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Qmentum Program

STANDARDS

Infection Prevention and Control

Accredited by ISQua
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Qmentum Program

Published by Accreditation Canada. All rights reserved. No part of this publication may be
reproduced, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without proper written permission from Accreditation
Canada.
Accreditation Canada, 2009
Infection Prevention and Control
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Qmentum Program

Accreditation Canadas Standards for Infection Prevention and Control (IPAC) build on previous Accreditation
Canada infection prevention and control standards. They are based on updated research and best practice in
the field, as well as standards from the Canadian Standards Association (CSA), the Public Health Agency of
Canada (PHAC), and the Community and Hospital Infection Control Association-Canada (CHICA-Canada),
Accreditation Canada extends its appreciation to to these organizations for their support and contributions.
These IPAC standards include structure, process, and outcome performance measures to promote assessment
of organizational compliance against standards of excellence, Required Organizational Practices (ROPs), and
indicators. They are flexible enough to apply to large and complex health systems as well as to small
organizations such as those outside acute care including home care and long term care, and they include the
client perspective. Front-line staff and service providers who often carry primary responsibility for preventing
and controlling infections may find these standards particularly valuable.
The standards are divided into four subsections:

Investing in infection prevention and control


Keeping people safe from infections
Providing a safe and suitable environment
Being prepared for outbreaks and pandemics

To complement these standards, a more detailed supplement addressing processes for sterilizatiion of
equipment and medical devices, based on CSAs standards, is available to organizations with sterilization or
reprocessing units. The supplement provides organizations with an opportunity to conduct a highly-specific, indepth evaluation of sterilization processes and outcomes.

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Infection Prevention and Control


INVESTING IN INFECTION PREVENTION AND CONTROL
1.0

The organization monitors trends in infections.


1.1

Efficiency

The organization allocates resources to track infections.


Guidelines
Resources may be human, financial, and informational. The organization identifies the
resources it needs to track infections, and works to obtain the necessary resources.
The organization relies on expertise from service providers, epidemiologists, infection
prevention and control professionals (ICP), and the microbiology laboratory, to identify
and study healthcare-associated infection rates, and to detect outbreaks. Large
microbiology laboratories are playing a growing role in infection prevention and control
surveillance by, for example, identifying new or rare infections, tracking antibiotic-resistant
organisms (AROs) such as methicillin-resistant Staphylococcus aureus (MRSA) or
vancomycin-resistant Enterococcus (VRE), and identifying clusters or trends.
The microbiology laboratory supports the organization in identifying infections by ensuring
timely access to laboratory analyses, including same-day turnaround for high-risk
infections such as C. Difficile.

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ROP
Effectiveness

1.2

REQUIRED ORGANIZATIONAL PRACTICE: The organization tracks infection


rates, analyzes the information to identify clusters, outbreaks, and trends, and
shares this information throughout the organization.
Guidelines
Tracking methods may focus on a particular disease or service area, or may be
organization- or system-wide. They may include virtual surveillance and data analysis
techniques to help detect previously unrecognized outbreaks.
The most common healthcare-associated infections include infections from viruses such
as influenza A and Norwalk; urinary tract infections, often related to the use and care of
urinary catheters; surgical site infections; bloodstream infections in particular from the use
and care of vascular access lines; postoperative pneumonia and pneumonia-associated
with respiratory support systems; and antibiotic-associated C. difficile.
The organization identifies the infections and infectious agents most common to their
services and client populations, e.g. child or adult, and tracks these as well as other
reportable disease and antibiotic resistant organisms. The information tracked includes
frequencies and changes in frequencies over time, associated mortality rates, and
attributed costs.
Staff who are well informed about infection rates are usually better equipped to prevent
and manage infections. The organization identifies who is responsible for receiving
information about infections and diseases, e.g. the governing body, senior management,
staff, and service providers, and establishes plans to disseminate information
appropriately and in a regular and timely way, e.g. quarterly reports to all departments.
In addition to staff and service providers, the organization also keeps the governing body
up-to-date about infection rates and associated infection prevention and control issues.
This may be done directly through senior management, or through a Medical Advisory
Committee (MAC).

Test(s) for Compliance


1.2.1

The organization tracks infection rates.

1.2.2

Staff and service providers know the infection rates.

1.2.3

The organization provides quarterly updates on infection rates.

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I
Safety

1.3

INDICATOR: Surgical Site Infection.


Guidelines
The organization selects procedures for which surgical site infection must be tracked,
based on highest risk, highest volume, or both. Recommended procedures include
cardiac surgery, colorectal surgery, hysterectomy, C-section, total joint arthroplasty,
craniotomy, CSF shunts, and spinal surgery.
The procedures to be tracked for rates of post-surgical infections do not need to be the
same as the procedures identified for prophylactic antibiotic administration. However, it
may be more efficient to collect data on both performance measures for the same
procedure. If organizations choose to track both, then the eligible list of surgical
procedures would be those procedures where preoperative antibiotic prophylaxis is
indicated.
Threshold information: Targets for each indicator are established based on literature
reviews and input from experts, as well as a comparative analysis of accreditation data
collected by Accreditation Canada, which allows organizations to be compared with
similar (peer) organizations.

Indicator Information
1.3.1

The organization tracks Accreditation Canadas patient safety indicators


for surgical site infection.

1.3.2

The team does not have any unaddressed priority for action flags based
on their rate of post-surgical infections indicator results.

1.3.3

The team does not have any unaddressed priority for action flags based
on their rate of timely administration of prophylactic antibiotics indicator
results.

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1.4

INDICATOR: Healthcare-associated (Nosocomial) Infection.


Guidelines
C. difficile infection is determined by positive toxin assays for C. difficile, plus symptoms
(diarrhea, abdominal pain), or endoscopic diagnosis with classic mucousal changes.
Symptoms occur = 3 days post-admission or cause readmission in a client who was
discharged from same hospital or another hospital within two months of the current
admission date, and who is not resident in a chronic care hospital or nursing home.
Clients identified as at risk for C. difficile at admission or for whom infection is a relapse or
re-infection are excluded from the calculation.

Safety

MRSA infection is determined by MRSA infection, MRSA colonization, and positive


laboratory based surveillance = 3 days post-admission. Clients with prior known MRSA or
a history of hospital admission, surgery, or dialysis within one year of MRSA culture are
excluded from the calculation. In addition, those who were a resident in long term care
facility within one year of culture or those with an indwelling catheter or medical device
within one year of culture are excluded from the calculation.
Threshold information: Targets for each indicator are established based on literature
reviews and input from experts, as well as a comparative analysis of accreditation data
collected by Accreditation Canada, which allows organizations to be compared with
similar (peer) organizations.

Indicator Information

1.5
Effectiveness

1.4.1

The organization tracks Accreditation Canadas patient safety indicators


for healthcare-associated (nosocomial) infections: MRSA and C. difficile.

1.4.2

The team does not have any unaddressed priority for action flags based
on their rate of healthcare-associated C. difficile (per 1000 client days)
indicator results.

1.4.3

The team does not have any unaddressed priority for action flags based
on their rate of healthcare-associated MRSA (per 1000 client days)
indicator results.

The organization uses standard definitions and accepted statistical techniques to


share and compare information about infections.
Guidelines
Standard definitions are available for many infections. For example, the Centers for
Disease Control and Prevention (CDC) in the United States has published a document on
standardized definitions.
Reporting units are clearly specified to promote comparisons.
Techniques may include statistical methods as well as using epidemiological principles to
identify at risk populations, identify infections, and analyze trends and risk factors.

1.6
Population Focus

The organization shares trends in infections and significant findings with other
organizations, public health agencies, and the community.
Guidelines
Depending on the results of tracking infection rates, the organization determines what
information is shared and in what format. For example, certain diseases or infections
must be reported to public health agencies. The Public Health Agency of Canada
maintains a national surveillance network through which organizations can obtain
surveillance data and participate in benchmarking.

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1.7
Effectiveness

The organization collects information about its infection prevention and control
activities and uses it to plan, implement, and evaluate those activities.
Guidelines
Planning includes identifying the scope of IPAC activities, and the resources needed to
support IPAC activities and achieve the organizations IPAC goals and objectives.
Evaluation includes ongoing monitoring to assess the impact of IPAC activities on
infection rates.

2.0

The organization establishes linkages with other organizations and the community
to improve infection prevention and control.
2.1

Population Focus

The organization creates partnerships with organizations across the continuum of


care, including public health, to communicate infection prevention and control
information and coordinate strategies.
Guidelines
Partners include peer organizations; organizations to which clients are referred and from
which clients are received; community organizations; professional associations, e.g.
CHICA Canada; Occupational Health and Safety bodies; local, provincial or territorial, and
federal governments; and public health agencies. The extent of the organizations
partnerships will depend on its size, mandate, and scope of services.

2.2
Population Focus

The organization collaborates with its partners to engage the community in


infection prevention and control initiatives and activities, including hand hygiene
initiatives, education, and awareness campaigns.
Guidelines
Working with partners may include joint initiatives, complementary roles and
responsibilities in the community, and creating consistent education and communication
messages.

2.3
Effectiveness

Guidelines
The evaluation includes the extent to which the organization, with its partners, is able to
achieve its goals and objectives for infection prevention and control.

3.0

The organization uses research, evidence, and best practice information to improve
infection prevention and control activities.
3.1

Effectiveness

The organization regularly evaluates its partnerships and develops new


partnerships based on gaps, community needs, and emerging trends.

The organization is aware of current issues in infection prevention and control


research.
Guidelines
Current and emerging issues in infection prevention and control research include
cost-effectiveness analyses of infection prevention and control policies and procedures;
effectiveness of specific infection prevention and control practices, such as isolating
clients; challenges in infection prevention and control outside acute care, for example in
home, outpatient, long term care and ambulatory settings; the impact of new materials
and equipment on preventing and controlling infections; best practices for surveillance
and tracking of emerging infections, including antibiotic-resistant organisms; the impact of
new trends in medicine on infection prevention and control, including transgenic therapy,
robotics, massive immune suppression for organ transplant, and xenotransplantation; the
role of housekeeping services in the prevention and control of certain infections;
behaviour change and compliance with infection prevention and control procedures, i.e.
hand hygiene; and overall clinical impact and economic effectiveness of infection
prevention and control practices.

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3.2

The organization shares IPAC research and best practice information with staff
and service providers involved directly in client service, senior management,
partners, and peer organizations.

3.3

The organization uses the latest research and best practice information to develop
IPAC activities, education, policies, and procedures.

Effectiveness

Effectiveness

4.0

The organization develops, implements, and updates infection prevention and


control policies and procedures.
4.1

Effectiveness

The organization develops policies and procedures to address infection


prevention and control issues.
Guidelines
When developing its policies and procedures, the organization considers trends in
diseases and infections in the community; the organizations strategic direction and
objectives; the availability of resources; the services offered by the organization, including
service setting and multiple sites; and scientific research, best practice, and standards of
practice related to infection prevention and control.
Examples of IPAC policies and procedures include an organization-wide hand hygiene
program and additional practices to limit infections including respiratory etiquette
promotion; antibiotic resistant organism (ARO) screening and management programs;
policies about preventing and controlling infections when services are delivered in a home
or community setting; procedures for handling specimens, contaminated equipment,
linen, or devices; policies guiding certain practices, e.g. use of antibiotic prophylaxis in
surgical clients, use of aseptic practices such as sterile barriers when placing central
venous catheters, and invasive device insertion and maintenance protocols; and
procedures on how to identify and report outbreaks to the appropriate public health
authorities.

ROP

4.2

Effectiveness

REQUIRED ORGANIZATIONAL PRACTICE: The organizations policies and


procedures meet international, federal, and provincial or territorial infection control
guidelines.
Guidelines
For instance, federal guidelines are available for Classic Creutzfeldt-Jakob Disease in
Canada, Quick Reference Guide issued by the Public Health Agency of Canada (PHAC)
in 2007. Also in 2007, the World Health Organization released its Guidelines on Hand
Hygiene in Health Care. Provincial guidelines or groups include the Provincial Infectious
Diseases Advisory Committee (PIDAC) in Ontario, the Comit sur les infections
nosocomiales du Qubec (CINQ), and Albertas Provincial Review of Infection Prevention
and Control.

Test(s) for Compliance


4.2.1
4.3
Effectiveness

The organization is aware of and follows evidence-based international,


federal, and provincial or territorial infection control guidelines.

Each policy and procedure includes up-to-date references to research and best
practice in infection prevention and control.
Guidelines
References may be taken from guidelines and standards of practice, or research and best
practice information from publications, presentations, and conferences.

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ROP

4.4

Safety

REQUIRED ORGANIZATIONAL PRACTICE: The organization develops and


implements an organizational policy and procedure to administer the influenza
vaccination.

Test(s) for Compliance


4.4.1

The organization has a policy and procedure for the administration of the
influenza vaccine.

4.4.2

The policy and procedure include identifying populations at increased


risk of complications associated with influenza.

4.4.3

The policy and procedure includes vaccinating staff and service


providers against influenza.

4.5

Each procedure includes clear and concise step-by-step instructions.

4.6

Staff, service providers and volunteers have access to the organizations policies
and procedures in an infection prevention and control manual.

Effectiveness

Accessibility

Guidelines
The manual is available where staff, service providers and volunteers have easy access,
i.e. in the care or service area.

4.7

The organization reviews and updates its policies and procedures at least every
three years, and as new information becomes available.

Effectiveness

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KEEPING PEOPLE SAFE FROM INFECTIONS


5.0

The organization educates and trains staff, service providers and volunteers to
prevent and control infections.
5.1

Safety

The organization develops an IPAC education program that is tailored to the


organization, its services, and client populations.
Guidelines
The IPAC education program covers infection prevention and control policies and
procedures, resources available, contact information for those responsible for IPAC in the
organization, common infections and diseases affecting the organization, and trends in
diseases and infections.
The education is specific to the particular service setting and the services provided by the
organization, and targets those settings with high-risk populations, e.g. the elderly,
immune-suppressed or surgical clients, and those in high-risk environments, e.g. in the
home, long term care, the operating room, or the intensive care unit.

5.2
Safety

The IPAC education program specifies each staff members, service providers
and volunteers role in preventing and controlling infections.
Guidelines
All staff, service providers, and volunteers play a role in preventing and controlling
infections. Staff roles include how to conduct risk assessments, select appropriate
precautions, follow routine practices, and properly place or isolate clients with or at risk for
infection.
It is important for everyone to understand their role and the roles of others in the
organization.
Depending on the organizations size and complexity, or the populations served, the
organization may also create a team to lead and coordinate infection prevention and
control initiatives within the organization. The team is representative of the organization
and includes senior management; infection prevention and control professionals (ICP);
clinicians; and support services such as food and linen services, diagnostic services,
laboratory services, clerical services, and information technology.

5.3
Safety

The IPAC education program covers personal precautions and high-risk activities
performed in the organization.
Guidelines
Personal precautions include immunization, hand hygiene, and personal protective
equipment (PPE) such as gloves, facial protection such as masks and eye protection, and
aprons and gowns, as appropriate to the service environment. Staff are trained on how to
choose PPE based on the type of exposure anticipated, durability, appropriateness, and
fit, as well as how to don, change, and remove PPE.
High-risk activities include performing aerosol generating procedures; handling spills,
specimens, and sharps; handling and reprocessing contaminated equipment and devices;
and exposure to contaminated linen and waste.

5.4
Safety

Staff, service providers, and volunteers attend the IPAC education program at
orientation and regularly thereafter.
Guidelines
Staff, service providers, and volunteers participate in the IPAC education program on
hiring, i.e. at orientation, and on a regular basis thereafter, i.e. annually or biannually. The
frequency of attendance will vary according to each individuals role in the organization
and in preventing and controlling infections.
The organization documents attendance, and may maintain an electronic learning
management system to track attendance at education sessions, identify necessary
follow-up training, and identify individuals overdue for education.

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5.5
Population Focus

The organization offers IPAC education and training to partners, other


organizations, and the community.
Guidelines
The extent to which the organization offers its IPAC education program more broadly
depends on its size, complexity, and mandate. All organizations link with their partners to
share lessons learned, and to explore possibilities to coordinate or combine education
initiatives. Larger organizations and health systems offer the education program to
partners, in particular smaller organizations, and play a role, in collaboration with public
health, in educating the community about preventing and controlling infections.

5.6
Accessibility

The organization provides its staff, service providers, and volunteers with access
to current IPAC education materials, resources, information, and tools.
Guidelines
Education materials, resources, information, and tools help increase compliance with
IPAC policies and procedures.
Resources and information include peer review journals, technology, such as computers
and internet, and linkages with professional associations, e.g. CHICA Canada.
Tools include on-site reminders of procedures at the point-of-care and IPAC checklists to
guide staff in their day-to-day activities.

5.7
Effectiveness

The organization monitors compliance with its infection prevention and control
policies and procedures.
Guidelines
Compliance may be monitored using audit tools or other methods. The organizations
processes include a mechanism for staff, service providers, volunteers, and clients and
families to report non-compliance.
The organization improves its IPAC policies and procedures, education programs, or
other IPAC activities to improve compliance.

6.0
ROP

The organization implements a comprehensive hand hygiene strategy.


6.1

Safety

REQUIRED ORGANIZATIONAL PRACTICE: The organization delivers education


and training for staff, service providers, and volunteers on hand hygiene.
Guidelines
Training on hand hygiene is multimodal and addresses the importance of hand hygiene in
preventing the spread of infections, factors that have been found to influence hand
hygiene behaviour, and proper hand hygiene techniques. Training also includes
recommendations on when to clean ones hands, such as before and after each direct
contact with a client.

Test(s) for Compliance

6.2
Safety

6.1.1

Education and training on hand hygiene and the hand hygiene protocol
is delivered.

6.1.2

Staff, service providers, and volunteers understand how to apply the


hand hygiene protocol.

The organizations senior leaders encourage and support implementation of


education and training on hand hygiene for staff, service providers, and
volunteers.
Guidelines
Support from senior leaders is a significant factor influencing the effectiveness of hand
hygiene initiatives.

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6.3

The organization has a process to select alcohol-based hand rubs.


Guidelines
The process includes seeking input from staff, service providers, and volunteers.
Internationally, the WHO Guidelines on Hand Hygiene in Health Care provide more
information on selecting hand rubs. The Public Health Agency of Canada is also currently
working on national guidelines for hand hygiene in health services.

Safety

6.4
Safety

The organizations staff, service providers and volunteers have access to alcoholbased hand rubs at the point-of-care and service delivery.
Guidelines
The WHO guidelines on hand hygiene require that hand rubs be within three feet of
where care is delivered. In acute care organizations, there is growing support for placing
hand rubs at the bedside to provide reminders to staff and service providers. However,
fire regulations or other considerations may limit the placement of alcohol-based rubs.
In community-based organizations and other organizations without beds, hand rubs are
placed as close to the point-of-care as possible, e.g. in the clinic room, at the entrance to
the clients room, or directly in the clients home. Service providers may also carry hand
rubs with them.
The organization audits the availability of hand hygiene equipment and supplies available
in the service environment.

ROP

6.5

Safety

REQUIRED ORGANIZATIONAL PRACTICE: The organization evaluates


compliance with accepted hand hygiene practices.
Guidelines
Ongoing and timely feedback contributes to better compliance. The organization
documents results of compliance audits and feedback discussions.

Test(s) for Compliance

7.0

6.5.1

The organization audits its compliance with hand hygiene practices.

6.5.2

The organization shares results from the audits with staff, service
providers, and volunteers.

6.5.3

The organization uses the results of the audits to make improvements to


its hand hygiene practices.

Service providers and volunteers educate clients and families about their role in
preventing infections.
7.1

Effectiveness

The organization provides clients and families with information and education
about preventing infections in a format that is easy to understand.
Guidelines
The organization provides information about preventing infections verbally and in writing.
Written materials may be available in a variety of languages depending on the
populations served. The language used is easy to understand, and may include visual
cues to improve understanding. Written materials may include pamphlets or posters.

7.2

The information and education provided to clients and families about IPAC covers
hand hygiene and respiratory etiquette, e.g. coughing and sneezing.

Safety

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7.3

Information provided to clients and families is documented in the client record.

7.4

Families and visitors have access to hand hygiene resources and personal
protective equipment, e.g. gloves and masks, if necessary.

Effectiveness

Accessibility

Guidelines
Hand hygiene resources include hand-washing facilities and alcohol-based hand rubs.

7.5
Safety

Staff, service providers, and volunteers encourage clients, families, and visitors to
follow effective hand hygiene behaviour.
Guidelines
Clients, families, and visitors play an important role in promoting hand hygiene, e.g.
washing their own hands, and helping clients to wash their hands.

8.0

The organization prevents contamination of food, linen, equipment, devices, and


supplies.
8.1

Staff and service providers store, prepare and handle food appropriately.
Guidelines
Proper storage, preparation and handling of food are critical to preventing food-borne
illness. Food storage, preparation and handling are monitored even if food is made using
pre-prepared mixes or ingredients, or if preparation is done off-site. Where food services
are contracted to external providers, the organization has a mechanism to define the role
of the external contractor and verify the quality of services provided.

Safety

8.2
Safety

The organization stores and handles linen, supplies, devices, and equipment in a
manner than protects them from contamination.
Guidelines
The organization has detailed processes that follow manufacturers requirements, to
prevent contamination to devices and equipment. Refer to CSA Standard Z314.3 Clause
9 for more information on proper storage and handling of sterile devices and equipment.

8.3
Safety

Staff and service providers use aseptic techniques when preparing, handling, and
delivering vaccines, parenterally administered medications, total parenteral
nutrition (TPN), and diagnostic media.
Guidelines
Contamination of equipment; vaccine, medication or nutrition; or client, staff, or service
provider can occur at several points during preparation and delivery of injected
substances. The organizations staff and service providers use aseptic techniques while
preparing, handling and administering sterile substances both within the preparation area
and at point-of-care.

8.4
Safety

The organization follows national and Occupational Health and Safety guidelines
on work restrictions for staff, service providers, or volunteers with transmissible
infections.
Guidelines
Work restrictions prevent the staff member, service provider or volunteer coming into
direct contact with clients, food or sterile supplies, devices, and equipment. They include
limiting duties and responsibilities, and taking precautions, such as personal protective
equipment.

9.0

The organization quickly identifies, manages, and controls infections.

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9.1
Effectiveness

The organization has a process to promptly detect suspected healthcareassociated infections in the organization.
Guidelines
Methods of detecting infections may be passive, i.e. identified during the course of routine
service delivery, or active, i.e. by trained professionals using planned monitoring of
multiple data and sources.
The organization promotes voluntary reporting by staff, service providers, and volunteers,
but also uses additional methods such as active identification, automated methods of
detection, or centralized identification through the microbiology laboratory.

9.2
Worklife

The process identifies who is responsible and what the reporting relationships are
for infection prevention and control issues.
Guidelines
Staff, service providers, and volunteers know to whom they must report IPAC issues.

9.3
Effectiveness

Once a significant number of an infectious agent or organism is identified, the


organization quickly mobilizes an epidemiologic investigation to investigate its
source or cause.
Guidelines
Methods of investigation may include epidemiologic analysis, root-cause analysis,
statistical or cluster analysis.
The investigation process includes identifying high-risk or problem-prone agents or
organisms requiring special attention or expertise, e.g. antibiotic resistant organisms,
airborne agents, or highly contagious agents.

9.4
Safety

The organization has policies and procedures to contain and prevent the spread
of infectious agents, including ventilation, isolation and other precautions, and
cohorting as necessary.
Guidelines
Isolation can include a private room, isolation facilities, or a negative pressure room.
Other precautions include vaccination, early detection and testing, post-exposure
protocols, and treatment.
Policies and procedures to contain and prevent the spread of infectious agents are
applicable to everyone who may be at risk, including clients, families, visitors, staff,
service providers, and volunteers.

9.5
Population Focus

The organization consults with infectious disease or public health experts to


control the infections, and reports the necessary information to the appropriate
authorities.
Guidelines
Experts may include medical microbiologists, nurses, or other professionals.
Certain infectious agents and organisms must be reported in terms of frequency and
location to authorities such as public health agencies. See the Public Health Agency of
Canada for more information.

9.6

The organization uses the results of investigations to improve its programs,


policies or procedures, and to prevent infections from recurring.

Effectiveness

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PROVIDING A SAFE AND SUITABLE ENVIRONMENT


10.0 The physical environment is clean and disinfected.
10.1
Safety

The organization has defined roles and responsibilities for cleaning and
disinfecting the physical environment.
Guidelines
Roles and responsibilities address those most involved in cleaning and disinfecting the
physical environment, such as housekeeping staff. They also address the roles and
responsibilities of other staff, service providers, and volunteers for checking the
cleanliness of the physical environment and reporting problems to the appropriate
individual or team.
Where cleaning services are contracted to external providers, the organization has a
mechanism to define the role of the contractor and verify the quality of services provided.

10.2

The organization properly cleans and disinfects client and staff areas.
Guidelines

Safety

Cleaning activities include cleaning all surfaces including walls, windows, and ceilings;
removing waste; promptly cleaning and managing spills; and maintaining general tidiness.
The organizations procedures outline the cleaning schedule and expectations for
documenting the frequency of cleaning; the choice of cleaners or disinfectants, e.g.
hospital grade disinfectant with valid drug identification number (DIN), the proper dilution,
and effective contact time; and cleaning protocols for equipment such as brooms and
mops.

10.3

Staff and service providers have access to the organizations cleaning policies
and procedures.

10.4

The organization monitors its heating, ventilation and air-conditioning (HVAC)


systems and the air quality in its physical environment.

Accessibility

Safety

Guidelines
HVAC systems are cleaned, well-maintained, and meet recognized standards. Air from
soiled or contaminated areas, e.g. decontamination areas, isolation areas, is properly
exhausted to prevent contamination of clean areas with infectious agents.

10.5
Effectiveness

The organization minimizes the risk of infections during regular maintenance, as


well as during construction or renovation, of the physical environment.
Guidelines
The organization involves individuals responsible for infection prevention and control
during planning stages and consults with experts when designing new buildings or
renovations. The organization completes a risk assessment to identify possible risks
during construction and renovation, such as Aspergillus and Legionnella.
The organization may refer to other publications and standards documents for detailed
recommendations during design, construction or renovation, e.g. the American Institute
for Architects Guidelines for Design and Construction of Health Care Facilities (2006
revised), the Canadian Standards Association Standards for Infection Control During
Construction or Renovation of Health Care Facilities (2003) or Health Canadas
Construction-related Nosocomial Infections in Patients in Health Care Facilities (2001).

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10.6
Effectiveness

The organization regularly monitors the quality of its cleaning and disinfection of
the physical environment, and uses the information to make changes to policies
and procedures.

11.0 The organization has specific procedures for handling contaminated materials,
equipment, and devices.
11.1
Safety

The organization follows its policies and procedures, and legal requirements,
when handling soiled laundry, infectious material, and hazardous waste.
Guidelines
Appropriate handling of contaminated and infectious materials minimizes the risk of
exposure and infection. Handling includes collection, storage, transportation, and
disposal.

11.2

The organization considers used equipment and devices to be contaminated and


potentially infectious, and transports them appropriately to a designated
decontamination or disposal area.

11.3

Staff members wear appropriate personal protective equipment (PPE) when


handling contaminated materials and equipment.

Safety

Safety

Guidelines
Appropriate PPE may include gloves, cover garments or gowns, masks, and footwear.
Refer to CSA Standard Z314.3-01, clause 5.4.2, and Z314.8 for more information about
PPE.

11.4

The team follows specific procedures to handle, clean, and disinfect mobile client
equipment.

11.5

The organization removes and disposes of sharps at the point of use in


appropriate puncture and spill resistant sharps containers, prior to transportation.

Safety

Safety

Guidelines
Sharps include needles and blades. CSA Standard Z314.8 provides more information on
safe and appropriate disposal of sharps.

11.6

The organization uses safety engineered devices for sharps and other high-risk
materials.

Safety

12.0 The organization follows manufacturers recommendations and accepted standards


of practice to clean and reprocess reusable medical devices.

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12.1
Worklife

The organization verifies the qualifications and competencies of staff involved in


reprocessing reusable medical devices.
Guidelines
Contaminated medical devices are a potential source of infection for clients, staff, and
service providers. Having written requirements for qualifications and competencies and
verifying the competency of staff involved in the reprocessing of medical devices is
important in preventing the mishandling or improper reprocessing of these devices.

12.2
Safety

For each contaminated device and piece of equipment, a trained staff person uses
a recognized classification system to determine whether sterilization is required.
Guidelines
Classification systems have been established by Health Canada and the Canadian
Standards Association, e.g. Spauldings classification system. The organization uses the
classification system to identify critical, semi-critical, and non-critical items based on the
use of the item and risk of infection. Each classification has requirements for
decontamination, cleaning, and disinfection or sterilization that reduce the risk of infection.
An item that only comes into contact with clients intact skin, i.e. blood pressure cuffs,
stethoscopes, may be classified as non-critical and require low-level disinfection. Items
that contact mucous membranes are considered semi-critical and require high-level
disinfection. Those that enter sterile spaces or contact non-intact skin are critical devices
and must be sterile.
The classification system clearly states that critical items may be used for non-critical
activities or procedures, but non-critical items may not be used for critical activities or
procedures.

12.3
Safety

If disinfection is required, a trained and competent staff member follows detailed


procedures for cleaning or disinfecting the reusable device.
Guidelines
The organizations disinfection procedures cover sorting, soaking, washing, rinsing and
drying the items, as well as inspecting each item after drying to ensure proper functioning
and to identify any chips, inappropriate sharp edges, wear, and other defects.

12.4
Safety

The staff member soaks, flushes, and cleans each device in a timely way to
remove inorganic and organic matter on the device.
Guidelines
Immersible devices may be soaked in water or a detergent-based product containing
enzymes to facilitate cleaning and prevent organic matter from drying. Saline is not used
as a soaking solution.
Cleaning removes inorganic and organic matter that can inhibit the disinfection process. It
may be done manually or using automatic methods. For example, lumens, e.g. catheters
and needles, are cleaned with a brush or pipe cleaner if possible and flushed with a
detergent solution. CSA Standard Z314.8 Clause 11.4 provides more information on
cleaning devices prior to disinfection.

12.5

The organization selects disinfectants based on the compatibility with the devices
being disinfected; the compatibility with other agents used in disinfection or
sterilization; the intended use of the devices being disinfected; and client, staff and
environmental safety.

12.6

For each disinfectant, the organization follows manufacturers recommendations


for use, contact time, shelf life, storage, appropriate dilution, and required PPE.

Effectiveness

Effectiveness

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12.7
Effectiveness

The organization verifies the concentration of its disinfectants daily using


appropriate test strips, and disposes of disinfectants that are more than two weeks
old, even if the concentration is verified.
Guidelines
Test strips are dated when opened and are not used past the expiry date.

12.8

The organization keeps a record of its disinfection procedures that identifies the
instruments and the disinfectants used.

12.9

The organization appropriately contains and transports contaminated items to the


reprocessing unit or area.

Effectiveness

Safety

Guidelines
The organization follows formal criteria for containing used items and transporting them to
and from the area where they are sterilized. Reprocessing may be done in a specific area
of the organization or at another site, or be outsourced to a private company.

12.10 The organization transports contaminated items separately from clean or sterilized
items, and away from client service and high-traffic areas.
Safety

Effectiveness

12.11 When transporting contaminated equipment and devices, the organization


complies with applicable regulations, controls the environmental conditions, and
uses clean and appropriate bins, boxes, bags, and transport vehicles.
Guidelines
Environmental conditions include temperature and humidity.
It may be necessary to install pneumatic suspension on vehicles involved in off-site
transportation of contaminated equipment and devices.
The organization may require special considerations, e.g. temperature controls, shocks,
special containers, when transporting devices or equipment over long distances.

12.12 The organization has policies and procedures for loaned, shared, consigned, and
leased medical devices.
Safety

Guidelines
If the organization extensively uses loaned, shared, consigned, or leased medical
devices, policies and procedures are developed to address the transport of these items to
and from the organization, and to handle items that are delivered unexpectedly, unclean
or not sterilized, or incomplete. Refer to CSA Standard Z314-22-04 for detailed guidelines
and standards for the management of loaned, shared, and leased devices and
equipment.

12.13 The organizations policies and procedures include traceability for all loaned,
shared, consigned, and leased medical devices.
Safety

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12.14 The organization maintains a dedicated bank of neurosurgical and ortho-spine


devices.
Safety

Guidelines
Traceability is particularly important for neurosurgical and ortho-spine devices, in order to
quickly identify and prevent the transmission of Creutzfeldt-Jakob disease (CJD).

12.15 The organization prevents the on-site reprocessing or sterilization of single-use


devices (SUD).
Safety

Guidelines
If reprocessing or sterilization of SUDs is done outside the organization, i.e. by a
recognized third-party reprocessor, the organization monitors these processes annually.

12.16 The organization tracks devices sent for sterilization so they can be recalled in the
event of a breakdown or failure in the sterilization system.
Safety

Safety

12.17 The organization consistently follows a documented process for internal recall of
surgical equipment and medical devices whenever there are questions about their
sterility.
Guidelines
Instruments, devices, and supplies could be recalled for a variety of reasons, such as
when reprocessing fails or when an unusual pattern of postoperative infection is
discovered.

12.18 The organization has a quality control program for the cleaning, disinfection and
sterilization of reusable medical devices.
Safety

Guidelines
The program includes ongoing supervision and competency assessment of staff
responsible for cleaning, disinfecting, and sterilizing reusable medical devices. The
program uses process monitoring or recording systems to verify adherence to accepted
standards of practice and organizational policies and procedures, and systems to quickly
identify breakdowns in the organizations cleaning, disinfection or sterilization processes,
including equipment recall as required.

12.19 If reprocessing and sterilization are contracted to external providers, the


organization establishes and maintains a contract with each provider.
Effectiveness

12.20 Where sterilization and reprocessing services are contracted to external providers,
the organization regularly monitors the quality of services provided.
Effectiveness

Guidelines
The organization verifies that the external provider follows accepted standards of practice,
e.g. Canadian Standards Association, to monitor the quality of services, e.g. daily
monitoring of printouts and data, reporting systems, and mechanisms to report
deficiencies. The organization reviews copies of reports and printouts and any other
documentation demonstrating the quality monitoring performed by the external provider.

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12.21 Where sterilization and reprocessing services are contracted to external providers,
the organization annually reviews each contract and maintains documentation
related to the contract and negotiations.

Effectiveness

ROP

12.22 REQUIRED ORGANIZATIONAL PRACTICE: The organization monitors its


processes for reprocessing equipment, and makes improvements as appropriate.

Effectiveness

Guidelines
Organizations reprocess equipment according to manufacturers instructions. If the
organization does not perform the reprocessing of equipment, it must have a process to
ensure equipment has been appropriately reprocessed prior to use.

Test(s) for Compliance


12.22.1 There is evidence that reprocessing processes and systems are
effective.
12.22.2 Action has been taken to examine and improve reprocessing processes
where indicated.
13.0 The organization follows specific requirements to reprocess endoscopy devices.
13.1
Worklife

The organization identifies and verifies the education and competency of staff
involved in reprocessing of endoscopy devices.
Guidelines
Endoscopy devices include, for example, gastroscopes, duodenoscopes, colonoscopes,
sigmoidoscopes, bronchoscopes, laryngoscopes, enteroscopes, and nasopharyngeal
endoscopes.
Contaminated endoscopes are a potential source of infection for clients, staff, and service
providers. The organization has written requirements for qualification and competency;
verifying the competency of staff involved in the reprocessing of endoscopy devices is
important in preventing the mishandling or improper reprocessing of these devices.

13.2

All endoscope reprocessing areas are physically separate from client care areas.
Guidelines
Work areas are cleaned daily.

Safety

13.3
Safety

All endoscope reprocessing areas are equipped with separate clean and
decontamination work areas as well as storage, dedicated plumbing and drains,
and proper air ventilation.
Guidelines
Ventilation helps to remove toxic vapors from the work areas. The organization regularly
monitors air quality according to its policies and procedures, and Occupational Health &
Safety (OHS) legislation.
Storage areas are also well-ventilated and cleaned and disinfected at least weekly.

13.4
Effectiveness

A qualified staff member follows manufacturers recommendations to reprocess


endoscopy devices immediately following the procedure.
Guidelines
If cleaning is not done immediately following the procedure, soil residue on the
endoscope can harden, becoming very difficult to remove (CSA Z314.8, clause 14.4.1).

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13.5
Safety

Before cleaning, a qualified staff member checks the endoscope for internal and
external damages, and follows manufacturers instructions and legal requirements
to package and ship endoscopes requiring repair.
Guidelines
The integrity of the endoscope is verified through leak testing. Damaged endoscopes are
identified, removed from service, and shipped for repair following manufacturers
packaging, labelling, and shipping instructions, and in compliance with federal, or
provincial or territorial regulations for the transportation of dangerous goods.

13.6
Effectiveness

Before beginning disinfection or reprocessing, a qualified staff member soaks and


manually cleans immersible endoscope components using water and an approved
cleaning agent.
Guidelines
An approved cleaning agent is an enzymatic detergent solution prepared and used
according to manufacturers instructions and compatible with the device.
While immersed, channels and lumens are flushed and brushed to remove debris;
brushes are appropriately sized, inspected before and after use, and discarded or
cleaned and dried after use.
Irrigation adaptors or manifolds that are compatible with the endoscopy device may be
used to facilitate cleaning.

13.7

Before beginning disinfection or reprocessing, a qualified staff member rinses and


dries each endoscopy device according to manufacturers instructions.

13.8

Following disinfection or reprocessing, a qualified staff member flushes all


channels with 70% isopropyl alcohol followed by forced medical grade air to
facilitate drying.

13.9

Before storage, a qualified staff member rinses each endoscopy device using
sterile water or water filtered using a submicron filter.

Effectiveness

Effectiveness

Effectiveness

13.10 The organization stores endoscopy devices in a manner that minimizes


contamination or damage.
Safety

Guidelines
To minimize damage, the organization does not store endoscopes coiled or in their cases.
Endoscopy devices with channels or lumens are stored vertically, with channel valves
outside the endoscope.

13.11 For each scope, the organization maintains a permanent record of endoscopy
device reprocessing.
Effectiveness

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Effectiveness

13.12 The record of endoscopy device reprocessing includes the identification number
and type of endoscope, the identification of the automated endoscope reprocessor
(AED) if applicable, date and time of the clinical procedure, the name or unique
identifier of the client, results of the individual inspection and leak test, and the
name of the person reprocessing the endoscope.
Guidelines
Identifying the client, endoscopy device, and reprocessing equipment used helps facilitate
outbreak investigations, device tracking, and quality control.

Effectiveness

13.13 The organization completes preventive and scheduled maintenance, including


repairs, of each automated endoscope reprocessor, and documents all
maintenance and repair in its files.
Guidelines
Documentation on the maintenance and repair of reprocessing equipment assists with
device tracking and recall.

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BEING PREPARED FOR OUTBREAKS AND PANDEMICS


14.0 The organization has a coordinated approach to identifying and managing outbreaks
and responding to pandemics.
14.1
Safety

The organization has policies and procedures that meet federal, and provincial or
territorial, guidelines to identify and respond to outbreaks and pandemics.
Guidelines
The Public Health Agency of Canada defines an outbreak as the occurrence of a disease
in excess of its expected frequency, whereas a pandemic is defined as an epidemic
disease of widespread prevalence around the globe.
The organizations policies and procedures address how to detect an outbreak, how to
identify the cause of the outbreak including those resulting from contaminated food,
collecting data and specimens to look for additional cases, and how to contain an
outbreak once it is identifed.

14.2

The policies and procedures for identifying and managing outbreaks and
pandemics are available to staff, service providers, volunteers, clients, and
families.

14.3

The organization collaborates with its partners, e.g. public health, to define
outbreaks in terms of person, place, and time.

Accessibility

Effectiveness

Guidelines
Using the person, place and time approach helps characterize the outbreak and
provides the organization with clues to control the spread of infectious agents.
Describing the person helps to understand the population at risk of acquiring the infection.
The organization evaluates client demographics and characteristics such as age,
underlying illness, possible exposures to diseases and infections, and procedural or
therapeutic risks such as surgery.
Describing the place in terms of service, unit, or location helps to understand if the
outbreak is localized, or if it has organization- or community-wide implications. It may also
help to identify clusters of cases.
Describing the time entails defining the exact period of the outbreak, from the first case or
first indications, and drawing the epidemic curve. It is based on diagnosis and probable
period of exposure. It helps the organization determine if the outbreak is from a single
(common) source or a propagated source (continuing source or person-to-person
transmission).

14.4
Safety

Guidelines
Processes for managing new, rare, or problematic organisms may include exchanging
information with partners, other organizations, and the community.

14.5
Effectiveness

The organizations policies and procedures address how to manage new, rare, or
problematic organisms, including antibiotic-resistant organisms.

The policies and procedures include defined roles, responsibilities, and


accountabilities for staff, service providers, and volunteers who are involved in
identifying and managing outbreaks and pandemics.

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14.6
Efficiency

The organization coordinates its planning for pandemics and outbreaks with its
overall planning for disasters and emergencies.
Guidelines
The organization works with partners and the community to develop plans, policies, and
procedures that integrate responses to pandemics, outbreaks, disasters and
emergencies.

14.7
Effectiveness

The organization communicates information about outbreaks and pandemics to its


partners, other organizations, and the community.
Guidelines
The organization identifies who is responsible for communicating and reporting
information about outbreaks and pandemics.
Information is disseminated to partners, other organizations including public health
agencies, and the community. Following an outbreak, a summary report including
background, details of the investigation, results, and recommendations is made available
to partners, other organizations, and the community.

14.8

The organization reviews its policies and procedures regularly, and following each
outbreak, and makes improvements as needed.

Effectiveness

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