SAFER Care CAH Road Map - Minnesota Hospital Association...2) Patient safety and quality goals, roles, and expectations, including Patient and Family Engagement concepts, have been

© 2015 Minnesota Hospital Association

SAFER CareCAH Road MapKeeping Patients Safe Across

All Areas of Hospital Care

| SAFER Care

The SAFER Care CAH Road Map provides evidence-based recommendations/standards for Minnesota hospitals in the development of a comprehensive patient safety program which includes key patient safety practices in the areas of pressure ulcers, falls, wrong procedures, adverse drug events, hospital-acquired infections, perinatal safety, readmissions, controlled substances and overall safety culture. The Road Map and accompanying tool kit was made possible with funding through the Centers for Medicare and Medicaid Services (CMS) Partnership for Patients (P4P) Initiative.

We would like to thank the Critical Access Hospitals that participated in the road map development discussions for sharing their time, expertise and stories which made the road map and tool kit possible.


Road Map to a SAFER Care CAH Program

SAFER Care Audit Questions Yes No

S Safety Teams and Organizational Structure

Board role1) The governing board demonstrates commitment to SAFER and understands resources

necessary to accomplish the goals, e.g. patient safety/quality agenda item at every board meeting, board member representation on safety/quality committee, board rounding, MHA trustee certification.

c c

Senior leadership role2) Senior leadership endorse and appoint a senior leadership sponsor to oversee

implementation and sustainment of the SAFER best practices.3) Senior leadership regularly reviews progress toward goals and supports adding

resources as appropriate.4) A patient safety culture survey is conducted at least every one to two years and a plan of

action is developed and carried out based on data results. 5) Senior leaders perform patient safety rounds by interacting with direct patient care staff

and patients on a regular basis. 6) Department/unit managers perform patient safety rounds by interacting with direct patient

care staff and patients on a regular basis (as applicable by unit/department).

c

c

c

c

c

c

c

c

c

c

Interdisciplinary team role7) An interdisciplinary team(s) is involved in implementing the road map practices with

representation from across the facility (the team can be an existing team, such as a patient/quality committee).

c c

Patient safety champions with clear roles and expectations have been designated for each key area of the SAFER Road map: 8) Falls9) Pressure ulcers10) ADE11) Perinatal safety n/a c12) Safe procedures13) Health care associated infections14) Readmissions15) Controlled substance diversion16) Stroke17) VTE18) Delirium19) Sepsis20) ED throughput21) Time critical care

cccccccccccccc

cccccccccccccc

22) The facility has a designated coordinator(s) for the SAFER road map. c c

23) The coordinator has adequate designated time to serve in this coordination function. c c

24) The coordination of topic specific areas should be distributed among operational and subject matter owners rather than relying solely on patient safety/quality leads (i.e. surgery director for procedures, designated nurse for fall prevention, OB manager for perinatal safety).

c c

The interdisciplinary team:25) Reviews the SAFER road map work plan throughout the year and updates the plan as

needed.26) Reviews outcome and road map data at least quarterly and identifies strengths and

opportunities.27) Develops a plan to prioritize and address improvement opportunities.

c

c

c

c

c

c

Page 1 | Road Map to a SAFER Care CAH Program© 2015 Minnesota Hospital Association

| SAFER Care



A Access to Information

Data Collection/tracking (* = mandatory measure)

A process is in place to collect the following (as applicable): 1) Patient falls/1000 patient days MHA 2) Patient falls with injury/1000 patient days MHA 3) Hospital-acquired pressure ulcers, stage II – unstageable/1000 patient days MHA 4) Catheter-associated urinary tract infections (CAUTIs)/1000 patient days, house-wide

NHSN *5) Central line-associated blood stream infections (CLABSIs)/1000 patient days, house-wide

MHA6) Surgical site infections (SSIs) – for any surgeries performed in the OR involving a skin

incision MHA7) Ventilator-associated events (VAEs)/1000 patient days MHA 8) Facility onset healthcare acquired CDI/1000 patient days MHA9) Facility onset MRSA bacteremia MHA (begin Q3 2015)10) Number of patients with ≥ 1 lab results with INR≥5 /1000 patient days MHA11) Number of patients with ≥ 1 lab results with blood glucose <40/1000 patient days MHA12) Number of patients with ≥ 1 Narcan administrations/1000 patient days MHA13) PC-01 Early Elective Deliveries not meeting exclusion criteria QNet *14) PSI 17 Birth Trauma Rate – Injury to Neonate – claims *15) PSI 18 Obstetric Trauma Rate – Vaginal Delivery with instrument - claims 16) PSI 19 Obstetric Trauma Rate-Vaginal Delivery without Instrument - claims17) Percent of birthing women with severe hypertension receiving appropriate treatment within 60 minutes MHA18) Number of women administered ≥ 4 units of RBCs/ Number of women giving birth ≥ 20

weeks MHA19) Sepsis mortality – MHA. Sepsis/blood culture ratio - MHA20) Number elderly patients at risk that received high delirium risk medications – MHA21) Readmissions – Medicare readmissions report, MHA all payer PPR data –claims22) Readmissions – 30 day readmissions for heart failure, pneuomonia, COPD CMS claims

report *23) HCAHPS survey results - HCAHPS vendor*24) ED transfer communications MHA*25) OP 1 Median time to fibrinolysis QNet*26) OP 2 Fibrinolytic therapy received with 30 minutes QNet*27) OP 3 Median time to transfer to another facility for acute coronary intervention QNet*28) OP 4 Aspirin at arrival Qnet*29) OP 5 Median time to ECG QNet*30) OP 20 Door to diagnostic evaluation by a qualified professional QNet*31) OP 21 Median time to pain management for long bone fracture QNet *32) OP 22 Patient left without being seen QNet*33) OP 23 ED head CT scan interpretation for acute ischemic stroke or hemorrhagic stroke

within 45 minutes of arrival QNet *34) HCP/OP27 Influenza vaccination coverage among health care personnel NHSN*35) IMM 2Patient Influenza immunizations QNet * 36) VTE 1 – VTE prophylaxis QNet*37) OP 25 SAFE surgery checklist use QNet (structural measure) *38) ED 1 Median time from ED arrival to ED departure for admitted ED patient QNet*39) ED 2 Admit decision time to ED departure time for admitted ED patients QNet *40) OP 18 Median time ED arrival to ED departure, discharged ED patients QNet*

cccc

c

c

ccccccccccc

c

cccc

ccccccccccc

ccccccc

cccc

c

c

ccccccccccc

c

cccc

ccccccccccc

ccccccc

41) The facility has a process in place (paper or electronic) for concurrent (real-time) reporting of incidents by providers and staff.

c c

42) The facility has a process in place to collect, track and review race, ethnicity, age, language (REAL) data.

c c

43) The facility includes REAL data on the UB-04 claims submitted to MHA. c c

Data analysis44) A process is in place to routinely review and analyze data for process improvement

opportunities/defects.45) A process is in place to track progress against established benchmarks e.g., run charts,

control charts, dashboards, scorecards. (e.g. state, national and internal hospital benchmarks)

46) A process is in place to prioritize and act upon identified issues.

c

c

c

c

c

c



Data and learnings are shared on a regular basis:47) With staff48) With leadership49) With medical staff50) With the board(s)51) With the public, e.g., posting progress on falls, hand hygiene.

ccccc

ccccc

F Facility Expectations 1) Senior leadership establishes and communicates clear patient safety and quality goals, roles and expectations.

c c

2) Patient safety and quality goals, roles, and expectations, including Patient and Family Engagement concepts, have been incorporated into new employee orientation for direct care staff, providers and other health care team members.

c c

3) Ongoing education on patient safety and quality goals, roles, and expectations, including Patient and Family Engagement concepts, is provided to direct care staff, providers, and other health care team members at least annually.

c c

4) Senior leaders and managers have adopted Just Culture principles and refer to this model while responding to safety incidents and near misses.

c c

The facility has a system in place to collect and learn from:5) Patient safety/quality incidents6) Employee incidents, including workplace violence7) Other safety events (e.g. environmental)8) Good catches/near misses

cccc

cccc

The learning process includes:9) Routinely reviewing and analyzing data for process improvement opportunities/defects.10) Prioritizing and acting upon identified issues.11) Sharing learnings throughout the organization on a regular basis.12) Providing appropriate feedback to person who reported the incident (e.g. thanking them

for reporting, including them in Root Cause Analysis, including them in the solution).

c

ccc

c

ccc

13) The facility has a clearly defined process(es) for speaking up and “stopping the line” if a potential safety issue has been identified by staff. The process(es) clearly outlines:

• When to stop the line; • How to stop the line, e.g. “I need clarity”; • The chain of command to follow if not supported in stopping the line; • Clear communication to staff from managers and leadership that staff will be

supported if they speak up.

cccc

cccc

14) A defined process is in place for any staff, patient or family member triggered initiation of a rapid response to a change in a patient’s condition

c c

15) The facility has structured communication tools (e.g., Situation, Background, Assessment, Recommendation (SBAR); white boards; shift report template) for communication at all levels of the organization.

c c

A structured hand-off process (e.g., checklist, huddles, bedside shift report) is in place throughout the organization with specific elements outlined that must be included for hand-offs:16) During shift change17) Between departments/units18) To other facilities/settings of care19) Medical staff hand-offs

cccc

cccc

71) Nursing shift report takes place at the bedside and includes the patient and family, as appropriate.

c c

E Engagement of Patient and Families

1) The facility has a dedicated person or team that is actively working on patient and family engagement.

c c

2) The facility has a formal patient and family advisory council. c c

3) A process is in place to assess and address any barriers to patient/family ability to understand their role in their care (e.g., cultural, language, hearing impairment and health literacy).

c c

4) Staff offer opportunities for patients to speak up and ask questions. c c

5) Patients/families are educated on prevention measures they can expect to see from staff (e.g., hand washing, repositioning, patient identification).

c c

6) Patients/families are educated on their role in patient safety (not getting up without assistance, asking visitors to wash their hands)

c c



7) The facility uses teach back technique to determine patient’s understanding of their role in their care.

c c

8) The facility has a formal process in place:• For patients and families to provide input to the organization on care concerns or

patient safety issues.• To report back to patients/families that have shared a concern or issue.

c

c

c

c

9) A process is in place to routinely review and analyze HCAHPS survey results data for opportunities for improvement.

c c

10) The facility has a process in place to review patient experience results in each dimension, identify areas for improvement, and create a plan of action based on findings.

a) Communication with doctorsb) Communication with nursesc) Responsiveness of hospital staffd) Pain managemente) Communication about medications f) Discharge in formationg) Cleanliness of hospital environmenth) Quietness of hospital environment i) Transitions of care

c c

11) Facility has completed the HCAHPS patient experience gap analysis n/a c (available after August 1, 2015).

c c

R Resiliency 1) Senior leadership and staff recognize that employee resilience has a key role in patient safety and quality of care.

c c

2) Senior leadership and staff measure employee resilience. c c

3) Strategies – hospital leadership and quality personnel develop an action plan tailored to their setting and resilience measurement findings.

c c

Hospital-Acquired Condition Specific PracticesTopic Audit Questions Yes No

Falls Currently working on the FALLS Roadmap (if yes, move to next section) c c

Falls screening & assessment of fall AND injury risk factors1a) The organization requires, and has a designated place to document, screening of all

patients for fall risk factors within 8 hours of admission for inpatients.1b) The organization requires, and has a designated place to document, screening of all

patients for injury risk factors (i.e., ABCs – Age; Bones; Coagulation; post-Surgical) within 8 hours of admission for inpatients.

c

c

c

c

Anti-Coagulants (increased injury risk for patients taking anti-coagulants)2a) Inpatients on anti-coagulants are identified within 4 hours of admission during the

medication reconciliation process.2b) Nursing falls screening also captures anti-coagulant use as part of fall injury risk screening.2c) Anti-coagulation usage is flagged within the electronic medical record to increase

awareness across providers and nursing staff.2d) Review care plan to include interventions specific to anti-coagulant risk:

• Patient is evaluated for discontinuation of anti-platelets by the provider• Patients are encouraged to wear shoes during ambulation versus slippers• Perform environmental checks to make sure any possible environmental hazards

are mitigated (e.g., no sharp corners, reduce equipment/furniture by bed that patient could hit if they do fall, obstacles between bed and bathroom)

• Institute “Within Arms Reach” with toileting and ambulation for all patients on anti-coagulants

• Video-monitored bed (if available) if meets following criteria: on anti-coagulants; impulsive or confused; risk of falling

• If video-monitoring is not available, evaluate for bed/chair alarms2e) Patient and family education is provided outlining increased risk for injury for patients

on blood thinners along with fall and injury prevention strategies and steps to take if the patient does fall.

c

c

c

c

c

c

c

c

c

c

Linking interventions to specific risk factors 3a) The organization has decision-support tools accessible (electronic or paper) that provide

staff with the interventions that should be considered for each fall and injury risk factor.c c



Topic Audit Questions Yes No

Learning from Events (Post-fall huddles)

A post-fall policy and process is in place that includes, at minimum:4a) A fall with suspected injury to the head, or an unwitnessed fall, experienced by a patient

taking anti-coagulants is included as part of a Rapid Response Team or Rapid Response Process (if a fall was unwitnessed, it is assumed that they did hit their head)

4b) Vital signs and neurological checks are performed immediately post fall at the following intervals, at minimum:

• q 15 minutes x 2, then• q 30 minutes x2, then• q 1 hour x 4, then• q 4 hours for 24 hours• Re-evaluate the need for frequent monitoring after 24 hours.

4c) Changes in patient’s status are reported promptly to physician, especially if patient is on anti-coagulants.

c

c

c

c

c

c

Safe Environment (Rounding; equipment such as video monitoring and alarms; room design)5a) Assess bathroom and pathways to the bathroom identifying opportunities for reducing

hazards 5b) Institute environmental changes in patient rooms and bathrooms to reduce hazards while

in the bathroom5c) A process is in place for staff to perform fall prevention checks as part of their rounding

process for every patient, which includes ensuring alarms are activated and working properly.

c

c

c

c

c

c

Pressure Ulcers Currently working on the Pressure Ulcer Roadmap (If yes, move to next section) c c

1) The facility requires a complete skin inspection on admission (ideally within 6 hours) and at least daily.

c c

2) The facility requires the removal or repositioning of devices for skin inspection (e.g., anti-embolism stockings, splints and respiratory equipment).

c c

3) The facility requires repositioning at least every 2 hours. c c

4) If regular repositioning is medically contraindicated, hourly micro-shifts/off-loads is required (e.g., less than 15 degree shifts, heel and sacral off-loads).

c c

5) If patients are not able to be adequately and routinely repositioned, the facility requires immediate and on-going evaluation for an advanced support surface with features and components such as low air loss, viscous fluid, air fluids, or alternating pressure.

c c

6) The facility requires pressure prevention surfaces for patients with Braden Score ≤ 18. (Note: check with manufacturer to determine if mattress is specified for pressure ulcer prevention).

c c

7) The facility requires off-loading/floating of heels any time patients have deficits in sensation, perfusion or mobility throughout the continuum of care (e.g., sedation, neuropathy, PVD).

c c

8) A process is in place to screen patients for nutritional risk within 24 hours and request a nutrition consult as needed.

c c

9) The facility requires the use of cleansers specifically designed for the perineal area and moisture barriers for patients with incontinence.

c c

Safe Procedures Currently working on the Procedural Harm Roadmap (If so, move to next section) c c

1a) Senior leadership has set clear expectations (e.g., establishes and enforces policy, reinforces practice during rounds, communicates support for staff stopping the line when practice not followed) for effective completion of the pre-procedure verifications and each step of the Time Out process prior to any invasive procedure, including anesthesia procedures (i.e. blocks/injections) performed prior to a surgical procedure.

c c

1b) The facility requires that the provider performing the procedure marks the procedure site with their initials using the VA List of Invasive procedures as a minimum guide for procedures requiring a site mark. For anesthesia, ideally this should be an “A” with a circle around it to distinguish it from any surgical markings. The facility requires that the 5 steps of the Minnesota Time Out process are conducted prior to any invasive procedure performed in the facility, including anesthesia procedures (i.e., blocks/injections) performed prior to a surgical procedure.

c c

1c) If surgeon is performing a local anesthesia injection prior to related surgical procedure that they will also perform, the Time Out is conducted prior to the injection and includes both the injection and the surgical procedure verification.

c c



1d) If the surgeon is not in continuous attendance with the patient after the injection, 2 Time Outs must occur – 1 Time Out with at least one additional healthcare provider prior to the injection; 1 Time Out just prior to the surgical procedure with the full team.

c c

1e) Time Outs for any invasive procedure include the person performing the procedure AND at least one other healthcare provider trained in the Time Out process.

c c

1f) The facility has a process in place to audit the effective completion of the specific pre-procedure verification and Time Out process steps for invasive procedures through observational audits.

c c

1g) The facility has a process in place to address gaps in the pre-procedure and/or Time Out process when observational audits results show less than 100% adherence to the process.

c c

Adverse Drug Events

Currently working on the ADE Roadmap (If so, move to next section) c c

1a) The facility has a comprehensive list of “look-alike, sound-alike” medications that is routinely updated.

c c

1b) The facility has implemented error-reduction strategies in storage, dispensing and administration practices of “look-alike, sound-alike” medications (e.g., use of TALLman lettering, separation on shelves and in medication dispensing cabinets).

c c

The facility uses Smart infusion pumps for IV medication administration of all high risk medications (e.g., opioid PCA, epidural, antithrombotics, platelet inhibitors, insulin) with functionality employed to:2a) intercept and prevent wrong dose errors.2b) intercept and prevent wrong infusion rate errors.

cc

cc

Patient Education

3a) The facility’s patient and family education on anticoagulants, hypoglycemic agents and opioids includes, at a minimum: indication, symptoms for monitoring, dietary issues, drug interactions, disease interactions, monitoring requirements, duration of therapy and potential adverse effects.

c c

3b) The facility’s patient and family medication education uses teach back methodology. c c

Anticoagulants

The facility has standard policies and practices in place for managing the initiation and maintenance of anticoagulation therapy which include: 4a) The specific medication used, e.g., Low Molecular Weight Heparin (LMWH), Warfarin,

Unfractionated Heparin (UFH), Vitamin K reversal, Direct thrombin inhibitors4b) The condition being treated 4c) The potential for drug interactions4d) Collection of baseline lab values prior to prescribing an anticoagulant, e.g., INR,

platelets, PTT, anti-Xa, serum creatinine.

c

ccc

c

ccc

4e) The facility has a protocol in place to determine the need to reverse supra-therapeutic INR values based on key criteria (e.g., the INR value, the presence or absence of bleeding, individual patient situation such as imminent surgery).

c c

4f) The facility has a renal anticoagulant dosing program in place which allows a pharmacist or provider to routinely adjust anticoagulant doses based on renal function.

c c

Hypoglycemic Agents

The facility has a process in place for follow up after initial hypoglycemic reaction occurs which includes: 5a) The adjustment of insulin dose.5b) The implementation of standard Blood Glucose monitoring after treatment of

hypoglycemia with glucagon or D50 (e.g., 0200 glucose check, glucose q 1 hr X 3). 5c) A plan for ongoing monitoring and dose adjusting to prevent hypoglycemia reoccurrence.

cc

c

cc

c

The facility has a process in place which evaluates staff competencies related to hypoglycemic agent use including: 5d) Hypoglycemia is always considered when a patient receiving insulin has an altered level

of consciousness for no apparent reason.5e) Hypoglycemia should not be ruled out as a cause of confusion or altered behavior based

on a capillary BG result; a venous lab result should also be obtained.

c

c

c

c



The facility has an established standard order set or protocol, approved by medical staff committee, in place for management of hypoglycemic patients which includes:5f) A standard method for management of hypoglycemia, including triggers to administer

glucose, (e.g., blood glucose value below threshold, signs and symptoms of hypoglycemia) is readily available to caregivers.

5g) Allows nurses to administer hypoglycemia “rescue” agents without prior physician order.5h) Hypoglycemia “rescue” agents (dextrose, glucagon) are readily accessible throughout

the facility where care is provided.

c

cc

c

cc

Opioids

The facility has opioid administration and monitoring practice guidelines in place, which include:6a) Vital signs monitoring, including pain, is defined for all clinical situations (oral narcotics,

PCA, epidural, IV injection).6b) Continuous pulse oximetry for all patients (excluding end of life patients) receiving IV

infusion narcotics.6c) Capnography monitors are used when patient is receiving supplemental oxygen

(excluding end of life patients) and receiving IV narcotic infusion, epidural, PCA, or frequent IV narcotic injections.

6d) Monitor alarms can be heard at the nursing station for pulse oximetry and capnography and cannot be turned “off”.

6e) Monitor alarms automatically default to hospital-defined thresholds.6f) Where appropriate, only dose forms that are needed for starting doses are available

as over-ride items in automated dispensing cabinets (e.g., morphine 2 mg syringes are available but 4 mg syringes are not available on over-ride).

6g) The organization has a process in place to address how and when to transition opioid therapy from one route to another (e.g., PCA to oral).

c

c

c

c

cc

c

c

c

c

c

cc

c

Perinatal Safety Currently working on the Perinatal Safety Roadmap (If yes, move to next section) c c

1a) The facility has a hard stop policy in place to prevent elective deliveries less than 39 weeks that do not meet medical exclusion criteria.

c c

1b) The facility has a quality improvement process in place to review all deliveries less than 39 weeks for appropriateness of the medical exclusion criteria.

c c

The facility provides regular inter-disciplinary education which includes:2a) Education for providers and nurses on Electronic Fetal Monitoring using the National

Institute of Child Health and Human Development (NICHD) common language.2b) Maternal/newborn team crisis training on issues such as: shoulder dystocia, postpartum

hemorrhage, emergency delivery, newborn resuscitation and pre-transfer stabilization, and hypertensive emergency.

2c) Regular educational drills for OB emergencies.

c

c

c

c

c

c

3a) The facility has standard practices in place for the appropriate and safe administration of uterotonics relative to uterine contractions.

c c

4a) The facility has standard practices in place for monitoring and documenting uterine activity in the medical record using the National Institute of Child Health and Human Development (NICHD) terminology.

c c

5a) The facility has standard practices in place for appropriate and safe performance of operative vaginal delivery. The guidelines may include: alternative labor strategies, consented patient, high probability of success (estimated fetal weight, fetal station, and fetal position), maximum number of application and pop-offs predetermined, exit strategy available (ensure surgical team/resuscitation team readiness), communication and documentation with infant caregivers about use of operative vaginal delivery.

5b) The facility has a quality improvement process in place to review operative vaginal deliveries, including neonatal complications, that fall outside the facility’s standard practices.

c

c

c

c

6a) The facility has a protocol for early detection and treatment of hypertensive emergency based on ACOG guidelines (add reference and hospitals will share examples for tool kit).

c c

7a) The facility has a process in place for early detection and management of obstetric hemorrhage, including identification of risk factors upon admission and throughout the interpartum care, to include:

• ongoing team communication,• access to recommended medications and tamponade devices, and• standardized protocols such as order sets or algorithms • emergent care planning such as massive transfusions, surgical intervention, or

transfer to higher level of care based on facility resources.

c c


8a) The facility promotes safe sleep practices by: 8b) modeling and teaching safe sleep practices per CDC/NIH SAFE to Sleep Campaign8c) providing patient/family education on preventing newborn falls

ccc

ccc

Health-Care Associated Infections

Currently working on SAFE from HAI Roadmap (If so, move to next section) c c

Hand Hygiene

1a) The facility conducts on-going observational audits to monitor hand hygiene compliance. c c

1b) The facility has a process to analyze and address issues identified through observational audit data.

c c

1c) The “Justice, Learning and Accountability” model is applied when staff or providers are observed not following facility expectations for appropriate hand hygiene.

c c

1d) Patients and families are educated on their role in preventing infections and prevention measures, e.g., hand washing, that they can expect to see from health care providers caring for them in the hospital.

c c

Environmental Cleaning

The facility’s prevention strategies for cleaning and disinfecting processes include: 2a) Hospital-grade Environmental Protection Agency (EPA) -registered germicide is used

according to manufacturers’ instructions for routine cleaning.2b) Environmental services staff is notified of patient rooms requiring special cleaning and

disinfection, such as for Clostridium difficile.2c) Chlorine-containing or other sporicidal product/technology is used for daily and terminal

environmental disinfection for all Clostridium difficile patient rooms and patient care equipment.

c

c

c

c

c

c

2d) A process to monitor room cleanliness, such as high touch surface monitoring of high touch surfaces

c c

A process is in place for environmental services cleaning staff to: 2e) Receive education on current environmental cleaning/disinfection practices and infection

control at least annually. 2f) Complete a competency evaluation of cleaning/disinfection practices at least annually.

c

c

c

c

Immunizations

Health Care Personnel immunizations3a) The facility has policies and procedures in place based on the Advisory Committee on

Immunization Practice (ACIP) recommendations that ensure employees are protected against vaccine-preventable diseases that pose a threat to the HCP’s or patient’s wellbeing within the institutional setting.

c c

Policy and procedure has been established for each HCP-recommended vaccine that includes the following:3b) Category of HCP indicated for vaccination 3c) Presumptive immunity for each vaccine-preventable disease3d) The ACIP recommended schedule3e) Annual review of these policies and updates as necessary (See Appendix A for summary of current guidelines)

cccc

cccc

Patient influenza immunizations3f) The facility has a process to screen and administer influenza vaccinations to hospitalized

persons 6 months or older according to National Hospital Inpatient Quality Measures and ACIP guidelines that includes:

3g) Incorporation of influenza immunization status into initial patient assessment3h) A review of influenza vaccination status included in the discharge process with

administration of vaccine if indicated on initial assessment and not already given during hospitalization.

c

cc

c

cc

Safe Injection Practices

4a) Facility follows recommendations outlined by the One & Only Campaign (http://oneandonlycampaign.org/content/what-are-they-why-follow-them).

c c



CAUTI

5a) The facility sets clear expectations that indwelling catheter placement is not appropriate for the following reasons:

• Incontinence• Specimen collection• Diagnostic testing when patient able to void

c c

5b) The facility has a process in place for daily review of the catheter necessity and for post surgical catheter removal by end of postoperative day 2.

c c

5c) The facility has a standardized practice, and related education, in place for all providers/staff allowed to insert/remove urinary catheters which includes:

• Appropriate use of catheters• Appropriate catheter size • Hand hygiene before and after placement• Aseptic technique and use of sterile equipment• Sterile gloves, drape, an antiseptic solution for periurethral cleaning, and a single

packet of lubricant for insertion• Identification and removal of catheters that are no longer needed• Proper maintenance of catheters (e.g., secure catheter, keep below level of the

bladder, periurethral cleaning, closed drainage system).

c c

5d) The facility has a process in place to educate the patient about their urinary catheter, such as symptoms of a urinary tract infection, catheter care, and what the patient can do to help prevent an infection.

c c

Clostridium difficile (CDI)

The facility’s core prevention strategies for CDI include:6a) Nurses are trained to recognize the signs/symptoms of CDI (e.g., Bristol Stool Chart).6b) Appropriate staff is trained in obtaining specimens for laboratory testing of patients

suspected of having CDI (e.g., collect unformed stools; no serial testing). 6c) Timely communication to the provider that a patient is suspected of having CDI. 6d) Contact Precautions 6e) Hand washing is performed with soap and water rather than, or in addition to, alcohol-based hand rub.6f) Patient and family education is provided on CDI including: symptoms; what health care

providers are doing to prevent an infection; and what the patient can do to prevent infection.

cc

ccc

c

cc

ccc

c

6g) Chlorine-containing or other sporicidal product/technology is used for daily and terminal environmental disinfection for all CDI patient rooms and patient care equipment.

c c

6h) Nursing staff and Environmental Services staff receive regular training on appropriate disinfection and cleaning techniques for CDI.

c c

CLABSI (applies to CLABSI house wide and includes PICC lines).

The facility has adopted the Checking CLABSI bundle:Insertion (n/a = do not insert any types of central lines) n/a c7a) Use insertion checklist 7b) An insertion checklist is to be used to audit every central line insertion 7c) Designate who will observe central line insertions 7d) Determine criteria for site selection7e) Consider best practice and facility needs (e.g. teaching vs. non-teaching) 7f) Standardize central line supplies7g) Reduce central line kit variability as much as possible 7h) Consistent location, standardized contents, and stocking process for central line carts/

containers/shelves7i) Manage non-sterily placed lines 7j) Provide patient/family education

cccccccc

cc

cccccccc

cc

Maintenance7k) Standardize dressing change kits 7l) Define dressing change frequency 7m) Transparent dressing change every 7 days, gauze dressing change every 48 hours 7n) If possible, change central line when 2 or more unintended dressing disruptions occur 7o) Scrub the hub with antiseptic (eg. CHG or alcohol) for at least 10 seconds with 20

second dry time before accessing line7p) Daily CHG head to toe bathing 7q) Daily assessment of need for central line7r) Critical central line information to be shared upon transfer to another unit or care setting:

• date of insertion• location of catheter

ccccc

ccc

ccccc

ccc




• type of central venous catheter (temporary non-tunneled, tunneled, dialysis)• whether inserted under sterile conditions• dressing change due date• copy of placement confirmation x-ray if available

Monitoring7s) Observation monitoring of every central line insertion using insertion

checklist7t) Develop maintenance process measures na c7u) Communicate progress on outcome and process measures to staff and providers

regularly7v) Education on teamwork/communication tools provided to staff and providers7w) Mini-RCA performed on every CLABSI identified with feedback to staff

c

cc

cc

c

cc

cc

Ventilator Associated Event (VAE) (n/a = facility does not utilize any form of mechanical ventilation) n/a c

The facility has adopted applicable elements of the Vanishing VAE bundle: 8a) Use tidal volume of less than 8 ml/kg 8b) Elevation of the Head of the Bed 30-45 degrees including during patient transport8c) Sedation Vacation BID n/a c8d) Spontaneous breathing trial BID immediately following sedation n/a c

vacation 8e) Q4h Oral Care with Chlorhexidine bid n/a c8f) Subglottic suctioning, continuous or intermittent at least q6h, and prn n/a c8g) For patients likely to require > 48 – 72 hour intubation, consider n/a c

endotracheal tubes with subglottic secretion drainage ports. 8h) Early progressive mobilization and ambulation n/a c8i) Consider managing ventilated patients without sedation or with n/a c

intermittent or minimal sedation whenever possible

cccc

ccc

cc

cccc

ccc

cc

8j) The facility regularly conducts and documents observational and chart audits for compliance with applicable elements of the Vanishing VAE Bundle.

c c

SSI

The facility has processes in place for appropriate cleaning and disinfection of the surgical environment and equipment which includes:9a) Immediate use steam sterilization (IUSS) practice adheres to The Joint Commission

recommendations:• All visible soil must be removed prior to sterilization. Manufacturers’ instructions

are available for all instruments; these include directions for the cleaning and decontamination process.

• Steam sterilization of all types, including IUSS, must meet parameters (time, temperature, and pressure) specified by both the manufacturer of the sterilizer, the maker of any wrapping or packaging, and the manufacturer of the surgical instrument. In addition to these instructions, parametric, chemical and biological controls must be used as designed and directed by their manufacturers.

• Each newly sterilized instrument must be carefully protected to ensure that it is not re-contaminated.

9b) Limits for IUSS to instances when there are not other viable options (i.e., do not use for convenience, preference or when adequate inventory could eliminate the need for it).

9c) Cleaning of the surgical environment is based on guideline(s) by nationally recognized organizations such as The Joint Commission, AORN and/or CDC and incorporates AAMI standards using Spaulding scale definitions.

9d) Training, including competency assessments, related to cleaning and disinfecting of the surgical environment provided to environmental services staff at orientation and annually.

9e) Regular evaluation and auditing of the OR cleaning and disinfection process.

c

c

c

c

c

c

c

c

c

c

The facility has adopted the MN Slashing SSI Bundle: n/a c(N/A = facility does no surgeries in an OR involving a skin incision)

c c

Showering/bathing9f) Patients are to be advised to shower or bathe (full body) with either soap (antimicrobial

or non-antimicrobial) or an antiseptic agent, once the evening before and once the morning of the surgical procedure.

9g) Upon admission to the preoperative area, an FDA approved antiseptic solution is to be applied in full strength to the operative site.

9h) Adherence to instructions for preoperative antiseptic showering or bathing at home is to be assessed upon admission to the preoperative area as a part of a preoperative bundle/checklist. If a patient reports that he or she was unable, an antiseptic shower, bath or full body wipe is to be completed pre-operatively.

9i) Hospital inpatients requiring surgery are to receive an antiseptic shower, bath, or full body wipe prior to surgery whenever possible.

c

c

c

c

c

c

c

c



• type of central venous catheter (temporary non-tunneled, tunneled, dialysis)• whether inserted under sterile conditions• dressing change due date• copy of placement confirmation x-ray if available

Monitoring7s) Observation monitoring of every central line insertion using insertion

checklist7t) Develop maintenance process measures na c7u) Communicate progress on outcome and process measures to staff and providers

regularly7v) Education on teamwork/communication tools provided to staff and providers7w) Mini-RCA performed on every CLABSI identified with feedback to staff

c

cc

cc

c

cc

cc

Ventilator Associated Event (VAE) (n/a = facility does not utilize any form of mechanical ventilation) n/a c

The facility has adopted applicable elements of the Vanishing VAE bundle: 8a) Use tidal volume of less than 8 ml/kg 8b) Elevation of the Head of the Bed 30-45 degrees including during patient transport8c) Sedation Vacation BID n/a c8d) Spontaneous breathing trial BID immediately following sedation n/a c

vacation 8e) Q4h Oral Care with Chlorhexidine bid n/a c8f) Subglottic suctioning, continuous or intermittent at least q6h, and prn n/a c8g) For patients likely to require > 48 – 72 hour intubation, consider n/a c

endotracheal tubes with subglottic secretion drainage ports. 8h) Early progressive mobilization and ambulation n/a c8i) Consider managing ventilated patients without sedation or with n/a c

intermittent or minimal sedation whenever possible

cccc

ccc

cc

cccc

ccc

cc

8j) The facility regularly conducts and documents observational and chart audits for compliance with applicable elements of the Vanishing VAE Bundle.

c c

SSI

The facility has processes in place for appropriate cleaning and disinfection of the surgical environment and equipment which includes:9a) Immediate use steam sterilization (IUSS) practice adheres to The Joint Commission

recommendations:• All visible soil must be removed prior to sterilization. Manufacturers’ instructions

are available for all instruments; these include directions for the cleaning and decontamination process.

• Steam sterilization of all types, including IUSS, must meet parameters (time, temperature, and pressure) specified by both the manufacturer of the sterilizer, the maker of any wrapping or packaging, and the manufacturer of the surgical instrument. In addition to these instructions, parametric, chemical and biological controls must be used as designed and directed by their manufacturers.

• Each newly sterilized instrument must be carefully protected to ensure that it is not re-contaminated.

9b) Limits for IUSS to instances when there are not other viable options (i.e., do not use for convenience, preference or when adequate inventory could eliminate the need for it).

9c) Cleaning of the surgical environment is based on guideline(s) by nationally recognized organizations such as The Joint Commission, AORN and/or CDC and incorporates AAMI standards using Spaulding scale definitions.

9d) Training, including competency assessments, related to cleaning and disinfecting of the surgical environment provided to environmental services staff at orientation and annually.

9e) Regular evaluation and auditing of the OR cleaning and disinfection process.

c

c

c

c

c

c

c

c

c

c

The facility has adopted the MN Slashing SSI Bundle: n/a c(N/A = facility does no surgeries in an OR involving a skin incision)

c c

Showering/bathing9f) Patients are to be advised to shower or bathe (full body) with either soap (antimicrobial

or non-antimicrobial) or an antiseptic agent, once the evening before and once the morning of the surgical procedure.

9g) Upon admission to the preoperative area, an FDA approved antiseptic solution is to be applied in full strength to the operative site.

9h) Adherence to instructions for preoperative antiseptic showering or bathing at home is to be assessed upon admission to the preoperative area as a part of a preoperative bundle/checklist. If a patient reports that he or she was unable, an antiseptic shower, bath or full body wipe is to be completed pre-operatively.

9i) Hospital inpatients requiring surgery are to receive an antiseptic shower, bath, or full body wipe prior to surgery whenever possible.

c

c

c

c

c

c

c

c


Postoperative wound care 9j) Surgical sterile dressings are to be left intact 24 – 48 hours unless there is bleeding or a

reason to suspect early infection.9k) Where postoperative dressing changes are necessary, sterile gloves and dressings

should be used. 9l) Patient education on the importance of hand hygiene in preventing SSI is to be provided

preoperatively, and hand hygiene products will be provided at the patient bedside.

c

c

c

c

c

c

Closing trays for class II open surgeries n/a c9m) For all class II and higher clean/contaminated open laparotomies, including

extracorporeal bowel anastomoses, clean instruments, water, and gloves/gowns are to be utilized for wound closure.

9n) The need for closing trays is to be added to the preoperative briefing or timeout script.

c

c

c

c

Antibiotic dosing9o) Intra-operative re-dosing of surgical prophylactic antibiotics is to be performed for

procedures that last longer than two half-lives of the drug.9p) Intra-operative re-dosing of surgical prophylactic antibiotics is to be performed for

procedures involving blood loss >1500cc.9q) A weight based dosing protocol is to be implemented per AHSP/SHEA guidelines

c

c

c

c

c

c

Glycemic control9r) Implement perioperative glycemic control and use blood glucose target levels <200mg/

dL for diabetic and non-diabetic patients. c c

Normothermia 9s) Maintain normothermia (body temperature ≥ 36ºC or 96.8º F) preoperatively,

intraoperatively and postoperatively.c c

OR traffic9t) An assessment of OR traffic, with the intent to reduce unnecessary traffic, is performed

upon implementation of SSI bundle and periodically thereafter.c c

9u) The facility regularly conducts and documents observational and chart audits for compliance with applicable elements of the Slashing SSI Bundle

c c

Readmissions Currently working on SAFE Transitions Roadmap (If so, move to next section) c c

The facility requires, AND has a designated form that contains, the MN Transition Core Elements of information for each appropriate transition setting:1a) Hospital to other settings 1b) Other settings to hospital 1c) Emergency department to hospital and other settings

ccc

ccc

The facility has a process in place for regular communications with receiving facilities or next setting of care including: 2a) A clear delineation of roles and responsibilities between facilities or organizations.2b) Timelines for communications that allow the receiving provider to effectively treat the

patient and take into account the patient’s clinical presentation and the urgency of the follow-up required.

2c) The format of communication which includes one of the following: call, voice mail, fax, or other secure, private, and accessible means including mutual access to an electronic health record.

2d) a system to elicit feedback from receiving facilities regarding patient outcomes in order to evaluate care provided prior to transfer.

cc

c

c

cc

c

c

The facility has a process for comprehensive transition planning with the patient and family, that includes at a minimum, in plain language: 3a) Reason for hospitalization3b) Medications summary3c) Self care activities3d) Durable medical equipment needs3e) Symptom recognition and management3f) Coordination and planning for follow-up appointments3g) Follow up of results from lab tests or other studies that are pending at discharge

ccccccc

ccccccc

4a) The facility has a process to review medication orders at the time of transition for accuracy, necessity, potential side effects and/or interactions for patients.

4b) The facility has a process to provide medication instruction for patients, including an assessment of the patient’s ability to accurately and reliably take medications.

c

c

c

c

5) The facility has a process to ensure that patients have a follow up appointment with their primary care physician within 5 business days or there is purposeful contact with the patient within 72 hours, by a team member with knowledge of the patient’s history and plan of care.

c c


6) The facility has a process to involve patients and caregivers in developing and executing the plan of care.

c c

7) The facility has a process to continuously review and track utilization data related to readmissions to identify avoidable readmissions and opportunities for improvement.

c c

VTE The facility has a process in place to administer VTE prophylaxis for high risk patients that includes:1a) Screening hospital inpatients for VTE risk1b) Administer VTE prophylaxis as indicated or document why no VTE prophylaxis was

given the day of or the day after hospital admission

cc

cc

Delirium Delirium practices include: 1a) Initial and ongoing education is provided for all clinical staff (including ED staff), and

includes, at a minimum:1b) Delirium risk factors1c) Delirium detection1d) Delirium prevention strategies1e) Strategies for management of delirium-related behaviors1f) Education is provided for physician and residents, and includes, at a minimum:1g) ABC medications that can perpetuate delirium (antihistamines, benzodiazepines, and

anti-cholinergics)1h) Use of other high-risk medications that can perpetuate delirium1i) Recognizing and diagnosing delirium

c

cccccc

cc

c

cccccc

cc

Patient/family education is provided for all patients at-risk for delirium and includes, at a minimum:2a) Delirium risk factors2b) How to recognize delirium2c) Their role in preventing delirium2d) The importance of movement

cccc

cccc

Prevention strategies are in place for all inpatient older adults which include, at a minimum:3a) A = Advance activity Strategies are in place to encourage movement, such as encouraging patients to eat

meals in the chair rather than in the bed, setting goals for early movement, and a plan for progressively increasing activity as patient’s condition improves.

3b) B = Better sleep Sleep hygiene practices/protocols are in place (e.g., determining normal sleep patterns,

avoiding daytime napping, increasing daytime stimulation, establishing bedtime routines) to assist patients in maintaining normal sleep/wake patterns.

3c) C = Control pain Patients showing initial signs of confusion or other signs of delirium should be evaluated

to ensure that there is not another underlying cause for these initial signs, such as: pain; electrolyte imbalance, incontinence/intestinal problems, or infection.

3d) D = Drug/dose reduction for medications that perpetuate delirium Review for potentially inappropriate medication which can contribute to delirium.3e) E = Encourage use of sensory aids Patients have access to, and are encouraged to use (or assisted in using), any sensory

aids such as hearing aids, glasses and dentures.

c

c

c

c

c

c

c

c

c

c

Sepsis The facility’s core strategies for the early detection and treatment of severe sepsis and septic shock include:1a) A physician designated to lead sepsis performance improvement efforts.1b) A process to enhance public awareness of sepsis and the importance of early medical

treatment.1c) Routine sepsis screening performed in the ED and inpatient units based on SIRS criteria. 1d) A process in place to initiate a rapid response to treat patients that screen positive for

sepsis, patterned after other time critical emergencies such as trauma, STEMI, or stroke. 1e) Standardized order sets in the ED and inpatient units for early detection and treatment of

severe sepsis and septic shock that incorporate the Surviving Sepsis Campaign 3 and 6 hour bundles.

1f) ICU admission or transfer guidelines for patients with severe sepsis or septic shock. 1g) Ongoing, regular, interdisciplinary education on early detection and treatment of severe

sepsis and septic shock, including simulation exercises where patient volumes are low. 1h) A quality improvement process in place that includes:

• Tracking and monthly review of sepsis mortality, length of stay, and cost• Monthly review of compliance with routine sepsis screening and rapid treatment

according to Surviving Sepsis Campaign 3 and 6 hour bundles. • Analysis of sepsis cases for opportunities to improve • a process to share all PI findings with staff regularly

cc

cc

c

cc

c

cc

cc

c

cc

c



6) The facility has a process to involve patients and caregivers in developing and executing the plan of care.

c c

7) The facility has a process to continuously review and track utilization data related to readmissions to identify avoidable readmissions and opportunities for improvement.

c c

VTE The facility has a process in place to administer VTE prophylaxis for high risk patients that includes:1a) Screening hospital inpatients for VTE risk1b) Administer VTE prophylaxis as indicated or document why no VTE prophylaxis was

given the day of or the day after hospital admission

cc

cc

Delirium Delirium practices include: 1a) Initial and ongoing education is provided for all clinical staff (including ED staff), and

includes, at a minimum:1b) Delirium risk factors1c) Delirium detection1d) Delirium prevention strategies1e) Strategies for management of delirium-related behaviors1f) Education is provided for physician and residents, and includes, at a minimum:1g) ABC medications that can perpetuate delirium (antihistamines, benzodiazepines, and

anti-cholinergics)1h) Use of other high-risk medications that can perpetuate delirium1i) Recognizing and diagnosing delirium

c

cccccc

cc

c

cccccc

cc

Patient/family education is provided for all patients at-risk for delirium and includes, at a minimum:2a) Delirium risk factors2b) How to recognize delirium2c) Their role in preventing delirium2d) The importance of movement

cccc

cccc

Prevention strategies are in place for all inpatient older adults which include, at a minimum:3a) A = Advance activity Strategies are in place to encourage movement, such as encouraging patients to eat

meals in the chair rather than in the bed, setting goals for early movement, and a plan for progressively increasing activity as patient’s condition improves.

3b) B = Better sleep Sleep hygiene practices/protocols are in place (e.g., determining normal sleep patterns,

avoiding daytime napping, increasing daytime stimulation, establishing bedtime routines) to assist patients in maintaining normal sleep/wake patterns.

3c) C = Control pain Patients showing initial signs of confusion or other signs of delirium should be evaluated

to ensure that there is not another underlying cause for these initial signs, such as: pain; electrolyte imbalance, incontinence/intestinal problems, or infection.

3d) D = Drug/dose reduction for medications that perpetuate delirium Review for potentially inappropriate medication which can contribute to delirium.3e) E = Encourage use of sensory aids Patients have access to, and are encouraged to use (or assisted in using), any sensory

aids such as hearing aids, glasses and dentures.

c

c

c

c

c

c

c

c

c

c

Sepsis The facility’s core strategies for the early detection and treatment of severe sepsis and septic shock include:1a) A physician designated to lead sepsis performance improvement efforts.1b) A process to enhance public awareness of sepsis and the importance of early medical

treatment.1c) Routine sepsis screening performed in the ED and inpatient units based on SIRS criteria. 1d) A process in place to initiate a rapid response to treat patients that screen positive for

sepsis, patterned after other time critical emergencies such as trauma, STEMI, or stroke. 1e) Standardized order sets in the ED and inpatient units for early detection and treatment of

severe sepsis and septic shock that incorporate the Surviving Sepsis Campaign 3 and 6 hour bundles.

1f) ICU admission or transfer guidelines for patients with severe sepsis or septic shock. 1g) Ongoing, regular, interdisciplinary education on early detection and treatment of severe

sepsis and septic shock, including simulation exercises where patient volumes are low. 1h) A quality improvement process in place that includes:

• Tracking and monthly review of sepsis mortality, length of stay, and cost• Monthly review of compliance with routine sepsis screening and rapid treatment

according to Surviving Sepsis Campaign 3 and 6 hour bundles. • Analysis of sepsis cases for opportunities to improve • a process to share all PI findings with staff regularly

cc

cc

c

cc

c

cc

cc

c

cc

c


ED Throughput 1a) The facility has a system for identifying door to provider, provider to decision and decision to discharge/transfer/admit times.

c c

1b) The facility has a system to standardize clocks. c c

1c) The facility has standardized protocols for ED throughput. c c

1d) The facility considers visual cues (EHR or other) when patients are over the targeted timeframe.

c c

1e) The facility performs analysis such as RCA on encounters where patient left without being seen.

c c

1f) Facility considers bedside registration. c c

1g) Facility has a process in place to analyze and improve lab turnaround time. c c

1h) Facility has a process in place to analyze and improve imaging turn round time. c c

Time Critical Care

1a) The facility has standardized time critical care protocols. c c

1b) The facility consider standard “kits” that include equipment/meds and protocols for time critical conditions.

c c

1c) The facility identifies ways to trigger administration of aspirin for AMI/Chest pain. c c

1d) The facility analyzes EKG turnaround for AMI, identifying and addressing barriers such as staffing, equipment availability.

c c

1e) The facility has adopted protocols and processes for early detection and treatment of stroke patients, including:

• CT/MRI scan interpretation within 45 minutes • Consultation/ transfer arrangements with stroke certified hospital

c c

Controlled Substance Diversion Prevention

Currently working on Controlled Substances Diversion Roadmap (If yes, move to next section)

c c

1a) The organization has designated a core team involved in developing and overseeing the Controlled Substance (CS) Diversion Prevention Program that includes prevention, detection and investigation.

c c

1b) The organization has a process to generate and review controlled substance data (e.g., controlled substance surveillance reports, high-user reports, disposition and Inventory sheets) on at least a monthly basis.

c c

1c) The organization proactively collaborates with local law enforcement to develop a process to respond to suspected diversion, including contacting local, state, federal law enforcement.

c c

1d) Expectations and supporting education have been incorporated into training for all new staff and Licensed Independent Practitioner (LIP), including, at a minimum, awareness training to know the signs of diversion.

c c

1e) The organization communicates the expectation that staff speak up when they become aware of an issue related to CS diversion.

c c



Appendix A: Guidelines for Vaccination of HCP (adapted from ACIP Recommendations)

Vaccination Indicated Population Presumptive Immunity Primary Vaccine Schedule and Boosters

Special Considerations

Hepatitis B HCP at risk for exposure to blood or body fluids

• 3 valid doses of Hep B vaccine or

• Anti-HBs titer of ≥ 10 mIU/mL

3 doses given at 0, 1-2, 4-6 month intervals; booster doses not necessary

Influenza All HCP N/A Annual vaccination with current seasonal vaccine.

Measles All HCP who lack presumptive immunity

• 2 valid doses of measles or MMR vaccine

• Laboratory evidence of immunity gained through either vaccination or disease

• Birth before 1957

2 doses at least 28 days apart

When there is a community outbreak, including an identified case within the health care facility, vaccination should be considered for those born before 1957.

Mumps All HCP who lack presumptive immunity

• 2 valid doses of mumps or MMR vaccine




When there is a community outbreak, including an identified case within the health care facility, vaccination should be considered for those born before 1957.

Rubella All HCP who lack presumptive immunity

• 1 valid dose of rubella or MMR vaccine



1 dose (However, due to the two dose requirements of measles and mumps, most HCP will have 2 doses of rubella-containing vaccine)

Pertussis All HCP, regardless of age N/A 1 dose of Tdap, as soon as feasible if Tdap not already received and regardless of interval from last Td

Varicella All HCP who lack presumptive immunity

• 2 valid doses of varicella vaccine

• Laboratory evidence of immunity

• Diagnosis or verification of either varicella or herpes zoster disease by a health care provider


Non Routine Vaccines (for “at-risk” HCP categories)

Meningococcal Clinical and research microbiologists who might routinely be exposed to isolates of Neisseria meningitides

1 dose; booster dose every 5 years if person remains in indicated population

Meningococcal conjugate vaccine, 4-valent (MenACYW) is preferred for persons through age 55 years and ACIP recommends off-label MenACYW for persons over 55 years who will need booster doses every 5 years


Typhoid Workers in microbiology laboratories who frequently work with Salmonella typhi.

Oral: 4 capsules every 48 hours; booster on same schedule every 5 yearsInjectable: One-time dose; booster every 2 years

Polio HCP who have close contact with patients who might be excreting polioviruses; or work in a lab with poliovirus.

Adults who have previously received a complete series of polio vaccine may receive one lifetime booster. Primary series for unvaccinated adults: 3 doses at 0, 1-2, 6 month intervals.

Routine Adult Immunizations (recommendation not based on occupational risk)

Consider offering to: Vaccine Schedule and Booster Doses

Special Considerations

Zoster All persons 60 years and older

1 dose Give vaccine regardless of history of shingles disease

Pneumococcal Conjugate (PCV13)

Persons 19-64 with who are immunocompromised, have chronic renal failure, nephrotic syndrome, asplenia, CSF leak, or cochlear implants and all persons 65 and older

1 dose, no booster • When both pneumococcal vaccines are indicated PCV13 should be administered first, PCV13 and PPSV23 should not be administered at the same visit

• Whenever possible, the conjugate vaccine should be given before the polysaccharide vaccine.

Pneumococcal Polysaccharide (PPSV23)

Persons 19-64 who are eligible for PCV13, and those who have heart disease, lung disease, liver disease, diabetes, alcoholism, or a smoker or resident of long term care and all persons 65 and older

2 doses in certain situations, most commonly, 1 dose

The timing and sequence of the pneumococcal vaccines is important to attaining an appropriate immune response, please see http://eziz.org/assets/docs/IMM-1152.pdf for detailed guidance.

Human Papillomavirus (HPV)

Females through age 26Males through age 21, additionally males 22-26 at high risk* or who simply want to be protected

3 doses at 0, 2 and 6 months

Meningococcal All adults at risk* 2 doses at least 2 months apart

Hepatitis A All adults at risk* or those who simply want to be protected

2 doses, usually at 0 and 6-18 months depending on vaccine brand

Hepatitis B All adults at risk* or those who simply want to be protected

3 doses at 0, 1-2, and 4-6 months, booster not necessary

Tetanus, Diphtheria, and Pertussis (Tdap, Td)

All adults not previously vaccinated, women need 1 dose in each pregnancy

1 dose if have received childhood series

All adults also need a Td-only booster every 10 years

The above table is for convenience purposes, more complete and detailed information should be sought out when providing these vaccinations. http://www.health.state.mn.us/divs/idepc/immunize/adult/ *see full Adult Immunization Schedule for risk categories

Documents

SAFER Care CAH Road Map - Minnesota Hospital Association...2) Patient safety and quality goals, roles, and expectations, including Patient and Family Engagement concepts, have been