ࡱ> {zCQ(   Phttp://www.immunize.org/catg.d/p4068.htmPhttp://www.immunize.org/catg.d/p4068.htmhttp://www.shea-online.org/publications/shea_position_papers.cfmhttp://www.shea-online.org/publications/shea_position_papers.cfmx.http://www.cdc.gov/flu/.http://www.cdc.gov/flu/lhttp://www.cdc.gov/ncidod/hip/nhsn/members/members.htmlhttp://www.cdc.gov/ncidod/hip/nhsn/members/members.htmhttp://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/Resources/National+Surgical+Infection+Prevention.htmhttp://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/Resources/National+Surgical+Infection+Prevention.htm4  http://www.medqic.org/dcs/ContentServer?cid=1122904930422&pagename=Medqic%2FContent%2FParentShellTemplate&parentName=Topic&c=MQParents http://www.medqic.org/dcs/ContentServer?cid=1122904930422&pagename=Medqic%2FContent%2FParentShellTemplate&parentName=Topic&c=MQParents< http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=256http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=256, http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=8021http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=8021dhttp://www.cdc.gov/ncidod/dhqp/dprc_ventilate.htmldhttp://www.cdc.gov/ncidod/dhqp/dprc_ventilate.htmlhttp://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htmhttp://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm\www.cacc.net(http://www.cacc.net/"Lhttp://www.leginfo.ca.gov/bilinfo.htmlLhttp://www.leginfo.ca.gov/bilinfo.html>\http://www.cdc.gov/ncidod/dhqp/guidelines.html\http://www.cdc.gov/ncidod/dhqp/guidelines.htmlLZhttp://www.quotationspage.com/quote/1688.htmlZhttp://www.quotationspage.com/quote/1688.html/ 00DTimes New Romantt/ 0DGaramond Romantt/ 0 DArialnd Romantt/ 00DWingdingsRomantt/ 0 C0.  @n?" dd@  @@`` X $!      ,() >>HH @HH**   5 ^_,, q r ,x y  AA1?@p1L2M3R4SmQ ʚ;t8ʚ;g4VdVdP/ 0bppp@ <4!d!d@w 0t/<4dddd@w 0t/<4BdBd@w 0t/ 0___PPT10 ___PPT9LdClick for further information about this quotation? %D79SB 739 What it Means to You and Your Acute Care Facility::* HistorySenator Speier introduced SB 1487 in 2004. It passed the legislative body but was vetoed by Governor Schwarzenegger as redundant & costly. In 2005, SB 739 was introduced but stalled in legislature and was carried over to the 2006 session.0ZZdZ,%History$In 2006, significant revisions were made as a result of the DHS taskforce whitepaper entitled: Recommendations for Reducing Morbidity and Mortality Related to Healthcare-Associated Infections in California (12-05). SB739 passed the legislature 8-30-06 and Governor Schwarzenegger signed it.DZZLZ LSB 739An act to add Article 3.5 (commencing with section 1288.5) to Chapter 2 of Division 2 of the Health and Safety Code, relating to health facilities. Effective 1-1-07 Copies available at http://www.leginfo.ca.gov/bilinfo.html " 0Burden or Benefit? Let s Make it Benefit Our Patients and ProgramsCCAUtilize this regulation to create partnerships between senior leadership and members of the Infection Prevention and Control Program. Shines the spotlight on prioritizing infection prevention as important. Gets acute care facilities in California on the same page regarding identification of process and outcome measures.BZBAdditional BenefitsBetter awareness of key measures within facilities. Ability to benchmark with other California hospitals. Begin to meet public expectation of infection reporting. Potential for improved resources/staffing for the infection prevention and control program.Summary of RequirementsDHS must: Create a multi-disciplinary advisory panel to monitor and oversee the operations and products of the California Healthcare-Associated Infections Reporting System by 7-1-07. Will include ICPs. Require general acute care facilities to prevent the spread of influenza by 7-1-07 .  W/&Summary of Requirements=Mandate reporting of process measures by acute care facilities beginning 1-1-08. Make process measure data reported to the department public within 6 months. Revise regulations (T22) to incorporate current guidelines and standards to prevent HAI. Require hospitals to have a process for judicious use of antibiotics.  =>Summary of RequirementsDHS must: Develop a plan to assess its own program and educate department staff on implementing recommendations by 1-1-08 . Explore electronic reporting by 1-1-08 . Recommend other process and outcome measures to be reported by acute care facilities by 1-1-08. Require facilities to develop policies & procedures to prevent SSIs and VAPs by 1-1-09 . Evaluate compliance with these policies & procedures during facility surveys. ,E\Summary of Requirements[Hospitals must: Create a written report every 3 years, as a component of the strategic plan, that addresses the resources and effectiveness of the infection control program. This is to be a joint effort between ICPs and hospital senior leadership. Submit process measure data to NHSN or other scientifically valid national HAI reporting systems. "ZKZ\0'Summary of RequirementsUtilize CDC definitions for defining HAIs. Hospitals participating in CHART shall publicaly report those HAI measures as agreed to by all CHART hospitals. >+pS CSummary of RequirementsHospitals must: Implement policies and procedures to reduce the risk of CLA-BSI as outlined by the CDC. Report CLA-BSI rates for ICUs. No date defined. Reduce Risk of Influenza/Pandemic by 7-1-07. Offer influenza vaccine to all hospital employees at no charge and require a declination for those choosing not to be vaccinated. Institute respiratory hygiene/cough etiquette procedures. Isolation plan for influenza patient. CDC recommends droplet. Adopt a seasonal influenza plan. Include pandemic planning in the disaster plan. lZZKZZKSummary of RequirementsHospitals must: Report success with selected process measures to DHS by 1-1-08 : Insertion of CVC practices Antibiotic prophylaxis in surgical patients Influenza vaccination rates of patients and employees By 1-1-08 have a process for evaluating the judicious use of antibiotics which shall be monitored by committees involved in QI. By 1-1-09 have policies and procedures in place to reduce SSIs. Reports of compliance to the IC and Surgical Committees. By 1-1-09 develop policies and procedures to prevent VAPs. pA}6A|6,q4Suggestions for Compliance by Acute Care Facilities<Report on Resources & Program Effectiveness 1288.6 (a) (1-3)==&Per JCAHO, annual plans and assessments are already required. Wording in SB739 confusing re: every 3 year strategic plan with annual updates. Suggest that data elements outlined in SB739 be added to your plan (section 1288.6 a1-3). See next slide.Z+Report on Resources & Program EffectivenessElements: Risk and cost and number of invasive cases performed at your facility (invasive cases is not defined so you should define what you are counting). Number of ICU beds, ER visits annually, outpatient visits annually, and licensed beds Employee health measures implemented at your facility Demographics of the community you serve Estimate of needs and recommendations for additional resources for the Infection Prevention and Control Program to address issues identified in your plan. Update as necessary to address changes.. Z Z   $Central Venous Catheters: 1288.6 (b)Implement P&P to reduces CLA-BSI (central line-associated bloodstream infections). Refer to CDC guidelines http://www.cdc.gov/ncidod/dhqp/guidelines.html &SHSH> 0k CLA-BSI RatesIdentify a way to collect line days from your ICU settings. Any patient with any number of central lines gets counted once. Familiarize self with CDC definition of laboratory confirmed BSI. Review positive blood cultures for ICU patients. Eliminate those without central lines. List CLA-BSIs not present on admission. Determine a rate (CLA-BSI/line days). Report findings to Medical Staff Committees (i.e. Infection Control , Critical Care). Z !Influenza: 1288.7 (a-c) Onsite influenza vaccinations to ALL hospital employees at no cost. If employee does not want vaccination, a declination must be signed. Immunization Coalition http://www.immunize.org/catg.d/p4068.htm or SHEA s Position Paper on HCW vaccination includes sample form available at http://www.shea-online.org/publications/shea_position_papers.cfm *ZZ:(E@ 0 0Y" Influenza2Develop respiratory and cough etiquette protocols, isolation procedures (droplet recommended) & seasonal influenza plans See CDC signs, protocols, and programs at http://www.cdc.gov/flu/ Revise Emergency Plans to include a pandemic component (JCAHO already requires a surge if infectious disease patients) NyBwyBw* y 0#Process Measures6These will be reportable to DHS starting 1-1-08 & DHS will make this data PUBLIC within 6 months (methods yet to be determined): Compliance with CVC insertion procedures Timing of surgical antibiotic prophylaxis Influenza vaccination rates of patients and employees (NHSN Healthcare worker vaccination module) &$HAI Definitions Expectation is that all facilities will utilize CDC definitions last updated 2004 and available at http://www.cdc.gov/ncidod/hip/nhsn/members/members.htm Use of NHSN when available or other national reporting system (yet to be defined by the HAI Advisory Committee)    0c% &Prevention of Surgical Site InfectionsEDevelop P&P to prevent SSIs and periodically evaluate compliance with same ( antibiotic prophy, skin prep, etc). Report compliance rates to Infection Control Committee and Surgery Committee. Sites IHI http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/Resources/National+Surgical+Infection+Prevention.htm $CZZF<=kw 0@&!More SSI SitesAHRQ http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=256 SCIP ( formerly known as SIP ) http://www.medqic.org/dcs/ContentServer?cid=1122904930422&pagename=Medqic%2FContent%2FParentShellTemplate&parentName=Topic&c=MQParents (O:4 "  0M  0o'" Ventilator Associated PneumoniasDevelop P&P to prevent VAPs. Sites: AHQR http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=8021 CDC http://www.cdc.gov/ncidod/dhqp/dprc_ventilate.html IHI http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm X&ZZZZ& JD2a  0+o 0u 0   Analysis of Data & Documentation;Be sure Infection Control minutes reflect the presentation and discussion of P&P developed or revised, measures of compliance, data submitted, and annual review of the Infection Prevention and Control Plan and Annual Assessment. Your minutes, if comprehensive, will often satisfy surveyors as proof of your actions.(#Updates & Next StepsEducate your senior leadership. Stay involved with your APIC Chapter for updates. Share resources, tools, forms and tips. Check the CACC website at www.cacc.net for updates. 0)$Summary1Many of these requirements are not entirely defined. The HAI Advisory Committee, yet to be appointed, may provide clarification down the road. 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