts, circulation of education boards and presentation of audiovisual materials to provide education to staff.

New employee education is provided by the IPCP staff every other week (except during hiring freezes) and covers basic infection control topics such as the chain of infection. Infection Control staff contributes to education of the volunteer staff, students, compensated work therapy (CWT) workers and other groups as needed. It is the responsibility of each department and unit to orient new employees to the infection prevention and control requirements of their specific environment.

Regulatory Compliance The IPCP staff performs duties necessary to ensure the hospital is in compliance with the mandates and guidelines of the appropriate regulatory agencies such as the Joint Commission, Centers for Medicare and Medicaid Services (CMS), Occupational Safety and Health Administration (OSHA), DPHHS, and Office of Inspector General (OIG), etc. The IPCP staff are responsible for collaborating with the Accreditation Program for infection prevention-related continuous accreditation preparation activities. The IP modifies policy and procedure, as needed, to reflect changes in regulatory requirements.

Minimize Risks With Use of Procedures, Medical Equipment, and Medical Devices MTVAHCS has implemented infection prevention and control activities and applicable standards to reduce the risk of infection when cleaning, disinfecting, sterilizing, using, disposing of and storing medical equipment, devices and supplies. All areas of the hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. This includes all hospital units, campuses and off site locations. The IPCP staff monitors environmental cleanliness of general areas and patient care areas.

Additionally, the IPCP staff monitors maintenance, repair and construction activities for potential infection control issues such as dust, contamination and water stagnation. IPCP staff report cleanliness issues to management or leadership for mitigation.

Reusable Medical Devices (RMD) MTVAHCS has a multidisciplinary RMD Committee. The Chief of Sterile Processing Services (SPS) is the chairperson and conducts mandatory monthly meetings. The IP is a member of this committee and works closely with the SPS Department to address issues related to reprocessing RMD. The IP, or designee, is a member of the RMD inspection team and conducts periodic program inspections at the two reprocessing sites within the system. IP and staff observers monitor for cleaning and disinfection of noncritical RMD.

Compliance rates are compiled and reported to pertinent parties regularly. In collaboration with the Associate Director Patient Care Services (ADPCS), Infection Prevention reviews all standard operating procedures (SOP) for cleaning, high level disinfection and sterilization of semi-critical and critical RMD.

Product Evaluation The IP is involved in product evaluation and offers recommendations on product selection as it relates to infection prevention and control. The IP is a member of Clinical Product Review Committee (CPRC).

Construction and Renovation IPCP staff are involved in the construction project planning processes. A comprehensive Construction Safety policy is in place and is based on the VHA Safety and Health During Construction Directive. IPCP staff actively facilitate and participate in the Infection Control Risk Assessment (ICRA) process for construction projects.

Infection prevention, the contracting officer representative (COR) and other identified stakeholders, develop a construction work permit/infection control risk assessment for jobs meeting criteria. This permit must be signed by the COR, construction company designee, Safety Manager and IP, or designee, before any work begins.

The IP is a member of the Construction Safety Committee which meets monthly. The IP, or designee, reports any concerns or trends regarding planned or current construction within the system.

A multidisciplinary team performs regular rounds/monitoring/documentation of the construction sites to assess infection control and other safety-related practices. IPCP staff conduct surveillance for construction/renovation related infections (e.g. aspergillus pneumonia). Hospital acquired cases are reported to IPCC, if identified.

Guidelines Evidence-based national guidelines are used when developing infection prevention performance improvement programs and policies. Expert consensus is used in the absence of such guidelines. Interventions are designed to incorporate relevant guidelines such as, but not limited to, the following:

• Centers for Disease Control and Prevention (CDC)

• Occupational Health and Safety Association (OSHA)

• Association for Professionals in of Infection Control and Epidemiology (APIC)

• The Society for Healthcare Epidemiologist of America (SHEA)

• The American Society of Health Care Engineers (ASHE)

• American Institute of Architects (AIA)

• The World Health Organization (WHO)

• Montana Department of Public Health and Human Services (MT DPHHS)

• The Infectious Disease Society of America (IDSA)

• Guidelines for Perioperative Practices (AORN)

• Others as applicable.

Infection Prevention Policies Applicable policies and SOPs are in place throughout the system that relate to the prevention and control of infections. IPCP staff are responsible for reviewing, updating and developing new and rescinding old policies/SOPs as needed. Those policies are presented to and approved by the IPCC and other identified stakeholders before being routed for Leadership approval and signature. Infection Prevention policies are available for review on the MTVAHCS Intranet page.

Disaster Preparedness The organization is continuously planning for an influx of potentially infectious patients utilizing elements of mitigation, preparedness, response and recovery, as needed. Applicable protocols/policies are in place to direct disaster response. Infection Prevention staff actively participate in a variety of internal, VHA, community, county and state preparedness groups as applicable. Infection Prevention is an active member of the Emergency Management Committee (EMC).

Infection Prevention and Control staff are members of the Health Alert Network (HAN) through the MT DPHHS. Infection Prevention and Control staff receive e-mails and correspondence pertaining to health alert issues as applicable. Information is distributed to healthcare providers as pertinent.

Environment of Care (EOC) Infection Prevention staff (or designee) visit each clinical area in the system a minimum of two times per year if travel restrictions allow. Recommendations and requirements vetted by the above listed organizations are used as references in conducting environment of care rounds. Additionally, The CDCs “Guide to Infection Prevention in Outpatient Settings, Minimum Expectations for Safe Care”, Joint Commission Standards, Office of Inspector General (OIG) recommendations, the VA EOC checklist and policy/directives are used to identify risk areas and assess infection prevention improvement opportunities in these CBOCs.

The following topics of interest and Infection Prevention recommendations are discussed below.

Potted Plants and Flowers Potted plants and flowers are allowed in nonclinical areas of the hospital unless they are harboring or contributing to issues with pests (insects, etc.) or are restricted by other policies. Potted plants and flowers are allowed in outpatient waiting areas unless otherwise restricted. Potted plants must drain adequately to prevent any stagnant water. Water in vases holding cut flowers and plants will be kept fresh and will be changed regularly. Hands are cleaned after handling soil or vase water.

Potted plants and flowers are not allowed in areas in which clean/sterile supplies or medical equipment are stored. Plants are not allowed in semi restricted and restricted areas. Soil and water in vases can harbor pathogenic microorganisms which could contaminate the area and supplies.

Fans Fans can be used in limited circumstances as a temporary comfort measure. Fans should not be used in the dental clinic, the microbiology laboratory, sterile processing, decontamination, airborne isolation rooms or anywhere there is a risk for airborne particles or contamination.

Food and Drink Food and drink is not stored or consumed in patient care areas. Per OSHA, consumption of food or drink is prohibited in areas with risk of exposure to blood or bodily fluids.

Clutter The primary function of clinical space is to provide safe treatment to patients. Unnecessary equipment and personal effects are not appropriate for patient care areas. Clutter creates barriers to cleaning/disinfecting surfaces and increases the risk of infectious reservoirs in the environment. See the Standards for the Physical Environment policy for more information.

Books, Magazines, Newspapers Placing donated used books and magazines in patient care areas is discouraged by the IPCP. Daily newspapers are acceptable if disposed of each day.

Water In the case of a water-related event, MTVAHCS utilizes the Checklist for Responding to Water Related Events.

This document is available on the Infection Prevention SharePoint site. All items must be dried within 72 hours or they will need to be discarded/replaced.

Furniture All furniture purchased should be cleanable with standard hospital grade cleaner/disinfectant. Purchase of cloth or non-cleanable surfaces should be avoided. Cloth chairs and other non-cleanable furnishings are not recommended in patient care areas.

Cardboard Corrugated cardboard should be avoided in all clinical areas that house clean and sterile patient care supplies.

Exceptions include the laboratory and pharmacy per the infection control risk assessment guidance.

Under-sink storage Storage of any item under the sink should be avoided. Under no circumstance will patient care supplies be stored under the sink. Items stored under a sink are subject to moisture damage and contamination.

Accreditation organizations routinely will cite site healthcare facilities for storing medical supplies under the sink.

Airborne Infection Isolation Rooms (AIIR) The inpatient units have four AIIR rooms: two in ICU (room 1 and 6), one surgical floor (room 325) and three on medical floor (410, 415, 470). There are two additional AIIR rooms in Same Day Surgery and in the Emergency Department. The AIIR rooms meet the CDC criteria. This criteria defines AIIRs as rooms that provide negative pressure with six air exchanges per hour for existing structures and 12 air exchanges per hour for new or renovated spaces.

Functionality of these rooms are checked routinely by facilities staff. Nursing staff is responsible for ensuring negative pressure is functioning prior to placing a patient in the room. Nursing is also responsible for ensuring continued function while the room is occupied.

Fiscal Year 2023 Infection Prevention Goals and Objectives for VAMTHCS

This plan compiles priorities identified by the risk assessments that were completed for all areas of the MTVAHCS. Hand hygiene and influenza vaccination are priorities for all areas by default.

# Goals Objectives Evaluation Sources 89% of employees were vaccinated during the 2021- 2022 influenza season*

46% of Veterans aged 66+ were vaccinated for the 2021-2022 season#

27% of Veterans aged 19-65 were vaccinated for the 2021-2022 influenza season#

*Based off Occupational Health program data #Based off Electronic Quality Management

Implement measures to reduce the risk of seasonal influenza outbreak.

Offer at least two convenient influenza vaccination opportunities to all staff to help MTVA reach an employee vaccination rate of greater than 90% for the 2022-2023 influenza season.

# of opportunities offered

Employee vaccination rate

Offer at least two interventions to promote influenza vaccination in enrolled MTVA Veterans during the 2022-2023 influenza season.

# of interventions offered

% of Veterans vaccinated by the end of the influenza season

Offer at least one educational opportunity about the importance of seasonal influenza virus to MTVA staff during the 2022-2022 influenza season. Ensure objectives tailored to FHMC and CBOC staff.

# of opportunities offered

Employee vaccination rate from Occupation Health

Offer at least one targeted educational offering to Veterans aged 66 and…