SHC Infection Prevention & Control Department 2012
Required Actions
Central Line Infection Prevention
 Documentation of central line insertion is required. Use the EPIC template that contains all the
process measures required.
 Daily documentation of central line necessity is required. EPIC Progress note template includes the
wording.
 Central line associated bloodstream infection (CLABSI) prevention education is provided prior to
insertion. Given in pre-op clinics (CT, Neurosurg), ICU packets.
MRSA Nares Screening (CA State Law)
 Screen all ICU admissions, all hemodialysis pts, and any patient who has been in a healthcare
facility the past 30 days.
 MD to inform patient of results and document in EPIC. Education given at discharge by nurse.
Hand Hygiene
 Perform hand hygiene (waterless alcohol gel or soap and water wash) before and after every patient
contact. “Gel in and gel out” of every patient room. Do not wear artificial nails. National Patient
Safety Goal
General Infection Prevention Activities
PPE (Personal Protective Equipment)
Wear PPE for contact with blood/body fluids:
GLOVES: non intact skin, mucous membranes, contact with body fluids
GLOVES & GOWNS: large draining wounds, any undiagnosed skin rash
GLOVES, GOWNS, EYEWEAR: intubation, irrigating large wounds or tubes under pressure
Annual fit-testing is required by CAL OSHA for N-95 respirator masks. Wear an N-95 respirator for all
patients with verified or suspect aerosol transmissible diseases.
Refrain from patient contact if you have a fever, cough/flu symptoms, and skin lesion drainage/rash
Infection Control Manual
Quick Guide Policy 5.10 for patient placement /isolation questions.
Go to Stanford Intranet, click Policies Tab, click Infection Control Manual
Tuberculosis
Do not discharge or transfer any patient with verified or suspect active TB, or patients placed on TB meds
until approval from the county TB Controller has been accomplished. Call Infection Control (5-1106) or
pager 16167 for adults.
For Stanford Hospital & Clinics, call Infection Prevention & Control Department at 650/725-1106 or pager 16167.
For Pediatric issues at LPCH call the LPCH Infection Control Office at 650/497-8447 or pager 15796