1. science
2. medicine
3. surgery

3/27/2015
Conducting a Facility Infection
Risk Assessment
Marcia Patrick, MSN, RN, CIC
Infection Prevention and Control
Consultant and Educator
marcia.patrickip@gmail.com
Does your facility have a written
infection risk assessment?
Have the risks been weighted and
prioritized?
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• Identify the rationale for performing an
infection risk assessment
• Describe how to perform a facility and
population infection risk assessment
A
process that examines recognized
and potential risk factors for acquiring
and transmitting infections in a
healthcare facility and identifies
evidence-based measures to reduce
these risks
◦ Includes a prioritization of risk factors
based on their actual or potential impact
on care, treatment, or services
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 Risks
can take many forms
◦ Some common to many healthcare
settings
◦ Others occur in specific settings
◦ Risk identification and reduction activities
must be tailored to meet each
organization’s specific challenges
 Promote
a safe environment for
patients and personnel
• Purpose
o Provide
a basis for infection surveillance,
prevention and control (ISPC) activities
o Identify
at-risk populations/procedures in
your facility
 high volume, high risk, or problem-prone
procedures
o Assist
o Meet
in focusing surveillance efforts
regulatory and other requirements
Lee TB, Baker OG. Lee JT, et al. APIC Surveillance Initiative Working Group. Recommended
practices for surveillance; Am J Infect Control 2007;35:427-440.
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Facility Infection Risk Assessment
Identify risks for acquiring and
transmitting infections based on:
•
•
•
•
•
•
Populations served (type/volumes)
Types of procedures, general & specialty
services
Personnel numbers and types
Geographic location and size of facility
Area endemic infections and related risks
Analysis of surveillance activities and other
infection control data
Facility Infection Risk Assessment
COLLABORATE to conduct risk assessment
(seek interdisciplinary input):
•
•
•
•
Infection prevention personnel
Medical and nursing staff
Leadership
Others- Building management, Facilities, etc.
Document and prioritize risks
• Use a template
• Determine which are most significant; which to
address first
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1. Choose a template/tool
• Review with others
• Assure it meets your needs, including
regulatory and accreditation
requirements
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2. Determine process you will use
• Who will be involved? Identify your
team
• Seek input from team and others (use
template)
• Collect organization and community
data
 We
are using ONE example of a tool
to assist in developing your Risk
Assessment
 There are many others
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Examples:
• Community and populations served
• Specific infections
• Treatment and care practices
• Instrument and medical device
cleaning, disinfection and handling
• Environment of care
• Healthcare worker factors
• Emergency management
• Others?
• State issue in the negative: lack of…,
failure to.., high levels of disease, etc.
Key point: identify issues and practices
that do not meet national/professional
standards or do not fulfill requirements of
CMS, state, and accreditation agencies
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Geography/topography/weather
◦ Natural disasters- hurricanes, tornados,
earthquakes, lahars, snow, rain, drought
◦ Accessibility of facility, nearest hospital,
etc.
Population
◦ Community, patients, socioeconomics,
other factors affecting health; adults vs.
pediatrics
Communications
• Within facility, among staff; with
hospital(s)
• With community including Emergency
Management, Health Department,
medical society, professional groups,
Emergency Medical Services
• Routine and emergency
8/44
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Employees
•
•
•
•
Hand hygiene compliance
Immunizations/policy/compliance
Sharps injuries/protocol followed
Sick policy; exclusion for certain
illnesses
• TB control: screening, exposures,
respiratory protection program,
respirators, fit-testing
Environment
• Appropriate for procedures, adequate space
for instrument/scope cleaning, disinfection
and sterilization
• Furnishings can be cleaned/disinfected
• Cleaning, disinfection of environment
• Biohazard waste management
• Construction: ICRA, involvement in planning,
barriers, equipment, furnishings
• Requirements for ventilation in OR, CS
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Cleaning, Disinfection, Sterilization
•
•
•
•
Following AAMI, AORN, CDC Guidelines
No reuse of disposables/single patient use
Proper monitoring of sterilizers
Proper monitoring of high level disinfection
(HLD) practices
• Preventive maintenance on all equipment
performed and documented
• Procedure for failed sterilizer or HLD tests
Risks for Infections
•
•
•
•
•
•
Surgical site infections (SSI)
Catheter-related UTIs
Diarrheal diseases (C. difficile, others)
Post-procedure pneumonia
Respiratory diseases- flu, colds, etc.
Significant organisms- MRSA, VRE,
ESBLs, CRE, others
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Procedures offered
• Risks vary by type of procedure
(endoscopy different from incision, Class
II wounds riskier than Class I)
• Population served (nutritional status,
hygiene, work setting, etc.)
• ASA score
• Education of the patient and family
Emergency Management
• Role in community- coordinate with local
EM and/or health department
• Anticipated emergencies (internal and
external)
• Adequate staff training
• Adequate supplies, equipment for
sustained operations or remain in place
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Education
• Initial orientation and training of new staff
• Include ALL staff, licensed independent
practitioners
• Appropriate to job and education
• Includes mandatory items (e.g., OSHA
Bloodborne Pathogens Standard & TB,
chemical hazards, etc.)
• Patient education on infection risk reduction
Competency evaluation
 Each staff member must demonstrate
competency in performing their duties
 How this is evaluated on hire and
after, or if tasks, procedures or
products change
 For physicians, done through peer
review
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 Evaluating
for Emerging Infectious
Diseases
◦ Ebola
◦ Measles
◦ Influenza
◦ Pertussis
◦ TB
◦ Enterovirus D 68
◦ MERS CoV
◦ CRE
• ASC assessment tool will help you
assess current practice
• Health department/local health
jurisdiction can provide data on
community TB cases to determine if
this is an issue
• If you have no surveillance data, this
will be part of your RA and ISPC Plan
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Next Steps…
Assess documented risks to determine
PRIORITIES BASED ON RELATIVE RISK
•
Who is at risk for infection or adverse event?
•
What LEVEL of risk is present?
•
What is the IMPACT on care, treatment or
services?
•
How PREPARED for this is the organization?
a.
POTENTIAL IMPACT
◦ For patient illness, injury, infection,
death; need for admission to inpatient
facility
◦ For personnel illness, injury, infection,
shortage
◦ Organization’s ability to function
◦ Degree of clinical and financial impact
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b. PROBABILITY OF OCCURRING
◦ Review information regarding
historical data, infection surveillance
data, reports in the literature
◦ Scope of services provided
◦ Environment of surrounding area
(topography, interstate roads,
chemical plants, railroad, ports, etc.)
c. ORGANIZATION’S
PREPAREDNESS
◦ Policies and procedures already in
place
◦ Staff experience and response to
actual situations
◦ Available services and equipment
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• Determine:
• Likelihood of happening: 0=none; 1=low;
2=medium; 3=high
• Degree of risk: 0=none; 1=temp harm; 2=
permanent harm; 3=life threatening
• Potential changes in care, treatment or
services: 0=none; = low; 2=medium; 3=high
• Preparedness: 1=good; 2=fair; 3=poor

After risk scores are assigned in
each category, TOTAL THE
NUMBERS in each row to provide
numerical risk level for each
event/condition
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
Rank events/conditions from
highest to lowest score
◦ Select risks with highest scores for
priority focus for developing annual
ISPC Plan
◦ NOTE: Some events/conditions with a
lower score may be selected because
they are an accreditation or regulatory
requirement
Do…



Use a tool/template
Document the risks
and rationale for
selecting
Prioritize risks based
on severity of impact,
ability to fix
Don't…


Include items with
negligible risk
Make everything a
priority – you will not
be able to do
everything!
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Event
Likelihood
High 3
E’quake
Poor HH
Compl.
SSI
Med 2
Low 1
None 0
2
3
1
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Event
Degree of Risk
LifeThreat 3
E’quake
Perm
Harm 2
Temp
Harm 1
3
Poor HH
Comp
SSI
2
1
Event
Potential Change
High 3
Med 2
Low 1
E’quake
1
Poor HH
Compl
1
SSI
None
0
None 0
2
Potential change in care, treatment or services
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Event
Preparedness
Low 3
E’quake
Med 2
3
Poor HH
compl
SSI
Event
High 1
1
2
P’bility
Degree
of Risk
Change
Prepared Total
E’quake
2
3
1
3
9
HH
Compl
3
2
1
1
7
SSI
1
1
2
2
6
Once you have scored each item and totaled scores, you
have an idea of what needs to be addressed first, second, etc.
From this, you develop goals and measurable objectives.
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
For each PRIORITIZED RISK event/
condition, identify:
◦ Goal
◦ Measurable objective
◦ Prevention strategies
◦ Responsible person(s)
◦ Time frame for completion
◦ Method for evaluating effectiveness of
strategies
RISK
EVENT/
CONDITION
GOAL
OBJECTIVE
(measurable, includes
timeframe for
completion)
STRATEGIES
IMPLEMENTATION
Responsible
Person(s)
Method for Evaluating
Effectiveness
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A goal is a broad statement indicating
the change you want to make.
 Improve hand hygiene compliance.
 Initiate earthquake preparedness kit.
 Reduce the risk of SSIs.
These are not measurable as they
stand.
• Specify measurable results over a
specific time period.
• Hand hygiene compliance will be
90% or better by the end of 2Q 2015
as measured by secret shoppers.
• An earthquake kit with sustainment
supplies to last 20 people at least 3
days will be in place by April 1, 2015.
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• SSI rates for inguinal hernia repair will not
exceed 0.3% by end of 3Q 2015 per
surveillance data
• Antibiotics will be given within 1 hr before
incision 95% of time by Oct. 30, 2015.
• All skin preps will be with 2% CHG/70% IPA
(unless patient is allergic) by Oct. 1, 2015.
• Tape for surgical dressings will be single
patient use by Sept. 15, 2015.
• The measurable objectives then become
part of one or more staff management
objectives for the next year. It’s the
WHO of the objectives.
• For hand hygiene, it might go in each
employee’s objectives--“Hands will be
washed or ABHR used before and after
each patient contact.” (90% threshold)
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• IV antibiotics will be administered
within one hour of incision.
• A decision will be made as to WHO
will do this--anesthesia, preop, OR
nurse, etc. This goes into THEIR
performance goals and performance
monitored by checking patient charts.
• It’s management responsibility to check
compliance, but staff can help monitor.
Charts reviewed in a group for elements
can be instructional.
• Some ASCs use personal goals and
objectives as part of compensation.
Bonuses are only awarded if facility
goals and objectives are met as well as
personal ones.
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Facility Services:
•Acme
Ambulatory Surgery Center is a 20-bed facility with 4
operating rooms and 2 procedure rooms
•Performs
outpatient surgical procedures and endoscopy on
adult (age > 18 years) and pediatric (2 – 17 years) patients:
• plastic surgery, general surgery, ear, nose and throat, dental, GI,
GU, and vascular procedures
•Procedures
performed under general, regional and local
anesthesia as well as conscious and deep sedation
•Only
patients with ASA score 1 and 2, BMI under 35.
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# Procedures last fiscal year
GS
Plastic
GI
GU
Adult >18 yrs
976
641
122
759
Peds (2-17)
381
32
798
801
1357
673
920
1560
Total
GS= general surgery; GI= gastrointestinal
procedures; GU=genitourinary procedures
Top 8 Procedures by Volume:
• Hernia repair
• Lap cholecystectomy
• Breast biopsy
• Breast augmentation
• Cystoscopy
• Colonoscopy
• Upper gastrointestinal endoscopy
• Exploration under anesthesia
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Goals:
•
Monitor selected procedures and practices/
processes (SSIs- outcome measure)
•
Compare findings and trends internally over time
•
Compare findings to external comparative
databases such as National Healthcare Safety
Network (NHSN) and state infection reporting
programs
Decision-Making Process
Assessment:
• Breast biopsy is clean procedure; should not get
infected; is high volume—conduct surveillance of
breast biopsy procedures (outcome measure)
• Many scopes (e.g., endoscopes, laparoscopes)
used; Infections related to scopes are difficult to
identify; therefore scope cleaning and disinfection
practices will be monitored (process measure)
• Monitor surgical site infections (SSI) related to
Laparoscopic Cholecystectomy and Inguinal
Hernia Repair (high volumes) to monitor SSI in
General Surgery
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•
•
•
Review literature, standards and
guidelines
Make recommendations to reduce risks
Use a template to present your risk
assessment findings and infection
prevention strategies
• With written, measurable objectives,
you can evaluate your progress
periodically and at least annually
• This can be done in a table format or
narrative.
• Tables or charts are effective to
communicate progress.
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2013
Goal
1Q
2Q
3Q
4Q
P/F
Hand
hygiene
90%
by 3Q
62%
85%
90%
90%
Pass
Antibiotic 95%
Adminis- by 3Q
tration
35%
60%
90%
95%
Fail
0.2
0.5
0
0
0.18
Pass
SSI Reduction
Hernia
<0.3%
NLT 3Q
E’quake
Prep
Kit for
In pro20 x 3d, gress
NLT 4/1
Done
Pass
• The risk assessment is the platform for
all infection surveillance, prevention, and
control activities
• It allows identification and prioritization
of activities to reduce risks
• Measureable objectives provide a basis
for evaluating the effectiveness of your
program
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Risk Assessment for Infection Surveillance, Prevention and Control Programs
in Ambulatory Healthcare Settings
Explanation of Risk Assessment Tool and the Template for a Risk Assessment Report
This Risk Assessment tool, beginning on page 6, can be used to conduct a facility risk assessment for acquiring and transmitting infections in a variety of
ambulatory healthcare settings. The results of the risk assessment can then be reported using the accompanying template for a Risk Assessment Report (beginning
on page 3). The findings of the risk assessment should be used to provide information about where an organization should focus its infection surveillance,
prevention and control activities.
A facility risk assessment is conducted by identifying and reviewing potential risk factors for infection related to the care, treatment, and services provided and to
the environment of care in a specific healthcare setting. The identified risks of greatest importance and urgency are then selected and prioritized. Based on these
identified risks, facility personnel should develop the organization’s Infection Surveillance, Prevention and Control (ISPC) Plan (i.e., an action plan).
The ISPC Plan should include a goal for reducing the risk of infection associated with each of these identified risks, a measurable objective for each goal, and
evidence based strategies for meeting each of these objectives. The Plan should also identify the personnel responsible for implementing the strategies and include
mechanisms for evaluating the effectiveness of meeting the ISPC Plan’s objectives.
Assessment Process
1. Convene a team to conduct the risk assessment.
2. Identify potential risk factors in each of the following categories:
 Community and populations served
 Potential for specific infection
 Treatment and care practices
 Instrument and medical device cleaning, disinfection and handling
 Environment of care
 Emergency management
 Others identified by the organization
3. Assess and score each potential risk factor based on the following:
a. Potential impact of the event/condition on patients and personnel, determined by evaluating the potential for patient illness, injury, infection, death,
need for admission to an inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to impact the organization’s ability
to function/remain open; and degree of clinical and financial impact.
b. Probability of the event/condition occurring determined by evaluating the risk of the potential threat actually occurring. Information regarding
historical data, infection surveillance data, the scope of services provided by the facility, and the environment of the surrounding area (topography,
interstate roads, chemical plants, railroad, ports, etc.) are considered when determining this score.
Page 1 of 12 c. Organization’s preparedness to deal with the event/condition determined by considering policies and procedures already in place, staff experience and
response to actual situations, and available services and equipment.
4. After risk scores are assigned in the three assessment groups, total the numbers in each group to provide a numerical risk level for each event/ condition.
5. Rank the events/conditions from the highest to lowest score in the table provided. Select the risks with the highest scores for priority focus for developing the
annual ISPC Plan. NOTE: Some events/conditions with a lower score may be selected because they are an accreditation or regulatory requirement.
The risk assessment and ISPC Plan should be reviewed and approved by the organization’s quality assurance and performance improvement committee (or other
designated committee). The risk assessment and ISPC Plan should be reviewed annually (and sooner if circumstances change).
________________________________________________________________________________________________________
Page 2 of 12 Cover Page for Risk Assessment Report
Risk Assessment Report for Infection Surveillance, Prevention and Control (ISPC) Program
Year: 20__
Organization Name: ________________________________
Date of Report: __________________
Overview
A facility risk assessment for acquiring and transmitting infections should be conducted annually in each healthcare facility. [Note: An annual risk assessment is
required for organizations accredited by The Joint Commission and other accreditation organizations.] The risk assessment provides a foundation for the Infection
Surveillance, Prevention and Control Program because it is used is used to provide information about where an organization should focus its infection surveillance,
prevention and control activities.
This facility risk assessment was conducted by identifying and reviewing potential risk factors for infection related to the care, treatment, and services provided
and to the environment of care in a specific healthcare setting. The identified risks of greatest importance and urgency were selected and prioritized and are noted
below. Based on these identified risks, facility personnel will develop the organization’s Infection Surveillance, Prevention and Control (ISPC) Plan (i.e., an action
plan, with goals and measurable objectives.)
The ISPC Plan includes a goal for reducing the risk of infection associated with each of the prioritized risks, a measurable objective for each goal, and evidence
based strategies for meeting each of these objectives. The Plan also (1) identifies the personnel responsible for developing the Plan and implementing the ISPC
Program strategies and (2) includes mechanisms for evaluating the effectiveness of the meeting the ISPC Program’s objectives.
Assessment Tool
An organizational Infection Risk Assessment tool (below) was reviewed and adapted for use by (Organization name) by the following personnel:
_________________________________________________________________________________________________________________
The Risk Assessment tool was used to identify potential infection risk factors in each of the following categories:
 Community and populations served
 Potential for specific infection
 Treatment and care practices
 Instrument and medical device cleaning, disinfection and handling
 Environment of care
 Emergency management
 Others identified by the organization
Page 3 of 12 Process
The following personnel conducted the risk assessment:
_______________________________________________________________________________________________________
The group identified, assessed and scored each potential risk factor based on the following:
1. Potential impact of the event/condition on patients and personnel, determined by evaluating the potential for patient illness, injury, infection, death, need
for admission to an inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to impact the organization’s ability to
function/remain open; and degree of clinical and financial impact.
2. Probability of the event/condition occurring, determined by evaluating the risk of the potential threat actually occurring. Information regarding
historical data, infection surveillance data, the scope of services provided by the facility, the environment of the surrounding area (topography, interstate
roads, chemical plants, railroad, ports, etc.), and health department data, are considered when determining this score.
3. Organization’s preparedness to deal with the event/condition, determined by considering policies and procedures already in place, staff experience and
response to actual situations, and available services and equipment.
Ranking of Scores
After risk scores are assigned in the three assessment groups, the numbers in each group were totaled to provide a numerical risk level for each event/condition.
The numerical risk level can range from 0 (lowest vulnerability) to 9 (highest vulnerability). The risk factors (i.e., events/conditions) were then ranked from
highest to lowest risk level in the table below. The risks with the highest scores will be used for priority focus for developing the annual ISPC Plan. NOTE: Some
events/conditions with a lower score may be selected because they are an accreditation or regulatory requirement.
Distribution of Risk Assessment
The Risk assessment was shared with others, such as the ____________________, to solicit comments. The original group evaluated and incorporated the
comments, as needed, and finalized this risk assessment. The risk assessment will be taken to the (governing body) ______________ and the
______________Committee for final approvals before the Infection Surveillance, Prevention and Control Plan is developed. After final approval of the risk
assessment findings, the ISPC Plan will be developed by __________with periodic reports back to the ____________Committee until the Plan has been fully
implemented.
Results
A numerical risk level of 9 is identified as the highest perceived potential risk.
Event or Condition
Score
Page 4 of 12 Event or Condition
Score
Page 5 of 12 Risk Assessment for the Infection Surveillance, Prevention and Control (ISPC) Program Year: 20___ Organization Name: ________________________________ Date of Report: __________________ Event or Condition
What is potential impact
of event/condition on
patients and staff?
High
(3)
Med
(2)
Low
(1)
None
(0)
What is probability of
event/condition
occurring?
High
(3)
COMMUNITY & POPULATIONS SERVED:
Emerging Infectious Disease
POTENTIAL FOR SPECIFIC INFECTIONS:
Page 6 of 12 Med
(2)
Low
(1)
None
(0)
What is organization’s
preparedness to deal with
this event/condition?
None
(3)
Poor
(2)
Fair
(1)
Good
(0)
Numerical
risk level
Total
Event or Condition
What is potential impact
of event/condition on
patients and staff?
High
(3)
Med
(2)
Low
(1)
None
(0)
What is probability of
event/condition
occurring?
High
(3)
CARE PRACTICES:
Page 7 of 12 Med
(2)
Low
(1)
None
(0)
What is organization’s
preparedness to deal with
this event/condition?
None
(3)
Poor
(2)
Fair
(1)
Good
(0)
Numerical
risk level
Total
Event or Condition
What is potential impact
of event/condition on
patients and staff?
High
(3)
Med
(2)
Low
(1)
None
(0)
What is probability of
event/condition
occurring?
High
(3)
INSTRUMENT & MEDICAL DEVICE CLEANING, DISINFECTION & HANDLING
Page 8 of 12 Med
(2)
Low
(1)
None
(0)
What is organization’s
preparedness to deal with
this event/condition?
None
(3)
Poor
(2)
Fair
(1)
Good
(0)
Numerical
risk level
Total
Event or Condition
What is potential impact
of event/condition on
patients and staff?
High
(3)
Med
(2)
Low
(1)
None
(0)
What is probability of
event/condition
occurring?
High
(3)
ENVIRONMENT OF CARE:
Page 9 of 12 Med
(2)
Low
(1)
None
(0)
What is organization’s
preparedness to deal with
this event/condition?
None
(3)
Poor
(2)
Fair
(1)
Good
(0)
Numerical
risk level
Total
Event or Condition
What is potential impact
of event/condition on
patients and staff?
High
(3)
Med
(2)
Low
(1)
None
(0)
What is probability of
event/condition
occurring?
High
(3)
Med
(2)
Low
(1)
None
(0)
What is organization’s
preparedness to deal with
this event/condition?
None
(3)
Poor
(2)
Fair
(1)
Good
(0)
Numerical
risk level
Total
EMERGENCY MANAGEMENT:
OTHER:
1.
2.
3.
Potential impact of the event/condition on patients and personnel: determined by evaluating the potential for patient illness, injury, infection, death, need for admission to
an inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to impact the organization’s ability to function/remain open; and degree of clinical
and financial impact.
Probability of the event/condition occurring: determined by evaluating the risk of the potential threat actually occurring. Information regarding historical data, infection
surveillance data, the scope of services provided by the facility, and the environment of the surrounding area (topography, interstate roads, chemical plants, railroad, ports,
etc.) are considered when determining this score.
Organization’s preparedness to deal with the event/condition: determined by considering policies and procedures already in place, staff experience and response to actual
situations, and available services and equipment.
Developed by: K. Arias, M. Patrick, K. Delahanty and S. Odachowski
Page 10 of 12 GOALS AND OBJECTIVES
RISK EVENT/ CONDITION
OBJECTIVE
(measurable, includes
timeframe for completion)
GOAL
Page 11 of 12 RISK EVENT/
CONDITION
OBJECTIVE
GOAL
(measurable, includes
timeframe for completion)
STRATEGIES
IMPLEMENTATION
Responsible
Person(s)
Page 12 of 12 Method for Evaluating
Effectiveness