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Disclaimer

The suggested template is intended for use as a guide of a general nature only and may not be relevant to particular practices, patients or circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgment or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. This publication is not comprehensive and does not constitute legal advice. You should seek legal or other professional advice before relying on any content, and practice proper clinical decision making with regard to the individual circumstances. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published.

WHS – Infection control policy template

The following are proposed for use in a policies and procedures manual, adapted to suit individual requirements:

Vaccinations for practice members

Working in the healthcare industry exposes staff to disease. Staff are educated on infection prevention and control guidelines to protect themselves against disease.

All staff members are responsible for their own wellbeing. However, the practice offers the following routine immunisation to all practice members:

diphtheria-tetanus
rubella
hepatitis B
sabin
influenza
pneumococcal
varicella
measles for those aged 18 – 30
meningitis C

A record of immunisation status is kept on individual staff member files indicating name, date, titre levels (where appropriate), booster due, who by, batch #, etc. The practice manager keeps a composite list of booster due dates and informs staff.

Advice should be sought from an infectious diseases expert when staff members have contracted a communicable disease.

Blood and body substance spills

Spill kit is kept … (e.g. under sink in store room)

All practice members are trained in the safe management of a contaminated waste spill. They understand the concept of removing the spill, decontaminating the area and safe disposal of waste.

Carpets:

Confine and contain the spill and clean up as soon as possible using the spill kit.
Wear gloves, gown, mask and goggles.
Absorb excess blood or body substance spill with paper hand towel and discard in contaminated waste bag.
Soiled carpet to be cleaned with neutral detergent and water and shampooed using carpet cleaner as soon as possible.
Dispose of all wastes in contaminated waste bag, seal and arrange for collection.
Restock spill kit.

Non-carpeted areas:

Confine and contain the spill and clean up as soon as possible using the spill kit.
Wear gloves, gown, mask and goggles.
Absorb blood and body substance spill from surface using paper towel or absorbent granules and discard in contaminated waste bag.
Clean the area with neutral detergent.
Dispose of all wastes in contaminated waste bag, seal and arrange for collection.
Ensure floor is dry.
Restock spill kit.

Blood and body substance exposure

All staff members are aware and trained in the process for dealing with blood or body fluid exposure.

The practice manager is responsible for managing this process and is required to inform all staff members of the potential risks with needle stick and sharps injury. A needle stick injury follow-up protocol should be visible in procedure rooms as well as in the policy and procedure manual.

The practice manager is responsible for maintaining and updating this policy.

Any staff member exposed to blood or body substances is required to report this incident immediately to the practice manager and complete an incident form.

The staff member is required to give informed consent for testing for HIV and hepatitis C and B. The results of these tests are confidential. All the required paperwork is to be completed in compliance with state-based health legislation.

If the source is known, test for HIV and hepatitis C and B with informed consent.

If the source is not known to be HIV, hepatitis C or B positive contact a doctor or the sexually transmitted diseases clinic for instructions.

Counselling is offered and recommended for the staff member and the source patient if testing is done.

Follow-up blood tests will be provided by the practice.

The results from any tests are confidential and the staff member receives them directly. These results are also forwarded to the referring practitioner. The staff member is under no obligation to inform the practice of the results.

The practice manager completes any insurance advice form required by the workers’ compensation insurer.

Sharps injury management

To reduce incidence of sharps injury:

All sharp objects, including needles, syringes and blood glucose lancets are deposited into the approved yellow rigid containers.
Keep containers out of children’s reach – not on the floor.
Needles are never recapped, purposely bent, broken, removed from disposable syringes or otherwise manipulated by handling.
When the sharps container becomes three-quarters full it is sealed. Sharps containers are collected by (company name) weekly.
Notices on sharps injury procedures are posted in all areas of the practice.

Example of notice for sharps injury:

Immediate treatment for sharps injury:

• Wash the affected area thoroughly with soapy water.

•Report incident to employer – consent to be gained from patient if the identity is known.

•Make appointment with doctor for counselling and blood tests

Cleaning

A regular cleaning and maintenance schedule is necessary to maintain a safe and clean environment.

The premises must be cleaned frequently, thoroughly and with the appropriate chemicals, to minimise infection transmission and offer a safe workplace. Neutral detergent is recommended for all general cleaning. Disinfectants are only recommended in the presence of most-resistant organisms (including C. difficile) or other infectious agents requiring transmission-based precautions. The surface/items should be physically cleaned with a detergent solution, followed or combined with a TGA-registered disinfectant with label claims specifying its effectiveness against specific infectious organisms.

A contract cleaner is employed to clean three times a week after business hours. They will be provided with a rear door key and the security code allowing access. They must also sign a confidentiality agreement. All contract cleaners are cognisant of healthcare cleaning requirements, including the use of colour-coded cleaning equipment.

All practice members will continually assess the contractor’s performance. The practice manager will perform monthly inspections with the contractor. Any problems should be reported to the practice manager. The contract cleaner will report directly, and be answerable to, the practice manager.

Contractors’ duties will be as follows:

Vacuum all floors.
Empty all bins (excluding those lined with yellow contaminated waste bags).
Take out garbage on **** evening.

Using the appropriate cleaning agent supplied by the practice:

Clean all internal windows and unbarred external windows.
Clean toilets.
Clean basins in all rooms.
Wipe over all seats and beds.
Sweep and mop all vinyl and tiled floors (do not polish).
Clean staff bathroom and shower.
Wipe over all furniture (excluding computer keyboards and screens).
Dust all surfaces.
Dust high fixtures (e.g. top of curtain rails).
Mop heads and cleaning cloths are to be laundered after use and stored dry.

The neutral detergent for all general cleaning is purchased by the surgery and kept in the cleaner’s storeroom.

The contractors are expected to wear heavy-duty gloves while cleaning.

The contractors wash children’s toys on the Friday of each week.

No sharps or instruments are to be touched by the contractors. The practice manager is to be informed via the communication book should any sharps or instruments be left exposed.

A communication book is kept in the practice manager’s office for any specific instructions for the contractors.

Contact details for the cleaner are: XXXXX

Waste removal

Waste management and removal of clinical waste are important in the control of infection and contamination.

‘Clinical waste’ is any matter that is soiled with any body substances.

Clinical waste is disposed of by approved waste contractors, in accordance with Australian Standards and local government regulations.

All clinical waste is placed into a yellow clinical waste bag as soon as possible after generation. This bag is sealed and placed in a locked collection bin, located either securely outside the collection area or in a locked room, to prevent public access. The secure clinical waste is collected weekly by an authorised waste management contractor who complies with EPA standards.

Company name collects the clinical waste on Friday of each week.

The waste is tracked and transported to a clinical waste high temperature incineration facility governed by … (The company transporting the waste can provide this information, e.g. NSW EPA regulation license number …).

Sterilising and disinfecting

Risk of infection and cross contamination is minimised if practice members are trained in infection prevention and control and sterilisation and disinfection techniques. This training/education will be recorded in personnel files.

Adequately decontaminating, disinfecting and/or sterilising all reusable medical equipment minimises the risk of cross infection.

Appropriate cleaning and decontaminating all practice equipment and the practice environment controls the possibility of infection spread.

Wearing protective clothing (gloves, impervious gowns, eye protections and hair covering) during these processes reduces the risks and ensures the safety of practice members.

Disposing of both clinical and non-clinical waste in a methodical manner, and ensuring this is done regularly, also minimises the risk of infection spread.

Example cleaning schedule

Area / Daily / Weekly / Monthly / Quarterly / As req’d
Vacuum carpets / Yes
Mop linoleum areas / Yes
Damp wipe desk tops and sinks / Yes
Empty clinical waste bins / Yes
Remove full sharps containers / Yes
Empty waste paper bins / Yes
Clean windows / Yes
Wipe marks from walls / Yes
Clean toilets / Yes
Clean kitchen fridge / Yes
Steam clean carpets / Yes