SAQ #16

DOES THE TEAM UNDERSTAND AND FOLLOW POLICIES TO PREVENT AND CONTROL INFECTIONS? GREEN FLAG, HIGH PRIORITY
Summary of Related Standard(s): 5.1 The organization develops an IPAC education program that is tailored to the organization, its services, and client populations. 5.2 The IPAC education program specifies each staff member’s/service provider’s/volunteer’s role in preventing/controlling infections. 5.3 The IPAC education program covers personal precautions and high-risk activities performed in the organization.5.4 Staff, service providers, and volunteers attend the IPAC education program at orientation and regularly.5.6 The organization provides its staff, service providers, and volunteers with access to IPAC education materials, resources, information, and tools.5.7 The organization monitors compliance with its infection prevention, control policies and procedures.
Process Currently in Place - Evidence of Current Status
• PACU 1:1 with ARO positive patients. Designated equipment and PPE worn. Curtains define patient area and ESP’s and PSP’s are specially trained for environmental cleaning
• Fit mask testing for N95 masks for all staff
• ARO testing is initiated in PAC and followed through the process
• IP&C P&P’s available on-line
• Q2yr certification for PPE application
• Hand hygiene retreat with IP&C involvement to occur in May
• PeriAnesthesia SSI committee members for both CV and Gen surg. Keep staff up-to-date on new initiatives
• Universal precautions are also adhered to
Improvement Strategy / Action Plan
November 2009 - February 2010
1. IPAC RN's invited to Staff meetings to talk about MRSA precautions in the perianesthesia environment with no definite isolation rooms
2. inservice also discussed how Eating and drinking in patient care areas is not permitted by staff or visitors
March 2010 – onward
Follow up with staff