And now, I would like to introduce our speaker to get us started today. 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, she served as the Director of Facility, Patient Safety, and Risk Management and Operations for COPEC 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, foreign area care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she 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 Judge Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. And she is licensed to practice law in Colorado and in California. Thank you for being here with us today, Laura, and we invite you to go ahead and get us started. Okay. Thank you, everyone. And thank you, Lindsay. Again, we're talking on infection prevention and control. And those of you who've been in the area of compliance or risk management, you know that issue's been around in the updates for a couple years. But with some of the infectious issues that are going around, whether it's impacts, a surgence of COVID, whatever it happens to be, the EMS keeps changing some of the rules on us. And so that's why it still remains very pertinent on what we have to do. I always include my disclaimer, and that is the program today is informational only. It is not intended to be legal advice or provide or establish an attorney-client relationship. Please reach out to your own in-house counsel or legal representative for assistance, and especially if it's a particular issue cropping up within your facility. Well, just a brief introduction. This is why we're here and why Georgia Hospital Association does these things for you. That's how you don't get one of these. And that's that statement of deficiency when the state or one of the deemed processes has come around and done their survey and found that we're not in compliance with certain conditions of participation. And no facility wants to get noticed that they have been involuntarily terminated from the Medicare-Medicaid agreement for a lack of compliance, not allowing the surveyors in, or whatever it happened to be. But that can be a huge financial impact for any facility. What we're covering today, and I'm going to start just showing you, here's Appendix A, that's where the bulk of this is. And then for W, for critical access, you have some of it, you have the regulation, we just don't have the interpretive guidelines. So here in Appendix A, and this is the most recent manual they put out in April of 24, you'll see now that they have updated the Infection Prevention and Control, NASP, whereas in the criticals, they haven't gotten around to that yet. That red lettering was what they changed back in 2019. Again, we have the regulation, we just don't have the interpretive guidelines. Now, as a heads up, if you're critical access, you might want to really listen, especially on the acutes, because though they haven't gotten your interpretive guidelines survey procedures out, what they have put out for regulation follows very closely, if not word for word, for the acutes. And they are due to put out a manual this year for critical access, haven't seen one yet, but they are due to put one out. I have a feeling hopefully they'll get all of that put into there, so that you will know exactly what you have to do. So just a couple deficiencies from Infection Prevention and Control. First we didn't have a performance improvement projects on any issues that the hospital happened to be having. They didn't immunize their staff with flu vaccine or ensure staff had immunity to infectious diseases, such as measles and mumps and chickenpox and all of those infectious diseases. There wasn't an infection control program that was ongoing, or have all the required policies. They didn't even enforce their hand hygiene guidelines. They weren't cleaning glucometers, or they even had a dirty keyboard for their computer. They didn't dispose of hazardous waste in the correct container. In other words, it could leak out. There was no documentation of their process, expired medications and equipment, and then just a few more housekeeping carts weren't cleaned, and then they didn't pre-soak dirty surgical instruments. They didn't throw sharps into the proper container. Sharps containers were over the line. I saw that on many of the, especially even just in the clinics, where you could see the syringes and that sticking out from the top of the container. Insulin pins were used inappropriately. Multi-dose vials hadn't been done, and they were also past their expiration date. Those are just some of the more common ones that I had seen when I was reviewing the deficiencies. All right, I'm going to start right off the bat with infection prevention, and we're going to go to Appendix A. I've included in here the tag number and the letter A is, of course, for the acutes. Now, in 2019, this is when the big changes came around. They called it Improvement in Patient Care Rule. Their interpretive guidelines and survey procedures, though, for what they changed in the regulation didn't come around until June of 22. I want to point out something. I showed you the manual for acute hospitals from 2024. It's still not in there, so you have to refer to the memo. I've got the link here to the memo on the next slide. Turn it off. Keep those side-by-side, whatever you want to do if you want to do it electronically, but that's where you'll find the interpretive guidelines. Criticals, you had new tag numbers, but again, only the regulation in there. Very few exceptions with any differences, so here's this memo you want to keep handy. These are the interpretive guidelines and survey procedures for an acute hospital. I wish they had gotten them in there, but when I asked them, I didn't get a response on, you know, when can we see these actually come forth, and why weren't they in that last manual when you had the opportunity to put them in? Lindsey mentioned we have a few questions, so I'm going to go ahead and start it right off. Lindsey. Okay, let's get this one up on your screen. Okay, so hopefully you can all see this one that 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 here? Surgery only, still processing, instrument cleaning, sterilization, nursing, hand hygiene, medical staff, hand hygiene, hygiene, or others? And if you would like to type in your explanation of others, I see several of you selecting that. You can type that into the chat. Really, this could be more than one if we wanted it to be. It didn't have to be one isolated area. We're going to have a couple of them to try and figure out. And the reason I put medical staff in here is there was one preventionist who I was working with and she mentioned, I had a problem with the doctors washing their hands. They'll go in and look at a surgical site, they'll take the dressing off, and then throw their dressing in the trash can and then leave and not wash their hands. So that's why I included medical staff. How do we get it across to everyone that we need to do this? This is our job. We need to protect patients when we are taking care of them from, you know, avoidable infections. And that's one great way to do it is wash your hands. And I see lots of comments here in the chat saying all of the above. Yeah. And that's great. There's the rest of the results there. Yeah. Absolutely. We don't have to stop with just one. Now, this particular situation, it was sterile processing where they were having some problems, but then it was as far as the E. coli, it was nursing. That's where they really had to focus on. It's like, wash your hands when you're getting them to the bathroom, et cetera, whatever you're doing, make sure you are actually washing your hands. So those of you who selected, absolutely, go for it, because you're going to hit the point. You're going to hit the mark and find out where it did actually occur. So we start at TAG A0747, and as I said, you have to have a hospital-wide program to keep an eye on these things, surveil them, prevention and control, not just healthcare associated ones, but things that come in from the outside. Along with that program, we have to have good use of our antibiotics, and that's through our stewardship. Now, one thing, criticals, I have your tag numbers at the bottom of these slides just to avoid redundancy. You do not have, though, a corresponding tag number for this particular item. What does your program have to show? Well, of course, we have to follow national guidelines because CMS doesn't establish those. They want us to go out, find them, and use them. They are the experts. Along with those guidelines, use the best practice to improve our antibiotic use. So we do decrease that MDROs or hospital-acquired infections, and make sure that all of these issues, whether it's infection prevention or antibiotics use, they go through a quality assurance performance improvement program. The interpretive guidelines that are now new, they just came out, it just pretty much repeats a lot of what's in the regulation. It has to be an active program, and it has to be throughout the hospital. It has to also make sure we are smartly using our antibiotics. We need to put a way to prevent, identify, report, investigate, and control all of these infections, and then, again, that same program to identify and control and improve our antibiotic use. It is based on your individual assessment of your hospital, while, of course, staying with our national guidelines and best practices. And also, we need to have policy, procedures, standards, all of these issues go through QAPI. Now, this doesn't have to be one thing all at once. You can do it as you're developing your program or reviewing your program. Now, maybe we do have something wrong with the procedure that we're doing, let's say changing a central line dressing, okay? Take that through our QAPI and find out what's going on. How can we make sure it's the best process? A surveyor will survey once they see your policy and procedures, because what they're looking for is, first off, an active program, that it is throughout your hospital, and that it's doing those items of surveillance, prevention, and control. Also, that you're following national standards of practice and best practices. They want to look at the antibiotic stewardship program. Same thing. Is it hospital-wide? Is it active? And again, we're following standards of practice and best practices. They also review the infection control program for evidence of hospital working with other departments. Like, for example, you're working with infection control. You're working with QAPI when you do have an issue. Same with antibiotic stewardship. They want to see that evidence that you are working collaboratively to identify and come up with your best practices. Next tag number talks about bodies. This is your preventionist. We used to call them the infection control nurse. Now they've taken that away, and it's infection preventionist. So you have to show you have one, maybe more, depending on your size. This person has to be qualified through education, training experience, or if they want to go to the level of certification, that's great. But it has to be an infection prevention and control. This person is appointed by your governing body because they are responsible for that program for the entire hospital. And they use that. They take the recommendations of medical staff and nursing leadership when they are making that appointment. So that's what they want to find out. Is this the best person based upon those who have to work with them in that role? And again, your tag number is below there. The guidelines, whatever you call them, that's up to you. Some of the references are epidemiologists, infection control professionals, preventionists, however you want to call them. That's what their job has to include. There is a definition from the CDC, and that's that person whose really primary training is in nursing, medicine, or medical technology, microbiology, or epidemiology. And they have a special training in infection control. We want to make sure that we have good clinical leadership from nursing, from medicine, because they have to be involved in this process. And you want to promote that culture of safety and quality, where you're really going across your departments in the hospital and finding out, okay, is this person going to be able to work in there? And they have to be so focused or so really limited in their training to one area where really they can't expand and focus on the entire and every department of the hospital. Otherwise, again, qualified through education, training, experience, or certification. If you have certification, that's great. It is not required, though. CMS won't tell you how many hours devoted to that program or how many bodies you have to have. That's up to you. If you have more than one, of course, they have to work together as an integrated team. And enough resources so they can do the job. Look at your census. What is your population characteristics? How many complex services are you offering? Are you offering transplant services? Are you a strict med search? Are you offering immunotherapy, where perhaps you have immunocompromised individuals? So look at that all together when trying to determine who do I need and how many of those folks do I need. The surveyor is going to do a couple things. First up, they want to make sure this person was actually appointed by the board. And what they're going to do is they're going to look at your minutes. That's what they want to do. And they want to make sure that it was based on the recommendations of medicine and nursing and that they have actually been given the responsibility for that program. So they will probably look at their personnel folder. They want to look at their education, training, or experience. And again, if they're certified, is it a current certification? Then they want to look at the criteria used to determine how many do you need? What resources do you have to have in order for this person or people to do their jobs? Policy and procedures. We have to have those for a program so that there are methods to prevent and control transmission of infection, not only within your facility, but between other settings. Now, whether it's coming from home, whether it's coming from a long-term care facility, or maybe from those who are unhoused, you know, they could have their own special set of infectious issues that you need to account for. Now, what does this require? Means that we really have to focus our efforts on preventing and control at all levels and all people. So keep an eye on your outpatient facilities along with your inpatient if they're moving between those settings. It is imperative that you use a multi-drug resistant organism control approach for broader perspective, and just be aware you are required to track both hospital and community onset cases of C. diff and MRSA. We just have to keep track of those. So how can you work with those other facilities that you may share patients? Is there a way you can have some information for those who have and potentially harbor these transmittable pathogens? Do you have, and I'm only going to say it because I'm here in Colorado, and we still have an issue with TB, and especially with some of our unhoused population. So we, some of the hospitals have tried to work closely with our homeless population services to see what we can do to help them with identifying those cases and trying to get them isolated. And these updates, they apply whether you have an outpatient location or an inpatient location. The surveyor, again, is going to look at your policy and procedures. I want to look at, are you following them? That's a biggie for them. It's great to have these wonderful, very extensive policy and procedures, but if we're not following them, you're going to be cited on that. Also, those methods that you're using, are they used within the hospital and between care settings? Is it applied throughout the hospital? Whether, can you have an outpatient surgery or maybe an outpatient mammography service, that's outpatient. We still have to keep those in mind. Your requirements, and really they did this right at the beginning, so they've reiterated these requirements throughout the regulation. The program has to have a way for you to have some surveillance, so you know, okay, what's out there? What's upcoming? So that we can prevent them and control it if it does occur, whether that's a clean and sanitary environment or just, again, a terminal cleaning after surgery. How do you address those issues that you have identified, maybe through your public health authorities? Are you seeing an uptick in some of your influenza, whether it's A or B? What about, again, COVID that has not left us, unfortunately, RSV, or maybe even IMPOX? What are those issues that are coming through your public health authority? And the guidelines, well, they just come right out and say, we've got to keep this place clean. We have to get sanitary so we don't have sources for transmission of the infections. And that's everywhere within the hospital. Again, all departments, all locations. That could be in radiology. It could be in neonatal intensive care. The program should have a way for appropriate monitoring of your housekeeping and also your maintenance, like repair and renovation. What about construction? Are you doing construction within your hospital? Is it a redo or is it a total new build? Because we still have to make sure that we're not spreading anything around that might be into the ventilation system or if you're taking down old drywall. Is there anything lurking behind there that you were unaware of? And some of the clinics, they had a problem with mold where the water would seep in or would have some flooding and then it wouldn't dry thoroughly. And so we had to really pull off the pull off the siding, pull off the drywall and get the mold under control. And they do give us several examples of where we need to be keeping an eye on these things, whether it's ice machines, inpatient rooms, treatment areas, food storage and preparation. Are we keeping our food at the proper temperature, whether it's in the refrigerator or being served up in the cafeteria, laboratory? Pretty much everywhere within the hospital, it seems to be included. I'm going to just touch briefly on water management because CMS did talk about it, that we have to have a policy and procedure so that we can cut back the risk of Legionella. And the guidelines do reference the American Society of Heating, Refrigeration and Air Conditioning Engineers. In 2016, CDC and other partners, they developed a toolkit to help with the implementation of that. It was updated 21. There is a free download. I have the reference in the appendix. That's what those asterisks means on my slide. There's a reference in the appendix for you. So they have a free toolkit for you to do an assessment. But it also includes that risk assessment of where these things can not only grow, but spread like your water system. And it talks about testing protocols, acceptable ranges for control measures. And also, we need to document. What did we find on our testing? What corrective actions have we taken? When that control limit cannot be maintained. What have we done? Otherwise, we need to do hospital-wide surveillance for any infectious risk, communicable diseases, have a reliable sampling, other ways so that we can identify and monitor them throughout the hospital and also all of the departments. We have to document what we're doing. We have to document those activities we have taken. And what measures did we identify that we're gonna use for monitoring? How are we going to collect it? What measures, what data points do we wanna see? And then how are we gonna analyze it? How is that going to be accomplished? And then, of course, keep an eye on these outbreaks. If you have more cases than what you expected in a given area, maybe among a specific population or over a period of time. Now, if you have a large pediatric department, you may have to be very vigilant on control the transmission of some of the respiratory issues because, unfortunately, they do get spread around. But don't forget your older population because they could be also at high risk if, say, you have a SNF unit within your hospital. Now, if an outbreak does happen, of course, we have to address it. And that means policy and procedures. How do we diagnose and manage the cases that are there? Maybe in ICU or in your immunocompromised, you have a C. diff outbreak. How are you gonna manage that? How are we going to put precautions in place so it doesn't get passed around anymore? And then document your follow-up activity. What you learned from that. What did we do to secure and make sure we have it contained? And then, of course, we have to comply with any state or local public health authorities where on identification, reporting, and containing when we do have an outbreak. Like, again, influenza has been going through many communities. And if you do get that outbreak, what is the reporting on it? So the surveyor's gonna be busy, by the way. When they're doing these infection prevention, they're very busy. First off, they're gonna be looking around. They're gonna look in patient rooms, maybe on the floor and even horizontal services like your walls. What they're looking for is soiling, blood, dirt. They will also look at air inlets. They're going to look at your central supply. Is that being contained and cleaned? What about vermin? Are there pests in their storage area? They even look at food service activities. Are people washing their hands? Are they using gloves when they're supposed to? What's the temperature of the food? Is it maintained correctly? Medication preparation areas, similar. They're looking to see how clean is it. When we talked about medication preparation a while ago, it was our nurses cleaning off the top of the rubber stopper and using a sterile needle and syringe each and every time. Are they washing their hands when they're supposed to wash their hands? They're also, of course, then do the paperwork. They're going to look at your policy and procedures. So they wanna see how are you doing your surveillance? They also will look to see, have you addressed that transmission of anything that your public health authority has given you information on? And is there a way that you report when you do have an outbreak of some infection? And then they're gonna look at your water management program. They still wanna see how they're doing that. Are you documenting when what you need to do for testing for Legionella? So for public health reporting, you have to report on a frequency that the secretary, this is, I remember it and I'm all of a sudden blinking what that stands for, so I apologize. But you have to do that where you have an inventory of your supplies, primarily for COVID, your therapeutics that not only do you have, but are on site. And what's your usage rate for therapeutics that you either delivered or have distributed. Back, we know during COVID, they had instituted some pretty rigid reporting requirements. They kind of went away for a while. Well, they brought them back last year. As of November 1 of 24, you have to report electronically when you get an outbreak or you have patients who present with COVID influenza or RSV. And the reason is they wanna make sure you're prepared for these things, that you have enough insight, you have enough supplies, whether it's medication, mask, whatever it is, so that you are prepared for this. Now, as far as how often and what, for all hospitals with the exception of psychiatric and rehabilitation hospitals or in a critical for your distinct unit, you have to, those send in only annually, but for everybody else, you have a couple of ways. One, you can submit daily data on a weekly basis and you have to do it by Tuesday at 11, 59 PM. And what they're looking for is daily data for each day of the previous week, Sunday through data, Sunday through Saturday. What did you have? How many of these issues? Now, they did realize that that did create somewhat of a firestorm of comments, that it was very onerous and work heavy. And they recognize that. So they decided, okay, we'll come up with a second process that you can use under certain circumstances. That second process, new admissions where you have confirmed illness like of those three, COVID influenza and RSV by age group. Now here, you report the data weekly totals instead of daily data. And I added that emphasis as you will have access to this information, you had the link there. Along with that, you have to have staff bed capacity and occupancy. How many hospitalizations do you have? How many ICU patients do you have according to those three respiratory illnesses? Here, you only have to do a one day a week snapshot. It's less onerous than doing daily data that you have to collect. That one day a week and weekly total, it is a nice pathway for weekly reporting, nice balance between the balance of the value and the burden. Now you may have changes over time based upon what your population health needs are and what technology advances or services you currently have. So for 2025, this is what that information includes. Again, the one day a week snapshot and the weekly total admissions. Again, behavioral health, rehab, distinct units, you are only yearly reporting. So they did give you some leeway, but now we have to go back to reporting those issues. Moving on. Of course, your program looks at what services you're providing, the scope and complexity of them. You are expected to show how you adequately represent the services you provide and a way to assess and reevaluate your program because you wanna make sure you're responding to what those needs are. Are you seeing all of a sudden an uptick in your pediatric population? Are you seeing an uptick within your community of maybe an older population? Now this is one tag number that had multiple deficiencies. So just be aware that that's what they want your program to do. The surveyor will look at your program. Is it hospital wide? Is it program specific? Have you been able to gather and assess the data and then take steps to reduce the infections based upon what you are seeing? Then they look at your program. What they're looking for is what are the parameters of your surveillance? And is it consistent also with the standards of practice? And is it really, does it fit your needs? Whether it's scope, complexity of services, are you meeting the needs of that population? And we know with reporting, by the way, NHSN is the National Healthcare Safety Network. So there's now where CMS and CDC put out a joint statement a year or so ago, all infections that meet that network's criteria and also what CMS wants for your incentive payment have to report it to here because they wanna use that data for tracking healthcare associated infections. CMS and maybe other payers like your Blues, your Signas, they use that data to determine any incentive for performance. All facilities should adhere to these protocols, the definitions, the criteria, that way that the data that is being submitted is reliable, it's consistent, they can compare that data. And so I've included here that link on it on reporting to the NHSN. And then also just some basic information on setting up on how maybe protocols for CLABSIs or CAUTIs and then the checklist for reporting, what do you have to do? This is nice because they put the information out on what they hope to see and get the information to get from you. I'm gonna move on now to Antibiotic Stewardship Program. And here's our next question, Lindsay. Okay. Right, hopefully you all can see this question that says, hospital B was cited for an insufficient antibiotic stewardship program following an increase in C. diff cases. The IP has reached out to you for suggestions on who to include in a committee to study the problem. Who would you suggest here? Pharmacy, nursing, medical staff, QAPI leadership, or all of the above? Just a couple of seconds to fill those in. For those of you who may have joined us a few minutes after we got started this morning, if you have questions for Laura as we go throughout the program, please feel free to type those questions into that Q&A option found there at the bottom of your Zoom window. Or if you don't see that, you can of course type your questions into the chat and we'll make sure that we read those out for Laura to answer as we go throughout the presentation as well. Okay, I see a pretty unanimous response. Yeah, I figure. Yeah, all of the above, that's the easy one. Yeah, that's, yeah, it's very true. Yeah, you'd wanna include everybody in the ASP because it's going to affect patients one way or another. It's going to affect them. So first off, just a couple updates. Some of the requirements are not in that current manual. And they're in the, of course, the 2019 rule. It starts at page 72 of the rule. I try to make this easy because that rule is pretty long, by the way. They do recognize, CMS does recognize that ASP can be a challenge to address problems, not only of infectious disease treatment, but then using medication wisely, using it safely. And what do we do about our MDROs, our multidrug-resistant organisms? They're still continuing to come up. So for your program, you have to be able to show that you have one, maybe one or more, maybe depending on your size. Again, like the preventionist, this person is educated, trained, or has experience in infectious disease and or antibiotic stewardship. Like the preventionist, they too are appointed by the governing body, they're leader of the program. And this is based on the recommendation of medicine, but here they include pharmacy, which makes sense because they're going to know what are the next generations of antibiotics. They also do this to have someone overseeing it. So we have that culture of safety and quality with again, input from every department or every area within your hospital. So we have to make sure this person is qualified and ideally, it is jointly led by a pharmacist and a physician, that is not required. They say that's ideal. But if you only have the physician, okay, that's great too. But again, they have to have the recommendation of pharmacy and medicine for that appointment. Usually we're going to see someone who has training or certification in infectious diseases, whether it's adult or pediatric, or if you're lucky to have someone or two that are in both. And these are folks who, through the American Board of Internal Med, Society of Infectious Disease Pharmacists or Pediatrics, they have that specialty training. Along with your leader, you do have to have a staff, a stewardship staff. And we need to make sure they continue with those qualifications, that they're going to go out and have courses. They go to national meetings, SHEA, IDSA. These are just some of those that CMS has put out there. Having that training and being able to go to those meetings, you can help share that information. What are you seeing cropping up? Have you been able to control it within your community or your facility? As with the prevention of CMS, CMS won't tell you how many, how many hours they're to dedicate to it. You just have to have enough resources so they can do their job. Likewise, work as a team and make sure all functions are covered. So that's why if you have one more, more than one, make sure those are spelled out what their responsibilities are. You take into account your census, your population, and your services. SHEA does have some recommendations for how many you need or should have based upon what you are providing, what services and your size. You have to have, develop, and implement policies on the optimal use of antibiotics. And really, they also have to include what are the roles and responsibilities of stewardship and the use within that hospital? How are committees and departments, how are they going to interface with this program? How do you optimize antibiotic use? Now, this doesn't have to be a 30-page policy and procedure, but it does have to address these key areas. The surveyor, they will look to make sure if leadership, ASP leadership and staff have been appointed by the board based upon the recommendation of pharmacy and medicine, that they also have that responsibility. They'll probably look for the board minutes or somewhere within this person's file to say, yes, indeed, they have this job. They will determine if staff have developed and implemented the policies, and then they look at the criteria. What are the necessary resources? What criteria did you use? And are they matching your need? Now, if you're a 300-bed hospital that just focused primarily on routine medical surgical, as opposed to that large teaching hospital or maybe a transplant center, they're gonna have a lot different needs than from each other. Course coordination among services, prevention, control, nursing, medicine, pharmacy, and QAPI. We all have to work together to make sure this is going to be successful. Interpretive guidelines say, yes, we have to develop and put to place interventions that we found under our assessments. So you've gone through, you've done your assessment, it's like, okay, we have an issue here, here, and here. Great, now, what are we going to do to make sure we can address those? Because what they're looking for is, does it work? We have to monitor the effectiveness of that intervention. Improve coordination amongst our components so that we can reduce the resistance. And again, whether it's lab, pharmacy, nursing, doesn't matter. Now, there was a recent article noted that there was an increase in our drug-resistant organisms after COVID. And surprisingly, it still remains at least 12% above our pre-pandemic levels. So I haven't gotten a handle on that just quite yet. But to do and improve our prescribing, use those evidence-based practices. Implement and maintain a program as an effective means to improve it. Curb that risk for not only antibiotic-resistant C. diff, but adverse drug reactions, treatment failures. If any of you have ever seen the Stevens-Johnson syndrome, that's an adverse drug reaction. So this is some of the areas that they're talking about. Really, that robust program has to be coordinated with the overall infection prevention and control program. We talked about the interoperability a while ago, and that this talks about electronic reporting for payment adjustments. Most acute hospitals do participate. Criticals, you are eligible to participate. You just have to check with somebody who's in charge of your reporting and quality to see if you are indeed eligible. And that's reporting your antibiotic use through the electronic health record that began in January of last year. I've got more information. I do not usually address anything to do with reimbursement or payment. The surveyor, they wanna look at your policy and procedures. And they're looking for a couple of things. Is there a way for coordination amongst all of these efforts? Also, they wanna see the program itself. They wanna see documentation on the program. Infection prevention and control program, the QAPI program, the nursing, medicine, pharmacy, coordination with your ASP, with all of these departments. As far as documentation, they want evidence-based use of your antibiotics. Again, reduce those adverse consequences and prevent our drug-resistant growth. Put down what are your improvements? How have you sustained those improvements through better antibiotic use? And also update with any advancements that are coming through. How long are we keeping that patient on IV antibiotics as opposed to converting them to an oral? What resources are we using? By the way, when you do develop your policy and procedures, it does help to have a reference or attach a copy of that best practice, those national guidelines. Because then it's going to show the surveyor, you put some thought into this. You know, you're just not attaching things. You're actually looking at this and then implementing it into your program. On adherence, again, you mentioned, they adhere to guidelines and best practices and that you're able to put together and maintain this active hospital-wide program. The surveyor will verify those nationally recognized standards have actually been instituted and the core elements of best practice have been included. So they are looking at what you have done. Not that you just printed it off and attached it, but that yes, indeed, you are actually doing it. There are resources for you, CDC core elements of ASP that has your key principles. It recognizes no one size fits all, that medical decision-making is crucial and how complex that can be. And again, variability of what you do, the patient population and the care you provide. They also mentioned the other professional resources. On your complexity, it does, again, reflect your complexity and scope. The surveyor will look at the parameters you used to determine that it was actually suitable to your facility. Again, whether you're a smaller hospital or your major educational department or area. Governing body doesn't get, they have a job here too. It's not just nursing, it's just not medicine or pharmacy. They included governing body in this program and the requirements, because they have to make sure that things are there because they're responsible for the operation of the hospital. That systems are in place, that they're working, that we can track, we can control, not only infections, but antibiotic use. And that it's successful, you can make this work. In the guidelines, they talk about development and implementation has to include leadership support. And again, accountability. That means we have medicine, pharmacy, nursing, and those who are responsible for the entire program. The board, or if you're a small hospital, like a critical access, you might just have one person, somebody who is responsible has to show and demonstrate, this is what we implemented, it's successful, and it was then, and we've sustained it. So that's usually through an interview that they will do that. They will sit down and talk to the leader of the governing board, whoever it happens to be, and say, how did you make sure this program is working? They also look, of course, at policy. What are the roles and responsibilities of, to make sure we're preventing infection, how are committees and departments working with this program? How do you prevent communicable diseases? How do you report them into your program? Policy should address the roles for antibiotic stewardship and the responsibilities, and again, how do all these community, I'm sorry, committees and departments interface with the ASP? How do you monitor, how do you improve your antibiotic use? And they want to see your policy and board minutes. What they're looking for is a record of support for that program. And again, they'll look at your policies and verify they're being followed. For QAPI leadership, they did also include this in this area, the governing body has to make sure that all healthcare associated infection or other diseases identified through the infection prevention and ASP program are addressed with QAPI leadership. Because we need to make sure these are being identified and handled. So that means we have to have a lot of internal coordination. And the components, again, infection prevention and control and ASP, QAPI, medical staff, nursing, pharmacy, lab, all of those folks have to be involved. The leadership duties, and this is through QAPI, they have training programs, they have to be involved in addressing any problems that have been identified. Leadership is jointly responsible to make sure there's a link between infection prevention and control, ASP, QAPI, and training. And also explicitly responsible so that any corrective actions are successful. That we're monitoring those corrective action plans, following them, we're assessing how effective that action plan is, and maybe go back and start over, what do we need to do to revise it so that this does work? There is education that they do recommend. The guidelines provide those recommendations on who should have education on the principles of prevention and transmission. Pretty much anyone who comes into contact with a patient or even medical equipment, anyone who prescribes or prepares administers antibiotics. And essentially, when you think about it, it's going to be everybody within your hospital has to have some form of training. Now, granted, for nursing, that's going to be very different than maybe your volunteers, or very different than what students and trainees that they're coming in because they have to have an understanding of what these principles are. The surveyor will confirm that your program has been coordinated with leadership and medical staff, nursing and pharmacy. And they will also sit down and determine that the QAPI program and training addresses those problems that you see in your infection prevention. Also, that those problems get up to leadership, and that leadership then acts. That there are going to be corrective actions are implemented and successful. Now, they can delegate those things. They just have to make sure it's being done. They do a little backtracking here, the way I look at it when I'm reading the regulations. We talked about the preventionists, what they had to have, you know, what is their expertise, etc. Well, then they go down later on and talk about, okay, here's your job, here's what you have to do, your responsibilities. They have to develop and make sure it's put into place a hospital-wide program for surveillance, prevention, and control. And these are the policy and procedures. And that these policy and procedures adhere to national guidelines. You have the flexibility to determine what fits you best. But they do want to see engagement in innovative practices. Well, still having, you know, that evidence-based model that, hey, it's worked in the past. We don't need to change it. We reviewed it, and it's still good. Or we reviewed it, and now we need to look at something different. The surveyor will verify that the program does follow national standards. They will have them. And sometimes they will actually have a surveyor who has done infection prevention and control in the past. So they're very in tune or up to speed on what's expected. Preventionists has documentation responsibilities that they have to document what are the programs and activities that they have done, whether surveillance or actually control. Now, how you do this, that's your choice, electronic or written. Sometimes if it's electronic, it's nice because it can be easily shared, and it can be maintained better rather than the written that might get the notes might get lost or misplaced. Collect and maintain that information in a systematic action. Health and Human Services, they have an action plan that you can tap into. There is the link that will give you some guidance. How do I do this? Where do I start to do this documentation? But surveyors want to see documentation of your activities, and that's why if it's handwritten, you don't want that to be at home with that individual when the surveyor shows up. The preventionist has to, they can't work in a vacuum. There has to be communication and collaboration with your QAPI, whether it's any emerging concern or something that it's been a problem and we continue to have a problem. They're trying as opposed to doing a look back and, okay, now we got to catch up. Rather be proactive so we can stop it. Okay, we had one case of this event. All right, we're going to clamp it down and see where we can improve it so it doesn't get to another patient. The surveyor wants some kind of indications of that communication and collaboration on all of those issues. That's what they want to see. Now, whether that's in the infection preventionist notes or QAPI, they don't care. It's just as long as they can see you're working together on it. The preventionist also has some education that they have to provide and also competency-based training. This goes to everybody, hospital personnel, medical staff, contracted personnel that they're aware of. These are your duties. This is what we expect to maintain our good clean infection issues. Include those practical applications for control, policy and procedures. Again, what you're going to be training to housekeeping may be vastly different than what you're doing down to x-ray someone, one of your x-ray technicians. What do they have to know to do their job? The guidelines do talk about that the preventionists take that active role in education and training in those practical applications. In other words, are they doing them? Have they revised the education program? Or if they're having people help do it, are they observing the training that's going on? The survey, as usual, looks at your policy and procedures on training. They will confirm the preventionist that they are doing competency-based training. Then they'll look at your staff records for completed competencies. Usually, if you have like an education day and you have a sign-off that this person did it, this is what we checked them off on, and they did it competently, that's what they're looking for. You can also put it in their individual files if that's what works within your system. The preventionist isn't done yet. They also have to audit how your staff is adhering to those policy and procedures, because they're responsible to communicate and collaborate with the ASP when there's other things that are cropping up, and that's what their surveyor wants to do. Are we looking and auditing our adherence? Is there communication and working with antibiotic stewardship program? Now, likewise, the leader of the ASP has very similar responsibilities. They have to develop and put into place the program throughout the hospital, again, based upon guidelines, and they also have to monitor and improve the use of antibiotics, so they have a little bit more to do. The guidelines talk about ensuring appropriate antibiotic use, so we reduce our reactions, we reduce our MDROs, and that means you really have to have dedicated expert leadership because they are responsible for the success of this program. That has to be hospital-wide also. Like the preventionist, they have documentation that they have to do. The guidelines that they're going to use, again, written or electronic, whichever the documentation want to do, and the surveyor will make sure that this leader has developed and put into place this program, that it's based on nationally recognized guidelines, and how do they monitor and improve the use, because, again, the ASP leader has to document these activities as they go along. Likewise, the ASP leader must communicate and collaborate with the medical staff, nursing and pharmacy, infection prevention, and QAPI on our antibiotic use. Which ones are we going to have within our collection of antibiotics? What are going to be the guidelines for their use? Again, three days IV, then convert to oral, five days IV, then convert, whichever it is. The leader is responsible for training, competency-based training, education, again, of all staff, medicine, contractors, so if you're seeing, let's say you have hospitalists that's with the contracted group, they're still responsible to make sure they are aware of the policy and procedures. The surveyor will verify the leader does give such training to those personnel. Now, this can be during a medical staff meeting for the medicine, it's just we have to make sure everybody partakes in that training. They just can't pass it off and say, I'm too busy, I'm not going to go do that. They have to make sure everybody is getting that training. I'm going to talk something about, it's called unifying integrated program for multi-hospitals. I just separated this because it was unique to acute hospital. It is not, it doesn't address applicability to critical access hospitals, but just be aware these are the requirements that are only listed for acute hospitals. That, I believe, takes me to my third question. Lindsay. Okay, perfect. Let's go ahead and get this one up for everybody. Okay, so you should see this question that 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 this division? The first option here, what can be gained as to resources, patient population served, are the other hospitals CMS certified for all of the above here? And I don't see any pending questions at this time, so if you have any questions for Laura, make sure that you are typing those in so we can address those throughout the presentation this morning. Lots of the same response here. I'll give you another couple of seconds. Okay. I tried to give you a few options on these questions, though, and it's just mainly to start conversations, if nothing else, within your own facility. Perfect. Okay, I'll go ahead in this and share those results there. All right, yeah, that's good that you are considering everything that we need to take into account. So let's, there we go, so integrate a program. By the way, this is optional. You don't have to do it. It's totally optional. You can do this where you have multi-hospital systems. One of the requirements was on that question, each hospital must be separately certified with CMS that you use a system governing body that has legal responsibility for at least two or more of those hospitals. Again, the governing body is the one that can elect to do this. That decision has to meet any state, local laws, and the governing body has to make sure each separately certified hospital meets each and every requirement of this section that I'm going to be covering. So if they're going to consider it, it has benefits, but it's not an easy one day done and you've got everything taken care of because there's a lot that goes into that. Each hospital, what they have to do, what they're accountable is to the system's governing body to make sure that their hospital meets those requirements of infection prevention and control and antibiotic stewardship. It must be established and set up a way to take into account each hospital's circumstance, whether it's patient population, size, service offered, location, other resources that they can tap into. The surveyor wants to see that process for how did we identify patient population, those services, and that those are integrated into this program. And that these policies and procedures, they ensure that each hospital is given consideration regardless of where they're located or what they do, what their services are. The surveyor will look at the program, how has each hospital's needs were considered when you developed your policy and procedures. It will be vastly different when you're looking at a burn hospital versus if you're strictly a mother-baby hospital. You have to have a way and a mechanism to make sure issues specific to that hospital are taken into consideration and addressed. You have to be able to identify, address QAPI issues to that hospital and that any issues are addressed in the Unified Integrated Program. So the surveyor will look at your QAPI notes. What they're doing is trying to identify unified elements and those unique to a particular hospital. So you may have three hospitals that are having the same problem, but then you have one or two over here that are smaller and it's not a problem for us. Well, that's great. But those three hospitals and the other two still have to come together and make sure everything is being addressed, how they integrate into that program. That means there has to be a lot of communication that's going back and forth, whether it's a group or one person. Likewise, this is, again, infection prevention. That person has expertise in prevention and control. They've been designated the responsibility for communicating with this unified program. They implement and keep policy and procedures that govern the program and they provide education and training to the hospital staff of those within the program. And these are the ones that are directed by the program in completing duties and responsibilities. Because again, that person or people, if it's a group of them, they have to make sure that the practical education they're giving to that hospital is applicable to them where it may not be. So that's what has to be done. They will look at governing bodies, policies also, because they want evidence this person has been designated that responsibility, that they are to communicate, that they are to train personnel, they are to implement and maintain policy and procedures. They will look for also that this person has communicated with the leadership and on any issues, whether it's infection prevention, antibiotic stewardship, whatever it happens to be. They will look at training documents. Is this person trained, not only in infection prevention, but then who's ever over antibiotic stewardship? You have the two people, the preventionist and the ASP leader. And they want also evidence of staff training, a sign-in sheet, however you're going to accomplish that. Again, this is an optional service. It benefits because you may have some hospitals in your multi-hospital system that are really leaders in the area of a particular infection and the control of it and how they've managed it. Or others may be struggling. And so that's why it's a huge benefit where you can share those best practices, that expertise. We're going to do a couple memos now on infection control. Some of these, just they've been around for a little bit, but it always helps to reiterate them because as I saw in the deficiencies, we're still having these problems. And one of those is infection and insulin pins. Again, the asterisk means I have that resource in the appendix for you. We know pins are only supposed to be used on one patient. That's it. And they found, nope, patients were sharing them. That's like sharing a needle. Every patient has to have their own pin and they have to be marked and identified with them. Next area was single dose vials. This talks about the safe use of them so that we prevent those healthcare associated infection. Now, there is an exception when we do have the shortages and we do have some medication shortages that still continue to plague us. The general rule is that if you had that single dose vial, it's only on one patient. However, you can use them on multiple patients with these limitations. One is prepared by a pharmacist under a laminar hood and are following USP 797 guidelines. Your pharmacist will know those. Any entry where you're going to be reconstituting it, done within six hours of the initial puncture. Only exception, again, when you can use it on multi-patients. Otherwise, using a single dose vial on multiple patients is considered a violation of CDC standards. You will be cited under infection prevention and control because, again, it talks about maintaining a sanitary environment. This isn't just your inpatients. This could be dialysis, hospice, ASCs, any infusion therapies you provide. It's not just inpatient. The basic requirements, if it does come in a single dose, buy it in such a way. If it's only multiple dose, it's only to be used on one patient. Mark it that it expires in 28 days. Of course, it doesn't go into the room or into surgery. It stays outside because these usually lack that antimicrobial preservative. Once entered, things can get in there. The vials have to have a beyond-use state and it has to have storage conditions on the actual label. If you are using compounding vendors, and that's when you have an arrangement with this off-site vendor or facility, the surveyor wants evidence that they have adhered to those 797 standards. The American Society of Hospital Pharmacists, they have a tool to assess your contractors who provide your sterile products. Your pharmacist is probably the better person. You want to work with them on having this assessment done. Then we have breaches that we have to notify our public health authorities. By the way, that could be when a state agency comes around. If you're getting a survey and they found a breach, that has to be reported. There is a list of any breaches that need to be referred, like the state epidemiologist or your infection prevention control coordinator, like the same needle on more than one patient, same insulin or other syringe on more than one individual, same lancing or finger stick more than one. Even if you change the lancet, it's still considered a breach if you're using the device. There are certain headlines you never want to see, especially if it affects your facility. Here we have this. This happened back in 2010. By the way, she's still in prison. This was a hospital technician. She worked in surgery. She liked working in surgery because that's where the good stuff was. And at that time, the hospitals, and it wasn't just one hospital, it was more than one hospital, they weren't adequately securing the anesthesia carts. So the anesthesiologist would come in and prepare the cart, get ready, pull up all the medications for administration and leave them out on the cart and then leave. They would leave the surgery room before the surgery started. Well, this individual, he was unfortunately very smart, I guess in one way, or very ingenious, and she figured this out. And she would go in, grab the syringes, take them to the bathroom, inject her, go back in, not change the needle, not change the syringe, and fill it with saline. And multiple, multiple patients were contaminated. Not only did she have hepatitis C, but they were thinking she might've been seroconverted, she converted to, or had HIV. So she ended up with 30 years, and it wasn't, again, just one hospital, it was a couple of hospitals, and it was outside the Denver Metro area. So that's one area where they had to clamp down on their security to prevent transmission such as that, like reusing that needle of syringes, where you've gone back in and accessed that container using the same syringe. That was an event down in Vegas. Another one, and we've already touched upon this briefly, was Legionellas, where it can cause that pneumonia, grows in your water systems. Do that facility risk assessment, could it spread? And then how do you control it? And here, this was just as 2023, two people at University of Washington Medical Center had Legionellas disease. It is still out there and still moving along. All right, I wanna talk briefly about this antibiotic stewardship program, some core elements that CDC has pulled together. They did update it in 19, that's the last update that I've been able to find, but it has examples of your leadership's commitment to this, and the priority interventions, the process measurements that you can use, the key role of pharmacy and nursing in improving our use. So again, it has the core elements, and there's even a tool, an assessment tool that you can print off, these are all free. That's what that looks like. Again, I checked yesterday, it has not been updated. This is the current one, and again, the antibiotic stewardship. They even have some for your smaller facilities, your critical access hospitals. This was a combination, American Hospital Association, Rural Health Pew Charitable Trust, CDC, they came out with something that's more practicable for the smaller facilities. And it has a lot of those very similar strategies, leadership's commitment and accountability, using that pharmacist with drug expertise, tracking how many days are they on therapy, the reporting and education. So again, they haven't left those small hospitals out, that's really nice that they put these together for them, and then it's checklist. So it wouldn't be complete without talking about procedures for cleaning, disinfecting, and sterilizing our reusable equipment, because it still is out there. There is an update. Again, for some reason, some of my hospitals here need to maybe pay attention to their infection control. This was one where nine patients at one of our hospitals got infection and three of them ended up dying. And this happened to be the duodenoscope. And that went down and they found out they hadn't been cleaning it according to what they were supposed to be doing. And so some of those tissues, the infected tissues remained in there and were transmitted. This was a cleaning, this was a training issue that they had to go back and really be specific in that cleaning. And as I recall, they also found out the reason that the cleaning hadn't been done as well as it could have been done, the seroprocessing felt rushed. And so they realized that maybe they needed to up their resources, and so that these things could take the time and be properly and adequately cleaned. So the CDC hospitals, you do have to keep a clean environment, disinfect, sterilize reusable equipment, have policies that are consistent with our current standards, follow what the manufacturer says for cleaning. Now, they also clarified an earlier manual that came out that if you outsource this maintenance and repair, you do not have to use a certified vendor. But since nobody was doing it, just be aware of that, that you don't have to use only a certified vendor. So just be aware of that because they realized no one was there, nobody was certified. So what are the items that we have to look at, the critical and semi-critical? Of course, the critical is what touches your tissues, surgical instruments, we know we have to clean and sterilize them before we reuse them. Then we have semi-critical like our endoscopies, laryngoscopes, anything that come into contact with mucus or non-intact skin. These require high-level disinfection prior to reuse, not sterilization, but high-level disinfection. And so CDC and the FDA, they did come together and they talk about device reprocessing. Maybe having someone who has that expertise in doing this, come in and look at your reprocessing procedures. Having that clean eye come in, a critical clean eye, they may identify areas you weren't aware of or that had maybe become drift where, oh, I've done it before, no harm, no foul, I'm gonna continue that drift away from what they're supposed to do. There's a list of training requirements, orientation and yearly, document your competency and training, and the trainer should observe staff before they're allowed to do an independent leave, that makes sense. Have copies of those instructions, I have them available, that link there for you. And then do your audit. How are they adhering to cleaning, disinfecting, sterilizing, even storage procedures? If you work in endoscopy, hanging up those cables and everything that needs to be done. And then get feedback, tell the person, hey, you're doing a good job here. This is what I noticed, of the five areas, all of you got five out of five. Great work, keep it up. You're the reason that we're not having terrible or life-threatening infections for our patients. On your policies, again, give them time to clean, follow what the manufacturer says, have a process to tell when it is ready for use, maybe a tagging or storage in a particular area. What if you have a reprocessing error? What are you going to do? What are the steps that you need to follow? Including maybe notification to your preventionist. And then just some other resources, there's some training, and I believe this is my last question, Lindsay. Okay, let's get this one up here for you all. Okay, this 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. What would you recommend hospital C do for this to occur? Have the person follow an infectious disease provider for one month, look for training through the CDC and national organizations, or appoint them and hope for the best. And there is one question that came in, Laura, we're waiting for those responses to come in, that says, did this person hear this correctly, that there is no multi-dose vials of insulin on the floors and only single dose, is that correct? If it, well, no, if it comes in a single dose, that's what they want you to do. Have them in single dose vials. Not that you can't have the multi-dose insulin, that's not it. It's just, if you can get it, great. It's just, if you can get it, great, because then you cut down. Now, having the insulin in single dose, that can be expensive, I get it. That's why, if you can, it's best if you can get it and use it in single dose. So take into account the cost of having single dose insulin vials. Most of them, I'll be honest with you, most of them I see do have the multi-dose. They keep in the fridge and it's multi-dose. Okay, perfect, I'll go ahead and end this poll and share those results there. Yeah, let's look for trainings. No, I'm not saying, that following one month, that may be fine until, that could also maybe help identify, you know what? I'm not getting this. I do need training in it, period. Or they've done this forever and they could just probably step in and take over and just be as fine, no problem. So just look at who you've got, how long have they been in that role? What are they doing? And then maybe you can get the training. So for profession, this is CDC. This is very widely read. We know there are changing sections on personal protective equipment, from masks to ventilators. There is a section on infection control guidance, a section on hand hygiene. So there is the section on infection control on their guidelines. There is also training, it is free. Now this particular training, this is nursing home based, but a lot of the same issues apply to you. 24 modules, again, everything from water management to hand hygiene, covering your mouth, infection surveillance and plan. And so that's what that IP training looks like. It's free. There is the STRIVE Continuum. This is, by the way, STRIVE is an acronym, excuse me, and that stands for States Targeting Reduction in Infection via Engagement, so STRIVE. And this was a joint effort between, with the Health Research and the Education Trust. It's good for your new employees, periodic training, annual infection, so it helps your preventionists get an idea about where am I supposed to be training them on, whether it's environmental cleaning or patient and family engagement. If you're sick and you're coming to see grandma, please stay home, look through the window and wave at them, whatever, call them, getting that patient and family engaged, PPEs, et cetera. So that's what that happens to look like. Other free training, the American Nephrology Nurses, they have some free training and control. There is also training for keeping your own personnel safe and healthy, eight elements of your occupational health, resources on immunization, organizational culture, make sure staff know what are their risk, what did they need to know and do for infection control, monitor performance measures for occupational infection control, have job description with their risk, vastly different from a nurse, maybe somebody working down in housekeeping or not housekeeping, but in food services or in central supply, maybe vastly different. There are also further updates that you can on infection control and additional guidelines. I do also wanna mention APEC has a competency in infection prevention that you could possibly look at if you're bringing a new person on and there's one other free one, it is through what's called DNV, that's Del Norte Veritas. This is a Danish organization. They're one of the accrediting organizations. So if you happen to have heard of it or maybe you are deemed status through them, they also have training, both basic and advanced that you can then tap into. I try to get you the most, the ones that are free for you so that you already have enough expenses. This is maybe one area that we can help out. And then finally, some worksheets. The worksheets were used back, I wanna say starting at 2016. And what they did, and these are CMS worksheets, they pulled them together and they looked at all of the requirements for three areas, discharge planning, infection prevention and control and quality improvement. And they use these worksheets to really, what they did was they redeveloped the guidelines and the requirements that we've just talked about for today. And again, one of them was infection control. This is the largest of those three worksheets. They are no longer used because what they learned from those worksheets, they put into the regulations and updated the regulations as we went along. They're a great source for a self-assessment tool and a good communication tool. I have the links in the appendix. Again, they're no longer used, but if you're using that as one of your self-assessment and CMS sees that, it might help, might give them a little bit better understanding what you're doing. And then just really quick, because this has raised some questions and it raised questions when I was even doing active nursing, artificial nails. And here, this is from AORN. This is not CDC, this is from AORN. Artificial nails, direct caregivers cannot wear artificial nails if they're in direct contact with patients at high risk for infection. ICU, OR, you use your hospital policy. Even gel nails, AORN says no. Now you don't have to follow that policy. Just be aware. This is one of those expert societies that CMS may look to. Just keep that in mind. On a tire overall, something that covers all head and facial hair. And this is for those in semi-restricted and restricted areas, your surgical suites. Masks by everyone in restricted areas where you have open sterile stuff, supplies, or they're scrubbed in. They have to be properly tied and fresh mask for every procedure. We don't wanna be reusing the same mask over and over for your doctor who's perhaps doing an open abdominal incision. They need to change it. So we have a few minutes left. I'm gonna go through our final issue here. This is one of the hospitals that I had worked with. They had a recent outbreak of C. diff, eight patients in two months. The prevention and ASP, they reviewed the records of all eight patients. There wasn't any specific trend, whether it was a patient type, why were they admitted? What was their care? Except the provider, all patients were in the same. What should the preventionists in leadership now do? Do they observe care to see is there a cause? Do they close the room permanently? Close the room, do a deep clean? Look at the schedule. What was done? Maybe was there a step they missed? Anything else you can suggest? And that can be multi-ones or any other suggestions that you may have. But again, patients weren't all in the same room at different times. And so with that, Lindsay, I'm gonna turn it back to you, see if there's any more questions. And just so you folks know, I have about 20, there's about 20 more slides of resources. Some of these are the links that I had talked about if you wanted to go get with the links, copy paste your surf engine. If you're having an issue, cause some of them are starting to get a little worn out, I have a feeling cause I tried it the other day. Like for example, the worksheets, a great way to do that is CMS, Infection Prevention Control Worksheet. Just type that in and it usually pops right up. Just be again, mindful that was from several years ago when they were using those worksheets. Get good assessment tool and not use anymore, but it's really helpful if you're looking at your program. Perfect, thank you so much, Laura. I see several of you putting in your response here to this honor discussion question. So we'll give you just a couple more seconds there to do that. And if you have any questions for Laura, make sure that you are typing those in to that Q&A option seen there at the bottom of your Zoom window or into the chat. So we'll make sure that we have a couple minutes left here to address any questions that you have for Laura today as well. I will go ahead and just post some information there for you all in the chat as we give you a couple more seconds to put in your responses here. This is another reminder that you will receive an email tomorrow morning, but just note that it does come from educationnoreplyatzoom.us. Just because it is coming to you from that Zoom email, it very well may get caught up in your spam or your quarantine folder. So if you don't see that in your inbox in the morning, you can just check those additional folders. But if it's still not there and you'd just like to access the recording of today's session, you can always just use the same Zoom link that you are using today to join us for the live presentation to also go back and access the recording. And the recording is available via Zoom for 60 days. And once you click on that Zoom link, it will ask you to enter your information. That will prompt an email to come to us to approve that recording access request. We ask that you give us one business day to grant those approvals, but we do typically approve those very quickly. And also included in that email tomorrow morning will be a link to the slides that Laura did present for us today, but I did go ahead and provide that link there for you in the chat now as well. So you'll have that as a resource now. I see lots of comments here, Laura, just saying thanks so much for the information, wonderful resources, wonderful comments. Thank you all so much. Yes, thank you. I'm going to end this poll and share those results here if you want to go back and do that final discussion. All righty, all right. So yeah, don't close the room. There was something else going on with this particular room. And you're right. Look at the care that was being provided. Didn't we drop a step in taking care of a particular patient? And when they did that, they couldn't really find anything. What they found was, number one, they did definitely do a deep clean. There was no question about that. And then they went back and at the same time, did more of the RCA. They looked at that cleaning schedule to see when was it done and how much was done. And there were a couple steps that were missing. And it wasn't that the cleaning crew intentionally did it. They didn't know because they had had a turnover in some of their staff. And so they just did a little bit refresh on, hey, this is what we expect and what we need to have done in there and why it is so crucial for patient safety. And after they did the deep clean and a little bit more education, then it went away, it stopped. They were able to contain that infection to just those eight patients. Oh yes, it wasn't a good idea that we did lose a few of them, but nonetheless that they did eventually find the cause and were able to fix it. And then they went back and started looking at the cleaning for the rest of the rooms and some of their hospital and found out this isn't just one area. We just happened to catch it in this one area. So it was a really good learning lesson for them. They did learn quite a bit from it. So, as I mentioned, I do wanna show you, again, the appendix has a lot. If you have any questions on some of these, I did mention the memos and the surveys, et cetera, how you find the deficiencies. If you are interested, there's the worksheets. Again, just copy paste that or put in infection control worksheet by CMS and they will usually crop up. So thank you, Lindsay. I'm not gonna make people dizzy, give them three minutes or so back of their day. And thank you again. Perfect, thank you so much, Laura. I did just put, you do see her content information here on the screen, but it also just posts in the chat there our email address, which is education at gha.org. So if you have any questions following today's presentation, you can always reach out to us via that email address. I'm happy to get those questions over to Laura. And she's wonderful about being timely and very thorough in her responses back to you as well. I do wanna make one quick plug. If you are joining us as a member of the Georgia Hospital Association, we are so excited to announce that we have a new resource available to you through the GHA Learning Academy. So if you would, I would encourage you to reach out to us at education at gha.org there so I can give you some additional information and just be on the lookout in your email for an announcement giving you further details regarding that as well. And we hope to give you that option as a new resource for GHA members and we're excited about that as well. Thank you so much, Laura, as always, for your time and information that you shared with us today. And I hope you all have a wonderful afternoon. Thank you so much, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

risk management

patient safety

infection prevention

healthcare-associated infections

compliance

infection preventionists

antibiotic stewardship programs

quality assurance

performance improvement

training

competency assessments

healthcare leadership