BTS CPI cheat sheet

A facility IPC program is a documented, resourced system: a qualified IP (typically CIC-credentialed), a written annual risk assessment, an infection control plan with measurable goals, and a committee with multidisciplinary membership that meets on a defined schedule and records minutes.

The annual risk assessment drives priorities: it appraises the population served, services and procedures performed, prior surveillance data, and community/regional epidemiology, then ranks risks by probability and impact to set the year's objectives.

Regulatory anchors: CMS Conditions of Participation require an active hospital-wide program, a designated leader, and surveillance of HAIs; Joint Commission standards (IC chapter) require a written plan, annual evaluation, and evidence of implementation.

Policy lifecycle: evidence-based policy → approval by the IPC committee → staff education with documented competency → implementation → monitoring of adherence → periodic review (commonly every 3 years or sooner when guidance changes).

An IPC program budget must cover surveillance software, laboratory support (e.g., molecular testing), education, PPE and hand hygiene supplies, and IP staffing; staffing benchmarks often cite roughly 1 IP per 100 occupied beds (adjusted for acuity and scope).

Outbreak-ready governance: pre-defined thresholds for declaring an outbreak, a designated incident command liaison, and written communication pathways to administration, public health, and the media.

Quality linkage: the IPC plan should align with the organization's quality and patient safety plan; HAI metrics are reported to the governing body and to public reporting systems (NHSN, state mandates).

Construction/renovation oversight: IPC reviews plans for air handling, water systems, and traffic flow; an infection control risk assessment (ICRA) is completed before and during projects.

Chain of infection: infectious agent → reservoir → portal of exit → mode of transmission → portal of entry → susceptible host; interruption at any link prevents transmission.

Transmission modes: contact (direct/indirect), droplet (large respiratory droplets, generally traveling about 1–2 m/3–6 ft), airborne (droplet nuclei or dust, remaining suspended and traveling on air currents), plus common vehicle and vector-borne routes.

Bacteria vs. viruses vs. fungi: bacteria are prokaryotes (no nucleus, peptidoglycan cell wall, susceptible to antibiotics); viruses are obligate intracellular parasites with no cell wall; fungi are eukaryotes with ergosterol membranes, targeted by antifungals.

Gram stain: Gram-positive organisms retain crystal violet due to a thick peptidoglycan layer and appear purple; Gram-negative organisms have a thin peptidoglycan layer and outer membrane and appear pink/red.

Spore-formers: Clostridioides difficile and Bacillus species form spores that resist alcohol and many disinfectants; sporicidal agents (chlorine, hydrogen peroxide, glutaraldehyde) are required for high-level decontamination.

Biofilm: surface-attached microbial communities encased in extracellular matrix that resist antibiotics and disinfectants; relevant to indwelling devices (catheters, central lines, endotracheal tubes).

Colonization vs. infection: colonization is microbial presence without tissue invasion or host response; infection involves invasion and clinical signs - key distinction for MDRO surveillance definitions.

Virulence and host factors: inoculum size, organism virulence factors (adhesins, toxins, capsules), and host immunity (neutropenia, immunosuppression, device presence, breaks in skin/mucosa) jointly determine disease risk.

Surveillance types: passive (routine reporting), active (IP seeks cases), targeted (high-risk populations), and sentinel; NHSN is the standard platform for CLABSI, CAUTI, VAP/VAE, SSI, and CDI reporting in U.S. hospitals.

Core measures: incidence rate = number of new cases / population at risk × 1000; device-associated rates use device-days in the denominator (e.g., CLABSI per 1,000 central line-days); SSI rates use procedure-specific denominators.

Standardized infection ratio (SIR) = observed infections / predicted infections (from NHSN risk models); SIR > 1 indicates more infections than predicted; the standardized utilization ratio (SUR) compares device use to predicted use.

Outbreak steps: confirm the diagnosis and case definition → establish case finding → describe by person, place, time (epidemic curve) → generate hypotheses → analytic study (case-control or cohort) → implement control measures → communicate and evaluate.

Attack rate = (number of cases / number exposed) × 100; relative risk compares attack rates in exposed vs. unexposed groups; odds ratios are used in case-control studies.

Case definition must specify clinical criteria, time, place, and person, and is classified as suspect, probable, or confirmed to standardize counting.

The epidemic curve's shape suggests transmission: a point-source outbreak shows a single sharp peak within one incubation period; a propagated (person-to-person) outbreak shows successive peaks at incubation intervals.

Surveillance data must be validated: inter-rater reliability checks, denominator verification, and comparison with laboratory and administrative data sources detect under- or over-reporting.

Standard Precautions apply to all patients regardless of diagnosis: hand hygiene, gloves, gown, mask/eye protection based on anticipated exposure, safe injection practices, and respiratory hygiene/cough etiquette.

Contact Precautions: gown and gloves on room entry; used for MRSA, VRE, C. difficile, ESBL-producing organisms, and scabies; single room preferred, cohorting acceptable if necessary.

Droplet Precautions: surgical mask on room entry plus Standard Precautions; used for influenza, pertussis, Neisseria meningitidis, mumps, and rubella; door may remain open.

Airborne Precautions: N95 or higher respirator and an airborne infection isolation room (AIIR) with ≥12 air changes per hour and negative pressure; used for tuberculosis, measles, varicella, and disseminated zoster.

C. difficile specifics: Contact Precautions plus soap-and-water hand washing (alcohol does not kill spores) and sporicidal environmental disinfection; gloves on entry, gown for anticipated contamination.

Isolation discontinuation rules vary: MRSA/VRE often require negative cultures per facility policy; C. difficile precautions typically continue until diarrhea resolves; airborne precautions for varicella continue until lesions crust.

PPE sequence: donning - hand hygiene, gown, mask/respirator, eye protection, gloves; doffing - gloves, eye protection, gown, mask/respirator, then hand hygiene; doffing is the highest-risk step for contamination.

Immunocompromised patients (e.g., hematopoietic stem cell transplant) may require protective environment rooms: positive pressure, HEPA filtration, ≥12 ACH, and restricted plants/flowers.

WHO 5 Moments: before touching a patient; before clean/aseptic procedure; after body fluid exposure risk; after touching a patient; after touching patient surroundings.

Alcohol-based hand rub is preferred for routine decontamination when hands are not visibly soiled; soap and water is required when hands are visibly soiled and for C. difficile or norovirus exposure.

Hand hygiene duration: ABHR - apply enough to cover all surfaces and rub until dry (roughly 20–30 seconds); soap and water - at least 15–20 seconds of scrubbing, then dry with a disposable towel.

Spaulding classification: critical items (enter sterile tissue/vasculature) require sterilization; semicritical items (contact mucous membranes, e.g., endoscopes) require high-level disinfection; noncritical items (intact skin contact) require low-level disinfection.

Sterilization methods: steam autoclave (moist heat, 121°C at 15 psi or 132°C flash), ethylene oxide (heat-sensitive items; requires aeration), hydrogen peroxide gas plasma, and dry heat; each requires biological monitoring.

High-level disinfectants: glutaraldehyde (≥20 min at 20°C for most endoscopes), ortho-phthalaldehyde, hydrogen peroxide, and peracetic acid; concentration and contact time must be verified per manufacturer instructions.

Environmental cleaning: EPA-registered disinfectant with labeled contact time; high-touch surfaces (bed rails, call buttons, keyboards, door handles) require frequent cleaning; terminal cleaning follows discharge or transfer.

Monitoring cleaning efficacy: fluorescent gel or ATP bioluminescence auditing of high-touch surfaces; results are used for feedback and education of environmental services staff.

CLABSI bundle: hand hygiene, maximal sterile barrier precautions, chlorhexidine skin antisepsis, optimal site selection (subclavian preferred over femoral in adults), daily review of line necessity, and prompt removal.

CLABSI definition (NHSN): a laboratory-confirmed bloodstream infection not secondary to another site, in a patient with a central line in place for >2 calendar days on the date of event, with the line in place on that day or the day before.

CAUTI bundle: avoid unnecessary catheters, use aseptic insertion, maintain a closed drainage system, keep the bag below bladder level, and remove promptly; nurse-driven removal protocols reduce catheter-days.

VAP/VAE bundle: elevation of the head of bed 30–45°, daily sedation interruption and spontaneous breathing trials, oral care with chlorhexidine (per policy), peptic ulcer and DVT prophylaxis, and subglottic suctioning.

SSI prevention: appropriate prophylactic antibiotic within 60 minutes before incision (120 minutes for vancomycin/fluoroquinolones), glucose control, normothermia, no shaving (clip instead), and sterile technique; SCIP/CMS measures track compliance.

C. difficile prevention: antimicrobial stewardship is the cornerstone; Contact Precautions, soap-and-water hand hygiene, sporicidal cleaning, and dedicated equipment; NHSN CDI LabID event uses positive stool testing in inpatients.

MDRO control: surveillance cultures (nares for MRSA, rectal for VRE/CRE), Contact Precautions for colonized patients, antimicrobial stewardship, and hand hygiene are core interventions; decolonization (e.g., chlorhexidine bathing) is used in some settings.

Device-day denominators: CLABSI per 1,000 central line-days, CAUTI per 1,000 catheter-days, and VAP per 1,000 ventilator-days; reduction strategies target both numerator (infections) and denominator (device use).

OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030) requires an exposure control plan, hepatitis B vaccination offered at no cost, PPE, engineering controls, post-exposure evaluation, and training at hire and annually.

Post-exposure prophylaxis: HIV - initiate PEP as soon as possible, ideally within hours and no later than 72 hours; HBV - vaccine and/or HBIG depending on immunity; HCV - no vaccine, monitor RNA and refer for treatment.

Needlestick prevention: safety-engineered devices, sharps containers at point of use, no recapping, and reporting all exposures; the Needlestick Safety and Injection Safety Act amended OSHA requirements.

Tuberculosis screening: baseline two-step tuberculin skin test or IGRA for new healthcare workers, annual screening for those at risk, and fit testing for N95 respirators at least annually.

Vaccine requirements for healthcare workers commonly include hepatitis B, MMR (or proof of immunity), varicella, influenza, and Tdap; COVID-19 vaccination per policy and jurisdiction.

Respirator program: medical evaluation, fit testing, and training before use; N95 respirators are required for airborne precautions and aerosol-generating procedures when indicated.

Exposure documentation: source patient testing (HIV, HBV, HCV), confidential worker records, and follow-up serology at defined intervals; workers' compensation and OSHA recordkeeping apply to sharps injuries.

Healthcare worker safety also includes safe patient handling, latex allergy prevention, hazardous drug handling (USP <800>), and violence prevention programs.

Core stewardship strategies: prospective audit and feedback, preauthorization/formulary restriction, de-escalation to narrow-spectrum therapy, dose optimization (PK/PD), and intravenous-to-oral conversion.

Antibiogram use: annual cumulative susceptibility reports guide empiric therapy; CLSI M39 provides standards for generating and interpreting antibiograms.

MDRO definitions: MRSA (mecA-mediated oxacillin resistance), VRE (vanA/vanB), ESBL producers (resistant to penicillins/cephalosporins, often carbapenem-sparing options limited), CRE (resistant to carbapenems), and C. auris (multidrug-resistant yeast).

Antimicrobial resistance mechanisms: enzymatic inactivation (beta-lactamases including KPC, NDM, OXA-48), efflux pumps, porin changes, and target modification; carbapenemase-producing organisms are a major public health threat.

Stewardship metrics: days of therapy (DOT) per 1,000 patient-days, defined daily dose (DDD), antibiotic time-outs at 48–72 hours, and C. difficile incidence as an outcome measure.

Diagnostic stewardship: appropriate culture collection, avoiding treatment of asymptomatic bacteriuria (except in pregnancy or before urologic procedures), and rapid diagnostics to guide therapy.

Antimicrobial timeout: at 48–72 hours, reassess indication, spectrum, dose, and duration; shorter courses are appropriate for many infections (e.g., uncomplicated UTI, community-acquired pneumonia).

Resistance containment: Contact Precautions for CRE, C. auris, and often MRSA/VRE; cohorting, dedicated equipment, and communication at transitions of care (e.g., interfacility transfer forms).

CMS Conditions of Participation for hospitals (42 CFR 482) include infection prevention and control (§482.42) requiring a governing-body-approved program, surveillance, and prevention of HAIs.

Joint Commission infection control standards require a written plan, annual risk assessment, surveillance, and evidence of implementation; surveys use tracer methodology and direct observation.

NHSN reporting is mandatory in many states for CLABSI, CAUTI, SSI, and CDI; data are publicly reported on Hospital Compare and used in CMS value-based purchasing.

Quality improvement frameworks: PDSA (Plan-Do-Study-Act) cycles, Lean, and Six Sigma; root cause analysis (RCA) for sentinel events and failure mode and effects analysis (FMEA) for proactive risk assessment.

Performance measures: structure (resources, policies), process (hand hygiene compliance, bundle adherence), and outcome (HAI rates, SIR); balancing measures detect unintended consequences.

Accreditation readiness: mock surveys, tracer audits, policy review, and staff competency documentation; deficiencies result in plans of correction with defined timelines.

Public reporting transparency: hospital-acquired condition (HAC) reduction program penalizes poor performance on selected HAIs; the Hospital IQR program requires NHSN submission.

Infection preventionists should participate in quality committees, use statistical process control (SPC) charts to detect special-cause variation, and report data with confidence intervals to avoid overinterpretation.