Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 07: INFECTION PREVENTION & CONTROL AND ANTIBIOTIC STEWARDSHIP 07.02.01 Risk mitigation measures for infection prevention Frequency of the citation: 90% Overview of the requirement: The hospital has identified and implements mitigation strategies to minimize transmission of infectious disease within the organization and from the facility to other settings. Strategies address at least: maintenance of a sanitary physical environment, measures to reduce risks to/from staff, measures related to patients presenting with infection, measures to reduce risk of healthcare-associated infections. Comment on deficiencies: Compliance is assessed through direct observation, interview, and document review. Most findings relate to observable, unmitigated infection risks. Similar findings are noted at standards in other chapters as well. In some cases, surveyors noted that facility practice did not align with policy. Examples of ACHC Surveyor findings: ■ In surgical services: Inadequate dwell time for disinfection of mattresses, dust/dirt accumulation in ORs. Carts carrying used OR instruments were observed to also transport sterile trays to the clean ORs creating risk of cross contamination. ■ In sterile processing: Surgical instruments in peel packs had surgical tape that was broken, chipped, or lifted. Surgical instruments were noted to be sterilized in the closed ratchet position. ■ In endoscope processing area: No demarcation between the clean and dirty areas. ■ In pharmacy: Visible debris in medication storage bins. ■ In materials management: Supplies, including intravenous catheters, gloves, gowns, and PPE, were stored in the staging area and pulled for distribution from corrugated shipping boxes. The facility's corrugated cardboard risk assessment states that there must be a delineation between the staging and clean areas and that outside shipping boxes should not be used for storage. Practice was not following the result of the risk assessment. ■ In housekeeping: Employee food items were stored alongside supplies. ■ The Director of Respiratory Services stated during an interview that hospital ventilators are not wiped down, not covered, and tubing is not always removed until brought to the respiratory department for decontamination. The policy for infection control for the pulmonary services department does not address cleaning locations or proper transport of dirty ventilator equipment throughout the hospital.
Compliance tips for:
The intent of the standard is that all staff are engaged with infection prevention and control efforts. Everyone “owns” facility cleanliness by following policies and alerting housekeeping/environmental services to problem areas where static dust buildup, dirt, and debris are frequently noted. ■ Make sanitary condition rounding a team activity that includes department staff, environmental services, and infection preventionists. ■ Conduct periodic audits of instruments in sterile peel packs looking for surgical tape, closed ratchets, and other issues. ■ Train environmental services/housekeeping to observe for and report rusted equipment, and damaged floors, walls, and doors when cleaning rooms. ■ Conduct periodic training for cleaning, sterilization, and storage of equipment. ■ Create infection control quality goals related to a sanitary environment by collecting and trending data from environmental rounds. Develop action plans for high-frequency issues. ■ Address variance from approved policies and procedures across all departments with team-building training.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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