Joint Commission Preparation: Tip of the Week

University of Maryland Shore Regional Health’s Infection Control Plan

The risk of development of a healthcare-associated infection (HAI) is minimized through a hospital-wide infection control program. The purpose of the infection control program at University of Maryland Shore Regional Health (UM SRH) is to influence, support and improve the quality of healthcare through the practice and management of infection prevention/control and the application of epidemiology in health settings. The mission of the UM SRH infection control program is to improve health and patient safety by reducing risks of infection and other adverse outcomes.

The primary goal of the organization-wide infection control program is to identify, prevent, and reduce risks of endemic and epidemic healthcare-associated infection in patients, employees, physicians and other licensed independent practitioners, contract service workers, volunteers, students and visitors and to ensure optimal operation of the health care facility by:

  • Preventing Infections
  • Identifying organisms of epidemiological importance coming into the hospital
  • Intervening directly to interrupt the transmission of infectious diseases; and
  • Educating and training healthcare workers and providers.

A Risk Assessment is conducted annually by the Infection Prevention & Control Committee and priorities identified. New risks or priorities are identified through surveillance monitoring and review of performance improvement indicators. Current prevention priorities include reduction of C. diff and urinary catheter associated UTI (CAUTI) rates

Key prevention strategies for C. diff include:

  • Increase hand hygiene performance
  • Optimize environmental cleaning using a Oxycide in all isolation rooms
  • Test only patients with unexplained new onset diarrhea ( 3 or more stools in 24 hours)
  • Do not test patients unless they have one of the following symptoms: abdominal pain, fever or leukocytosis
  • Prompt initiation and adherence to Contact Precautions
  • Appropriate use of antimicrobials (UM SRH has an active antimicrobial stewardship program led by Tawes Harper, PharmD, BCPS, BCCCP

Key prevention strategies for CAUTI:

  • Avoid unnecessary catheter use: insert for appropriate reasons
  • Consider alternatives to an indwelling catheter: intermittent or external catheters
  • Assess the need for a catheter daily and remove as soon as possible
  • Insertion performed by trained RNs or Techs
  • Never collect a urine culture specimen from the catheter bag
  • Perform optimum routine catheter management:
    • Maintain a closed system without kinks or loops; replace if there are breaks in the closed system
    • Use securement device
    • Perform daily perineal care

Questions? Reach out to your Infection Prevention Team: Julie Bryan, 410-463-085; Amy Stafford, 410-310-5513; Donna Saunders, 410-810-5672