Operational Policies
Infection Prevention/Control and Employee
Health Plan
Policy Number:
Adopted:
Revised:
POLICY
ASC Name, through its Infection Prevention/Control and Employee Health Program, seeks to
reduce the risk of acquisition and transmission of healthcare associated infections in patients,
healthcare workers, and visitors. The ASC Infection Prevention/Control Committee (ICC) directs
all activities for surveillance, prevention, and control of infections in patients, visitors, and
healthcare workers. The Committee sets standards related to Infection Prevention/Control and
Employee Health at all facilities and across all levels of care to reduce the risk of nosocomial and
occupational acquired infections.
Infection Prevention/Control and Employee
Health Plan
Procedures for:
Adopted:
Revised:
PROCEDURES
EXPLANATION:
The Infection Prevention/Control Committee, a multidisciplinary committee of medical staff and
operations, directs the Infection Prevention/Control and Employee Health Program of the ASC.
The core committee members are: the hospital epidemiologist and chair of the committee,
Director Infection Control and Employee Health, Infection Preventionist’s (IP) from each
geographic location, Employee Health Coordinator, Community Health representative, medical
staff representatives, nursing representative, a laboratory representative, and hospital
administrator. Other relevant departments (i.e., pharmacy, central services and reprocessing,
facility/environmental services) will be requested to participate as needed for consultation in
their area of expertise.
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APPLICABILITY:
This policy applies to all healthcare workers at the ASC.
DEFINITIONS:
Healthcare Worker:
All employees, participating practitioners, contracted, students, and
volunteers.
Participating Practitioner: A participating practitioner has privileges and sees patients in the
ASC facility.
RESPONSIBILITIES AND GUIDELINES:
I.
AUTHORITY
The authority to carry out the plan is vested in the Infection Prevention/Control
Committee by the ASC CEO.
II.
INFECTION PREVENTION/CONTROL COMMITTEE (ICC) RESPONSIBILITIES
General:
1. Provide oversight for the six functions of the Infection Prevention/Control and
Employee Health Program (properties of each function described following item 7):
A. Surveillance
B. Policies & Procedures
C. Employee Health
D. Outbreak Intervention
E. Education & Training
F. Clinical Consulting/Committee Work
2. Conduct regularly scheduled meetings, at least quarterly.
3. Annually evaluate the Infection Prevention/Control and Employee Health Program for
effectiveness, practicality, and cost effectiveness.
4. Promote science-based approach to infection control.
5. Review, revise and evaluate the goals of the Infection Prevention/Control and
Employee Health Program annually. The goals are based on the Infection
Prevention/Control and Employee Health Risk Assessment, which includes;
geographic location and community environment of the hospital, program and
services provided, and characteristics of the populations served.
6. The goals and evaluation are reported annually to the Hospital Quality Committee.
7. Review the Infection Prevention/Control and Employee Health Structure Standards
annually. (Refer to Infection Prevention/Control and Employee Health Structure
Standards.)
Six Functions of Infection Prevention/Control and Employee Health Program (item 1):
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A. Surveillance
The Center for Disease Control and Prevention (CDC) National Healthcare Safety
Network (NHSN) system definitions are used to identify healthcare associated
infections. The surveillance data is appropriately analyzed and used to monitor
and improve infection control and healthcare outcomes. Such activities include:
1. Approve the type and scope of focused surveillance monitors and ongoing
review of surveillance activities, prevention, and control of infections as
described in the current Infection Prevention/Control and Employee Health
Risk Assessment and Plan.
a. Analyze:
i. For infection clusters
ii. Significant and/or unusual pathogens
iii. Occurrence of healthcare associated infections that exceeds the usual
baseline levels
b. Control activities include:
i. Case finding
ii. Reporting of information about infections
iii. Development and implementation of prevention strategies
iv. Outbreak intervention and control
2. Compile and analyze surveillance data to identify trends in healthcare
associated, community, and occupational acquired infectious diseases and to
develop appropriate measures for prevention and control. Infection rates for
targeted surveillance will be calculated and benchmarked using NHSN
national rates.
3. Monitor patient care activities to identify practices, equipment, or supplies,
which constitute a risk of transmitting infections.
4. Monitor and evaluate healthcare worker blood exposures and provide
guidance and expertise.
5. Identify and implement infection prevention/control measures that are
appropriate for high-risk populations and procedures (i.e., wound care) across
the continuum of care.
6. Review and evaluate risks and significant events related to infection control.
These include, but are not limited to, epidemiologically significant community
acquired infections, product recalls, changes in community standards and
practice, and new scientific information or technology.
7. Review antibiotic sensitivity profiles and trends. Make recommendations in
antibiotic prescription practices and, when appropriate, refer specific issues in
drug utilization trends to the Antibiotic Utilization Review Group of the
Pharmacy and Therapeutics Committee.
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B. Policy/Protocol/Procedure
Infection Prevention/Control and Employee Health will facilitate
policy/protocol/procedure development, implementation, and effectiveness across
the continuum of care:
1. Collaborate with ASC departments using consistency and continuity in all
infection prevention/control policies and procedures in order to provide a safe
environment for patients, visitors, and healthcare workers.
2. Promote compliance with standards defined by regulatory and accrediting
agencies that relate to infection control (e.g., NIAHO, DOSH, DOH, and
county health departments).
3. The authority to develop, review and revise policies, protocols, and procedures
is delegated to the Infection Control Committee Chairperson, the Director of
Infection Control and Employee Health, Infection Preventionists, and the
Employee Health Coordinator, consistent with Infection Prevention/Control,
Employee Health, and facility standards. This body will collaborate with
administration, medical staff, and healthcare workers in the review process.
a. Cooperative-wide standards will be reviewed annually.
b. Departmental policies are reviewed at least every two years or more
frequently if changes in practice are dictated.
4. Establish lines of communication with contracted services and facilities to
assess comparable and acceptable standards of care.
C. Employee Health
Provide oversight of the development, implementation, and effectiveness of
infection prevention/control aspects of the Employee Health Program for the
protection of healthcare workers and the monitoring and intervention of employee
health issues. Employee Health will:
1. Review and evaluate the infection prevention/control elements of the
Employee Health Program.
2. Implement and monitor the healthcare worker screening and immunization
and TB programs (see policies; Healthcare Worker Screening and
Immunization Policy and TB Exposure Control Plan).
3. Monitor healthcare workers with significant infectious diseases and evaluate
action taken to prevent transmission.
4. Review and evaluate the Accidental Parenteral Exposure program.
5. Monitor the incidence of healthcare worker exposures to infectious diseases
and accidental parenteral exposures.
6. Develop, implement, and evaluate strategies for the prevention of healthcare
worker exposures.
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7. Evaluate post-exposure intervention and follow-up of healthcare worker
exposures.
D. Outbreak Intervention
Infection Prevention/Control and Employee Health will quickly identify and
implement measures to control endemic and epidemic infections and emergency
preparedness/bioterrorism events by the following:
1. Emergency Authority of the Infection Prevention/Control Committee
Chairman (refer to policy; Emergency Authority of Infection
Prevention/Control Chairman). The Infection Prevention/Control Committee,
through its chairman or the chairman designee (the Director of Infection
Control and Employee Health, an Infection Preventionist, or a physician
committee member), has the authority to institute any control measures or
studies deemed appropriate to provide safe care for patients or personnel.
These may include, but are not limited to the following:
a. Instituting appropriate isolation procedures (as per CDC Disease-Specific
Precautions or Public Health/CDC recommendations)
b. Closing a patient care or service area until the infectious hazard no longer
exists
c. Transferring a patient
d. Ordering disinfection of a patient care or service area
e. Ordering laboratory studies on patients, employees, or environmental
samples
f. Establishing healthcare worker immunity and furlough procedures for
exposed healthcare workers through periods of potential communicability
g. Quarantining equipment
2. Develop, implement, and evaluate an ongoing system to obtain pertinent
laboratory data.
3. Develop ongoing communication and consultation with clinical staff
throughout the organization to:
a. Identify infectious and adverse events
b. Assist in maintenance and monitoring of infection prevention/control
procedures
c. Provide consultation on infection prevention and control measures
4. Access adequate resources and authority to ensure a comprehensive and timely
investigation and implementation of appropriate control measures.
E. Education
Infection Prevention/Control will provide ongoing infection prevention/control
educational programs to ASC healthcare workers.
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1. Review and disseminate current infection prevention/control information to
individuals or departments within ASC.
2. Develop and provide education programs on infection prevention/control and
employee health to ASC healthcare workers.
3. Provide content, advice, and support for education programs related to
infection prevention/control.
4. Evaluate the effectiveness, appropriateness, and availability of ongoing
Infection Prevention/Control and Employee Health educational programs (i.e.,
New Employee and Provider Orientations, Safety Training, Annual Updates)
to healthcare workers and departments.
5. Develop and implement tools to provide patients and caregivers appropriate
information regarding infection prevention and control.
F. Consultation and Committee Work
Promote ongoing Infection Prevention/Control and Employee Health
collaboration between departments, disciplines, and outside organizations to
provide consultation, standardization, interventions, and clinical expertise on
infection control, employee health, and safety.
The ICC is the approval body for equipment, products, items, or issues pertaining
to, or involving, Infection Prevention/Control and Employee Health. Examples
include but are not limited to:

Cleaning, disinfection, sterilization equipment, products and solutions

Hand lotions

Skin antiseptics

Hand soaps, antimicrobial soaps, surgical scrubs

Personal Protective Equipment

Safer devices and safety equipment

Collaborate with Capital Requests and requesting Departments on
equipment purchases to ensure item meets Infection Prevention/Control
standards for cleaning and disinfection

Construction and facility remediation
III. FACILITY, DEPARTMENT MANAGER, SUPERVISOR, CHIEF, AND HEALTHCARE
WORKER RESPONSIBILITIES IN SUPPORT OF INFECTION
PREVENTION/CONTROL AND EMPLOYEE HEALTH PROGRAM
Facility/Dept Manager/Supervisor/Chief
Responsibility
Surveillance
Surveillance
Promptly notify infection prevention/control
Promptly report infectious disease exposures,
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Health-Care Worker Responsibility
Facility/Dept Manager/Supervisor/Chief
Responsibility
and investigate circumstances surrounding
infectious disease exposures, significant
employee infections, clusters of nosocomial
infections, and unusual trends related to
Infection Prevention/Control.
Health-Care Worker Responsibility
significant employee infections, clusters of
nosocomial infections and unusual trends to
their manager and Infection
Prevention/Control.
Policies and Procedures
Policies and Procedures
Implement and require compliance with ASC
Infection Prevention/Control and Employee
Health policies and procedures.
Comply with ASC and department specific
Infection Prevention/Control and Employee
Health standards.
Develop written department specific Infection
Prevention/Control policies and procedures.
Enforce compliance with department specific
standards.
Employee Health
Employee Health
Enforce department compliance with screening
and vaccination program.
Comply with screening and vaccination
program.
Investigate staff exposures. Require post
exposure control activities related to staff
exposures are completed.
Report occupational exposures.
Outbreak Intervention
Outbreak Intervention
Participate in the development of outbreak
control measures. Ensure measures are
implemented.
Comply with outbreak control measures.
Education
Education
Ensure healthcare worker training and
orientation to cooperative–wide and
department-specific Infection Prevention/
Control and Employee Health standards.
Attend orientation and participate in annual
updates on infection control and employee
health.
Participate in post exposure control activities
Provide additional training when procedures
change or when new procedures or equipment
are introduced which affect the employees’
exposure to infectious materials.
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Document attendance at training sessions by
sign in sheets or completing training tests.
Facility/Dept Manager/Supervisor/Chief
Responsibility
Health-Care Worker Responsibility
Schedule and maintain documentation of
annual training for all healthcare workers.
Records must be readily available for review
for regulatory inspections.
 Orientation records: for duration of
employment
 Inservice Records: for 3 years
Clinical Consulting & Committee Work
Clinical Consulting & Committee Work
Request Infection Prevention/Control
consultation as needed for the prevention of
infection of patients and staff.
Request information from manager/chief,
Infection Prevention/Control, and Employee
Health as needed.
Promote departmental participation in
committee activities to establish and maintain
effective infection prevention/control and
employee health measures.
Participate in committee activities as assigned
by manager/chief.
REFERENCES:
SHEA Position Paper: Requirements for Infrastructure and Essential Activities of Infection
Control and Epidemiology in Hospitals: A Consensus Panel Report. Infection Control and
Hospital Epidemiology 1998; 19:114-124.
SHEA Position Paper: Requirements for Infrastructure and Essential Activities of Infection
Control and Epidemiology in Out-Of-Hospital Settings: A Consensus Panel Report.
Infection Control and Hospital Epidemiology 1999; 20:695-705.
Infection Prevention/Control and Employee Health Structure Standards
Infection Prevention/Control and Employee Health Risk Assessment and Plan
REVIEW:
Approved by:
Designated Content Expert:
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