INFECTION CONTROL



Required Actions

Central Line Infection Prevention

• Documentation of central line insertion is required. Use the EPIC template that contains all the process measures required.

• Daily documentation of central line necessity is required. EPIC Progress note template includes the wording.

• Central line associated bloodstream infection (CLABSI) prevention education is provided prior to insertion. Given in pre-op clinics (CT, Neurosurg), ICU packets.

MRSA Nares Screening (CA State Law)

• Screen all ICU admissions, all hemodialysis pts, and any patient who has been in a healthcare facility the past 30 days.

• MD to inform patient of results and document in EPIC. Education given at discharge by nurse.

Hand Hygiene

• Perform hand hygiene (waterless alcohol gel or soap and water wash) before and after every patient contact. “Gel in and gel out” of every patient room. Do not wear artificial nails. National Patient Safety Goal

General Infection Prevention Activities

PPE (Personal Protective Equipment)

Wear PPE for contact with blood/body fluids:

GLOVES: non intact skin, mucous membranes, contact with body fluids

GLOVES & GOWNS: large draining wounds, any undiagnosed skin rash

GLOVES, GOWNS, EYEWEAR: intubation, irrigating large wounds or tubes under pressure

Annual fit-testing is required by CAL OSHA for N-95 respirator masks. Wear an N-95 respirator for all patients with verified or suspect aerosol transmissible diseases.

Refrain from patient contact if you have a fever, cough/flu symptoms, and skin lesion drainage/rash

Infection Control Manual

Quick Guide Policy 5.10 for patient placement /isolation questions.

Go to Stanford Intranet, click Policies Tab, click Infection Control Manual

Tuberculosis

Do not discharge or transfer any patient with verified or suspect active TB, or patients placed on TB meds until approval from the county TB Controller has been accomplished. Call Infection Control (5-1106) or pager 16167 for adults.

For Stanford Hospital & Clinics, call Infection Prevention & Control Department at 650/725-1106 or pager 16167.

For Pediatric issues at LPCH call the LPCH Infection Control Office at 650/497-8447 or pager 15796

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