GHC Infection Control and Employee Health Plan, D-07-003



Operational Policies | |

|Infection Prevention/Control and Employee Health Plan |Policy Number: |

| |Adopted: |

| |Revised: |

POLICY

ASC Name, through its Infection Prevention/Control and Employee Health Program, seeks to reduce the risk of acquisition and transmission of healthcare associated infections in patients, healthcare workers, and visitors. The ASC Infection Prevention/Control Committee (ICC) directs all activities for surveillance, prevention, and control of infections in patients, visitors, and healthcare workers. The Committee sets standards related to Infection Prevention/Control and Employee Health at all facilities and across all levels of care to reduce the risk of nosocomial and occupational acquired infections.

|Infection Prevention/Control and Employee Health Plan |Procedures for: |

| |Adopted: |

| |Revised: |

PROCEDURES

EXPLANATION:

The Infection Prevention/Control Committee, a multidisciplinary committee of medical staff and operations, directs the Infection Prevention/Control and Employee Health Program of the ASC. The core committee members are: the hospital epidemiologist and chair of the committee, Director Infection Control and Employee Health, Infection Preventionist’s (IP) from each geographic location, Employee Health Coordinator, Community Health representative, medical staff representatives, nursing representative, a laboratory representative, and hospital administrator. Other relevant departments (i.e., pharmacy, central services and reprocessing, facility/environmental services) will be requested to participate as needed for consultation in their area of expertise.

APPLICABILITY:

THIS POLICY APPLIES TO ALL HEALTHCARE WORKERS AT THE ASC.

DEFINITIONS:

HEALTHCARE WORKER: ALL EMPLOYEES, PARTICIPATING PRACTITIONERS, CONTRACTED, STUDENTS, AND VOLUNTEERS.

PARTICIPATING PRACTITIONER: A PARTICIPATING PRACTITIONER HAS PRIVILEGES AND SEES PATIENTS IN THE ASC FACILITY.

RESPONSIBILITIES AND GUIDELINES:

I. AUTHORITY

The authority to carry out the plan is vested in the Infection Prevention/Control Committee by the ASC CEO.

INFECTION PREVENTION/CONTROL COMMITTEE (ICC) RESPONSIBILITIES

General:

1. Provide oversight for the six functions of the Infection Prevention/Control and Employee Health Program (properties of each function described following item 7):

A. Surveillance

B. Policies & Procedures

C. Employee Health

D. Outbreak Intervention

E. Education & Training

F. Clinical Consulting/Committee Work

2. Conduct regularly scheduled meetings, at least quarterly.

3. Annually evaluate the Infection Prevention/Control and Employee Health Program for effectiveness, practicality, and cost effectiveness.

4. Promote science-based approach to infection control.

5. Review, revise and evaluate the goals of the Infection Prevention/Control and Employee Health Program annually. The goals are based on the Infection Prevention/Control and Employee Health Risk Assessment, which includes; geographic location and community environment of the hospital, program and services provided, and characteristics of the populations served.

6. The goals and evaluation are reported annually to the Hospital Quality Committee.

7. Review the Infection Prevention/Control and Employee Health Structure Standards annually. (Refer to Infection Prevention/Control and Employee Health Structure Standards.)

Six Functions of Infection Prevention/Control and Employee Health Program (item 1):

A. Surveillance

The Center for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) system definitions are used to identify healthcare associated infections. The surveillance data is appropriately analyzed and used to monitor and improve infection control and healthcare outcomes. Such activities include:

1. Approve the type and scope of focused surveillance monitors and ongoing review of surveillance activities, prevention, and control of infections as described in the current Infection Prevention/Control and Employee Health Risk Assessment and Plan.

a. Analyze:

i. For infection clusters

ii. Significant and/or unusual pathogens

iii. Occurrence of healthcare associated infections that exceeds the usual baseline levels

b. Control activities include:

i. Case finding

ii. Reporting of information about infections

iii. Development and implementation of prevention strategies

iv. Outbreak intervention and control

1. Compile and analyze surveillance data to identify trends in healthcare associated, community, and occupational acquired infectious diseases and to develop appropriate measures for prevention and control. Infection rates for targeted surveillance will be calculated and benchmarked using NHSN national rates.

2. Monitor patient care activities to identify practices, equipment, or supplies, which constitute a risk of transmitting infections.

3. Monitor and evaluate healthcare worker blood exposures and provide guidance and expertise.

4. Identify and implement infection prevention/control measures that are appropriate for high-risk populations and procedures (i.e., wound care) across the continuum of care.

5. Review and evaluate risks and significant events related to infection control. These include, but are not limited to, epidemiologically significant community acquired infections, product recalls, changes in community standards and practice, and new scientific information or technology.

6. Review antibiotic sensitivity profiles and trends. Make recommendations in antibiotic prescription practices and, when appropriate, refer specific issues in drug utilization trends to the Antibiotic Utilization Review Group of the Pharmacy and Therapeutics Committee.

B. Policy/Protocol/Procedure

Infection Prevention/Control and Employee Health will facilitate policy/protocol/procedure development, implementation, and effectiveness across the continuum of care:

1. Collaborate with ASC departments using consistency and continuity in all infection prevention/control policies and procedures in order to provide a safe environment for patients, visitors, and healthcare workers.

2. Promote compliance with standards defined by regulatory and accrediting agencies that relate to infection control (e.g., NIAHO, DOSH, DOH, and county health departments).

3. The authority to develop, review and revise policies, protocols, and procedures is delegated to the Infection Control Committee Chairperson, the Director of Infection Control and Employee Health, Infection Preventionists, and the Employee Health Coordinator, consistent with Infection Prevention/Control, Employee Health, and facility standards. This body will collaborate with administration, medical staff, and healthcare workers in the review process.

a. Cooperative-wide standards will be reviewed annually.

b. Departmental policies are reviewed at least every two years or more frequently if changes in practice are dictated.

4. Establish lines of communication with contracted services and facilities to assess comparable and acceptable standards of care.

C. Employee Health

Provide oversight of the development, implementation, and effectiveness of infection prevention/control aspects of the Employee Health Program for the protection of healthcare workers and the monitoring and intervention of employee health issues. Employee Health will:

1. Review and evaluate the infection prevention/control elements of the Employee Health Program.

2. Implement and monitor the healthcare worker screening and immunization and TB programs (see policies; Healthcare Worker Screening and Immunization Policy and TB Exposure Control Plan).

3. Monitor healthcare workers with significant infectious diseases and evaluate action taken to prevent transmission.

4. Review and evaluate the Accidental Parenteral Exposure program.

5. Monitor the incidence of healthcare worker exposures to infectious diseases and accidental parenteral exposures.

6. Develop, implement, and evaluate strategies for the prevention of healthcare worker exposures.

7. Evaluate post-exposure intervention and follow-up of healthcare worker exposures.

D. Outbreak Intervention

Infection Prevention/Control and Employee Health will quickly identify and implement measures to control endemic and epidemic infections and emergency preparedness/bioterrorism events by the following:

1. Emergency Authority of the Infection Prevention/Control Committee Chairman (refer to policy; Emergency Authority of Infection Prevention/Control Chairman). The Infection Prevention/Control Committee, through its chairman or the chairman designee (the Director of Infection Control and Employee Health, an Infection Preventionist, or a physician committee member), has the authority to institute any control measures or studies deemed appropriate to provide safe care for patients or personnel. These may include, but are not limited to the following:

a. Instituting appropriate isolation procedures (as per CDC Disease-Specific Precautions or Public Health/CDC recommendations)

b. Closing a patient care or service area until the infectious hazard no longer exists

c. Transferring a patient

d. Ordering disinfection of a patient care or service area

e. Ordering laboratory studies on patients, employees, or environmental samples

f. Establishing healthcare worker immunity and furlough procedures for exposed healthcare workers through periods of potential communicability

g. Quarantining equipment

2. Develop, implement, and evaluate an ongoing system to obtain pertinent laboratory data.

3. Develop ongoing communication and consultation with clinical staff throughout the organization to:

a. Identify infectious and adverse events

b. Assist in maintenance and monitoring of infection prevention/control procedures

c. Provide consultation on infection prevention and control measures

4. Access adequate resources and authority to ensure a comprehensive and timely investigation and implementation of appropriate control measures.

E. Education

Infection Prevention/Control will provide ongoing infection prevention/control educational programs to ASC healthcare workers.

1. Review and disseminate current infection prevention/control information to individuals or departments within ASC.

2. Develop and provide education programs on infection prevention/control and employee health to ASC healthcare workers.

3. Provide content, advice, and support for education programs related to infection prevention/control.

4. Evaluate the effectiveness, appropriateness, and availability of ongoing Infection Prevention/Control and Employee Health educational programs (i.e., New Employee and Provider Orientations, Safety Training, Annual Updates) to healthcare workers and departments.

5. Develop and implement tools to provide patients and caregivers appropriate information regarding infection prevention and control.

F. Consultation and Committee Work

Promote ongoing Infection Prevention/Control and Employee Health collaboration between departments, disciplines, and outside organizations to provide consultation, standardization, interventions, and clinical expertise on infection control, employee health, and safety.

The ICC is the approval body for equipment, products, items, or issues pertaining to, or involving, Infection Prevention/Control and Employee Health. Examples include but are not limited to:

▪ Cleaning, disinfection, sterilization equipment, products and solutions

▪ Hand lotions

▪ Skin antiseptics

▪ Hand soaps, antimicrobial soaps, surgical scrubs

▪ Personal Protective Equipment

▪ Safer devices and safety equipment

▪ Collaborate with Capital Requests and requesting Departments on equipment purchases to ensure item meets Infection Prevention/Control standards for cleaning and disinfection

▪ Construction and facility remediation

III. FACILITY, DEPARTMENT MANAGER, SUPERVISOR, CHIEF, AND HEALTHCARE WORKER RESPONSIBILITIES IN SUPPORT OF INFECTION PREVENTION/CONTROL AND EMPLOYEE HEALTH PROGRAM

|Facility/Dept Manager/Supervisor/Chief Responsibility |Health-Care Worker Responsibility |

|Surveillance |Surveillance |

| | |

|Promptly notify infection prevention/control and investigate |Promptly report infectious disease exposures, significant employee |

|circumstances surrounding infectious disease exposures, significant |infections, clusters of nosocomial infections and unusual trends to |

|employee infections, clusters of nosocomial infections, and unusual |their manager and Infection Prevention/Control. |

|trends related to Infection Prevention/Control. | |

|Policies and Procedures |Policies and Procedures |

| | |

|Implement and require compliance with ASC Infection Prevention/Control|Comply with ASC and department specific Infection Prevention/Control |

|and Employee Health policies and procedures. |and Employee Health standards. |

| | |

|Develop written department specific Infection Prevention/Control | |

|policies and procedures. Enforce compliance with department specific | |

|standards. | |

|Employee Health |Employee Health |

| | |

|Enforce department compliance with screening and vaccination program. |Comply with screening and vaccination program. |

| | |

|Investigate staff exposures. Require post exposure control activities |Report occupational exposures. |

|related to staff exposures are completed. | |

| |Participate in post exposure control activities |

|Outbreak Intervention |Outbreak Intervention |

| | |

|Participate in the development of outbreak control measures. Ensure |Comply with outbreak control measures. |

|measures are implemented. | |

|Education |Education |

| | |

|Ensure healthcare worker training and orientation to cooperative–wide |Attend orientation and participate in annual updates on infection |

|and department-specific Infection Prevention/ Control and Employee |control and employee health. |

|Health standards. | |

| |Document attendance at training sessions by sign in sheets or |

|Provide additional training when procedures change or when new |completing training tests. |

|procedures or equipment are introduced which affect the employees’ | |

|exposure to infectious materials. | |

| | |

|Schedule and maintain documentation of annual training for all | |

|healthcare workers. Records must be readily available for review for | |

|regulatory inspections. | |

|Orientation records: for duration of employment | |

|Inservice Records: for 3 years | |

|Clinical Consulting & Committee Work |Clinical Consulting & Committee Work |

| | |

|Request Infection Prevention/Control consultation as needed for the |Request information from manager/chief, Infection Prevention/Control, |

|prevention of infection of patients and staff. |and Employee Health as needed. |

| | |

|Promote departmental participation in committee activities to |Participate in committee activities as assigned by manager/chief. |

|establish and maintain effective infection prevention/control and | |

|employee health measures. | |

REFERENCES:

SHEA Position Paper: Requirements for Infrastructure and Essential Activities of Infection Control and Epidemiology in Hospitals: A Consensus Panel Report. Infection Control and Hospital Epidemiology 1998; 19:114-124.

SHEA Position Paper: Requirements for Infrastructure and Essential Activities of Infection Control and Epidemiology in Out-Of-Hospital Settings: A Consensus Panel Report. Infection Control and Hospital Epidemiology 1999; 20:695-705.

Infection Prevention/Control and Employee Health Structure Standards

Infection Prevention/Control and Employee Health Risk Assessment and Plan

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