Infection Prevention Manual

EXPOSURE CONTROL PLAN * Strategies to detect home care-acquired CLABSI through surveillance activities and reporting requirements * CLABSI and performance measures: actual and expected performance The Agency Director of Nursing will need to evaluate the current content of our education material to determine if the required education are addressed. If not, staff education will need to be performed and completed before to provide central line catheter care, and then the staff educated on an annual basis thereafter, also the Board Introduce a full Manual for IV therapy, as part of our Policy and Procedures. The frequency for this staff education is to occur: * On hire (and prior to providing central line catheter care) * On an annual basis * Whenever a staff member's job duties change that now involve them in central line catheter care and maintenance (when it was not required at the time of hire) Elements of Performance: * Prior to insertion of a central venous catheter, our Agency will educate the patients, families as needed, about central line associated bloodstream infection prevention. * Use a catheter checklist and a standardized protocol for central venous catheter insertion. * Perform hand hygiene before central venous catheter insertion * Use standardized supply cart or kit that is all inclusive for the insertion of central venous catheter * Use standardized protocol for maximum sterile barrier precaution during central venous catheter insertion * Use a chlorhexidine based antiseptic for skin preparation for central venous catheter insertion on patients over 2 months of age, unless contraindicated. Our Agency also need collecting surveillance data on CLABSI. Collecting these data require active, prospective surveillance of CLABSI that develop 48 hours after admission while a patient is receiving care in the home. Any trained person can report the infection, but for accuracy and consistency, the Infection Preventionist should review the surveillance report, and the clinical record if needed, to make a final determination as to whether the patient met the surveillance definition. It is important that consistent surveillance methods and definitions be used to allow for data comparison. The total number of patient cases that met this surveillance definition should be aggregated on either a monthly or quarterly basis (if there is a low sample size). In addition, the total number of central line device days for the month for all patients who had a central line in place should be collected. A risk assessment of the population served and range of services provided should be a starting point to identify appropriate process and outcome indicators. These outcome measures may include, but are not limited to: a. Vascular access device infections b. Central line associated bloodstream and local cannula infections c. Peripheral line associated bloodstream infections d. Catheter associated urinary tract infections e. Skin and soft tissue infections (i.e., pressure ulcers or other wounds) acquired during home care. Primary outcome objectives include reductions in morbidity, emergent care, acute care hospitalizations, mortality, and cost. Criteria for Home Healthcare Associated Infection (HAI): The evaluation of a suspected infection should include consideration of whether the symptoms are new or acutely worse from the established baselines. Non-infectious causes also must be considered. The definition of infection includes more than a single sign or symptom. Physician diagnosis should be accompanied by compatible signs and symptoms of infection in most cases. Laboratory reports