FMD-002.pdf

VA Medical Center Memorandum FMD-002 Milwaukee, WI April 2021

INFECTION CONTROL POLICIES AND PROCEDURES

FACILITY MANAGEMENT DIVISION

1. PURPOSE: To establish policies, procedures, and guidelines for development and implementation of the Infection Control Program in the Facility Management Division.

2. POLICY: It is the policy of Facility Management to ensure a safe environment for their employees.

3. RESPONSIBILITIES:

A. The Facility Manager is responsible for compliance with this program as follows:

1. Providing the required personal protection safety equipment needed by divisional employees.

2. For monitoring compliance with this program.

3. For providing annual employee training and review the Infection Control Policy with the PI Coordinator for Infection Control. Validation performed by taking part in the annual Employee Education on TMS.

4. PROCEDURES:

A. Personnel Hygiene

1. Personnel are required to practice good personal hygiene. Good hygiene includes, but is not limited to, wearing of clean uniforms, washing of hands after use of toilet, handling objects that could contain harmful bacteria, or upon removal of any protective barrier.

B. Exposure Control Plan

1. This hospital follows the Occupational Safety and Health Administration (OSHA)

Bloodborne Pathogens Standards.

2. The Exposure Control Plan for this hospital is found in Medical Memorandum 00S-043, Bloodborne Pathogen Exposure Control Plan, dated March 2019 and is accessible to all staff.

3. In the MCM 00S-043, all employees have been assessed as to their risk of potential exposure to bloodborne pathogens such as the viruses that cause AIDS, Hepatitis B, and Hepatitis C, and have been assigned a category.

a. The following FM jobs positions have been identified as Category I, ‘job classifications in which all employees have occupational exposure:

Job / Position

Series #

Pipefitter 4204

b. The following FM job positions have been identified as Category II, defined as ‘job classifications and tasks/procedures in which some employees have occupational exposure’:

Job / Position Series # Air Conditioning Equipment Operator 5415 Motor Vehicle Operator 5703 Pipefitter 4204

4. All employees who have any potential contact with blood or other body fluids which may be considered infectious are eligible for the Hepatitis B vaccine:

a. These employees are assessed by the Employee Health Clinic upon hire and after an exposure to Hepatitis B.

b. The Hepatitis B vaccine is administered in a series of three injections given over a six-month period of time.

c. The employee may decline the vaccine; however, a special OSHA form must be signed. The form notes that the employee can still receive the vaccine, at no charge, in the future should the individual change his or her mind.

5. Employees performing tasks where there could be anticipated exposure to blood, body fluids, or encountering equipment/items contaminated with same are to wear appropriate personal protective equipment (PPE) and use the principals of Standard Precautions. These are described in the next section.

C. Work Performed in Patient Care Areas

1. Standard precautions – refer to MCM 00S-043.

D. Maintenance and Repairs of Patient Care and Non-Patient Care Equipment

1. Patient care equipment, as well as non-patient care equipment received by

Facility Management for repair will not be worked on unless it has been properly cleaned before delivery to the PM&R Team.

a. If equipment is received for repair and its external surfaces are visibly contaminated with blood or body fluids, the equipment will be returned by deliverer (SPS) to the point of origin for further decontamination.

b. If, after opening the interior of equipment, visible soiling is found i.e., blood, sputum, etc., the equipment will be returned to the place of origin for further cleaning before work is resumed.

E. Transportation and Disposal of Non-Burnable Waste

1. Items such as construction debris containing heavy wood, concrete, brick, etc., are transported to a holding container located on the medical campus grounds and then transported to a landfill by a contract service.

F. Transportation of Food

1. Hot and cold prepared foods are transported in a covered Commissary truck used for no other purpose. The foods are in the food transport carts, fully enclosed. No other items are allowed to be transported with food, i.e., food transport cannot be shared with the soiled laundry truck when food truck is inoperable.

G. Medical Center Sewage

1. The hospital sewage system delivers all sewage to City of Milwaukee Sewerage

System.

H. Cleaning of Ice Machines

1. The exterior surfaces of the ice machine cabinet are to be cleaned by Environmental Management Staff on a regular basis.

2. A/C Mechanics repair ice machines following the manufacturer’s protocol for removal/cleaning of all internal electrical and/or mechanical components.

3. PM&R staff perform weekly preventative maintenance on ice machines.

I. Cleaning of Heating, Ventilation and Air Conditioning Systems

1. The interior surfaces of air ducts in the hospital will be cleaned when deemed necessary by FM staff. Based on experience, FM will call in EMS, Safety, and Infection Control for evaluation on an as needed basis.

2. The exterior of air supply diffusers and air exhaust intake grills will be cleaned as often as necessary to maintain a sanitary appearance by Environmental Management Staff if they can be reached without the use of a ladder. For ceiling mounted diffusers and grilles that can only be reached with the use of a ladder, the A/C mechanics are responsible to clean.

J. Cleaning of Heating Convectors and Fan Coil Units in Inpatient Rooms

1. Cleaning and repair of heat convectors and fan coil units which requires the cover to be removed in hospital patient rooms shall not be done when any isolation patient occupies the patient room and will not be done while a patient is in the room.

2. Employees assigned to clean heat convectors in hospital patient rooms shall consult with the Nurse Manager of the ward before entering any patient room to ensure the room is vacant. Immediately prior to the start of convector cleaning (or repair) on the ward, the nurse should be asked for the isolation status of each room to have convectors cleaned (or repaired) on that day. The employee shall note in writing for his own reference, all specific isolation ruled in effect for each specific room.

a. If any room scheduled for convector or fan coil unit work is empty, the employee shall ask the Nurse Manager the status of the room (occupied, isolation, non-isolation or clean and empty) in order to assure himself that Environmental Management Staff has decontaminated the room.

NOTE: This procedure is intended to prevent infection exposure to the worker in the event the isolation (sign) specifics were removed from the room after patient discharge, but before Environmental Management Staff cleanup.

K. Items H-1 and paragraph I-1 through J-1-3 apply only to hospital patient rooms.

Standard precautions are required for employees cleaning convectors or radiators in domiciliary or other areas of hospital, or other buildings.

5. REFERENCES: None

6. RESCISSION: Facility Management Memorandum FMD-002 dated April 2018.

7. REVIEW MONTH: Every three years in April

LINDA SUE SCHWARZ, P.E., CHFM, LEED-AP

Division Manager, Facility Management

Distribution:

All Engineering Supervisors Infection Control Coordinators (00C)