Volume 2024 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 07: INFECTION PREVENTION & CONTROL AND ANTIBIOTIC STEWARDSHIP 07.02.01 Risk mitigation measures for infection prevention Overview of the requirement:
The hospital has identified and implements mitigation strategies to minimize transmission of infectious disease within and from the facility to other settings. Compliance is evaluated through observation, interviews, and document review. The broad scope of the standard contributes to the frequency with which it is noted as a deficiency. Required elements address staff immunization, aseptic technique, isolation precautions, hand hygiene, use of PPE, and other specifics, but most deficiencies identified issues with disinfection and sterilization of instruments, and environmental cleanliness and maintenance issues.
Comment on deficiencies:
ACUTE CARE HOSPITAL ACCREDITATION
Frequency of citation:
65%
Examples of surveyor findings:
n Instruments in sterile peel packs had broken or peeling surgical tape on Metz scissors, knife handle, hemostatic clamps, Allis clamps, and Baron suction tubes. n GI scopes were stored touching one another. n Rust was observed in OR suites on microscope bases, medical gas tanks, IV poles, stool casters, surgery table bases, and on code carts. n Significant dust accumulation was noted on plastic supply bins, at ceiling air vents, on storage shelving, within and on door seals of medication refrigerators, on high equipment throughout the laboratory, on lamps, cupboards, and ledges in patient rooms, on top of medication dispensing machines, and in clean linen storage areas. n Surgical mattresses were torn. n Encourage all staff to own facility cleanliness. Housekeeping/environmental services should be alerted to problem areas where static dust buildup, dirt, and debris are frequently noted. n Train environmental services/housekeeping to observe for and report rusted equipment, and damaged floors, walls, and doors when cleaning rooms. n Make sanitary condition rounding a team activity that includes department staff, environmental services, and infection preventionists. n Address variance from approved policies and procedures for housekeeping services, linen service, and environmental maintenance. n 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. n Conduct periodic training for cleaning, sterilization and storage of equipment.
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 07.02.01 08.00.03 10.01.16 15.01.08 15.02.08 15.02.17 15.03.02 16.01.02 18.00.08 24.01.03 24.01.08 24.01.09 25.01.03 30.03.03 FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN ACUTE CARE HOSPITALS
Tips for complianc e:
Nursing Services
Anesthesia Services
Pharmacy Services/ Medication Use
Medical Records
Infection Prevention & Control and Antibiotic Stewardship
Patient Rights and Safety
Nutritional Services
Conduct periodic audits of instruments in sterile peel packs looking for surgical tape, closed ratchets, and other issues to promote accountability.
Materials Management
Surgical Services
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