THE UNIVERSITY OF TOLEDO

MEDICAL CENTER
I.

Surveillance, Prevention
And Control of Infection Plan - 2014

INTRODUCTION

The Surveillance, Prevention and Control of Infection Plan is a description of the multidisciplinary, systematic,
coordinated approach developed by the University of Toledo Medical Center (UTMC) of the University of
Toledo (UT) to reduce the risks of acquiring and transmitting infections among patients, employees, physicians
and other licensed independent practitioners, contract employees, volunteers, students, and visitors.
The Surveillance, Prevention and Control of Infection Plan supports the Hospital Plan for Provision of
Collaborative Patient Care Services and is organized, developed and implemented in order to positively impact
quality and add value to the care and services provided at UTMC. Ultimately this plan supports the mission,
vision and strategy of UTMC.
MISSION
The mission of UTMC is to improve the human condition by providing patient-centered, university quality care
in a way that facilitates the achievement of the University's educational mission.
Authority Statement
The Infection Control Committee is a medical staff committee and shall, through its chairperson, the Infection
Prevention Staff and all members of the committee have the authority under the medical staff bylaws to institute
appropriate control measures when and if an infectious hazard is identified or anticipated that may affect any
patient, visitor, student or employee. The chairperson and the Infection Prevention staff shall be notified of the
potential issue and shall confer with committee members as necessary to institute appropriate control measures.
In their absence, an appropriate director or administrator shall assume responsibility for instituting control
measures. The 1C committee also has the authority for routine identification and analysis of the incidence and
cause of infectious diseases within the hospital and shall develop and implement processes for the surveillance,
prevention and control of infection hazards.

II.

INFECTION PREVENTION and CONTROL (IPC) PROGRAM GOALS

The 2014 goals for the infection prevention and control program are as follows:
1.
2.
3.
4.
5.
6.
7.
8.
9.

III.

Eliminate surgical site infections in cases performed at UTMC

Eliminate hospital acquired device related infections
Achieve 100% compliance with hand hygiene
Achieve 100% compliance with influenza vaccination
Achieve 100% compliance with deadlines for regulatory reporting
Eliminate sharps injuries in employees
Prepare for the response to an influx of infectious patients
Maintain consistent cleaning of patient care areas and reusable equipment
Achieve 100% containment of construction and renovation projects

COMPONENTS OF PLAN

Risk Assessment for University of Toledo Medical Center

1

Several considerations are made to guide the activities of the program, including internal and external pressures
and activities related to health care. Careful consideration is made based on internal and external surveillance
activities from the preceding year.
Surveillance Activities
The activities related to IPC surveillance are based on the risk assessment of populations served at UTMC
hospitals and clinics, high risk/high volume indicators, CDC definitions of infections, and facility needs based
on the annual assessment. County, state, and CDC emerging and reemerging disease reports, as well as reported
outbreaks are taken into consideration when planning surveillance activities. These activities are fluid based on
current internal and external information.
Surveillance and prevention activities are designed to coordinate processes with the related patient care support
departments/services. Examples of related patient care support departments/services include Family Medicine
Clinic, Central Processing, Environmental Services, Linen and Laundry Services, Microbiology, Nursing
Services and the Safety & Health Department.
Priority-directed, targeted surveillance is utilized and related to the scope of service. High volume and/or high
frequency infectious complications, reoccurrence of previous infection prevention and control issues and issues
that have potential for significant adverse patient outcomes are included in the surveillance process.
The IPC staff obtains from the Microbiology laboratory relevant culture data to assist in determining whether or
not an infection has occurred and determines whether or not the infection was health care acquired. A daily
report is provided from the on-site microbiology department. Methods for determining presence and
classification of infection are based on national guidelines published by the CDC/NHSN program.
Selected IPC Indicators for FY2014
1. Eliminate surgical site infections in cases performed at UTMC
a. Knee arthroplasties
b. Hip arthroplasties
c. Cardiac surgeries
d. Spine surgeries
e. Colon surgeries
f. Abdominal Hysterectomy surgeries
g. Cases classified as clean
2. Eliminate hospital acquired device related infections
a. Ventilator related pneumonia/Ventilator Associated Events
b. Central line associated blood stream infections
c. Catheter associated urinary tract infections
3. Prevention indicators
a. Achieve 100% compliance with influenza vaccination
b. Eliminate sharps injuries in employees
c. Achieve 100% compliance with deadlines for regulatory reporting
d. Prepare for the response to an influx of infectious patients
e. Maintain consistent cleaning of patient care areas and reusable equipment
f. Achieve 100% compliance with containment of construction and renovation
projects
4. Integrated Departmental Indicators
a. Achieve 100% negative results with water cultures in Hemodialysis
b. Achieve 100% compliance with Air Quality measures
c. Achieve 100% results with water testing
d. Eliminate sharps sent to the contract laundry facility
e. Eliminate contaminated blood cultures

The IPC Committee approves the goals for each year based on the risk assessment. In addition the following
four factors have been considered in the selection and design of the surveillance programs:
1. The surveillance process selected is continuous, ongoing and effective.
2. Use of the information obtained from surveillance activities improves patient care.
3. Assessment rates are evaluated and are epidemiologically valid.
4. Data is linked to the hospital wide performance improvement activities
UTMC currently uses Infection Control software for benchmarking health care associated infection data. The
data mining surveillance system adjusts reports of surgical site infection for patients' risk factors. Other reports
are generated by rate, count and NHSN expected infections. The Family Medicine Clinic uses the Occupational
Health Manager system for tracking blood borne pathogen exposures and employee vaccine status.
All direct care and support departments/services are included in the Program. Patient care support
departments/services, such as Family Medicine Clinic, which provides employee health services, Central
Services, Housekeeping Services, Linen and Laundry Services, Laboratory and Nursing Services are involved in
the prevention and control of infections.
Written policies and procedures describe the role and scope of participation of each department/service in
infection prevention and control activities.
Responsibilities for the Infection Control Program
Medical Directors for Infection Prevention and Control
The Medical Director for IPC is an Infectious Disease Physician, board certified in Internal Medicine and
Infectious Diseases, and a Professor of Medicine and Pathology and Chairperson of the Infection Prevention and
Control Committee, and member of the UTMC Pharmacy and Therapeutics Committee and other Committees at
UTMC. The Family Medicine Clinic also provides services to volunteers, and contract staff when necessary.
Student Health Services, located on the lower level of the Rupert Health Center serves the student population.
Infection Prevention and Control Staff
The Infection Control Practitioner is an RN, MSEM CIC and has 21 years of experience in Infection Prevention.
The Infection Control Coordinator is a MSN, RN with 28 years' experience in wound care. Education to
support UTMC's IPC functions is incorporated into the activities of the department. The core responsibilities
and time allocations are: 30% allocated to surveillance monitoring, 20% allocated to education/prevention
activities, 25% allocated to committee/task force related issues, 20% allocated to management activities, and
5% allocated to policy review/literature research associated activities. This time appropriation fluctuates
depending on the needs of the institution and issues affecting clinical practice, changes in federal legislation and
any suspected outbreak occurrence.
The IPC department receives copies of all positive microbiology reports from the laboratory. An annual antibiogram, based on previous susceptibility testing is prepared by the pharmacy for distribution to the medical
staff.
The IPC department receives copies of serology reports for Hepatitis A, B, and C and positive syphilis titers.
Syphilis and other STDs (sexually transmitted diseases) are reported directly to the State by the laboratory. The
IPC department completes these reports with the demographics, if needed and additional requests for
information from the department of health.
The IPC department notifies institutions transferring or receiving patients with infection, using the regional
reporting form.

The IPC department collaborates with nursing units when any communicable disease requiring isolation is
identified. When isolation is needed, the unit is notified by the lab, and the staff enters it into the patient record
(EMR). This documentation is available after discharge and if the patient is readmitted, populates the face sheet.
The IPC Department develops and maintains an Infection Prevention and Control Policy and Procedure Manual
that includes the Blood borne Pathogen and Tuberculosis Exposure Control Plans. As a Medical Staff
committee, all policies are reviewed on a three year cycle or more frequently if federal guidelines or practice
implicate needed changes. All policies are based on current published literature. Policy reviews and/or
revisions are documented in the IPC Committee minutes.
Wellness promotion activities are provided through the Family Medicine Clinic with recommendations and
approval of the IPC Committee. Such services include: Hepatitis B vaccination, tuberculosis skin testing,
respiratory fit testing (coordinated with the Safety & Health Department) and influenza vaccination.
Nursing Directors and Department Heads:
1.
2.
3.
4.
5.

Assure that proper patient care safety practices and product safety are maintained in all patient care areas
and departments.
Assure that staff knows where to locate the IPC Manual online.
Formulate department-specific policies and procedures in coordination with pre-existing Infection
Prevention and Control Guidelines.
Coordinate, with the IPC Practitioner, educational programs on infection control and prevention and
document attendance.
Enforce IPC policies and procedures.

Nursing Staff:
1.
2.
3.
4.
5.
6.

Consult as needed with the IPC department concerning patient related infections.
Resolve questions with the IPC department concerning patient placement, isolation practices or infection
control issues.
Assist in revision of IPC policies and procedures.
Assist in preparation of educational programs relevant to IPC.
Provide the patient with education and materials on infectious diseases and infection prevention and control
practices.
Attend annual training on infection prevention through the online safety test bank

Medical Staff:
1.
2.

Initiate and discontinue isolation precautions in a timely and appropriate manner, according to approved
criteria.
Adhere to IPC policies and procedures.

Infection Prevention and Control Committee:

1.
2.
3.
4.
5.

Reviews and approves IPC policies, procedures and practices.

Reviews IPC data to identify and intervene when outbreaks or hazardous practices occur.
Works cooperatively with other committees to identify patterns / trends and corrective action.
Monitors data trends of selected indicators.
Appoints subcommittees for special project resolution.

Microbiology Lab:
1.
2.
3.
4.

Provides the attending physician or physician in charge of the patient with reports of all identified
infectious agents. These reports are maintained in the patient's medical record.
Generates annual reports on the changes in antibiotic susceptibility patterns of culture isolates.
Notifies the Infection Control Practitioner of positive cultures of highly transmissible organisms.
Reports select isolates to the Ohio Department of Health according to state requirements.

Immunology Lab:
1.

Reports to the Infection Control Practitioner positive results that are to be reported to the Ohio Department
of Health with the exception of reactive HTV antibody screens. These screens are sent to the HTV Clinical
Nurse Specialist for reporting and follow up.

Quality & Clinical Safety Department:

1.
2.
3.

Assists in the collection of data for post-operative surgical wound infections and device related infections.
Assists in entering findings into the 1C software system.
Develops reports for review by the IPC Committee and other interested committees.

Family Medicine and Student Health Services:

1.
2.
3.
4.

Revises policies to meet the recommendations of the Centers for Disease Control and Prevention (CDC)
Guidelines for Infection Control in Healthcare Personnel, 2011 (in conjunction with the IPC Committee).
Implements the above mentioned guidelines.
Implements the influenza program
Manages the Exposure Program

Infection Prevention and Control Committee

A multidisciplinary committee oversees the program for surveillance, prevention and control of infection.
Committee membership includes representatives from the medical staff, nursing, hospital administration and
persons directly responsible for management of the infection surveillance, prevention, and control program. An
up-to-date listing of committee members can be obtained from the Medical Staff Office.
The IPC Committee is a committee responsible to the Executive Committee of the Medical Staff. Its purpose is
to monitor infection control practices and support the goals of the infection prevention and control program.
Additionally, this committee provides epidemiological direction and consultation to patient-care staff.
The IPC Committee, by virtue of the authority vested in its Chairman by the Executive Committee of the
Medical staff, has the authority to institute appropriate control measures when there is reasonable evidence of a
danger to patients and personnel. That authority may be given to the designee of the chairman. That designee
may be the Infection Control Staffer another physician acting for the chairman when the chairman is not
available. (See Hospital Administration Policy #3364-100-40-3).
The Infection Prevention and Control Committee meets at least quarterly as reflected in medical staff policy
3364-87-13.
Under the direction of the chairman of the IPC Committee, the Infection Control Practitioner or designee
investigates all suspected outbreaks. This is done in collaboration with appropriate medical and administrative
staff. Appropriate corrective actions are made and findings are documented and reported to the IPC Committee.

The IPC Committee strives to reduce infection rates by employing continuous quality improvement activities.
Any cluster of infections or suspected outbreaks in three or more patients is brought to the attention of the
Infection Control Practitioner and the Chairman of the IPC Committee by active surveillance methods.
Data and recommendations are documented in the IPC Committee minutes. Any unusual infections or rates that
exceed threshold are reported immediately to the IPC Committee chairperson. The chairperson/designee
documents his/her findings and forwards them to the appropriate department director for investigation and
correction.
The IPC Committee approves the type and scope of surveillance activities. These activities minimally include:
annual review of antibiotic susceptibility patterns of microbiology laboratory isolates, the quality indicators for
each year and the methods to collect data on these.
Definitions of infections are based on the guidelines established by the CDC, NHSN, and Ohio Department of
Health.

Orientation, Education and Coordination with Departments

For patient care and employee health activities, mechanisms or processes exist that are designed to reduce the
risks of healthcare associated infections. These mechanisms include:
A.

Annual Training
Training is accomplished at three levels, at the time of hire, at the department level, and when assigned
a position.
Infection Prevention and Control content is provided at all levels.

B.

Departmental Coordination
Support departments such as central services, environmental services, and linen / laundry services
coordinate activities to prevent and control infections.

C.
Central Processing of Equipment
Central Processing is responsible for processing all surgical instrumentation and equipment. Instruments used
and stored by the Clinics and Ancillary departments are sent to the Central Service decontamination room after
use and are accompanied by proper documentation. In instances when processing is done on site by ambulatory
care areas, procedures are approved through the manager of Central Processing. Departmental procedures
address such issues as storage, reprocessing of disposable items by outside contractor, and quality assurance
controls.
D.
Linen
UTMC currently contracts with an off-site source for the processing of linens. Clean linen is delivered
in such a way as to minimize microbial contamination from surface contact or airborne deposition. The
linen is placed in a clean cart with a plastic liner, and the liner is closed and secured. The vehicle used
for transport is cleaned between soiled and clean deliveries. (Refer to Contracted Linen Service
Policies)
The Laundry service area is organized, equipped and ventilated to provide hygienically clean linen. The
Linen Service Department is responsible for verifying that proper laundry plant practices and
procedures are followed. (Refer to Contracted Linen Service policies.)
Representatives from Linen Services, Environmental Services, Infection Prevention and Control
department or other designated individual will conduct an-annual on-site inspection of the laundry
service plant. The inspection covers:
1. Laundry layout, separating clean linen processing areas from soiled linen areas.
2. Laundry ventilation to assure that there is positive / negative airflow from clean to soiled areas
with adequate intake, exchange, and exhaust rate.
3. Documentation of laundry equipment, formulas and chemicals used in the washing process.

4.
5.

Availability of adequate hand washing facilities and protective apparel for all laundry personnel.
Soiled linen collection process and quality assurance that it is collected in such a manner as to
minimize microbial dissemination into the environment.

E.

Regulated Waste:
The UT/UTMC Exposure Control Plan addresses the issue of regulated waste management in
accordance with the Ohio Revised Code and the Occupational Safety and Health Administration
(OSHA) and CDC requirements. The UT/UTMC Health and Safety Officer are responsible for the
infectious waste stream and management of infectious waste manifests.

F.

Material Safety Data Sheets (MSDS)

All cleaning agents used by Environmental Services and other individuals are reviewed prior to use
MSDSs are reviewed and the Environmental Services supervisors assure education on all new products.
MSDS are available on line through the Safety and Health web page.

Bioterrorism Activity
The Infection Prevention and Control (IPC) department monitors patient admissions and laboratory data for
extraordinary findings that may be evidence of biological weapon activities in the community. UTMC submits
daily reports of Emergency Room and Acute Care Admissions to the Toledo/Lucas County Department of
Health at the online Sentinel Event Webpage.
In the event of a community event of a large magnitude, the IPC department will work with the Safety and
Health Manager to assure appropriate protective equipment is available to the staff. The IPC department will
communicate with the ED Manager, Infectious Disease physician and the state and local health departments as
needed and provide support in monitoring the clinical lab results and reports. The IPC staff will serve as adjunct
members of the Emergency Preparedness Committee of UT/UTMC.
The IPC department investigates all suspected outbreaks, under the direction of the Chairperson of the Infection
Prevention and Control Committee and in collaboration with appropriate medical and administrative staff.
Institutional bylaws authorize the Chairperson or his designate to take measures to control an outbreak.
Resources for Infection Control
Management systems provide the health care acquired infection risk reduction process with appropriate data
analysis, interpretations, and presentations of findings. The IPC department interfaces with the Microbiology
Laboratory, Family Medicine and Student clinics, and Infectious Disease Physicians on a regular basis. The
Safety and Health Council, Information Systems Department, Quality Management Department, and Risk
Management Department provide support to the Infection Control Program.
Web based surveillance system is used by IP department.
UT provides sufficient office space and equipment, statistical and computer support and clinical microbiology
and pathology laboratory services to support the infection surveillance, prevention and control program of the
institution. Educational support is provided to the Infection Prevention and Control Department.

Tuberculosis Control Process

Prevention of transmission of tuberculosis is a strong focus of the Infection Prevention and Control Program at
UTMC. As a major treatment center for HTV care, potential risk of exposure to Mycobacterium tuberculosis is
a reality. Structural renovation, train the trainer fit testing programs, PAPR training and annual targeted TST
screenings reflect efforts to minimize this risk. Additionally, an exposure control system is in place for possible
exposure follow-up and is as follows:
The Microbiology Lab immediately notifies the Infection Control Practitioner of positive acid fast stains.
Transmission Based Precautions are rapidly instituted.

IV.

Family Medicine and Student Health manages the investigation of possible staff exposure and implements
follow-up procedures, as outlined in the Tuberculosis Exposure Control Plan.
Communication with the local health department tuberculosis unit is employed on an as needed basis.
ANNUAL REVIEW PROCESS

The Surveillance, Prevention and Control of Infection Plan shall be updated annually.
SUMMARY:
The goals of UTMC's infection control program are to identify and reduce the risks for acquiring and
transmitting infections among all internal and external customers through scientifically and epidemiologically
based surveillance, prevention and control of infection activities. The Surveillance, Prevention and Control of
Infection Plan provides the framework for these goals.

David Morlock
Chief Executive Officer

Original Date: 1/91

Revised:

2/92
10/93
6/95
5/96
8/96
1/99
4/99
5/00
3/02
10/03
12/04
05/06
12/07
12/08
2/2010
2/2011
02/01/12
04/05/2013
03/25/2014

A i/
Carl Sirio, M.D.
Medical Director

Kris Brickman M.D.

"
- Chief of Staff

CONFIDENTIAL INTER-AGENCY INFECTION REPORT FORM

The following patient was recently admitted to:
infection that may be related to a hospitalization or procedure at:

and has been found to have an

Address:
City:

State:

Zip:

Patient Name:
Type of infection:

DOB:
D SSI

DBSI

D Vent-associated Pneumonia

D Other

Culture date:
Culture result:
Comments:

Notification was done by:

Date:
Telephone:
APIC 93 Infection report form inter agency

Microbiology Manual
University Medical Center
Department Of Pathology
REPORTING SYSTEM
Routine and Preliminary Reports
Preliminary and Final Reports for Microbiology tests are viewed in the Horizon Lab and Care Manager
Systems. Hard-copy results are charted daily by Pathology Central Office Staff.
Phone Notification
UTMC Laboratory notifies UTMC Nursing and medical Personnel of the following findings:
^ All positive blood cultures.
> Positive cultures or Gram Stain on sterile body fluids or any other positive culture that might be
critical to patient care.
> The isolation of Salmonella, Shigella, Campylobacter, E. coli 0157:H7, Neisseria gonorrhea,
Chlamydia, Neisseria meningitides, Clostridium difficile
> Positive acid fast smears or positive acid fast cultures.
> All group a beta Streptococcus from in-house patients.
> Any respiratory specimen that is unsuitable for culture.
> Meningococcal isolates from CSF
Phone notifications are written in the phone log by the tech receiving the call. The tech notifies the nurse
or physician of the patient and notes the date, time and identity of the person receiving notification.
Public Health Reports
UTMC along with (send out lab) confirms and prepares and reports cases to be reported to the Ohio
Department of Health. Integrated Laboratories sends certain disease reports to the Ohio Department of
Health for required communicable reporting, according to Ohio Revised Code 3701-3-02. A
comprehensive list is kept in the Infection Control office.
Downtime Reports
In the event the lab computer or hospital computer systems are not functioning, test results will be
available by phone as needed

10

Prioritization Matrix - 2014

Surveillance, Prevention and Control of Infection Goals
Improve Patient Safety
R^ubtoiy

Inftrtantii;
Opportunity

Hand Hygiene
Staff compliance with
immunizations
Cleaning of environment
Environmental Monitoring
Improve Resource Utilization

High

Pfobferri

Physicitn

Regulafoiy

Reduce Unnecessary
Device Utilization
Reduce Readmission
by preventing infection

Eliminate Infection
"listen

Physician,

Clinical

Ventilator Associated
Pneumonias
Central Line Infections
Surgical Site Infections
CAUTI
Monitor External Regulatory Compliance Indicators
SalsfacBon

NHSN/CMS
NDNQI
CFR/ODH
FDA

11

Requirement