Infection Prevention Orientation Manual
Section 2: Infection Preventionist Job Description
Baerbel Merrill, MS, BSN, CIC and Deborah F. Wilson, MS, RN, CIC
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At the completion of this section the Infection Preventionist (IP) will be able to:
- Create, implement, and evaluate the position description for the IP
- Apply the principles of infection prevention outlined in the position description in the development of educational and training programs
- Verbalize understanding of the authority statement in the position description enabling the IP to act independently in emergent situations requiring immediate action
Number of hours
- Key Concepts – 2 hours
- Methods – 2 hours
- Grota P, Allen V, Boston KM, et al, eds. APIC Text of Infection Control & Epidemiolo 4th Edition. Washington, D.C.: Association for Professionals in Infection Control and Epidemiology, Inc.; 2014.
- Chapter 1, Infection Prevention and Control Programs, by C Friedman
- Chapter 3, Education and Training, by I Kenneley
- Chapter 9, Staffing, by PW Stone
The IP is a key person on the infection prevention team and in most cases is designated as the person having responsibility for the program. The IP is responsible for dissemination of infection prevention information, including surveillance data and policy decisions. The IP typically comes from a nursing background, but the IP may come from other disciplines such as medical technology, microbiology, and public health. The IP should have a working familiarity of the IP position description and should make recommendations to administration for revisions as the profession evolves.
The IP is responsible for the effective direction, management, and operation of the infection prevention program, including the education of facility staff members and independent practitioners, and consulting with the county and state department of health. The IP utilizes evidence-based practices such as those published by the Centers for Disease Control and Prevention (CDC). Additionally, the IP ensures compliance with regulations and requirements from the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), other accrediting healthcare organizations, and state regulations.
Infection Preventionist: The IP is responsible for the facility’s activities aimed at preventing healthcare-associated infections (HAIs) by ensuring that sources of infections are isolated to limit the spread of infectious organisms. The IP systematically collects, analyzes, and interprets health data in order to plan, implement, evaluate, and disseminate appropriate public health practices. The IP conducts educational and training activities for healthcare workers through instruction and dissemination of information on healthcare practices.
Responsibilities: The IP is responsible for the implementation and review of the facility’s infection prevention program. The IP ensures that existing standards and guidelines of applicable professional organizations and regulatory and governmental agencies are incorporated into the program. The IP reviews relevant public health issues to integrate into practice, serves as a consultant and resource person regarding infection prevention issues for all facility personnel, collaborates with other healthcare professionals within and outside of the facility, and implements infection prevention education programs. The IP systematically collects and analyzes healthcare-associated infection data using epidemiological principles and statistical methods to identify trends and risk factors. Additionally, it is often the responsibility of the IP to perform the reporting of HAI and quality data for the various facility, county, state, and federal reporting requirements. The IP incorporates the principles of fiscal responsibility into practice and promotes the standards of advanced professional practice.
Duties: The IP conducts rounds, discusses and monitors infection prevention practices with staff members, collects infection data from departments, maintains records for each case of healthcare- associated infection, conducts outbreak investigation, trains staff members on implementation of infection prevention practices, investigates incidents of infections and reports such incidents to the appropriate person/department, and ensures availability of supplies required for infection prevention activities. Specifically, the IP is responsible for the following:
- Making recommendations regarding the prevention and control of infection on a 24-hour basis
- Providing advice for all staff members regarding the management of infectious patients/residents and other infection prevention issues
- Coordinating the annual infection control risk assessment in conjunction with the Infection Prevention Committee (IPC) (Please refer to the IPOM sections on Committee Leadership & Membership [#4] and Construction & Renovation [#14] for more details.)
- Developing and implementing the annual infection prevention plan in conjunction with the IPC
- Evaluating the annual plan for goal achievement in conjunction with the IPC
- Conducting surveillance of infections (Please refer to the IPOM section on Surveillance [#5] for more details)
- Ensuring the completion of audits regarding the implementation of and compliance with selected policies
- Providing education and training for all staff members and independent practitioners regarding the prevention of HAIs
- Liaise with the Employee Health Nurse regarding relevant staff member health issues
- Liaise with clinical teams regarding the development of standards, audits, and research
- Presenting/providing the infection prevention annual report to the IPC, Quality Assurance department, Chief Executive Officer, and Board of Trustees (as applicable to the institution); this report is to include results of infection prevention program goal achievements and matters of concern
- Cooperating with the county and state department of health regarding infectious and communicable disease reporting
Skills: The IP should be a highly energetic individual who demonstrates a desire to develop and implement the infection prevention and control program. The IP is able to plan and conduct training seminars and exercises and has a working knowledge of nursing practice and theory. The IP should have excellent written and oral communication skills, display leadership and creativity, possess time management skills, and have extensive presentation experience. The IP should be adaptable and flexible in order to meet a wide range of service needs. The typical position of IP requires:
- moving throughout the organization
- lifting up to 20 pounds
- sitting for long periods of time
Education: A highly successful IP has the following educational background:
- Bachelor’s Degree in an applied clinical science (Nursing, Medical Technology, Microbiology, Public Health)
- Five years of relevant clinical experience for non-nurse applicants; Registered Nurses should have a broad level of experience including critical care, emergency medicine, and medical/surgical nursing.
- Master’s Degree in nursing, epidemiology, public health, or related field is helpful
- Current professional licensure in the State of Wyoming if appropriate to the primary discipline
- Certification in Infection Control (CIC) should be achieved within two years in the position
- Previous experience in teaching, curriculum development, and instruction is desired
- Membership in either APIC (Association of Professionals in Infection Control and Epidemiology) or SHEA (Society for Healthcare Epidemiology of America)
- Attending face-to-face and/or completing online educational offerings (Sponsored by APIC, SHEA, or State Departments of Health
Other requirements: The IP should be able to:
- Read, analyze, and interpret contracts, technical procedures, and/or government regulations
- Display proficiency in computer and software skills
- Write reports and other forms of correspondence
- Present verbal and/or written information and respond to the most sensitive inquiries or complaints
- Apply mathematical concepts such as fractions, percentages, rates, and proportions to practical situations
- Work with mathematical concepts such as probability and statistical tools for analysis and problem solving
- Create and interpret various charts and graphs to present in an understandable format
- Reason, define problems, collect data, establish facts, and draw conclusions
- Interpret instructions furnished in written, oral, schematic, and schedule form
- Apply principles of logical and/or scientific thinking to a wide range of intellectual and practical problems
- Interpret nonverbal symbolism (formulas, scientific equations, graphs)
- Use information management systems for:
- Data entry and retrieval
- Data collection and organization
- Data analysis and evaluation
- Required reporting
- Integration of diverse sources of data
- Interpret Wyoming Department of Health standards, CMS Conditions of Participation (COP), Health Insurance Portability and Accountability Act (HIPAA) standards, information on CDC websites, and medical/legal concepts regarding healthcare data
- Complete data entry into the National Health Safety Network (NHSN) on a timely basis
- Apply knowledge and skills regarding quality improvement tools and techniques, including statistical process control
The IP is responsible for the following:
- Establishing, implementing, and administrating infection prevention program goals, objectives, policies, and procedures
- Conducting ongoing review of hospital policies, procedures, and guidelines to identify infection prevention discrepancies and implement revisions as necessary
- Ensuring that the infection prevention program goals are compatible with and enhance the facility’s mission, vision, values, and strategic plan
- Providing information to facility committees and department managers to formulate changes in the policies, procedures, and/or processes which could reduce the spread of infection
- Interacting with medical and nursing staff, department managers, supervisors, and employee health (occupational health) and other professional/non-professional staff members to provide resource information, resolve infection prevention and control issues, and identify new opportunities to improve services and reduce cost.
- Working with department managers to apply effective policies and procedures for the departments and facility that ensures compliance the TJC, OSHA (Occupational Safety and Health Administration), CDC, CMS and other local, county, state, and federal regulatory and/or accrediting agencies
- Developing reports and statistical data for the IPC, medical staff committees, medical executive committee, and the facility’s administration, as well as other committees as needed
- Developing and coordinating the infection prevention program throughout the facility; implementing the program by formulating, establishing, and evaluating policies and procedures related to patient care infection prevention measures throughout the facility, clinics, and all other ventures operated and/or owned by the organization
- Performing an annual risk assessment and developing action plans from the prior year’s activities, which may include development of a dashboard to maintain monthly data
- Making recommendations regarding construction and renovation projects, and participation in all Infection Control Risk Assessment (ICRA) activities and environmental rounds; this includes assuring compliance with national and/or professional standards
- Working with employee health in monitoring work-related exposures
- Developing and updating the Blood-Borne Pathogens Exposure Control Plan
- Reviewing the components of the facility’s infection prevention and control program to include:
- Policies and procedures
- Program oversight
- Surveillance activities
- Process surveillance
- Outcome surveillance
- Antibiotics included in the facility’s formulary
- Antibiogram review of the facilities resistant pattern over time
- Laboratory processes including the minimum inhibitory concentration (MIC)
- Conducting outbreak investigations which includes knowing what constitutes an outbreak
- Reviewing the Wyoming Department of Health’s Reportable Disease and Conditions requirements and ensuring they are met
Documentation and Reporting
The IP will on a monthly basis:
- Update a log of all HAIs
- Review all laboratory results for Multi-drug-resistant-organisms (MDRO)
- Data entry into the NHSN reporting system according to the facility’s reporting plan:
- identified surgical cases
- surgical site infections
- CAUTI (Catheter-Associated Urinary Tract Infection)
- Clostridium difficile infections (facility wide)
- CLABSI (Central Line-Associated Blood Stream Infection)
- Data entry into the NHSH reporting system regarding employee influenza vaccination status
- Compliance with hand hygiene and precaution policies; this information is reviewed with the clinical department managers
- Ensure all communicable diseases are reported to the appropriate county and state health department personnel
- Report all pertinent data to assigned committees (please refer to the IPOM section on Committee Leadership & Membership [#4] for more details)
- In conjunction with the IPC, review national data for HAIs, review the facility’s data, and develop goals for the reduction of HAIs
- Data analysis of:
- the number of infection per patients at risk
- frequency of infections over time
- HAI rates and graphs from the data output in NHSN
The IP should initiate and/or follow-up on:
- Developing strategies regarding program development/implementation and how IP oversight will emphasize the prevention and management of HAIs
- Reviewing the facility’s tuberculosis screening program, management of exposure, and ensuring follow-up on cases consistent with state requirements
- Reviewing food safety policies and procedures in conjunction with the dietary manager
- Reviewing the facility’s pest control program
- Reviewing the facility’s hazardous waste disposal program
- Bennett G, Morrell G and Green L, ed. Infection Prevention Manual for Hospitals; revised edition. Rome, GA: ICP Associates, Inc.; 2010. Section 1: pages 12-17.
- Bennett G. Infection Prevention Manual for Ambulatory Care. Rome, GA: ICP Associates Inc.; 2009. Section 1: pages 8-13.
- Bennett G and Kassai M. Infection Prevention Manual for Ambulatory Surgery Centers. Rome, GA: ICP Associates, Inc.; 2011. Section 1: pages 13-19.
- Bennett G. Infection Prevention Manual for Long Term Care. Rome, GA: ICP Associates, Inc.; 2012. Section 1: pages 13-19.
- Blooms Taxonomy. Available at: bloomstaxonomy.org/. Accessed on February 20, 2014.
- Murphy D, Hanchett M, Olmsted RN, et al. Competency in Infection Prevention: A Conceptual Approach to Guide Current and Future Practice. American Journal of Infection Control 2012; volume 40, issue 4, pages 296-303.
- Lautenback E, Malani PN, Woeltje KF. Practical Hospital Epidemiology: An Introduction. In: E Lautenbach, KF Woeltje, and PN Malani, eds. SHEA Practical Healthcare Epidemiology (3rd Edition). Chicago, IL: University of Chicago Press; 2010: pages 3-6.
- Schweon S, Burdsall D, Hanchett M, et al. Infection Preventionist’s Guide to Long-Term Care. Washington, D.C.: Association for Professionals in Infection Control and Epidemiology, Inc.; 2013.
- Chapter 1, Understanding Infection Prevention in Long-Term Care, by D Patterson Burdall
- Chapter 3, Infection Prevention and Control Programs, by M Hanchett and P Rosenbaum
Helpful Contacts (in WY or US)
- Cody Loveland, MPH, Infectious Disease Surveillance Epidemiologist and HAI Prevention Coordinator, Wyoming Department of Health, 307-777-8634, email@example.com
- Baerbel Merrill, MS, BSN, CIC 307-689-3942 , firstname.lastname@example.org
- Deborah F. Wilson, MS, RN, CIC, Infection Preventionist/MDRO Prevention Coordinator, Cheyenne VA Medical Center, email@example.com, 307-778-7550, ext. 7091
- Wyoming Department of Health, Infectious Disease Epidemiology Unit, Healthcare-Associated Infection Prevention: health.wyo.gov/phsd/epiid/HAIgeneral.html
- Mountain-Pacific Quality Health – Wyoming: mpqhf.com/wyoming/index.php
- APIC Professional Practice Resources: apic.org/Professional-Practice/Overview
WIPAG welcomes your comments and feedback on these sections.
For comments or inquiries, please contact:
Cody Loveland, MPH, Healthcare-Associated Infection (HAI) Prevention Coordinator
Infectious Disease Epidemiology Unit,
Public Health Sciences Section, Public Health Division
Wyoming Department of Health
6101 Yellowstone Road, Suite #510
Cheyenne, WY 82002
Tel: 307-777-8634 Fax: 307-777-5573