Board Quality Review Committee

BOARD QUALITY REVIEW COMMITTEE

AGENDA

MONDAY, APRIL 17, 2017 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:30 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 6:00 p.m. Meeting 418 E. GRAND AVENUE, ESCONDIDO, CA 92025

Time Form A Target PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING Page # CALL TO ORDER ROOM 6:00  Establishment of Quorum ...... 1 N/A 6:01  Public Comments 1 ...... 15 N/A 6:16  Information Item(s) 1. *Approval: Open Session Meeting Minutes/Attendance Roster – Monday, March 20, 2017 (ADD A, Page 7 - 14) ...... 5 3 6:21 2. “Approval: Closed Session Meeting Minutes Attendance Roster – Monday, March 20, 2017 (ADD B, Page 15 - 18) ...... 3 4 6:24

3. Update: Joint Commission Survey – PMC Escondido and PMC Poway 10 N/A 6:34 Deborah Barnes, District Director, Regulatory Coordination

 Standing Item(s) 1. Journal Club Assignment: - “Bad typography has ruined more than just the Oscars” Video by Christophe and 10 N/A 6:44 Haubursin and Benjamin Bannister, VOX Understand the news

 New Business 1. Infection Prevention and Control (ADD C, Page 19 -80) ...... 45 5 7:29 a. Infection Prevention and Control 2016 Annual Review and Program Assessment b. *Infection Prevention and Control 2017 Risk Assessment and Plan (ADD D, Page 81 - 101) ......

Valerie Martinez, RN, BSN, MHA, CIC, CPHQ, NEA-BC District Director, Quality/Patient Safety/Infection Prevention Presentation – 40 minutes Questions & Answers – 5 minutes 2. Resource Utilization – Presentation was deferred until June 19, 2017 ...... -- N/A -- Marcy Adelman, RN, MSN, CCM, ACM, District Director Clinical Resource Management

 Public Comments 1 ...... 15 N/A 7:44 ADJOURNMENT 1 7:45

Note: The agenda, without public comments, is scheduled for 1 hour, 15 minutes. Based on above agenda, without public comments the meeting starts at 6:00 pm and adjourns at 7:15 pm.

1 Page 1

BOARD QUALITY REVIEW COMMITTEE

AGENDA

PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING ROOM Board Quality Review Committee Members VOTING MEMBERSHIP NON-VOTING MEMBERSHIP – Chairperson, Board Member Bob Hemker, FACHE, President & CEO Joy Gorzeman, RN – Chairperson, Board Member Frank Beirne, FACHE, EVP, Operations Hans Sison, LVN, Board Member Alan Conrad, MD, EVP, Physician Alignment Dara Czerwonka, MSW, Board Member Della Shaw – EVP, Strategy Sabiha Pasha, MD - Chair of Medical Staff Quality Management Maria Sudak, RN, MSN, CCRN, NEA-BC – VP, Palomar Medical Center Committee for Palomar Medical Center Escondido Escondido Ed Gurrola, MD - Chair of Medical Staff Quality Management Jeannette Skinner, RN, MBA, FACHE -VP, Palomar Medical Center Committee for Palomar Medical Center Poway Poway and Palomar Medical Center Downtown Escondido Karen Buckley, CNO, Palomar Medical Center Escondido Sheila Brown, RN, MBA, FACHE – VP, Continuum Care Larry LaBossiere, MBA, MSN, RN, CNS, CEN, Palomar Medical Center Poway Jerry Kolins, MD, FACHE – VP, Patient Experience and Co-Chair of Patient Safety Committee Valerie Martinez, RN, BSN, MHA, CPHQ, CIC – Co-Chair of Patient Safety Committee

NOTE: If you have a disability, please notify us by calling 760-740-6353, 72 hours prior to the event so that we may provide reasonable accommodations

 Asterisks indicate anticipated action. Action is not limited to those designated items.

1 5 minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details & policy, see Request for Public Comment notices available in meeting room.

2 Page 2

Attendance Roster and Meeting Minutes Board Quality Review Committee Meeting Monday, April 17, 2017

TO: Board Quality Review Committee

MEETING DATE: Monday, April 17, 2017

FROM: LouAnn Quibuyen, Executive Assistant

Background: The minutes of the Board Quality Review Committee Open Session meeting, held on Monday, March 20, 2017, are respectfully submitted for approval. Also included is the attendance roster for the Committee’s review.

Budget Impact: N/A

Staff Recommendation: Approval

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A – Addendum A – 03.20.17_Open Session Meeting Minutes/Attendance Roster 3

Attendance Roster and Meeting Minutes Board Quality Review Committee Meeting Monday, April 17, 2017

TO: Board Quality Review Committee

MEETING DATE: Monday, April 17, 2017

FROM: LouAnn Quibuyen, Executive Assistant

Background: The minutes of the Board Quality Review Committee Closed Session meeting, held on Monday, March 20, 2017, are respectfully submitted for approval. Also included is the attendance roster for the Committee’s review.

Budget Impact: N/A

Staff Recommendation: Approval

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A – Addendum B – 03.20.17_Closed Session Meeting Minutes/Attendance Roster 4

Board Quality Review Committee Monday, April 17, 2017 2016 Infection Prevention and Control Annual Review and Assessment Report

TO: Board Quality Review Committee

MEETING DATE: Monday, April 17, 2017

FROM: Valerie Martinez, District Director, Quality / Patient Safety and Infection Control and Prevention

Background: Valerie Martinez, District Director, Quality / Patient Safety and Infection Prevention & Control will present the 2016 Infection Prevention and Control Annual Review and Assessment Report.

Budget Impact: N/A Staff Recommendation: For information only Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A – Addendum C - 2017 Infection Control and Prevention Annual Report 5

Board Quality Review Committee Monday, April 17, 2017 2017 Infection Prevention and Control Risk Assessment and Plan

TO: Board Quality Review Committee

MEETING DATE: Monday, April 17, 2017

FROM: Valerie Martinez, District Director, Quality / Patient Safety and Infection Control and Prevention

Background: Valerie Martinez, District Director, Quality / Patient Safety and Infection Prevention & Control will present the 2017 Annual Infection Prevention and Control Risk Assessment and Plan for approval.

Budget Impact: N/A Staff Recommendation: Approval Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A – Addendum C - 2017 Infection Control and Prevention Annual Report 6

ADDENDUM A

Addendum A

BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MARCH 20, 2017

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

CALL TO ORDER The meeting – held in the iExplore Conference Room of the Palomar Health Learning & Development Center, 418 E. Grand Avenue, Escondido, CA – was called to order at 6:01 p.m. by Committee Chair Joy Gorzeman

ESTABLISHMENT OF QUORUM  Quorum comprised of Board Directors: Gorzeman, Sison, Czerwonka, and both physician Chairs of Medical Staff Quality Management Committees, Dr. Sabiha Pasha, Palomar Medical Center Escondido and Dr. Edward Gurrola, Palomar Medical Center Poway  Excused Board Absences: None

NOTICE OF MEETING Notice of Meeting was posted at Palomar Health Administrative Office; also posted with full agenda packet on the Palomar Health website on Wednesday, March 15, 2017 which is consistent with legal requirements. A revised agenda packet was posted on the Palomar Health website on Monday, March 20, 2017.

PUBLIC COMMENTS

There were no public comments.

*INFORMATION ITEMS  Tina Pope, Manager, Service Excellence introduced the Patient Family Advisory Council (PFAC) members Estelle Wolf, Chair, PFAC and Jim Lyon, Immediate Past Chair, PFAC. The backgrounds of both members were shared with the committee. Estelle Wolf reported she has lived in Rancho Bernardo for 20 years, is a Registered Nurse, retired in 2010 and is a former patient Palomar Health. Estelle joined the Patient Family Advisory Council last year. She also has an active role in San Diego County as the immediate past chair of the Aging and Independence Advisory Council. Jim Lyon worked in city government in the areas of development and planning. He is retired and a former patient of Palomar Health.  Director Gorzeman welcomed the new Patient Family Advisory Council members to the Board Quality Review Committee. The Committee recognizes the value of the key stakeholders, i.e., the patient and the family.

 Dr. Jerry Kolins announced that LouAnn Quibuyen has accepted the position of Executive Assistant for the Patient Experience Division.

1. *Minutes: Board Quality Review Committee Meeting – Monday, March 23, 2017 No discussion MOTION: by Director Czerwonka, N/A Y second by Board Member Edward Gurrola MD and carried to approve the February 23, 2017, Board Quality Review Committee meeting minutes. All in favor. None opposed

8 03.20.17 BQRC Meeting Minutes - DRAFT V2

Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MARCH 20, 2017

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

STANDING ITEM(S)

2. Journal Club Assignment

Dr. Kolins opened the discussion for comments on the Journal Club assigned reading N/A N/A Y entitled “Heroism of Incremental Care” by Atul Gawande, MD. Dr. Pasha shared that the difficulty of taking care of patients in the acute care environment. She emphasized the challenge associated with the very narrow window of time the healthcare providers have responsibility. A brief overview of the Schwartz Rounds program was provided. These rounds have been conducted at Palomar Health approximately 4-5 years. The late Dr. Schwartz, Founder of the Schwartz Rounds, noticed the difficulty and compassion of the staff caring for him. He was being cared for with compassion but he wondered about the care for the caregiver. The focus of these rounds is the acknowledgement and well-being of the caregiver. Dr. Pasha shared that a case is selected and reviewed not for what went right or wrong but how the event made the caregiver feel. Dr. Kolins shared with the committee that care for the caregiver will be a topic that we will be discussing in the future. Donita Phillips noted that the upcoming patient safety conference has a key note speaker, Carole Hemmelgarn, who will deliver a presentation that includes care for the caregiver.

Director Gorzeman acknowledged the contributions of primary care and other healthcare providers as we move to close the gaps in our population health efforts.

There were no other questions presented for discussion.

OLD BUSINESS

 There were no old business items presented for discussion. N/A N/A Y

NEW BUSINESS

9 03.20.17 BQRC Meeting Minutes - DRAFT V2 2

Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MARCH 20, 2017

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

4. Clinical and Diagnostic Services None None Y Utilizing the presentation distributed in the meeting packet, Maureen Malone, Assistant Vice President, Clinical and Diagnostic Services introduced her team members for their Annual Report to the Board Quality Review Committee.

 Linda Acklin, District Director, Cardiopulmonary, EEG, Sleep Center and Neuro Diagnostics provided a detailed presentation on Cardiopulmonary, EEG, Sleep Center and Neuro Diagnostic Services for the district. Data was provided for ventilator weaning, arterial blood gas analysis, and patient satisfaction. She also shared with the Board Process improvements in Cardiology for fiscal Year (FY) 2016. Discussion ensued on the ventilator weaning protocol and the process to initiate the protocol. She reported that this is a multidisciplinary collaborative effort. There were no additional questions presented for discussion.

 Jeremy Lee, District Director, Pharmacy Services provided a detailed report on Pharmacy Services at Palomar Health. Key areas of focus for 2017 were discussed. The Director reported that Transition of Care is our major focus because this is a high risk area for medication errors. He shared with the Board the role of the MIC (Medication Intake Coordinator) in the completion of the patient’s medication history within 24 hours of the patient’s admission. Data for the Antibiotic Stewardship program was also presented including the implementation of Verigene, a technology that decreases turn-around-time for pathogen identification and resistance. Discussion ensued about the Retail Pharmacy not being available or open 7 days a week. Our current staffing resources are limited. Dr. Gurrola requested management to review options for improvement.

 Gloria Austria, District Director Laboratory Services provided a detailed report on Laboratory Services district wide. Key Areas for Focus:

- CAP re-accreditation inspection occurred last week. Few minor recommendations for improvement (RFI) were identified but most have been fixed prior to survey exit. - Turn-around-time (TAT) of laboratory testing was presented and discussed. A Performance Engineer assisted the work group in identifying the area of focus to continue to decrease TAT. - The Finance Pillar was also discussed. The principal focus is on decreasing claim denials due to missing information, insurance eligibility information and medical necessity. - Inpatient and Outpatient patient satisfaction were discussed. Focus is on patient and staff rounding. The Laboratory is in process of developing a training video on customer service, scripting, and best practices for a positive patient experience. This is most important in the phlebotomy area.

There were not additional questions presented for discussion.

 Donna Rolin – District Director Imaging Services provided a detailed report on Imaging Services district wide. Quality Improvement Activities were discussed. Of those activities, a collaborative team process with the Emergency Department led to the reduction of Cat Scan (CT) turn-around-times by 17 minutes. The Director also reported that in the recent Joint Commission Survey at PMC Escondido, Imaging Services received no deficiencies.

Also discussed was the MRI Safety Plan. The Safety Plan is being developed in coordination with the Radiologists. The target audience is staff and First Responders. Staffing and recruitment gains were also discussed. There were no additional questions presented for discussion.

Accolades were given by Frank Beirne to Donna Rolin and staff. They stayed the course. Frank reminded us to celebrate the things that are working and also talk about the challenge of higher levels of performance.

10 03.20.17 BQRC Meeting Minutes - DRAFT V2 3

Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MARCH 20, 2017

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

7. Workplace Safety Redesign – Employee A RECOMMENDATION WAS MADE TO SHEILA BROWN / Y HAVE THE CORPORATE/EMPLOYEE RUSSELL RIEHL HEALTH QUARTERLY REPORT IS PROVIDED TO THE BOARD HUMAN RESOURCES COMMITTEE MOVING FORWARD.

Utilizing the presentation distributed in the meeting packet, Sheila Brown, Vice President, Continuum Care and Russell Riehl, District Director, Corporate /Employee Health provided a high level report on Workplace Safety Redesign. As part of the Workplace Safety Redesign, they reported that Palomar Health has moved towards a self-insured program. As a result of this redesign, additional resources have been added to Corporate/ Employee Health. Fiscal Year (FY) 16 vs. FY17 outcome analysis data were also presented. Next steps were also discussed.

A discussion ensued regarding employee choice of a physician after a workplace injury. It was noted that employees must utilize the physicians who are contracted with Palomar Health. Currently we have a large medical network and the group of providers that we utilize is familiar with the American College of Occupational and Environmental Medicine (ACOEM) guidelines that follow the California Laws.

Frank Beirne commented that this is a progression towards risk prevention and preemption and not just effective claims management. When we are doing an investigation, we are doing it with the goal of determining what happened and why it happened.. He stressed that we are a learning organization. And as a learning organization we will assure that we move beyond claims management and into risk reduction.

Director Czerwonka commended the group on the progress that has been made thus far. Director Czerwonka queried the group as regards the best board committee to receive updates from corporate health. A recommendation was made to have the Corporate/Employee Health Quarterly reports provided to the Board Human Resources Committee.

There were no additional questions presented for discussion.

ADJOURNMENT TO CLOSED SESSION Meeting adjourned at 7:33 p.m. MOTION: by Director Czerwonka, second by Board Member Edward Gurrola, MD and carried to adjourn the meeting at 7:47 p.m. All in favor. None opposed  Pursuant to California Government Code Section 54956.9(d)(2) - Conference with Legal Counsel concerning potential litigation

ADJOURNMENT TO OPEN SESSION The meeting was adjourned at 8:31 p.m. MOTION: by Director Czerwonka, second by Board Member Edward Gurrola, MD and carried to adjourn the meeting at 8:31 p.m. All in favor. None opposed

PUBLIC COMMENTS There were no public comments.

The Open Session meeting was adjourned at 8:31 p.m. MOTION: by Director Czerwonka, second by Director Sison and carried to adjourn the meeting at 8:31 p.m. All in favor. None opposed

11 03.20.17 BQRC Meeting Minutes - DRAFT V2 4

Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MARCH 20, 2017

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

COMMITTEE CHAIR Joy Gorzeman, RN

SIGNATURES:

COMMITTEE ASSISTANT

LouAnn Quibuyen

12 03.20.17 BQRC Meeting Minutes - DRAFT V2 5 Addendum A

Board Quality Review Committee Meeting

OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2017

Meeting Dates: Palomar Health By-Laws’ 1/16/17 2/23/17 3/20/17 4/17/17 5/15/17 6/19/17 7/17/17 8/21/17 9/18/17 10/16/17 11/20/17 12/18/17 Voting Members Membership Annl Rpt CANCELLED DIRECTOR JOY GORZEMAN, RN - CHAIR Board Member P P P DIRECTOR DARA CZERWONKA Board Member P P P DIRECTOR HANS SISON, LVN Board Member P Ex P DIRECTOR DOUGLAS MOIR (ALT) Board Member - A SABIHA PASHA, MD QMC Chair, Palomar Medical Center P Ex P Escondido EDWARD GURROLA, MD QMC Chair, Palomar Medical Center P P P Poway Non-Voting Members BEIRNE, FRANK, FACHE EVP, Operations P P P BUCKLEY, KAREN, RN, BSN, MHA, CENP CNO, PMC Escondido P P P BROWN, SHEILA, RN, FACHE VP, Continuum Care P P P CONRAD, ALAN, MD EVP, Physician Alignment P P P HEMKER, BOB, FACHE President & CEO P P P KOLINS, JERRY, MD, FACHE VP, Patient Experience and Co-Chair, Patient P P P Safety Committee LABOSSIERE, LARRY, MBA, MSN, RN, CNS, CEN CNO, PMC Poway P P P Co-Chair, Patient Safety MARTINEZ, VALERIE, RN, BSN, MHA, CIC, NEA-BC P P P Committee SHAW, DELLA EVP, Strategy A A P VP, PMC Poway and PMC SKINNER, JEANNETTE, RN, MBA, FACHE P P P Downtown Escondido VP, Palomar Medical SUDAK, MARIA, MSN, CCRN, NEA-BC, RN P P P Center Escondido Patient Family Advisory ESTELLE WOLF P Council (PFAC) Chair JIM LYON Patient Family Advisory Council (PFAC) Immediate P Past Chair Guests ACKLIN, LINDA P ADELMAN, MARCY, RN ANDREWS, SHELLY, RN AUSTRIA, GLORIA P BANDICK, BRET Meeting Dates: 13Page 1 of 2 Addendum A

1/16/17 2/23/17 3/20/17 4/17/17 5/15/17 6/19/17 7/17/17 8/21/17 9/18/17 10/16/17 11/20/17 12/18/17 Guests (continued) BARNES, DEBBIE, RN, CDS P CALLERY, CHARLES, MD P DELANGE, NICOLE FARROW, DAN GOELITZ, BRIAN, MD GRIFFITH, JEFF (BOARD MEMBER) HANSEN, DIANE JANUSZEWICZ, LOURDES P JENNINGS, TAMRAH P KAUFMAN, JERRY (BOARD MEMBER) KIM, JESSICA LEE, DAVID, MD P P P LEE, JEREMY P MALONE, MAUREEN P MARTIN, FRANK, MD MCCUNE, RAY (BOARD MEMBER) MOIR, DOUGLAS, MD (BOARD MEMBER) P NAMENYI, JASMINA NEU, MARK P NICPON, GREGORY, MD PHILLIPS, DONITA, MBA, ARM P P P POPE, TINA P P P RIEHL, RUSSELL P ROLIN, DONNA P ROSENBURG, JEFFREY SCHULTZ, DIANA SOLOMON, LESLIE P A P WATSON, RAE ANNE WIESE, LISHA

14Page 2 of 2

ADDENDUM B

Addendum B

BOARD QUALITY REVIEW COMMITTEE CLOSED SESSION MEETING MINUTES – MONDAY, MARCH 20, 2017

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

ADJOURNMENT TO CLOSED SESSION MOTION: by Director Czerwonka, second by Board Member Edward Gurrola, MD and carried to adjourn the meeting at 7:47 p.m. All in favor. None opposed.

1. Pursuant to California Government Code Section 54956.9(d)(2) - Conference with Legal Counsel concerning potential litigation

 Jeannette Skinner, Vice President, Palomar Medical Center Poway and Palomar Medical Center Downtown Escondido provided a presentation to the committee regarding a potential litigation event.

ACTION ITEMS TAKEN, IF ANY There were no action items taken.

ADJOURNMENT TO OPEN SESSION 8:31 P.M. MOTION: by Director Czerwonka, second by Board Member Edward Gurrola, MD and carried to adjournment to Open Session at 8:31 p.m. All in favor. None opposed.

PUBLIC COMMENTS There were no public comments.

Meeting adjourned to Open Session at 8:32 p.m. MOTION: by Director Czerwonka, second by Director Sison and carried to adjourn the meeting at 8:33 p.m. All in favor. None opposed.

COMMITTEE CHAIR Joy Gorzeman, RN SIGNATURES:

BOARD ASSISTANT

LouAnn Quibuyen

16 03.20.17 CLOSED SESSION BQRC Meeting Minutes - DRAFT V2 Addendum B

Board Quality Review Committee Meeting

OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2017

Meeting Dates: Palomar Health By-Laws’ 1/16/17 2/23/17 3/20/17 4/17/17 5/15/17 6/19/17 7/17/17 8/21/17 9/18/17 10/16/17 11/20/17 12/18/17 Voting Members Membership Annl Rpt CANCELLED DIRECTOR JOY GORZEMAN, RN - CHAIR Board Member P P P DIRECTOR DARA CZERWONKA Board Member P P P DIRECTOR HANS SISON, LVN Board Member P Ex P DIRECTOR DOUGLAS MOIR (ALT) Board Member - A SABIHA PASHA, MD QMC Chair, Palomar Medical Center P Ex P Escondido EDWARD GURROLA, MD QMC Chair, Palomar Medical Center P P P Poway Non-Voting Members BEIRNE, FRANK, FACHE EVP, Operations P P P BUCKLEY, KAREN, RN, BSN, MHA, CENP CNO, PMC Escondido P P P BROWN, SHEILA, RN, FACHE VP, Continuum Care P P P CONRAD, ALAN, MD EVP, Physician Alignment P P P HEMKER, BOB, FACHE President & CEO P P P KOLINS, JERRY, MD, FACHE VP, Patient Experience and Co-Chair, Patient P P P Safety Committee LABOSSIERE, LARRY, MBA, MSN, RN, CNS, CEN CNO, PMC Poway P P P Co-Chair, Patient Safety MARTINEZ, VALERIE, RN, BSN, MHA, CIC, NEA-BC P P P Committee SHAW, DELLA EVP, Strategy A A VP, PMC Poway and PMC SKINNER, JEANNETTE, RN, MBA, FACHE P P P Downtown Escondido VP, Palomar Medical SUDAK, MARIA, MSN, CCRN, NEA-BC, RN P P P Center Escondido Patient Family Advisory ESTELLE WOLF Council (PFAC) Chair JIM LYON Patient Family Advisory Council (PFAC) Immediate Past Chair Guests ACKLIN, LINDA ADELMAN, MARCY, RN ANDREWS, SHELLY, RN AUSTRIA, GLORIA BANDICK, BRET Meeting Dates: 17Page 1 of 2 Addendum B

1/16/17 2/23/17 3/20/17 4/17/17 5/15/17 6/19/17 7/17/17 8/21/17 9/18/17 10/16/17 11/20/17 12/18/17 Guests (continued) BARNES, DEBBIE, RN, CDS P CALLERY, CHARLES, MD P DELANGE, NICOLE FARROW, DAN GOELITZ, BRIAN, MD GRIFFITH, JEFF (BOARD MEMBER) HANSEN, DIANE JANUSZEWICZ, LOURDES P JENNINGS, TAMRAH P KAUFMAN, JERRY (BOARD MEMBER) KIM, JESSICA LEE, DAVID, MD P P P LEE, JEREMY MALONE, MAUREEN MARTIN, FRANK, MD MCCUNE, RAY (BOARD MEMBER) NAMENYI, JASMINA NEU, MARK P NICPON, GREGORY, MD PHILLIPS, DONITA, MBA, ARM P P P POPE, TINA P P RIEHL, RUSSELL ROLIN, DONNA ROSENBURG, JEFFREY SCHULTZ, DIANA SOLOMON, LESLIE P A WATSON, RAE ANNE WIESE, LISHA

18Page 2 of 2

ADDENDUM C

19 Addendum C Passion. People. Purpose.TM

PALOMAR HEALTH INFECTION PREVENTION AND CONTROL 2016 Annual Review and Program Assessment

Presented to Board Quality Review Committee April 17, 2017

Valerie Martinez, RN, BSN, MHA, CIC, CPHQ, NEA-BC, District Director of Quality/Patient Safety/Infection Prevention, Stroke and Diabetes Programs

20 1 Addendum C Mission

• Target zero patient harm – Every patient in need of health care is intrinsically at risk for infection • Reduce the risk through objective surveillance and facilitation of evidenced-based interventions throughout the healthcare system

21 2 Addendum C Structure

‹#› 22 Addendum C Surveillance Goals

• Reduce healthcare -associated infections (HAI) from 2015 – Measured as Standard Infection Ratio (SIR), a risk- adjusted value • Reduce HAI SIR below Palomar Health threshold of 0.5 – Central line-associated bloodstream infection (CLABSI) – Catheter-associated urinary tract infection (CAUTI) – Surgical site infection (SSI) – Ventilator-associated pneumonia (VAP) – Clostridium difficile infection (CDI) – MRSA-VRE bloodstream infections (-BSI)

‹#› 23 Addendum C Infection Prevention Engagement • Environment of Care and unit rounds – Focus on patient, staff, and environment safety • Education • Reportable diseases – Mandated by California Department of Public Health • Exposure investigation – Employee and first responders • Value Improvement Process engagement • Facilities – Construction/Renovation – Environmental testing • Performance Improvement projects • Medical and non medical committee engagement • Regulatory alerts – Monitor, act, educate, audit • Long Term Care IC liaison (14)

‹#› 24 Addendum C

SURVEILLANCE DATA

‹#› 25 Addendum C PMC Escondido CLABSI SIR 2015-2016

0.634 0.622

0.6

0.452 0.434 0.418 0.4

0.206 0.180 0.2 0.175

0.0 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

PMC Poway CLABSI SIR 2015-2016

7.0

6.0

5.0

4.0 2.568 3.0 2.558

2.0

1.0 0.000 0.000 0.000 0.000 0.000 0.000 0.0 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

‹#› 26 Addendum C CAUTI SIR 2015-2016

PMC Escondido

1.000

0.658 0.550 0.527 0.515

0.486 0.405

0.500 0.315 0.284 SIR

0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

CAUTI SIR 2015-2016

PMC Poway

0.800

0.600 0.424

0.378 0.338

0.400 SIR 0.200 0.000 0.000 0.000 0.000 0.000 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

CAUTI SIR 2015-2016

PMC Downtown Escondido

3.000

2.160

2.000 1.471

0.918 SIR 0.800 1.000 0.732 0.000 0.000 0.000 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

‹#› 27 Addendum C

PMC Escondido Total VAP Rate 2015-2016

6.000 PMC Escondido 4.862 5.000 5W CCU

4.000 PMC Escondido 4SW TICU 3.000

Trauma ICU, National Pooled Mean 2012 (3.6) VAP per 1000 vent days

2.000 1.164 1.159 Medical -Surgical ICU, National Pooled Mean

1.000 0.554 2012 (0.9) 0.000 0.000 0.000 0.000 0.000 2015H1 2015H2 2016H1 2016H2

PMC Poway Total VAP Rate 2015-2016

4.000 3.500 PMC Poway 3.000 ICU 2.500 2.000 Medical -Surgical ICU, National Pooled Mean 2012 (0.9) 1.500 1.000 0.500 0.000 0.000 0.000 0.000

VAP per 1000 ventilator days 0.000 2015H1 2015H2 2016H1 2016H2

‹#› 28 Addendum C CDI SIR 2015-2016

PMC Escondido

4.000

3.000

1.677

2.000 1.421 1.266 SIR 1.162 1.010 0.798 0.757

1.000 0.313 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

CDI SIR 2015-2016

PMC Poway

4.000 3.615

3.000 2.242

2.000 1.508 SIR 1.180 1.157 0.974 0.614

1.000 0.380 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

CDI Cases (SIR is not calculated by NHSN) 2015-2016

PMC ARU

6 5 4 4 2 2 1 1 1 CDI CDI Cases 0 0 0 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

‹#› 29 Addendum C

MRSA BSI SIR 2015-2016

PMC Escondido

2.000 1.777

1.500

0.986

1.000 0.896 SIR

0.500

2 Cases* 2 Cases* 0 Cases* 0 Cases* 0.000 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

MRSA BSI (SIR not calculated by NHSN) 2015-2016

PMC Poway

2.000

1.500

1.000 SIR

0.500 0 Cases* 0 Cases* 0 Cases* 0 Cases* 0 Cases* 1 Case* 1 Case* 1 Case* 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

‹#› 30 Addendum C PMC Escondido SSI-All SIR 2015-2016

PMC Escondido 2.500 2.000

1.500

SIR 1.000 0.735 0.744 0.515 0.575 0.430 0.481 0.500 0.311 0.193 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

PMC Poway SSI-All SIR 2015-2016

PMC Poway 2.500 2.000 1.408 1.526 1.500 0.820 SIR 1.000 0.526 0.728 0.441 0.317 0.361 0.500 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

PMC Downtown Escondido SSI-All SIR 2015-2016

PMC Downtown Escondido

2.500 2.000 1.173 1.001 1.500 0.723 SIR 1.000 0.324 0.574 0.430 0.500 0.000 0.000 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

‹#› 31 Addendum C

Hand Hygiene Compliance by Facility, 2016Q4 (N=4189)

BEFORE Patient Care AFTER Patient Care

100% 94% 91% 90% 84% 79% 80% 74% 70%

60% 52% 50% 47% 42% 40%

30%

20%

10%

0% Palomar Health System PMC Escondido PMC Downtown Escondido PMC Poway

‹#› 32 Addendum C Focus 2017

• Surveillance – Central Line Bloodstream Infections, Surgical Site Infections, Catheter Associated Urinary Tract Infection, Multi Drug Resistant Organisms • Improve hand hygiene compliance and expand to outpatient departments • Employee Health collaboration – Flu vaccine declination – Employee exposure

33 ‹#›

Addendum C

‹#› 34 Addendum C

ANNUAL INFECTION PREVENTION AND CONTOL PROGRAM Palomar Health Data CY 2015-2016 2016 ANNUAL REVIEW AND ASSESSMENT

35 Addendum C

Introduction Annual Review and Program Assessment: The Infection Prevention and Control Department performs an annual review and assessment of the Infection Control program. This assessment compares outcomes from 2016 to 2015. The assessment includes all of the surveillance modalities, both process and outcome measures, the Infection Preventionists (IP) perform. In addition to infection control measures, monitoring processes involving high level disinfection, SPD, medication preparation, food and nutrition services, construction, and satellite services are ongoing. The IP staff use their role as department resources to provide insight, support, and evidence based recommendations to the program and the system wide surveillance plan. The program assessment provides information to steer the Infection Prevention and Control Department’s focus for the upcoming year. Each measure is evaluated for effectiveness and is considered to be the driver for departmental and unit based action planning. Process and outcome measures are shared at the physician and nursing level and used to maintain or improve patient care activities. Infection Control rounding activities help to identify opportunities for improvement. Liaisons for Infection Prevention provide an extension of the Infection Prevention and Control Department with collaboration and implementation of program activities in specialty areas. Guidance from various regulatory and nationally recognized professional organizations including but not limited to include The Centers for Disease Control, The Joint Commission, CDPH, CMS, and CalOSHA. These organizations provide direction in identifying indicators and implementation of the plan. The program is fluid and can change based on emerging infectious diseases or new risks associated with the provision of care. The Infection Prevention and Control Department keep abreast of these through the media, participation in the San Diego County Emerging Infectious diseases community meetings, and scientific journals. This assessment provides the reader with information on the status of the Infection Control Plan. Infection Prevention Mission: Develop and maintain an Infection Prevention and Control program that reflects the Mission, Vision, and Values of Palomar Health. The program promotes patient safety aiming for zero harm by reducing the risk of acquiring and transmitting infections among patients, healthcare providers, volunteers, and visitors. The program is guided by Quality and Regulatory Standards developed by The Joint Commission (TJC), the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), California Public Health Department (CDPH), CalOSHA and other nationally recognized organizations. Purpose: Provide a framework and structure for an organization-wide, facility specific approach in identifying and reducing the risk of endemic and epidemic healthcare-associated infections (HAI). To ensure optimal provision of services, the management of the infection prevention and control process is assigned to qualified personnel by virtue of education, training, licensure, experience and/or certification. Authority Statement: The hospital has designated one or more individual(s) as its Infection Control Officer(s) per CMS. The Infection Control Officer(s) is/are qualified and maintain(s) qualifications through education, training, experience and/or certification related to infection control. The Infection Control Officer(s) have the authority and responsibility for ensuring the implementation of a planned and systematic process for monitoring and evaluating the quality and appropriateness of the Infection Prevention and Control Program. The Infection Control Committee, through its chairperson and/or Director of the Infection Prevention and Control Program, are granted authority to institute any 1

36 Addendum C

appropriate emergency control measures throughout the health system when there is a reasonable risk or danger to any patient, healthcare provider, volunteer, or visitor.

Department Structure: The Infection Prevention and Control Department is structured under the Patient Experience Division.

37 Addendum C

SURVEILLANCE Central Line-Associated Bloodstream Infection (CLABSI) Process Measures CLABSI Process Measures – Central Line Insertion Practices (CLIP), Device Utilization Ratio (DUR) and Dressing Assessment Goal: Maintain 95% compliance with CLIP measures as demonstrated by National Healthcare Safety Network (NHSN) CLIP data.

Palomar Health 2015-2016 Central Line Insertion Practices

98.9% 97.1% 98.0% 95.0%

100.0% 2015 50.0% 2016

0.0% Medical Staff RN

Summary: CLIP compliance rate for PMC Escondido and PMC Poway is 95%-97% and met the goal. The documentation shows 38 incidents of missed compliance during 2016 (Hand hygiene- 8; mask-2; gown-3; drape-4; sterile gloves-4; surgical cap-9; allowing prep to dry-8). CLIP is a process measure that is monitored when Physicians and RNs (PICC team) insert a central line. The “missed compliance” incidents are used to track and trend for educational purposes and can be used to correlate CLABSI events. The CLIP measures contain 11 elements and all elements must be met to achieve 100% compliance. The elements are the following: The location of unit, the person recording insertion practice, the person inserting the line, person inserting 90, RN), reason for insertion, hand hygiene performed, maximum sterile barrier, skin prep, skin prep allowed to dry, insertion site, and antimicrobial coated catheter used.

Recommendations: 1. Present data to stakeholders and appropriate committees. 2. Provide ongoing education on missed opportunities. Goal Met/Unmet: PMC Escondido - Goal Met

38 Addendum C

PMC Poway – Goal Met PMC Downtown Escondido – Goal Met

Goal: Reduce Device Utilization Ratio from 2015 CDC NHSN Mean

Palomar Health Central Line DUR 2015-2016

0.25 0.232 0.231 0.224 0.222 0.214 0.2

0.15 PMC Poway PMC Escondido 0.1 PMC DT ESC 0.05 0.023 Device Device Days / Patient Days 0 2015 2016

Summary: To provide a mean, the DUR threshold was averaged for PMC Poway (0.202), PMC Escondido (0.209), and PMC Downtown Escondido (0.05). Device Utilization Ratio (DUR) is calculated by dividing the number of patients with central lines (device days) by the number of patient days. The result measures device use in a particular population and can be compared with CDC NHSN thresholds for that population. Daily device assessment for necessity by a physician is a mandatory regulation and is documented in the medical record. Device necessity is discussed during Interdisciplinary rounds and on the daily safety huddle call. There is a decrease in device utilization at Palomar Health comparing 2015 to 2016. However there is an opportunity to further reduce device utilization in the following locations which exceed threshold; PMC Poway – Med/Surg/IMC 3rd floor and ICU, PMC Escondido - 5W CCU, 4SW TICU, 4NW, 6W, and 8W. These units remain above the CDC NHSN mean benchmark. Recommendations: 1. Provide device utilization data to units and medical committees. 2. Units to review line days and monitor for appropriateness. 3. Monitor completeness of daily assessment by MD form and provide data to MDs. Goal Met/Unmet: PMC Escondido - Goal Unmet PMC Poway – Goal Unmet PMC Downtown Escondido – Goal Met

39 Addendum C

Goal: Assess compliance with evidence based practice for central line dressing maintenance

Summary- The above graph represents findings from an annual point prevalence study conducted at PMC Escondido. The study was conducted to assess the compliance to dressing assessments by the RN. This study included all inpatient units and all patients with a Peripherally Inserted Central Catheter (PICC) or Central Venous Catheters (CVC). There are 10 elements included in the assessment which are listed above With the exception of CHG dressing present and catheter secured to the patient (97%) the remaining 8 elements were below 95%. The results indicate the need for improvement in all central line dressing assessments and dressing changes. Initial education was provided to the nursing staff and will be included in the 2017 annual skills day for nursing staff.

CLABSI Standardized Infection Ratio (SIR)

Goal: Reduce CLABSI SIR from 2015 and below SIR Threshold of 0.5.

PMC Escondido CLABSI SIR 2015-2016

0.634 0.622

0.6 0.452 0.434 0.418

0.4

0.206 0.180 0.2 0.175

0.0 Infections / Predicted Infections Infections / Predicted 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

40 Addendum C

PMC Poway CLABSI SIR 2015-2016 7.0

6.0 5.0

4.0 Infections 2.568 3.0 2.558

Infections Infections / Predicted 2.0

1.0 0.000 0.000 0.000 0.000 0.000 0.000 0.0 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

Summary: PMC Escondido overall annual SIR was 0.445 and below the threshold. The data reveals a total of 14 CLABSI cases. During the first and second quarter CLABSI was above threshold. An investigation of all CLABSI cases revealed that the majority of patients who developed CLABSI had multiple CVC’s. In addition, there were two CLABSI with PICC alone, three CLABSI with Internal Jugular (IJ) alone, and 1 port associated CLABSI. The duration of the central lines before infection revealed that infection was likely not related to insertion practices but rather to the care and maintenance of the catheter. Due to these findings, Infection Control partnered with the BARD Company to perform an assessment of central line dressings and observe nursing compliance with evidence based practices during drug administration and blood draws (results shown in graphic above). In addition to this effort the Agency for Healthcare Research and Quality (AHRQ) identified PMC Escondido Trauma ICU (TICU) and Critical Care Unit (CCU) as candidates for their Safety Program for ICU’s. Participation in this program began in October 2016.

PMC Poway had three CLABSI in 2016; April (2) and May (1). Although these numbers are low, the annual SIR exceeded threshold at 0.668. Of note, there was zero CLABSI in 10/12 months. Most CLABSI’s occurred 5 days or more after insertion, revealing a correlation with the care and maintenance of the CVC. No identified trend in organism or type of device in the 3 cases.

PMC Downtown Escondido had zero CLABSI during 2016 (no graphic shown).

Goal Met/Unmet: PMC Escondido - Goal Met PMC Poway – Goal Unmet PMC Downtown Escondido – Goal Met Impact: There is a mortality rate as high as 23.8% associated with CLABSI. Estimated direct costs of CLABSI are calculated at $5,734.00 to $22,939.00 in 2003 dollars (R. Douglas Scott II, CDC 2009).

41 Addendum C

Recommendations: 1. Evaluate changes to the CVC dressing kits to enhance compliance with sterile technique. 2. Central Line Insertion Practices (CLIP) checklist with ongoing feedback. 3. Intensivist group engagement with focused education and data. 4. Provide feedback to the PICC team and medical committees. 5. Monitor electronic alerts for physicians to assess patient with CVC for necessity. 6. Provide patient prevention education. 7. Unit based review of all CLABSI cases (identify trends and a focus on dwell times). 8. Daily huddle accountability for necessary of catheters. 9. Chlorhexidine (CHG) bathing in ICU for all patients. 10. Central venous catheter care and maintenance observations site rounding assessment with presentation of findings to stakeholders. 11. Unit Based Champions identified for Central Line care and maintenance training scheduled for FY 2018. 12. Infection Preventionist (IP) rounding with Physicians and staff in CCUs/ICUs.

42 Addendum C

Catheter-Associated Urinary Tract Infections (CAUTI) Process Measures Prevention Measures – CAUTI Bundle and Device Utilization Ratio CAUTI Bundle Monitoring Goal: Compliance with the CAUTI prevention bundle at > 95.

CAUTI Bundle 2015-2016 97% 96% 97% 97% 100% 93% 93%

80% 60% PMC Escondido 40% PMC Poway 20% PMC ARU Percent Percent Compliance 0% 2015 2016

Summary: CAUTI Bundle compliance is down compared with 2015 and below threshold (higher % is better) at PMC Poway and ARU. The decrease in compliance attributed to seal broken (catheter and drainage bag connection) and unobstructed urine flow (kinks in tubing). The CAUTI bundle contains 6 elements: tamper seal intact, securement device, unobstructed urine flow, drainage tubing/bag off floor, drainage tubing/bag below bladder, indication for catheter documented if not discontinued. Goal Met/Unmet: PMC Escondido – Goal Met PMC Poway – Goal Unmet PMC Downtown Escondido – Goal Unmet

Action: Skills Day 2016 – Education provided and Acute Care RNs performed Foley Catheter insertion competency.

Recommendations: 1. Ongoing bundle monitoring by unit and report at IC Committee. 2. IC to meet and collaborate with data collectors to assess validity of data. 3. Simplify data monitoring tool for ease of use by collectors.

43 Addendum C

Indwelling Foley Catheter Device Utilization Ratio (DUR) Goal: Reduce DUR below CDC NHSN 2015 mean

Palomar Health Central Line DUR 2015-16 0.4

0.35 0.335 0.311 0.3 0.244 0.252 0.25 0.199 PMC Escondido 0.2 PMC Poway 0.15 PMC DT Escondido 0.103 0.1

0.05

0 2015 2016 Summary: To provide a mean, the DUR threshold was averaged for PMC Poway (0.221), PMC Escondido (0.253), PMC Downtown Escondido (0.12).The Device Utilization Ratio (DUR) is calculated by dividing the number of patients with devices (device days) by the number of patient days. The result measures device utilization in a particular population and can be compared with CDC NHSN thresholds. Comparing 2016 to 2015, DUR’s decreased at PMC Escondido, PMC Downtown Escondido and at PMC Poway. There is opportunity to reduce device utilization in the following nursing locations which remain above the CDC NHSN DUR mean in the following units; Acute Rehab Unit, PMC Escondido -5W CCU, 4SW TICU, 6E, 7E, 7W, 8E, 9E, PMC Poway - ICU, Med/Surg 2, Med Surg 3, Med Surg 4. Goal Met/Unmet: PMC Escondido – Goal Met PMC Poway – Goal Unmet PMC Downtown Escondido – Goal Met Recommendation: 1. Continue to monitor device utilization rate and benchmark with NHSN SIR. 2. Report device utilization rate to the Infection Control Committee and other medical committees as appropriate. 3. Daily audits by units on Foley Catheter necessity and remove using discontinuation protocol.

44 Addendum C

Catheter-Associated Urinary Tract Infections Standardized Infection Ratio Goal: Reduce CAUTI SIR from 2015 and below 0.5 SIR threshold

CAUTI SIR 2015-2016

PMC Escondido

0.800 0.658

0.550

0.527 0.515

0.600 0.486 0.405

0.400 0.315 0.284 Infections 0.200 Infection / Predicted 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

CAUTI SIR 2015-2016

PMC Poway

0.800

0.600 0.424 0.378 0.338 Infections 0.400

0.200 Infections Infections / Predicted 0.000 0.000 0.000 0.000 0.000 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

CAUTI SIR 2015-2016

PMC Downtown Escondido

3.000

2.160

2.000 1.471

Infections 0.918 0.800 1.000 0.732 0.000 0.000 0.000 Infections Infections / Predicted 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

Summary: PMC Escondido CAUTI SIR is 0.513 up from 2015 (0.432) and above threshold. The majority of the CAUTI are attributed to the CCU 5W. PMC Poway CAUTI SIR is 0.205 up from 2015 (0.102) however remains below threshold. PMC Downtown Escondido (ARU) SIR is 0.742 and a significant decrease from 2015 (1.127) although remains above threshold. Of note there were zero CAUTI last 3 quarters of 2017.

45 Addendum C

There is inconsistent use of the nurse driven Foley Catheter removal protocol and meeting the CAUTI bundle 100%. Goal Met/Unmet: PMC Escondido – Goal Unmet PMC Poway – Goal met PMC Downtown Escondido – Goal Unmet (however significant decrease from 2015). Impact: Estimated CAUTI costs range from $589.00-$758.00 (R. Douglas Scott II, CDC 2009). Recommendations: 1. Daily assessment of the patient with a urinary catheter and bundle reporting to stakeholder committees. 2. Intensivist involvement in CAUTI reduction program through Agency for Healthcare Research and Quality (AHRQ). 3. Provide education on dependent loops and protecting the seal provided at unit level through huddles and Palomar Health Huddle Highlight newsletter. 4. Alternative smaller catheter is being evaluated at Value Improvement Team (VIP) level to improve compliance with intact seal. 5. Explore alternative external female catheter. 6. Unit based review of all CAUTI cases with focus on necessity and appropriately implementing the catheter removal protocol. 7. Daily huddle accountability for necessary catheters. 8. Infection Preventionist rounding with Physicians and staff in ICUs.

Ventilator Bundle Monitoring Goal: 95% compliance with overall bundle.

PMC Poway Ventilator Bundle Compliance 2016 99% 99% 100% 100% 100% 100% 96% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HOB 30-45 Daily Wakening Assess for PUD Prophylaxis DVT Prophylaxis Daily Oral care degrees Readiness to with CHG Extubate

46 Addendum C

PMC Escondido Trama ICU 2016 98% 99% 100% 100% 95% 90% 79% 79% 80% 70% 60% 50% 40% 30% 20% 10% 0% HOB 30-45 Daily Wakening Assess for PUD Prophylaxis DVT Prophylaxis Daily Oral care degrees Readiness to with CHG Extubate

PMC Escondido CCU 2016 100% 89% 83% 87% 86% 80% 63% 58% 60%

40%

20%

0% HOB 30-45 Daily Wakening Assess for PUD Prophylaxis DVT Prophylaxis Daily Oral care degrees Readiness to with CHG Extubate

Summary: The Ventilator Bundle includes six measures for reducing risks associated with mechanical ventilation; head of bed (HOB) up 30-45 degrees, daily awakening of the patient, assessment for readiness to extubate, peptic ulcer disease (PUD) prophylaxis, deep vein thrombosis (DVT) prophylaxis, and daily oral care with chlorhexidine (CHG). Overall compliance at PMC Poway is 99%, PMC Escondido 5W CCU is 78% and 4SW trauma ICU is 92%. 5W CCU was greater than 95% compliant with the bundle during the first quarter of 2016. A new auditor took over compliance measuring and it was identified that measures done on night shift, while patients were sleeping impacted compliance with daily awakening and assessment for readiness to wean. These measures took a sharp decline since patients were not assessed during night shift. Considering oral care with CHG was performed on day shift this measure was also inaccurately defined with zeros, though patients did meet the measure. IC worked with unit based leadership and provided education.

47 Addendum C

Goal Met/Unmet: PMC Escondido 5W CCU – Goal Unmet PMC Escondido 4W Trauma ICU – Goal met PMC Poway ICU – Goal Met

Recommendations: 1. Meet and provide education to any new auditors to ensure appropriate data collection. 2. Include bundle assessment in ICU patient rounds.

Ventilator-Associated Pneumonia (VAP) Rate Goal: Reduce VAP rate from 2015 (NHSN to provide SIR this year 2017)

PMC Escondido Total VAP Rate 2015-2016

6.000 PMC Escondido 4.862 5.000 5W CCU 4.000 PMC Escondido 4SW TICU

3.000

Trauma ICU, National Pooled

2.000 1.164 1.159 Mean 2012 (3.6)

1.000 0.554 Medical -Surgical ICU, 0.000 0.000 0.000 0.000 VAP per 1000 vent days National Pooled Mean 2012 0.000 (0.9) 2015H1 2015H2 2016H1 2016H2

PMC Poway Total VAP Rate 2015-2016

4.000 PMC Poway 3.000 ICU 2.000 Medical -Surgical ICU, National Pooled Mean 2012 (0.9) 1.000 0.000 0.000 0.000 0.000 0.000

VAP per 1000 ventilator days 2015H1 2015H2 2016H1 2016H2

Summary: PMC Escondido CCU and PMC Poway had zero VAP during 2016. Four VAP’s occurred in Trauma ICU (TICU) at PMC Escondido during 2016 compared with one during 2015. Three of four VAPs in TICU occurred during the second half of 2016. With very low VAP rates in all ICU’s until 4Q2016, IP’s focused on data reliability and compliance with NHSN participation rules to identify total VAP. A new cost effective CHG kit for oral care was implemented in the middle of the year.

48 Addendum C

Goal Met/Unmet: PMC Escondido – Goal Unmet PMC Poway – Goal Met PMC Downtown Escondido – No intensive care locations Impact: Estimated costs of VAP range from $11,897.00 - $25,072.00 (R. Douglas Scott II, CDC 2009). Recommendations: 1. Infection Control to report all Infectious-related Ventilator-associated (IVAC) Conditions SIR for 2017. 2. Infection Control, Critical Care and Pulmonary committee review of data and drill down on cases as appropriate, including device utilization. 3. Enhance surveillance and identify opportunities to improve the current VAP bundle in Trauma ICU. 4. Removal of ventilators when patient is assessed to be ready to wean.

Multi-Drug Resistant Organism (MDRO) Lab-Identified Event MDRO Process Measures 2016 Goal: 90% compliance with measures implemented to reduce MDRO transmission

Palomar Health MDRO Process Measures 2016 100% 90% 80% 70% 60% PMC Downtown 50% PMC Escondido 40% 30% PMC Poway 20% 10% 0% Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Summary: Processes that reduce the risk of transmission for MDRO’s include; Isolation initiation, patient education, use of the correct signs, ensuring gloves and gowns are available and wearing them when it is indicated. PMC Downtown Escondido met goal in all months but June. PMC Escondido did not meet goal in Jan May June and Nov. PMC Poway met goal in all months during 2016. Challenges with providing and documenting patient education have been met with

49 Addendum C

education and reinforcement. Gown and glove use when indicated is addressed in real time when identified. It was identified that staff didn’t use gowns because they didn’t like them and the closure would pop open during use. A new gown was trialed and implemented during 2016 to enhance the use of gowns. PMC Escondido had challenges initiating isolation due to isolation cart availability. An assessment of cart availability and use was performed and revealed that there are enough carts to supply however, the process for storing and retrieval was changed accommodate space for the Birth Center move. Carts were decentralized making it more difficult to obtain. The Environment of Care Committee designated a small team to identify storage issues and resolve them.

Goal Met: PMC Escondido – Met 8/12 months PMC Poway – Met 12/12 months PMC Downtown Escondido - Met 11/12 months

Impact: See MDRO rates below.

Recommendations: 1. Continue to monitor and provide data to stakeholder committees. 2. Provide isolation education in real time. 3. Provide objective data for glove and gown purchases. 4. Staff focus group to identify barriers to PPE use.

Clostridium difficile Infection (CDI) Goal: Reduce Hospital-Onset (HO) CDI SIR below SIR threshold of 0.5. CDI SIR 2015-2016

PMC Escondido

4.000

3.000

2.000 1.677 1.421

1.266 1.162 1.010 0.798 1.000 0.757 0.313 0.000

Infection / Predicted Infection 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

50 Addendum C

CDI SIR 2015-2016

PMC Poway

4.000 3.615

3.000

2.242

2.000 1.508

1.180 1.157 0.974

1.000 0.614 0.380

0.000 Infection / Predicted Infection 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

CDI Cases* 2015-2016

PMC ARU

6 5 5

4 4 3 2

CDI CDI Cases 2 1 1 1 1 0 0 0 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

*SIRs cannot be calculated when the predicated value is < than 1.0 Summary: At PMC Escondido, there were 38 cases of hospital onset CDI infection reported during 1st half of 2016 (SIR 1.293) and 22 CDI cases during 2nd half of 2016 SIR (0.815) for a 42% reduction in number of cases. Although there was a significant reduction during the 1st half of 2016 compared to the 2nd half of the year the SIR remained above the 0.5 threshold.

PMC Poway, there were 16 hospital onset CDI cases reported during 1st half of 2016 (SIR 2.361) and 3 CDI cases during 2nd half of 2016 (SIR 0.509) for an 81% reduction in number of cases.

PMC Downtown Escondido, there were 6 cases of hospital onset CDI during 2016 all occurred during 1st half of 2016. There was a significant reduction during the 1st half of 2016 compared to the 2nd half of the year.

Goal Met/Unmet: PMC Escondido – Unmet PMC Poway – Unmet PMC Downtown Escondido – Unmet

51 Addendum C

Impact: Conservative estimates in 2003 dollars estimate direct costs of CDI ranging from $5,042 - $7,179 (R. Douglas Scott II, CDC 2009). Actions taken in 2016/2017 1. Multidisciplinary project focused on by the Healthcare Associated Infection Team (HAI Team) coordinated by Infection Control. 2. Implemented and educated on C- diff testing algorithm 3. Lab refusal of formed stools, and use of Bristol Chart for stool collection. 4. PCR reflex testing modifications and approved by Med Exec Committee. 5. Limiting protein pump inhibitor usage. 6. Implementation and education on fecal microbiota therapy. 7. Antibiotic stewardship recommendations and review of C-diff cases. 8. EMR auto order for Contact Plus precautions. 9. Collect Multi-drug resistant organisms (MDRO) process measures, disseminate and provided education. 10. EMR auto order for CDI testing within three days of admission when liquid stool x3 without laxatives within 24 hours. 11. UV light (Xenex) reboot with targeted units with high cases of C-diff. 12. Timely reporting of all HAI cases to the Unit for review and education. 13. Implemented daily system wide safety huddle reporting out days from last HAI C-diff case. 14. Pharmacy performed medication utilization evaluation (MUE) and identified fluoroquinolones antibiotics to be associated with increasing risk of CDI. 15. Invited CDPH HAI Liaison for a consultative visit and observations of process and cleaning measures.

52 Addendum C

Summary: An interdisciplinary investigation on the data was performed with Infection Control, Infectious Disease, Microbiology, and Antimicrobial Pharmacist. The team reviewed multiple patient records to identify any trends in time of collection, symptoms on admit, stool consistency, medical history, testing methodology. The graph below demonstrates case incidence of lab confirmed C-diff at PMC Escondido and PMC Poway. The graph validated the investigation by the interdisciplinary team of inappropriate stool collection.

Case Incidence of Lab-Identified CDIFF (PMC, Escondido & Poway - Excludes CO-HCFA and Recurrent Cases)

Hospital-Onset Community-Onset

35 30 25 20 15 10 5 0 01/15 03/15 05/15 07/15 09/15 11/15 01/16 03/16 05/16 07/16 09/16 11/16

MRSA Bloodstream Infection (BSI) Goal: Reduce MRSA BSI SIR below threshold 0.5

MRSA BSI SIR 2015-2016

PMC Escondido 2.000 1.777

1.500

0.986 1.000 0.896

Infection 0.500 2 Cases* 2 Cases* 0 Cases* 0 Cases* 0.000

InfectionPredicted / 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

53 Addendum C

MRSA BSI SIR 2015-2016

PMC Poway CASES 2 2

1 Case* 1 Case* 1 Case* 1 1 0 Cases* 0 Cases* 0 Cases* 0 Cases* 0 Cases* 0 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

*SIRs cannot be calculated when the predicated value is < than 1.0 Summary: PMC Escondido reduced MRSA BSI significantly during 2016 from seven cases reported in 2015 to one case in 2016. CHG bathing in the ICUs was implemented to support this reduction. PMC Poway did not realize a demonstrated reduction, reporting two cases for 2016 compared with one during 2015. As a result of these findings at PMC Poway, CHG utilization was assessed. 62% of patients admitted to ICU PMC Poway received CHG bathing during the months after implementation. PMC Downtown Escondido had zero MRSA BSI in 2015-16 (no graphic shown). Goal Met: PMC Escondido - Goal Met PMC Poway - Goal Unmet PMCE – Goal Met Impact: MRSA BSI is a surrogate marker for MRSA acquisition in healthcare facilities. Mean costs associated with MRSA infection are $35,367.00 (Association for Professionals in Infection Control and Epidemiology (APIC), 2007). Recommendations: 1. Aim for 95% compliance for daily CHG bathing in the ICU’s. 2. Continue MRSA screening for; ICU admissions, patients with a recent acute care stay (30 days), Skilled Nursing Facility (SNF) admissions, and dialysis patients upon admission and at discharge. 3. Disseminate data to appropriate committees and education as needed. 4. Focus on increasing hand hygiene compliance during 2017.

54 Addendum C

Surgical Site Infections (SSI) Goal: Reduce SSI SIR and below SIR threshold of 0.5.

PMC Escondido SSI-All SIR 2015-2016

PMC Escondido

2.500 2.000 1.500

1.000 0.735 0.744 0.575 0.515 0.430 0.481 0.500 0.311 0.193 0.000

Infection / Predicted Infection 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

PMC Poway SSI-All SIR 2015-2016

PMC Poway

2.500 2.000 1.408 1.526 1.500 1.000 0.820 0.728 0.441 0.526 0.500 0.317 0.361 0.000 Infection / Predicted Infection 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

PMC Downtown Escondido SSI-All SIR 2015-2016

PMC Downtown Escondido

2.500 2.000

1.500 1.173 1.001 1.000 0.723 0.574 0.430 0.500 0.324 0.000 0.000 0.000

Infection / Predicted Infection 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

Summary: The Infection Prevention team performs targeted Surgical Site Infection surveillance.

55 Addendum C

There are 25 surgical procedures with numerous ICD-10 codes that are reviewed monthly. The first 3 graphs consist of the combined 25 surgical procedures SIR, if those procedures are performed. PMC Escondido was below SIR threshold 0.5 during three of four quarters in 2016. Colon surgical site infections during the fourth quarter were above threshold driving the increase in overall SIR. A colon bundle is being evaluated and work on that bundle will continue through 2017 with implementation. PMC Poway 2016 annual SIR (0.558) is less than 2015 SIR (0.939) but above threshold (0.5). The SIR was above threshold in quarters two and four. A focus on orthopedic surgical site infection was undertaken as a result. Colon bundle principles will be implemented at PMC Poway.

PMC Downtown Escondido 2016 annual SIR (0.636) increased compared to 2015 SIR (0.430) and above the threshold. C-sections SSI attributed to the increase in the SIR; however there was a significant reduction in 2016 compared to 2015 SIR. The C-sections are now being done at PMC Escondido with the OB move December 2016. There was great collaboration from the OB team and Infection Control to standardize preoperative CHG bathing which impacted the 2016 SIR.

PMC Escondido SSI-COLON SIR 2015-2016

PMC Escondido

2.500 2.077 2.000 1.531 1.621 1.500 1.235 1.000 0.393 0.384 0.500 0.280 0.334 0.000

Infection / Predicted Infection 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

PMC Poway SSI-COLON SIR 2015-2016

PMC Poway

2.500 2.000 1.408 1.526 1.500 1.000 0.820 0.728 0.441 0.526 0.500 0.317 0.361 0.000

Infection / Predicted Infection 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

56 Addendum C

Summary: PMC Escondido annual 2016 SIR (0.464) decreased compared to 2015 SIR (0.530) and below the threshold 0.5 SIR. PMC Escondido colon surgery had a spike in SSIs above threshold in the fourth quarter. Colon surgery annual 2016 SIR (0.644) significantly decreased compared to the annual 2015 SIR (1.3860). In spite of the decrease the SIR remains above the threshold (0.5). Colon surgical site infections are above threshold as noted above. PMC Poway Colon surgery annual 2016 SIR (0.556) significantly decreased compared to the annual 2015 SIR (1.085). In spite of the significant decrease, the SIR remains above the threshold (0.5). PMC Poway Orthopedic and Colon surgery SSI are contributing to SIR.

PMC Escondido SSI-HYST Cases* 2015-2016

PMC Escondido

1 1 1 HYST HYST Cases - SSI 0 0 0 0 0 0 0 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

*SIRs cannot be calculated when the predicated value is less than 1.

PMC Poway SSI-HYST Cases* 2015-2016

PMC Poway 2 2

1 HYST HYST Cases -

SSI 0 0 0 0 0 0 0 0 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

*SIRs cannot be calculated when the predicated value is less than 1. Summary: There were zero Hysterectomy surgical site infections during 2016 at PMC Escondido and PMC Poway.

57 Addendum C

PMC Escondido SSI-ORTHO* SIR 2015-2016

PMC Escondido

2.500 2.000 1.500

1.000 0.502 0.393 0.352 0.363 0.384 0.500 0.215 0.101 0.096 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4 Infection / Predicted Infection *ORTHO includes Knee and Hip prosthesis replacement, Fusion, ReFusion, Laminectomy and Fractures Summary: PMC Escondido Orthopedic surgeries SIR (0.336) well below the SIR (0.5) threshold.

PMC Poway SSI-ORTHO* SIR 2015-2016

PMC Poway

4.000 3.749 3.500 3.000 2.500 1.861 2.000 1.599 1.529 1.632 1.500 0.860 0.808 1.000 0.500 0.000 0.000

Infection Infection Infection / Predicted 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4

*ORTHO includes KPRO, HPRO, and FX Summary: PMC Escondido did well all 4 quarters during 2016 for orthopedic surgeries. PMC Poway Orthopedic surgery annual 2016 SIR (0.822) significantly decreased compared to the annual 2015 SIR (2.184). SSI for Hip and Knee prosthesis surgery are contributing factors to the 2016; however there has been significant reduction from 2015 SIR. There continues to be great collaboration from the Orthopedic COE team and Medical Director in reviewing the cases. In addition, a summary of cases was presented and a Root Cause Analysis (RCA) was performed to address processes that could impact reduction. The results of the RCA identified further need to standardize SSI preventive measures, appropriate dosing of antibiotics, and damp dusting prior to first case.

58 Addendum C

PMC Downtown Escondido SSI-CSEC SIR 2015-2016

PMC Downtown Escondido

2.500 2.000 1.198 1.500 1.033 1.000 0.640 0.726 0.346 0.437 0.500 0.000 0.000 0.000 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4 Infection Infection Infection / Predicted Goal Met/Unit: All SSI (25) procedures PMC Escondido – Goal Met PMC Poway – Goal Unmet PMC Downtown Escondido - Goal Unmet Impact: Cost estimates associated with SSI are $10,443 - $26,800 depending on the depth of the SSI. In addition, deep and joint SSI increases readmission rates and length of stay. Recommendations: 1. EVS OR cleaning competency and UV light Xenex utilization after terminal clean. 2. Refine Surgical Services attestation form for Sterilization parameters to IC Committee. 3. Surgical attire procedure updated February 2017. Monitor adherence of procedure. 4. Implement Colon bundle initiative. 5. Ongoing data sharing with surgeons and review cases accordingly. 6. Pre-operative CHG bathing and 3M nasal decolonization in orthopedics and CABG procedures. 7. Implementation of new fracture bundle, monitor outcomes. 8. SPD staff certification. Upon hire and annual sterilization competency. 9. Surgical observations and recommendations as appropriate. 10. CDPH consultative visit with recommendations made at Poway campus in 2016. Ongoing monitoring of recommendations. 11. Pursue timely and appropriate antibiotic prophylaxis administration.

59 Addendum C

Hand Hygiene Goal: Increase hand hygiene observations to ensure good sample size and representation in all inpatient departments.

Hand Hygiene Compliance by Facility, 2016 (N=4189*) BEFORE Patient Care AFTER Patient Care 91% 94% 100% 84% 79% 74% 80% 52% 60% 47% 42% 40% 20% 0% Palomar Health System PMC PHDC POM

*Excludes Villa Pomerado

Hand Hygiene Compliance by Discipline, 2016 (N=4265) BEFORE Patient Care AFTER Patient Care 100% 87% 83% 81% 79% 80% 73% 70% 57% 58% 60% 57% 60% 44% 43% 37% 39% 40% 27% 18% 20% 7% 7% 0% Nurse MD Resp EVS Lab Rad FANS Trans Other

60 Addendum C

Summary: During 2015 there were insufficient data to determine compliance. In addition, the observations were provided by a departmental representative. This mechanism for collecting data may have skewed results in the department’s favor. The goal for 2016 was to engage secret shoppers to evaluate hand hygiene compliance and to increase the sample size to better represent actual hand hygiene compliance. System wide hand hygiene observations increased to 4189 which is significant and met the 2016 goal. Appropriate hand hygiene is expected BEFORE contact with the patient AND/OR the patient’s environment as well as AFTER. Presented in the above graphs, it is observed that hand hygiene compliance is significantly lower for the system at 47% before patient contact as compared to 79% after patient contact. Initial analysis of low compliance prior to entering the patient’s room, is due to the belief hand hygiene isn’t required when applying gloves. Healthcare workers falter in compliance when having contact with the patient’s environment (e.g. IV pole, curtains, bed rails, etc.).

Hand hygiene compliance prior to patient contact, by discipline, ranges anywhere from 7%-57%. Hand hygiene compliance prior to patient contact remains low with the exception of Rehab services and Dialysis. This data requires a deeper analysis as to why the Healthcare Providers are more compliant with hand hygiene prior to leaving the patient room as opposed to performing when they walk in the room. Directors of disciplines where compliance was low were notified and staff was provided face to face in-service education by Infection Control staff.

Goal Met: (Increase in number of observations) PMC Escondido – Goal Met PMC Poway – Goal Met PMC Downtown Escondido – Goal Met

Recommendations: 1. Measure focused on before and after patient/environmental contact. Explore how observations with all hand hygiene opportunities can be achieved without bias. 2. Disseminate data to department leaders with a focus on low compliance. 3. Continue Infection Control education to low compliance departments. 4. Engage SOS team to perform “secret” hand hygiene observations outside of their department. 5. Explore incentivizing hand hygiene compliance with goal of 90%. 6. Expand to outpatient and satellite locations. 7. Present new outcome categorization including patient care unit.

61 Addendum C

Environment of Care (EOC) Rounding

Goal: 95% compliance

Summary: Environment of Care rounds is performed monthly with an interdisciplinary team led by the Facilities department. The goal of the rounds is to assess the environment for patient safety, staff safety and environmental safety. The graph shown above demonstrates the number of EOC rounds performed from July to December. Prior to July the data was collected manually and difficult to capture full compliance. The new software (Sentact) program was implemented and has the ability to capture the percent compliance with EOC via assessment points. Satellite locations and PMC Downtown Escondido met goals for compliance during 2016. PMC Escondido, PMC Poway and Villa Pomerado are below compliance expectations. Compliance below 80% was documented and reported to Department Directors regarding the following assessment points; log documentation complete, patient microwave clean, equipment and medications within recommended expiration, environment clean, food refrigerator clean, and food labeled and dated. Goal Met: PMC Escondido – Goal Unmet PMC Poway – Goal Unmet PMC Downtown Escondido – Goal Met Recommendations: 1. Continue EOC team rounding monthly in scheduled areas. 2. Continue to report findings to Department Directors to address according to urgency of identified issue. 3. Revise EOC rounding form and urgency requirements to assist departments with prioritizing needs. 4. Report trends and data to EOC and Infection Control committees.

62 Addendum C

Specialty Area Rounding Goal: 95% compliance with EOC rounding log

Summary: In addition to routine EOC rounding, the Infection Preventionist (IP) team round in the following specialty areas; Pharmacy, Surgical Services, FANS, Dialysis, High Level Disinfection (Respiratory Therapy, Sterile Processing Department, Perinatology, Endoscopy) and during construction. Trends at PMC Poway are hand sanitizer and soap availability, stocked isolation carts, clean storage areas free of dirty equipment, personal belongings in sterile areas, biohazard storage free of clean equipment and supplies, equipment cleaned according to manufacturer recommendations, expiration dates of medications, evidence of pests, patient refrigerator clean temp monitored and food labeled. Department leaders are notified of findings immediately after rounding is complete.

Goal Met/Unmet:

PMC Escondido – Goal Met PMC Poway – Goal Unmet PMC Downtown Escondido – Goal Met

Recommendations: 1. Continue to perform Specialty Department rounding and report through Sentact. 2. IP will work directly with leadership (subject matter expert) in specialty areas that continue to have low compliance. 3. Engage the staff on safety from the specialty areas to assist in identifying any barriers to maintaining compliance. 4. Review EOC rounding forms to include updated standards. 5. Continue to report at EOC and Infection Control Committees.

63 Addendum C

Environmental Cleaning Measures - Glow Germ Translucent Marker Goal: Increase the number of glow germ assessments and increase compliance with ten out of ten markers. Compliance is expected to be 95%.

Summary: Glow Germ compliance involves the use of a translucent marker to assess Environmental Services (EVS) cleaning processes. The EVS Supervisor marks ten “high touch” surfaces with a translucent agent prior to the EVS staff cleaning the room. The areas where Glow Germ is applied is not known to the EVS, however the staff are aware of this measure. The EVS worker then cleans the area following procedure. When finished, the EVS Supervisor uses a black light to identify how many of the ten marked sites glow. If any site glows, this is noncompliance to room cleaning. The EVS worker is provided real time education and reinforcement on how to improve the cleaning process to avoid missing spots or improve friction applied to surfaces. The above graph represents compliance with the ten marker evaluation process of environmental cleaning. This measure was implemented in accordance with the California Public Health Department Senate Bill requirement. Although the goal of 95% compliance was not met, there was excellent improvement of glow germ environmental cleaning measures during the 2nd half of 2016. In addition, the EVS Leadership did an excellent job increasing the number of assessments. In April, there was no data available to include. Goal Met/Unmet: PMC Escondido – Goal Not Met PMC Poway – Goal Not Met PMC Downtown Escondido – Goal Not Met Recommendations: 1. Continue to monitor observations and use as a practice enhancement tool. 2. Routine reporting through Infection Control Committee by EVS Leadership. 3. IP staff to perform additional observations of EVS cleaning compliance.

64 Addendum C

Ultraviolet (Xenex) Disinfection Utilization Goal: Focus Xenex Utilization to high risk locations with increased incidence of C. difficile Infection (CDI). Palomar Medical Center Escondido 2016 Xenex Utilization by rooms

Palomar Medical Center Poway Xenex utilization by number of rooms

Summary: Infection Control (IC) coordinated a “reboot” that occurred in July to focus on possible lateral translocation of C-diff. Prior to July, Xenex U/V disinfection was used to disinfect rooms and bathrooms housing patients with CDI. Under the guidance of the manufacturer, Infection Control, and Environmental Services (EVS) the team refocused the interventions and the results are evidenced in the graphs above. The numbers represent total number of rooms where Xenex was used. In addition, a decrease was noted in Hospital Onset CDI cases during second half of 2016. Goal Met/Unmet: PMC Escondido – Goal Met PMC Poway – Goal Met PMC Downtown –IC focus on appropriate stool collection

Impact: UV light has a proven efficacy in killing C-diff spores in the environment if used appropriately and in targeted locations and enhances the cleaning process.

65 Addendum C

Recommendations: 1. Infection Control collaboration with manufacturer and EVS on targeted focus. 2. Monthly utilization review with manufacturer representatives, IP team and EVS. 3. Continue recent changes made to the standard operating procedure reflecting manufacturer’s recommendations to focus on units with high incidence of healthcare onset CDI. PMC Escondido units include 8E, 9E and 5W. Patient population changes on the 8th floor made it necessary to redirect Xenex elsewhere, so the entire 5th floor is being treated now. PMC Poway include ICU and th4 4th floor med/surg unit.

Infection Control Education Goal: Provide Infection Prevention education to Palomar Health staff on areas of focus

Infection Control Education by Subject 2016

PPE CDIFF Zika

Annual IC

Hand Hygiene HLD

Construction

SSI Prevention

Cleaning Survey CAUTI Prevention

66 Addendum C

Infection Control Education by Audience 2016 Laboratory Villa Pomerado US Nursing Radiology Birth Center NSO EVS FANS ARU MHU

SPD

Vendor/Facilties

UPC Perinatology Summary: The Infection Preventionists (IP) provided 170 focused educational sessions. High Level Disinfection (HLD) is the topic most addressed by IP’s followed by Construction, and Personal Protective Equipment (PPE) use. PPE was a focus since new protective gowns were brought into the system. Extensive education was provided to the EDs and Women’s Center on Zika Virus via face to face, written communication, and the Huddle Highlights newsletter. There was also a new web link for Zika provided for staff on the Palomar Health Intranet. Surgical site infection prevention was a focus for Women’s Center at PMC Escondido Downtown, Orthopedics at PMC Poway, and Colon surgery at PMC Escondido due to increased incidence in this population. Interventions: Infection Control provided education routinely, upon request and during real time opportunities. Goal Met/Unmet: (education) PMC Escondido - Goal Met PMC Poway – Goal Met PMC Downtown Escondido – Goal Met

Recommendations: 1. Address emerging infectious diseases as necessary with impacted departments. 2. Provide real time education when indicated during IP unit/department rounds. 3. Provide hand hygiene education addressing non-compliance. 4. Perform gap analysis and educational needs assessment with focus on high risk units.

67 Addendum C

Construction Goal: Provide consultation education and perform Infection Control Risk Assessment (ICRA) for construction and renovation projects.

Class of Precautions for Construction Activity 2016

30 27 25

20 17 PMC Escondido 15 PMC Poway 9 10 6 7 PMC Downtown Number ICRAs of 5 2 2 0 0 Class I Class II Class III Class IV

Summary: Palomar Health has an infection control procedure in place for assessing the risk of construction/renovation jobs to determine the appropriate barriers for mitigating dust dispersion. Since dust can cause illness in patients, the class of the job is determined by assessing patient population and construction activities. IP’s completed seventy five infection control risk assessments (ICRA); class I (2), class II (8), class III (49) and class IV (16). Class IV jobs are the highest risk to the environment and patient population. During Class IV construction at PMC Escondido (Surgical Services), surveillance identified two patients with post-surgical infections that were suspicious. Both patients had surgery performed in a room adjacent to the construction area. An epidemiologic investigation was performed, construction ceased, the OR room was closed, and air quality samples were performed. Particle count results were not significant and no organisms were identified as causative factors to the SSIs. Construction resumed and no other cases were identified and both patients recovered. Goal Met/Unmet: PMC Escondido - Goal Met PMC Poway – Goal Met PMC Downtown Escondido – Goal Met

Recommendations: 1. Add baseline and routine air quality sampling for Class IV jobs by a third party vendor. 2. Continue to monitor all construction activities and report non-compliant findings to the Project Manager. 3. Report all ICRA’s and any results from air quality samples to the IC Committee.

68 Addendum C

Reportable Diseases 2016 Goal: Compliance with CDPH Confidential Morbidity Reporting (CMR) Requirements. Summary: The Infection Prevention and Control department IP’s are obligated to comply with the CDPH reporting requirements under CMR. The IP team reported 397 cases of infectious diseases; PMC Downtown Escondido (10), PMC Poway (91), and PMC Escondido (306). IP’s routinely work with San Diego County Epidemiology staff, responding to requests and initiating reports. There was an unusual cluster of Guillain-Barre syndrome (GBS) cases identified by Neurology and the IP team. Fifteen cases were identified at the Escondido Campus. Typically there are 10 cases reported for the entire county in a year. An epidemiologic investigation was performed and the Infection Control Officer worked with representatives from San Diego County Epidemiology and the Centers for Disease Control to identify a cause for this cluster. There were multiple lab requests and collaborative efforts to determine if there was a common focus. Among the tests ordered were Zika and Campylobacter - all were negative. There wasn’t a common source identified and no further cases identified. In addition to routine reporting, the County provides Palomar Health Infection Prevention with Syndromic Surveillance data which is compiled from the Emergency Department visit information. IP’s review and share this information as needed. It is included in the Infection Control Committee on a monthly basis along with information on influenza and emerging infectious diseases. Goal Met/Unmet: PMC Escondido – Goal Met PMC Poway – Goal Met PMC Downtown Escondido – Goal Met

Recommendations: 1. Continue to report cases when identified in a timely manner. 2. IC and lab to respond to requests for information. 3. Use the information and data to identify unusual clusters in the patient population.

69 Addendum C

Emerging Infectious Disease during 2016 Zika VIrus Zika Virus is a disease caused by a virus transmitted primarily by Aedes mosquitoes. People with Zika virus disease can have symptoms including mild fever, conjunctivitis, muscle and joint pain, malaise or headache. . The Infection Preventionists provided education for staff involved in the care of patients who are at risk for Zika Virus. Focused departments included the Emergency Services and Birth Center. Education was provided via multiple routes and a Zika Virus link was added to the Infection Control intranet site for access to all employees. Zika Virus testing, when indicated, was coordinated with San Diego County Epidemiology by the Infection Control team. Reinforcement of Standard Precautions during infant deliveries was a focus for staff. Although there are no known local transmission the Aedes mosquitos are present in San Diego county therefore IP’s followed local mosquito spraying events. The Infection Prevention and Control Committee Chairman provided education to the committee on Zika epidemiology and prevention.

Tuberculosis Risk Tuberculosis statistics San Diego County reported 234 cases of active TB in 2015 (case rate of 7.3 per 100,000). The number of cases in 2015 was 50% lower than 1993 (469 cases), the year with the highest number of cases in decades, and 26% lower than the 5-year average from 2002-2006 (316 cases). Since 2006, the case total and case rate have declined with fluctuations, with less than 250 cases reported annually since 2011, representing a case rate of approximately 7 per 100,000. The racial and ethnic breakdown of San Diego County TB cases was 124 (53%) Hispanics, 89 (38%) Asian/Pacific Islanders, 17 (7%) non-Hispanic whites and 4 (2%) non-Hispanic blacks. Of the 174 cases born outside the United States, 88 (51%) were from Asia (including 43 from the Philippines, and 16 from Vietnam), 78 (45%) were from Mexico, and 5 (3%) were from Africa. TB drug susceptibility information was available for 100% of 204 culture-proven cases in San Diego. Resistance to at least one of the four major first-line drugs was found among 35 (17%) of these specimens. A multidrug-resistant (MDR TB) strain was found in 1 (0.5%) of the cases. A comprehensive TB Risk assessment was performed in which Palomar Health was rated as intermediate risk. This is no change from 2015.

70 Addendum C

Environmental Testing 2016 Goal: Periodic environmental testing with timely action planning and resolution. Summary: Environmental Testing performed routinely on potable water, Pharmacy compounding rooms, and Dialysis cultures (Dialysis cultures all negative). Potable water testing revealed locations where bacterial counts were above acceptable limits, although not at a dangerous level. Action planning included allowing water to run routinely in effected locations and removal of a water cooler where there was very little use. All areas were retested and within normal limits. Pharmacy clean room air viable and surface cultures are performed quarterly and when indicated, action planning followed out of range results. Pharmacy leadership, IP’s and Environmental Services (EVS) addressed activities to improve performance. IP’s provided Pharmacy staff with recommendations and assessed practice, Pharmacy specialists provided education and arranged testing. Scrub attire was recommended or bunny suits for clean room access. IP’s assessed EVS worker cleaning process compliance, and technique. Goal Met/Unmet: PMC Escondido – Goal Met PMC Poway – Goal Met PMC Downtown Escondido – Goal Met Recommendations: 1. Continue environmental testing via 3rd party vendors for identification and control of environmental hazards. 2. If results exceed threshold services may be interrupted while investigations and action plans are created and implemented.

71 Addendum C

Value Improvement Process (VIP) – Infection Control Goal: Improve healthcare safety and fiscal sustainability through attendance and collaboration with Supply Chain VIP process.

Phlebitis Cases 1Q2015 - 3Q2016 6 5 4 4 4 3 2 2 2 1 1 Phlebitis cases Phlebitis

0 1Q2015 2Q2015 3Q2015 4Q2015 1Q2016 2Q2016 3Q2016 4Q2016

MRSA BSI 2015-2016 2.5 2.115 2.0 1.956 POM 1.5 1.402 1.0 0.954 PMC 0.519 0.5 Linear (PMC) 0.439 0.0 0 0 1H2015 2H2015 1H2016 2H2016

Summary: IP’s had an opportunity to reduce expenditures for medical supplies by increasing the dwell time of peripheral intravenous catheters to seven days. In coordination with the Clinical Educators and VIP team this was accomplished. Phlebitis cases were followed (see graph) and there was an observed decrease after implementation. In addition, the IV tubing manufacturer extended the life of the tubing enabling us to prolong use to seven days. This allowed bedside staff to change all intravenous components once every seven days decreasing access and risk of infection. IP’s introduced Chlorhexidine bathing of patients in intensive care units and coordinated with VIP team. The graph (MRSA BSI) shows a downward trend in 2016 when bathing was implemented. Goal Met/Unmet: PMC Escondido – Goal Met PMC Poway – Goal Met PMC Downtown Escondido – Goal Met Impact: IV dwell time and infusion tubing project decreased the risk of infection and projected savings for the healthcare system are $123,760.00 annually. Recommendations: IP staff will continue to participate in the VIP process.

72 Addendum C

Medical Equipment - Monitoring of Regulatory or Other Nationally Recognized alerts Goal: Provide safe care through provision of properly disinfected instruments and equipment. Summary: Endoscopic Retrograde Cholangio-Pancreatography (ERCP) scopes have been identified as at risk for transmission of CRE. Multiple changes were put into place during 2016 including a new procedure to address the specific cleaning requirements of these scopes. A risk assessment for hang time of scopes and repeating the disinfection process was implemented. A process for determining the efficacy of the cleaning procedure prior to disinfection was recommended and was implemented. All scopes were tested initially and found to be within normal limits. ERCP scopes are now routinely tested.

Sorin heater cooler machines were identified by the CDC and Food and Drug Administration (FDA) as a cause of atypical mycobacterial infections in patients who underwent cardiac surgery. Although PMC Escondido had a machine that was manufactured after the date of the notification, Infection Control implemented all recommendations for cleaning and maintaining the device. Along with Surgical Services Staff, IP’s assessed practice and provided a checklist with manufacturer’s recommendations. A competency training tool was created by the Surgical Educator and coordinated with manufacturer to achieve competency training for staff involved with cleaning and maintenance of the machine. IP’s performed a lookback of atypical mycobacteria cases and there were none associated with cardiac surgery. Ongoing surveillance will remain in place.

McGrath Intubation Device Manufacturer’s recommendations for the McGrath device included a new high level disinfection method with a new product called Revitalox. The IP team in collaboration with the Respiratory Therapy leadership at PMC Escondido (where this device is used) education was provided and competency validation was performed. Goal Met/Unmet: PMC Escondido – Goal Met PMC Poway – Goal Met PMC Downtown Escondido – Goal Met

Recommendations: 1. Continue routine testing of ERCP scopes per Palomar Health Procedure and in accordance with the manufacturer of the scope. 2. Adhere to FDA notifications regarding medical equipment. 3. Ongoing surveillance for atypical mycobacterial infection associated with Cardiac Surgery. 4. Continue assessment of new products and adhere to manufacturer’s recommendations for reprocessing.

73 Addendum C

Long Term Care Community Facility Liaison Consultation

Summary: Palomar Health Infection Prevention supports fourteen community Long-Term Care (LTC) facilities acting as a liaison for their infection prevention needs. The consultation provided by the IP liaison is of benefit to Palomar Health in providing ongoing collaboration and addressing IC concerns as these patients are often admitted to one of our medical centers. The designated IP performs the following duties: 1. Attends facility Quality Assurance Meetings. 2. Provides staff in-services and educational materials. 3. Notifies when MDROs are identified. 4. Performs EOC rounds and communicates findings to facility leadership. 5. Assists with outbreak investigations. 6. Product recalls. 7. Provides consultation via text messaging, phone, or email for questions related to Enhanced Standard Precautions, appropriate PPE, reportable conditions, and survey assistance. 8. Provides notification of regulatory updates. 9. Introduction to Antibiotic Stewardship. 10. Encourages the use of McGeer Criteria. 11. Informs about novel organisms. 12. Provides information on education opportunities, i.e. conferences, webinars.

Results: Introduced Antibiotic Stewardship into LTC practice, and use of McGeer Criteria infection surveillance definitions to help guide assessment for potential infection.

Recommendations: 1. Work to establish EOC rounds twice annually at all facilities. 2. Establish consistent contact with each facility. 3. Continue to offer education opportunities per individual facility needs and any identified needs from any of the Palomar Health campuses. 4. Encourage use of Antibiotic Stewardship assessment tools to track infections and appropriate antibiotic use. 5. Continue to encourage use of McGeer Criteria through education.

74 Addendum C

Employee Health Influenza Vaccination Compliance Goal: >90% compliance with immunization program

SYSTEM Employees Med Staff Volunteer & Students Contractors Total Total Personnel 4418 662 1212 622 6914 Received Vaccination 3720 336 1052 545 5653 Received Elsewhere 153 319 143 45 660 Medical Contraindication 15 1 1 0 17 Declined 284 4 15 30 333 Unknown 246 2 1 2 251 All 88% 99% 99% 95% 91%

Summary: Palomar Health System exceeded 90% overall compliance (91%) with influenza vaccintation. Compliance includes receiving vaccination at Palomar Health, receiving vaccination elsewhere, and medical contraindication. Those who declined were asked to provide a reason. Of those who declined (333), two hundred fifty one didn’t provide a reason. The lack of response makes it difficult to proactively address common reasons for declination and improve compliance during next influenza vaccination season. Medical staff was noted to have the highest compliance (99%). The highest compliance among employees was identified at Villa Pomerado and MHU (94%), and ARU (95%). Three thousand eight hundred and eighty eight employees were compliant with the program (88%). Lowest compliance was among employees at PMC Downtown Escondido 82%; PMC Escondido 88%; PMC Poway 88%. Anyone who does not receive the vaccination is mandated to wear a surgical mask while in clinical areas throughout the designated flu season.

Goal Met/Unmet: Palomar Health – Goal Met PMC Escondido – Goal Unmet (for employees) PMC Poway – Goal Unmet (for employees) PMC Downtown Escondido – Goal Unmet (for employees)

Impact: Influenza deaths in San Diego County during 2016-17 (82) exceeded the 3 year average (74). Staff awareness and participation in the program is incouraged and mandated masking breaks the chain of transmission of those who may unknowingly be contagious.

Recommendations: 1. Work with employees to identify the reason for declination and then include education on common reasons for influenza vaccination declination during 2017-18 program. 2. Congratulations to the Medical Staff for achieving high level of compliance

75 Addendum C

Palomar Health Exposure Follow up Goal: Collaborate with Employee Health and San Diego County Epidemiology in identifying and verifying exposures to communicable diseases.

Summary: IP’s provided Employee Health Services with information on forty two “possible” Tuberculosis (TB) exposures. Of those confirmed to have active pulmonary TB, a number of cases were identified after isolation had been discontinued. IC followed procedure in releasing patients who were tested for tuberculosis with three negative results. It was noted that some of these patients had final culture results revealing active tuberculosis, although ruled out by protocol. New processes have been put into place to mitigate exposure to high risk patients who have been through the rule out process but no other diagnosis has been identified. Non- compliance with exposure follow up procedure is noted among exposed workers (20). Under committee review it was recommended that administrative leave be enforced just as it is for annual TB testing. There was one possible measles exposure at PMC Poway. Measles exposures are high risk because the disease is highly communicable. It is an exhaustive process to collaborate with Employee Health, County Epidemiology, Medical Staff and others. When measles is confirmed there is a procedure for employee furlough. Community notification processes are done through County Epidemiology if the exposure involved other patients or visitors. In this particular case there was a four day window, awaiting confirmation of diagnosis. During these times, Employee Health identified exposed staff and confirmed immune status. Measles was ruled out. Goal Met/Unmet: PMC Escondido – Goal Met PMC Poway – Goal Met PMC Downtown Escondido – Goal Met

Impact: Exposure processes are time consuming, expensive, and can involve diagnostic testing and furlough. Infection Prevention and Employee Health work collaboratively during exposures. There were unusual numbers of exposures to tuberculosis this past year.

76 Addendum C

Recommendations: 1. Individual tuberculosis case reviews with medical staff collaboration and when there is no other disease process identified. 2. Patients should be considered to remain in isolation until further evaluation and IP team involvement. 3. Non-compliant employees should undergo the same process when non-compliant with routine tuberculosis testing which includes administrative leave. 4. Ongoing education on transmission based precautions. 5. Emergency Department awareness high risk for communicable disease screening.

First Responder Exposures Goal: Comply with Ryan White Law for exposure to bloodborne pathogens and Cal OSHA Aerosol Transmissible Disease Regulations

Summary: Twenty five possible medic exposures were investigated for the Palomar Health system (tuberculosis- 11; bloodborne pathogens- 7; meningitis- 4; scabies-1; shingles, disseminated-1; measles-1). In accordance with established processes, 14 medic agencies submitted at least one exposure form for IP follow up. Three source patients were positive for tuberculosis. In an abundance of caution, due to one patient’s presentation, medics were treated for a meningitis exposure without confirmation of disease (the patient expired and diagnostic testing was not performed). All results were communicated to the Medic Infection Control Officer for follow up.

Goal Met/Unmet: PMC Escondido – Goal Met PMC Poway – Goal Met PMC Downtown Escondido – Goal Met

Recommendations: 1. Palomar Health IP will provide education to ED leadership/ staff to complete the medic exposure forms at the time of possible exposure and forward immediately to Infection Prevention for follow up. 2. IP will continue monitoring and timely communication of source patient results to the first responder Infection Control Officer. 3. Palomar Health IP will work with first responder agency Infection Control officers to encourage PPE use for anticipated exposure and education as necessary. 4. Collaborate with first responder agency to provide education on exposure prevention as needed.

77 Addendum C

Summary of Projects – IC collaboration with Departments CLABSI and CAUTI Reduction ICU initiative: Agency for Healthcare Research and Quality (AHRQ) NHSN identified that CAUTI and CLABSI infections were above threshold in PMCE ICU’s. They invited these units to become involved with their “Safety Program for ICU: CLABSI/CAUTI” initiative. The project is headed by the Health Research and Educational Trust (HRET), a non-profit research and education affiliate of the American Hospital Association (AHA). A unit based assessment was provided, and data is shared through NHSN. Educational opportunities are provided and recommendations for reducing infections are shared by other healthcare facilities. Infection Control coordinated the formation of a team including the Medical Directors of each intensive care unit, the Nursing Director and unit based staff. System-wide Initiative: Preventing CLABSI - BARD AllPoints Program Lead by IP’s, the BARD Access Systems’ Clinical Specialist performed a point prevalence study for patients with central venous catheters to determine compliance with Palomar Health procedures and nursing standards. Also assessed was nursing practice during lab draws, dressing and injection cap changes, and medication administration. Data was presented to the Executive Team and the BARD AllPoints prevention program was approved for educational purposes. Education sessions were coordinated through Organizational Learning and would include, Unit Based Champions, Clinical Educators, PICC Team Members and IP’s. Program recommendations will be a part of 2017 Skills Day education and a new dressing kit will replace the old kit, which needed updating. MDRO Reduction A comprehensive MDRO Risk assessment was performed. CDI and MRSA BSI were priority focus during 2016. For MRSA reduction, IP’s introduced Chlorhexidine bathing daily in ICU’s. A review of MRSA BSI data shows reduction during 2H2016 at PMC Escondido. PMC Poway did not realize the same impact. ICU leadership reviewed usage and identified opportunity to improve daily bathing for all patients. CDI infection prevention was a focus of the Healthcare Associated Infection (HAI) Team. Inappropriate specimen collection in patients who were on laxatives or who had formed stool was identified. An algorithm for stool collection was distributed and multiple educational sessions were provided by IP’s. Based on current literature and Infection Control data, the Infection Prevention and Control Committee made new recommendations for Palomar Health’s CDI testing protocols. These recommendations prescribed toxin testing without reflex Polymerase Chain Reaction (PCR) testing. Toxin testing identifies patients with disease causing toxin in their stools. Previously, testing was automatically performed (reflexed) if toxin testing was negative. In the absence of toxin positive results, PCR testing further informs when there are C.difficile organisms present which are capable of toxin production. In the absence of a positive toxin result, there is most likely no CDI, indicating colonization. Performing C. difficile testing with reflex PCR caused over-diagnosis of patients who have C. difficile capable of disease, but no infection is present. This practice of “reflex testing” compelled physicians to provide treatment for patients who were without infection. PCR testing is still reserved for physician use,

78 Addendum C

but no longer automatically prompted when there is a negative toxin result. Palomar Health has realized a reduction in the use or oral vancomycin as a result of this testing recommendation. IP’s also performed an assessment of isolation garb. New more protective gowns were brought in and education was finalized. Personal Protective Equipment for Bloodborne Pathogens Protection An effort was undertaken to identify and reduce surgical masks that are not appropriate for use in surgical settings. All masks that did not meet OSHA regulatory requirements were removed from the system. This required ongoing education and conversations with medical staff. Now all masks available to staff are compliant. Colon Surgical Site Infection Prevention Bundle IP’s joined with Surgical Services, Clinical Educators, and Infectious the Disease Pharmacist to create a Palomar Health colon surgery infection prevention bundle. Several bundle samples were collected including The Joint Commission’s recommendations. Challenges with full implementation were met which slowed down the implementation processes. The team is continuing to work on this in 2017. Transformation - Birth Center relocation to PMC Escondido Infection Control worked closely with leadership of the Birth Center to ensure a smooth transition of services from the PMCD to the PMCE Campus. Infection Control representation transitioned from the IP at PMCD to the one of the IP’s at the PMCE location. IP’s provided assistance with equipment transfer, paths of travel were established, and staff was introduced to the new IP. Communication is ongoing and staff appears to have adjusted to the change in IP support. Informatics IP’s continue to work with the Informatics team to improve the use of Infection Control Software and enhance Clarity functions. Included in the improvements; add CDI testing algorithm for nursing access, create automated order trigger for CDI testing when a patient has three liquid stools within twenty four hours, and exploring auto isolation orders when tuberculosis testing is requested. Antibiotic Subcommittee During a Medicine Utilization Evaluation requested by Infection Prevention and performed by the Infectious Disease Pharmacist, Proton Pump Inhibitors (PPI) and fluoroquinolones therapy were identified as a combined risk for CDI. Reduction in PPI use was requested by the Healthcare Associated Infection Team and realized during 2016. The Antibiotic Subcommittee is attended by Infection Prevention and this team is focusing on the reducing use of fluoroquinolones which appears to be declining. In support of Infection Control recommendations, fecal microbiota transplantation for high risk patients with CDI was implemented.

79 Addendum C

Procedure Review IP’s worked to update and maintain all Infection Control Procedures in Lucidoc. IC reviewed nineteen procedures and collaborated with other departments who have procedures that relate to infection control.

Centers for Disease Control (CDC) National Healthcare Safety Network NHSN 2015 Re-baseline (benchmark)

Palomar Health is obligated to participate with CDC NHSN database and follow the established protocols and definitions for reporting infections. Protocols include baseline comparison to 2008 national data. For the purpose of this report the 2008 national database are used to enable comparison.

“Re-baseline” is a term that CDC’s National Healthcare Safety Network (NHSN) staff is using to describe updates to 2008 Healthcare Associated Infection (HAI) benchmarks. The 2015, re- baseline updates around the source of aggregate data and the risk adjustment methodology were used to create the new baselines. Risk adjustment refers to the processes used to account for the differences in risk that may impact the number of infections reported by a hospital, such as type of patient care location, bed size of the hospital or patient age. When the data are risk- adjusted, it makes it possible to fairly compare hospital performance. HAI prevention progress will be measured in comparison to infection data reported to NHSN using updated risk- adjustment models beginning January 2017.

References 1. The Direct Medical Costs of Healthcare-Associated Infection in U.S. Hospitals and the Benefits of Prevention R. Douglas Scott II, Economist Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention March 2009 2. Dudeck, MA., et al., 2013. National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. American Journal of Infection Control 41 (2013) 1148-66. 3. CDC, 2016. National and State Healthcare Associated Infections Progress Report (2014 data).

ADDENDUM D

81 Addendum D

2017 Infection Control Risk Assessment and Plan

BACKGROUND Palomar Health conducts an annual risk assessment and plan. The risk assessment and plan are a living document, is updated with any significant changes and forms the foundation of a comprehensive program. The risk assessment provides a basis for infection surveillance, prevention and control activities, identifies at-risk populations/procedures in Palomar Health facilities, assists in focusing surveillance efforts toward targeted goals, and aids in meeting regulatory and other requirements. Of note, Villa Pomerado and Home Health conduct a risk assessment and plan related to their patient population and is approved through the Infection Prevention and Control Committee.

Palomar Health is the largest hospital District in California and covers 850 square miles in San Diego. The communities we serve are regulated by California Public Health Department (CDPH) and requirements for reporting transmissible diseases are followed. Reporting Healthcare Associated Infections (HAI) is accomplished through the Centers for Disease Control (CDC) National Patient Safety Network (NHSN). Syndromic Surveillance and County Influenza data are produced by the San Diego County Public Health Department and monitored by Palomar Health Infection Preventionists for trends. These are reviewed by the Infection Prevention and Control Committee (IPCC) on a monthly basis and recommendations are made for Risk Assessment and Plan revisions. Palomar Health Infection Preventionists collaborate with the County through attendance at the monthly County Epidemiology Current Issues (CECI) to assess trends and recommend action planning as indicated.

Routine campus surveillance activities include, but not limited to, Infection Control and Environment of Care rounds. Findings are summarized and provide direction for the focus of the Infection Control Plan. Infection Control Surveillance for HAI’s is a necessary part of the organization’s Infection Prevention and Control planning. Data is compiled and used to identify opportunities for improvement and a focus for the plan.

The care, treatment, and services provided at Palomar Health consist of three medical centers, a skilled nursing facility and several satellite programs. Palomar Medical Center (PMC) Downtown Escondido has 350 licensed beds and serves as an Acute Rehabilitation center, Inpatient Psychiatric Unit and a Crisis Stabilization Unit. Other services include radiation therapy, infusion therapy, and microbiology. PMC Escondido has 288 licensed beds and provides emergent (annual 101,724 visits) and inpatient intensive care, medical/surgical, pulmonary, level II trauma, oncology, neurology, interventional /surgical platform, and mother/baby care. PMC Escondido offers NICU services through Rady Children’s Hospital. In addition, there are diagnostic services, clinical and non-clinical support services. PMC Poway has 107 licensed beds and provides emergent (annual 33,336 visits) and inpatient intensive care, mother baby and NICU II, and surgical/medical/telemetry services. In addition, there are diagnostic services, clinical and non-clinical support services. There are pharmacy locations at each campus and an outpatient pharmacy at PMC Escondido. There is a Peripherally Inserted Central Venous Catheter (PICC) team supports inpatient locations throughout the system. Palomar Health is accredited by The Joint Commission disease specific certification in Diabetes and Stroke care. Villa Pomerado is a skilled facility located adjacent to PMC Poway. This 129 bed facility offers long term care, subacute unit, rehabilitation, respite and hospice care.

Satellite Services at Palomar Health include Corporate and Employee Health Services, Wound Care, Expresscare Clinics, Cardiac Rehabilitation, Outpatient Rehabilitation, Perinatology, Home Health, and Outpatient Behavioral Health.

82 Addendum D

SCOPE OF ASSESSMENT This risk assessment is Palomar Health System-wide in scope. An Infection Control Risk Assessment (ICRA for Villa Pomerado and Home Health is developed by the respective Infection Control Liaisons and approved by the Infection Prevention and Control Committee (IPCC).

PROCESS The risk analysis is conducted and reviewed at least annually and whenever there is a significant change. The assessment is facilitated by the Infection Prevention and Control Department and presented to the IPCC for review, input and approval. Once risks are identified, Palomar Health prioritizes those risks that are of epidemiological significance. Certain risks are automatically prioritized based on their nature, scope, and impact on the care, treatment, and services provided. These risks are outlined in this document. Specific strategies are developed and implemented to address the prioritized risks. These strategies may take the form of policy and procedure establishment, surveillance and monitoring activities, education and training programs, environmental and engineering controls, or combinations thereof. Strategies may differ in approach, from, scope, application, and/or duration depending on the specific risk issue, the care setting(s), and environment involved.

ASSESSMENT FINDINGS / MITIGATION STRATEGIES The table below outlines the prioritized risks identified as the result of the assessment; provides a brief description of those risks, assigns a risk level (low, medium, or high) based on the care setting, outlines – in summary form – actions that have been or will be taken by the organization to address the risks, and how the organization will evaluate the effectiveness of actions taken:

RISK ASSESSMENT / MITIGATION STRATEGIES The table below outlines the prioritized risks identified as the result of the assessment; provides a brief description of those risks, assigns a risk level (low, medium, or high) based on the care setting, outlines – in summary form – actions that have been or will be taken by the organization to address the risks, and how the organization will evaluate the effectiveness of actions taken:

Prioritized Risk Care Setting / Summary of Risk How Effectiveness of Description Risk Level Mitigation Strategies Strategies is Evaluated (See legend) I A O Transmission of infection through H H H Hand hygiene Alcohol gel purchase potential non-compliance to CDC procedures follow CDC data guidelines and recommendations guidance for hand hygiene Staff education initial Observation data. and at least annually Staff on safety collaborative Observation Data shared at department level Availability of alcohol gel Availability of hospital approved hand lotions

Unprotected exposure to pathogens M L L Staff education (initial Staff education records throughout the organization and annual) Exposure report

83 Addendum D

through potential non-compliance Blood borne pathogen MDRO process with policies addressing category / exposure control plan measures disease specific isolation and other Aerosol Transmissible Influenza Vaccination precautions. Diseases Control/TB data control plan Isolation report Cough etiquette MRSA screening program compliance Visitation procedure PPE storage and availability IC Isolation list/rounds Influenza vaccination program Immunity verification MDRO flags in EMR Patient education MRSA screening and testing

Potential for transmission of M M M Disinfection and Environment of Care infection related to procedures, Sterilization procedures Rounds medical equipment, and medical using manufacturer’s BI and sterilization devices related to appropriate Information for Use compliance reporting storage, cleaning, disinfection, (IFU) and CDC guidance HLD compliance sterilization, reuse and/or disposal - Spaulding reporting of supplies and equipment, as well Classification IUSS compliance as use of personal protective Sorin Cleaning Quality monitoring equipment. Assessment and surveillance Data submission to VIP Classification system team Value Improvement IUSS % reporting Process (VIP) Team Sure Step process Education/competency report Dialysis cultures Xenex/Glow Germ High level disinfection Report (HLD) logs, rounding Surveillance data and reporting Immediate use steam sterilization (IUSS) monitoring Biological Indicator monitoring (BI) Intradepartmental sterilizations surveys EVS cleaning observation audits Equipment cleaning procedures Conveniently located Germicide wipes Oxycide with C. difficile

84 Addendum D

claim Staff awareness of wet contact times Xenex U/V disinfection Clean and dirty transport procedures Sure Step – Endoscopy Glow germ – EVS Annual Linen Plant tour Potential for infection in ambulatory L H M Cough Etiquette Exposure Reports care and outpatient settings due to stations located at potential prolonged wait times in entries of ED, hospital common areas and potential lobby, and satellite exposure to infectious individuals. services waiting areas. Patients discouraged from OP visits when ill Community-wide outbreaks of M M M Emerging Infectious Disaster Committee communicable diseases that carry Disease awareness and and IPCC agenda and the potential of adversely impacting education. minutes operations and service capabilities Emergency Department Drills and tabletop (ED) travel screening. exercises and debriefs Positive Air Purifying Surveillance Data Respirator (PAPR) inventory County Cache Disaster and Surge Plan Syndromic Surveillance Initial and annual training Annual Hazard Vulnerability Analysis Long Term Care Risk Assessment and Enhanced Standard Precautions California Healthcare Alert Network

Potential for a bioterrorism event L L L PAPR inventory Disaster Committee that would require specific County Cache Hazard Vulnerability responses from the organization to Disaster and Surge Plan successfully meet the threat. Decontamination Procedures Initial and annual training

Emergency Preparedness Infectious L L L Disaster Committee Annual Hazard Disease Suspect encounter (novel Staff education Vulnerability and epidemic), naturally occurring Management of influx Assessment events including; earthquakes, fires of infectious patients Disaster and IPCC and drought and boil water alerts Erecting isolation minutes

85 Addendum D

are the top priority followed by an barriers including epidemic. Human related events appropriate PPE such as mass casualty (medical or Disaster plan infectious). IC procedures Disaster drills Supply chain – VIP attendance

MRSA bloodstream infection (BSI) H M L Hand Hygiene - CDC MDRO Process Standard and Measures Transmission Based MRSA Screening Precautions Compliance Cart and sign system MRSA BSI SIR NHSN Reflex isolation orders Antibiotic utilization Rounding reports Glow germ Cerner Medical Record reports flagging Pet therapy attestation Antibiotic Stewardship records Review of PICC line Antibiograms indications for antibiotics TPN procedure review MRSA Screening CHG bathing ICU Selected surgical procedures of Pre-op CHG bathing

Glow germ audits Certified Pet therapy Program

VRE BSI L L L Standard and MDRO Process Transmission Based Measures Precautions VRE BSI SIR NHSN Cart and signs system Antibiotic Utilization Reflex isolation orders Reports Rounding Glow germ reports Cerner Medical Record Antibiograms and flagging monitoring of specific Antibiotic Stewardship combinations Hand hygiene – CDC Glow germ audits Reduction in usage combined anti- anaerobic agents (BLIC and metronidazole- clindamicin)

Clostridium difficile infection M L L Standard and MDRO Process Transmission Based Measures CDI SIR NHSN

86 Addendum D

Precautions Antibiotic Utilization Reports Reflex isolation orders Glow germ reports Rounding Xenex Utilization Antibiotic Stewardship Fluoroquinolone usage with specific focus on PPI usage usage of fluoroquinolones Acid suppressive therapy reduction (PPI) Rectal tubes for incontinence Fecal microbiota transplant Xenex UV Disinfection Stool collection procedures Daily Huddle case reporting Changes to microbiology result interpretation and reflexing Glow Germ audits Automated triggers in EMR Medical staff education, “Guidance to Providers”

Carbapenem-resistant L L L Standard and MDRO Process Enterobacteriaceae (CRE) Transmission Based Measures Precautions CRE incidence Reflex isolation orders Antibiogram Rounding Endo round results Antibiotic Stewardship Channel check logs Control of carbapenem NHSN analysis reports usage Antibiotic Utilization – Rectal tubes for carbapenem Reports incontinence Glow germ reports Xenex UV Disinfection Xenex Utilization Glow Germ Automated triggers in EMR Endoscope Hang time risk assessment Channel Check and quality review of HLD process. Double disinfection of endoscopes.

87 Addendum D

Central Line Infections (CLABSI) H L L AllPoints Training CLIP compliance Unit Based Champions AllPoints Training ICU participation in attendance AHRQ CLABSI reduction CLABSI SIR NHSN initiative PMC ESC Nursing Skills Day Central Line Insertion topics Practices (CLIP) TPN practice in pharmacy Ventilator Assisted Pneumonia L L L VAP bundle compliance VAP bundle Data (VAP) VAP surveillance VAP SIR NHSN Oral Care with CHG

Catheter Associated UTI’s (CAUTI) M L L CAUTI Bundle CAUTI bundle Data compliance CAUTI SIR NHSN CAUTI Surveillance ICU participation in AHRQ CAUTI reduction initiative PMC ESC

Surgical Site Infections overall (SSI) M M L CHG bathing Surgical Site Infection Decolonization with 3M SIR NHSN product SCIP recommendations Weight based Antibiotic dose Sorin Heater Cooler procedures Rounding Timely prophylactic antibiotic administration

Colon SSI H L L Colon Bundle initiative Surgical Site Infection SIR NSHN Hysterectomy SSI L L L

Caesarian Section SSI M L L CHG bathing Surgical Site Infection Case Observations SIR NHSN Stakeholder review of cases Orthopedic and spine SSI H L L Pre-op CHG Surgical Site Infection bathing/3M nasal SIR NHSN decolonization Case Observations Stakeholder review of cases

88 Addendum D

Legend* I = Inpatient services such as medical surgical, critical care, maternal / child, surgery, behavioral health, and other care units A = Ambulatory care services such as outpatient surgery, procedural and diagnostic services, and the Emergency Department O = Outpatient services such as primary and specialty care clinics, wellness centers, infusion centers, rehabilitation clinics, and other services H = Home health, hospice, home pharmacy, DME, and other home health services L = Long-term care, sub-acute care, skilled nursing, and other long term care services.

* For each setting, the risk assessment also takes into account - as applicable - support services such as facilities, environmental services, materials management, sterile supply and processing, dietary, clinical laboratory, and all other departments and services of the organization.

Allocation – Enter the Level of Assessed Risk for Each Care Setting: L = Low risk M = Medium Risk H = High Risk

89 Addendum D

Surveillance Plan 2017

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Score Risk Population Reporting Analysis Activity “M” (Indicator)

Hand Hygiene System: Adherence to CDC Inpatient and IC Committee, Percent CDPH, CMS (HH) CDC Hand Hygiene ED Stakeholder compliance: and Joint 90% recommendations committees and Commission High Risk Compliance Expand to departments at least Before and mandatory to Triclosan soap outpatient after quarterly have a Hand alcohol based hand services patient/environ Hygiene Facility: sanitizer mental contact program To improve Conveniently Discipline located dispensers HH rate from Patient care 2016. Working group for task Expand to stakeholders to outpatient provide what is services going well and identify what can be improved

Case Finding Methodology:

(#compliant / #observations) x 100 – Health Care providers are observed by a “secret shoppers” who are assigned to different units. Data is presented by unit and by discipline to various medical and other committees.

90 Addendum D

SCIP Colorectal Enter procedures Surgical Site System: recommendations Hip Prosthesis by ICD10 SIR 2017 NHSN CDPH Infections (SSI) Knee Prosthesis Mandatory definition mandatory for for CDPH Eliminate 26 surgical SSIs Evidence based Fusion requirement by targeted 25 practices for joint Re-fusion CDPH and CMS. procedures surgical Facility: replacement Laminectomy Data downloaded CMS procedures Fracture for internal SSI SIR mandatory Colorectal and HICPAC Guideline Abdominal dissemination. Hysterectomy reduction on Prevention of Hysterectomy IC Committee and Orthopedic/ and maintain and Colon Spine SSIs Vaginal other stakeholder below 0.5 Hysterectomy committees and High Risk SIR in all Surgical Attire Ovary departments at procedures C-section least quarterly Departmental AAA Graphic rounding CABG presentation and with/without line listings shared Disinfection and donor site with medical Sterilization Cardiac director of standards; AORN, Pacemaker Ortho/Spine COE AAMI, ANSI, CDC Thoracic Biliary Rectal Appy Chole Small bowel Neph Spleen Gastric

Case Finding Methodology:

Infections identified through a microbiology cultures, antibiotics prescribed, readmissions, reports from surgeons, and diagnosis codes. NHSN criteria used. Electronic medical record review. Post discharge surveillance by PH Home Health.

Central Line- System: CLIP form Patients with Participation in CDC Standardized CMS and Associated CVC’s ICU National Healthcare Infection Ratio CDPH Blood Stream Eliminate HRET CLABSI CAUTI Med/Surg, Safety Network (SIR) = mandatory for Infections CLABSIs prevention adult, and (NHSN) ICU and all NICU # of infections inpatient High Risk Minimize the use of Mandatory Central Venous # of predicted units. Facility: requirement by CDPH Catheters (CVC) by and CMS. using only when 2017 NHSN Reduce definitions CLABSI SIR indicated Designated internal CDPH

91 Addendum D

from 2015 CHG impregnated committees (at least NHSN analysis mandatory patch quarterly) reports CLIP entry into NHSN. Care and stakeholders when Line lists maintenance identified assessment CLIP data analysis Unit based champions, skills day requirement

CVC dressing kits

CLABSI Case Finding Methodology: Discern analysis. Infections identified through prospective and retrospective review of blood cultures and Electronic Medical Record (EMR). When case meets NSHN definition for CLABSI the case it is entered into NHSN database.

Hand Hygiene CDC Hospital Onset System: Patients with Enter MRSA, VRE, CDI Incidence and CMS and (HO) MDROs Evidence-based MRSA and data into NHSN prevalence as CDPH MRSA, VRE, VRE BSI, CRE calculated by mandatory MRSA BSI C. difficile practice strategies Mandatory using APIC, HICPAC clinical culture NHSN reporting all HO <0.5 SIR and CDI requirement by CDPH inpatient CDI, High Risk AORN AAMI, ANSI, and CMS. Hand hygiene SGNA and MRSA VRE BSI C. difficile data and VRE BSI HO <0.50 SIR Lab reports to IC all Low Risk Targeted UV light CRE - critical results MDRO process Maintain disinfection measure C. difficile zero CRE HO Data downloaded for compliance Infection cases EVS cleaning internal practices dissemination. Departmental Medium Risk Facility: HLD compliance Line List CRE cases all reports CRE Reduce Channel Check clinical cultures MDRO rates Endoscopy quality Channel Check Low Risk from 2016 marker IC Committee and results other stakeholder

Risk assessment for committees and endoscope hang departments at least time (7 days) quarterly

HLD rounding

Glow germ or ATP

Case Finding Methodology:

Review of cultures and PCR screens, positive isolates, clinical records, and definitions for healthcare onset from NHSN surveillance definitions. July 2015 “Go live” with Cerner Infection Control data mining module. This has enhanced case finding and improved inefficiencies in data mining.

92 Addendum D

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Score Risk Population Reporting Analysis Activity “M” (Indicator)

Established Catheter System: Indications Patients with CDC NHSN CAUTI SIR 2017 NHSN CMS Associated- IC catheter urinary definition mandatory for Urinary Tract Eliminate catheters (ICU Unit based case ICU and all CAUTI CAUTI Bundle review NHSN analysis Infections Bladder scanner and adult inpatient units Med/Surg) reports Medium Risk Facility: Nurse Driven Designated internal Protocol committees (at least Line lists Reduce Female alternatives quarterly) CAUTI SIR Foley Assessments CAUTI Bundle from 2016 HRET CAUTI/CLABSI stakeholders when identified Discern analysis

CAUTI Case Finding Methodology:

1. Discern analysis. Prospective and retrospective culture and EMR review. When case meets NSHN definition for CAUTI the case it is entered into NHSN database.

Ventilator- System: Bundle measures All adult (>18 CDC NHSN (not in SIR 2017 NHSN Not Associated and compliance on yrs.) plan) definition Mandatory Events Eliminate all ventilated ventilated IVAC Plus patients patients Identify and report NHSN analysis Low Risk IVAC Plus reports Facility: CHG oral care Designated internal Line lists IVAC Plus SIR Daily assessment of committees (at least below 0.5 ventilator necessity quarterly) Bundle and weaning compliance Stakeholders when identified

Not publically reportable

IVAC Plus Case Finding Methodology:

Charge viewer identifies ventilated patients. Infections are identified through review of positive respiratory and blood cultures, antimicrobial use, radiologic exam, clinical record, FiO2, and PEEP. CDC NHSN VAE calculator.

93 Addendum D

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Score Risk Population Reporting Analysis Activity “M” (Indicator)

Record Review Unusual Review all Water sampling Inpatients Line listing Line listing CDC Organisms unusual Look back recommendat organism Construction ICRA Reporting per CDPH ions Low Risk CMR including but Routine culture not limited review to:

Aspergillus Legionella

Case Finding Methodology:

Discern analysis. Routine culture review and culture look back.

Influenza Achieve Continue All clinical and Enter data into NHSN Compliance CDPH and Vaccination >95% mandatory mask non-clinical rate is CMS acceptance program employees, IC Committee and calculated by mandatory Medium Risk of influenza volunteers, other stakeholder number of staff, Influenza Vaccine committees and vaccination physicians, MDs, students, Campaign students, departments residents, etc. beginning in contractors, divided by 100 September working in the for % facility for at compliance. least one day during the influenza season.

Employee Health oversight with Infection Control collaboration. Employee Health collaboration with medical staff to improve process for data collection.

94 Addendum D

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Score Risk Population Reporting Analysis Activity “M” (Indicator)

Sharps/ Blood Reduce the Education safe All OSHA Log # needle sticks CDPH, CMS, borne number of needle practices, employees, and Cal OSHA Pathogen needle sticks use of PPE/proper volunteers, Employee Health Log #blood/body mandatory to fluid exposures (BBP) and blood disposal physicians, IC Committee and have a BBP Exposures borne surgeons, plan PPE readily other stakeholder pathogen residents, committees and Medium Risk exposures available for medical immediate use departments at least from 2016 students and quarterly Report anyone injuries/exposures working in the during daily huddle facility

Encourage correct PPE during splash- producing procedures

Case Finding Methodology:

All exposures reported through Employee Health with appropriate follow up.

Tuberculosis Reduce the Evaluate patient Inpatients Employee Health Log # Actual TB OSHA Exposures number TB risk on case by case Outpatients exposures mandate Exposures basis. Prolong IC Committee and Medium Risk compared isolation other stakeholder with 2016 precautions even if committees and data AFB negative x3 in departments at least high risk patients. quarterly

Case Finding Methodology:

All exposures reported through Employee Health with appropriate follow up.

Environmental 100% IC rounding: Inpatients Sentact Reports Percent CMS CDPH Surveillance participation Outpatients compliance in EOC EOC EOC committee with rounding USP 797 Medium Risk rounding HLD observations Pharmacy IP/OP IC committee Improved USP 979 garbing Pharmacy culture Third party outcomes in Environmental air results vendor, Sentact quality testing in environmental Reports pharmacy testing compounding area

95 Addendum D

EVS Observations Surgical Services FANS Gift Shop Dialysis Linen Plant Tours Satellite Services

PH Strategies to Reduce and Eliminate Infection Risk

Strategies Description Plan

A. Environmental  Participate in monthly  Environmental Rounds The Infection Preventionist (IP) environmental rounds with participates in environmental other facility team members rounds with other facility team members to assess patient and environmental safety and quality.

 Continue testing per existing  Dialysis Testing Water used to prepare dialysis requirements and guidelines. solutions must meet AAMI Standards for hemodialysis water quality. Total viable bacterial counts in water used to prepare dialysate or to reprocess hemodialyzers should not exceed 2000 cfu/ml. Total viable count for dialysate should not exceed 200 cfu/ml. Chemical monitoring of treated water should be done at least annually if RO or deionizers are used, and more often if other treatment methods are used.

 Continue autoclave testing per  Sterilizer Testing Sterilizer testing is done in existing requirements and accordance with IFU, AORN, AAMI guidelines. and CDC recommendations.

The Infection Preventionist  Periodic water testing.  Water System Testing collaborates with the Facility Plant  All test results are presented to Operations team regarding facility the IC Committee on a regular waterborne pathogen prevention basis. If results are out of strategies. acceptable range, a plan of correction is created.

96 Addendum D

Strategies Description Plan

B. Construction  Work with the construction An Infection Control Risk team prior to work to Assessment (ICRA) is completed on determine infection control areas for renovation or new risks via the ICRA. Attend pre- construction in the facility. The con meetings as needed. ICRA determines which barriers and  Continue monitoring hospital- practices, air monitoring wide construction activities. precautions, negative pressure  Aspergillus surveillance monitoring (HEPA), patient placement, and cleanup are required to eliminate and/or reduce dust and debris during construction.

C. CDC Recommendations for  Outpatient IP rounding at least Outpatient Settings Assess compliance with CDC annually and as needed. Guidelines in PH Outpatient areas.  Continued education following Areas assessed: Expresscare, CDC Ambulatory Care Guide Corporate Health, Outpatient  Site leadership to address any Rehab, Wound Care, and issues noted, with IP follow up. Outpatient Behavioral Health.

D. Outbreak Management  A full scale investigation will be An outbreak is described as the conducted in the event of a sudden occurrence or increase of suspected outbreak using sound infectious and non-infectious epidemiological principles as diseases and conditions. The outlined in the Outbreak Infection Prevention and Control Investigation Procedure. team investigates potential  Work in consultation with outbreaks to identify the source County Epidemiology for and/or likely cause of infections. In direction and support. addition the team investigates patients who have pathogens with high transmission potential to assure that control measures appropriate to the pathogen have been instituted. In circumstances where a significant potential for transmission of an infectious pathogen from either a patient or employee has been identified, the Infection Prevention team works closely with the Employee Health Program to identify both patients and employees who may be at risk for disease acquisition and to intervene as appropriate to the circumstance.

97 Addendum D

Strategies Description Plan

E. Infection Control  Continue procedure review Procedures Infection Control procedures are every three years and as based on State and Nationally necessary. recognized guidelines and  Procedures will reflect current applicable laws and regulations. accepted and approved The procedures address the Infection Prevention practices prevention of infection based on regulatory transmission among patients, recommendations, standards, employees, visitors, and and guidelines. environmental issues. Procedures are reviewed and approved within three years and/or as needed based on regulatory recommendations and guidelines.

IC Risk Assessment/Plan, Blood borne pathogen, and Tuberculosis Control are reviewed annually.

F. Facilitate Health Care  Potential cases will be referred Associated (HAI) case Facilitate and/or participate in to Quality/Risk Management review or other infection review of identified cases of and IC Medical Director to related processes requiring unanticipated deaths or major initiate the review process. RCA and/or FMEA review. permanent loss of function associated with a healthcare associated infection.

G. Communication Communication regarding the Hospital Level – Data Provided Infection Prevention and Control Program is ongoing.  Leadership – monthly leadership Communication between local and meeting regional health care organizations  Physician committees and offers opportunities for early physician newsletter identification of infections.  Staff – reports to managers responsible for sharing with staff  Students and Volunteers – IC orientation Communication to County  Staff education - unit in- Epidemiology and TB control is services, orientation, fact ongoing and is required for sheets, 5-minute updates and specified circumstances. Huddle Highlights  IP rounding on units  New Leader Employee Orientation

98 Addendum D

Strategies Description Plan

Community Level

 Between hospitals (referring hospital will be notified when an infection is identified in transferred patient)  Public Health Departments – reportable diseases  Local IC Chapter meeting – monthly  Health Department/ hospital meetings H. Education  Staff: new employee and Leader Infection prevention education is orientation, nursing orientation, provided to employees at hire and huddles updates annually as required based on job  LIPs: newsletters description. Additionally, education  Patients, visitors, families: fact is provided to LIPs, patients, sheets, signage visitors, and families.

I. Influx/Surge of Potentially Infectious Patients The Infection Preventionist Refer to PH Disaster Plans participates in the facility plan, response, and recovery of activities related to the influx of infectious patients and other emergency situations. J. Data Analysis  All data collected for infection Case definitions for healthcare control should be presented in a associated infections shall be those rate/ratio based format for developed, adopted and published clarity and comparison by the National Healthcare Safety purposes. For data that have Network (NHSN), unless another established bench-marks, i.e., authority dictates otherwise. NHSN, these shall be used.  For data that are in the NHSN system and have an available standardized infection ratio (SIR), these shall be used for comparisons and for presentation as part of the Quality Assurance and Performance Improvement program. K. Cleaning of Medical  A system for the cleaning of Equipment, Supplies and The Infection Preventionist medical equipment will be Devices collaborates with hospital implemented that assures departments and the Environment equipment is cleaned on a of Care Committee to assure that a routine basis. The cleaning system for the cleaning of medical process must be in accordance

99 Addendum D

Strategies Description Plan

equipment, devices, supplies and with the manufacturer’s supply rooms is implemented. recommendations.  Germicidal Sani-cloths and Surgical services and IP perform sodium hypochlorite wipes will audits of HLD and sterilization be available in areas where processes and report to IC medical equipment is handled committee. and cleaned.  “Wet Contact Time” is defined and will be used during the cleaning process.  IPs will work with EVS to assure supply closets are cleaned and work with Pharmacy, Materials Management and other departments to assure supply bins are cleaned.  If the facility is reprocessing single use items with a selected vendor – the items will be placed in the appropriately labeled containers provided by the company and follows all reprocessing guidelines.  A monitoring system is implemented to assure compliance with cleaning of medical equipment, devices and supplies. L. Facility Response to a  Notification chain established. recognized exposure event In the event of a sterilization or  Determine if any instruments involving reusable medical high level disinfection failure have been used for patient care devices. Palomar Health has a plan to identify potentially exposed  Responsibility defined: patients, facilitate patient contact,  Infection Prevention and Control document all follow up and retain will: records, and systematically provide o Define exposure appropriate testing and result o Identify patients at risk notification. o Maintain list of patient and procedure including date performed o Review patient records as indicated for exposure follow up.  Risk Manager and/or VP Patient Experience will: o Establish a call center

100 Addendum D

Strategies Description Plan

as needed o Arrange for appropriate laboratory testing  Call Center will: o Maintain patient log o Other duties as assigned  The Vice President, Patient Experience will: o Answer medical questions o Provide physician order for testing  Marketing will: o Provide a statement for community awareness as needed  Patient notification of results established process.

M. Injection Safety Prevent transmission of bloodborne  CDPH one and only campaign viruses to patients. materials posted in high risk areas.  Champion MD  Provide CME  Glucometer cleaning as focus of Environment of Care rounds.  Assess areas where medications are drawn up and provide visual ques.

101