Youth Consultation Service INFECTION CONTROL MANUAL

Transcription

1 Youth Consultation Service INFECTION CONTROL MANUAL TABLE OF CONTENTS SECTION I - INFECTION CONTROL PROGRAM... 4 OVERVIEW... 5 Goals... 5 Scope... 5 Division of Responsibilities... 6 Reporting Mechanisms... 6 ROLE OF THE INFECTION CONTROL LIAISON... 7 Role Summary... 7 Qualifications... 7 Duties and Responsibilities... 7 INFECTION CONTROL COMMITTEE... 8 SECTION II - SURVEILLANCE OF INFECTIONS... 9 INFECTION CONTROL SURVEILLANCE INFECTION CONTROL PLAN REPORTABLE DISEASES INFECTIOUS DISEASE OUTBREAK CONTROL INFECTION CONTROL OUTBREAK/DISASTER PLAN Definitions Reporting Case Investigation SECTION III - INFECTION CONTROL EDUCATION INFECTION CONTROL ORIENTATION AND INSERVICES INFECTION CONTROL ORIENTATION OUTLINE OSHA BLOODBORNE PATHOGENS CLIENT AND FAMILY EDUCATION CRITERIA FOR DETERMINING EXPOSURE TO COMMUNICABLE DISEASE PREGNANT PERSONNEL SECTION IV - INFECTION CONTROL PRECAUTIONS STANDARD PRECAUTIONS Personal Protective Equipment Barriers Indicated in Standard Precautions Other Methods of Standard Precuations USING GLOVES HANDLING AND/OR DISPOSING OF USED NEEDLES Equipment and Supplies Safety Precautions CARE OF THE CLIENT WITH COMMUNICABLE DISEASE Laundry Garbage Cleaning the Isolaiton Unit CONTACT PRECAUTIONS Resident Placement Revised 06/2010

2 Gloves and Hand-Washing Gowns Resident Transport Resident Care Equipment DROPLET PRECAUTIONS Resident Placement Masks Transport SECTION V - EMPLOYEE HEALTH REPORTING EMPLOYEE INFECTIONS HEPATITIS B IMMUNIZATION PROGRAM POST-EXPOSURE EVALUATION AND FOLLOW UP HEALTHCARE PROFESSIONAL'S WRITTEN OPINION SECTION VI - CLIENT CARE POLICIES CLIENT ADMISSION CLEANING AND DISINFECTING TOYS HAND HYGIENE Hand-washing Alcohol-Based Hand Rubs (Hand Sanitizers) INFECTIOUS WASTE MANAGEMENT Definition of Biomedical/Regulated Waste Handling of Needles and Sharps Handling of Blood and Blood Products Labeling of Biomedical/Regulated Waste Storage of Biomedical/Regulated Waste Disposal of Biomedical/Regulated Waste Other (Non-Regulated) Wastes PERSONAL HYGIENE COLLECTION OF SPECIMENS SECTION VII - DEPARTMENT PROTOCOLS DIETARY SERVICES Food Service Coordinator Responsibilities Nursing Service Responsibilities Personnel Personal Hygiene Food Storage Refrigerator Thermometers Proper Food Handling Supplemental Feedings Dietary Housekeeping Dietary Garbage Removal ICE CHESTS AND ICE MACHINES DIETARY HAND-WASHING POLICY HOUSEKEEPING SERVICES Frictional Cleaning Disinfectant Fogging Routine Cleaning of Horizontal Surfaces Choice of Cleaning Agents Cleaning of Spills of Blood and Other Bodily Fluids Infection Control Carpeting in Client Areas Trash HUMIDIFIER CLEANING POLICY Revised 06/2010 2

3 LAUNDRY SERVICES Routine Handling of Soiled Linen Transportation of Soiled Linen Separating Clean from Dirty in the Laundry...64 Protecting Personnel Who Sort Laundry Washing Heavily Soiled Items MAINTENANCE DEPARTMENT Preventive Maintenance Incineration Barrier Precautions General Facility Maintenance Preventive Maintenance of Filters Miscellaneous SECTION VIII - OSHA BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN PROGRAM ADMINISTRATION EMPLOYEE EXPOSURE DETERMINATION METHODS OF IMPLEMENTATION AND CONTROL Standard Precautions Exposure Control Plan Engineering Controls and Work Practices...72 Personal Protective Equipment Housekeeping Laundry Labels Hepatitis B Vaccination Post-Exposure Evaluation and Follow-Up Administration of Post Exposure Evaluation adn Follow-Up Procedures for Evaluating an Exposure Incident Employee Training Recordkeeping SECTION IX - TUBERCULOSIS CONTROL PLAN TUBERCULOSIS CONTROL PLAN CLIENT ADMISSIONS AND ON-GOING SURVEILLANCE Admissions On-Going Surveillance Transport PROSPECTIVE EMPLOYEES, ON-GOING SURVEILLANCE, AND EXPOSURE-INCIDENTS Prospective Employees Annual Personnel Screening Exposure Incidents Documentation of Occupational Exposure Revised 06/2010 3

4 SECTION I INFECTION CONTROL PROGRAM Revised 06/2010 4

5 YCS Infection Control Manual Section I Infection Control Program INFECTION CONTROL PROGRAM OVERVIEW 1) Goals The goals of the Infection Control Program are to: a) Decrease the risk of infection to patients and personnel. b) Monitor for occurrence of infection and implement appropriate control measures. c) Identify and correct problems relating to infection control practices. d) Ensure compliance with state and federal regulations relating to infection control. 2) Scope of the Infection Control Program The Infection Control Program is comprehensive in that it addresses prevention, detection, and control of infections among patients and personnel. a) THE MAJOR ACTIVITY OF THE PROGRAM IS PREVENTION OF INFECTION i) Client and staff education is done to focus on risk of infection and practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment. Immunizations are offered as appropriate to patients and personnel to decrease the incidence of preventable infectious diseases. b) DETECTION OF INFECTIONS i) There is on-going monitoring for infections among clients and personnel and subsequent documentation of infections that occur. c) IMPLEMENTATION OF CONTROL MEASURES i) Prevention of spread of infections is accomplished by use of Standard Precautions and other barriers, appropriate treatment and follow-up, and employee work restrictions for illness. Revised 06/2010 5

6 YCS Infection Control Manual Section I Infection Control Program 3) Division of Responsibilities for Infection Control Activities The Vice President of Health Services, Pediatrics, is ultimately responsible for the Infection Control Program. a) INFECTION CONTROL LIAISON i) Responsibility is delegated to the Infection Control Liaison (ICL) to carry out the daily functions of the Infection Control Program. Those functions are described in the Role of ICL. b) INFECTION CONTROL COMMITTEE i) The Infection Control Committee meets quarterly and provides input and direction for the Infection Control Program. Policies and procedures relating to Infection Control are developed by the committee for presentation to and approval by the Executive Policy and Procedure Committee. Reports of infections are presented to the committee which recommends actions and control measures when needed. 4) Reporting Mechanisms for Infection Control a) Client infection cases are monitored by the ICL. The ICL completes the monthly report forms for infectious diseases and: i) Reports to the Infection Control Committee ii) Provides feedback to clients and staff as needed. b) Employee infections are reported by the employee to the employee's supervisor. i) The employee s supervisor responds to reports of employee infection as per current Human Resources Policy and Procedure c) Compliance with infection control practices is monitored and documented by: i) Internal audits ii) Observation of Practices NOTE: Policies and procedures of the Infection Control Program may be found in the Infection Control Manual. Minutes of the Infection Control Committee meetings are maintained and reviewed by the Vice President of Health Services, Pediatrics, and reported to the Environment of Care (EOC) committee quarterly Revised 06/2010 6

7 YCS Infection Control Manual Section I Infection Control Program ROLE OF THE INECTION CONTROL LIAISON ROLE: REPORTS TO: Infection Control Liaison Vice-President of Health Services, Nursing 1) Role Summary a) Collects and reports client infection data; presents infection data to the Infection Control Committee; monitors employee compliance in the use of barriers and infection control measures; prepares and presents infection control educational offerings for clients and staff; serves as a resource to clients and program personnel; implements recommended corrective actions for infectious disease and outbreak situations 2) Qualifications a) Holds a current New Jersey state license as an LPN or RN. b) Completion of a basic training program for infection control. 3) Duties and Responsibilities a) Does on-going monitoring of healthcare-associated infections. b) Identifies infection control problems and makes recommendations for corrective action. c) Monitors infection control practices. d) Serves as a resource for clients and personnel on infection-related issues. e) Works with Infection Control Committee to conduct outbreak investigation and initiate control measures. f) Reports infectious disease data to the Infection Control Committee g) Reports communicable diseases to the State of New Jersey as required by law. h) Provides infection control educational offerings for clients and staff. i) Consults with medical and individual site/program administration as needed to improve care. j) Initiates follow-up on client exposures to communicable diseases. k) Participates in quality improvement activities. l) Participates in short and long range planning for the infection control department. m) Performs other duties as directed. n) Revised 06/2010 7

8 YCS Infection Control Manual Section I Infection Control Program INFECTION CONTROL COMMITTEE 1) Responsibility The Infection Control Committee is responsible for the prevention, detection and control of infections. The Committee is ultimately responsible for monitoring staff performance to ensure that Infection Control policies and procedures are executed. The Infection Control Committee meets on a quarterly basis. 2) Purpose Prevention, detection and control of infections. 3) Authority To take immediate and appropriate action to correct any deficiencies relating to Infection Control that creates a hazardous condition. 4) Reporting The ICL prepares infection reports and submits them to the Committee. Problems are identified and actions are planned for resolution. 5) Membership The Infection Control Committee is composed of the following: a) Medical Director b) Vice-President of Health Services (Pediatrics and Nursing) c) Assistant Vice-President of Health Services (Northern and Southern Regions) d) General Pediatrician e) Program Integrity and Accountability (PIA) Representative Revised 06/2010 8

9 SECTION II SURVEILLANCE OF INFECTIONS Revised 06/2010 9

10 YCS Infection Control Manual Section II Surveillance of Infections INFECTION CONTROL SURVEILLANCE PURPOSE: POLICY: To have knowledge of client infections to guide prevention activities and allow for appropriate actions and follow-up. The Infection Control Liaison does surveillance of infections among clients 1) The Infection Control Practitioner does surveillance of healthcare-associated infections by: a) Review of client culture reports and other pertinent lab data b) Physician/Advanced Practice Nurse (APN) consultation and referral c) Chart review d) Follow-up on communicable disease exposure 2) Healthcare-associated infections are reported monthly on the Monthly Nursing Department Report 3) Every six months, the Infectious Disease Aggregate Form is completed by the Nurse Manger and is forwarded to Health Services. 4) Results of the Infectious Disease Aggregate are tallied presented by the Infection Control Committee to CCQI on an annual basis. 5) Reporting of infections to the New Jersey Department of Health and Senior Services as required by law. Revised 06/

11 YCS Infection Control Manual Section II Surveillance of Infections INFECTION CONTROL PLAN PURPOSE: To develop and maintain a written plan for infection control including an assessment of risk, services provided, the population served, strategies to decrease risk, and a surveillance plan. POLICY: A written Infection Control Risk Assessment and Plan (Plan) will be implemented. 1) The Plan will be outlined on the "Infection Control Risk Assessment Form" and will include: a) Assessment of risk b) Assessment of services provided c) Assessment of the population served d) Prioritized strategies to decrease risk e) Surveillance plan based on analysis of previous data. 2) The Plan will guide the activities of the Infection Control Committee and will be updated at least annually and more often as needed. Revised 06/

12 YCS Infection Control Manual Section II Surveillance of Infections REPORTABLE DISEASES PURPOSE: POLICY: To report infectious diseases to the New Jersey Department of Health and Senior Services as required by law. Behavioral Health Care Facilities are required by law to report certain infectious diseases. 1) A list of reportable infectious diseases, as well as required reporting forms, is made available to the ICL on an annual basis by the Infection Control Committee, or more often as warranted. 2) An exception to reporting is if there is knowledge that the disease has already been reported by the laboratory or other provider. Revised 06/

13 YCS Infection Control Manual Section II Surveillance of Infections INFECTIOUS DISEASE OUTBREAK CONTROL PURPOSE: POLICY: To effectively identify infectious disease outbreaks early in their courses and prevent further spread of infection to clients and staff The Infection Control Committee maintains an Infectious Disease Outbreak Control Plan (Plan) 1) The Plan is reviewed and updated on an annual basis, and more frequently as warranted 2) Infectious disease outbreaks are identified through on-going surveillance activities as outlined in Section 1: Infection Control Program, of this manual 3) When an infectious disease outbreak is identified, the Infection Control Committee will identify individuals responsible for carrying out the steps outlined in the Plan 4) Copies of the Plan will be maintained by the Health Services Administration, Northern and Southern Region, and Nurse Manager at each residential site Revised 06/

14 YCS Infection Control Manual Section II Surveillance of Infections INFECTION CONTROL OUTBREAK/DISASTER PLAN At the time of an Outbreak, the Infection Control Committee will determine who is directly responsible for executing the following steps, as this will vary by site 1) Definitions The definitions below refer to respiratory illnesses as per the January 2009 NJDHSS- CDS Guidelines for the Control of Respiratory Outbreaks in Long-Term Care and Other Institutional Settings monograph, but will be generalized to be used for all infectious diseases at YCS a. Cluster i. Defined by the CDC as three or more cases of acute illness occurring within 48 to 72 hours, in residents that are in close proximity to each other (e.g. in the same area of the facility). b. Outbreak i. Defined by the CDC as a sudden increase in cases over the normal background rate, or when any single resident tests positive for influenza Of note, the facility should not wait until an arbitrary number of cases, (such as 10% of census) has occurred) 2) Reporting a. Calling Guardian/DYFS i. If the Guardian would like to take the client home for a family visit, he or she must do so with informed consent stating that the risk of transmission of the illness to other family members is understood and that YCS will not be liable or responsible for any illness that results from the client s presence in the home. b. Initial outbreak (to LHD) i. MUST REPORT TO LHD BY PHONE. If they cannot be reached, call DHSS directly ( , after-hours) c. Routine updates of outbreak status 3) Case Investigation Even in the absence of LHD involvement, the following steps must be followed in order to prevent disease spread. a. Confirm the outbreak (based on the number of cases present on the unit/wing/throughout the facility). b. Verify the diagnosis i. Based on history and physical, lab exams as needed Revised 06/

15 YCS Infection Control Manual Section II Surveillance of Infections c. Develop a case definition i. In order to describe the criteria that the individual must meet in order to be counted as an outbreak case: 1. Clinical signs and symptoms 2. Physical location 3. Specific time period d. Perform active surveillance e. Document and count cases f. Identify and eliminate possible transmission sources i. Exclude sick staff ii. Monitor personnel absenteeism iii. Inform receiving facilities of the outbreak when transferring residents g. Institute control measures i. Cohort residents, staff, equipment, and supplies according to living/work area. When it is necessary to transport clients to another location, it must be coordinated in consultation with the Infection Control Committee to determine a means of transport and transport precautions to prevent further spread 1. Ill 2. Exposed (not ill, but potentially incubating) 3. Not ill/exposed a. Restrict use of equipment and supplies to use in each cohort area b. Do not allow inter-mingling among cohorts (e.g. dining, recreation, etc) c. Keep symptomatic residents in their rooms (or infirmary) until 24 hours after symptoms have resolved d. Do not allow staff assigned to affected units to rotate to unaffected units ii. Maintain standard precautions 1. Check cdc.gov regarding necessary precautions based upon pathogen involved 2. Reinforce/reemphasize hand-washing among residents, staff, and visitors 3. Post signs to discourage those who are ill from visiting the facility, and to encourage visitors to inform the facility if they have symptoms of infection 4. Provide tissues and/or masks to residents and visitors with cough/sneeze so that they may cover their mouth and nose 5. Provide tissues and alcohol-based hand rubs in common areas Revised 06/

16 YCS Infection Control Manual Section II Surveillance of Infections 6. Ensure that supplies for hand-washing are available where sinks are located, provide dispensers of alcohol-based hand rubs in other locations 7. Provide hands-free waste receptacles whenever possible iii. Provide in-service education within 24 hours or by the next business day 1. In consultation with Infection Control Committee, who will provide standardized information to be presented to all staff on all shifts h. Evaluate the effectiveness of control measures and modify as needed i. Outbreak is generally considered over when two incubation periods have passed without a new case being identified 1. Infection Control Committee will determine the incubation period of the offending agent in consultation with the LHD and through other resources (e.g. cdc.gov) i. Summarize the investigation/cases in a final report i. This report will be reviewed by the Infection Control Committee during its quarterly meetings to determine any areas for possible improvement ii. A copy of the report will be kept on file in the office of the Chairperson of the Infection Control Committee In the case of an infectious disease outbreak that attracts media attention, all calls/requests for information/interviews are to be directed to the President/CEO of the organization Revised 06/

17 SECTION III INFECTION CONTROL EDUCATION Revised 06/

18 YCS Infection Control Manual Section III Infection Control Education INFECTION CONTROL ORIENTATION AND INSERVICES PURPOSE: To ensure instruction of personnel regarding the importance of infection control and the use of infection control policies and procedures. POLICY: 1) All new personnel will attend an orientation program that addresses basic principles of infection control, OSHA bloodborne pathogens regulations, and hepatitis B infection. 2) All personnel will attend at least one mandatory infection control update per year. OSHA bloodborne pathogens regulations will be included as well as other infection control issues of importance to the agency. 3) Records will be maintained by the training department documenting: a) Date and time of training b) Instructor Content outline c) Participants and department 4) The ICL will conduct one-on-one training with personnel as practices are observed and corrections or changes in practice are needed. Revised 06/

19 YCS Infection Control Manual Section III Infection Control Education INFECTION CONTROL ORIENTATION OUTLINE 1) General Infection Control Principles a) Hand-washing and Hand Hygiene i) Washing with soap and water ii) Use of alcohol hand-rubs 2) Standard Precautions and other barrier precautions a) Reasons for Standard Precautions i) Employee protection against bloodborne diseases ii) OSHA regulations iii) CDC recommendations 3) Components of Standard Precautions a) Barriers for protection i) Gowns ii) Gloves iii) Masks iv) Eye protection v) Arm protectors (for programs with autistic children) vi) Safer sharps devices 4) Biomedical waste 5) Linen handling 6) Summary/questions/answers Revised 06/

20 YCS Infection Control Manual Section III Infection Control Education OSHA BLOODBORNE PATHOGENS STANDARDEMPLOYEE TRAINING OUTLINE 1) History of the Standard a) Hepatitis B b) HIV/AIDS c) CDC Recommendations d) OSHA Standard 2) Bloodborne Diseases a) Hepatitis B i) Epidemiology ii) Transmission iii) Symptoms b) Hepatitis C i) Epidemiology ii) Transmission iii) Symptoms c) HIV Infection i) Epidemiology ii) Transmission iii) Symptoms 3) Exposure Control Plan a) Review of each element b) Exposure determination: recognition of tasks requiring occupation exposure c) Universal application of exposure control plan 4) Personal Protective Equipment a) Types b) Use c) Location d) Selection e) Removal Revised 06/

21 YCS Infection Control Manual Section III Infection Control Education f) Handling g) Decontamination h) Disposal 5) Work Practice and Engineering Controls a) Environmental Modifications b) Work Practices i) Hand-washing/hand hygiene ii) Safer Sharps and Sharps Handling iii) Other 6) Standard Precautions a) Overview 7) Hepatitis B Immunization a) Who is at risk? b) Benefits of Immunization c) Method of Administration i) Dose ii) Schedule iii) Site d) Consent Form e) Declination 8) Exposure Incident a) Definition b) Reporting c) Follow-up 9) Questions/discussion NOTE: A qualified instructor must be available at each training session for interactive questions and discussion. Revised 06/

22 YCS Infection Control Manual Section III Infection Control Education CLIENT AND FAMILY EDUCATION FOR INFECTION CONTROL AND INFECTIOUS DISEASES PURPOSE: POLICY: To establish an educational process for clients and family relating to infection control. It is the intent of this facility to identify educational and teaching opportunities for clients and/or family members relating to infection control and infectious diseases. YCS recognizes that not all clients are capable of participating in educational activities. The professional staff should determine individual client s educational needs for infection control. 1) Infection control teaching may be provided in a variety of ways (verbal, written, etc.) and should include: a) Personal hygiene (completed annually) b) Hand hygiene (at least annually) c) Isolation and barrier precautions used by staff and visitors d) Transmission of infection e) Specific infectious diseases f) Antibiotic treatment g) Room changes relating to infections h) Other as needed. 2) Infection control teaching may be considered: a) On admission to the facility b) On re-admission following a hospital stay c) On change of condition relating to infection d) Other situations as appropriate. 3) Documentation of teaching may be found in the medical record. Revised 06/

23 YCS Infection Control Manual Section III Infection Control Education CRITERIA FOR DETERMINING EXPOSURE TO COMMUNICABLE DISEASE PURPOSE: DISEASE AIDS To identify significant exposures in order to direct prophylaxis. DEFINITION OF EXPOSURE Parenteral or mucous membrane exposure to blood or body fluids of a patient who is HIV positive or diagnosed as having AIDS. Hepatitis A An eligible contact should be a person who has during a period of 15 days before onset of overt symptoms and/or during a few days after the development of jaundice: a. Lived in the same household with the patient/employee. b. Had intimate sexual contact with the patient/employee. c. Incurred known exposure to fecal material or vomitus of non-isolated patient or employee if exposed individual has not followed good hand-washing technique. Hepatitis B Herpes (acute gingivostomatitis) Documented percutaneous or permucosal exposure to infective body fluids. Direct contact with the saliva of carriers. Measles Direct contact with nasal or throat secretions or airborne by droplet spread by personnel who have not had measles or immunization against measles. Revised 06/

24 YCS Infection Control Manual Section III Infection Control Education Meningitis (Meningococcal) Direct contact with respiratory secretions from nose and throat of infected people. Mumps Pediculosis capitis (Head lice) Rubella Scabies Tuberculosis Varicella zoster (Chickenpox) NOTE: Airborne transmission or by droplet spread and by direct contact with saliva of an infected person by those not having had mumps or mumps vaccine. Direct contact with an infested person and/or indirect contact with their clothing, head gear or linens Direct contact with nasopharyngeal secretions of infected people Direct contact with the skin of infested persons. Can also be acquired during sexual contact. Significant exposure to persons capable of generating aerosolized particles containing tubercle bacilli from the respiratory tract. Direct contact, droplet or airborne spread of vesicle fluid or secretions of the respiratory tract of chickenpox cases or of vesicle fluid of persons with herpes zoster (shingles). Significant exposures will be determined on an individual basis. Factors to be considered include: Etiologic agent Mode of transmission Degree and method of contact Susceptibility Reference: Chin J., Control of Communicable Diseases Manual, 17th. ed., 2000, American Public Health Association, Washington, DC. Revised 06/

25 YCS Infection Control Manual Section III Infection Control Education PREGNANT PERSONNEL Management of Occupational Exposures to Infectious Diseases in Pregnant Personnel Agent Cytomegalovirus Potential Effect on the Fetus hearing loss; various congenital syndromes Rate of Perinatal Transmission Prevention 15% Standard Precautions Hepatitis B hepatitis; development of chronic infection of the infant HBeAg +, 90% HBeAg -, 0-25% Vaccine; Standard Precautions Hepatitis C Hepatitis 2-5% Standard Precautions Herpes simplex sepsis; encephalitis unlikely from nosocomial exposure Standard Precautions HIV AIDS by 2-3 years 8% - 30% Avoid high risk behaviors; postexposure prophylaxis Influenza Inconsistent Rare Vaccine (safe during pregnancy); Droplet Precautions Measles prematurity; abortion Rare Airborne Precautions If non-immune, Immune Globulin within 6 days Rubella congenital syndrome 45-50% overall; Droplet Precautions Tuberculosis hepatomegaly, CNS, pulmonary 90% in 1st trimester Rare Immune Globulin Airborne Precautions Varicella-zoster malformations (skin; limbs, eye, CNS) total 25%; congenital syndrome (0-4%) Airborne,Contact Precautions Varicella-Zoster Immune Globulin Revised 06/

26 SECTION IV INFECTION CONTROL PRECUATIONS Revised 06/

27 YCS Infection Control Manual Section IV Infection Control Precautions STANDARD PRECAUTIONS Purpose: It is the intent of YCS that all client blood, bodily fluids, excretions and secretions other than sweat will be considered potentially infectious. Standard Precautions are indicated for all clients. 1) Personal Protective Equipment a) PPE is provided to all employees to be used when following procedures of Standard Precautions. b) Each employee is responsible for knowing where the equipment is kept in the department. c) The type of protective barrier(s) should be appropriate for the procedure being performed and the type of exposure anticipated. d) PPE available includes gloves, gowns or aprons, masks and eye protection (or face shields), and resuscitation devices. 2) Barriers Indicated in Standard Precautions a) Gloves - Gloves will be kept in designated areas of the nurse s office, kitchen, classroom, and in all first-aid kits. Gloves should be worn whenever exposure to the following is planned or anticipated: i) Blood/blood products/body fluids with visible blood ii) Urine iii) Feces iv) Saliva v) Mucous membranes vi) Wound drainage vii) Drainage tubes viii) Non-intact skin ix) Performing venipuncture or invasive procedures b) Masks and eyewear (or face shields) - should be worn during procedures that are likely to generate droplets/splashing of blood/body fluids. Supplies of disposable masks are to be kept in the nursing office. c) Gowns/Aprons - should be worn when there is potential for soiling clothing with blood/body fluids. d) Resuscitation Equipment mouthpieces or other ventilation devices should be available as alternatives for mouth to mouth resuscitation. Revised 06/

28 YCS Infection Control Manual Section IV Infection Control Precautions 3) Other Methods for Instituting Procedures of Standard Precautions a) Private Room - consider when client hygiene is poor or in cases where blood/body fluids cannot be contained. b) Hand-washing/hand hygiene refer to procedure on hand-washing/hand hygiene. c) Sharps Precautions safety engineered sharps should be used and used sharps should be placed in an appropriately labeled puncture resistant container. d) Lab Specimens should be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping. If outside contamination of the primary container occurs, it should be placed within a second container. e) Blood Spills spills of blood or other body fluids should be removed and the area decontaminated using the facility-approved blood spill kit. Gloves should be worn during cleaning and decontamination. The manufacturer s directions will be followed for use of the product in cleaning and decontaminating spills. f) Linen soiled linen should be handled as little as possible. Gloves should be worn to handle linen wet with blood or body fluids. g) Waste waste should be bagged in impervious bags. References: Department of Labor Occupational Safety and Health Administration, Occupational Exposure to Bloodborne Pathogens, Needlestick and Other Sharps Injuries; Final Rule. 66: January 18, Department of Labor Occupational Safety and Health Administration, Occupational Exposure to Bloodborne Pathogens: Final Rule 29 CFR Part December 6, HICPAC, Guideline for Isolation Precautions in Hospitals, Infection Control and Hospital Epidemiology, January, Revised 06/

29 YCS Infection Control Manual Section IV Infection Control Precautions USING GLOVES PURPOSE: To provide guidelines for the use of gloves for client and employee protection. 1) Gloves are used primarily to prevent the contamination of the employee's hands when providing treatment or services to the client and when cleaning contaminated surfaces. 2) Gloves are to be used when: a) Touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin b) Employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis etc. c) Cleaning up spills or splashes of blood or body fluids d) Handling potentially contaminated items e) It is likely that hands will come in contact with blood, body fluids, or other potentially infectious material f) Performing phlebotomy or immunization 3) Disposable single-use gloves are to be worn a) If hypersensitivity to latex occurs, employee will be provided with an alternative. 4) Gloves must be replaced as soon as practical when contaminated, torn, punctured, they exhibit signs of deterioration, ortheir ability to function as a barrier is compromised. 5) Used gloves must be discarded into the waste receptacle inside the room. 6) Perform hand hygiene after removing gloves. Gloves do not replace hand hygiene. Revised 06/

30 YCS Infection Control Manual Section IV Infection Control Precautions HANDLING AND/OR DISPOSING OF USED NEEDLES PURPOSE: To provide guidelines for the safe handling and disposal of used needles. 1) Equipment and Supplies a) Safer sharps devices b) Sharps container c) Gloves (as indicated) d) Other as necessary or appropriate 2) Safety Precautions a) Needles, used or unused, may not be discarded into trash receptacles. b) After use, discard the needle after activating the safety feature (if present) and without (1) re-capping by hand, into the sharps container. ii) Do not bend, break, or cut needles. c) When the sharps container is ¾ filled, the container must be stored until picked up by a licensed vendor for proper disposal. d) In the event of a needle-stick injury, the employee should: i) Immediately wash the wound with soap and running water ii) Cause the injured site to bleed iii) If desired, apply alcohol or hydrogen peroxide to the wound and iv) Notify the Program Director/Site Administrator and Program Nurse of the incident immediately after the above steps have been completed Revised 06/

31 YCS Infection Control Manual Section IV Infection Control Precautions CARE OF THE CLIENT WITH COMMUNICABLE DISEASE Policy: It is the policy of YCS to institute procedures to facilitate the containment of potentially infectious diseases Clients will be placed in the infirmary or physically separated from other residents if deemed necessary until they are determined to be non-contagious by the physician or Advanced Nurse Practitioner for the conditions listed below but not limited to: Diarrhea Fever above 101 degree F. Infectious Mononucleosis Infestations (Scabies, Head Lice) Influenza/Upper Respiratory Infections Purulent Conjunctivitis Streptococcal pharyngitis Varicella Vomiting 1) Any client who exhibits any of the above or shows signs or symptoms of a suspected infectious disease must be assessed by an RN or LPN prior to departing for school. a) If no nurse is present on-site, the child is to be held back until one arrives to assess him or her. 2) Following diagnosis of client with an infectious disease, care must be taken to assure the safety of other clients, staff, families, and visitors from the transmission of organisms that cause disease and/or illness. a) The on-site Infection Control Liaison will issue staff alerts to all department heads. b) Precautions will be taken to prevent transmission to other clients. c) Staff will be in-serviced by the Nursing Department on precautions to be taken based on CDC recommendations found in the Control of Communicable Disease Manual d) Nursing Department will contact any family member with visitation privileges on the nature of the child s illness, treatment, and prevention of transmission. Revised 06/

32 YCS Infection Control Manual Section IV Infection Control Precautions GENERAL ISOLATION PROCEDURES Policy: It is the intent of YCS to practice general infection control procedures for the handling of potentially infectious materials 1) Laundry - Consists of all linens, gown, and clothing worn by client on isolation and by visitors and staff caring for client. a) The isolation client s personal laundry will be cared for in the facility. Family will be asked not to take home any personal laundry while the client is in isolation. Personal laundry will be handled the same as facility linen. b) Soiled linen is to be handled as little as possible. Laundry personnel will wear gloves when handling isolation linen or any linen visibly contaminated with blood. The following procedures are to be followed: i) Double-bagging in the isolation room, using first, a water-soluble laundry bag and second, a regular clear plastic bag. ii) Clearly mark and label as Infectious Material, then hold in a designated, isolated area for immediate pick-up by Housekeeping. Nursing will call for pickup. iii) Removed from the plastic bag and washed separately from other facility linen inside the water soluble bag. (1) The hottest water temperature should be used along with a detergent and a germicidal solution. (2) The washing machine must be run a full cycle on empty with disinfecting solution/germicidal solution to cleanse the machine when the washing of infected linen has been completed 2) Garbage consists of all garbage and disposal items in a room assigned to an isolation client. a) Garbage is to be double-bagged. b) Housekeeping will remove the garbage in a timely manner and dispose of as regulated medical waste if indicated (Refer to Patient Care Policy on Infectious Waste Management). Revised 06/

33 YCS Infection Control Manual Section IV Infection Control Precautions c) Isolation garbage must be kept in a separate container from other garbage. Container will be clearly labeled. 3) Cleaning the Isolation Unit- this may be an infirmary or a client room that has been used for isolation or cohorting of individuals with infectious disease a) Thorough isolation unit cleaning will be done upon discharge or at any time deemed necessary. b) The type of cleaning will depend on the organisms involved and will be determined by the ICL at each site. c) Laundry and Garbage Isolation procedures will be followed. d) Housekeeping will strip all linens from the unit and beds e) The walls, ceiling, floor, closets, and all bedroom furniture and room fixtures will be sprayed and scrubbed with a germicidal solution. f) Bathroom fixtures, walls, ceiling, and the sink area will be sprayed and scrubbed with an agency-approved germicidal solution. g) Isolation laundry procedures will be followed for all curtains and linens after removing them from the unit. Revised 06/

34 YCS Infection Control Manual Section IV Infection Control Precautions CONTACT PRECAUTIONS Purpose: It is the intent of YCS to use Contact Precautions for clients known or suspected to have infectious diseases or epidemiologically significant pathogens transmitted by direct client contact or by contact with items in the client s environment. Contact Precautions shall be used in addition to Standard Precautions for clients with specific infections that can be transmitted by direct and indirect contact and are indicated for suspected or confirmed cases of the following (please note this list is not all-inclusive): Scabies Pediculosis Varicella Impetigo Herpes Simplex Virus 1) Resident Placement a) Client may be placed in a private room. i) Examples of clients that may require a private room include clients with resistant organisms who have copious drainage from a wound. ii) Cohorting: If a private room is not available, the client may be placed in a room with a client(s) who has active infection with the same organism (1) A decision will be made on a case by case basis regarding the safety of placing the client in a room with another client. iii) When a private room is not available and cohorting is not an option, consider the organism and client population when determining placement. 2) Gloves and Hand-Washing a) Gloves should be worn when entering the room and while providing care for a client on Contact Precautions. (a) Gloves are to be changed after having contact with infective material (e.g. fecal material and wound drainage). (b) Gloves are to be removed before leaving the client s room and hand hygiene should be performed immediately. (c) After glove removal and hand hygiene, hands are not to touch potentially contaminated environmental surfaces or items. Revised 06/

35 YCS Infection Control Manual Section IV Infection Control Precautions 3) Gowns 4) Resident Transport (a) For extra precaution, a gown must be worn when entering the room of a client under Contact Precautions when it is anticipated that clothing will have substantial contact with the client, environmental surfaces, or items in the client s room, or wound drainage is not contained by a dressing. (b) If a gown is worn, it must be removed before leaving the client s room. (c) After removal of the gown, clothing must not contact potentially contaminated environmental surfaces. (a) Activities of the client may need to be limited. This will be determined on a case by case basis. (b) If the client leaves the room, precautions must be maintained to minimize the risk of transmission of microorganisms to other clients and contamination of environmental surfaces or equipment. 5) Resident Care Equipment (i) These precautions include the use of a gown i) Dedicated client-care equipment should be considered for the client. (1) If use of common equipment or items is unavoidable, the items must be adequately cleaned and disinfected using an agency-approved cleaner/disinfectant before use for another client. Revised 06/

36 YCS Infection Control Manual Section IV Infection Control Precautions DROPLET PRECAUTIONS Purpose: It is the intent of this facility to use Droplet Precautions for clients known or suspected to have infectious diseases or epidemiologically significant pathogens transmitted by droplets. Droplet Precautions shall be used in addition to Standard Precautions for clients with infections that can be transmitted by droplets and are indicated for suspected or confirmed cases of the following (please note this list is not all-inclusive): Influenza Mycoplasma pneumonia Strep pharyngitis or pneumonia 1) Resident Placement a) Client may be placed in a private room. i) Cohorting: If a private room is not available, the client may be placed in a room with a client(s) who has active infection with the same organism (1) A decision will be made on a case by case basis regarding the safety of placing the client in a room with another client. b) When a private room is not available and cohorting is not an option, maintain spatial separation of at least 3 feet between the infected client and other clients/ visitors. i) Special air handling and ventilation are not necessary and the door may remain open. 2) Masks a) A mask is recommended when within 3 feet of the client who is in the contagious stage of the disease process. 3) Transport a) Limit the movement and transport of the client. If transport is necessary, masking the client may minimize dispersal of droplets. Revised 06/

37 SECTION V EMPLOYEE HEALTH Revised 06/

38 YCS Infection Control Manual Section V Employee Health PHYSICAL CLEARANCE PURPOSE: A physical examination is required for all staff to insure that staff is physically fit to perform the essential functions of the job and to determine that they are free of communicable diseases. POLICY: All new employees, volunteers, interns or students must have a physical exam prior to reporting to work. 1) A Physical Clearance Form, provided by YCS, signed by a physician or other designated healthcare professional must be presented to Human Resources prior to reporting to the first day of employment. a) A previous physical exam documented as completed within six months prior to starting employment at YCS will be accepted in lieu of the YCS Physical Clearance form if it contains the same information 2) If at any time during employment, a physician or other designated healthcare professional indicates that an employee is unable to perform the essential functions of the job, or if there is reason to suspect the employee is putting others at risk due to a communicable disease, the employee will not be permitted to work in that position until further evaluation and clearance to work by a physician is obtained. Revised 06/

39 YCS Infection Control Manual Section V Employee Health REPORTING EMPLOYEE INFECTIONS PURPOSE: To ensure identification and follow-up of communicable illness among employees, thereby minimizing the risk of transmission to others. POLICY: 1) Any employee suspected of having a communicable illness is responsible for reporting it to their supervisor, who will then refer to the Human Resources Policy on Sick Leave. 2) Human Resources will follow the agency s policy on work restrictions for communicable diseases. a) Work restrictions will be determined on an individual basis 3) OSHA logs are maintained by Human Resources. 4) Annual compilation of all illnesses and injury data is completed by the agency s contracted Employee Health Provider. Revised 06/

40 YCS Infection Control Manual Section V Employee Health HEPATITIS B IMMUNIZATION PROGRAM PURPOSE: To establish guidelines for employee screening for Hepatitis B immunity and vaccine administration. POLICY: 1) All YCS employees will be offered the Hepatitis B Vaccine free of cost to be provided by the agency s contracted Employee Health Services provider. 2) Following a review of the disease and vaccine information, the employee will sign consent to receive the vaccine. (See "Information on Hepatitis B and the Vaccine".) i) If an employee declines Hepatitis B immunization, he/she will sign a statement to that effect. ii) If the employee chooses to be immunized in the future, he/she will be offered the Hepatitis B vaccine as per this protocol. 3) Should an employment-associated exposure to Hepatitis B virus occur, the post-exposure algorithm that follows shall be instituted. Revised 6/

41 YCS Infection Control Manual Section V Employee Health POST-EXPOSURE EVALUATION AND FOLLOW UP 1) Should a possible exposure to bloodborne pathogens occur, the Program Administrator/Director will be notified 2) The Program Administrator/Director will complete the First Report of Injury form as per the YCS Human Resources Policy and Procedure on Reporting All Work-Related Incidents. 3) The employee is referred to the agency s contracted Employee Health Services provider or, when necessary, the nearest acute-care facility for initial evaluation and management and instructed to follow-up with the agency s contracted Employee Health Services provider for further management 4) When necessary, the source individual s HIV, HCV, and HBV status will be provided to the employee s treating healthcare provider in a manner that is compliant with the agency s HIPAA guidelines and regulations 5) Employees who have suffered an incident of exposure will receive all medical evaluations, procedures, tests, and prophylaxis at no cost as per the YCS Human Resources Policy and Procedure on Reporting All Work Related Incidents. 6) The employee should be advised to seek medical attention for any illness that occurs within twelve weeks of exposure and should be provided counseling and medical evaluation of reported illnesses. 7) Within fifteen days after evaluation of the exposed employee, YCS will provide the employee with a copy of the health care professional s written opinion. a. The written opinion for post-exposure evaluation must document that the employee has been informed of the results of the medical evaluation and of any medical conditions resulting from the exposure incident that may require further evaluation or treatment. i. All other diagnoses must remain confidential and will not be included in the written report. Revised 6/

42 YCS Infection Control Manual Section V Employee Health BLOODBORNE PATHOGENS POST-EXPOSURE EVALUATION/HEALTHCARE PROFESSIONAL'S WRITTEN OPINION WRITTEN OPINION I have assessed on employee date for an exposure incident which occurred on. Date I have a copy of the Updated 2001 OSHA standard, the "YCS Exposure Incident Report" form from the employer and a copy of the 1998 USPHS Recommendations for Hepatitis B Prophylaxis Following Percutaneous or Permucosal Exposure. I. HEPATITIS B IMMUNIZATION (Check one) Hepatitis B prophylaxis is Hepatitis B prophylaxis is not indicated. indicated. II. POST EXPOSURE EVALUATION AND FOLLOW-UP (Check all that apply) The employee has been informed of the results of my evaluation. The employee has been informed of any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment. Signature of Healthcare Professional Date Signature of Exposed Employee Date Witness of Employee's Signature Date This form or a prescription from the evaluating physician must be received by the employer and a copy provided to the employee within 15 days of the evaluation. Revised 6/

43 SECTION VI CLIENT CARE POLICIES Revised 6/

44 YCS Infection Control Manual Section VI Client Care Policies CLIENT ADMISSION POLICY: YCS requires certain medical information to be presented by the referring agency to be reviewed by the program medical team prior to client admission with the goal of preventing the influx of infectious disease 1) A comprehensive physical examination (performed by a licensed physician) must be completed within 30 days of the admission date. a) The physician must certify that the child is free of communicable diseases at the time of examination. 2) Admission laboratory tests are to include the following in order to determine any potential infectious diseases: a) CBC with differential b) RPR c) Varicella titer (if no positive history of chicken pox or proof of varicella vaccination) d) HIV Screening i) By law, this test cannot be mandated. However, this information is requested in that the client can receive any necessary services for optimal health maintenance 3) Immunizations should be up-to-date in accordance with the most current CDC Recommended Childhood and Adolescent Immunization Schedule a) Admission of clients without immunization records or up-to-date immunizations will be considered on a case-by-case basis in consultation with the covering pediatric MD or APN. 4) A Tuberculosis Skin Test (TST) should be administered and read before admission (within 6 months of the admission date). (Refer to Section IX : Tuberculosis Control Plan) a) Every effort must be made to obtain the TST results at least 72 hours prior to admission b) Admission of clients without a current TST will be considered on a case-by-case basis in consultation with the covering pediatric MD or APN. Revised 6/