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Aft Task 1 Corrective Action Plan

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Submitted By aanderson
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Effective Date: May 2, 2014

I. PURPOSE: A. The goal of Nightingale Community Hospital is to establish a comprehensive Infection Control Program to ensure that the hospital has processes in place to minimize/eliminate the risk of Surgical Site Infections (SSI) and Healthcare Associated Infections (HAI) B. The Infection Control Program at this hospital incorporates the following on an ongoing basis: i. Surveillance/identification, prevention/control, and reporting of infections throughout the hospital not limited to patients, employees, or physicians focusing on Nosocomial Infections (Endogenous infections and cross contamination infections) 1. Nosocomial Infections: known as hospital acquired infections are infections are not presenting at the time of admission but develop over the course of stay. a. Endogenous: the patient already has the infection at the time of admission minus the signs/symptoms of such infection but resistance lowers over course of stay and infection presents b. Cross Contamination: patient becomes infected while staying in the hospital by coming in contact with infective agents subsequently developing an infection ii. Evaluate and monitor the results of changes made 2. Continually edit procedures and policies as needed iii. Select and implement best techniques to minimize negative outcomes 3. Separate the infection source from the rest of the hospital (aspetic techniques included) 4. Cut off any further route of transmission

II. PROBLEM IDENTIFICATION: C. Nightingale Community Hospital recently had a review revealing unsatisfactory results in the Surgical Site Infection (SSI) rates iv. Focus was placed on rectifying SSI rates for total knee replacements and general surgeries D. Overall Infection Control data reveals sub-par levels of compliance v. Infection Control: Environment Rounds Data reveals only 83.6 % compliance with policy protocols for an all department initial review

III. ROOT CAUSE EVALUATION:
An Infection Control risk assessment was performed at Nightingale Community Hospital by the Joint Commission and the rates of infection were statistically higher for general surgery procedures. In a health care facility the sources of infections and/or preceding contamination can be a result of three entities: hospital personnel, the patients themselves, or the inanimate environment. Transmission of these microorganisms from one host to another happen through direct or indirect contact, through the air, or by vectors (i.e. insects carrying from one host to another).
During general care for a patient, healthcare workers come into close contact with the patient on a regular basis; therefore, the hands of the clinical personnel are the most conspicuous for transmission of pathogens. This results in direct or indirect contact transmission as being the primary source of transmission. Internal analysis of Nightingale Infection Control Environmental Rounds Data reveals 100% compliance with hand hygiene guidelines and negative pressure tests but inadequate and sub-par compliance with all other listed protocols. One of the lowest scores was applied to the cleanliness of overall environment and compliancy of food/drink restrictions of the staff.
The overall lack of cleanliness of the facility (scoring a 66.7% in the bi-annual rounds review) would lead one to the conclusion that direct or indirect contact transmission is a primary source of the increases SSI rates. IV. ACTION STEPS: 1. Designate an individual(s) as the Infection Prevention Specialist who is responsible for direction, management, and education of hospital personnel in relation to outbreak prevention/investigation of infections. To ensure that the organization is in compliance with CDC, state and local health department and OSHA codes, Joint Commission standards. This individual(s) establishes and implements goals and objectives policies and procedures to identify infection control discrepancies. This is communicated to all hospital managers and after reviews changes can be formulated to reduce future outbreaks 2. An infection control/prevention program needs to be implemented throughout the hospital with continuous education of personnel and support needs to be garnished from the executive levels 3. Standards and policies need to be implemented for isolation of infected patients. Disease specific precautions should be respected and taken in to account for the specific disease/infection 4. Standards and policies need to be created or enforced in the most basic of cleaning. Superficial cleaning could potentially have a negative effect in that the micro-organisms are now dispersed over a greater area contaminating more surfaces. Cleaning therefore needs to be carried out in a specific and precise manner to guarantee an adequate level of cleanliness. 5. Standards and policies need to be created or enforced with sterilization processes. These processes can be either physical (autoclave) and/or chemical sterilization (soaking in chemicals or gases). 6. Hand hygiene is a primary preventative measure critical to the eradication of infectious diseases. Criteria and specific policies for hand hygiene needs to be clear, concise, and have continual review to ensure that all personnel are following the basic principles of hand washing. V. IMPROVEMENT BENCHMARKS AND TIMEFRAME

VI. REVIEW AND REISSUE DATE
One year from date of signing and subsequent implementation VII. DISTRIBUTION
All hospital policy manuals and department management leaders

VIII. CONCLUSION

IX. CERTIFICATION
_______________________________/______/______ _______________________________/______/______
Hospital Administrator Medical Director

_______________________________/______/______ _______________________________/______/______
Infection Control Specialist

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