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INFECTION CONTROL COMMITTEE
ANNUAL REPORT
[This template is provided to outline the scope and responsibilities of the Infection Control Committee at the University of Michigan Hospitals and Health Centers. Data and activities specific to UMHHC have been omitted.]
Respectfully submitted by: Chair, Infection Control Committee
Committee Membership Roster:
Committee Charge:
Committee Meeting Dates: The Committee meetings were on the following dates:
Major Accomplishments:
The Infection Control Committee (ICC) continued a high level of activity throughout the year. These actions included routine responsibility for review and analysis of surveillance data, quality improvement activities, review of policies and procedures related to infection control, education of staff members, and implementation of regulatory compliance actions, consultation, and provision of necessary control measures. Members of the Infection Control Department (IC) provided staff to the Committee.
I. To meet the charge to review the mechanisms and parameters of a nosocomial infection control program including surveillance criteria, infection definitions and criteria of acceptance, and epidemiological follow-up. Institute corrective actions as appropriate.
A. Routine surveillance of patients was performed. Surveillance definitions are in accordance with the National Nosocomial Infections Surveillance Study from the Centers for Disease Control and Prevention. Data from selected surveillance activities were provided through the Quality Improvement Report.
Infection Control staff performs continuous, priority-directed, targeted surveillance. This method of surveillance enables staff to focus on high-risk areas. Target areas are identified based on the population at risk; those areas or services with a potential for prevention; and those areas/patients with a high potential for adverse patient outcomes. Patient populations monitored are primarily intensive care and/or immunocompromised patients. Areas to monitor are reevaluated semi-annually.
Data are used in studies for improving patient care. IC staff works with the quality assurance committees for all ICUs and other high-risk areas on improvement projects. Data are presented routinely to the Infection Control Committee in the form of rates. Infection information is also reported to the Quality Improvement program, Multidisciplinary Quality Committees, Physician-Nurse dyads, and unit staff.
Any problem areas are also brought to the attention of the nurse manager and medical director. Recommendations are made related to the problem in order to decrease infectious complications and improve patient care.
B. The Infection Control Committee had many activities related to antibiotic-resistant microorganisms.
1. The Antibiotic-Resistant Precautions Policy was reviewed and revised.
2. A web-based educational program was continued on ARP and antibiotic-resistant microorganisms with Nursing Services.
C. Various clusters of infections were researched. These included the following major epidemiological investigations:
II. Review UMHHC’s infection control measures including isolation requirements, aseptic procedures, disinfection and sterilization procedures, etc.
A. To meet the JCAHO charge to routinely review all written policies and procedures with elements pertaining to the Infection Prevention and Control Program, 102 area-specific surveys were performed and Infection Control manuals were reviewed and endorsed by the UMHHC Infection Control Committee.
In addition, updates for policies/procedures were reviewed and approved by the Committee.
B. The Infection Control Committee continued its activities related to Universal Body Substance Precautions to be in accordance with the needs of the UMHHC as well as the Occupational Safety and Health Administration criteria. A program entitled “Safe Practice and Infectious Diseases: A Healthcare Worker's Guide” was continued for training all appropriate staff members.
C. The Infection Control Committee is charged by JCAHO to determine preventive measures regarding inanimate and animate environments in the UMHHC. This activity includes sterilizer monitoring, disinfection practices and quality improvement activities related to infection control which were continuously performed during the last year. Problems related to sterilization and disinfection practices have been addressed by the Infection Control Committee and resulted in the appropriate corrective actions in each area.
D. Other activities of the Infection Control Committee included the following: Consultation on renovation and construction and compilation of biological disaster information into a web site.
III. Review elements of the employee health program which impacts infection control policy and procedures.
A. A body substance exposure task force developed recommendations on safety products to protect staff from injuries. Recommendations were provided to the Operations Improvement Council.
B. Employee Health Service provides a routine report to the ICC on body substance exposures, TB tests, exposure follow-up results, and communicable diseases in staff.
C. Additional employee and patient protection activities included follow-up for potential communicable disease exposures.
IV. Report actual or suspected infections.
To meet the regulatory requirement for reporting communicable diseases to the Michigan Department of Public Health, 1067 cases identified by the Microbiology Laboratory and Medical Information Services were reported to the appropriate health department.
V. Institute quality assurance studies. Provide epidemiologic follow-up on all quality assurance studies to identify improvement areas.
A. In May, Infection Control launched a five-week educational program as one strategy in a campaign to reduce ICU catheter-related bloodstream infection rates.
VI. JCAHO preparedness: IC staff were represented on the Accreditation & Regulatory Readiness Council and participated in the Ambulatory Care Services JCAHO preparedness group. The JCAHO survey resulted in no issues related to surveillance, prevention and control of infections.
Challenges:
Selected Goals for the Coming Year: |
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发表于 2007-10-6 22:56
发表于 2007-10-9 22:20