U.S. Department of Health and Human Services

Chapter 33 – Infection Control and Prevention

Part 3 - Professional Services

Title	Section
Introduction	3-33.1
Purpose	3-33.1A
Policy	3-33.1B
Scope	3-33.1C
Goals	3-33.1D
Background	3-33.1E
Authorities	3-33.1F
Program Policies	3-33.1G
Definitions	3-33.1H
Responsibilities	3-33.2
Director, IHS	3-33.2A
IHS Chief Medical Officer and Deputy Director for Quality Health Care	3-33.2B
Headquarters Technical Consultants on Infection Control	3-33.2C
HQ Ad Hoc IC Workgroup	3-33.2D
Area Director	3-33.2E
Area Federal Technical IC Consultants	3-33.2F
Governing Boards	3-33.2G
Chief Executive Officers	3-33.2H
Clinical Director	3-33.2I
Director of Nursing	3-33.2J
Director, Quality Assurance and Performance Improvement	3-33.2K
Infection Control/Prevention Officer	3-33.2L
Infection Control Committee	3-33.2M
Service Unit Department Supervisors	3-33.2N
Employees	3-33.2O
Procedures and Core Elements of an Infection Control Program	3-33.3
General Program Requirements	3-33.3A
Program Planning, Assessment, Improvement, and Evaluation	3-33.3B
Education and Training Services	3-33.3C
Clinical Surveillance	3-33.3D
Investigation of IC Breaches and Disease Outbreaks	3-33.3E
Surveillance of the Physical Environment of Patient Care	3-33.3F
Core IC Program Elements References	3-33.3G

3-33.1 INTRODUCTION

Purpose. This chapter establishes the program policies, procedures, and responsibilities required for ensuring a comprehensive Infection Control and Prevention (ICP) program exists in all Indian Health Service (IHS) health care facilities and Service Units. An ICP program is required to meet and maintain readiness with applicable health care accreditation standards.
Policy. It is the policy of IHS that all health care facilities and Service Units follow relevant infection prevention and control practices in accordance with federal regulations, accreditation organization standards, and professional standards.
Scope. This chapter applies to IHS health care facilities (hospitals and ambulatory care) and employees. Tribally-operated health care facilities may adopt this policy. Related IHS policies include those on Occupational Safety and Health, Housekeeping and Linen and IHM Chapters from Part 3-Professional Services. As used in this policy, ICP refers to preventing, monitoring, and responding to the risk and outcomes of infectious diseases.
Goals.
1. To ensure each IHS health care facility and/or Service Unit develops, maintains, and actively implements a comprehensive ICP program appropriate to the facility.
2. To facilitate the adoption of proven interventions to prevent and control infectious agents. Specific interventions include hand hygiene, cleaning, disinfection, and sterilization, standard precautions, isolation precautions, and bloodborne pathogen exposure control.
3. To support the prevention and treatment of anti-microbial resistance (AMR) consistent with the IHS National Pharmacy and Therapeutics Committee and national standards.
4. To establish guidelines and protocols for managing common pathogens including Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C-diff), Tuberculosis (TB), Influenza, and Multidrug-Resistant Organisms (MDROs).
Background. According to the Centers for Disease Control and Prevention (CDC), healthcare-associated infections (HAI) account for significant morbidity and mortality in the United States. A robust and dynamic infection control program is critical to the health and safety of patients, visitors, and staff of IHS facilities, and requires the engagement and commitment of all IHS Healthcare Personnel (HCP). This chapter includes content consistent with numerous standards and guidelines, including the CDC Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings .
Authorities.
Program Policies. It is the policy of IHS that:
1. The IHS federally operated health care facilities and/or Service Units will establish a comprehensive ICP program in accordance with Infection Prevention and Control federal regulations and guidance, accreditation organization standards, professional organization standards, scope and level of services provided, and evidence based best practices;
2. The IHS leadership and management at all levels of the organization will provide support in the form of staff, facilities, equipment, supplies, time, and training to establish and implement the ICP program;
3. Health care facilities and/or Service Units will integrate their ICP program into their Quality Assurance and Performance Improvement (QAPI) program or Quality Improvement (QI) program;
4. The IHS facilities and employees must commit to ongoing and sustained performance of hand hygiene, cleaning, disinfection, sterilization, Bloodborne Pathogens (BBP) exposure prevention standard and transmission-based isolation precautions, and management of common pathogens; and
5. The Service Unit and Area will comply with infection control breach investigation and reporting of Infection Control (IC) actual or potential events for formal notifications in accordance with the IHS adverse incident reporting requirements and CDC guidance.
Definitions.
1. Bloodborne Pathogens (BBP). Pathogenic microorganisms present in human blood. These BBPs include, but are not limited to, hepatitis B virus and human immunodeficiency virus.
2. Breach [ICP Breach]. The improper use or failure of a procedure, device, equipment, or practice that may result in patient or employee exposure to body fluids, tissues, or other biologic substances.
3. Clinical Surveillance. Surveillance is the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health. Surveillance typically refers to tracking of outcome measures (e.g., HAIs), but can also refer to tracking of adherence to specific process measures (e.g., hand hygiene, environmental cleaning) as a means to reduce infection transmission.
4. Common Pathogens. As used in this chapter, refers specifically to Methicillin-Resistant Staphylococcus aureus, C-diff, TB, Influenza, and Multidrug-Resistant Organisms.
5. Hand Hygiene. This general term applies to hand washing, antiseptic hand wash, or alcohol-based hand rub.
6. Hand Washing. Cleaning hands with plain soap and water.
7. Healthcare-Associated Infection (HAI). A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s), that occurs in a:
  1. Patient, who was:
    1. Admitted to an inpatient healthcare facility prior to symptom onset and for whom the infection:
      1. Was not present or incubating at the time of admission, or
      2. Was related to a previous health care encounter.
    2. Recently treated or discharged, and for whom the infection has an etiology consistent with being healthcare-associated as outlined by national guidelines (Refer to National Healthcare Safety Network (NHSN) for additional guidance) https://www.cdc.gov/nhsn/acute-care-hospital/index.html .
  2. Healthcare Personnel, related to occupational exposure.
8. Healthcare Personnel (HCP). Employees, volunteers, students, trainees, and contract workers who have contact with patients or potential for exposure to blood and other infectious materials (e.g., body substances, used medical supplies and equipment, and soiled environmental surfaces).
9. Infection Control and Prevention (ICP). As used in this policy, refers to preventing, monitoring, and responding to the risk and outcomes of infection.
10. Infection Control Competency. The proven ability to apply essential knowledge, skills, and abilities to prevent the transmission of pathogens during the provision of care.
11. Microorganisms. Bacteria, fungus, virus, or other organism that is too small to be seen with the naked eye.
12. Occupational Exposure. Reasonably anticipated skin, eye, mucous membrane, respiratory or parenteral contact with blood, droplets, aerosols, or other potentially infectious materials during work duties.
13. Pathogen. A microorganism capable of producing disease.
14. Personal Protective Equipment (PPE). A variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. The PPE includes gloves, gowns, masks, respirators, face shields, eye protection, and shoe or hair covers.
15. Respirator (Filtering Facepiece Respirator). A type of disposable (single-use), negative-pressure, air-purifying respirator where an integral part of the facepiece or the entire facepiece is made of filtering material.
  The N-95 Respirator is a half mask air-purifying respirator with National Institute of Occupational Safety and Health approved particulate filters or filter material.
16. Standard Precautions. Group of minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status of patient.
17. Transmission-Based Precautions (TBP). Broad category for precautions appropriate to symptoms/diagnoses implemented to minimize the spread of infectious organisms with highly transmissible or epidemiologically significant pathogens for which additional precautions beyond standard precautions are needed to interrupt transmission. The TBP include Contact, Droplet, and Airborne precautions.
18. Work Practice Controls. Controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

3-33.2 RESPONSIBLITIES

Director, IHS. The Director, IHS, must ensure compliance with E.O. 12196 and support a comprehensive ICP program as defined by this chapter, as well as support AMR prevention.
IHS Chief Medical Officer and Deputy Director for Quality Health Care. The IHS Chief Medical Officer (CMO) and Deputy Director for Quality Health Care (DDQHC) must:
1. Support the implementation of a comprehensive ICP program as defined by this chapter, as well as support AMR prevention.
2. Review reports of ICP breaches and communicable disease outbreaks, provide recommendations for response, and communicate information as appropriate to the Director IHS.
Headquarters Technical Consultants on Infection Control. The Headquarters (HQ) Technical Consultants include the following: Chief Clinical Consultant Infectious Diseases, HQ Office of Quality (OQ) Medical Officer, HQ OQ Associate Director Quality Assurance and Patient Safety, HQ OQ Infection Prevention and Control Coordinator, and HQ OQ Patient Safety Nurse Consultant; or Agency designees.
The HQ Technical Consultants are responsible to:
1. Develop and facilitate IHS-wide IC policies, standards, initiatives, and procedures;
2. Consult with Areas and Service Units in the development of performance measures and quality improvement projects;
3. Coordinate maintenance of and compliance with this chapter according to IHS guidelines;
4. Recommend and advocate for resources to train and educate the IC Officers specifically, and IHS HCP more broadly;
5. Advocate for resources to implement ICP services and AMR prevention;
6. Respond to inquiries from frontline HCP about the interpretation of ICP guidelines, accreditation, or other requirements; and
7. Consult with Areas and Service Units in response to ICP breaches or communicable disease outbreaks.
HQ Ad Hoc IC Workgroup. The HQ IC Technical Consultants may consult with and receive assistance from all professional services and programs supporting patient care and the care environment. The HQ IC Technical Consultants will convene, as necessary, an ad hoc workgroup to plan national policy, or respond to ICP breaches or communicable disease outbreaks at IHS federal health care facilities. Staff or national consultants for the following programs must participate in the ad hoc workgroup upon request: Laboratory, Nursing, Patient Safety, Oral Health, Pharmacy, Quality, Environmental Health, Clinical Engineering, and any other program as deemed appropriate.
Area Director. Each Area Director must ensure that the IC programs and AMR prevention programs are consistent with IHS IHM 3-33 and are operational and effective within their region.
Area Federal Technical IC Consultants. The Area CMO, or designee, must be the ICP technical consultant for Service Units. The Area Technical IC Consultant will develop and facilitate Area policies and procedures, and performance improvement measures and projects. As appropriate to the issue, the CMO may refer or receive assistance on specific issues from Area representatives from clinical programs (such as the Nursing, Dental, Pharmacy, or Quality), or supporting programs (such as Environmental Health, Biomedical Engineering, or Facility Operations).
Governing Boards. Governing Boards are responsible to ensure accountability for compliance with these standards and this policy and should dedicate a portion of every meeting to a review of pertinent IC quality and performance data. Where deemed necessary, the Governing Boards may require additional data collection or the implementation of additional quality/performance activities and reporting. Governing Boards should request or pursue training on IC as needed to carry out their oversight responsibilities.
Chief Executive Officers. The Chief Executive Officer (CEO) of IHS-operated Service Units must:
1. Support the development and implementation of an ongoing prospective risk assessment process for the safety of patients, visitors, and staff, which includes ICP as a primary component;
2. Ensure that issues identified by the ICP program are addressed through the QAPI and training programs;
3. Empower and support the authority of those managing the ICP program to ensure effectiveness of the program;
4. Implement corrective action plans for issues identified as requiring improvement, including reporting to the Area Office;
5. Implement the requirements of 29 C.F.R. 1960.16 and E.O. 12196, Section 1-201 at the local level. Implicit in these responsibilities is protecting HCP from the spread of communicable disease; and
6. Ensure Service Unit and facility staff with specific ICP service or oversight responsibilities have adequate training and resources to implement a comprehensive IC program and AMR prevention.
Clinical Director. The Service Unit/health care facility Clinical Director, or a designated physician, will provide technical assistance to the ICP Officer and support the implementation of the ICP program.
Director of Nursing. The Service Unit/health care facility Director of Nursing will provide technical assistance to the ICP Officer and support the implementation of the ICP program.
Director, Quality Assurance and Performance Improvement. The QAPI Director, or equivalent, will oversee the implementation of the ICP Program and provide management, budgetary, and logistical support as appropriate to the local organizational structure.
Infection Control/Prevention Officer. The ICP officer is responsible and empowered to implement the day-to-day activities of the ICP program consistent with accreditation standards, federal regulations (e.g. OSHA), best practices, and IHS policy.
Infection Control Committee. The multi-disciplinary Service Unit ICP Committee is responsible to support the ICP Officer, CEO, and the facility related to ICP services and AMR prevention. The ICP Committee is responsible for assessing risks, making decisions and recommendations, communicating requirements to staff throughout the facility/Service Unit, evaluating the effectiveness of the ICP program, and monitoring compliance and practice to ensure the goals and objectives of the program are met. The ICP Committee must include the ICP Officer and could include Clinical Director (or Physician designee), Employee Health Specialist, Laboratory Supervisor, Pharmacy Supervisor, Nurse Executive, Environmental Services (Housekeeping) Supervisor, Facility Manager, Safety Officer, Environmental Health Officer, Clinical Department Representatives (including Dental), Public Health Nursing, and Administration.
Service Unit Department Supervisors. Individual department supervisors are responsible for implementing ICP policies and ensuring employee compliance with safe work practices. Department supervisors will support education and training of their staff, and will participate in routine and periodic inspection of their work environment.
Employees. All IHS HCP are responsible for complying with this policy and all subsequent local policies related to ICP. All IHS HCP are responsible for identifying potential infection control issues and taking immediate action, as appropriate to their professional scope, to prevent or correct such issues. All IHS HCP are encouraged to participate in the development, implementation, and evaluation of the ICP program.

3-33.3 PROCEDURES AND CORE ELEMENTS OF AN INFECTION CONTROL PROGRAM

General Program Requirements.
1. Organizational Placement. The Service Unit/health care facility will integrate the ICP program into the QAPI/QI program. If the ICP Officer is not under the direct supervision of the QAPI/QI program, upper level management should provide direct supervision to prevent potential conflicts of interest within clinical programs and ensure information can be shared readily with leadership for evaluation and action.
  The CEO will identify the ICP Officer, and any other staff, to whom they confer the authority to implement or intervene in any activity necessary to prevent infections and interrupt the transmission of infectious diseases.
2. Resource Allocation. Health care facility/Service Unit leadership must ensure that sufficient fiscal and human resources are available to implement the ICP program. The primary expenses include designated IC staff, required administrative and management support, equipment and supplies necessary for electronic data collection/management/mining/analysis, standard and TBP, HAI and environmental surveillance, environmental, medical, and dental equipment cleaning, disinfection, and sterilization. Each facility should maintain up-to-date copies of all pertinent professional standards, guidelines, and regulations as outlined in IHS, Area, or local policy and as appropriate to their services and equipment. The IC Officer should maintain a central library of reference materials, with additional copies maintained by the Sterile Reprocessing, Facility Management, Environmental Services, or other departments, as deemed appropriate.
3. Recommended Staffing Levels. Each healthcare facility and/or Service Unit must designate one or more staff to oversee and implement the ICP program. Service Units and facilities should consider patient census, the patient population, and complexity of the health care services it offers in determining the size and scope of the resources it commits to ICP program. Outpatient facilities should assure that at least one individual with training in infection prevention is employed or regularly available.
4. IC Officer Competencies. The ICP Officers should be qualified through education, training, experience, or certification. The IC Officer and his/her supervisor should regularly develop short and long-term goals for individual development. The Association for Professionals in Infection Control and Epidemiology (APIC) Competency Model may serve as a useful basis for this discussion. The ICP Officers should maintain their qualifications through ongoing education and training, participation in ICP courses, or in local and national meetings organized by recognized professional societies, such as APIC, Organization for Safety, Asepsis and Prevention, and the Society for Healthcare Epidemiology of America. The ICP Officer and their supervisor should maintain documentation of current competencies.
5. Infection Control Committee Function. Each IHS federal facility or Service Unit must establish a committee to address ICP. A dedicated ICP Committee should work to ensure that HAI risks are assessed, goals established, requirements communicated, staff trained, resources allotted, and program evaluated. It is recommended that the Clinical Director, or their designee, be appointed as the chairperson of the ICP Committee. In addition, a secretary must be assigned from the committee or from administrative support staff to document required meeting minutes.
Program Planning, Assessment, Improvement and Evaluation.
1. Planning and Assessing. The ICP program will have clearly defined objectives and priorities that contribute to the prevention of HAI and AMR. The ICP program must develop and refine policies and procedures based on evidence-based guidelines, regulations, or standards. The ICP program should tailor plans, policies and procedures to the facility, and re-assess them on a regular basis.
  The ICP policies should address the roles and responsibilities for ICP within the health care facility/Service Unit; how various committees and departments interface with the ICP program; how to prevent infectious/ communicable diseases; and how to report infectious/communicable diseases to the ICP program. The education and training of relevant HCP and the monitoring of compliance should be undertaken to achieve successful implementation of ICP policies and procedures.
  
  The successful development, implementation, and evaluation of an IC program requires frequent collaboration with persons administratively and clinically responsible for inpatient and outpatient departments and services, and non-patient-care support staff, such as maintenance and environmental services staff.
  
  Supporting information on specific proven interventions is included in Section 3-33.4 of this policy. When designing ICP interventions, facilities should incorporate behavioral science principles to help ensure staff compliance.
2. Comprehensive Infection Control Program Risk Assessment. A comprehensive program risk assessment takes into consideration all the types of services provided by the facility as well as the location, patient population, and available ICP data. Through risk assessment, the ICP Committee prioritizes resource allocation and focuses extra attention on those areas that are determined to pose greater risk to their patients. The comprehensive risk assessment should be used to help identify if changes are required to equipment (including PPE) or work practices. The risk assessment process should also result in the facility setting goals and objectives for process and outcome measures designed to reduce the identified risks and limit transmission of infection. Risk assessment examples include the APIC 2013 Infection Control Risk Assessment-Example Template , and the CDC Infection Prevention Checklist for Outpatient Settings .
3. Program/Intervention Evaluation. The ICP programs must be evaluated regularly to assess the extent to which objectives are met, goals accomplished, whether the activities are being performed according to requirements, and to identify aspects that may need improvement. Important information that may be used for this purpose includes audits of compliance with work practices, other process indicators (for example, training activities), dedicated time by the ICP Officer, and resource allocation. Strategic assessment of goals and objectives should be supported by performance measurement with measures identified through the program’s Comprehensive Infection Control Program Risk Assessment. Long-term response and system improvements to prevent future breaches/events should be developed using the Institute for Healthcare Improvement Model for Improvement and monitored according to issue severity.
Education and Training Services. Ongoing education and competency-based training of HCP are critical for ensuring that ICP policies and procedures are understood and followed. Educational activities should be based on standard adult learning methods and the educational needs of the learner population. Education for all HCP should utilize team and task-based strategies that are participatory and include simulation training whenever feasible. Education should be a part of an overall facility education strategy, including new employee and contractor orientation, updates on revised policies or procedures, and continuous educational opportunities for existing staff, regardless of level and position (for example, including senior administrative and environmental services staff). Periodic evaluations of both the effectiveness of training programs and assessment of staff knowledge should be undertaken on a routine basis by the ICP Committee and/or QAPI program. For example, training on hand hygiene, standard precautions, and BBP exposure prevention should be provided at least annually to existing employees.
Clinical Surveillance. In order to prevent, control, and investigate infections and communicable diseases, the ICP program must include an active surveillance component that covers both patients and personnel. The HAI surveillance must be performed to guide interventions and detect outbreaks, including AMR surveillance with timely feedback of results to HCP and stakeholders. Surveillance systems should be linked to integrated public health infection surveillance systems. A system to ensure surveillance data quality assessment is of the utmost importance.
1. Standard Surveillance Case Definitions and Rate Calculations. Surveillance should be based on national recommendations and standard definitions, as appropriate to the facility risk assessment and available resources, with clear objectives and strategies. Surveillance case definitions may vary from clinical case definitions used for diagnosis and treatment, which requires thorough and careful adherence when documenting HAIs. Surveillance definitions are designed to study and identify trends in a population. The application of standardized criteria in a consistent manner allows confidence in aggregation, analysis, and reporting. The NHSN is one source of standard definitions applicable to hospitals, and also provides the means to collect and benchmark data. Whenever possible, data should be presented as an appropriate standardized infection ratio, a rate, or a proportion (numerator with relevant denominator).
2. Targeted Surveillance. Although comprehensive, whole house surveillance may be feasible in some locations, it is expected that most IHS facilities will undertake targeted surveillance based on their local risk assessment, accreditation requirements, and IHS policy.
  1. Common Pathogen Infections. Health care facilities are expected to identify and track infections and communicable diseases in any of the following categories whether in patients or staff:
    1. The HAIs selected by the ICP Committee as part of a targeted surveillance strategy based on nationally recognized guidelines and periodic risk assessment;
    2. Patients or staff with identified communicable diseases that local, State, or federal health agencies require be reported;
    3. Patients identified by laboratory culture as colonized or infected with an MDRO;
    4. Patients who meet CDC criteria for requiring TBP during a hospitalization;
    5. Patients or staff with signs and symptoms requested to be reported by local, State, or federal health agencies; and
    6. Staff or patients who are known or suspected to be infected with epidemiologically significant pathogens that are identified by the facility or local, State, or federal health agencies.
  2. Surgical Site Infections. Multiple preventive measures, including the judicious use of prophylaxis and aseptic technique, have been demonstrated to reduce the frequency of surgical site infections.
    Even with the use of all of the effective preventive measures, infections still occur and require effective management to minimize the consequences of the infection. Surgical Site infections must be monitored according to risk and accreditation standards, but process measures such as preoperative evaluation, prophylaxis use, environmental quality, and device sterilization, postoperative care, discharge instructions, and follow-up must be incorporated as appropriate.
  3. Device-Associated Infections. Health care facilities should implement measures specific to prevention of HAIs associated with devices (e.g. central venous catheters (lines), peripherally-inserted central catheters, ventilators). Preventive measures recommended by APIC, NHSN, CDC, or The Joint Commission (TJC) National Patient Safety Goals should be implemented. Facilities should also implement, as appropriate, measures specific to prevention of other device-associated infections (e.g., those associated with ventilators, indwelling urinary catheters, etc.). As a routine duty, the ICP Officer should conduct active surveillance for the identification of device-associated infections. Direct patient care HCP should be educated on the signs and symptoms of device-associated infections and the process to report such instances to medical/dental providers and the IC Officer.
3. Benchmarking and Reporting. Regular monitoring of healthcare practices according to standards and facility procedures must be performed to prevent and control HAI and AMR. Feedback must be provided to all audited persons and relevant staff. Surveillance reports must be disseminated in a timely manner to those at the managerial or administration level (decision-makers) and the unit/ward level (frontline HCP).
  1. Reporting to Infection Control and Prevention Committee. As part of setting goals and objectives, the ICP Committee must determine how and what information will be reported regularly to the committee. Data trending must be used, as well as benchmark data to help provide perspective to the IC Committee members.
  2. Reporting to Facility/Service Unit Leadership. Through discussion between the ICP program and facility, Service Unit, and Area leadership, critical reporting events should be established that require informing neighboring IHS facilities, or administrative levels outside of the facility. The HQ Technical Consultant(s) on infection control may establish requirements and processes to report significant infection control issues as well as to provide regular reports on the state of the national goals (outcomes and processes) and strategies.
  3. Communicable Disease Reporting. At a minimum, facilities will adhere to local, state, and federal requirements regarding reportable disease and outbreak reporting. Facilities should check the local and state requirements to assure that they are compliant with all regulations and should have contact information for their local and/or state health department available to ensure required reporting is completed per state and federal requirements.
  4. Inter-Facility Reporting. Pertinent information must also be communicated to other facilities transferring/receiving patients with HAIs and other common pathogens.
  5. Informing Patients. Patients exposed to infectious disease will be notified and referred for follow-up according to CDC guidance.
  6. Lab Services. Based on assessed risks, defined surveillance processes, and ICP program goals, laboratory services must collaborate with the ICP Officer to ensure consistent, on-going communication. Participation by laboratory services is vital in the ICP Committee.
4. Antimicrobial Resistance. The severity and extent of disease caused by pathogens with AMR varies by the population(s) affected and by the institution(s) in which they are found. Because of this, the approaches to AMR prevention and control need to be tailored to the specific needs of each population and individual institution. Prevention of AMR depends on appropriate clinical practices that should be incorporated into routine patient care. Facilities must establish Antibiotic Stewardship Programs, and implement reporting mechanisms, in accordance with Part 3, Chapter 39, Antimicrobial Stewardship.
Investigation of IC Breaches and Disease Outbreaks.
1. Breaches of ICP practices, processes, or systems. Practices such as safe injections, processes such as sterilization and high-level disinfection, and utility system management are vital to prevention of HAIs. These practices, processes, and systems must be evaluated in the comprehensive infection control risk assessment, with local policies and procedures developed to monitor actively for ongoing compliance. Any breach in infection control practices, processes, or systems suspected to have exposed patients to infectious agents, and/or any breach that resulted in a confirmed HAI requires response and resolution.
  1. Communication and Reporting.
    1. The Service Unit and Area will comply with infection control breach investigation and reporting for formal notifications in accordance with the IHS adverse incident reporting requirements and CDC guidance https://www.cdc.gov/hai/outbreaks/steps_for_eval_ic_breach.html .
    2. Based on Area investigation reports, the HQ ICP Technical Consultant(s) and DDQHC will determine the need to assemble the HQ Ad Hoc ICP Workgroup. The HQ Ad Hoc Workgroup will provide technical consultation if additional internal and/or external investigation or patient notification is required.
2. Health Care Facility Outbreaks. Outbreaks of both infectious and noninfectious adverse events can occur in any health care setting and pose a threat to patient safety. A multi-disciplinary team with experience in epidemiology and public health should be engaged to identify probable contributing factors and determine steps to stop current outbreaks and to prevent similar events in the future. The elements of such investigations can be found in the APIC Text of Infection Control and Epidemiology, 4th edition, Chapter 12 “Outbreak Investigations.”
3. Community Outbreaks. Community outbreaks of communicable diseases (such as measles, Severe Acute Respiratory Syndrome (SARS), SARS-CoV-2, influenza) present many of the same issues and require many of the same considerations and strategies as other HAI threats. Health care facilities confront a set of issues similar to naturally occurring communicable disease threats when dealing with an influx of potentially infectious patients or a suspected bioterrorism event. Because of the many similarities between man-made and naturally occurring threats, an all-hazards approach to developing emergency response plans is preferred, and facilities are encouraged to work with their State and local emergency response agencies to develop their plans.
Surveillance of the Physical Environment of Patient Care. Patient care activities should be undertaken in a clean and/or hygienic environment that facilitates practices related to the prevention and control of HAI.
1. Environmental Surveillance Processes. Regular evaluation and periodic inspection of the environment of patient care should be conducted in accordance with accreditation standards and the assessed levels of risk. A multi-disciplinary team (e.g., ICP, facility management, safety, facility leadership, and department supervisor) should conduct formal inspection through focused ICP rounds and/or through environmental rounds. Areas for specific attention include food services, refrigerators, ice machines, air handlers, autoclave rooms, venting systems, inpatient rooms, treatment areas, labs, waste handling, surgical areas, supply storage, and equipment cleaning.
2. Construction-Related Infection Control Risk Assessment and Monitoring. Consistent with IHS policy on facility design and construction, and guidelines from the Facilities Guidelines Institute, the ICP program must be consulted prior to construction, renovation, or remediation projects inside and adjacent to the health care facility. The ICP Committee must adopt a pre-construction risk assessment tool and process such as those available from APIC and TJC to evaluate risk and to identify mitigation actions. A similar process should also be established for maintenance tasks with potential ICP impacts.
  Construction requirements must be communicated to staff and construction crews. Participation and compliance with the ICP requirements should be included in related contract documents. The risk assessment process should continue throughout construction, and should include clearly defined surveillance roles and requirements. When mitigation actions identified during the risk assessment are found to be out of compliance, the ICP Officer may institute a temporary stoppage until conditions or mitigating practices are sufficient to protect staff and patients.
Core IC Program Elements References.
1. Centers for Medicare and Medicaid Services, Publication # 100-07 State Operations Manual , Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, Rev. 176, 2017 or current revision;
2. The Joint Commission, Comprehensive Accreditation Manual, 2021 or current version;
3. Accreditation Association for Ambulatory Health Care, 2020 or current version;
4. Centers for Disease Control and Prevention, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, 2017 or current version ;
5. Centers for Disease Control and Prevention, Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care , version 2.3, 09/2016, or current version;
6. Centers for Disease Control and Prevention, Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care , October 2016, or current version;
7. World Health Organization, Guidelines on Core Components of Infection Prevention and Control Programmes , 2016 or current version;
8. Association for Professionals in Infection Control and Epidemiology (APIC), APIC Text of Infection Control and Epidemiology, 2017 or current revision;
9. Association of PeriOperative Registered Nurses, Guidelines for Perioperative Practice, 2020 or current version;
10. 42 C.F.R. § 482.42, Conditions for Coverage & Conditions of Participation; and
11. Association for the Advancement of Medical Instrumentation , 2022 or current version.