And now, I would like to introduce our speaker to get us started this morning. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, Laura served as a Director of Facility, Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities including critical care, coronary care, perioperative services and pain management. Prior to joining COPIC, she served as a Director, Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, Laura provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us this morning, Laura, and we invite you to go ahead and get us started. Okay. Thank you very much, Lindsay, and welcome everyone. As Lindsay mentioned, our program today is on a very interesting topic that's really starting to take some more toehold in some of the CMS visits that they're making, and that's infection prevention, control, and then antibiotic stewardship program. And I say it's taking more of a toehold because there's been a recent outbreak and more incidents, I guess is a better word to put, of measles. Now, something that we thought had been eradicated and was gone, but no, it's really, really coming back, and the CDC and other infectious disease societies are a little bit concerned about it because of how quickly it can spread and the prevalence that they're just seeing. Well, overall, this is my disclaimer that I do have to add, and that this information is strictly just that, informational only. It is not meant to provide legal advice or establish an attorney-client relationship, so please consult with your own in-house counsel or professional legal representative for advice, specifically as it relates to very specific state laws. So just a quick brief introduction. Why are we here? So we don't get one of these. Those of you who've gone through surveys, you may have seen them, and that's where we do have to do a plan of correction. Now, these are usually when it's a condition-level issue that they find, but they can also do standard levels also, and no one ever wants to receive this notice of involuntary termination from a Medicare agreement or a Medicaid agreement. This usually happens when we have so many deficiencies or it's just one where there's not enough corrective action taken or no corrective action even taken, and there was also one hospital just recently this week that happened to be shuttered because they weren't following the standards. They completely got a hold of the state and took away their license. So how does it work? Well, the regulations we're covering today all start out in the Federal Register, and then CMS has certain duties after that. One, they put the regulation into a transmittal that goes to their surveyors that says, hey, this is new, so be on the lookout. They are responsible to develop interpretive guidelines and survey procedures as it relates to any of those changes or standards, and then they're to update the manual. There are three types of survey, certification, complaint, and then validation. Of course, nobody wants to have that complaint survey because though it may be just around one issue, if they find corresponding complaint or areas of concern, they will also go visit those. How do you keep up with the changes? And I have the links here, by the way, on any of my items that I'm going to touch on this slide. Just copy-paste it to your SERF engine, but of course, subscribe to the Federal Register because that way, you will get email notices and updates. You always want to make sure you have the most current manual. I check this site daily. You don't have to. Monthly should be enough, but definitely check for a new manual. And the reason I say that is because I'd sent the slides off to Lindsay a couple weeks ago, and sure enough, what would you know, CMS updated the manual on Friday the 19th, and so we had to resend the slides. So the last manual came out in April of this year. If there are updates, you want to check the transmittal page. I'll show you again what that looks like. And then again, the survey and certification website. So they do have an entire list of all the areas that CMS has responsibility for. And what we're talking about is Part A, but then some in Appendix W. That's for critical access hospitals. So if you have both in your system, you want to keep these handy in your library. Also one other thing, take that immediate jeopardy, Appendix Q, because that will have some good information in there just in case that they do do an immediate survey. So what we're talking about today, again, you can see this came out April 19th of this year, so there were a few changes, one in particular that had to do with surgical procedures. But to find those transmittals, that will come up on the blue letter, and you will click it, and of course, W has the same thing, but that's what will pop up. And it will tell you what's new, what's revised, what has been deleted. And that's what it looks like for any one of them that does come out. The last one, again, when it came out in April this month, it addressed, again, informed consent, and that was only in the surgical component. Now, since informed consent is in three areas, we may see another one coming out if they decide to expand it to medical records and also patient rights. So CMS is making some changes for us. So this is what we're talking about today, the Infection Prevention and Control and Antibiotic Stewardship Program. For critical access hospitals, this is where yours would be located. It's in red because they haven't updated your manual since 2020. And I want to point out one thing. There are some changes that we'll be covering today that even though there is a new manual and these changes that I'm going to be touching on came out in 2020, they're still not in the manual, but I will show you how to find them. And that happens to be, again, through the policies, and this is the link for it. Just scroll to which one you want, and that's what will pop up. And it will tell you who it applies to, and really, once this is out, it's in effect. So that's why we have to keep them handy. Deficiencies. Deficiencies continue, especially in Infection Prevention and Control. We can access the data. It has the tag numbers, the address, the name of the facility, usually a brief description, but it won't have the plan of correction. But you can request it if you did want to go to that extent. Updated quarterly. The last one came out in January of this year. And I have the link here. This is on slide number 20. Scroll to the bottom of the page where it says Full Text Statements, and that's what pops up. So there, you do have to put the letter and the four-digit number. If you don't put that information in, you go to the wrong area. So again, the letter for your appendix, and then the four-digit number. And for what we're covering today, you can see that there have been several. Even though it's not that long of a time frame, there's still about 2,700 that have continued. I'm just going to do a brief, just a brief coverage of what some of those deficiencies were. One, there wasn't a PI, Performance Improvement on Infection Control Issues. Didn't immunize staff for the flu vaccine. Didn't make sure there was other immunities or plans for those who were able to refuse the immunization for infectious diseases. And again, I bring this up because measles is cropping up again. No infection control program. They didn't have the required policies. And they didn't even enforce hand hygiene guidelines. As far as some equipment, they didn't clean their nebulizer between uses or the glucometers. And they also, even dirty keyboards. When you think, yeah, they're cleaning, they're typing away, not recognizing those things can get pretty nasty looking. Not disposing of hazardous waste in the correct container. And then no longer documentation of what they have done. Housekeeping carts weren't cleaned at the end of the day. Sharps containers were over the line. Didn't even throw sharps into the sharps container. We had an event where the physician assistant, not quite thinking ahead of the game, threw needles and syringes when he was injecting athletes, put them right into the wastebasket and the housekeeping person got stuck. Using multidose vials inappropriately. And then also expired vials. So again, quite a bit of deficiencies. And these are just a few of them that I touched on. So infection prevention and control. I have the tag numbers and I'm going to cover in this first section here. But again, going back to that rule I mentioned, it was called the improvement in patient care rule. I have the link and an example of what that memo looks like in the appendix. The interpretive guidelines, they didn't come out until June of 2022. Well, it's still not in the manual. It wasn't in the July 23 manual and it wasn't in the April 24 manual. You have to go to the, so that's why I urge you print this one off and keep it handy because that's where the interpretive guidelines are. The changes for a critical access hospital, they did change all of their tag numbers and like the acute, they don't have the interpretive guidelines. So really they just followed what's in Appendix A. And that's why if you do have one, have them listen to this so that they're aware of it. This is the memo where it talks about the updates to the program itself. So Lindsay mentioned we have questions, so I thought I'd start us right out the gate. Lindsay, would you get us started on this one? I'm happy to. So I'll read this first part and then I'll post the options there for you to select your answer. This says Hospital A had a recent outbreak of post-surgical site infections, primarily MRSA and E. coli. The infection preventionist has started investigating the root cause. What areas should they review? And then here are your options. Surgery only, sterile processing, instrument cleaning or sterilization, nursing, hand hygiene, medical staff, hand hygiene, or possibly others. You should see that option there on the screen to select your responses. If you happen to miss our opening comments there, we will pause during the time of these polling questions throughout the presentation to address any questions that you have for Laura. So if you do have any questions at this time, you can type those into the Q&A option at the bottom of your Zoom window. Or if you don't see that, you can, of course, type in any questions there in the chat as well. We have some good responses here. Give us another second. I see a couple more still coming in. Good. And I wanted to bring up all of, you know, those folks who handle patients. It's not always nurses. Some of you may have, in your past, had a few of the providers where you had to remind them, please wash your hands before and after, especially when you're handling that dirty wound that you might be looking at or examining the patient. So we still sometimes have to remind our providers that they are involved in this one also. Okay. I'll go ahead and end that and share those results there. Good. Yeah, pretty much everybody had to be involved in this one because it does come up. All right. Prevention, control, and antibiotic stewardship program. And it used to be just infection control. And then they realized back, they did some really good investigation. And they used a worksheet, which, yes, you will have access to that worksheet. And what they identified was that sometimes these transmissions came from a long-term care manual or long-term care setting to the hospital. And they had a really good one for long-term care. And so they thought, well, why don't we just stop it before it ever gets here? And so that's where prevention came into the word phrase. And that's why it's now prevention and control. So you have to have a program that is throughout your hospital to do surveillance, prevention, and control of not only those that come up within your facility, but other infectious diseases. And they're also including now things like impacts and COVID and the other flus that are going around. Plus, at the same time, really use antibiotics well through that stewardship. You don't have a corresponding tag number to this one. But it is expected that you will have a program. What does your program have to show? Well, of course, following those nationally recognized guidelines for both prevention and control. Best practices in using your antibiotics were, of course, were applicable. And part of the reason for the antibiotic stewardship is to really reduce those antibiotic-resistant organisms. Because they are seeing those cropping up too. Those drug-resistant organisms are getting to be real smart. And they're getting tougher and tougher to treat. Of course, this has to be one that you've identified through your QAPI, your problems that you've, whether it's control or antibiotic use. And the interpretive guidelines say, yes, you have to have an active program throughout your hospital. And not only for infection prevention, but use of your antibiotics. The program has to have a way, a system so that you can prevent, identify, report, investigate, and then control infections. And then to improve your antibiotic use. They're based on your individual hospital assessment, while also, of course, following national guidelines and best practices. They have to have policies, procedures, standards, any issues. Those are all identified and addressed through your QAPI program. The surveyor is going to want to see those. They want to see your policy and procedures. They're also looking for evidence of this program. Number one, it's hospital-wide and it's active. And that it is to address the surveillance, prevention, and control. So that you are following and identifying those national standards of practice and best practices. They want to look at your antibiotic stewardship program also. Same thing. Is it hospital-wide and is it active? Are you really using antibiotics to the best you can through stewardship based upon standards of practice and then just best practices? As far as the program, for example, they want to make sure that you're working collaboratively between control and your QAPI. And especially when you do have an issue that is cropping up. So when they have the issues of maybe C. diff coming up in ICU or in your med-surg unit, or you have an MDRO that's coming in. Are you working together to find out why is this happening? Same with the antibiotic stewardship program. That you are also working with QAPI when you have antibiotic issues that are coming up. Why isn't this class of antibiotics working? Perhaps you have one or two providers that are falling outside the norm for the antibiotic ordering. If so, why is that happening? I'm going to talk about the preventionist. We used to call this our infection control nurse. Now they refer to this as preventionist. Because you have to show and demonstrate that you have a person or persons who are now qualified through either education, training, experience, or if they want to go to that next level and be certified. This person is appointed by your governing body. That's also known as your board. And they are responsible for the program. And this appointment is based upon the recommendations of the medical staff and nursing leadership. This is the preventionist. By the way, I try to include the critical access hospital tag number when it correlates to the acutes also. Again, this person could be infection control professional, your preventionist, your epidemiologist, however you want to call them. CDC has a definition. And that's someone who is primarily trained in either nursing, medical technology, microbiology, or epidemiology. And they've acquired specialized training in infection control. Again, they don't have to be certified. They have to be certified through education and training. And that, again, is a CDC definition. They have to make sure that this person has high-level leadership, again, approval that medical and nursing are involved in that process. Because what they want to do by having that collaborative decision on who's going to be this person, it's a culture of safety and quality where input is gained and gathered from all areas within that hospital. Again, qualified through education, training, experience, or certification. They don't tell you how many or how many hours to devote to the program. Yes, the larger your hospital, you may have one or two full-time. Smaller, maybe part-time. Doesn't matter. Overall, this person or persons have to have enough resources so they can do their job. They can accomplish those tasks that they have to for the program. And, of course, if there's more than one integrated team. If you want to have someone be the lead, that's, again, your decision. And determining that, of course, look at your patient census. What are the characteristics of your population? Are they fairly healthy? Or do you see anything and everything? Do you see those who maybe are immunocompromised, those who are going through cancer care? Maybe you have children who are very good at spreading things around. How about the complexity of your services? Are you maybe doing transplants where you have to keep an eye on those individuals? The surveyor, first off, they want to make sure this person was actually appointed by the board based on the recommendations of nursing and medical leadership because that's their job. They have the responsibility. How will they do that? First off, look at the board minutes to find out how was this person identified and actually approved? They may look into the personnel folder of this person. They want to find out, okay, what are the qualifications? How much education have they had, training, experience? Are they certified? When did they go through certification? Is it current? And then what criteria did you use or make decide on that you have enough resources and that it's allocated to meet the needs of your hospital and what that person has to do? Policy and procedures. That's where the program goes. That's the method you use to prevent and control transmission of infections within the hospital and between your settings. That could be home. That could be a long-term care. That might be a nursing home, hospice, wherever it happens to be. It does require you to really focus your efforts to preventing and controlling infections at all levels and for all persons. And so they also suggest, don't forget those outpatient facilities that might be coming into your inpatient units or when patients are moving between settings. What if you have someone who's in ICU and now they're going to the step-down unit? What are they taking with them? Or I should say, bringing to the floor. It's an imperative that you do approach multi-drug resistance organisms. Really look at that at a broad perspective. You are required and acute is required to track hospital and community onset cases of your MRSA and your C. diff infections. So think how can you work with those facilities where you might share patients? And this could be between hospitals if you have a system. You set up and share information on those patients who might have those potentially hazardous or transmittable pathogens. And really, again, it applies to inpatient and your outpatient locations. Your surveyor wants to, again, see your policy and procedures. Are you doing what's in your policy? Are you following your own policies? Do you have ways to prevent and control transmission? And that is throughout the hospital and between those care settings. And is it applied throughout the hospital? Is it really from the point they enter until the point they leave? Your program has to include surveillance, prevention, and control. And that even means keeping the place clean, a clean and sanitary environment. And then a way, of course, to address your infection control issues that come from your public health authorities. There was an alert that's been going out lately, again, not only on measles, but some of the drug-resistant organisms that we really need to start focusing on how we're going to prevent these. Again, you have to keep a clean, sanitary environment, all areas, all departments. And the guidelines also talk about what your program should include. Monitoring of housekeeping, maintenance, that includes repair and renovation. And if you are doing any construction, making sure that that area is properly sealed off, because who knows what's floating up in some of these ceilings. Other activities to make sure we do keep it clean, that's not just the floors. They're talking laundry, food service areas, food preparation, your ventilation system, air handlers, treatment areas, ice machines of all things. We have to keep an eye on those. Labs, you name it, pretty much everywhere that we are keeping it clean and sanitary. Which by the way, I want to just mention the water management. You do have to have policy and procedures to cut down that risk of growing Legionella. They do reference the American Society of Heating, Refrigerating and Air Conditioning Engineers. There is a program they put out in 2015 that talks about it. CDC, they're also and other partners, they developed a toolkit to help implement this. They updated it in 2021. It is a free download and there is the link on it. There's more information in the appendix for you on what that would look like, but it's free. So why wouldn't, of course you'd want to access it. But as far as your water management program, you have to do a risk assessment because what you're looking for is where can this stuff grow? Where can these bugs grow? And there's others, also pseudonomas. Do put together testing protocols. Have acceptable ranges so you have your control levels. Okay, is this okay? Or are we really seeing a spike in those infections? And then document what you've done. You're testing any corrective actions that you can't make those control limits when you cannot maintain them. Certain parts of the US, you have a lot bigger problem with mold and pseudomonas and other areas that are just constantly wet than say Las Vegas or even my area in Denver. Right now we're in a rainy season, yes, but as August and July roll around, we get dry. So we don't have that potential so much as other areas of the country do. Otherwise, look at your locations where you have risk of communicable diseases. And of course that's in any location. Do a really good reliable sampling. Should be your water management person would know what that is. Identify and monitor infections. And it doesn't have to be just within the inpatient. You may have an outpatient area that you've seen a spike. And infections. Document your surveillance activities and what you've done, measures that you've selected for monitoring, measures you've done for collecting. And then how did you analyze it? What'd you come up with on that analysis? And I've said it before, it could be as simple as sitting in the corner and observing how many times do care providers, whether it's an aid or a physician, wash their hands before and after touching patients. You have what you're monitoring, you're doing your hand hygiene guidelines and compliance, how often you're collecting it, how you're collecting it and then looking at that data. And it can be an eye opener. You may find one area that's phenomenal that they just do great. Maybe another area you might wanna do a little reeducation on the importance of something as simple as hand hygiene. If you do have an outbreak, you know, that's an occurrence of more than one than what's expected. Usually it's in a given area or your patient population. And that's over a period of time. So look for those outbreaks. Again, it could be C. diff, could be that. If it does, you must have policies and procedures to handle that, how you're going to diagnose and manage those cases. And then put precautions in place so it doesn't transmit further, so it doesn't go anywhere past there. And of course, we wanna make sure we're documenting our follow-up activity. Of course, you wanna comply with any state and local public health authority requirements, whether it's identification or reporting. And that's on our communicable diseases and outbreaks. The surveyor, you may not hear much from them, but they're looking because they are really observing your area. They're looking at patient rooms. They're looking on floors and even walls because what they're looking for is dirt and blood. They'll check out the air inlets. Mechanical rooms, is there something floating around in there? Food service activities has been big. Treatment and procedure areas, that's just part of their routine. Central supply, are you keeping things sterile? Is your clinic working? How are you testing it? Storage area, medication prep areas. They're really looking around. They're also checking your policy and procedures. Do you have a way? What is your mechanism to do this? Surveillance to identify any transmission. And then if there is a transmission, are those being reported accordingly? Public health authorities. They wanna make sure there's a process to do that when an outbreak does happen. And then what's your process on detecting, investigating and controlling those outbreaks. They will also look at your water management program documentation. Has it been implemented? And are you following it? The next tag talks about your services. That it reflects what you do and the complexity of those services. It is expected to show how it does adequately represent what you are providing. And there should be a mechanism for assessment and reevaluation of the program. Because you may find, hey, we got this handled over here, but this area needs a little bit work. So we're going to be reevaluating our program. This tag number has a lot of deficiencies because unfortunately things just didn't get done. The surveyor will determine if it is hospital-wide and program specific. They will also make sure that it gathers and assesses the data. Has a process to do that. And then what steps did you do to reduce that risk of infections? They'll look for evidence of parameters of your active surveillance. How did you do it? How long did you do it? Who did you check on? They'll make sure that it's consistent with the standards of practice and that it's suitable for what you are doing. Again, they won't tell you, oh, maybe, you know, you should do more of this or maybe more of that. They want to make sure that first off you're doing it and maybe it is appropriate. They won't tell you what to do. That's up to you. They'll just identify if it's not quite meeting the complexity of your services. Now, CMS and CDC did put out a joint statement. All infections that meet the specified, this is a national reporting network, criteria. And this is what CMS requires for your incentive payment or public reporting. CMS, other payers, they use this to determine your pay for performance. And all facilities really need to adhere to these protocols, definitions, and criteria to ensure that you are making, comparing data adequately. And so here's the link there for you, acute care hospitals, your reporting to the National Healthcare Safety Network on your infections. And it tells, it just gives some also examples on how to set up reporting to the network and protocols. I did try to put up the most recent one for August of 2022. I've not seen a newer one come up as of yet. And there's even a checklist on reporting to CMS for what you do have to do. So these are for your acutes, your MDRO, CDI monthly denominators, for example, device associated, like with the intensive care unit, your ventilators, your nebulizers, whatever helps to be. So from infection prevention, I wanna now go to antibiotic stewardship program. This is a little bit different. And again, I'm just gonna cover the aspects of it. As we go through the program, I'm really gonna then give more information on the preventionist and the leader of the antibiotic stewardship program, what they have to do. And that brings us to question two, Lindsey. Okay, again, I'm gonna read this top part for you, and then I'll put up your options here for your answers. This question says, hospital B was cited for an insufficient antibiotic stewardship program following an increase in C. diff cases. The infection preventionist has reached out to you for suggestions on who to include in a committee to study the problem, and who would you suggest? And let's go ahead and get these options up here for you. Okay, you should now see this on your screen. So pharmacy, nursing, medical staff, QAPI leadership, or possibly all of the above. And Laura, we do have one question that has come in here to the Q&A while we still have some answers coming in, that asks, what are the implications for the entire conversation and rule changes for newly converting rural emergency hospitals? Ooh. Oh, that's so new. Mm-hmm. Because I did check into that rural, there's not too many that have converted yet, but they have to follow what the acute and critical access, and especially critical access, because that's who's converting. You've got a critical that's converting to your rural emergency hospital. So I would listen to this and follow this, because that's what the criticals have to do, is what the regulations are here. They've just pretty much mimicked it. We just don't have the interpretive guidelines as of yet. Because granted, yes, rural emergency hospitals, they don't have inpatients. They're not allowed to have inpatients, but you might have a patient who's there longer than what you hope to until you can get them transferred. So they may be bringing in all sorts of bugs and hosts with them. That's why you still need to follow. I'd follow this until further notice from CMS. Okay, and I'll go ahead and end this poll and share that result. There, looks like we have a pretty resounding response here. Oh, the above. When in doubt, add some more bodies, right? Okay, so here's just some updates. Now, there are several requirements we're talking on antibiotic stewardship program. They are not in this manual. Now, I know that says 2023, but it's the same thing. They haven't updated 2024 either. The tag numbers go from 760 to 768. Eight whole tag numbers, but they've made some changes. Everything that I'm gonna be covering for interpretive guidelines are in the burden reduction, excuse me, memo. It starts on page 72 of that rule. That's why I wanted to give you as much information to try and follow and find what do I have to do for this one. Now, CMS does know this is a very special challenge for facilities. What you're trying to address, treatment of infectious diseases, medication safety, and yet preventing those MDROs. Now, what is that fine balance? Like I have to treat this patient, but okay, now I'm over my criteria limit, but yet the patient still remains sick. So CMS still does recognize it is a challenge. So the program itself, just the program, is that you have to show with this program, you have someone who is qualified in either infectious disease or antibiotic stewardship program. And they can be qualified through education, training, or experience. Like the preventionist, they are also appointed by the governing body as the leader, but that's based on the recommendations of medical and pharmacy, not nursing. Because again, they wanna promote this hospital-wide culture where everybody, all areas are being solicited. Could you include nursing? Sure you could. There's no reason you can't, but at a minimum, the recommendation is on pharmacy and medicine. This person, again, has to show they are qualified through education, training, experience, or certification and stewardship. Now, ideally, you can have a joint leadership between medicine and pharmacy. That's great. But again, the appointment is made from those two components of your hospital leadership. Training, they can be by specialty boards. It can be adult or pediatric infectious disease. And there's a few that they do list as far as where you can get that training and certification, internal medicine, pediatrics, infectious disease pharmacists that they can. Now, like the preventionist a little bit, the antibiotic stewardship, they have to have a staff. And they also need to keep up with their qualifications through ongoing training. Now, they can go through courses that they want, or if you have national meetings, whatever it is. I've listed just some of them out here that provide these meetings, that if you are going to have a stewardship staff, because you're big enough, and it's probably helpful to you also, those are just some of them. Society of Healthcare, Epidemiology of America, Infectious Disease Society, all of these, that's what they do. That's what they talk about. As far as how many, just like with the preventionists, they won't tell you how many you need, how many hours they have to dedicate to the program, but they also have to have enough resources so they can do their job. And like with the preventionists, if you've got more than one, work together. You might wanna look at your census, population, and complexity of services. Shaya has those recommendations already spelled out. How many would I need based upon the size of my hospital, based upon the services we provide, and our patient population? What should we have based upon that national recognized society? You have to have policies also to implement as far as optimum use of antibiotics, and that's where the staff and the leader is responsible for it. Those policies need to cover what are the roles and responsibilities for stewardship, and that's used within the hospital. How are your committees, your departments, are going to interface with the stewardship program? Again, the overall goal is to optimize the use of antibiotics. So we're using them appropriately, but not too much. The surveyor, they, like the preventionists, will determine that they are first appointed by the board, and they'll look at their staff files to make sure they're qualified. Is it there? Now, when they are looking at, especially the leader, they wanna make sure that somewhere, like in their job description, it designates what they are responsible to do. They're responsible for the program. They are responsible to communicate back to the board, to QAPI, when there are issues or concerns. They'll make sure that the staff, that they're developed and implemented those policy and procedures, and what criteria did you use to determine how many resources do you need in order to meet the needs for this program? There also has to be coordination among all components who are responsible for antibiotic use, infection prevention and control program, nursing, pharmacy, medicine, QAPI. So they, again, want you all working together. The guidelines say we have to develop and put into place interventions to address those issues you've identified through your own assessments. And then how are your interventions working? Are they effective? Are we improving our coordination amongst all of those who are responsible for antibiotic use? Again, like we just mentioned, everybody, QAPI, medical staff, nursing, lab, we got to include lab in there because we need to find out what bugs are we growing? And pharmacy, what's our more vacant, and excuse me, most recent antibiotic? What's our third generation if that's the case? Because the idea is we're just trying to improve prescribing of antibiotics and reduce that chance of C. diff or drug-resistant organisms. We have to put into place and keep a program that is effective for doing so. And curbing also the risk for treatment failures. C. diff, adverse drug events even. I don't know if any of you have ever seen a Stevens-Johnson response to an administration of an antibiotic, but it is horrific. And that's some of the adverse drug events that they are talking about. And that robust program that really is coordinated through everything to do not only with ASP, but infection prevention and control. Now, surprisingly, I just wanna point one thing out. They did notice in a recent article, an increase of drug-resistant organisms after COVID. And it still is at least 12% above our pre-pandemic levels, surprisingly. This just came out, but it's higher than it was before COVID, surprisingly. CMS, CDC, they talk about their interoperability program, that electronic report, again, for payment, like we did for reporting of infections. Most acute hospitals, they already participate. You're already in there. I don't cover that in here because it's a very specialized program that really your antibiotic steward and leadership people need to be a part of. If you're critical, you are eligible. Just check with who's in charge of your quality reporting to see if you're eligible to participate. It's reporting your antibiotic use, surveillance measures, that's for your electronic record, that began in January of this year. I have more information on where you can find as far as that interoperability program. Surveyor procedures, they, again, will look at your policy and procedures. They want evidence, this is going across the hospital, that all components are responsible for this program. Also, they want to make sure infection prevention and control, QAPI, nursing, medicine, pharmacists, they're all involved in this entire program. As with anything, we have to do documentation. And hospital-wide program documents, they want evidence-based use of antibiotics. Again, reducing the consequences and preventing our CDIs. Document what you're doing. Take credit for your improvements and those you've been able to sustain. You must provide documentation of those improvements toward better use of your antibiotics. And any advancements that come along, make sure that you are updating your documentation in that respect. The guide program has to adhere to nationally recognized guidelines and best practices. You have to make sure that it help implement and maintains that hospital-wide program consistent with those standards. Surveyors, they want to make sure that they have been implemented. Core elements of best practices have been included in the program. Speaking of which, there is a resource, CDC has those core elements for you on antibiotic stewardship program. Includes those key principles to help improve the use. And it does know, okay, just because hospital A is doing it and it's working great, doesn't mean that's working for hospital D. They know that. And also there is, you know, this medical decision-making is very complex. So they do also recognize that. And variability in size, type of care, you have to be flexible. And so they do recognize that there are some things that just not one size fits all, but it definitely has to reflect your scope and complexity. It must. And the surveyor wants those parameters. Is it suitable for the size of your facility and the services you offer? As with anything governing body leadership, they have responsibilities. And CMS is really focusing on some of those. They want to make sure there are systems in place. These systems are operational for tracking, not only your infection prevention and control, but your antibiotic use. And then that they are providing resources to show implementation. It's successful and you can sustain it. The guidelines under here, that it does require their support and they're accountable for it too. They want to make sure there's participation of your medical and pharmacy director and your leadership, not only from just administration, your C-suite, but just overall nursing and those who with designated responsibilities for both programs. The board, or if you're small enough, maybe one person, they have to show that the program has been implemented. It works, it's successful, and it's sustainable. Policies should also address the roles and responsibilities for those who have that duty, infection prevention, how committees and departments work with your control program, how you're preventing these infectious and communicable diseases, how you report them to the program. We have to have policies on antibiotic stewardship also, and that what are the roles and responsibilities, how did the committees work together, how are you monitoring and improving antibiotic use? The surveyor wants to see those policies and board minutes for record of support of those programs. They will verify policies are being done. They want to make sure they're being followed. What they will probably do they'll look through your policy and they go talk to your staff. They will look through your policies and go look at medical records, antibiotic use. Is there been some communication between perhaps physicians and pharmacy when there's an issue on long-term IV antibiotic therapy or extended IV antibiotic therapy? That's what they're looking for. Leadership with QAPI, governing board has to make sure that infections, diseases, all hospital acquired infections that go through QAPI and antibiotic uses are addressed. And also, especially with QAPI leadership because then this is a hospital-wide program. There has to be internal coordination of all components for this program. Prevention and control, ASP, QAPI, medical staff, nursing, lab, pharmacy. A lot of people are involved in that coordination. As far as specific leadership duties, well, QAPI and training has to be involved in these problems, addressing these problems. Leadership, they're jointly responsible to make sure infection prevention and control, ASP, QAPI, and leadership, they're all connected together, that there's a linking of those. Oh, they don't have to carry it out, of course, but they need to know it's there and how does it work. And they are explicitly responsible for implementation of a successful corrective action plans. In other words, if there's a problem, they are responsible to make sure the plan is in place, it's being followed, it's being assessed. Is this plan of action actually working? And if not, then you go back and do a corrective action. That is explicitly a responsibility of leadership. And then there's certain education that CMS did lay out on who should have education infection prevention, and especially the principles. Well, a lot of that, the really hardcore principles, that, of course, goes to those who have direct patient contact or in contact with medical equipment, those who prescribe and administer antibiotics. But they pretty much say just about everyone. That can be nursing, medicine, pharmacy, but don't forget the others who may come into contact with the patients or deal with equipment. That could be your biomed technicians, could be housekeeping, are they keeping the place clean? Do you use volunteers for patient care? That could be transporting. And are they wearing a mask if they're showing any signs and symptoms? Students and trainees in healthcare professionals. So pretty much everyone needs to have some training on the principles of infection prevention and those who prescribe antibiotics. The surveyor will confirm that there is coordination with QAPI, medicine, nursing, and pharmacy. They wanna see the minutes. That's what they're going to look for. They'll make sure the program training, they address those problems. Problems are also reported to leadership. And then leadership is doing what they're supposed to do. Take actions, put those corrective items into place that they're working and that they're successful. But also I would urge that they're sustainable. Now, if you're going through major changes within your program, you may find it just, you can't keep doing it because it's so itemized, so in depth. Maybe you need to go back and look at it again because sometimes once it gets so many steps and so many things, we drop a step or we do a workaround. So keep that in mind when you're developing, if you have to do any improvement projects. All right, now I'm gonna go back to the preventionists. I only do this because this is how CMS set up the manual. This is what your infection preventionists must do. They have to put together policy and procedures for the hospital-wide program that adheres to those national guidelines. You have the flexibility to do what works best for you, but they do wanna see engagement in innovative practices. And don't forget those evidence-based models. You know, those work, they're evidence-based. We've proven that. The surveyor will confirm that program is consistent with the standards. That's what they will do. And that includes documentation because the preventionists must keep documentation of the program and the activities. Again, surveillance and control. How you do it, that's up to you. Electronics, nice, because then you'll have a handwriting issue, but you can keep it, whereas if it's written, the notes may get lost, misplaced, wherever it happens to be. Under the guidelines, you wanna collect and maintain pertinent information in a systematic fashion. So Health and Human Services, they have an action plan to prevent hospital-acquired events. I've got the link there. This is on slide number 90. Surveyor wants documentation of those activities. So they need to see what you've done. It can't all be in your head. It doesn't work that way. They need to have it written out so they can review it. The preventionists, they have to communicate and collaborate with QAPI on all issues, whether it's prevention or control. They need to be up on what are the emerging concerns. Again, are MDROs for one thing, but also measles. Maybe those that are already there and problematic within your hospital because they really want to foster and enhance that proactive culture. And that's what the surveyor will look for. How are they communicating with that QAPI program? Are there minutes? Are they part of their monthly meetings? And is their documentation something to support what they're doing? They have to be trained. So they have to also provide training to others. They have to provide competency-based training and education, not just sitting there chatting, but there has to be some, hey, how are you know you're competent? Whether it's staff, medical staff, even contracted personnel. If you have hospitalists, you need to make sure that they are also included in this training and competency. And it must include those practical applications for prevention and control. But don't forget your policy and procedures. Going through those highlights with, hey, this is what you need to know to complete your job. The preventionist has to have an active role. The surveyor will look at the policies on your training and your education. They want to make sure also that it is competency-based and they will look at staff records for that completed competencies. This can be a short five-question quiz to show, yes, they are competent or how many ever wish to have. They're also responsible for auditing personnel's adherence. Are they, as a staff, doing what they're supposed to do? They're responsible to communicate and collaborate with the ASP, the Antibiotic Stewardship Program. The surveyor, they want something of auditing for adherence and communication and collaboration. These could be minutes. And if you're gonna be doing emails back and forth, keep those emails so you can show, hey, yes, indeed, we are communicating with each other. As with the preventionist, the leader of the Antibiotic Stewardship Program, they are responsible to develop and put into place the hospital-wide program. And like everything else, it's based on nationally recognized guidelines and best practices with the goal to monitor and improve the use of those antibiotics. The guidelines, you have to make sure that we're using antibiotics appropriately. And this does require dedicated and expert leadership. You just can't have someone who said, yeah, I've got some interest in doing that. No, they need to have education, experience, and training because they are responsible and accountable for the success of this entire hospital-wide program. As with the preventionist, they also have to document. And that's everything that goes on with the program, the activities, they can be written or electronic documentation, they don't care. But again, having that electronic, it's there and you can easily access it. The surveyor, as far as the past two, they wanna make sure the leader has developed and put into place guidelines, a program that is based on nationally recognized guidelines and that they can monitor and improve the use of antibiotics. They document the activities. And it's not that they have to document each and every one of them, but they have to make sure it is being documented by their staff. They also have to communicate with folks, medical staff, nursing and pharmacy leadership, our preventionist on antibiotic use. And they also, like the preventionist, have to do education and training for staff. And that includes medical staff and those contracted, those who write prescriptions. There are guidelines, policy and procedures that they have to make sure they're aware of. Now, this is how we do our antibiotic ordering. Surveyor will verify they do provide training to all required personnel. Now, I'm gonna go over to a unified integrated program. And this is for multi-hospital, this is for systems in place. Now, it mentions here not for critical access hospitals. I only mentioned that because CMS didn't quite address critical access hospitals as being a part of this. If you're in a system, a unified integrated system where you happen to have a critical access hospital, they can do it, they can still participate, but they don't reference critical access hospitals. You will not see a coordinating tag number for critical access hospitals. Why they didn't do that, I think they just kind of forgot. But you're not prohibited from participating. So that brings me to question number three, Lindsey. Okay, I'm gonna again read this top part and then I'll post your options up there for you. This says hospital A is considering a joint arrangement with a large system to improve its infection prevention and control program. What should be considered in that decision? Okay, and here are your options. What can be gained as to resources, patient population that will be served? Are the other hospitals CMS certified and all of the above? It looks like we just have one question that has come in, Laura, that asks, what qualifies as a national standard? Look for those, I had listed out those like SHEA, IDEA. They're the experts in developing those standards. CMS can't, they won't do it. But that's who you wanna look for. Those professional organizations that develop the standards, like ACR would do it for radiology, ASA would do it for anesthesiology. It's those societies, that's the nationally recognized standards and guidelines for doing a guideline. Okay, I don't see any other pending questions. I'll go ahead and end this poll and share the results there. All right, all of the above. Yep. Because it's really nice when you can use other resources, you can do this. The requirements are each and every hospital must be separately certified. If you're going to do this, you have a governing body that is legally responsible for two or more hospitals. And the governing body elects to do this, it's not required, it's simply an option. You have to conform, every hospital has to conform with that decision and make sure it does meet state or local laws if there is any prohibition on anything. And the governing body has to make sure that every hospital that's going to participate meets all of the requirements of this section. So what does each hospital have to do? Well, they have to make sure that they are accountable to the governing body, they meet all of the requirements of both infection prevention and control and antibiotic stewardship programs. It must be set up in such a way that takes into account what are your circumstances, each hospital's circumstances, patient population, services offered, that must be taken into account. They can't just say, well, we're not going to participate that much, but we're not going to be involved. But if they're going to play along, they have to play along, they have to be there. The survey looks at the process so that each one of the services or patient populations are actually integrated into this program. You have policies, procedures in place that make sure those needs, the concerns are given due consideration, doesn't matter where they're located, doesn't matter what practice. Those of you who may have, you're part of a system, you have behavioral health patients. Okay, they still have to be protected and taken into account, just as if you're running in the same system, a mother baby. They all have to be taken into consideration. The surveyor looks at the program. How did you identify the needs of each hospital when you put together your policy and procedures? Now, how did you take into account when you have that burn unit or burn hospital versus a child's hospital? How did you do that, that you've identified those needs? There has to be a mechanism to ensure that if there's an issue at a hospital, again, taken into account and addressed. You have to identify and address any QAPI issues to that hospital. And the surveyor, likewise, will look at your QAPI to identify, is it a unified element and those that are unique to a hospital? How do they all go into this program so that it's well done? You can have a qualified person or group who has, again, expertise in infection prevention and control, designated the responsibility for communicating with that unified program that they maintain and implement policy and procedures over your unified infection prevention program. And they give education and training to those hospitals and the staff at those hospitals. Now, they don't have to go to each hospital. They don't want to. You can have all the people come to your hospital, whatever works best and most efficient, but they still have to have that education and other duties that they're responsible for in completing and making sure the program is successful. They're going to look at the governing body policies. They want to make sure that person is qualified to make sure there's communication, training, implementation, and maintaining all of those policy and procedures. They want documentation that this person has also communicated back with leadership with what's going on in this unified program. And are there issues that are going on in one hospital? Not in another one, but we're starting to see an uptick in a different infection throughout the system. They look at training documents, that education and prevention and control, also staff training. They, again, they do a lot of deep dives on some of these visits. Okay, let's move over to joint commission. So what, if you have deemed status in particular, this is kind of important for you to listen to because if you have deemed status, you don't have to go through a state survey. Not that you won't, but CMS is pretty good. They're beefing up some of their activities. We're looking to revamp their infection prevention and control. As far as antibiotic stewardship, they reference, it's reference only here, because I want to help you with your CMS regs, again, especially with deemed status. They updated the antibiotic stewardship program requirements, like CMS. The idea is they want to slow the progression and spread of those resistant infections. They mentioned the CDC statuses and statistics, 2.8 million antibiotic resistant infections annually. 35,000 people died as a result of those antibiotic resistant infections. And that's why really using antibiotics is so crucial. They put it under medication management, and they updated the chapter, really took out a whole bunch of the elements of performance, but did add one. So like with CMS, you establish an antimicrobial stewardship program, and they have it as an organizational priority. There are 12 elements of performance. Again, there used to be a lot more. Now there's only 12. And it starts at elements of performance 10. Here they say, and this one's new, a hospital allocates financial resources for staffing and IT to support this program. Back in CMS, they said, make sure you have enough resources, but Joint Commission says financial resources. They really hone it down. The governing body elects this person, whether it's a physician or a pharmacist or both, who have education and experience in infectious disease and or antibiotic stewardship program, and based on recommendations at the pharmacy and medical staff. This leader develops and puts together their program based upon those guidelines. They document the activities, and they collaborate with medicine, nursing, pharmacy, and infection prevention. They provide training for all staff on practical applications of these guidelines, policy, and procedures. And you probably think, okay, what can nursing do? Sometimes nursing can remind a physician, hey, we're getting close to those days that there can be on IV antibiotics before we convert them to orals. So just want to do a quick general reminder, if pharmacy has not done that already. They talk about a multidisciplinary team on antimicrobial stewardship. They oversee the program. And note one discusses who should be on that team. Here they add IT and microbiology that CMS didn't. They added medicine, pharmacy, infection prevention, nursing, QAPI. Note two talks about the members. And here they say they can be part-time, full-time, consultant, on-site, remote, wherever it works for you. So I like that Joint Commission did give us a little bit more information on what's required. We have to have coordination of all components within the hospital. This is another new one. And again, like with CMS, the infection prevention, QAPI, medicine, nursing, and pharmacy. So somewhat of a repeat, but not quite. You document evidence of your antibiotics, your uses within services and departments. You monitor your antibiotic use. Here they do give us some guidance on the number of days, you know, data of days on therapy per 1,000 days of patient days. So they give you an idea about what to look for. And also reporting to the National Healthcare Safety Network that antibiotic use, excuse me, that I had mentioned earlier. This program implements one or a couple strategies to optimize antibiotic prescribing. They talk about preauthorization for specific antibiotics, such as internal review and approval prior to use. Also giving prospective feedback regarding prescribing practices. This is usually by someone, a member of the ASP, say treatment for positive blood cultures, giving feedback to those providers. So, you know, hey, this worked in this situation, but now we're finding a trend where that's not working so much anymore. And then putting together the guidelines that you have at least two evidence-based guidelines to improve our antibiotic use. And again, this is another new one. They talk about everything from skin, soft tissue infections, to C. diff, going from parentals to orals, and using those national guidelines. But also don't forget your local susceptibilities and your patients you're serving and maybe formulary options. The medical board determines, excuse me, medical staff determines the formulary for your hospital. Then, of course, we have to look at our adherence to at least one of those guidelines. Measure adherence, you go by maybe an individual prescriber, or maybe it's a group. Maybe you want to look at how internal medicine is prescribing. Maybe you want to look at how pediatrics is prescribing. And obtain your adherence data. Do a sampling of your records for clinical areas, chart audits, EHR data. Sometimes that's where IT can really help you because they can put in what are your parameters and do a quick search and run for you. And then also taking action that the ASP collects and reports data to leaders and prescribers. What is our pattern, our resistant pattern, prescribing practices, evaluation of our stewardship activity. And like everything, you act on those improvement opportunities that your antibiotic stewardship program has identified. So joint commission gives you a little bit more down and dirty information than what CMS would provide. Well, I do want to talk a couple memos. These have changed over the years. I'm trying to circulate in some of the more newer memos, but there are still some that we have to, some happen to be insulin pins because that still comes up. One patient, one patient only. Everyone has to have their own pin and of course marked with the patient's name. Single dose files. We do have, there have been some issues with drug shortages and single dose files are only to be used on one patient, but when we have those shortages or it's a medication that maybe it can be used on more than one, they recognize that through this memo. And so it talked about safe use of these single dose files. One, you can use single dose files on more than one patient if it's prepared by a pharmacist under a laminar hood following those 797 guidelines. Your director of your pharmacy should know those by now. So that's time when you can. If you are doing that, any entry for reconstituting, repackaging, those have to be used within six hours of the initial puncture. Otherwise, if you're using a single dose on more than one patient, it's also a violation of CDC. And so they may notify CDC of this violation. They're cited under infection control because it has to be a sanitary environment. And it doesn't just mean surgery or medicine floors. They're talking any, this applies to anybody, ASCs, hospice, critical access, dialysis, infusion therapy. It's all the same. And the basic requirements are very, very common. These been around for a while. If it comes in a single dose file, buy it as such. If it's only multi-dose, then use on one patient, mark it to expire in 28 days, and don't take it into the room or surgery. That the reason is that they only want the single dose on one is because there's no antimicrobial. There's no preservatives. And once entered, it takes over the microorganisms can grow. Have a beyond you state, storage conditions on the vial. This is where your pharmacy needs to help you with it. If you're using compounding vendor within your hospital, these are those where you've got your medications who they call it repackaging, but it's constituting, putting it together. It's an offsite vendor or facilities, ask for that evidence of their compliance and adherence to those 797. You can ask for that. In fact, I've even put it into a contract that you are, you can get it when you want it. There is a tool to assess these contractors who do provide your sterile products. The link is in the appendix for you on where to find it. How do you assess it? That's where your pharmacist is so crucial in helping with this part of infection prevention. We also have several breaches that we have to notify health authorities. And this includes those where a state agency might come in and find an issue. CMS, they have a list of those breaches that should be referred to your state authority, like your state healthcare associated infection prevention coordinator. For one, using the same needle on more than one patient. And it has cropped up again. It's back again. Same pre-filled injection syringe. Same Lansing device on more than one. Even if you change the Lancet, it's still contaminated. And of course, we don't ever want to get the headline or hospitals in the headlines when we do have an issue. This happened, unfortunately, back in 2010. And there's still a little bit of fallout from it, but we had a technician who was going into the surgical suites, and she would be in there before a surgery started. And the good stuff, the fentanyl, the Versed, and all that stuff had already been pre-drawn up and laid out on the anesthesia cart with the trusting environment that nobody's going to disturb them. Unfortunately, this individual had quite a substance use disorder. And she went in, grabbed them, injected herself, returned the dirty needle and syringe filled with saline back to the cart. And this had gone on for a while before they caught on that we have all of a sudden, what's this outbreak of HIV and hepatitis? And there were some patients who actually did contract it as a result of that use. So reusing a needle or syringe that's already been given, you don't do that. You just don't use it. Because this is when the contents go into that other container. We're all very familiar with the event down in Nevada, where I believe this was a gastroenterologist who was doing it. They had one patient, first patient of the day, happened to have hepatitis C, and the reuse just passed it on down. Thousands of patients were infected. The physician ended up going to prison. And by the way, there has been another recent event in New Mexico this time, where needles were reused. And I believe they called it the vampire facial. And these occurred between 2018 and 2023, but they were finally able to track it back and find out what had happened, and they had reused the needles. And this was a situation where one patient, one patient, their partner was HIV positive. And so that's where the transmission came when they withdrew blood using the dirty needle and syringe, and then injected another patient using that same dirty needle and syringe. So unfortunately, this does continue. Okay, Legionella, as I mentioned, that's still going on. I want to talk about some of the Joint Commission standards in respect to this one. The bacterium causes pneumonia. Those of us who've been around for weeks, and we like to have to admit to, remember the huge outbreak back in the 80s, where it all started. That's where they realized it started in water systems that were continually wet. And it happened to be actually started, they first noticed it and really made the headlines because of a hotel where it broke out, but it's in other areas. That's why hospitals really started to become the focus because we have areas that are constantly wet, whether it's a showerhead, a water storage tank, eyewash stations, ice machines. If it can be continuously wet, it has the potential for growing up. So they want hospitals to do this facility risk assessment. Could it spread within your entire system? If it could, and I mean it could, you have to make sure you have policies and procedures implemented, because it still remains an issue. This was last year, two people came up with Legionellas at UW Medical Center in Washington State. So joint commission, they do, in their environment, this bug, along with other pathogens, following any laws and regulations, and there are four elements of performance. And what they're looking at is following those, these really do follow CMS pretty much word for word. Someone's responsible, or you have a team for oversight of your water management program. They develop it, they manage it, and make sure maintenance activities are done. They have to develop the basic diaphragm. Really what they're doing is they want you to map out your water supply sources. And that also, where is the treatment of these water supplies? How are you going to process it? Control measures for your water management program. And then end use points. So that's what that person has to map out. You have to have a program that is based on that diagram, that uses evaluation of physical or chemical conditions, each step of that water flow, looking at those areas where something could happen. Is it slow, stagnant water? Have you shut down part of your hospital, or your floor, or unit, an area? You've got stagnant water, so you need to take that into account. Is it unoccupied, or temporarily closed? If you're doing reconstruction, that's one area you really want to make sure you're focusing on, because that water system may have been shut down. Now this does refer to the CDC Prevention Water Infection Control Risk Assessment. There is that tool, as I mentioned, that you can use as an example. Look at your patient populations, and especially those who are immunocompromised. This is a very, how do I want to say, very host-seeking bug. And when you have those patients who are higher risk, the elderly, immunocompromised, they are very opportunistic. Monitor protocols, acceptable ranges for your control measures. Also that you give consideration to best practices, temperature, residual disinfectant, pH, and then, of course, protocols on monitoring it. Documentation, like with anything, we have to keep documentation of all of our actions, our procedures. What do you do if you're outside your scope, and how are you going to handle that? And corrective actions, when you don't, when you're not able to maintain them. Okay. Program review, look at your program annually, and then any changes that you may have made to your water system. Did you update a water heater? Did you maybe put down new plumbing, or reroute plumbing? Any other new equipment that could generate even aerosols, like a new wing, a new building, ICU? Joint Commission, CMF, they don't require culturing, but they do mention the ASHRAE Standards Legionellosis, so they do mention it. You're not required to culture for Legionella and others. Just keep that in mind, but if you're doing a water management program, how else would you know culturing? Okay. Antibiotic stewardship, I do want to talk about some of the core elements for the program. They updated in 19, good examples of leadership's commitment, and really looking at those priority interventions and measures. The key role of your pharmacy and nursing in improving our antibiotic use. This is great, because these are all free. You can download them, nice checklist, that assessment tool that you can utilize. By the way, they have, again, the program assessment tool that you can tap into. They have one for small hospitals and critical access hospitals. They talk about in criticals that you can have a pharmacist leader who has drug expertise if you don't have the benefit of physician for your antibiotic stewardship program. I've always tried to include all of these that have their link so you can include it. So as we start to wind down, I do want to talk about our devices and our reasonable medical devices because, again, we had a little issue here in Colorado where we had patients who died who, after becoming infected with a medical device that caused these fatal injections. And it was that good old Duodenoscope and how getting in and trying to clean out those little items. It did shut down the program for a little while until they couldn't figure out. You know, nine patients, that's nine too many. They do have the CDC and FDA update, keep your clean environment, disinfect or sterilize reusable medical devices. That's why you have to policies consistent with those current standards, comply with the steps that's set out by the device manufacturer. They also put out a memo that clarified that if you outsource contract maintenance and repair, it doesn't have to be only a certified vendor because no one was doing it. There was a little confusion when it first came out, but there were no certified vendors when that came out. And so that just to be the update, I've got the link there for you. So what they do here is they separate between critical and semi-critical. Critical is the ones that have to be sterilized. That's your instruments, your surgical instruments, where you're going into the sterile tissue or vascular system, you're doing your counts. Yes, you have to have it sterilized. And if you're using anything that could be attached to it, like a suction, they have to be cleaned and sterilized. Semi-criticals, that's where they require cleaning and high level disinfection. That's where we dropped a few steps here in Colorado. That's what they found out, that they weren't quite getting into those crevices as was required by the manufacturer. So it could be your laryngoscopes, endoscopies, whether it's upper endoscopy, colonoscopy. FDA, CDC, they have device reprocessing. That's why they suggest use that professional, someone who knows it. And if nothing else, you want to do an internal, okay, have them come in and assess it. Are you missing a step? Do we need to do a little more training? They talk about training requirements, not only with orientation, but annually, as just a refresher. And of course, documenting that training, that competency, that see one, do one, teach one if that works for you. Trainer, observe staff before they're allowed to do it alone, but always have a copy of the instructions so they can go back and refer to it. And you might want to just do some spot checks now and then, your infection preventionist or whoever's tasked with that responsibility. Did they drop a step? They figure, eh, no, we don't need to do that. Every step has to be done accordingly. So that's why you want to do some audit. How are they cleaning and disinfecting? Ask them, how would you do this? Teach me how to do this as though I'm a brand new person. You might find a step might have accidentally got missed. And of course, policy and procedures. One of the issues that we've seen in the past is there's not enough time to do what's required. So you have to provide that adequate time. Cleaning. Following each step the manufacturer has set out. Have a way to tell. Is it ready for patient use? Do you have to tag something? Is it appropriately sealed for that tag to maintain? What do you do if there is a reprocessing error? What's the next step? How are you going to handle that? And then some infection control information for you. And that's my last question in this segment. Lindsay, would you put that up for me? Sure will. I'll read this first part here first that says Hospital C has experienced a turnover in staff and they are having challenges keeping an infection preventionist. Leadership wants to designate a person who has been an infection control champion for years. Who do you recommend that Hospital C do for this to occur? Let's go ahead and get your options here. Okay. The first one is have the person follow an infectious disease provider for one month. Look for training through the CDC and national organizations or possibly appoint them and hope for the best. And I know that sounds like really well, you'd be surprised. There may be some of the attendees who go, oh yeah, I know that person. And Laura, we do have a few questions that have come in. If you want to address those now. Absolutely. Yes. Okay. This one asks, what are there a few examples of what you meant by other pathogens in water management plans? There were bacterial, bacterium, I'm trying to remember. It's a long word. I've got them into the, into the program on how I think bacterial bacterium, I'm sorry if I'm butchering the name there, but that's one of those that really come into the water pathogen program. Now there was a mention of Pseudomonas a while ago. I'm not too sure if that was what they meant to include in that list. But that was another one that had cropped up on a previous list that they had happened to have. Check again, your epidemiologists would know what more of those are your manager of your water management program. What can crop up in that, along with Legionella. Okay. And then this next question asks, is comprehensive water culturing expected to be done in addition to Legionella screening? Again, they won't tell you. CMS and Joint Commission doesn't say you have to do it. But if that's part of a normal nationally recognized guideline, that's what you want to follow, your culturing of your water management system. Okay. And then this last question I see says, potable tap water is not expected to be sterile. Have acceptable limits been established? That I cannot answer. I can't answer if the tap water, if there's any acceptable limits on those. Because that could depend on, again, where you live. I'm from a farming community. And when I think of some of the water supply there, it can get a little interesting. As if you're living in or near an industrial area, what are the limits that you're allowed to have? And we're going through that here in Colorado, where we have a petroleum manufacturing and refining area. And we keep having issues with our water control that's cropping up as a result of it. And that could be where, check again with your state guidelines on which ones they're allowing and which ones they're not allowing. Perfect. And then I see somebody has typed in here into the comments. Thank you, Kate. She's typed in the other pathogens in water management plans. So hopefully that's helpful there for everyone. Thank you. Some of those words. And I wouldn't, I was going to say, I wouldn't even attempt to say some of those words. Okay. I'm going to go ahead and end this poll and share those results here. Yes. Look, they're training. Yes. CDC, national organizations. Yeah. Go with what's free, because if they're doing it, CDC is doing it. You know, they've got a pretty good handle on what's going on. All right. Excuse me. There we go. They have it. That's very widely read. They change sections and in particular with PPE, whether it's how much do you have to have on eye protection, gowns, face masks, respirators, ventilators, what are the requirements for those? There's a section even on infection control on hand hygiene. There are the core infection prevention control settings for delivery. This was the most recent one that, you know, I could find on what they have to have. Some really good free training through CDC. Now, yes, this is nursing home oriented, but a lot of those same issues apply to you. 24 modules, handles everything from water management to injection safety, covering your mouth when you cough or whatever, your plan, your surveillance. It's nice. Again, it's free. You can download it. It will tell you how long they usually last and how long they run. There's the STRIVE program. This was developed with Health Research and Education Trust. Do it any order you want. This is really good for new employee training. It's a lot more broad and basic. It includes, again, personal protective equipment, hand hygiene, competency-based audit and feedback, even including patients and family. Now, when family come in, they got to remember it might not be a bad idea to wash your hands, especially with your elderly or immunocompromised patients that, you know, we got to protect them from, you know, make sure they're also covered with the family. And again, just the American Nephrology Nurses Association retraining. They do talk about CDC. Infection control for your personnel. And these are your staff members. They did update the guidelines for healthcare personnel, eight elements for occupational health. Of course, we want resources on your immunization program. Have that organizational culture that, yes, this is important. We're going to protect each other. What are their risks in their particular job? It's very different when you have somebody who works in nursing and bedside care than, say, someone who works in medical records. Performance measures, how you monitor, a job description so they know what are their risks. For working bedside nursing, my job description included that I may be exposed to some pretty nasty bugs just in my day-to-day patients. And then there is the executive summary updates for you. And then guidelines on your core infection program for safe delivery. I did want to mention APEC, their competency for infection prevention. I tried to find out if there was a cost for this, but I could not find it. So there may be a cost on this competency model. So just keep that in mind. But one that doesn't is your DNV. That's Del Norte. This is a Danish company, but CMS has recognized them, and they have deemed status also with CMS. So they have healthcare training in infection prevention. There is a very basic, and then there is also the advanced portion, if that's what you want. And I did talk briefly about the CMS worksheets. CMS used this years ago. They don't use them anymore. They did it when they were trying to put together those new hospital improvement and burden reduction. So they have discharge planning, quality improvement, and infection prevention. Now infection prevention happened to be the big one. It's 49 pages long. They never used it in a critical access hospital, but these were great self-assessment tools because it really gives you an idea. What are they going to be looking at? What do they want to focus on? You won't find everything that's in these worksheets that's in the manual. You won't find everything or even in that memo, but it's a good way to find out, how are we doing? In case you're looking at, oh, it's about time for us to be surveyed, and keep an eye on that. So again, good resource. I've got the links in the appendix. And then just a few items I do want to mention, because this sometimes brings up a little discussion. One is artificial nails. This was from, part of it was from AORN. I did want to include it. If you have in your surgical, your director of surgery, please make sure they have access to this resource. Yes, there is a fee to join, but it is so crucial. AORN is one of those nationally recognized guidelines, and society, they can develop and help you with these. Direct caregivers cannot wear artificial nails when having direct contact with patients who are at high risk for infection. Because there was some confusion when I said, wait a minute, why can't I have my artificial nails? No, no, they meant those who are at risk, like ICU. Look at your hospital policy. Jail nails, AORN just said flat no, because it's just too much of a risk for contamination. So jail nails, no. Surgical attire, that also raised a lot of discussion, and I think this is still going on in some hospitals. It talks about keeping everything covered, masks, scrubs, caps, even the shoes, what you're wearing. As far as the caps and hoods, cover all head and facial hair. Those in semi-unrestricted areas, in other words, surgery. Masks by all personnel who are in those areas where you have open sterile supplies, scrub people are located. Make sure they are properly tied. And a fresh, clean mask when there is a new surgery or procedure going on. So for some reason, we've managed to complete this a little bit early, and this is my final situation, so hopefully we might have a little time or give folks back a little more time in their morning. And the final discussion was we've got a hospital, C. diff infection, eight patients in two months. Preventionist, ASP, they looked at the records of all eight patients. No real trend as far as type of patient, why were they admitted, and the provider. With the exception of we had all in the exact same room. What should they do now? Observe care, close the room permanently, say it's bad, we're going to get rid of it. Do they close the room and do that deep clean? Review the cleaning schedule. What was done? What was not done? When was it done? Anything else? And you might want to just put your additional suggestions in the comment or the chat section, and Lindsey can read those off for me. And so what would you suggest they do in this situation? And then Lindsey, I'll give it back to you, see if we have any other questions. Perfect. Okay. I don't see any other pending questions at this time. So as Laura said, we do have a few extra minutes here. So if you are thinking about typing in a question, go ahead and do that. Go ahead and put into the Q&A option at the bottom of your Zoom window. Or of course, if you don't see that, you can just go ahead and type your questions there in the chat so we can make sure to address those as well. I see some good responses coming in. And as Laura mentioned, if you have any other suggestions here in response to this final discussion, you can type that into the chat. And I see a couple coming in now. One here that says, change the mattress, perform UV cleaning if available. Looks like we've gotten some good responses here in the chat as well, or excuse me, in the poll as well. So I'll go ahead and end that here and share those results. This says, culture services to see what is found, change the curtains. Oh, those are excellent suggestions. Changing, getting rid of the curtains or changing the mattress, that'd be an excellent suggestion. And sometimes it does, there's a little bit of a financial impact, but it's better than having eight patients with C. diff. Absolutely. Okay. Review the cleaning process of rooms is another comment that just came in here. Now while you're doing, while folks are continuing to type, I do want to just show you, here's the links for those worksheets. You can copy paste whatever you need to do, but they're still there, download them and keep them. They haven't changed since they stopped using them at the site. That happens to be the burden reduction. Keep this handy because again, the interpretive guidelines are in the updated manual. Why they didn't include them, I don't know, they did one in 2023, they did this one just last week or so, and they still don't have them in there. But you will be assessed on them. That happens to be the toolkit for your water management program. This is the most recent toolkit. They talk about adherence to those definitions and criteria. And then just some other items. I do try to always include free items so you don't have to pay, but I do strongly suggest if you have your surgical director, please get them the membership for AORN. That is a huge benefit for your hospital, especially your surgical department, keeping it clean. So again, thank you, everyone. We're done a little bit early. Like I said, you get about 20 minutes back to go get some more coffee, whatever you need to do. And thank you, Lindsay, for all your help during the program today. Absolutely. And I did go ahead and just post some final comments for you all in the chat, just as that reminder that you will receive an email tomorrow morning. Please note that it will come from educationnoreplyatzoom.us, and so because it comes from that Zoom email, those emails do seem to often get called in your spam, quarantine, junk folders, the like. So if you don't see it in your inbox in the morning, I would encourage you to check those additional folders. And then if it's still not there and you'd like to go back and access the recording, we do record these as on demand, meaning that you can use that same Zoom link to access the recording that you're also using to join us for today's live presentation. And then just remember that the recording link is available for 60 days from today's date. And then we do have an additional security measure in place of manually approving each of those recording access requests. So you'll need to click on the Zoom link, type in your information, that will prompt an email to come to us for approval. We approve those requests very quickly. We just ask that you give us one business day, but typically we approve those within a few moments of receiving the request. And then again, you'll have full access for 60 days. And then again, also included in that email tomorrow morning will be a link to the slides that Laura presented today. But I did go ahead and provide that link there for you in the chat to have as a resource now as well. Just seeing lots of hand claps and, you know, great comments here in the chat. Laura, I know this was a great presentation and you always present valuable information. We so greatly appreciate you doing so. And Laura is also wonderful about answering any follow up questions or if you need further clarification. So please don't hesitate to reach out to us at education at gha.org. We'll be happy to get those questions over to Laura and then the response back to you as soon as possible. Okay. Thank you all so much for joining us today and I hope you have a wonderful afternoon. Thank you, Laura. Okay. Thank you, everyone. Thank you, Lindsay.

infection prevention

control

antibiotic stewardship programs

healthcare facilities

qualified leaders

hospital-wide active programs

guidelines adherence

post-COVID era

drug-resistant organisms

policies

staff training

surveillance activities

leadership role