Infection Control Annual Plan 2024

仙 39ttu出 ぃ 枷
Effective Date: January to December 2024
陶財 爛 Applicable to: All KSH Unaizah Health care workers

) Description
o Outlines the annual prevention priorities ofKing Saud Hospital Unaizah, Qassim
o Table ofContents
. Description
. Rationale
. policy
o Goals
o Risk Assessment
. Strategies to reduce Infection Risk
r Evaluation ofPlan Effectiveness
. Responsibility
o Reviewed/Approved by
) Rationale
An organized, systemic plan based upon the annual infection control risk assessment that provides the foundation for an
effective infection control program

! Goals
o Overall
. To Reduce risk ofHealthcare-associated infections for all patients, employee and visitors.
 INFECTION PREVENTION AND CONTROL PLAN 2024
Risk Priority Organization Infection Control Goal Measurable Stratery Evaluation Responsibility
GoaU Stratesy Objective

1. Contaminated Patient Safety Reduce endotoxin level Reduce Disinfect the water Monitoring monthly o Public Health Dept.
dialysis water (0-<0.125 EU/ml) for endotoxin level treatment system to the water analysis o Director of
system water analysis in positive result of Purifl, the water and for endotoxin level Maintenance &
Hemodialysis 0.250 to reduce endotoxin Support Services
satisfactory level level o Infection Control Team
of 0-<0.125 o Hemodialysis Team
EU/ml (MOH
standard)

2. Decrease Patient Safety Reduce related Reduce related Collect VAP/ VAE Monitoring monthly Infection Control Team
Ventilator VAPA/AE rates from VAP/ VAE rates surveillance data VAP/ VAE rates Statistic Department
Associated 2.4 to 1.6 per 1000 from2.4 to 1.6 Evaluate Bundle Analyze data Medical Services
Pneumonia ventilator days per 1000 compliance Report rates to I.C Nursing Services
(vAP) (NHSN) ventilator days Orientation about Committee,
(vAE) Decrease morbidity (NHSN) prevention of Concerned
and mortality Increase bundle VAPA/AE (bundles) Ward/Unit
Decrease hospital stay compliance to Initiate technique
100% improvement team
Recommend products
that facilitate
adherence to
recommendations
3. Reduce Patient Safety Reduce Healthcare Reduce Health Administrative Monitoring r Hospital Director
MDRO Associated MDRO Care Associated Support Epidemiologic o ICC
Reduce Morbidity and MDRO to 50o/o Education to all Trends o Clinical Pharmacist
Mortality from from the average HCWs Report rates to o Unit staff
MDRO infections 7.711000 patient Judicious use of medical and o Unit physicians
day. Antimicrobial operational services
Agents Report rates to HCWs
MDRO Surveillance Report rates to ICC
Infection Control
Precautions
Environmental
Measures
Decolonization
 INFECTION PREVENTION AND CONTROL PLAN 2024
Risk Priority Organization Infection Control Goal Measurable Stratery Evaluation Responsibility
GoaU Stratesv Objective

4. Reduce Patient Safety Reduce related Reduce related o Collect CLABSI Monitoring monthly Infection ControlTeam
CLABSI CLABSI rates from CLABSI rates surveillance data CLABSI rates Statistic Department
(Central line 1.25 to < 0.9 per 1000 from 1.25 to < o Evaluate Catheter Analyze data Medical Services
Associated Blood central line days 0.9 per 1000 placement and Report rates to LC Nursing Services
Septicemia oHSN) central line days technique (Bundle) Committee,
Infection) Decrease morbidity (NHSN) o Education session Concerned
and mortality Increase bundle (bundles Ward/Unit
Decrease hospital stay compliance from o Sub-committee for Initiate technique
86Yo to 100"4 Prevention of improvement team
CLABSI Recommend products
r SustairV Maintain that facilitate
CRRS Program adherence to
o Ensure Central line recommendations
Insertion/
Maintenance
supplies are not
intemrpted
5。 Prevent Patient Safety o Zero Outbreak To identifr Active Surveillance Report rates to Infection ControlTeam
occurrence of Employee major health Sensitize staff on Ministry of Health Outbreak Management
Outbreak / Safety Threats & timeliness and Analyze data (HAI Team
second Visitors Safety maintain Zero completeness of Surveillance) Cluster
Transmission outbreak reporting Ministry of Health
of Infectious To increase the Develop and update
Diseases awareness of the various reporting
HCW regarding forms (weekly
the definition reporting, monthly
and management reporting, case-
ofoutbreak. based reporting,
laboratory specimen
referral and
reporting forms,
etc.)
 INFECTION PREVENT10N AND CONTROL PLAN 2024
Risk Priority Organization
GoaU Stratesy
Infection Control Goal Measurable
Objective II Stratery Evaluation

o
Responsibility

6. Manage the Patient Safety Adequate Medical Increase the medical C)rientation of Monitoring of Hospital Director
Lack of Supplies (PPE) supply up to the Proper use of PPE to compliance (Use of o Director of Medical
Medical Health care required quantity. avoid misuse and PPE) Supply
Supplies worker's safety o >20% ofPAR underuse Managerial indicator

０
level Utilization of PPE (observing isolation

０
Increase requisition precautions)

０
Monitoring use of
PPE

●
PPE Plan
7. o

０
Increase Patient Safety Improve overall hand Improve hand Monitor compliance Collecting hand Infection Control
Hand hygiene hygiene compliance hygiene through monthly hygiene compliance Committee
from 75 ohtoS0oh

●
Compliance Health care compliance observation of Infection Control Team

●
worker's safety Establish baseline data from 75Y" to targeted areas Report rates to Quality Management

●
on hand hygiene 80 Yo Provision of high Hospital Director, AllHead of
Visitors safety compliance rates quality alcohol hand Medical and Departments
Decrease healthcare rubs Nursing services

●
associated infection. Education session

●
Hand hygiene Report rates to
campaigns with Health care workers
provision of posters Report rates to lC
reminders etc. Six Committee
sigma/perforrnance
improvement
support

●
8. Improve Health care To maintain Improve compliance Staff Education Monitor compliance Employee health Clinic

●
Immunization personnel and elimination of cases of with Ensure compliance with required and

●
●
/ vaccination Patient Safety vaccine preventable vaccine/immunization Mandatory pre- recommended IPC Team
compliance diseases among health to 100 oh employment health immunizations
care workers evaluation and BICSL
annual evaluation
 INFECTION PREVENTION AND CONTROL PLAN 2024

Risk Priority Infection Control GoaI Measurable Stratery

Objective

o Ch*klirt *d Ardit.

０
9. Ensure that Patient Safety To ensure From 807o to 95 Orientation

●
o/oManagerial using WHO hand
Isolation/ implementation to Job Specific
Transmission Health care prevent/minimize the Indicator- Training hygiene form &

●
based worker's safety transmission of observing Increase PPE supply Isolation Precaution
- Audit

●
Precaution is infectious agents from Isolation Public Awareness to Form
implemented Visitors safety patients to susceptible Precaution Target the visitors
hosts namely other External Website- to
patients, health care enhance Visitors
workers Knowledge about
Isolation Precaution
.

０
10.Inhibit For safety of Prevent healthcare- Keep Maintain Respiratory Monitoring Infection Control Team

０
MERS CoV and health care associated transrn ission MERSCOV/COVID Visual Triage& Epidemiologic Trends Nursing Units

●
COVID‐ 19 worker, patients of MERS-CoV/ COVID- l9 transmission to improve the quality Physicians
and visitors l9 or other respiratory Zero Transmission. Education Session
tranSELiSSiOn
viruses Maintain Zero Outbreak isolation Precautions
Standard precautions
Prevention of
overcrowding
Environmental
Cleaning and
Disinfection

●
Universal Masking
o 0&M Manager(AL

●
11. To ensure Patients , To develop and maintain To ensure proper Education Session for Checklist and audit tools
proper Healthcare effective and efficient cleaning and Housekeeping will assist supervisory IMANCO Company
Environment workers and cleaning methods and disinfection of the Services staff in monitoring and IPC Tcarn
Visitors safety schedules which are environment to establish a documenting cleaning Head Nurses(AH Units)
al Cleaning,
Disinfection
necessary to provide a o Scheduled monitoring tool for and disinfection of
clean healthy ongoing assessing cleanliness environmental
environment for patients, monitoring of the and quality control surfaces
staff and visitors thoroughness of
disinfection
Cleaning
 INFECTION PREVENTION AND CONTROL PLAN 2024

Risk Priority 0rganization Infection Control Goal Measurable Stratery Evaluation Responsibility
GoaV Strategy Objective

12. Decrease Patient Sal'ety Maintain related CAUTI Maintain CAUTI Collect CAUTI Monitoring o I.C Director
CAUTI rates below the Trend (below the surveillance data monthly rates o I C Practitioner
benchmark o

●
(Catheter national benchmark Analyze data Statistic Dept.
Decrease morbidity and 0.5/ 1000 catheter . Medical Services

●
associated Evaluate Catheter Report rates
Urinary
mortality
days placement and monthly to
o Director of Nursing &
Decrease Hospital
Tract stay
o Increase bundle technique (Bundle) ICC Head Nurses
Infection compliance from Initiate technique
88% to 100 oh Orientation about improvement team
Prevention of for Catheter
CAUTI (Bundles placement
Recommend
products that
facilitate
adherence to
recommendation
13. Decrease Patient safety Reduce / eliminate to Collect data of Sharp Monitoring monthly Employee
Employee Needle stick and Body injuries Needle stick Sharps Health Physician
Needle stick
Safety Fluid Exposure Analyze data& find Injuries rates
and Body Reporting System cause a Report rates monthly
Fluid Encourage staff to report Assess sharps safety a Distribution of report
Infection Control
Exposures incident products to appropriate Practitioner
Continuous orientation departments
of HCWs

14. Manage the Patients Safety Prevent healthcare- To request sufficient M.rtt", pr"dr"t Director of Medical
Lack of associated infection supplies availability and Store

●
supply in To ensure quality CSSD Supervisor

●
CSSD availability of IPC Team
(Biological supplies
and chemical Maintain PAR level
indicator)
 INFECT10N PREVENTION AND CONTROL PLAN 2024
Risk Priority

15. To ensure
IP"tt"rtr,
Infection(Control Goal

To ensure that
MeaSurable
Obi∝ t市 e

Infection Prevention
Stratery

IPC will be active Irf*ti., C.rt

Responsibility

Director of
implementati Healthcare environmental health and Control team members in all "l
Risk Assessment Maintenance & support
on of workers and risk assessments, Department (IP&C) phases ofany Form: Construction services
preventive Visitors safety interventions, and will be involved and construction/renovat Permit IPC Team
maintenance infection control be pre-informed of ion projects -Completed
to all practices are all current and future Provide education to construction
construction/ incorporated into the construction workers and staff renovation follows
renovation planning of activities at the involved in the up form
works within construction and healthcare facilities project to ensure that Walk-Through
healthcare renovation in the preventive measures Assessment Form
facilities healthcare Zeroharmafter are outlined, Follow-Up for
construction implemented, and Construction Permit
maintained

●
16. Reduce Patient safcty Reduce Healthcare Reduce Health o Screening and isolation C"ll""tlrg h",rd Medical Staff

０
MRSA Associated MRSA Care Associated of MRSA patients. Hygiene compliance Nurses
o Decolonize when

０
Transmission Reduce Morbidity and MRSA Trend. rates Infection Control
throughout Mortality from MRSA Appropriate Report rates to
the hospital infections r Staff and visitor medical and
education Operational services
o Judicious use of Report rates to HCWs
antibiotics
r Start MRSA prevention Report rates to ICC
bundle

０
1"7. Ensure Post Health care To decrease the Encourage reporting Training of healthcare I"juy P."""rti", Employee Health

０
exposure personnel and transmission of infections incident personnel assessment Infection Control
management Patient Safety from health care personnel Rapid access to Collecting and
system to patients Increase post clinical care, post- analyze Exposure
exposure reporting exposure prophylaxis,
compliance reporting
testing of source
compliance to 100%o
patients and exposed
Clear
policy/procedures
Follow up and
counseling
 INFECTION PREVENTION AND CONTROL PLAN 2024
Risk Priority 0rganization Infection Control Goal Measurable Strategy Evaluation Responsibility
GoaU Strateey Objective

18. Maintain Job

Specific
Enhance
staff
To implement evidence
based strategies to
*To ensure
compliance with
. In-services,
presentations,
T M"rit*
compliance
Education Department

Training education prevent infections policy and educational materials 2. Monthly reports Infection Control
procedures (booklets, educational Infection control
Increase awareness of *Ensure 100% videos rounds report and
HCW's regarding attendance of HCWs annual compliance
Infection Control Job Specific assessment
Practices Training
*At least 85 oZ score
in Post test

19. ⅣIaintain Enhance To achieve compliance fiom T" i.p."r" o Educational material to Feedback fiom o Patient and Family
Education awareness to patients and approved "*r*n*"
of patient and family to patient and family patient and visitors Educators
for Patient prevent spread watcher and visitors prevent spread of o Educational videos in o Infection Control
and Family of infection infection corridors and waiting o Nursing Services
To increase Hand areas Medical Services
Hygiene compliance in
visitors fuom 7 5 o/o to
80%
 INFECTION PREVENT10N AND CONTROL PLAN 2024
Risk Priority Organization Infection Control Goal Measurable Strategy Evaluation Responsibility
GoaU Stratew Objective

Reviewed by: ...

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●´9:352024/1/8 ANNUAL RiSK ASSESSMENT OF HEALTH CARE FACILITY KSH― Google Sheets

ANNUAL RISK ASSESSMEN7 0F H■ ALTH CAR■ FAC:LttTY:K]NG SAUD HOSPttTALttUNAlZAH

Year:2023
RisUlmpact (Heahh, Financial, Legal,
Potential Risks Probability of Occurrence Reoulatorv) Current Systems/Preparedness Score
Life Prolonged

ｂ
ａ
ｙ
丁hreat Serious Length of te

ｅ
Expected Likely Rare Never en:nc Loss Stav Ciinicai None Poor Fair Good Solid
4 2 0 S 4 3 2 5 4 3 2
Failure of Prevention Activities
Lack of Hand Hygiene Compliance 4 24
Lack of Respiratory Hygiene/ 8
Cough Etiquette 2
Lack of Supplies for Hand Hvgiene 2 2 12
Lack of Patient Influenza 18
Immunization
Isolation Activities 2 18
Lack of Standard Precautions 3 2 12
Lack of Airborne Precautions 2 18
Lack of Droplet Precautions 2 12
Lack of Contact Precautions 2 8
Lack of Supplies Necessary for 27
Isolation 3 3
Ilealthcare Acquired Infections
SSI 6 9

VAP in ICUs 4 36 2
CLABSIin ICUs 30 3
Dialysis‐ Related lnfec6ons 6 9
CAUTI 7

Outbreak 3 27 4
Sentinel Event 1 4 1 4 12

Other― ⅡAI DIIDRO Z 3 36 2

CSSD

８
Lack of Biological and chemical 8

１
３
Lack of Staff 1 1 2

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。こ9:352024/1ノ 8 ANNUAL RISKASSESSMENT OF HEALTH CARE FAC|Llry KSH - Google Sheets

Environment
Contaminated dialysis water 60
svstem 4 3 1

Infection From Inadequate 6

Sterilization 9

Poor IC Practices in Laundry 2 2 4 12

Problems with Cleaning/ 18

Disinfection 2 6

Contamination/ Infection From 5

Pharmacy Environment 1 11

Infection Related to Construction/ 6

Renovation 2 10

Poor IC Practices with Regards to 8

Waste Manasement 2 2 8

Employee Health
Lack of Staff Influenza 18
Immunization 6

Exposure to Blood borne

Pathosens 2 2 7

Exposure to Tlrberculosis 2 2 8 8

TB Transmission among HCWs im 12

the Emergencv Department (ED) 2 3 8

Other
New Program - Mandatory
Reporting Law
Other (MDRO)
Other (MERS)

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