10 Elements to Consider When Conducting an Infection Risk Assessment

Almost everything we do in the healthcare industry is designed around one main focal point: patient safety. And infection prevention and control (IPC) is no exception. Industry leaders are developing IPC protocols to keep patient safety and outcomes at the forefront of all decision making. That is why it is so important to take a proactive approach to preventing infections from occurring by assessing the risks that may derail IPC efforts.

By Marcia Patrick, MSN, RN, CIC

Almost everything we do in the healthcare industry is designed around one main focal point: patient safety. And infection prevention and control (IPC) is no exception. Industry leaders are developing IPC protocols to keep patient safety and outcomes at the forefront of all decision making. That is why it is so important to take a proactive approach to preventing infections from occurring by assessing the risks that may derail IPC efforts.

What is Infection Control Risk Assessment?
An infection control risk assessment is more than just running down a list of potential hazards and informing personnel of best practices. A sophisticated infection control risk assessment is a living document that forms the foundation of any comprehensive IPC program. The policy evolves over time as goals and measurable objectives change, while maintaining a solid framework for consistent patient safety.

Often when developing an infection risk assessment, healthcare leaders understand what the outcomes should be but have no idea where to begin. Before setting any goals or objectives, leaders must create a structure from which to work. An infection risk assessment considers potential hazards and prioritizes them to better guide goal-setting and strategy development.

Infection control risks can stem from a variety of areas in a healthcare organization, and most can lead to significant patient (or staff) harm. Some common examples include:
• Lack of hand hygiene
• Unsafe injection practices
• Poor cleaning, disinfection, sterilization of instruments and scopes
• Inadequate environmental cleaning

To understand which risks pose the greatest threats to your facility, you must assess your current operations.

Why is an Infection Control Risk Assessment Important?
While the subpar practices listed above may seem like obvious pitfalls to avoid, IPC protocol is not always adequately enforced. That is why the Accreditation Association for Ambulatory Health Care (AAAHC) recently added a requirement for written risk assessments documenting how facilities are prioritizing patient safety. The new standard underscores why healthcare organizations must have an infection risk assessment in writing that can be updated annually. A formal risk assessment:
• Provides a basis for infection surveillance, prevention and control activities
• Identifies at-risk populations/procedures in your facility
• Assists in focusing surveillance efforts toward targeted goals
• Aids in meeting regulatory and other requirements

When conducting an infection control risk assessment, take an interdisciplinary approach to collecting information and feedback from employees. Once your team is ready, you can start identifying all potential risks, documenting your findings and prioritizing processes to improve outcomes.

What Elements Should You Consider?
There is a plethora of factors that may impact IPC success, ranging from procedures performed to earthquake vulnerability. An infection risk assessment must consider a variety of elements before establishing IPC protocol, goals and objectives. Here’s what to look for:

1. Geography/Topography/Weather
Depending on where you are located, IPC efforts may be hindered by Mother Nature. Natural disasters – such as hurricanes, earthquakes, snow, rain and drought – can disrupt IPC efforts by creating emergency situations. When resources are limited and personnel is stretched thin, healthcare facilities may find higher rates of infection than under normal circumstances, and should therefore plan accordingly.

2. Population
Another aspect of your location that can affect IPC success is the community your facility serves. When assessing for risk, be sure to take into account the demographics of patients, their socioeconomic situation, their age and other factors that directly or indirectly impact health. For example, your infection risks may change depending on if you treat more infants than adults. 

3. Communications
One element often overlooked when developing IPC protocol is a facility’s communication strategy – which applies to both internal and external efforts. Leaders should evaluate how messages are communicated within a facility, among staff, or between entities in a health system. Within the community, a healthcare facility should have a comprehensive plan for how to work with third parties such as emergency management teams, health departments, medical societies, professional groups and emergency medical services. Not only should each strategy have clear processes to follow, but offer options for both routine and emergency situations.

4. Employees
Along the lines of internal communications, healthcare facilities should gauge how employees are managed and provide services to patients. Managers should develop strict hand hygiene requirements and monitor for compliance, as well as assess how well sharps injuries protocol is being followed to avoid unnecessary risks. Furthermore, healthcare facilities can proactively work to keep their staff healthy by developing a sick policy that keeps employees away from patients when they have certain illnesses. This policy should include expectations for proper immunizations, as well as a TB control program that screens staff to prevent spread.

5. Environment
The efficacy of staff performance is only as good as the tools they use. Healthcare facilities must look at the working environment to ensure there is adequate space and resources to clean, disinfect and sterilize all instruments, scopes and furnishings. A clean, healthy environment may call for a better biohazard waste management protocol, upgraded ventilation systems or changes to the construction of the facility itself to support IPC initiatives.

6. Cleaning, Disinfection, Sterilization
Once it is determined there is adequate space to conduct cleaning, disinfection and sterilization, health leaders should evaluate if these practices are following AAMI, AORN and CDC guidelines. Facilities can develop procedures to monitor the use of all disposables, sterilizers and high-level disinfectants, as well as steps to take for a failed sterilizer or HLD test. In addition, a schedule and log should be created for preventive maintenance on all equipment to ensure maximum efficiency.

7. Risks for Infections
There are a handful of major risks for infection any healthcare facility should be mitigating:
• Surgical and other device-related infections
• Diarrheal diseases (e.g. C. difficile)
• Post-procedure pneumonia
• Respiratory diseases (flu, colds)
• Significant organisms (MRSA, VRE, ESBLs, CRE)
Many of these risks may remain prevalent in your facility without you realizing. For example, the AAAHC Quality Roadmap 2015 found more than ten percent of ambulatory surgery centers, more than nine percent of primary care organizations and more than fourteen percent of office-based surgery organizations surveyed had deficiencies in their safe injection practices.

8. Procedures
Just as you gauged the different populations served, it is equally important to factor in what types of procedures are being performed at your facility. Risks can vary greatly by type of procedure, and the safety of the patient can be affected differently after each service provided. Mitigating these unique risks goes beyond establishing protocol during the actual procedure. Employees should consider the behaviors and environmental factors affecting the health of the patient population in the community. Understanding the background of each patient is as vital as informing them of the risks to avoid and healthy behaviors to follow to remain safe post-procedure.

9. Emergency Management
Any type of emergency situation places strain on a healthcare facility and can lead to a higher rate of infection. Healthcare facilities should understand the role they place in the community in the event of an emergency and coordinate with the local health department or emergency management team to define expectations and develop strategies. When planning for an emergency, anticipate a variety of scenarios that could occur both internally or externally. Then determine what staff training, supplies and equipment must be prepared to sustain operations when disaster strikes. Infection Prevention can be adversely affected if there is no water, ventilation is compromised or there is physical damage to the facility.

10. Education and Competency Evaluation
Educating staff does not end with teaching the protocol in an emergency situation. There should be annual or biannual training opportunities and competency testing for all employees and licensed independent practitioners to ensure the facility is functioning at top performance. Each staff member must demonstrate his or her ability to perform assigned duties routinely as well as whenever tasks, procedures or products change. Just as new staff receives an orientation on industry standards and policies (e.g., OSHA Bloodborne Pathogens Standard), patients should also be educated on infection risks and best practices to reduce threats. Once they leave the facility, much of the IPC control rests in the hands of the patients themselves and they should have comprehensive information to strengthen outcomes.

How Do You Assess The Risks?
Documenting all your facility’s infection control risks will help you set priorities and goals based on relative risk. Rate each risk of the 10 risks on the following criteria using a severity scale of 0-3:
• WHO is at risk for infection or adverse event?
• What LEVEL of risk is present?
• What is the IMPACT on care, treatment or services?
• How PREPARED for this is the organization?
Add up the scores and create a list of priorities placing risks with the highest number at the top and work your way down.

How Do You Put It Into Action?
Now that you understand what the most menacing risks are to your healthcare facility, you can develop goals and measurable objectives to combat these threats and improve IPC success.
A goal is a broad statement indicating the change you want to make. Goals are not measurable as they stand, but rather identify an overarching issue. For example, goals may include:
• Improving hand hygiene
• Initiating disaster preparedness kits
• Reducing the risk of surgical site infections
A measurable objective specifies quantifiable results over a specific period of time. It defines the who, what, when, where and how of your strategy. The measurable objectives that fall under the umbrella of each goal can then become part of one or more staff management objectives for the following year.
For example, a measurable objective may call for IV antibiotics to be administered within one hour of incision with a 95 percent threshold. The objective will be incorporated into the performance goals of affected employees, and will be monitored for progress and compliance by checking patient charts. You should evaluate how each goal and measurable objective not only addresses an infection risk but also promotes change in operations. Many healthcare organizations will use goal setting as a vehicle for employee bonuses. Bonuses are not awarded unless both personal and facility goals and objectives are met each year.

Because each goal and objective will impact a variety of departments and employees, it is essential to conduct an infection risk assessment and identify goals in a collaborative manner. Each department will require different solutions and strategies to combat their unique risks and challenges. Therefore, input should be collected from all levels and teams to ensure nothing is overlooked and increase the chances of success.

The AAAHC has created an IPC program designed to help facilities build risk assessment goals and objectives together. Like-minded organizations come together at a preconference to Achieving Accreditation to share ideas and results to extract insights and best practices for future risk assessment exercises. Participants have developed a network of collaborative facilities across the country that provides information-sharing opportunities and a myriad of valuable IPC resources.
The lessons learned from each risk assessment effort can help your facility, as well as facilities nationwide, improve their processes for the next assessment and strengthen their overall outcomes. When facilities work together and share what they learn, the industry as a whole benefits and we can remain focused on the ultimate goal: patient safety.

Marcia Patrick, MSN, RN, CIC is a Tacoma, Wash.-based consultant and surveyor for AAAHC.