Infection Prevention Manual

EXPOSURE CONTROL PLAN The implementation of these policies and protocol will be evaluated through: * competence assessment activities, * in-home supervisory visits. or * a skills lab. Also, our Agency requires evaluate the effectiveness of our CLABSI prevention efforts. This will be performed though a combination of analyzing the surveillance data collected for CLABSIs against their targeted outcome performance measure (i.e., zero CLABSIs) and monitoring our internal compliance with implementing best practices or evidence-based guidelines through internal or external staff. CLABSI prevention outcome measures are established: Our Agency will have zero CLABSI rate on a monthly basis. The outcome measure formula would provide the Agency with a rate of infection that could be monitored over time and displayed on a run chart and analyzed against the targeted compliance rate set by the organization, and as data become available, with other home care providers. The results from our agencys' evaluation of our effectiveness in preventing CLABSI, and in meeting our CLABSI prevention outcome measure should be communicated to key staff including leaders, licensed independent practitioners, nursing staff, and other clinicians (including contracted professional staff) at a frequency that is set quarteUOy. These key staff would also include governing body members and the SURIHssional sWDII in our agency. This information can be communicated to others on run charts or bar graphs, displaying the outcomes on a statistical tool. Other infection prevention measures, such as hand hygiene compliance monitoring and any data collected may also be used, as hand hygiene is also an important infection prevention measure. Catheter Hub Disinfection Protocol Colonization of microorganisms on the catheter hub is an important source of pathogens causing catheter-related infections. As such we requires that home care field authorized staff use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports. This protocol address: * What product will be used to clean the hub and injection port. * How long the cleaning product should remain on the catheter hub and injection port during cleaning. * The method of cleaning the catheter hub and injection port. * The frequency of injection cap changes. Before anyone accesses a catheter hub on a central line (either a CVC or an accessed implanted port) hand hygiene should be performed and the hub or injection port cleaned with 70% alcohol or povidone-iodine by aseptically cleaning the injection or access port using a twisting, turning, and scrubbing motion, similar to “juicing an orange for 15 seconds. The CDC recommends that injection caps not be changed more frequently than every 72 hours or according to the manufacturers' recommendations; however, the INS's Infusion Nursing Standards of Practice recommend that the injection cap on a CVC be changed when the catheter dressing is changed, any time the injection cap is removed from the catheter, if residual blood remains in the injection port, or whenever contamination occurs. We choose to monitor our internal performance as to whether the catheter's hub and injection port are being properly cleaned and disinfected according to our internal protocol by collecting data. This data collection is not required, but could serve as evidence of the agency's compliance with infection prevention. The data collection could occur during supervisory visits or on-site competence assessment visits in which the number of times the staff disinfected the catheter hub or port prior to accessing the central line is divided by the total number of times that the catheter hub or port was observed to be accessed and then multiplied times 100. This formula would provide the home care or