6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 11

Current through Register Vol. 47, No. 20, October 25, 2024

Part 11 - INFECTION PREVENTION AND CONTROL AND ANTIBIOTIC STEWARDSHIP PROGRAMS

11.1 Infection Prevention and Control Program

(A) The hospital shall have an infection prevention and control program responsible for the prevention, control, and investigation of infections and communicable diseases.

(B) The infection prevention and control program shall reflect the scope and complexity of the services provided by the hospital.

11.2 Infection Prevention and Control Committee

(A) There shall be a multi-disciplinary infection prevention and control committee charged with:

(1) Developing and implementing policies and procedures regarding prevention, surveillance, and control of healthcare acquired infections and infectious diseases.

(2) Making findings and recommendations to prevent and control healthcare acquired infections and infectious diseases.

(3) Reviewing the policies and procedures of the following services periodically, but no less than every three (3) years: anesthesia, critical care, dietary, environmental, linen and laundry, materials management, pediatric, perinatal, respiratory, and surgical and recovery.

(B) The committee shall make findings and recommendations available promptly to the infection control officer for action.

(C) The committee shall meet at least once every quarter and maintain minutes of the meetings.

(D) The policies and procedures shall be based on nationally recognized guidelines and best practices for infection prevention and control. The policies shall address, at a minimum, the following:

(1) Maintenance of a sanitary hospital environment;

(2) Development and implementation of infection prevention and control measures related to hospital personnel, staff, and volunteers;

(3) Mitigation of risks associated with patient infections present upon admission;

(4) Mitigation of risks contributing to healthcare associated infections, including, but not limited to, isolation procedures;

(5) Monitoring compliance with all policies, procedures, protocols, and other infection control program requirements;

(6) Program evaluation and revision on an annual basis or as necessary;

(7) Coordination with other federal, state, and local agencies, as necessary;

(8) Complying with reportable disease requirements, as found at Section 25-3-601, C.R.S., et seq.;

(9) Implementation of infection prevention and control measures during hospital renovations; and

(10) Training and education of hospital personnel, staff, and personnel providing contracted services in the hospital on the practical applications of infection prevention and control guidelines, policies, and procedures.

(E) A hospital with twenty-five (25) beds or fewer that is not part of a multi-hospital system may choose not to have an infection prevention and control committee. If a hospital chooses not to have an infection prevention and control committee, the infection prevention and control officer is responsible for ensuring all requirements of this Part 11 are met.

11.3 Infection Prevention and Control Officer

(A) The hospital shall have an infection prevention and control officer or officers, qualified through education, training, competencies, experience, and/or certification.

(B) The infection prevention and control officer(s) shall implement the policies and procedures and the recommendations of the infection control committee.

(C) The infection prevention and control officer(s) shall coordinate with the Administrative Officer, Elected Medical Staff Leader, and Senior Nurse Executive to implement corrective action plans, as necessary.

11.4 Infection Prevention and Control Policies and Procedures Regarding Equipment and Instruments

(A) The Infection Prevention and Control Committee shall develop and implement policies and procedures regarding equipment and instrument cleaning, disinfecting, sterilizing, reprocessing, and storage.

(B) The policies and procedures shall be based on nationally recognized guidelines, such as those promulgated by the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control and Epidemiology (APIC), The Society for Healthcare Epidemiology of America (SHEA), the Association of periOperative Registered Nurses (AORN), and/or the association for the Advancement of Medical Instrumentation (AAMI).

(C) Manufacturers' instructions shall be followed for the cleaning, disinfecting, and sterilizing of all reusable equipment and instruments.

11.5 Antibiotic Stewardship Program

(A) The hospital shall have an antibiotic stewardship program responsible for the optimization of antibiotic use through stewardship.

(B) The program shall be overseen by an individual who is qualified through education, training, competencies, and/or experience in infectious diseases and/or antibiotic stewardship.

(C) The program shall involve coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the quality management program, the medical staff, nursing services, and pharmacy services.

(D) The program shall document the evidence-based use of antibiotics in all departments and services of the hospital and any improvements in proper antibiotic use.

(E) The program shall adhere to nationally recognized guidelines and best practices for improving antibiotic use.

(F) The program shall reflect the scope and complexity of the hospital services provided.

(G) Hospital personnel and staff, as identified by hospital policy, shall be trained on the practical applications of antibiotic stewardship guidelines, policies, and procedures.

11.6 Unified Infection Prevention and Control and Antibiotic Stewardship Programs for Multi-Hospital Systems

(A) If a hospital is part of a hospital system consisting of multiple hospitals using a system governing body that is legally responsible for the conduct of two or more hospitals, the system governing body may have unified infection control and antibiotic stewardship programs, provided the unified programs do the following:

(1) Take into account each hospital's unique circumstances and any significant differences in patient populations and services offered in each hospital.

(2) Establish and implement policies and procedures to ensure the needs of each hospital, regardless of practice or location, are given due consideration, and that the programs have mechanisms in place to ensure that issues localized to particular hospitals are duly considered and addressed; and

(3) Ensure a qualified individual(s) with expertise in infection prevention and control and in antibiotic stewardship has been designated at the hospital as responsible for:

(a) communicating with the unified infection prevention and control and antibiotic stewardship programs,

(b) implementing and maintaining the policies and procedures directed by the unified infection prevention and control and antibiotic stewardship programs, and

(c) providing education and training on the practical applications of infection prevention and control and antibiotic stewardship to hospital staff.

6 CCR 1011-1 Chapter 04, pt. 11