Policy Manual sample

MDT Home Health Care Agency, Inc. INFECTION SURVEILLANCE, MONITORING AND REPORTING OF EMPLOYEES AND PATIENTS Surveillance is an essential component of an effective Infection Control program. It is the systematic method of collecting, consolidating, analyzing, interpreting and disseminating data to those that need to know about the distribution and determinants of a given disease or event for the purpose of action. Surveillance can be used for the following purposes: • To determine the endemic rate which is the usual presence of a disease, infection or condition in a specific population of a disease or event. This can be used as a baseline which is the number or value used as a comparison. • To detect and investigate clusters or outbreaks. • To assess the effectiveness of prevention and control measures and interventions. • To detect and report diseases to the Infection Control Committee as required by Policy. • To identify organisms and diseases of epidemiological importance such as AROs, MRSA, Tb, and Clostridium difficile, and prevent their spread. • To ensure compliance with agency requirements for accreditation/certification. • To monitor injuries and identify risk factors for staff. • To detect a bioterrorist event or an emerging infectious disease. • To provide data to conduct facility risk assessments. Surveillance Methodologies 1. Total House Surveillance: All infections are monitored in the entire population of the Agency (active patients) and an overall infection rate is calculated. This total house surveillance infection rate is generally not used as overall rates cannot be adjusted for specific infections or injury risks. It is also not appropriate for measuring trends over time, making comparisons over groups within the facility (or between facilities), or benchmarking. 2. Targeted Surveillance: This type of surveillance can focus on a particular care area, infections related to medical devices (i.e. urinary tract catheters), or an organism of epidemiological significance (i.e. MRSA). Targeted programs usually focus on high-risk, high volume procedures and on those health care-associated infections and adverse outcomes that are potentially preventable. 3. Combination Surveillance Strategy: In practice, many infection investigations utilize a combination of targeted and modified total house surveillance. An example would be monitoring house wide laboratory reports to detect: MRSA, VRE, reportable diseases, and clusters that may indicate an outbreak or breakdown of Infection Control practices. Outcome or Event Indicators: Include occurrences of reportable diseases, nosocomial (facility- acquired) infections (i.e. urinary tract, pneumonia, upper respiratory tract, local IV site, or wounds); admissions, and HCW infection or colonization with a specific organism (i.e. C. difficile, MRSA, VRE, RSV or rotavirus); patient falls; influenza or tuberculin skin test conversions; or incidents involving HCWs such as sharps injury and blood/body fluid exposures. Surveillance data for each indicator should be collected consistently and for a defined period such as a month, quarter, or year. It is difficult to interpret rates for events that rarely occur or procedures that are infrequently performed. If this is done, it is necessary to use an observation period that is long enough to accumulate a sufficient number of events in order for the measurement to be valid. Home Health Agency Nursing Care & Procedures K-165