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SACRED HEART HOSPITAL
421 CHEW STREET
ALLENTOWN, PA 18102-3490
MEDICAL STAFF POLICY AND PROCEDURE MANUAL
Subject: _Infectious Diseases____
Policy Number: __378___
Approval: _____________________
Initial Effective Date: _8/2005_
Revision Date: 8/2013
I.
PURPOSE:
A.
To describe the process by which Medical Staff and Allied Health
Professionals are referred for assessment, potential testing, immunization
and or prophylaxis for potential exposures or known exposures.
B.
To describe the responsibility of physicians to report their
immunization/vaccination status.
II.
SCOPE: This policy includes all members of the medical staff and allied health
professional staff
III.
RESPONSIBILITY:
A. All Medical Staff and Allied Health Professionals are required to obtain the
following immunizations and vaccinations:
a. TST (tuberculin skin testing)
b. Measles*
c. Mumps*
d. Rubella*
e. Varicella/chicken pox (disease or vaccination)**
f. Hepatitis B (or declination)
* (unless born before 1957 and had the disease)
**(unless had the disease)
B.
In accordance with the Sacred Heart Hospital Exposure Control Plan,
Medical Staff and Allied Health Professionals can minimize or eliminate
exposure to blood or other potentially infectious materials by utilizing
personal protective clothing and equipment and exercising use of standard
precautions.
C.
All Medical Staff and Allied Health Professionals are encouraged to
participate in training provided by Sacred Heart Hospital on standard
precautions.
Infectious Diseases
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IV.
RESPONSIBILITY (CONTINUED):
D.
It is the responsibility of the Medical Staff and Allied Health Professional
staff members to report their TST at the time of initial appointment and
reappointment.
E.
It is the responsibility of the Medical Staff and Allied Health Professional
Staff members to report their immunization/vaccination status at the time
of initial appointment.
V.
METHODS
A.
Medical Staff and Allied Health professionals may utilize their private
physician for screening and vaccination for infectious diseases.
B.
Screenings and vaccinations may be obtained through the
Sacred Heart Hospital Employee Health Office upon request. If a
TST is given, the staff member has the responsibility to return within
48-72 hours to have the test results read.
C.
If Quantiferon TB Gold Test (QFT) is obtained, the results may be
provided in lieu of TST.
D.
If Medical Staff or Allied Health Professional is occupationally exposed to
an infectious disease, they may choose to seek advice and treatment from
their private physician or can present themselves to the Sacred Heart
Employee Health office to be seen.
VI.
REFERENCES
Comprehensive Accreditation Manual for Hospitals (CAMH) , Infection Control
Chapter, Standard 4.10, Elements of Performance 5 and 6
Sacred Heart Hospital TB Exposure Control Plan, IC #234
Sacred Heart Hospital Exposure Control Plan, IC #207
VII.
EXCEPTIONS
There are no exceptions to this policy.