Medical Center Infection Control Manual 2021.pdf

Infection Control Manual Version 1.0 Page 1

Revisions made to the Infection Prevention and Control Manual after the tri-annual review are approved by the Infection Prevention and

Control Committee (IPCC).

Revisions are indicated in RED in “Contents” and in the revised document.

W.G. (BILL) HEFNER

DEPARTMENT OF VETERANS AFFAIRS

MEDICAL CENTER

1601 Brenner Avenue

Salisbury, North Carolina 28144

Infection Prevention and Control Manual

The protection of our Veterans and employees from communicable diseases is one of our most important responsibilities. This manual contains the elements of a medical center-wide program designed to reduce to the most practical level the development of nosocomial infections. Each employee must take the personal responsibility for performing his or her job with this goal in mind. The Veterans and the employee’s co-workers are depending on them. All medical center infection control policies are based on current VACO, CDC, OSHA, APIC and other local, state and federal guidelines.

This manual has been revised to reflect current guidelines recommended/required by federal, state and local regulatory agencies to include but not limited to Veterans Health Administration (VHA), the Joint Commission, Centers for Disease Control (CDC) and Employee Occupational Safety and Health Administration (OSHA).

Infection Control Manual Version 1.0 Page 2

OPERATIONAL STANDARDS WERE REVIEWED, REVISED AS INDICATED, AND APPROVED:

Charles A. de Comarmond, MD Date ACOS Medicine, Chairman, Infection Prevention and Control Committee

Randall Gehle, MD Date Medical Center Chief of Staff

Joseph Vaughn, MBA Date Medical Center Director

Infection Prevention & Control Contacts

Charles de Comarmond, MD Pager (704) 642-3228 ACOS Medicine Service Office ext. 13983

Chris Carman, RN, MSN, CIC Pager (704) 638-7456

Infection Prevention & Control Program Coordinator Office ext. 13328

Roslyn Patterson, RN, MSN, CIC Office ext. 12639

Infection Preventionist

Lanette Mayer, RN Pager (704) 638-7900

MDRO Prevention Coordinator Office ext. 14469

Summary of Changes: Please click on this link to be directed to a summary of the revisions of the IPC Manual:

Summary of Changes

Infection Control Manual Version 1.0 Page 3

CONTENTS

Section 1: Infection Control (IC) Program MCM 659-11G-6 Infection Prevention and Control Committee (IPCC) 1.1

IC Summaries, Risk Assessments, Plans

IPC Risk Assessments-Goals-Plans

Section 2: IC Key Points 2.1

Section 3: Quick Links

• Don/Remove Personal Protective Equipment 3.1

• Cleaning Frequency Schedule 3.2

• Log for Negative Pressure Rooms 3.4

Section 4: Departmental Guidelines

• Anesthesiology

• Audiology

• Autopsy/Morgue

• Barber and Beauty Shops

• Canteen Service

• Cardiac Catheterization

• Cardiovascular/Pulmonary

• Chaplain Service

• Community Living Center (CLC)

• Dental Clinic

• Dental Clinic (Kernersville)

• Dialysis Unit Health Care Centers (HCCs)

• Education and Research

4.1

4.2 4.3

4.4

4.5

4.6

4.7

4.8

4.9

4.10

4.10.2 4.11

4.12

• Employee Occupational Health Services (EEOHS)

• Engineering [Facilities Management Services (FMS)]

• Environmental Management Services (EMS)

• Eye Clinic

• Health Care Center (HCC)-see Satellite Sites

• Home Based Primary Care (HBPC)

• Imaging

• Intensive Care Unit (ICU)

• Laboratory

• Logistics 4.20

• Medicine 4.21

• Mental Health and Behavioral Sciences

4.13

4.14 4.15

4.16

4.17

4.16 4.18

4.19 4.21 4.22

• Mental Health Intensive Care Management (MHICM) 4.23

• Nursing Home(Community) 4.24 file://///v06.med.va.gov/SBY/Service/Service%20Directory/11G%20-%20Medicine%20Service/Infectious%20Diseases/Infection%20Prevention%20and%20Control/6-IPCC%20Risk%20Assessments-Plans-Goals

Infection Control Manual Version 1.0 Page 4

• Nursing Service 4.25

• Nutrition and Food Service (also see MCM 659-120-7) 4.26

• Employee Occupational Health Services (EEOHS) 4.27

• Pharmacy 4.28

• Podiatry 4.29

• Police Service 4.30

• Post Anesthesia Care Unit (PACU) 4.31

• Primary Care 4.32

• Rehabilitation 4.33

• Respiratory Services 4.34

• Satellite Site [Health Care Center (HCC)] 4.35

• Sleep Lab 4.36

• Speech Pathology 4.37

• Sterile Processing Service (SPS) 4.38

• Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) 4.39

• Surgery (see also PACU) 4.40

• Urology 4.41

• Voluntary Service 4.42

Section 5: Policies and Procedures

• Acquired Immune Deficiency Syndrome (AIDS) (MCM 659-11-62)

• Bedbugs (see Pest Control)

• Bioterrorism/Respiratory Plan (see “Plans” section 6)

• Bloodborne Pathogens Plan (see “Plans” section 6)

• Blood Glucose Monitoring

• Bronchoscopy

• Carbapenem Resistant Enterobacteriaceae (CRE)

• Central Venous Pressure Catheter (see Intravenous)

• Cidex (OPA)

• Cleaning (see Environmental Management Services and Reusable Medical Equipment)

5.1

5.2

5.3

5.4

5.5

• Clostridium difficile (C.diff) (also see Isolation) 5.6

• Communicable Disease 5.7

• Construction (see MCM 659-138-25 “Project Development and

Implementation”)

• Corrugated Boxes (see Management and Use of Corrugated Cardboard Containers)

• CPR Training Manikins (Cardio-Pulmonary Resuscitation) 5.8

• Creutzfeldt Jakob Disease (also see Isolation) 5.9

• Cultures and Sensitivity Studies 5.10

• Ebola Plan (see “Plans” section 6)

• Equipment 5.11

• Fans 5.12

• Flash / Immediate Use Steam Sterilization (IUSS) 5.13

• Flu Outbreak 5.14

Infection Control Manual Version 1.0 Page 5

Flu Vaccine 5.15

• Food and Beverage Consumption by Employees 5.16

• Glutaraldehyde (see Cidex OPA)

• Hand Hygiene (also see MCM 659-11-82)

• Health Care Associated Infections (HAI)

• HIV (Human Immunodeficiency Virus) see AIDS

• Ice Machines

• Infectious Waste Management (see Waste)

• Imaging Transport

• Intravascular Recommendation

• Isolation Guidelines

• Jakob Creutzfeldt Disease (see Isolation and also Creutzfeldt Jakob)

• Legionella (MCM 659-11-67)

• Lice (Pediculosis)

• Laundry/Linen

• Methicillin Resistant Staphylococcus Aureus (MRSA) (Revised 10/31/2019)

• Microbiological Sampling

• Multidose Vials

5.17

5.18

5.19

5.20

5.21

5.22

5.23

5.24

5.25

5.26

5.27

• Multi-Resistant Organisms (also see Isolation, Vancomycin Resistant Enterococci, and Methicillin Resistant Staphylococcus Aureus) Revised 9/11/2020 5.28

• Negative Pressure Room Log- (see “Quick Links”) 5.29

This space left blank intentionally

Infection Control Manual Version 1.0 Page 6

• Outbreak Investigation 5.30

• Outbreak (Foodborne) 5.31

• Pandemic Influenza Plan (see “Plans” section 6) 5.32

• Pentamidine 5.33

• Personal Hygiene 5.34

• Personal Protective Equipment ( also see “Quick Links”) 5.35

• Pest Control 5.36

• Pet, Visiting Pet Program (MCM 659-11E-7; MCM 659-07-12) 5.37

• Plant s and Flowers 5.38

Pneumonia (Pneumonia, Healthcare Associated (includes Legionnaires, Pertussis, Aspergillosis, and Respiratory Syncytial Virus (RSV), Influenza- also see Isolation) 5.39

• Pressure Ulcer Wounds (Prevention of) 5.40

• Rabies (Animal Bites) 5.41

• Razors 5.42

• Refrigerators 5.43

• Respiratory Hygiene Stations 5.44

• Reusable Medical Equipment (RME) (also see MCM 659-118-12) 5.45

• SARS (Severe Acute Respiratory Syndrome) 5.46

• Scabies 5.47

• Skin (see MCM 659-118-9 Skin Integrity and wound Care Management) 5.48

• Smallpox Plan (see “Bioterrorism Plan”) 5.49

• Standard Precautions (see Isolation) 5.50

• Total Parenteral Nutrition (TPN) (also see Intravascular) 5.51

• Tracheostomy Care 5.52

• Transporting Patients, Supplies, and Equipment (also see Imaging) 5.53

• Tube Feeding (see MCM 659-120-2 Enteral Nutrition) 5.54

• Urinary Catheter Care 5.55

• Vancomycin Resistant Enterococci (VRE) 5.56

• Vending Machines 5.57

• Ventilation (mechanical)( also see Pneumonia) 5.58

• Visiting (also see MCM 659-11-12) 5.59

• Vital Signs 5.60

• Warehouse 5.61

• Waste, Disposal of Infectious 5.62

• Wound Management (See MCM 659-118-9) 5.63

Section 6: Plans

• Bioterrorism Plan 6.1

• Bloodborne Pathogen Plan 6.2

• Ebola Plan 6.3

• Pandemic Influenza Plan 6.4

• Tuberculosis (TB) Plan 6.5

• High Consequence Infection 6.6

Infection Control Manual Version 1.0 Page 7

References

Current 2021 VHA Directives, Memorandum and Handbooks

APIC Infection Control and Applied Epidemiology Principles and Practices, 2021. VHA APIC Link

Heymann, David L. Control of Communicable Disease in Man. Eighteenth Edition, 2004. American Public Health Association, Washington, DC.

Joint Commission Comprehensive Accreditation Manual for Hospitals (2018)

Guideline for Isolation Precautions in Hospitals. Center for Disease Control and Prevention. (2007)

Guideline for Prevention of Intravascular Device-Related Infections. Center for Disease Control and Prevention. (2011)

Guideline for Prevention of Nosocomial Pneumonia. Center for Disease Control and Prevention. (2003)

Guidelines for Infection Control in Health Care Personnel. Centers for Disease Control and Prevention. (1998)

Federal Register. Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities (2005). Centers for Disease Control and Prevention.

Federal Register. Employee Occupational Exposure to Tuberculosis (2003). Employee Occupational Safety and Health Administration.

Guidelines for Environmental Infection Control in Health Care Facilities, CDC, (HICPAC) (2003).

Guideline for the Prevention of Surgical Site Infection, CDC, 2017.

Guidelines for Construction and Equipment of Hospitals and Medical Facilities.

American Institute of Architect, Washington, DC. (2001).

Morbidity and Mortality Weekly Report. CDC.

North Carolina Tuberculosis Policy Manual, Department of Health and Human Services (2010)

Public Health Service Guidelines for the Management of Health Care Worker Exposures to HIV and Recommendations for Post Exposure Prophylaxis. CDC-MMWR (2005). Update 2013.

NC Infection Control Part I “Clinical Surveillance of Healthcare Associated Infections” and Part II. “The http://vaww.visn6.va.gov/WorkArea/linkit.aspx?LinkIdentifier=id&amp%3BItemID=26330 http://vaww.vhaco.va.gov/VALNET/APIC.asp

Infection Control Manual Version 1.0 Page 8

Infection Control Professional as an Environmentalist. UNC-Chapel Hill, NC.

SECTION 1: 1.1

Infection Prevention and Control Committee (IPCC)

MCP 659-11G-6

W. G. “Bill” Hefner VA Medical Center Salisbury, NC 28144

Signatory Authority:

Executive Director

Responsible Owner:

Associate Chief of Staff for Medicine Service

1. POLICY

Rescinded Document:

MCM 659-11G-6, June 5, 2017

Effective Date:

June 5, 2020

Recertification Date:

June 6, 2025

June 6, 2021 MCP 659-11G-6

This medical center policy (MCP) revises the Infection Prevention and Control Committee (IPCC) (formally the Committee on Medical Center Infections). The purpose of the IPCC is to support the missions, vision, and values of the Salisbury VA Health Care Systems (SVAHCS) through surveillance, prevention, and control activities that are designed to enhance organizational performance. The goal of the committee is to identify and reduce risks of endemic and epidemic health care associated infections in veterans and health care workers and all other persons served by the SVAHCS.

a. The scope of service includes all services and activities that impact on reducing risks for health care associated infections in the Veteran population. Activities are also designed to reduce risks for transmission of infection among Veterans, employees, consultants, contract services, volunteers, students, and visitors. All activities related to the surveillance, prevention, and controls health care associated infections are included. Committee membership is designed to utilize support systems to reduce the risks of infection from the environment.

b. This is a multidisciplinary committee composed of, at the minimum, the following representatives:

Infectious Disease Physician (IDP), Chair

Infection Control Practitioners (ICP)

Methicillin Resistant Staphylococcus Aureus (MRSA) /Multi-Drug Resistant

Organisms (MDRO) Prevention Coordinator

Chief Nurse/Acute Care

Chief Nurse/Geriatrics and Extended Care

Chief Nurse/Primary Care and Community Based Outpatient Clinic

Chief Nurse/Mental Health and Behavioral Sciences AFGE Representative Environmental Management Service Representative

Engineering Service (Safety) Representative

Food and Nutrition Services Representative

Microbiology Section Specialist

Occupational Health Services Representative

Patient Safety/Office of Performance and Quality (OPQ) Representative

Sterile Processing Services Representative

Surgical Nursing Manager Representative

Home-Based Primary Care Representative

Pharmacy Representative

Social Work/Mental Health Intensive Case Management

c. Note: All other departments will serve on consultative basis. Members who are unable to attend a meeting should send an alternate.

2. JUSTIFICATION

All activities of the committee including surveillance, recommendations, and interventions are based on the most current Centers for Disease Control (CDC) guidelines, Occupational Safety and Health Administration regulations, The Joint Commission (TJC), VHA Directives, and current practice guidelines from other organizations as appropriate.

3. RESPONSIBILITIES

a. The committee is responsible for:

(1) The committee oversees the infection control process through evaluation, analysis, and interpretation of infection control data. The performance-improvement framework is used to design, measure, assess, and improve the organization's performance of the surveillance, prevention, and control of infection

(2) Policies and procedures are reviewed every three years with the exception of those requiring annual review (e.g., Bloodborne Pathogen and Tuberculosis).

(3) The scope of surveillance activities is approved by the IPCC. They may include whole house surveillance, targeted (focus) surveillance, or prevalence surveys. The criteria for determining infections are consistent with the most recent guidelines established by the CDC and adopted by the IPCC. Data for infection control for the SVAHCS is based on our unique circumstances and current research. The data collected internally is benchmarked against system-wide data as well as data published in current infection control journals and CDC reports.

(4) All activities, data, and other information are reported by Infection Control staff to the organization through minutes and special reports as indicated. All information is confidential. Minutes are forwarded to services and other committees as required for review. This ensures that information is shared as appropriate with all staff.

Communicable diseases reporting logs are completed by Infection Control staff and are forwarded to Medical Records for information release to the health department in compliance with local and federal guidelines. A listing of reportable communicable diseases is available in the Infection Control Manual (ICM). In the event of a major or unusual infection or apparent epidemic, a special report will be promptly made through the Chief of Staff (COS) to the Medical Center Director (MCD) by the Chair of the IPCC.

(5) In order to enhance the antibiotic utilization review program as it relates to infection control, the committee will make recommendations based on the review of antibiotic-related data and infection control data to facilitate appropriate antibiotic therapy. Physicians are notified as indicated.

b. The Infection Control Staff is responsible for the integration of the principles of infection control throughout the SVAHCS through investigation, education, and consultation. Infection Control has the authority to initiate isolation procedures, placement and/or disposition of patients, and to initiate diagnostic studies as indicated.

The scope and method of surveillance and study activities will be determined in consultation with the Chair, IPCC and approved by the committee. The ICP will resolve questions about patient placement or infection control issues, assist in revisions of infection control policies and procedures, survey infections occurring on the units, and report the results to the IPCC and other appropriate services. The ICP will assist in preparation of educational programs relevant to infection control and provide patient education information on infectious diseases and infection control practices. ICP participate in the selection of equipment and supplies and provides consultation regarding renovation and construction. Infections that may impact on the health of employees will be reported to Occupational Health Services (OHS). Records of incidents related to infections and communicable diseases are maintained.

c. The Service Chiefs (SC) is responsible for ensuring that their employees follow the infection control guidelines established for the SVAHCS and their unique service.

SC is responsible for ensuring that their staff can access the ICMs. Provision of appropriate equipment and supplies is the SC responsibility. Education and training are the responsibility of the SC at the time of employment, annually, and as needed when technology changes. Documentation must be maintained in accordance with policy.

Evaluation of employee practice and compliance with infection control guidelines should be documented. Policies and procedures are reviewed and revised as necessary and forwarded to the committee for review and approval. Data from minutes, as appropriate, should be reviewed at staff meetings. Any actions mandated by the committee are to be resolved by the SC. SC will ensure that, when necessary, personnel under their jurisdiction consult with OHS for examination and treatment of infections.

d. The Physicians responsible for ensuring that Infection Control staff is informed of patients who may have a communicable disease. Physicians are responsible for following isolation guidelines designed to prevent the spread of infections. Physicians ensure that the veterans and their families receive appropriate information regarding the disease process.

e. The Nurse Manager, or her/his designee, will be responsible for consulting with the staff physician to verify diagnosis of any infections discovered on the unit. This information will be documented in the patient’s record and the Infection Control Staff notified. At the Health Care Centers and satellite centers, the clinic nurse manager is responsible for consulting with a physician to verify diagnosis of infections discovered and reporting to the Infection Control Staff. Patient education needs for infection control are identified at the unit level and appropriate interventions documented. All employees are responsible for following policies and procedure guidelines as established in the Infection Control Manual. Nursing management is responsible for ensuring that all patients, staff, and visitors on their units comply with all Infection Control guidelines.

f. The Chief, Health Administration Services (Medical Records) will be responsible for establishing procedures for reporting communicable diseases to state, county, and city health departments.

g. OHS is responsible for reporting to Infection Control Staff all illnesses or injuries in employees that may be potentially infectious. Trending of illness, immunization, and injuries of significance to Infection Control is analyzed by OHS and reported to Infection Control for review and inclusion in the minutes. OHS Staff are to report communicable diseases in employees to Infection Control Staff for required follow-up. OHS assists in educating staff about the risk of transmission and appropriate exposure precautions for communicable diseases.

h. All staff is responsible for following SVAHCS policies and procedures related to infection control. Staff is responsible for attending mandatory training for infection control. Staff is responsible for reporting infection control hazards promptly. All elements of the Bloodborne Pathogen and Tuberculosis plans must be followed.

Appropriate protective equipment and supplies will be utilized as required.

4. OUTBREAK MANAGEMENT

(a) Procedures for outbreak identification are defined in the Infection Control Manual.

(b) Infection Control Staff will investigate unusual occurrences.

(c) Outbreak monitoring for home health and contract nursing homes will be done by home health staff and reviewed by Infection Control for trending to determine if intervention is required.

(d) Early notification of anticipated outbreaks or emerging public health issues are provided to all staff in order to ensure early identification and intervention.

(e) In the event of a major or unusual infection or an apparent epidemic, a special report will be promptly made through the COS to the MCD by the Chair of the IPCC. At the Health Care Centers and satellite clinics the Medical Director/Administrator will be responsible for reporting to the Chair, IPCC.

5. INFECTION CONTROL COMMUNICATION PROCESS

(a) A multidisciplinary process is designed to ensure communication of infection control information to all staff in the SVAHCS. Minutes will be sent to the services.

Infection Control data must be shared at the service meetings. Infection Control Staff will collect data and analyze it by area in order to effectively target specific needs.

Consultation and educational materials will be provided by Infection Control Staff as appropriate. Service specific feedback will be provided to each nurse manager on a quarterly basis or more often if indicated.

6. STANDARD PRECAUTIONS

(a) All patients will be assumed to be "infectious" when admitted. Standard precautions will apply to all patients seen in the SVAHCS. Additional disease specific guidelines are listed in the Infection Control Manual.

7. MEETINGS

(a) The committee will meet at least six times per year at 2:30 p.m. on the fourth Tuesday of the month.

(b) The Chair, IPCC will be responsible for consolidating and incorporating information into the minutes of the meeting. The IPCC minutes will be forwarded to the Chief, Infectious Disease (IPCC Chair), the COS and the MCD for their review and approval. A copy of the approved minutes is forwarded to the OPQ and other services and staff as appropriate.

8. DEFINITIONS

a. None.

9. REFERENCES

a. TJC Comprehensive Accreditation Manual for Hospitals, January 9, 2017

b. TJC National Patient Safety Goals 2017

c. VHA Directives e.g., MRSA, CAUTI, Intravascular Catheters, HIV, etc.

https://vaww.visn6.portal2.va.gov/apps/sby/mcm/SitePages/Home.aspx.

d. Association for Professionals in Infection Control and Epidemiology, Inc. (APIC)

e. Principles and Practice Manual, Mosby, 2011

f. Centers for Disease Control (CDC), Healthcare Associated Infection, 2017.

10. RESCISSION

MCM 659-11G-6, June 5, 2017, is rescinded.

11. REVIEW

At minimum at recertification and including when there are changes to the governing document.

12. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of June 2025. This MCP will continue to serve as local policy until it is recertified or rescinded.

In the event of contradiction with national policy, the national policy supersedes and controls.

13. SIGNATORY AUTHORITY

Joseph Vaughn 309641 https://vaww.visn6.portal2.va.gov/apps/sby/mcm/SitePages/Home.aspx

D i g i t a l l y s i g n e d b y

J o s e p h

V a u g h n

Date: 2020.11.18 13:32:18 - 05'00'

Joseph P. Vaughn, MBA, FACHE Executive Director

Date Approved:

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: MCPs are available at:

https://vaww.visn6.portal2.va.gov/apps/sby/mcm/SitePages/Home.aspx.

Return to Contents https://vaww.visn6.portal2.va.gov/apps/sby/mcm/SitePages/Home.aspx

SECTION 2: 2.1

INFECTION CONTROL KEY POINTS

Key Points Table of Contents:

1. Food and Drink

2. Checking Expiration Dates

3. Disposable items

4. Clean Environment

5. Hand Hygiene

6. MRSA

7. Personal Protective Equipment (PPE)

8. Guidelines for checking supplies (expiration symbols)

9. Clean and Soiled Storage

10. Damaged Mattresses, stretcher pads, chair padding, etc.

11. Equipment Removal

12. Extension for Light Cords

13. “Dwell” Time

14. Sharps Boxes/Biohazard Waste Disposal

15. Corrugated boxes

16. Non-porous pallets

17. Contact isolation (stethoscopes, etc.)

18. Plants and flowers

19. The “28-day rule”

20. Sterile water/saline solutions-expiration dates

21. Reusable Medical Equipment (RME)

22. Employee Refrigerators

23. Documentation

24. Patient Education

25. Patient Placement

26. “Topping Off” Liquids

Key Points:

1. FOOD AND DRINK IS NOT ALLOWED IN ANY AREA TO WHICH PATIENTS HAVE

ACCESS. THIS INCLUDES REGISTRATION DESKS; NURSING STATIONS AND

OFFICES WHERE PATIENTS ENTER; LAB SPECIMENS ARE PLACED; ETC.

2. Check expiration dates on:

• Medications

• Hand Hygiene Products

• Disinfectants e.g., Dispatch (IF has no date-product is good until wipes are dry)

• Enteral Tube Feedings

3. Any item marked as disposable or single use MUST be discarded after a single use. The re-use or re-processing of disposable items is not allowed at the Medical Center and/or

Healthcare Centers (HCCs).

4. Ensure that the environment is clean including bathrooms, dayrooms, dining areas, break rooms, etc.

5. Hand hygiene:

a. When decontaminating hands with an alcohol-based hand rub:

• Apply product to palm of one hand

• Rub hands together covering all surfaces of hands and fingers especially between fingers and around cuticles and wrists.

• Apply to hand until hands are dry.

Note: Alcohol is not sporicidal and is not effective in removing C. difficile from the hands. See the antimicrobial soap procedure.

b. When using antimicrobial soap and water

• Wet hands under warm running water.

• Apply handwashing agent.

• Vigorously rub hands together for at least 15 seconds.

• Ensure that all hand surfaces, between fingers and around cuticles and wrists are cleaned thoroughly.

• Rinse hands thoroughly with hands in the downward position for an additional 10 seconds.

• Dry hands with a paper towel.

• Turn faucets off with a dry paper towel.

Remember that artificial nails, nail extenders, gels, etc. are not allowed if you are involved with direct patient care. If not born with them, they are considered artificial!

6. MRSA:

a. Must document verbal consent for nares swabs

b. Nares swabs to be done on admission to unit, also required on transfer and discharge if NOT previously positive this admission.

c. Positive in last 12 months, Contact Precautions required until criteria for flag removal met.

d. Nares swabs to be delivered to lab within 2 hours.

e. Specimens must be labeled with the patient’s full name, complete social security number, date, time, and initials of collector.

7. Ensure that PPE is readily available and keep PPE carts supplied and clean (inside and out).

8. Guidelines for checking supplies (expiration symbols):

• If the product has an hourglass on the package the expiration date is beside of it and reads 2008-10 which means it will be out of date October 2008.

• If your see a manufacturer’s date on the package it is good for 5years after the date unless the package integrity is compromised (damaged).

• Commercially sterilized items usually carry an indefinite shelf life. It is indicated on the label that the contents are sterile unless the package integrity has been compromised.

• Logistics, the staff in the area and the user of the supply item(s) are responsible for routinely checking the expiration dates on supplies. The date and packaging should always be checked prior to use.

9. Ensure cleaned and soiled equipment, etc. are located in separate LOCKED rooms.

10. Holes, tears or damaged mattresses, stretcher pads, wheelchairs padding, etc. must be removed from use and replaced as soon as identified due to being unable to clean them appropriately.

11. Any equipment that is broken or is not being used should be removed from the patient care area.

12. Materials that cannot be cleaned e.g., gauze are not allowed to be used as pull- cords. Cords must be made of a cleanable product e.g., plastic, vinyl, etc.

(Example- Kerlix/Kling has been used in some areas as an extension for light cords).

13. Follow the directions on disinfectant containers for length of time required to be effective (also known as “dwell” time).

14. Sharps/Biohazard Waste Disposal

• Sharp containers should be closed securely when 3/4 full by turning the closure until locked into place.

• Place several strips of tape to ensure closure.

• Placed the container BESIDE of the trash container in the soiled utility area.

• EMS staff are responsible for disposing of the sharps containers.

• EMS will transport the sharps container on top of or in a separate transport system to the designated locked compacting area.

DO NOT PLACE SHARP CONTAINERS INTO THE REGULAR TRASH

OR RED BIOHAZARD BINS!

15. Corrugated boxes are not allowed in any area where patients are allowed to enter or on any patient care area. Items must be removed from the boxes and placed in plastic bins for storage.

16. All items must be stored off of the floor on non-porous pallets (NO WOOD ALLOWED).

17. Stethoscopes should never be removed from a Contact Isolation room until discharge or unless it is thoroughly cleaned. (Baskets are available in-patient rooms for the stethoscopes).

18. Plants and flowers are not allowed in any outpatient office or exam room where patient care is provided (patient care includes taking vital signs, performing exams, etc.). Plant soil may be contaminated with mold over time which may place some patients with weak immune system at risk for severe infections.

Live and artificial plants and/or flowers are allowed in the inpatient setting except when exclusions are posted at the entrance to the patient rooms e.g., as neutropenic precautions.

Staff may have decorative plants in administrative offices; however, this practice is not encouraged. It is imperative that plants and flowers be kept to a minimum in order to maintain a clean, pest-free environment.

Artificial plants, trees and/or flowers are allowed in patient waiting areas only with facility/interior designer guidance.

19. The “28 day” expiration rule applies to all multidose vials to include both injectable and non-injectable formulations. Non-injectable formulations such ophthalmic eye drops, betadine and alcohol will be discarded after 28 days unless contamination occurs e.g., tip touches the eye or touches a surface, container is dropped or the container appears contaminated. If the manufacturer instructs the user to discard after a specific time period that is shorter than 28 days after opening, these instructions must be followed e.g., “discard 14 days after opening”. All multidose vials and solutions require labeling of the container to include initials, the date the container was opened and the 28-day expiration date. Creams, ointments and gels will be discarded based on manufacturer’s expiration date or manufacturer’s instructions for discarding after opening the container”

20. Sterile water and saline solutions expire 24 hours after being opened.

21. MCM 659-118-12 “Reusable Medical Equipment (RME)” is available online to assist staff with identifying appropriate cleaning protocols. All staff is responsible for the cleaning of RME.

All reusable medical equipment (RME) must have a written SOP on how the item is to be cleaned between patient uses unless the cleaning of the item is covered in MCM 659- 118-12 or in a department specific policy. All processing and cleaning of RME will follow the manufacturer’s guidelines.

Make sure that all RME is appropriately cleaned, labeled, and stored.

22. Food items in employee refrigerators do not have to be labeled with a date and initials;

however, employees are responsible for ensuring that the refrigerators are cleaned on a regular basis (inside and out); and that a work order is entered for maintenance and repairs.

23. Documentation must be completed on all invasive devices e.g., central lines, IV sites, indwelling catheters, trach sites, etc.

24. Pamphlets/booklets available for patient education include MRSA, VRE, C.diff, MDRO, Infection Control Prevention Booklet and Hand Hygiene.

25. Patient Placement:

Common

Illness / Condition

Bed Placement Options

Comments

MRSA

• Place only with a patient with MRSA OR in a room by themselves.

• Avoid shared bathrooms

Contact isolation.

See MRSA policy for more information.

VRE

• Must not share a bathroom.

• Must be in a room by themselves OR may put two VRE patients together if same site.

Strict contact isolation.

See VRE policy for more information.

C. difficile

• Must be in a room by themselves OR may put two C.diff patients together.

• Do not place with someone who is very immunosuppressed.

Contact isolation. Wash hands with soap and water (Alcohol gel not effective). Dispatch to be used for cleaning.

Shingles

Localized: Cover the lesions with clothing/gauze dressing until all lesions are crusted.

Standard Precautions.

Disseminated (spread over large area that cannot be covered):

Place in private room with negative pressure airflow until all lesions are crusted.

Required:

Airborne precautions.

Contact precautions.

Negative pressure airflow room.

Tuberculosis

• Private room with door closed at all times

• Negative pressure required.

• N-95 mask required to enter the room. (Requires fit testing)

Airborne isolation.

(TB)

Known or suspected

Patient Scheduled for Surgery

• Avoid placing patients with anyone with a known infection.

Cancer with

Chemo and/or Radiation

• Private room preferred.

• Avoid placing patients with anyone with a known infection.

26. “Topping off” (adding liquid to a container) is NOT allowed due to “Topping off” makes expiration dates invalid.

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3.2

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3.3

DAILY LOG OF NEGATIVE PRESSURE TESTING FOR TB ISOLATION ROOMS

(TEST MUST BE PERFORMED DAILY WHILE BEING USED FOR TB ISOLATION)

DATE

TIME

LOCATION-

ROOM #

SIGNATURE

TISSUE TEST

SHOWS

NEGATIVE

PRESSURE

YES OR NO

FMS

NOTIFIED (if not Negative

Pressure)

IMPORTANT: PROCEDURE FOR

TISSUE TEST: HOLD

A STRIP OF TISSUE

APPROXIMATELY 2 INCHES AWAY

FROM DOOR UNDERCUT.

OBSERVE - IF TISSUE IS PULLED

TOWARD DOOR, ROOM IS IN

NEGATIVE PRESSURE STATUS.

*ADD COMMENTS BELOW:

*Negative pressure logs must be kept in a file and be readily accessible for review by

Infection Control, Surveyors, etc.

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SECTION 4: 4.1

VA Medical Center Salisbury, North Carolina Infection Control

ANESTHESIOLOGY SECTION

ANESTHESIA PERSONNEL

A. Dress code

1. Personnel will wear clean operating room attire laundered by the medical center laundry. This attire will consist of:

a. Clean scrub suits

b. Long sleeved jackets

c. Hair completely covered with scrub cap

d. Clean shoes or shoe covers

e. Face masks

2. Operating room attire, including shoes, are not to be worn outside the main operating area.

3. Face masks are to be discarded and clean masks obtained for each case.

4. In the event operating room attire is worn out of the operating room, and become contaminated, scrub attire must be changed before re-entering the operating room.

B. Patient contact

1. Hands must be washed repeatedly with detergent bactericidal soaps, e.g., after each procedure and between patients.

2. Hands washed before going from one operating room to another.

3. Bed linens on stretcher should be clean and not agitated unnecessarily as bacterial flora in the air will be increased.

4. Patients are to wear a cap to cover their hair prior to entering the operating suite.

5. Anesthesia personnel with active respiratory or skin infections must not enter the operating room.

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6. Regardless of the type of anesthesia, a protective operative drape must be placed between the patient's face and the operative site after the patient's skin preparation is completed.

7. Patients with pulmonary infection should wear a face mask until the anesthesia face mask is applied.

8. To prevent bloodborne infections (HIV and Hepatitis B transmission) "standard precautions" as recommended by CDC, will be implemented for all patients in the operating room and P.A.C.U.

Gloves, masks, gowns and in some cases protective eyewear will be utilized for all procedures where exposure to blood, and blood tinges secretions are possible, e.g., (1) Surgical procedures,

(2) Catheter insertions, (3) Airway manipulation, (4) Arterial venous punctures.

EQUIPMENT. Every patient is to be protected from cross contamination by using disposable equipment as much as possible.

For all procedures:

1. Disposable needles and syringes are used for all medications and are disposed of after each patient use in biohazard containers.

2. All drugs are to be administered via stopcock rather than by I.V. ports to avoid recapping needles. Stopcocks should be maintained in a sterile manner.

3. Filtered needles are used to withdraw and mix any solutions.

4. Repeated refilling of disposable syringes is discouraged because of bacterial contamination of the syringed contents.

5. Disposable breathing circuits and ventilator tubes with bacterial filters are utilized for each patient for cases involving general anesthesia and are disposed of at the end of each case.

6. The surfaces of the anesthesia machine and worktable will be kept clean and orderly.

Waste receptacles are used for disposable objects. Contaminated equipment, e.g., endotracheal tubes and laryngoscope blades should be wrapped in towels and kept separate from clean materials.

7. An individual I.V. start-pack is used for venipuncture procedures and the venipuncture site is surgically prepared before puncture.

8. No disposable supplies or equipment will be reused and are to be disposed of in their proper containers.

9. Reusable equipment is processed after each use.

10. All reusable equipment is scrubbed with a disinfectant solution after each use.

Equipment that has to be sterilized is then sent to SPS and is sterilized and sent back in individual packages. Other items are disinfected as indicated and returned.

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11. At the end of each day the anesthesia machines are cleaned, disinfected, and restocked in preparation for the next day.

12. The work area is cleaned when contaminated and at the end of each day.

DRUGS AND SOLUTIONS

A. Every bag of intravenous fluid and medication vial must be checked and discarded if particulate matter or cloudiness is present.

B. Anesthesia solutions which have been mixed are to be used within 24 hours of breaking seal.

Unused portions are to be refrigerated, and then discarded after 24 hours.

C. Single dose vials should be used whenever possible.

1. If multidose vials are used, the vial is to be dated and initialed at the time of the first needle puncture.

2. All vials should be stored according to label instructions. All punctured vials will expire according to manufacturer's directions or within 28 days of opening.

3. The soda lime must be changed at least monthly, or more often, based on color indicator or contamination.

MICROBIOLOGIC SAMPLING

The Infection Control Staff retains the authority to obtain samples and/or advise personnel in the obtaining of material for culturing and sensitivity testing. Routine sampling is not done.

AIR FLOW IN THE OPERATION ROOMS AND RECOVERY ROOM

The air flow in the operating rooms has an exchange rate of 15 or more changes per hour.

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4.2

AUDIOLOGY INFECTION CONTROL POLICY

General aseptic practices – Hand washing is considered the most important single procedure for preventing infection in the clinic.

a. Hands must be washed between patients and as indicated by hospital policy.

b. Other hand washing indications.

1. Before performing invasive procedures whether or not sterile gloves are worn.

2. Before and after contact with wounds, with an invasive device (e.g., and intravenous cannula entrance wound).

3. Before contact with particularly susceptible patients.

4. After contact with a source that is likely to be contaminated, such as an infected patient or an object or device contaminated with secretions and excretions from patients e.g., a urinary catheter system; and

5. Between contacts with patients.

Protective equipment is available and must be used in all cases of contact with blood and body fluids.

(See Exposure Control Plan)

Employees who have signs of contagious disease should avoid patient contact.

Clean supplies and equipment must be provided for each patient to prevent cross-infections.

Questions regarding proper decontamination of equipment should be referred to the Infection Control staff.

Clinical Audiometers

1) Disposable insert earphones are used almost exclusively in the Audiology Clinic and are replaced between each patient. Earphone cushions are covered by disposable fabric covers which are discarded between patients.

2) Clinically, adult patents with draining ears are seen infrequently in a VA Audiology Clinic.

In the event a patient is scheduled for audiology examination and, upon inspection, does demonstrate a draining ear (such as an examination for C&P purposes) the audiology exam is deferred, and the patient is rescheduled at a later date for audiology exam when

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Clinical impedance meters/bridges

1. Cone of probe tip. The aluminum probe tip is unscrewed weekly and disinfected with 70% isopropyl alcohol.

2. The earphone cushion on the headset is cleaned weekly with 70% isopropyl alcohol as described above. Earphones are cleaned immediately following contact with patients with active external and/or middle ear pathology.

3. Ear canal plastic or rubber tips (placed onto the tip of the aluminum probe tip) are disposable and changed between patients.

Portable Audiometers Earphone cushions are cleaned after each use because this type of equipment is used only on irregular and infrequent basis.

Clinical Tools Reusable tools which do not come in contact with patients must:

1. Be cleaned of any visible debris following each use.

2. Be disinfected using disinfecting wipes following the package instructions for required dwell time following each use e.g., pointed tweezers, tubing expanders, needle plyers, tubing scissors, reamers, screwdrivers, files, drills, nelson tools, suction needles, battery removers, etc.

Standard Precautions:

a. All patients are assumed to be potentially infectious and care must be taken with blood and body fluids of all patients.

b. Audiology & Speech Service should be notified when patients needing services have a disease transmitted by the respiratory route. Appropriate barriers must be used.

c. Audiology staff is job classified as High Risk.

The Audiology Section is responsible for following policies of Employee Occupational Health, Exposure Control Plan, and those outlined in the Infection Control Manual. Employees in this service are required to attend all mandatory Inservices.

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4.3

AUTOPSY - PATHOLOGY AND LABORATORY MEDICINE

Unauthorized personnel will not be allowed in the morgue when an autopsy is being performed.

Permission to observe an autopsy shall be requested in advance and granted by the pathologist only.

All used clothing will be replaced into impervious laundry bag and put into the linen chute.

All disposable materials will be placed in the designated yellow metal waste container and will be emptied every night. The autopsy room must be cleaned immediately and thoroughly with an appropriate disinfectant.

In all autopsies, the autopsy personnel must wear approved uniforms, gowns, gloves, and other protective devices. A pair of shoes must be placed in the autopsy suite to be used only in the suite.

Boots are also available.

After an autopsy, each person must thoroughly wash their hands or take a shower as appropriate.

EATING, DRINKING, AND SMOKING ARE NOT ALLOWED IN THE MORGUE.

See Laboratory Safety Manual for additional information.

Special requirements will be necessary when the patient is suspected of having Creutzfeldt-Jakob disease.

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4.4

BARBER AND BEAUTY SHOPS

SANITATION

Modern barber and beauty shop practices are essential elements in the total sanitation program of the station. As this personal service presents the potential for the spread of fungal and bacterial skin and hair infections in patients and employees, all procedures should be conducted in a sanitary manner.

The Canteen Officer must frequently visit the barber shop and wards while barber service is being performed to check sanitation standards. He will ask the station sanitation office to include the barber shop in his inspections and to carefully note procedures for sanitizing tools.

Sanitation techniques practiced in the barber shops and by the ward barber must be adequate to prevent the spread of any disease, fungus, or sickness from the common use of tools. The following is required:

EQUIPMENT MUST BE CLEANED BETWEEN EACH PATIENT

After each use, the clipper heads and other metallic tools not specifically covered in this procedure must be wiped or brushed and effectively treated to remove all pathogenic organisms or fungi by an approved bacterial and fungicidal process.

After each use, razors, scissors, combs, and similar tools will be immediately washed with soap and water.

The tools will then be disinfected. Razor blades must be disposed of after each use in labeled rigid plastic containers. Any articles contaminated with blood must be disinfected with an approved hospital disinfectant.

After each use, hairbrushes must be cleaned of hair and other debris (usually combing vigorously with a coarse comb), disinfected, and rinsed well in running water prior to reuse.

Disinfection solutions will be approved by the appropriate agencies, and when used, will be changed daily.

Tools disinfected chemically will be rinsed in running water prior to use.

A separate, freshly laundered towel or a disposable towel will be used for each patron.

Individual disposable sanitary neck strips will be used for each patron.

Haircloths may be used on more than one customer, so long as they are clean, but must be replaced when soiled.

The headrest of barber chairs will be covered with a clean sheet of headrest paper or clean towel for each patron.

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Employees must be well groomed and will wash their hands with soap and water between patrons. If gloves are worn, they must be changed between patients and hands washed. Gloves should not be worn unless in direct contact with a patient or handling potentially contaminated items.

PROHIBITIONS

Neck dusters, shaving mugs, shaving brushes, powder puffs, sponges, lump alum, styptic pencils, and similar products are prohibited.

Only a powder or liquid applied with a clean towel or sterile absorbent cotton will be used to stop the flow of blood. These must be discarded in trashcans.

Service to patrons with scalp, face, or neck infections is not permitted unless medically approved.

Therapeutic practices such as treating blackheads, infected hairs, sores, or lesions, pulling of hair from ears, nostrils, and mustaches is prohibited.

The use of brushes for shampooing is prohibited.

Barbers and beauticians will not smoke, eat, or chew gum while attending patrons.

Barber carts are not permitted in food service areas.

Barbers and beauticians will not work when ill with a communicable disease or condition, which might be transferred to a patron.

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4.5

CANTEEN SERVICES

Purpose:

To provide for sanitary handling of all food and supplies and the sanitary maintenance of the equipment and food preparation areas in order to avoid food contamination and to protect the health of those served.

Policy:

Sanitary food handling procedures and techniques will be applied in the preparation and service of all goods. All food being received, stored, prepared, held, displayed, served, or transported will be protected from contamination.

Responsibilities:

The canteen services chief is responsible for administering/monitoring the infection control policy in the canteen services.

It is the responsibility of all canteen service personnel to follow established policies and guidelines in order to avoid food contamination and to control infection within the service.

All employees are responsible for maintaining a clean and sanitary environment.

Guidelines:

Health policies will be in compliance with the Employee Occupational Health Service (EOHS) guidelines.

Employees will be free of communicable disease or other infections.

Employees with open wounds or sores will not be permitted to work.

Employees who develop communicable diseases will inform the EOHS immediately.

Employees will maintain acceptable personal hygiene. Employees will report for duty in clean uniforms each day.

Smoking, eating, or drinking is not permitted in the food production and service areas.

Caps and/or hair nets will be worn to cover and contain hair.

Unauthorized personnel (patients/ visitors) are not permitted in the food preparation and service areas.

Air flow and exchange systems are maintained by Facilities Management Services.

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Handwashing is the most effective means of preventing the spread of infection. Employees will wash hands per protocol to include:

▪ after leaving the restroom,

▪ when reporting to the food preparation area

▪ after handling raw foods,

▪ after completing dirty task such as handling trash,

▪ whenever hands become soiled,

▪ and frequently during food preparation

Food temperatures will be maintained, recorded, and documented in accordance with Canteen Service requirements and guidelines .

The canteen services chief is responsible for ensuring that all employees receive training annually on safe food handling practices.

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4.6

CARDIAC CATHETERIZATION/ELECTROPHYSIOLOGY LABORATORY

PURPOSE:

The purpose of these guidelines is to document the measures taken to prevent or decrease the risk of infection during invasive procedures including, but not limited to, visualization of the heart and blood vessels with fluoroscopy, alteration of coronary or peripheral vasculature through intervention measures and electrical responses of cardiac tissue with pacing equipment.

GENERAL INFORMATION:

I. EMPLOYEE HEALTH AND HYGIENE:

A. All staff will follow Standard Precautions when providing patient care.