In 2020, our organization added an infection prevention role for approximately 250
affiliated ambulatory clinics. A rounding assessment tool was developed and initiated.
During this initial rounding, it was discovered that several locations were not performing
High Level Disinfection on endocavity ultrasound probes, and those that were performing
the HLD, were not following manufacturer's guidelines. Upon further investigation,
similar findings were discovered for both HLD of endoscopes as well as sterilization
using tabletop autoclaves. There was no official training or competency program in
place for any of these processes in the ambulatory clinics.
First, a gap analysis was performed. Data was collected on the current processes and
a complete device inventory was created. A cluster analysis was performed and revealed
the infection rate among potentially affected patients over the last 3 years to be
within the expected range. A 3rd party infection control consultant was brought in
to validate and verify our proposed plan of creating new processes, educating staff,
and developing a sustainable competency program.
Broken processes were immediately halted and corrected. Three competency programs
were developed and implemented for HLD and Sterilization, which included online modules,
webinars, hands-on training (for endoscopes), and a competency check-off. This involved
175 staff members in almost 50 clinics across the state and only one IP. New logs
were created and distributed to the practices as well as supply lists of necessary
items to maintain compliance.
At the time of this abstract, 64% of staff had completed the competency training and
were checked-off. Those who are unable to complete it by the deadline, will be unable
to perform that skill. This will be a required annual competency moving forward.