The document discusses indicators for accrediting infection control units and hospitals. It proposes assessing structure, process, and outcomes, including monitoring incidence of multidrug-resistant organisms, adherence to infection control guidelines, and environmental cleaning. Outcome indicators like infection and colonization rates are prioritized. Risk stratification into categories like low, medium, and high is recommended based on national guidelines and expert opinion. Both resident and ward-level factors should be considered.

1. 28-­‐03-­‐15
1
Who
do
you
want
to
accredit?
A. The
hospital
as
a
whole
–
with
regard
to
infec=on
control
B. The
Infec=on
Control
unit
Both
works
–
depending
on
how
broad
you
evaluate
the
seFng
in
which
the
IC
unit
operates
Na=onal
IC
guidelines
Norm
with
regard
to
size
and
structure
of
IC
units
¤ Na=onal
IC
guidelines
¤ Norm
with
regard
to
size
and
structure
of
IC
units
¤ Recognized
training
for
ICP
&
MD’s
¤
Laws
with
regard
to
CME
¤
Laws
with
regard
to
transmissible
diseases
¤
Inspectorate
² An
authority
that
can
penalize
non-­‐conforming
healthcare
ins=tu=ons
¤ Risk
of
acquiring
preventable
infec=ons
due
to
breaks
in
preven=ve
measures
² Guidelines
implementa=on
&
behavioral
change
¤ An=microbial
resistance
impeding
pa=ent’s
safety
² Interrupt
transmission
of
MDROs
² An=microbial
stewardship
Indicators
need
to
asses
the
above!

2. 28-­‐03-­‐15
2
¤ Structure
¤ Process
¤ Outcome
¤ to
ensure
that
the
infec=on
control
team
is
geFng
the
necessary
funding
to
adequately
do
their
work
in
a
seFng
that
commits
to
pa=ents
safety
aspects
Important
indicator,
but
² Par=cular
considera=on
needed
² Major
piXalls
-­‐
weighing
of
individual
steps
of
the
process.
• “A
chain
is
only
as
strong
as
it’s
weakest
link”
is
not
correct
for
many
processes!
Process
if
okay,
but
outcome
is
what
it’s
all
about
¤
Incidence
of
defined
MDRO
in
blood-­‐cultures
per
100,000
days
at
risk
² Overall
admisson
days
of
the
hospital
-­‐
(2
x
admissions)
¤
Environmental
cleaning
²
final
cleaning
a`er
discharge
of
isola=on
pa=ent
check
with
microbiology
or
ATP
¤ Hand
hygiene
² WHO
method
or
compliance
rate
Please
–
No
more!
Medicine
2015
Paper
work
instead
of
work
with
pa=ents

3. 28-­‐03-­‐15
3
¤
Easy
to
collect
²
Extractable
from
LIS
and
HIS
²
App
support
¤
Clearly
and
well
defined
²
Everyone
really
measuring
the
same,
comparable
between
different
hospitals
¤
Immediately
accessible
for
the
user
²
Guide
interven=ons
Do not allow non-
professionals to
formulate them
MD*
*lead
ICP ICP
ICT
Inspec-
torate
Willemsen
et
al
Antmicrob
Resistance
Infect
Control
2014;3:26
Crosssec8onal
surveillance
of:
¤ Two
outcome
variables:
² Prevalence
of
HAI
(SSI,
LRTI,
UTI,
GI,
bacterial
conjunc=vi=s)
² prevalence
of
rectal
carriage
of
ESBL
producing
Enterobacteriacea
¤ Two
resident-­‐related
risk
factors:
² prevalence
of
medical
device
² prevalence
of
an=microbial
therapy
¤ Three
ward-­‐related
risk
factors:
² environmental
contamina=on
² shortcomings
in
infec=on
preven=on
precondi=ons
² availability
of
local
infec=on
preven=on
guidelines
Willemsen
et
al
Antmicrob
Resistance
Infect
Control
2014;3:26
¤
For
each
outcome
variable
or
risk
factor,
breakpoints
were
set
to
make
the
division
in
3
categories
²
low,
intermediate
and
high
²
Classifica=on
based
on
na=onal
prevalence
surveys,
scien=fic
publica=ons
and
if
no
data
was
available
on
expert
opinion
¤
Popula=on
characteris=cs
get
considered
Willemsen
et
al
Antmicrob
Resistance
Infect
Control
2014;3:26
Willemsen
et
al
Antmicrob
Resistance
Infect
Control
2014;3:26

4. 28-­‐03-­‐15
4
¤ Infec=ons
in
NH
¤ Intravenous
administra=on
¤ Medicine
administra=on
¤ Cleaning/disinfec=on
and
steriliza=on
¤ Storage
of
sterile
materials
¤ Waste
collec=on
and
transport
¤ Urine
drainage
and
defeca=on
¤ Care
of
airways
¤ Wound
care
¤ Tube
feeding
¤
MDRO/MRSA
¤
Norovirus
¤
Scabies
¤
Legionella
control
¤
Food
safety
¤
Pets
in
the
NH
¤
Registra=on
of
ID
¤ Hand
hygiëne
¤ PPE
¤ Personal
hygiene
¤ Personnel
ID
blood
exp
Willemsen
et
al
Antmicrob
Resistance
Infect
Control
2014;3:26
¤
Bathroom
sink
¤
Bedside
cabinet
¤
Table
living
room
¤
Microwave
kitchen
¤
Bedside
commode
¤
U=lity
room
¤
Sterile
storage
shelve
¤
Toilet
seat
¤
Washing
bowl
Willemsen
et
al
Antmicrob
Resistance
Infect
Control
2014;3:26
¤
Availability
of
hand
alcohol
¤
Availability
of
gloves,
gowns,
masks
¤
Availability
of
needle
container
¤
Availability
of
bedpan
washer
¤
Availability
of
plas=c
aprons
¤
Presence
of
at
least
one
HH
sink
per
15
residents
¤
Presence
of
at
least
wo
toilet
groups
per
15
residents
¤
Presence
of
at
least
one
single
room
with
bathroom
per
15
residents
Willemsen
et
al
Antmicrob
Resistance
Infect
Control
2014;3:26
Willemsen
et
al
Antmicrob
Resistance
Infect
Control
2014;3:26
Willemsen
et
al
Antmicrob
Resistance
Infect
Control
2014;3:26

5. 28-­‐03-­‐15
5
Dutch
Society
of
ICP
Dutch
Society
of
Medical
Microbiology
Quality
Visita8on
commiEee
(2006)
¤
Aiming
at
the
work
of
the
infec=on
control
team/unit
–
not
the
hospital
as
a
whole
¤
Audits
are
done
by
ICPs
and
IC-­‐MDs
¤
The
audit
is
based
on
interna=onal
and
na=onal
laws
and
guidelines,
including
ISO
14001
and
OHSAS
18001
¤
Uses
Plan-­‐Do-­‐Check-­‐Act
(PDCA)
principles
The
quality
criteria
are
defined
as:
¤
Norms
=
must
haves
¤
Points
of
anen=on(
POA)
=
the
minimum
norms
(checkable
via
quick-­‐scan)
¤
Addi=onal
points
=
want
to
haves
1. Mission
and
vison
2. Strategy
Aims
3. Work
of
the
IC
unit
4. Human
resource
aspects
5. Finances
6. Housing
7. Internal
Quality
Control
Norm
¤ Unit
has
a
vision
and
mission
POA
¤ Present
on
paper
¤ Only
one
vision
and
mission
¤ Concurrent
with
hospital
VM
¤ The
ambi=on
formed
by
VM
should
be
known
to
others
¤
Quality
system
¤
Strategy
planning
report

6. 28-­‐03-­‐15
6
Norm
¤ Quality
system
designed,
documented
and
implemented
PAO
¤ Complete
Quality
Manual
¤ Inten=on
to
cooperate
documented
¤ Scope
defined
¤ Responsibili=es
of
controlling
groups
documented
Norm
¤ Strategy
and
according
aims
are
formulated
and
supported
(FTE,
$)
¤ Responsibili=es
formulated
POA
¤ Mul=-­‐year
strategy
plan
present
¤ Year
plan
present
² SMART-­‐formulated
² corresponding
with
mul=-­‐year
plan
² Controlled
planning
and
achievements
² Safety,
integrity,
privacy,
communica=on
Norm
¤ Clear
descrip=on
of
responsibili=es
and
what
the
unit
is
doing
POA
¤ What
are
the
primary
tasks
–
documented
¤ “Customers”
know
what
the
tasks
are
¤ Tasks
are
priori=zed
¤ Possible
overlap
with
technical
services,
cleaning,
CSD,
…
described
I
skip
the
next
7
slides
but
they
are
online
¤ Surveillance
and
implementa=on
of
improvement
IC
guidelines
based
on
na=onal
laws/guidelines
¤ Outbreak
management
¤ Training
¤ Audits
¤ Consultancy
¤ Cleaning,
disinfec=on,
steriliza=on
¤ Construc=on
¤ Control
of
water
and
air
¤ Buying
of
disposables
othet
biomedical
products
¤ Research
Norm
¤
Posi=on
and
hirachical
and
func=on
management
of
units
is
described
POA
¤ Organogram
present
¤ SLA
with
external
organisa=ons
¤ Par=cipa=on
in
comminees
(internal
extermal)
¤ Communica=on
and
exchange
of
informa=on
with
microbiology
lab

7. 28-­‐03-­‐15
7
1. Mission
and
vison
2. Strategy
Aims
3. Work
of
the
IC
unit
4. Human
resource
aspects
5. Finances
6. Housing
7. Goods
8. Internal
Quality
Control
¤ Internal
structure
and
responsibility
¤ Descrip=on
of
the
professional
func=ons
¤ Overview
of
individuals
tasks
and
addi=onal/
external
work
¤ Planning
(free,
on-­‐duty,
…)
including
con=nuity
in
the
work
and
communica=on/reachability
¤ SOPs
² New
co-­‐worker,
(cont.)
eductaion/training,
size
of
the
unit,
guidline
with
regard
to
part-­‐=me
work,
…
¤ Yearly
professional
evalua=on
of
each
co-­‐worker
¤
Independence
of
the
unit
¤
Document
who
is
responsible
for
finances
–
budget
control
¤
Contracts
and
SLAs
¤
Insurances
¤
Close
to
wards
¤
Adequate
rooms
² including
telephones,
computers,
printers,
…
¤
Access
to
all
systems
(LIS,
HIS,
OR
ystem,
…)
¤
Safety
aspects
¤
Documents
and
archives
¤
Internal
and
external
quality
control
of
the
unit
¤
Management
review
¤
Lots
of
good
stuff,
and
probably
needed
for
an
accredita=on,
best
we
have,
but
…
¤
Very
theore=cal
Long
and
a
lot
of
work
¤
Addi=onal
to
professional
audit
by
peers
–
instead
of
integrated

8. 28-­‐03-­‐15
8
We
can’t
make
it
fun,
but
we
do
our
best
to
make
it
prac=cal
and
easy