SAQ #15

HOW DOES THE TEAM IDENTIFY, REPORT, AND MANAGE INFECTIONS? YELLOW, HIGH
Summary of Related Standard(s) 9.1 The organization has a process to detect suspected healthcare-associated infections 9.2 The process identifies who is responsible and what the reporting relationships are for infection prevention and control issues. 9.4 The organization has policies and procedures to contain and prevent the spread of infectious agents, including ventilation, isolation and other precautions, and cohorting as necessary.
Process Currently in Place - Evidence of Current Status
• ARO & respiratory screening is done in PAC. PAC follows isolation precautions if pt is known MRSA
• Results are followed up, the OR is informed, it is noted on OR schedule. EPR is checked the night before by the PAA in SDS and PACU to double check ARO status of all patients
• Isolation precautions are followed as soon as a patient is admitted to SDS pre-operatively and information is communicated on the handover tool
• Isolation precautions are followed post-operatively in PACU, SDS. At this time, MRSA and Isolated patients do not meet the admission criteria for the SSSU, as per IPAC the curtains no longer meet isolation criteria after 12 hours
• On-line P&P IP&C standards are followed
• If there is a break in communication, or a pt has not been identified in a timely manner, an e-safety report is filed and IP&C is informed immediately.
• Pt with identified isolation precautions will only be admitted to an isolation room once transferred out of PACU
· the bed management system will flag ARO's
· -manager and educator attend monthly Gen surg and Cardiac SSI meetings and relay information back to staff. Inservices have been held regarding pre-warming Gen surg patients in SDS, and correct clipping method for cardiac patients, as well as mouth care.
· All Patients are instructed by PAC to take chlorhexidine showers for 3 days prior to their surgical date
· Braden Skin Risk documentation is started in PAC
· Mandatory Hand Hygiene classes for all staff. ABHR strategically located and signs posted to encourage staff and visitors to comply with HH.
· all staff required to be N95 fit-tested q 2 yrs, as well, are req'd to pass IPAC PPE class q2
· Self surveillance for ARO: healthy workplace environment promoted.
· Flu clinics also available yearly by Occ Health
· Visitors are also requested to abstain from visiting if they are unwell. 1 visitor per patient is encouraged: visitor policy in effect.
· No food or drink at bedside, for staff and visitors.
· no hand or wrist jewelry when providing direct patient care


Improvement Strategy / Action Plan
July 2009-October 2009
1.PeriAnesthesia Handover Tool being utilized well.
2. IPAC RN's have attended staff meetings and education days to assist with education regarding PPE and HH
November 2009 - February 2010
1. Currently there are some MRSA in-patients who go to the OR, and then isolation requirements are not relayed to the PACU staff. The BMS is being introduced Nov 17 this will identify ARO flags. There are identified super users in each unit who will help the other staff learn the system
2. Hospital committee on Transfer of Accountability working on standardized SBAR tool between units. This will help also help identify ARO positive patients. TOA to be rolled out in January 2010.
3. Braden Skin Risk documentation needs to be completed in PACU will require inservicing on the importance of this tool
March 2010 - onward
1. Reassess to see if the BMS is identifying all ARO patients
2. Reassess to see how the TOA guide is working at identifying ARO pts at handover
3. Reassess to see if PACU is completing the BSR doc