2011 National Patient Safety Goals

National Patient Safety Goal 07.03.01: Preventing Health Care Associated Infections due to Multi-Drug Resistant Organisms.

The Physician Role:

• Practice meticulous hand hygiene before and after contact with patients and the patient’s environment (100 percent compliance in our goal).

• Comply with and support the infection control policies and practices approved by the Infection Prevention and Control Committee. (These policies can be accessed on the intranet under hospital policies, infection control chapter)

• Comply with isolation policies-wear personal protective equipment (gowns, gloves, masks).

• Obtain appropriate microbiological specimens when an infection is present or suspected prior to initiating empiric antibiotics.

• Notify infection prevention at 695- 2964 or 671-4941 with cases of hospital acquired infections, as well as admission of infectious patients.

• Comply with the recommendations of the Antimicrobial Stewardship Team regarding the use of antibiotics (coming in 2011).

• Advise patients, visitors and staff on techniques to prevent the spread of infections (consult with the infection preventionists as needed).

National Patient Safety Goal 07.04.01: Prevent Central Line Associated Blood Stream Infections.

The Physician Role:

• Avoid the use of vascular catheters unless there is a medical indication.

• Use the central line checklist and the standardized protocol for central venous catheter insertion (mask, cap, and sterile gloves and gown).

• Use the standardized insertion kit that contains all necessary equipment for the insertion of central venous catheters.

• Use full barrier precautions during insertion.

• Use an antiseptic for skin prep that is evidenced based to be most effective (chlorhexidine/alcohol). Use biopatch with transparent dressings per hospital policy.

• Do not insert catheters into the femoral vein unless other sites are unavailable. (The subclavian site is preferred to jugular)

• Reassess the need for the line daily.

• Maintain clinical competency in central line insertion practices.

• Scrub the HUB for 10 seconds with alcohol or chlorhexidine/alcohol swab when accessing the system. Ensure that nursing staff is doing the same.

National Patient Safety goal 07.05.01: Prevent Surgical Site Infections

The Physician Role:

• Educate patients and their families on surgical site infection prevention (MRSA screening, hand hygiene).

• Consider the use of preoperative showering for patients with chlorhexidine solution the night before and the morning of surgery.

• Administer appropriate antibiotics within 30-60 minutes of cut time per SCIP guidelines.

• Discontinue antibiotics within 24 hours of surgery end time (48 hrs for CABG).

• Consider the use of Chloraprep preoperative surgical antiseptic. New evidence supports its use and efficacy in prevention of surgical site infections.

• Remove foley catheters within 48 hours of surgery to reduce the risk of symptomatic urinary tract infections.

• Maintain normothermia in surgical patients.

• Maintain normal glucose levels in cardiac surgery patients.

• Clip or do not remove hair at surgical site.

• Discourage flash sterilization whenever possible.

• Limit traffic in the OR.

Please contact the Hospital Infection Preventionists for any assistance and questions related to infection issues, 303-695-2964 or 303-671-4941. Your Infection Preventionists are Robin Meinberg and Christina Ewers.  If you are interested in participating in the Hospital Infection Prevention Committee please contact Dr. James Neid or Robin Meinberg, RN MSN, at 303-692-2964.