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By Carolyn A. Ramsey, RN, MSN, CNOR
1. To describe various types of planning strategies that can be used in developing an infection control plan.
2. To list suggested topics to be included in an effective infection control plan.
3. To recommend methods to use in dissemination of the contents of an infection control plan.
On effective infection control plan is essential in any healthcareorganization. The author describes various types of planning strategies andgives suggestions in developing and maintaining an infection control plan. Thepurpose of the article is to assist anyone responsible for establishing andmaintaining an infection control plan in a health care setting. Personalobservations, published journal articles and nursing management text books areused as reference. Once an effective plan is developed, a routine review processcan be used to keep the information current and activities up to date.
Dwight D. Eisenhower once said, "Plans are worthless, planning isessential."1 This statement could refer to any written planfound in manuals on shelves in our institutions. Planning could be described asdeciding what to do, who to do it, how to do it, when and where to do it, wellin advance of any action. Developing a workable infection control plan is thefirst step in actually implementing and having a plan for all to use.
Like any process or plan in a healthcare institution, the infection controlplan must flow from the overall philosophy, mission and goals of theorganization. If the mission statement of the organization includes reference tocommunity service for example, the infection control plan should also addresscommunity activities. All infection control plans must be flexible. There mustbe room to alter the plan in response to unexpected disease processes orenvironmental issues. All plans should also include an evaluation step and aregular review process to ensure up-to-date information and activities.1
Young and Hayne (1988 in Marquis and Huston, 1994) described reactiveplanning, accomplished after a problem occurs. Reactive planning is usuallydirected toward changing situations back the way they were in the past.Frequently this is done in haste addressing some crisis and could be a carelessdecision.
Inactivism considers the status quo as a stable environment. A great deal ofenergy is spent preventing change and maintaining conformity. If there areproblems, they are treated, rather than solved.
Preactivism-type plans use technology to accelerate change. Preactivists areunsatisfied with the past or present, do not value experience and think thefuture is always better. A preactive infection control plan could be verydifficult to use in the day-to-day operation of an organization.
The interactive or proactive planning mode is the most desirable type ofplanning for infection control issues. Proactive planners consider past,present, the future, and how to adapt the plan to all eventualities. Proactiveplans encourage the best use of resources, and minimize risks and uncertainty.Plans can include anticipated issues such as providing for expanded services.
Healthcare organizations usually have several types of plans in effect at anygiven time from long-range strategic plans to daily operational plans. Theinfection control plan should be of intermediate length, in the one-year tofive-year range. Intermediate plans involve a particular project or an ongoingprogram such as infection control.
Education of Infection Control Professionals
Emerson (1997) describes an educational program in the United Kingdom thatoffers a diploma in hospital infection control. The purpose of the course is toprovide training that prepares practitioners to develop a thorough infectioncontrol service. Topics included in the course are epidemiology, microbiology,economics, statistics, surveillance methods and patient management. The courseis open to physicians and nursing personnel with prior infection controlknowledge.
The course is divided into modules that include theory as well as hands-onpractice. Much of the course is self-directed, which helps busy professionalsset their own schedule for learning and completing the assignments andpost-tests required. Each participant is also given a mentor with which to workto improve the overall outcome of learning.
The course is usually completed on a part-time basis in two years. Somestudents advance at a faster pace while others may take the entire five-yearmaximum time frame to complete the course. Extensive education may be requiredfor persons responsible for developing and maintaining an infection controlplan, however, timely evidence-based education must be provided for all staffwho are responsible for carrying out the plan.
Components of an Infection Control Plan
An infection control plan may be a document labeled as such, or a group ofpolicies and procedures identified as guidelines used to deal with infectioncontrol issues. Infection control starts with staff members. Each hospitalemployee must learn how to protect him or herself from possible infection thuspreventing passing the infection to other patients or other healthcareproviders.
Methods of Communication
The infection control plan should include how the plan will be communicatedto the staff. Many institutions may have one or two copies of the infectioncontrol manual which includes the plan and associated policies, educationalmaterial, and other supporting documentation, while others may have a copy oneach nursing unit, and supporting departments such as the lab and X-ray. Themanual or plan may also be on the institutions' intranet or other computerizedresource. Besides written information, the plan may also include methods ofcommunicating the contents of the infection control plan. Posters, videos, oralreports or formal presentations may be used to communicate the contents of theplan.
An infection control practitioner (ICP) should oversee the distribution ofthe information in the plan. All employees should know the contents of the planand how they are to use the plan in everyday patient-care situations. Theinfection control plan should be a part of orientation and reviewed periodicallyby all employees. Annual or periodic review could take place in a variety ofways. There are many computer-assisted programs that can offer information,include a post test for reinforcement and record each person's participation.Hospital-wide newsletters could be used to communicate the plan, or simpleposters or other types of announcements are also effective. Infection controlinformation could also be posted during routine educational programs such asbasic life support.
Approval and Review Process
Dates of approval and revision dates should also be included. It is suggestedthat the infection control plan be reviewed on the same schedule as the policiesof the hospital. This will help assure that the plan is reviewed and revised ona regular basis. The persons required for the review should be included on aface sheet or heading with areas for signatures. Signatures of leaders in anorganization always give credence to the contents of a policy or manual.
One basic component of any infection control program is hand washing withrelated skin integrity of healthcare providers. Medical schools have realizedthe importance of teaching their students the importance of good handwashingtechniques. Nursing education has always included handwashing, but there isalways room for improvement. Creative ways of teaching proper handwashing havebeen used for years. One effective method is by applying a personal examinationhandwash product that shows areas missed during routine handwashing when thehands are held under an ultraviolet light.
Posters have also been strategically placed in employee, patient and visitorbathrooms. This practice had fondly been referred to as "pottytraining." Care should be taken to change the posters every few weeks asthey become "invisible" after being viewed day after day.
Available supplies and proper location of sinks should also be considered.Use of waterless antimicrobial solutions can be used, but everyone must realizethe restrictions of such products. They do not remove foreign matter or debrisfrom the hands. Proper use of all products for hand washing should be includedin the infection control plan.
Infectious Waste Management
Infectious waste and its disposal has become an important element to includein infection control plans. Regulations for the handling and disposal ofinfectious waste have caused the cost of infectious waste management todrastically increase. Many hospitals have chosen to contract outside servicesfor waste management, which has also shown to increase costs. Some hospitals,however, have developed educational programs to inform the staff about effectivewaste management. Instead of placing all trash in special marked bags forincineration or sterilization, many items could be disposed of in regular trash,which requires no special treatment before transport to a landfill. The key tosuccess with such a program lies with communication and education of appropriatedisposal techniques.
Areas to consider involving the patient should include education aboutbloodborne pathogens with hepatitis B and HIV (human immunodeficiency virus)being the most life threatening. Hepatitis B is much easier to contract fromexposure than HIV. About 9,000 healthcare workers in the United States contracthepatitis B each year. Of that number, approximately 200 will die from theinfection (OSHA #2, 1992, by Hunter, 1998). Since the early 1980s when AIDSbecame a recognized diagnosis, there have been a total of 52 cases reported ofwork-related exposure among healthcare providers. An additional 114 are stronglysuspect, but not confirmed (CDC #1, 1997, by Hunter 1998).
Vaccination for hepatitis B should be a part of the infection control plan.Any employee that has the chance of coming in contact with blood or body fluidsshould be given the opportunity to receive the vaccine. For those who choose notto receive it, comprehensive education and counseling must be given.
Hepatitis C is also of concern. At least one Board of Nurse Examiners nowrequires education on the topic of hepatitis C for relicensure. All healthcareproviders should be included in the education of all bloodborne pathogens.
A comprehensive, but simple program for reporting exposure should be includedin the plan. All levels of employee are to be considered when procedures arewritten. If the steps are confusing, or not clearly listed, reporting might notbe carried out.
"The Association for Professionals in Infection Control and Epidemiology(APIC), in cooperation with the Centers for Disease Control and Prevention (CDC)have developed the Bioterrorism Readiness Plan: A Template for HealthcareFacilities. (Shadel 2001, p. 347). In addition to this document, hospitalsmay want to include a portion, or summarize the contents to include in theirinfection control plan. As was mentioned, plans require flexibility. Even thebest thought-out plan may require instantaneous revision in the event of such anevent as a bioterrorist attack.
In a recent study reported by Shadel et at (2001) educational topics forconsideration included, isolation, triage and epidemiology of pathogens. Theparticipants felt it was important for healthcare professionals to have theability to identify an infectious process as compared to a chemical hazard.
The goal of any infection control plan is to prevent nosocomial infections.Much time may be spent on developing the contents of the plan, educating thestaff about the contents of the plan and implementing each step in the plan, butthe value of any plan lies in the data collected regarding patient outcomes.Infection rates must be accurately collected and reported.
The Centers for Disease Control and Prevention (CDC) developed the NationalNosomomial Infections Surveillance (NNIS) system more than 30 years ago.Hospitals participating in NNIS have the advantage of benchmark activities tocompare infection rates between similar hospitals. Standardized data collectionmethods are provided, as well as guides to prevention.
As more healthcare services are provided outside the hospital, post dischargeand outpatient surveillance techniques must be refined. Gaynes et al, (2001)report that two thirds of nosocomial infections are preventable. By changing thebehavior of caregivers, surveillance can improve the quality of patient care.
All hospitals are challenged with isolation practices. The infection controlplan should include procedures for identifying patients requiring various typesof isolation. In a report by Kidd et al (1999) a comprehensive plan wasdescribed to change isolation practices to the new CDC guidelines for isolation,standard precautions, and transmission-based precautions. Formal presentationswere given to employees over a two-month period. Participants were given a posttest and signed a statement of accountability for the content of the program. Avideo was made of one of the live presentations that was available for viewingby those who were not able to attend a live presentation. A third method was awritten self-learning packet that could be completed by the learner. They weremade available to physicians and managers who had not attended one of the otherofferings. Physicians were asked to instruct incoming residents and all newemployees were given the information during hospital orientation.
Despite all the work the education department did to ensure all staffreceived the information needed to institute a change in isolation techniques,there was zero compliance using the appropriate signage for patients whorequired isolation. Only when infection control practitioners made rounds on allunits and advised staff members as patients were put into isolation, didcompliance improve. Each unit received individualized instruction and coachingwhich proved to be much more effective than formal presentations. This reportshows that any type of change is best implemented when the participants can seethe change in action and practice the change with individual instruction.
This description of changing infection control practices could be seen as anevidence- based practice change. Recent emphasis on outcomes research has ledinfection control professionals across the nation to develop programs includingevidence-based practice, patient safety and quality improvement issues. The maingoal of any infection control practice is to improve health.
In summary, infection control plans must be carefully developed, reviewed ona regular basis, and most importantly, be communicated to everyone using theplan. Education plays a big part in the communication process. Nursing and othereducation resources in a hospital setting should be involved at the onset ofplan development.
Carolyn A. Ramsey, RN, MSN, CNOR, is staff development educator forTrinity Mother Frances Hospital in Tyler, Texas.
|TEST QUESTIONS: TRUE OR FALSE||T||F|
|1. Planning could be described as deciding what to do and when to do it.|
|2. All infection control plans must be rigid and consistent.|
|3. Components of an infection control plan should flow from the mission of the organization and contain an evaluation step.|
|4. Reactive planning is frequently carried out in haste.|
|5. The proactive mode is the most desirable type of planning.|
|6. An infection control plan should be a strategic, long-term plan.|
|7. Infection control starts with administration.|
|8. It is suggested that the infection control plan be reviewed on the same schedule as the policies.|
|9. Teaching handwashing techniques is one of the most important components of any infection control plan.|
|10. The use of waterless antimicrobial solutions do not require any additional education for the staff.|
|11. All waste in a hospital should be considered infectious.|
|12. Hepatitis B is easier to contract than HIV in healthcare environment exposures.|
|13. Bioterrorism plans are of no concern to hospitals, since APIC and CDC have developed a plan.|
|14. The infection control plan should be presented during orientation and periodically for all employees.|
|15. The value of an infection control plan is evidenced by patient outcomes.|
|16. The NNIS system is based on each hospitals infection control data individually.|
|17. Two thirds of nosocomial infections are preventable.|
|18. The most effective education about an infection control plan is carried out on individual units.|
|19. Data collection of compliance of infection control practices is considered evidence-based research.|
|20. Hospital educators should be involved with any infection control plan from the beginning of development.|