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Infection prevention risk assessment.


The Joint Commission requires hospitals to conduct an annual risk assessment for infections, which will serve as the basis for goal setting and prevention activities. A risk assessment should also be conducted whenever there's a significant change in services provided.

Why it's done

The risk assessment is an evaluation of the characteristics and resources of the current infection prevention program. It should identify the probability of an infection occurring and the impact of the occurrence on the organization, including harm to the patient; the legal, regulatory and accreditation ramifications; and financial impact.


(1) Assess patient demographics and the community served

Health care-acquired infections occur in all settings, but certain areas and patient populations are at greater risk than others, Children, the elderly and people with compromised immune systems are more vulnerable. HAIs are more common in the ICU, burn unit and operating room, for example, than in the radiology and cardiology departments.

Hospitals should work with local departments to determine community trends that may impact infection risk in the facility.

(2) Review the care, services and treatment provided

HAI transmission s commonly linked to the use of certain medical devices such as catheters, central lines and mechanical ventilators. The risk assessment should determine the frequency of use of those devices and the volume of high-risk services, such as surgical procedures.

(3) Analyze surveillance data

Surveillance data should be reviewed to determine trends in antimicrobial resistance among organisms, patient populations and departments.

(4) Evaluate the resources available to the infection prevention department

A review of the infection prevention department should include the number of personnel and their certification levels, availability of data mining and external reporting requirements. Hospitals should also review their cleaning and sterilization processes. The organization must provide education and training on safe sterilization practices

(5) Review successful practices past and present

A review of current literature should be conducted to identify current best practices in the prevention of HAIs. Initiatives, such as the Surgical Care Improvement Project and the use of bundles for ventilator-associated pneumonia and central-line associated bloodstream infections, should be evaluated for performance

Sources: APIC, The Joint Commission, Premier Safety Institute, 2010

Who should be involved?

No two infection prevention programs are the same. The program should reflect the organization's size, resources and potential for risk. Smaller hospitals might not employ a full-time infection preventionist, for example. It's important for that person or people in that role to form partnerships with key staff throughout the organization to assist with the risk assessment and infection prevention program. Key stakeholders include: senior management, physicians, nurses, laboratory, risk management, patient safety, central services, environmental services and IT.

Setting priorities

The risk assessment should serve as a foundation for setting priorities and goals in infection prevention. The goals relate to preventing the transmission of infections associated with procedures, preventing the unprotected exposure to pathogens and preventing the transmission of infections associated with the use of medical devices, equipment and supplies.


Once infection control issues are prioritized, the infection prevention team should develop a plan to address the potential risk. A clearly defined strategy should be developed for each goal based on solid scientific evidence. The plan should include methods to measure and evaluate the impact of the proposed intervention. The infection prevention plan should also include the hospital's strategy for investigating an infectious disease outbreak.

Characteristics of successful infection prevention programs

Although the risk level for infections varies from hospital to hospital, even from department to department, successful IP programs share these key characteristics.

1. Visible support from senior leadership.

2. A well-qualified infection prevention staff.

3. A blame-free culture in which all employees are able to voice their concerns.

4. Accountability for performance. Accountability must occur on the individual and system levels. All employees must understand how their actions can impact the occurrence of infections within the organization. And the organization must work toward common goals.

5. Real-time data. The availability of real-time surveillance data enables organizations to identify outbreaks and respond in a timely manner to prevent widespread infection.

Sources: The Joint Commission and Premier Safety Institute, 2010
Have public reporting mandates and
other regulatory, requirements reduced
your department s capacity to focus on
infection prevention and control efforts?

Yes   52%
No    35%
N/A   14%

Source: 2009 APIC Economic Survey, Association for Professionals
in Infection Control and Epidemiology

Note: Table made from pie chart.

Have you had any reductions in
staffing or in resources for the
infection prevention department in
the last 18 months?

Yes      41%

If yes, check all that apply:
Reduction in staffing                  39%
Hiring freeze                          35%
Reduced education funding              74%
Reduced infection prevention budget    53%

No       59%

Source: 2009 APIC Economic Survey, Association for Professionals
in Infection Control and Epidemiology

Note: Table made from pie chart.

What services did you provide in the
past that you no longer can,
due to cutbacks?

Less support to attend outside educational events   45%
Decreased meetings                                  44%
Decreased rounds                                    42%
Decreased education                                 38%
Decreased IP oversight                              34%

Source: 2009 APIC Economic Survey, Association for Professionals
in Infection Control and Epidemiology

Note: Table made from bar graph.

Do you have
data mining?

Yes    20%
No     80%

Source: 2009 APIC Economic Survey, Association for Professionals
in Infection Control and Epidemiology

Note: Table made from pie chart.

Infection Prevention

Step 1: Risk Assessment

Infection preventionists face significant challenges in their efforts to eliminate outbreaks in health care settings. The economic downturn has forced organizations to reduce infection prevention resources at a time of heightened public awareness, regulatory oversight and nonpayment for certain avoidable conditions,

The Joint Commission requires that organizations conduct an annual infection prevention risk assessment. This process is critical for hospitals and health systems to set priorities that will have the greatest impact on quality of care as well as the bottom line. "No two organizations have the same level of risk," says Louise Kuhny, R.N., associate director of the Joint Commission's Standard Interpretation Group. "The populations served, the community at large and the services provided will be different."

The national spotlight on infection prevention is achieving positive results. "There's been tremendous progress in eliminating infections, but there's still more to do," says Kathy Wayre, CEO of the Association for Professionals in Infection Control and Epidemiology. She notes, for example, that some organizations have failed to adopt best practices, such as the use of a checklist to prevent central line-associated bloodstream infections, which have proven to reduce errors. Too often, lack of appropriate staffing and resources prevent organizations from adopting and educating employees on evidence-based best practices, Wayre says.

Despite the progress, there's much work to be done. The Centers for Disease Control and Prevention estimates that 1.7 million health care-acquired infections occur in U.S. hospitals each year and are associated with 99,000 deaths. HAIs also place considerable financial strain on hospitals and health systems. "In a capitated market, anything you can do to reduce length of stay, increase throughput and reduce antibiotic costs is important," says Vickie Brown, RN, associate director of hospital epidemiology at UNC Health Care, Chapel Hill. "The cost of adding one full-time infection preventionist is a smaller investment than what you will get in return for reducing HAIs."

Hospital executives are faced with countless priorities, notes Wayre, "Infection prevention is an area where progress can be made that will benefit the patient and the organization's financial performance," she says. APIC has developed a free Infection Prevention Program Evaluation Tool to help organizations assess the current infection prevention services and resources.

Infection preventionists need to connect with senior leadership to develop ongoing communication. It's important for infection preventionists to provide clear, up-to-date information about the organization's progress. And hospital executives should discuss infection prevention efforts during leadership rounds. "Infection prevention is a two-way street," says Judene Bartley, a clinical consultant for the Premier Safety Institute and vice president of Epidemiology Consulting Services, Beverly Hills, Mich. "It must come from the top down and bottom up."

This gatefold examines how the infection prevention risk assessment can help organizations develop successful infection prevention programs.


Health Care-Associated Infections page, Centers for Disease Control and Prevention,

Health Care-Associated Infection Elimination Program Framework, Premier Safety Institute, topics/HAI/index.jsp

Hospitals in Pursuit of Excellence, American Hospital Association, services/safety/topics/HAI/index.jsp

Infection Control Initiatives, The Joint Commission,

IP Program Evaluation Tool, Association for Professionals in Infection Control and Epidemiology, APICNews/IP_Program_Evaluatio.htm

Action Plan to Prevent Healthcare-Associated Infections, U.S. Department of Health & Human Services,
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Author:Jarousse, Lee Ann
Publication:H&HN Hospitals & Health Networks
Geographic Code:1USA
Date:Aug 1, 2010
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