2009 Annual Hospitals Report - Nevada State Health Division ...

Infection Risk Assessment Tool
Background
2009 Annual Hospitals Report
According to CDC, HAIs cause at least 99,000 deaths among about two million patients who contract these infections
each year. Therefore, any efforts to reduce patients’ risk to be exposed to or contract such infections will probably have
an immediate impact on reducing the morbidity and mortality associated with HAIs and improving the quality of life for
the patients and their families. Additionally, preventing HAIs will also ease the financial, societal, and public health heavy
burden of this major public health concern.
Although HAIs are among the leading, most costly and most preventable causes of death in the United States,
surprisingly, hospitals and other healthcare facilities have very limited or no resources to address this significant
healthcare problem. When it comes to infection prevention, most hospitals in Nevada and nationwide are understaffed,
do not have an adequate infrastructure, adequate resources, or plans to address such an emerging and evolving public
health concern. Furthermore, outpatient surgery centers, ambulatory care centers, and long term care skilled nursing
facilities rarely have any experienced staff to coordinate the extremely needed infection prevention programs.
The recent hepatitis C outbreak in Clark County resulted in numerous cases of hepatitis C; tens of thousands of
potentially exposed individuals to blood-borne pathogens; and a formidable financial, societal, and emotional burden.
Preventing and ultimately eliminating HAIs is a top priority for NSHD, and in order to ensure that a ‘never event’ such as
that outbreak would never happen again, NSHD conducted numerous facility inspections and accomplished thorough
evaluations of the healthcare and public health systems over the past two years. Multi-system failures and many gross
imperfections were identified and currently it is quite obvious that no one single agency by itself has adequate
resources, the proper expertise, or the means to address this issue and reverse the alarming trends of the HAI epidemic
in Nevada. NSHD is directly collaborating with healthcare facilities of all sizes and specialties in order to identify, reduce,
and eventually prevent modifiable risk factors and behaviors that could result or may lead to an increase in the patient’s
risk to contract or spread HAIs.
During the investigation of the hepatitis C outbreak and the detection of unsafe injection practices that resulted in
subsequent inspections to all ambulatory surgery centers, NSHD epidemiology staff developed and successfully
implemented the infection risk assessment survey tool. The survey tool was mainly used to enable state surveyors from
BHCQC to identify inappropriate activities and behaviors that may lead to increasing risks for patients to contract or
spread infections. This highly focused infection control tool helped surveyors to detect infection breeches and system
failures that posed serious risks for the patients and healthcare providers as well. Unfortunately, in the past, such
infection control breeches remained undetected as routine facility inspections required by CMS were not geared to
detect infections and did not focus on preventing HAIs.
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