Infection Preventionist Starter Kit: Infection Prevention Programs

A comprehensive surveillance program is critical to the detection and prevention of healthcare-associated infections (HAI) and epidemiologically significant organisms. Your program’s surveillance plan should be based on your facility risk assessment. It should be updated at least annually and whenever there is a change to the risk assessment.

Surveillance plan considerations

Identify specific events being monitored and criteria used. This could include, device associated infections, multidrug-resistant organisms, or communicable disease exposures.

• Determine rationale for selecting the specific event, such as process, outcome, or mandatory reporting.
• Select methodology for case identification, data collection, and analysis. Evidence- based surveillance criteria such as National Healthcare Safety Network (NHSN) or McGeer’s criteria are necessary.
• Determine necessary data analysis reports, including analysis frequency and recipients.
• List any required state or federal reporting requirements, (including by statute, accreditation, or public reporting) or mandatory reporting (such as state communicable disease or CMS (Centers for Medicaid & Medicare Services)).

Annual risk assessments

A facility infection control risk assessment should be performed annually. It assesses potential risks for infections, contamination, and exposures, as well as the program’s readiness to eliminate or mitigate such risks.

You may use the DHS Annual Infection Prevention and Control Risk Assessment Template (Excel) when conducting annual infection prevention risk assessment and goal setting for your facility. Templates are also available from the CDC (Centers for Disease Control and Prevention), including assessments for outpatient facilities.

Situational risk assessments

Situational risk assessments can also be done when a potential infection risk is identified. Learn more by viewing the IP Lunch and Learn webinar recording on situational risk assessments (opens external video).

A situational risk assessment template is also available.

A bloodborne pathogens (BBP) plan, also known as an exposure control plan, is an Occupational Safety and Health Administration (OSHA) requirement to protect employees. To learn more about bloodborne pathogens and components of a BBP plan visit the DHS reportable exposures webpage.

 IP tip: Review a sample BBP plan from OSHA.

TB (Tuberculosis) is caused by a mycobacteria called Mycobacterium tuberculosis. It can be transmitted through the air from person-to-person. For more information on TB disease visit the Wisconsin TB Program webpage.

OSHA requires that all health care facilities that may care for active TB patients have a TB infection control program. For more information on TB infection control programs in health care settings, visit the CDC webpage.

 IP tip: Review a sample TB risk assessment.

OSHA requires that health care facilities establish and maintain a respiratory protection program (RPP) under the Respiratory Protection Standard (29CFR 1910.134). For more information on RPP, visit the DHS RPP webpage.

The Wisconsin State Laboratory of Hygiene’s (WSLH) WisCon Program, as part of the University of Wisconsin-Madison and in conjunction with the U.S. Department of Labor, currently offers free on-site consultation services to assist Wisconsin employers in meeting the obligations and responsibilities covered under the federal Occupational Safety and Health Act. They also provide a webpage and training program that details the OSHA RPP requirements.

 IP tip: Review a sample RPP.

Antimicrobial stewardship (AS) is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics, antivirals, antifungals, and antiprotozoals). AS programs improve patient and resident outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.

Follow the CDC Core Elements of Antibiotic Stewardship for your facility type:

• Long-term care
• Hospital (PDF)
• Outpatient

For more information about antimicrobial stewardship visit the DHS antimicrobial stewardship webpages.

In collaboration with your facility’s medical director, develop an outbreak management plan. Regularly revisit and update the plan as the situation changes or new information becomes available. It’s essential to clearly communicate and educate staff and partners on the outbreak management plan.

Components of an outbreak management plan

• Facility-wide outbreak policies and procedures
• Employee immunity or vaccination policies and procedures
• Employee illness policies and procedures

For more information about managing outbreaks, visit the outbreak management section of the Infection Preventionist Starter Kit.

 IP tip: Forming your infection prevention program requires building relationships and reaching out to leaders in your facility.