Youth Consultation Service
INFECTION CONTROL MANUAL
TABLE OF CONTENTS
SECTION I - INFECTION CONTROL PROGRAM
Overview
Goals
Scope
Division of Responsibilities
Reporting Mechanisms
Role of the Infection Control Liaison
Role Summary
Qualifications
Duties and Responsibilities
Infection Control Committee
Section II - Surveillance of Infections
Infection Control Surveillance
Infection Control Plan
Reportable Diseases
Infectious Disease Outbreak Control
Infection Control Outbreak/Disaster Plan
Definitions
Reporting
Case Investigation
Section III - Infection Control Education
Infection Control Orientation and Inservices
Infection Control Orientation Outline
OSHA Bloodborne Pathogens
Client and Family Education
Criteria for Determining Exposure to Communicable Disease
Pregnant Personnel
Section IV - Infection Control Precautions
Standard Precautions
Personal Protective Equipment
Barriers Indicated in Standard Precautions
Other Methods of Standard Precuations
Using Gloves
Handling and/or Disposing of Used Needles
Equipment and Supplies
Safety Precautions
Care of the Client with Communicable Disease
Laundry
Garbage
Cleaning the Isolaiton Unit
Contact Precautions
Resident Placement
Gloves and Hand-Washing
Gowns
Resident Transport
Resident Care Equipment
Droplet Precautions
Resident Placement
Masks
Transport
Section V - Employee Health
Reporting Employee Infections
Hepatitis B Immunization Program
Post-Exposure Evaluation and Follow Up
Healthcare Professional's Written Opinion
sECTION vi - client Care Policies
Client Admission
Cleaning and Disinfecting Toys
Hand Hygiene
Hand-washing
Alcohol-Based Hand Rubs (Hand Sanitizers)
Infectious Waste Management
Definition of Biomedical/Regulated Waste
Handling of Needles and Sharps
Handling of Blood and Blood Products
Labeling of Biomedical/Regulated Waste
Storage of Biomedical/Regulated Waste
Disposal of Biomedical/Regulated Waste
Other (Non-Regulated) Wastes
Personal Hygiene
Collection of Specimens
Section VII - Department Protocols
Dietary Services
Food Service Coordinator Responsibilities
Nursing Service Responsibilities
Personnel
Personal Hygiene
Food Storage
Refrigerator Thermometers
Proper Food Handling
Supplemental Feedings
Dietary Housekeeping
Dietary Garbage Removal
Ice Chests and Ice Machines
Dietary Hand-Washing Policy
Housekeeping Services
Frictional Cleaning
Disinfectant Fogging
Routine Cleaning of Horizontal Surfaces
Choice of Cleaning Agents
Cleaning of Spills of Blood and Other Bodily Fluids
Infection Control
Carpeting in Client Areas
Trash
Humidifier Cleaning Policy
Laundry Services
Routine Handling of Soiled Linen
Transportation of Soiled Linen
Separating Clean from Dirty in the Laundry
Protecting Personnel Who Sort Laundry
Washing
Heavily Soiled Items
Maintenance Department
Preventive Maintenance
Incineration
Barrier Precautions
General Facility Maintenance
Preventive Maintenance of Filters
Miscellaneous
sECTION VIII - OSHA Bloodborne Pathogens
Exposure Control Plan
Program Administration
Employee Exposure Determination
Methods of Implementation and Control
Standard Precautions
Exposure Control Plan
Engineering Controls and Work Practices
Personal Protective Equipment
Housekeeping
Laundry
Labels
Hepatitis B Vaccination
Post-Exposure Evaluation and Follow-Up
Administration of Post Exposure Evaluation adn Follow-Up
Procedures for Evaluating an Exposure Incident
Employee Training
Recordkeeping
Section IX - Tuberculosis Control Plan
Tuberculosis Control Plan
Client Admissions and On-Going Surveillance
Admissions
On-Going Surveillance
Transport
Prospective Employees, On-Going Surveillance, and Exposure-Incidents
Prospective Employees
Annual Personnel Screening
Exposure Incidents
Documentation of Occupational Exposure
1
Revised 05/2010
SECTION I
INFECTION CONTROL PROGRAM
1
Revised 05/2010
YCS Infection Control Manual – Section I – Infection Control Program
INFECTION CONTROL PROGRAM
OVERVIEW
1)Goals
The goals of the Infection Control Program are to:
a)Decrease the risk of infection to patients and personnel.
b)Monitor for occurrence of infection and implement appropriate control measures.
c)Identify and correct problems relating to infection control practices.
d)Ensure compliance with state and federal regulations relating to infection control.
2)Scope of the Infection Control Program
The Infection Control Program is comprehensive in that it addresses prevention, detection, and control of infections among patients and personnel.
a)THE MAJOR ACTIVITY OF THE PROGRAM IS PREVENTION OF INFECTION
i)Client and staff education is done to focus on risk of infection and practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment. Immunizations are offered as appropriate to patients and personnel to decrease the incidence of preventable infectious diseases.
b)DETECTION OF INFECTIONS
i)There is on-going monitoring for infections among clients and personnel and subsequent documentation of infections that occur.
c)IMPLEMENTATION OF CONTROL MEASURES
i)Prevention of spread of infections is accomplished by use of Standard Precautions and other barriers, appropriate treatment and follow-up, and employee work restrictions for illness.
3)Division of Responsibilities for Infection Control Activities
The Vice President of Health Services, Pediatrics, is ultimately responsible for the Infection Control Program.
a)INFECTION CONTROL LIAISON
i)Responsibility is delegated to the Infection Control Liaison (ICL) to carry out the daily functions of the Infection Control Program. Those functions are described in the Role of ICL.
b)INFECTION CONTROL COMMITTEE
i)The Infection Control Committee meets quarterly and provides input and direction for the Infection Control Program. Policies and procedures relating to Infection Control are developed by the committee for presentation to and approval by the Executive Policy and Procedure Committee. Reports of infections are presented to the committee which recommends actions and control measures when needed.
4)Reporting Mechanisms for Infection Control
a)Client infection cases are monitored by the ICL. The ICL completes the monthly report forms for infectious diseases and:
i)Reports to the Infection Control Committee
ii)Provides feedback to clients and staff as needed.
b)Employee infections are reported by the employee to the employee's supervisor.
i)The employee’s supervisor responds to reports of employee infection as per current Human Resources Policy and Procedure
c)Compliance with infection control practices is monitored and documented by:
i)Internal audits
ii)Observation of Practices
NOTE:Policies and procedures of the Infection Control Program may be found in the Infection Control Manual. Minutes of the Infection Control Committee meetings are maintained and reviewed by the Vice President of Health Services, Pediatrics, and reported to the Environment of Care (EOC) committee quarterly
ROLE OF THE INECTION CONTROL LIAISON
ROLE:Infection Control Liaison
REPORTS TO:Vice-President of Health Services, Nursing
1)Role Summary
a)Collects and reports client infection data; presents infection data to the Infection Control Committee; monitors employee compliance in the use of barriers and infection control measures; prepares and presents infection control educational offerings for clients and staff; serves as a resource to clients and program personnel; implements recommended corrective actions for infectious disease and outbreak situations
2)Qualifications
a)Holds a current New Jerseystate license as an LPN or RN.
b)Completion of a basic training program for infection control.
3)Duties and Responsibilities
a)Does on-going monitoring of healthcare-associated infections.
b)Identifies infection control problems and makes recommendations for corrective action.
c)Monitors infection control practices.
d)Serves as a resource for clients and personnel on infection-related issues.
e)Works with Infection Control Committee to conduct outbreak investigation and initiate control measures.
f)Reports infectious disease data to the Infection Control Committee
g)Reports communicable diseases to the State of New Jersey as required by law.
h)Provides infection control educational offerings for clients and staff.
i)Consults with medical and individual site/program administration as needed to improve care.
j)Initiates follow-up on client exposures to communicable diseases.
k)Participates in quality improvement activities.
l)Participates in short and long range planning for the infection control department.
m)Performs other duties as directed.
n)
INFECTION CONTROL COMMITTEE
1)Responsibility
The Infection Control Committee is responsible for the prevention, detection andcontrol of infections. The Committee is ultimately responsible for monitoring staff performance to ensure that Infection Control policies and procedures are executed. The Infection Control Committee meets on a quarterly basis.
2)Purpose
Prevention, detection and control of infections.
3)Authority
To take immediate and appropriate action to correct any deficiencies relating to Infection Control that creates a hazardous condition.
4)Reporting
The ICLprepares infection reports and submits them to the Committee. Problems are identified and actions are planned for resolution.
5)Membership
The Infection Control Committee is composed of the following:
a)Medical Director
b)Vice-President of Health Services (Pediatrics and Nursing)
c)Assistant Vice-President of Health Services (Northern and Southern Regions)
d)General Pediatrician
e)Program Integrity and Accountability (PIA) Representative
1
Revised 05/2010
SECTION II
SURVEILLANCE OF INFECTIONS
1
Revised 05/2010
YCS Infection Control Manual – Section II – Surveillance of Infections
INFECTION CONTROL SURVEILLANCE
PURPOSE:To have knowledge of client infections to guide prevention activities and allow for appropriate actions and follow-up.
POLICY:The Infection Control Liaison does surveillance of infections among clients
1)The Infection Control Practitioner does surveillance of healthcare-associated infections by:
a)Review of client culture reports and other pertinent lab data
b)Physician/Advanced Practice Nurse (APN) consultation and referral
c)Chart review
d)Follow-up on communicable disease exposure
2)Healthcare-associated infections are reported monthly on the Monthly Nursing Department Report
3)Every six months, the Infectious Disease Aggregate Form is completed by the Nurse Manger and is forwarded to Health Services.
4)Results of the Infectious Disease Aggregate are tallied presented by the Infection Control Committee to CCQI on an annual basis.
5)Reporting of infections to the New Jersey Department of Health and Senior Services as required by law.
INFECTION CONTROL PLAN
PURPOSE:To develop and maintain a written plan for infection control including an assessment of risk, services provided, the population served, strategies to decrease risk, and a surveillance plan.
POLICY:A written Infection Control Risk Assessment and Plan (Plan) will be implemented.
1)The Plan will be outlined on the "Infection Control Risk Assessment Form" and will include:
a)Assessment of risk
b)Assessment of services provided
c)Assessment of the population served
d)Prioritized strategies to decrease risk
e)Surveillance plan based on analysis of previous data.
2)The Plan will guide the activities of the Infection Control Committee and will be updated at least annually and more often as needed.
1
Revised 05/2010
YCS Infection Control Manual – Section II – Surveillance of Infections
REPORTABLE DISEASES
PURPOSE:To report infectious diseases to the New Jersey Department of Health and Senior Services as required by law.
POLICY:Behavioral Health Care Facilities are required by law to report certain infectious diseases.
1)A list of reportable infectious diseases, as well as required reporting forms, ismade available to the ICL on an annual basis by the Infection Control Committee, or more often as warranted.
2)An exception to reporting is if there is knowledge that the disease has already been reported by the laboratory or other provider.
INFECTIOUS DISEASE OUTBREAK CONTROL
PURPOSE:To effectively identify infectious disease outbreaks early in their courses and prevent further spread of infection to clients and staff
POLICY:The Infection Control Committee maintains an Infectious Disease Outbreak Control Plan (Plan)
1)The Plan is reviewed and updated on an annual basis, and more frequently as warranted
2)Infectious disease outbreaks are identified through on-going surveillance activities as outlined in Section 1: Infection Control Program, of this manual
3)When an infectious disease outbreak is identified, the Infection Control Committee will identify individuals responsible for carrying out the steps outlined in the Plan
4)Copies of the Plan will be maintained by the Health Services Administration, Northern and Southern Region, and Nurse Manager at each residential site
INFECTION CONTROL OUTBREAK/DISASTER PLAN
At the time of an Outbreak, the Infection Control Committee will determine who is directly responsible for executing the following steps, as this will vary by site
1)Definitions
The definitions below refer to respiratory illnesses as per the January 2009 NJDHSS-CDS “Guidelines for the Control of Respiratory Outbreaks in Long-Term Care and Other Institutional Settings” monograph, but will be generalized to be used for all infectious diseases at YCS
- Cluster
- Defined by the CDC as “three or more cases of acute…illness…occurring within 48 to 72 hours, in residents that are in close proximity to each other (e.g. in the same area of the facility).”
- Outbreak
- Defined by the CDC as “a sudden increase in…cases over the normal background rate, or when any single resident tests positive for influenza”
Of note, “the facility should not wait until an arbitrary number of cases, (such as 10% of census) has occurred)”
2)Reporting
- Calling Guardian/DYFS
- If the Guardian would like to take the client home for a “family visit,” he or she must do so with “informed consent” stating that the risk of transmission of the illness to other family members is understood and that YCS will not be liable or responsible for any illness that results from the client’s presence in the home.
- Initial outbreak (to LHD)
- MUST REPORT TO LHD BY PHONE. If they cannot be reached, call DHSS directly (609-588-7500 9-5, 609-392-2020 after-hours)
- Routine updates of outbreak status
3)Case Investigation
Even in the absence of LHD involvement, the following steps must be followed in order to prevent disease spread.
- Confirm the outbreak (based on the number of cases present on the unit/wing/throughout the facility).
- Verify the diagnosis
- Based on history and physical, lab exams as needed
- Develop a case definition
- In order to describe the criteria that the individual must meet in order to be counted as an outbreak case:
- Clinical signs and symptoms
- Physical location
- Specific time period
- Perform active surveillance
- Document and count cases
- Identify and eliminate possible transmission sources
- Exclude sick staff
- Monitor personnel absenteeism
- Inform receiving facilities of the outbreak when transferring residents
- Institute control measures
- Cohort residents, staff, equipment, and supplies according to living/work area. When it is necessary to transport clients to another location, it must be coordinated in consultation with the Infection Control Committee to determine a means of transport and transport precautions to prevent further spread
- “Ill”
- “Exposed” (not ill, but potentially incubating)
- “Not ill/exposed”
- Restrict use of equipment and supplies to use in each cohort area
- Do not allow inter-mingling among cohorts (e.g. dining, recreation, etc)
- Keep symptomatic residents in their rooms (or infirmary) until 24 hours after symptoms have resolved
- Do not allow staff assigned to affected units to rotate to unaffected units
- Maintain standard precautions
- Check cdc.gov regarding necessary precautions based upon pathogen involved
- Reinforce/reemphasize hand-washing among residents, staff, and visitors
- Post signs to discourage those who are ill from visiting the facility, and to encourage visitors to inform the facility if they have symptoms of infection
- Provide tissues and/or masks to residents and visitors with cough/sneeze so that they may cover their mouth and nose
- Provide tissues and alcohol-based hand rubs in common areas
- Ensure that supplies for hand-washing are available where sinks are located, provide dispensers of alcohol-based hand rubs in other locations
- Provide hands-free waste receptacles whenever possible
- Provide in-service education within 24 hours or by the next business day
- In consultation with Infection Control Committee, who will provide standardized information to be presented to all staff on all shifts
- Evaluate the effectiveness of control measures and modify as needed
- Outbreak is generally considered over when two incubation periods have passed without a new case being identified
- Infection Control Committee will determine the incubation period of the offending agent in consultation with the LHD and through other resources (e.g. cdc.gov)
- Summarize the investigation/cases in a final report
- This report will be reviewed by the Infection Control Committee during its quarterly meetings to determine any areas for possible improvement
- A copy of the report will be kept on file in the office of the Chairperson of the Infection Control Committee
In the case of an infectious disease outbreak that attracts media attention, all calls/requests for information/interviews are to be directed to the President/CEO of the organization
1
Revised 05/2010
1
Revised 05/2010
SECTION III
INFECTION CONTROL EDUCATION
1
Revised 05/2010
YCS Infection Control Manual – Section III – Infection Control Education
INFECTION CONTROL ORIENTATION AND INSERVICES
PURPOSE:To ensure instruction of personnel regarding the importance of infection control and the use of infection control policies and procedures.
POLICY:
1)All new personnel will attend an orientation program that addresses basic principles of infection control, OSHA bloodborne pathogens regulations, and hepatitis B infection.
2)All personnel will attend at least one mandatory infection control update per year. OSHA bloodborne pathogens regulations will be included as well as other infection control issues of importance to the agency.
3)Records will be maintained by the training department documenting:
a)Date and time of training
b)Instructor Content outline
c)Participants and department
4)The ICL will conduct one-on-one training with personnel as practices are observed and corrections or changes in practice are needed.
INFECTION CONTROL ORIENTATION OUTLINE
1)General Infection Control Principles
a)Hand-washing and Hand Hygiene
i)Washing with soap and water
ii)Use of alcohol hand-rubs
2)Standard Precautions and other barrier precautions
a)Reasons for Standard Precautions
i)Employee protection against bloodborne diseases
ii)OSHA regulations
iii)CDC recommendations
3)Components of Standard Precautions
a)Barriers for protection
i)Gowns
ii)Gloves