San Francisco General Hospital INFECTION CONTROL SCOPE OF SERVICE 2009 The Infection Control Program at San Francisco General Hospital is a comprehensive quality improvement function that serves patients, physicians, nurses and other health care workers at the hospital, as well as entire departments and services. The Infection Control Committee, under the Department of Medicine, provides the administrative and structural framework to enact infection control policies and surveillance at SFGH. The Infection Control Committee is responsible for directing all phases of the Infection Control Program for the hospital and its clinics. Surveillance plans are based on a continuous review of communicable diseases in the hospital and community, changes in organism antimicrobial resistance, and the particular vulnerabilities of the populations served by the hospital. The Infection Control risk assessment process requires the integration of these factors to address the needs across all strata of the institution. I. It is the goal of the Infection Control Program to reduce infection and infectious risk through strategic plans for surveillance and control of healthcare-associated infection; to identify trends and patterns in antimicrobial resistance; to address epidemiologically important issues; and to advise hospital employees, departments and services in developing policies, procedures, and practices which reflect current infection control guidelines and standards of care. II. Functions of the Infection Control Program at SFGH include: a) Provide surveillance for healthcare-associated infections and prevention activities through: Periodic monitoring for compliance with Body Substance Precautions (BSP), hand hygiene, and other standard infection control protocols, Data collection and reporting of infection trends, Surveillance of targeted areas at high risk for healthcare-associated infections. Investigation of outbreaks or unusual clusters of healthcare-associated infections and infections deemed significant by the Committee. Prevention and control activities appropriate to the type of infection and the susceptibility of the patient population. b) Report healthcare-associated and epidemiologically important infections to the Infection Control Committee, and to share these reports, with suggested intervention plans, with other relevant committees, departments and clinical units and external reporting agencies (e.g. SFDPH, CDPH). c) Maintain a current Infection Control Manual electronically available to all areas of the institution. This manual contains a description of the Infection Control Program, isolation requirements, Infection Control Committee policies, and guidelines for developing departmental policies. The Infection Control Manual policies are based on current scientific knowledge, practice guidelines, and clinical staff consultation. Revised 12/14/09: Added: II. l); Added Staff 4. Healthcare Analyst & Renumbered Database Support 4 5; Inserted III.4. Oversight and Surveillance to Food and Nutritional Services and renumbered items below.
Page 2 of 5. d) The Infection Control Program reviews the development of policies and procedures as applied to: Patient care practices Aseptic technique Cleaning and decontamination of the environment Medical care products/devices/equipment pertinent to Infection Control Environmental disinfectants Medical disinfectants Cleaning, decontamination, disinfection and sterilization procedures. Medical waste management e) Consult with the Department of Education and Training regarding the infection control and prevention content of educational programs for personnel. For facility-wide education and training, Infection Control will: Review and approve educational material for hospital personnel regarding the importance of the Infection Control Program, the responsibility of all personnel for their participation in the Program, personal hygiene, and infection prevention and control measures. Provide information obtained from audits and other surveys to Medical Staff, Nursing, and other Departments for use in upgrading current practices. Serve as a resource to the community through information and teaching. Maintain current knowledge of infection control practices and regulations for use of the Infection Control Committee and other clinical Departments. f) Investigate suspected epidemics of healthcare-associated infections and outbreaks or exposure to infectious diseases. g) Provide consultation on a wide variety of patient care practices, problem resolution, cleaning/disinfection/sterilization, and employee health issues related to infection control. h) Participate in hospital functions and committees such as Risk Management, Performance Improvement and Patient Safety, Utilization Review, Product Evaluation and Standardization, Environmental Health and Safety, Operating Room Committee, Support Services, Safety Devices Assessment, Emergency Planning, and Environment of Care rounds. i) Provide guidance regarding the scope and content of the Employee Health Program through the Infection Control Committee. j) Work jointly with the Clinical Laboratory, especially Microbiology, regarding services available for diagnostic, treatment, and epidemiological purposes, as they pertain to infection control. k) Report required diseases to state and local Public Health Department, as appropriate. Perform ongoing review of the scope and effectiveness of infection control activities. l) Provide guidance and oversight to the Food and Nutritional Service department to ensure compliance with safe food practices.
Page 3 of 5 The Infection Control Program at SFGH is staffed with professionals who are trained and qualified to perform the necessary functions of infection control and healthcare epidemiology. III. Staff persons who provide support to the Infection Control Program for SFGH include: 1. Infection Control Professionals 3.0 FTE 2. Hospital Epidemiologist, (MD) 0.6 FTE (Co-Chair, Infection Control Committee) 3. Chief, Div. Of Infectious Disease, (MD) 0.35 FTE (Co-Chair, Infection Control Committee) 4. Healthcare Analyst 1.0 FTE 5. Database Support 1.0 FTE The Infection Control Professionals (ICPs) have a broad knowledge base which includes: epidemiology, infectious diseases, microbiology, statistics, patient care practices, quality management, regulations and recommendations of outside agencies, adult education, product evaluation, sterilization and disinfection, environmental health, employee health, and public health. The ICPs may be registered nurses or other health care professional (e.g. RN, BSN, MD, PhD, MPH, MS, or other appropriate Masters Degree). Certification in Infection Control is recommended. The supervisory ICP is the Associate Hospital Epidemiologist, who supervises and coordinates the Infection Control Program under the guidance of the Infection Control Committee Chair(s). The ICPs report to and are directed and evaluated by the Chairperson(s) of the Committee. Duties of the infection control practitioner ( ICP ) include: 1. Surveillance: a) Assume responsibility for surveillance, under the direction of the Committee and Chairpersons, to identify infection risks to patients and personnel. b) Coordinate the investigation of infection exposure incidents or outbreaks. c) Work with Infection Control Chairs and Committee to plan and implement epidemiological studies necessary for control of outbreaks of infection. Use statistical analysis as appropriate to judge significance of data. d) Request or take specimens for culture from patients, personnel or environment in order to determine appropriate Infection Control measures and make independent decisions or take actions on corrective preventive measures, within the guidelines of the Committee. e) Maintain Infection Control information and record keeping. 2. Program, Policy, and Decision Support: a) Provide consultation to department heads for development of departmental infection control policies and procedures, and collaborate with nursing service, physicians, hospital departments and the Infection Control Committee to develop appropriate infection precautions. b) Evaluate department-specific policies regarding Infection Control content for compatibility with hospital policy, state licensing regulations, and Joint
Page 4 of 5 Commission regulations, and confer with department heads on appropriate changes. c) Monitor and assist with implementation of programs to minimize infectious hazards in the environment through interpretation of policies to department heads, and inform them of any unsafe practices observed. d) Coordinate application of Infection Control procedures throughout the Medical Center by communicating with and interpreting policies for staff. Maintain close communication with head nurses, physicians, department supervisors and microbiology laboratory in order to ensure use of correct methods and be aware of problems that need further work or require Committee action. 3. Evaluation of Policies, Procedures, and Products relating to Sterilization and Disinfection: a) Evaluate cleaning, sterilization, disinfection, and decontamination procedures for acceptability by community standards; interpret regulations with personnel responsible for these functions; meet and confer to solve problems in this area and teach principles of sterilization and disinfection to appropriate personnel. b) Evaluate medical products and disinfectants in consultation with the Product Evaluation Committee to determine acceptability for use according to standards of practice, current regulations, and Committee recommendations. 4. Food and Nutritional Service Program Oversight and Monitoring for Compliance to Food Safety Code. a) Evaluate policies and procedures for cleaning and sanitation of stationary food production surfaces and equipment and kitchen equipment and food storage areas. b) Perform periodic surveillance for proper food handling through all stages, e.g. preparation, holding, serving, and storage to verify proper temperature of food items in accordance with food safety guidelines. c) Perform periodic surveillance cleaning and sanitation of stationary food production surfaces and equipment, kitchen equipment, food storage areas, and environmental surfaces in accordance with food safety code and equipment manufacturers instructions. 5. Committee Membership and Participation: a) Participate as an active member of the Infection Control Committee. Provide information to Committee on effectiveness of Infection Control programs, problems requiring action, and contribute to development of new policy and procedure. b) Gather information from professional literature and participate in professional groups outside the Hospital to determine community standards of infection control practice. Communicate this information to the Infection Control Committee for consideration.
Page 5 of 5 c) The Infection Control Professional is an active member of the following hospital committees: Health and Safety, BBP Safe Devices, Performance Improvement and Patient Safety, Operating Room, Antibiotic Review, Product Evaluation, Disaster Committee, Environment of Care, and Support Services. The Infection Control Professional provides direct communication between those committees and the Infection Control Committee. 6. Education and Training: a) As needed, teach Infection Control principles and their application to hospital departments including all levels of personnel. b) Consult with the Department of Education and Training (DET) regarding teaching of infection control policies and practices, and appropriateness of teaching materials (e.g.. audiovisuals) used by DET. Provide to DET updates on changes in regulations and recommendations that may affect educational content. c) Serve as a resource on Infection Control to the community outside the hospital through consultation and teaching within limits set by the Committee. d) The Infection Control Professional is a liaison with other units in the Health Department outside the SFGH setting. e) The Infection Control Professional will perform other duties related to Infection Control as prescribed by the Committee Chairperson(s). VI. The Infection Control Program provides consultation and services to SFGH twenty-four hours a day throughout the year. An ICP can be reached at pager: 415-443-1566. If an ICP is not available, the Infectious Disease Fellow can be reached on pager 443-2847. The Hospital Epidemiologist can be reached at pager 443-0719. The hospital operator has these pager numbers for urgent questions or concerns after regular business hours.