The University of Connecticut Health Center
shall have infection control policies which are promulgated and interpreted as
provided within
this manual.
Infection Control policies are developed by
the Infection Control Committee to assist Hospital employees, physicians,
students, volunteers
and contract workers in carrying out their
functions and responsibilities as safely as possible.
All policy statements, requirements,
procedures, and guidelines set forth in this manual are intended as standards
for the efficient and safe
delivery of patient care.
Purpose
This manual contains approved statements of policy and procedure which
provide:
-
Written direction for consistency and continuity in decision-making and
patient care.
-
Established standards against which actual performance can be
measured.
-
A
source document for inspection for licensing and accrediting
agencies.
Infection
Control Program
The State of Connecticut Department of Public Health, State of
Connecticut Occupational Safety and Health Administration, State of Connecticut
Department of Environmental Protection, the Federal Centers for Disease Control
and Prevention and the Joint Commission on Accreditation
of Health Care Organizations have adopted requirements for licensure and accreditation, one
being the establishment of an Infection
Control Program. The mandate of this program shall have as its purpose the protection of
patients admitted to and employees working at
the
University of
Connecticut. The institutions' regulations govern the
structure and function of the Infection Control Program and is a part
of the Medical Staff Bylaws.
The authority of the Infection Control Program is delegated to the
Infection Control Committee, a multi-disciplinary group who assist
in:
-
Providing a system
to develop and review infection control policies and procedures.
-
Adopting working definitions of nosocomial
infections.
-
Developing systems for the surveillance of nosocomial infections and
conditions predisposing to infection.
-
Developing systems to monitor nosocomial infections in patients and
personnel.
-
Develop mechanisms for monitoring environmental conditions with infection
control potential.
-
Review and revising the Infection Control Manual.
-
Provide training and educational programs.
-
Providing consultative services to
Health
Center
departments.
-
Consult with Employee Health Services for activities related to
infectious disease prevention and post-exposure care.
-
Monitor
quality assurance issues relating to patient care or personnel health.
-
Investigate
outbreaks when identified.
-
Conduct
research projects.
Approval
Process
All proposed policies and procedures are reviewed, and approved/rejected
by the Infection Control Committee.
Infection Control policies involving the
Medical/Dental Staff are
approved by the Medical Board.
Unit/Department Infection Control plans, policies and procedures need to
be reviewed and approved by the Infection Control Committee. It is the responsibility of
the appropriate department
head or administrative officer to review departmental plans, policies and
procedures once every year and to assure that they are not in
conflict with general
Infection Control Policies.
Staff are encouraged to
offer suggestions, to recommend other areas for policy development or to submit
Infection Control policy for approval to the Infection
Control Committee.
Organization
and Distribution
The manual is distributed to all patient care areas throughout the
Health
Center. The Infection Control Manual
is divided into four major sections
Table of Contents
Introduction
01.
General
02. Patient
Related
03. Employee
Related
04.
Reference
SECTION: GENERAL INFECTION
CONTROL
NUMBER:
1.1
INFECTION
CONTROL COMMITTEE AUTHORITY
PURPOSE:
To establish Infection Control authority at the University of Connecticut
Health Center.
POLICY:
-
The charge of the Infection
Control Committee is to establish an infection prevention, surveillance and
control program that protects
patients, students volunteers, visitors and personnel at the University of Connecticut
Health Center from hospital-acquired, community associated, and
workplace related infections. The
authority statement, reporting mechanisms, and the committee's function and
governance will be administered through the Chancellor's Office. This would ensure that the authority of
the committee is endorsed by the Health Center Administration and that all
segments within the
Health
Center are represented. The Health Center Infection Control
Committee will submit meeting minutes on a regular basis for John Dempsey
Hospital Medical Board review.
-
The Health Center Infection Control Committee, through its Chairman, is
granted authority to institute any appropriate emergency control measures or studies throughout the
Health
Center and other off-campus
facilities when there is a reasonable risk or danger to any patient or personnel.
-
The department chairperson and the appropriate University of Connecticut
Health Center staff shall be informed immediately regarding any problem that merits infection control measures or epidemiological studies related to the
above.
-
There shall be an individual responsible for infection prevention,
surveillance and control who shall coordinate and/or conduct these aspects of
the
program as directed by the Infection Control Committee. This person shall be directly
responsible to the Infection Control Committee.
-
The committee is required to meet monthly
during which a review of surveillance activities is conduct.
-
The Health Center Infection
Control Committee will be the only sanctioned committee in the
Health
Center with responsibilities for infection control
issues.
REFERENCE:
Public Health Code of the State of
Connecticut, 1994, Chapter 4, Section
19-13-D3, (2).
Infection Control. In: Accreditation Manual for Hospitals,
Joint Commission on Accreditation of Healthcare
Organizations.
Chicago, Illinois,
1996.
Peter J. Deckers,
M.D.
Executive Vice President for
Health Affairs
Dean,
School of
Medicine
SECTION: GENERAL INFECTION
CONTROL
NUMBER:
1.2
PURPOSE: To
establish infection control guidelines which are designed to minimize the risk
of health-care worker exposure to the blood and body fluids
of all patients.
POLICY:
The Infection Control Committee endorses the
following:
-
Health-care workers are to
consider all patients as potentially infected and to adhere rigorously to
infection control precautions for minimizing the risk of exposure to blood and
body fluids of all patients.
-
Health-care workers are defined as persons, including employees,
physicians, students, trainees, contract workers and volunteers whose activities
involve contact with patients or with blood or other body fluids and tissues
from patients in a health-care setting.
-
All health-care workers are expected to
follow basic infection control standards to ensure their own safety, and that of
other workers and patients.
PROCEDURE:
-
All health-care workers must
routinely use appropriate barrier precautions to prevent skin and
mucous-membrane exposure when contact
with blood or other body fluids of any patient is anticipated.
a.
Gloves must be worn for touching blood and body fluid, mucous-membrane,
or non-intact skin of any patient, for handling items or surfaces
soiled with blood or body fluids and other vascular access procedures. Gloves must be worn when performing
venipuncture. Gloves must be
changed after contact with
each patient.
b.
Masks and protective eye wear must be worn during procedures that are
likely to generate droplets of blood or other body fluids to prevent
exposure of mucous membranes
of the mouth, nose and eyes.
c.
Gowns or aprons must be worn during procedures that are likely to
generate splashes of blood or other body fluids.
-
Hands and other skin surfaces must be washed immediately and thoroughly
if contaminated with blood or other body fluids. Hands must be washed after
gloves are
removed.
-
All health-care workers must take precautions to prevent injuries caused
by needles, scalpels, and other sharp instruments or devices dufing-,
procedures;
when cleaning used instruments; during disposal of usesneedles; and
when handling sharp instruments after procedures.
-
To prevent needlestick injuries, needles must not be recapped, purpo bent
or broken by hand, removed from disposable syringes, or otherwise
-
manipulated by
hand. A one-handed scoop method may
be used if recapping can not be avoided.
After they are used, disposable syringes and needles,
-
scalpel blades, and other sharp items must be
disposed of as close as practical to the use area.
-
Although saliva has not been implicated in FHV
transmission, to minimize the need for emergency mouth-to-mouth resuscitation,
mouthpieces,
-
resuscitation bags or other ventilation
devices shall be available for use in areas in which the need for resuscitation
is predictable.
-
-
Health-care workers who have exudative
lesions or weeping dermatitis shall refrain from all direct patient care and
from handling all patient-care equipment
-
until the condition resolves.
-
7.
Pregnant health-care workers are not known to be at greater risk of
contracting nosocornial infection than health-care workers who are not pregnant;
-
however, if a health-care worker develops an infection during pregnancy, the
infant may be at risk of infection resulting from pefinatal transmission. Because of
-
this risk, pregnant health-care workers must
be especially familiar with and strictly adhere to precautions to minimize the
risk of possible transmission.
-
REFERENCE:
Centers for Disease Control.
Recommendations for Prevention of HIV Transmission in Health-Care
Settings. 1987;36:3s18s
Occupational Safety and Health Administration Standard 29 CFRI910.1030,
Occupational Exposure to Bloodbome Pathogens, Federal
Register, Vol. 5 6, No. 23 5,
December 6,
1991.
SECTION: GENERAL INFECTION
CONTROL &n
