Current Status: Active PolicyStat ID: 677584 Implementation: 06/1977 Effective: 12/2007 Last Reviewed: 12/2007 Last Revised: 12/2007 Next Review: 11/2010 Owner: Policy Area: References: Applicability: Yvonne Strader: VP CNO St Mary Med Center Patient Care Services WA - Providence St. Mary MC Infection Control And Prevention, 8720.5405 POLICY Nursing Service staffs are responsible to practice prevention measures that decrease the risk of health care associated infection among patients, visitors, and staff. PURPOSE To provide an overview of policies and procedures relating to the patient care aspects of infection prevention and control risk reduction measures. To provide written guidelines to minimize the risk of cross infection among patients, health care workers and visitors. PROCEDURE GENERAL INFECTION PREVENTION and CONTROL PRACTICES 1. Infection Prevention and Control policies are unit-specific and available on line or in the Infection Prevention and Control office. The Infection Control Practitioner is available for consultation using Meditec or by telephone. 2. Patient Services staffs are requested to observe for signs/symptoms of infections and inform Infection Prevention and control and Primary physician when identified. Elevated temperature Development of a productive cough Dysuria or odorous urine Wound induration or purulence (surgical or IV access site) Readmission with an infection suspected to be associated with health care. 3. Admission assessments are to include signs/symptoms of infections, infections that may be associated with prior health care or communicable conditions. Infection Control Meditech referrals should be made for these findings. 4. Patient Services staffs are to perform hand hygiene between patients and after glove removal to prevent Page 1 of 6
cross infection. Reference Policy #8720.5044. 5. Standard Precautions, including Respiratory Hygiene/cough Etiquette are to be practiced by all staff for all patients regardless of diagnosis or presumed infection. In addition, transmission based precautions may be necessary when Standard Precautions do not prevent transmission: Contact Precautions Used when drainage/secretions are not contained by dressings. Airborne Infection Isolation Precautions Droplet Precautions See policy #8720.5405 Isolation 6. Patient Services staffs are to handle sharps in a manner which prevents accidental sharps exposure. Needles are not to be recapped. (Reference Policy #8720.5406) Sharps safety devices are to be used. Requests for new sharps safety devices or sharps safety concerns should be reported to Infection Prevention and Control or the unit manager. 7. Patient Services staffs are to maintain aseptic technique during: Dressing changes No Touch clean technique Vascular access procedures. Policy #8720.5420, 8720/5423, 8720.5425 1. Scrupulous hand hygiene 2. Aseptic technique 3. Vigorous friction to hubs prior to access 4. Ensure patency. Bladder catheterization. 1. Appropriate indications for use considered 2. Aseptic technique for placement 3. Hand hygiene before/after emptying 4. Keep system closed 5. Maintain the collection bag lower than patients bladder Airway suctioning-respiratory Policy #7180.6065, 7180.5066. Obtaining specimens. Policy #8720.5680. The Lippincott Manual for Nursing Procedures is the reference used for procedures. 8. Regulated medical wastes are handled in accordance with Federal, State and County requirements and as approved by the Infection Control Committee. Reference Policy #8610.5404. 9. Patient Services staffs are provided an annual Infection Prevention and Control, pulmonary tuberculosis and bloodborne pathogens training. 10. Unit-specific Infection Control policies are available and elaborate on increased risks of infections that may be encountered in those patients groups: Page 2 of 6
Clinic Settings 9570.6000 Pediatrics 6071.5404 TCU 6200.5404 OR 7021.5404 Women's Services 6085.5404 Home Health 7400.5404 ICU 6010.5404 Emergency Department 7230.5404 Imaging 7140.5404 Cancer Center 7155.5404 Infusion Services 6078.5404 11. Electronic thermometers are to be maintained in a manner which decreases potential for cross contamination. Reference Policy #8720.5287. Sheaths are to be used that cover the probes. Electric thermometers are not be used for patients with diarrhea. Read out unit is to be cleaned/disinfected at least daily using environmental wipes or alcohol. Patients in additional isolation are to have dedicated thermometers. 12. Multidose vials are dated when opened and discarded after 28 days or until the manufacturer's expiration date. If the sterility is questioned, the vial is to be discarded. Vial access ports are to be scrubbed with alcohol before accessing and the integrity of the stopper evaluated prior to use. Reference Policy #7170.5345. PHYSICAL ENVIRONMENT 1. Patient rooms are private with the exception of sixteen double rooms on 4 South with a shared bathroom. In the semi-private rooms, individual shelves are provided to separate equipment and personal belongings. 2. Handwashing facilities are in each room with a hospital approved handwashing agent provided. Alcohol based agents are placed outside of each patient room. Patients and visitors are encouraged to practice hand hygiene as part of patient safety. 3. Nurse Servers - Most rooms have an individualized storage area accessed from both the inside and the outside of the room. The upper portion of the nurse server is for clean items only. Care is to be taken to avoid contaminating this section and clean supplies. Access with clean hands only. The lower portion of the nurse server is for soiled items only. Soiled linen. A bin for small soiled items to be reprocessed by CP&D. No sharps are to be placed in this bin. Reprocessable sharps are to be taken to the soiled hold. Items contaminated with body fluids are to be bagged for transport. 4. Washers and dryers located on 4 South are to be maintained per Policy #8720.6010. 5. Refrigerators on the nursing unit are maintained according to Policy #7170.6000. The medication Page 3 of 6
refrigerator is checked by Pharmacy. Facility prepared nourishments are to be discarded on the discard date. Manufactured foods are to be discarded on the expiration date. Foods prepared outside the facility and brought in for patients are not placed in the nourishment refrigerators and are to be eaten as soon as possible. TRAFFIC CONTROL 1. Reference Visiting Policy #8720.1051 2. Visitors are to be allowed into clean or contaminated work areas and should confine visiting to patient's rooms or waiting rooms. Visitors observed to be ill should be asked to not visit patients. Visitors who are coughing may be asked to wear a mask. 3. Pet visitation may be allowed per policy #8720.5200. PATIENT PLACEMENT 1. Reference Infection Prevention and Control Policy #8720.5404 for Isolation. Patients with suspected or confirmed airborne transmitted illnesses are to be admitted to the negative airflow rooms 315, 316, or 436 (measles, mumps, tuberculosis, chicken pox) and placed into Airborne Illness Isolation. 2. Patients with Foley catheter should not share a room with another patient with a bladder catheter. 3. Patients infected or colonized with multidrug resistant organisms are to have a private room or may be cohorted with patients with the same organism. 4. Patients with droplet spread conditions are to be admitted to a private room (RSV, Influenza, pneumonia, Group A beta strep, meningitis). Cohorting of patients with the same condition may be done with consultation with Infection Prevention and Control. 5. Patients with uncontrolled diarrhea or poor personal hygiene should be admitted to private rooms. 6. Patients at increased risk for infections are to be admitted to private rooms (i.e., immunosuppressed patients). Immunocompromised patients should not be admitted to negative airflow rooms. 7. Infants with suspected communicable conditions will be admitted to Pediatrics or ICU. Admission to Newborn Nursery is to be avoided. LINEN See Policy #8355.5400 1. Linen is delivered to units in covered carts by Environmental Services and stored in the Nurse servers for each room. Extra linen is kept in clean storage areas in a manner which prevents contamination. 2. Soiled linen is to be carefully handled away from the body and not placed on the floor. All soiled linen is considered contaminated and placed in a clear plastic bag. Soiled linen is to be placed in the lower section of nurse server in clear plastic bags and filled only 2/ Page 4 of 6
3 full. Environmental Services is to collect soiled linen twice daily and as needed. EMPLOYEE HEALTH PARTICIPATION 1. Employees are not allowed to work until they have met the health requirement for new hires. Reference Policy #9280.4420 and #9280.4415. Tuberculin Skin testing Immunization history 2. Employee injuries and/or exposures are to be reported immediately to Employee Health or the Emergency Department after business hours. 3. Employees are encouraged to take advantage of wellness benefits including vaccinations offered through the Employee Health Services. 4. Health care workers who are febrile, have draining lesions or are otherwise ill, are not to work and are asked to inform Nursing Scheduling and/or Employee Health. a. Infection Prevention and Control assists Employee Health with post exposure investigations of communicable conditions. b. Employee illnesses are monitored for clusters of common symptoms. PRACTICES OF STERILIZATION, DISINFECTION & ENVIRONMENTAL CONTROL 1. The reprocessing of equipment and supplies is done by the CP&D department. Soiled items are taken to the soiled hold area for pick up by CP&D and Environmental Services. Items contaminated with body fluids are contained for transport to soiled holds. Contaminated reprocessable sharps are to be placed into an instrument container and covered with enzyme spray. 2. Prior to use, sterile packaged items (in house or commercial) are to be inspected for indications of moisture or integrity of packaging. All outdated or compromised packaged items are to be returned to CP&D. Event related sterility is to be practiced. 3. Clean equipment/supply areas are separate from the soiled hold areas. Soiled items are taken only to the soiled hold. 4. Multiple use items are to be reprocessed following the manufacturer recommendations: Items that enter sterile tissue or vascular system are to be sterile. CP & D reprocesses these items. Objects which come into contact with mucous membranes or non-intact skin are to be free of microorganisms through high level disinfection procedures in CP&D. Items which come into contact with intact skin but not mucous membranes (stethoscopes, table tops, B/P cuffs) are cleaned using soap and water or a ready to use hospital approved germicides. 5. Disposable, single use items are used once discarded and are not to be reprocessed. 6. Wheel chairs are be wiped down using the hospital germicide on a routine basis and when ever visibly soiled. Grossly soiled wheelchairs will be cleaned by SP&D. Wheelchairs will be left in discharged Page 5 of 6
patient's room for cleaning by Environmental Services. 7. Equipment used between patients, such as bladder scanner, is to be wiped off with approved cleaner/ disinfectant after each use by the user. Environmental Services cleans B/P cuff after every patient discharge. IV pumps are cleaned upon patient discharge by Environmental services. 1. Patient Service staff clean the pumps when in use and when visibly soiled using the disinfectant recommended by the manufacturer. Multiple use shower area, bathtubs and equipment are to be used in a manner which prevents cross infection: Bath benches and tubs are to be cleaned and disinfected by patient care staff after each patient use using the hospital approved germicide. 8. Room and discharge cleaning is done by Environmental Services. Reference Environmental Services Policy #8460.5060. Patient services staffs may wipe high tough surfaces in patient rooms is there is frequent soiling of the environment by excretions and or drainage. The hospital approved disinfectants and/or disinfectant cloths may be used REFERENCES WAC 296-62-8001 Bloodborne Pathogens WAC 248-318-035 Infection Control Joint Commission Infection Control Standards APIC, Text of Infection Control Epidemiology. 2005 CDC Guideline for Isolation Precautions 2007 CDC Guideline for the Prevention of Intravascular Catheter-related Infections 2002 Attachments: No Attachments Page 6 of 6