Running head: NIGHTINGALE INFECTION CONTROL STATUS

Nightingale Infection Control Status
Daniel Pennebaker
Western Governors University, College of Business

Abstract
This executive summary will judge the status of Nightingale Community Hospital’s Infection Control performance against the Joint Commission’s accreditation standards. The summary will include a corrective action plan designed to aid Nightingale in meeting all standards.

Nightingale Infection Control Status
Executive Summary
TASK A Accreditation Audit Consultants was asked to provide a review and corrective actions plan for each of the Joint Commission Primary Focus Areas as part of Nightingale Community Hospital’s Re-Accreditation readiness program. While each of the Primary Focus Areas will be reviewed, this Executive Summary will cover Nightingale’s performance in the Infection Control PFA. Using the Surveillance Objections document created April 23rd and comparing that to data collected over the course of the year the following successes and areas to be improved are noted.
Hand Hygiene, one of the four main areas for Infection Control as listed in the Joint Commissions Standards for Infection Control, is performing above the goal stated in the Surveillance Objectives documents. The goal stated is >90% and Nightingale is clocking at a hospital-wide 92% with even higher observed compliance scores for Physicians (94%) and Ancillary Providers (96%). While this success is to be applauded it should not generate a lack of attention to continuing compliance with all stated hand hygiene policies.
Areas for improvement include reported infections in both the Central Line-Blood Stream Infection category and the Multi-Drug Resistant Organisms category. While performance in both of these areas generally improved over the course of the year, neither was able to hit their stated goals of <0.1/1000 patient days for CL-BSI occurrence and <0.15/1000 patient days for MDRO occurrence. A major contributing factor to this deficiency appears to be lack of compliance with Evidence-Based Care Standards in both of these categories. At year-end both Central Line Compliance (87%) and MDRO Compliance (88%) finished with less than 90% compliance. Please find the corrective action plan below.
A.1: Corrective Action Plan: CL-BSI Central Line Insertion
Responsible Parties: General Surgery Medical Staff, Interventional Radiology Medical Staff, Surgery Department and Interventional Radiology Department Staff
Due Date: The required date by which this action must be implemented is 60 days after introduction. * Central Line – Blood Stream Infection avoidance action plan will be introduced in January 2014. * All skin preparation prior to Central Line insertion will be performed utilizing only Chlorhexidine, unless contraindicated by a known allergy. * All central venous catheter insertions will be performed using full-barrier precautions and a maintained sterile field for the insertion site. * Central Line insertion will not be performed using the femoral area unless there is no other viable vessel. * Competency testing for use of full-barrier precautions and sterile field maintenance is due within 60 days of the action plan’s introduction. This testing will verified by either the department Medical Director or Director of Nursing for the specified unit. * Competency will be retested annually with the same approval process.
Central Line Access
Responsible Parties: All Hospital Nursing Staff
Due Date: The required date by which this action must be implemented is 30 days after introduction. * Central Line – Blood Stream Infection avoidance action plan will be introduced in January 2014. * All Central Line access will be performed only after utilizing Chlorhexidine to sterilize the access the port, unless contraindicated by a known allergy.
Measure of Success: The action plan’s success will be measured based on the recorded occurrence of CL-BSI. This will be reported quarterly, semi-annually and annually.
Goal: The goal for CL-BSI for the coming calendar year to 0 occurrences/1000 catheter days. Corrective Action Plan: MDRO
Responsible Parties: All Medical Staff, All Nursing Staff, All Technical Clinical Staff, All Clinical Staff, All Administrative Staff
Due Date: The required date by which this action must be implemented is 30 days after introduction. * Multidrug Resistant Organism avoidance and containment action plan will be introduced in January 2014. * All suspected occurrences of MRDO must be immediately reported to the attending physician, the laboratory and pharmacy. * Attending physician is required to immediately request a stat consultation by the on-call Infectious Disease physician. * Attending physician will also institute full isolation and full-barrier contact precautions. * Competency testing for use of isolation procedures and full-barrier precautions is due within 60 days of the action plan’s introduction. This testing will verified by either the department Medical Director or Director of Nursing for the specified unit. *Full-barrier precaution testing based on the CL-BSI action plan will be counted to fulfill this requirement as well. * Competency will be retested annually with the same approval process.
Measure of Success: The action plan’s success will be measured based on the recorded occurrence of MDRO. This will be reported quarterly, semi-annually and annually.
Goal: The goal for MDRO occurrence for the coming calendar year is .05 occurrences/1000 patient days.
A.2: Infection Control and Healthcare Associated Infections have become one of the major watchwords in the healthcare industry. The number one reason to focus on Infection Control is that it has the most direct and dramatic impact on patient safety of all of the Joint Commission’s Primary Focus Areas. Healthcare has become and continues to develop into a remarkably competitive industry and the perception amongst the population going to the hospital can in fact make a person sick can be devastating. Meeting all of the Joint Commissions standards in this focus area and then publishing that success can make huge strides in combating this negative image. This all pales of course to the most important facet of why this Focus Area is most important, the fact that every patient that does not contract a Healthcare-related Illness is a patient that can be treated, nursed and discharged home only needing to recover from whatever brought them there rather than having to recover something new the hospital infected them with on top of that.