Proof of Compliance to Prevent HAIs

Proof of Compliance to Prevent HAIs

Maintaining an infection-free hospital takes more than just a few tools and procedures. Not only are your patients and staff at risk of Healthcare-Associated Infections (HAIs), but your team also needs to think about proof of compliance for both internal and external auditors. Bundling your infection control solutions – including UV disinfection tools – better protects from the spread of infections and provides the proof of compliance you require to operate a safe hospital.

HAI Reporting

Mandatory HAI reporting laws add even more reporting to an already demanding work day for your IP team. But a bundled approach helps. According to the International Society of Infection Diseases, a bundled approach that includes a set of evidence-based measures can produce better outcomes and have a greater impact than isolated implementation of individual measures—especially those that involve buy in from every department.

Bundled care promotes multi-disciplinary collaboration, since bundles should be developed together and consensus should be obtained with strong clinician engagement and endorsement.”

International Society of Infection Diseases
International Society for Infections Diseases

Each element of a bundle must be implemented collectively and consistently to achieve the best outcome. Effective implementation requires that measures are:

  • adapted to the local setting
  • appropriately followed
  • entrenched in the patient care culture
  • recorded and evaluated to ensure compliance by all members of the healthcare team involved

A Proven UVC Bundle

The American Journal of Infection Control states that bundling UV cleaning technology with traditional manual cleaning is proven to be one of the most effective ways to reduce HAIs. UVC technology uses Ultraviolet light to penetrate the cell walls of bacteria and viruses and render them unable to replicate. Dangerous pathogens can’t reproduce and spread after being treated with UVC energy.

Bundling strategies helped Rochester General Hospital show how effective their hospital disinfection was and provided the team and management clear efficacy data. RGH used multiple IP tactics to tackle rising C. difficile rates resulted in a 56% reduction between 2011 and 2015. Working with their multidisciplinary team, RGH developed a multi-pronged bundle with infection prevention, microbiology-laboratory, and pharmacology components to ensure hospital room disinfection.


Rochester Regional Health
Step 1
Established equipment grids outlining who was responsible for cleaning each piece of equipment as part of overall hospital room disinfection.
Step 2
Created isolation timelines to establish when CDI isolation could be discontinued using UVC technology, bleach-based disinfectants, ATP testing, and detailed cleaning protocols for staff.
Step 3
Reeducated staff on the definition of diarrhea and developed guidelines for stool testing.
Step 4
Engaged pharmacy to create a tiered algorithm for CDI treatment.
Step 5
Produced clean sweep protocols to implement after unit CDI burdens were evaluated.
Step 6
Used an empty swing bed to facilitate patient movement while units, portable equipment, and common areas were terminally cleaned with UV disinfection.

Nationally, RGH’s efforts yielded statistically significantly better-than-average standard infection ratios than the Centers for Medicare and Medicaid Services for three consecutive years, proving that bundling with UVC can be an effective way for medical facilities to reduce the risk of HAIs while remaining compliant.

Why Every Medical Department Should Prioritize Infection Control

Why Every Medical Department Should Prioritize Infection Control

Learn more in our new whitepaper about how your hospital or medical center can prioritize infection control and why not prioritizing can pose health and financial risks.

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