Download Infection Control Program

Infection Prevention Program – Policy
Infection Prevention Program
Objective
The Infection Prevention Program at PHS is a plan of action designed to identify infections that
occur in patients and staff that have the potential for disease transmission, and recommend risk
reduction practices by integrating principles of infection prevention into standards of practice.
All employees will be oriented to the Infection Prevention Program and will receive appropriate
education regarding infection prevention procedures.
Corresponding Document
M Files #4491 - Blood/Body Fluid Exposure Checklist for Management
Policy
A) Mission
1. The Infection Prevention Program has been established to define a realistic framework
that contributes to organizational effectiveness through the identification of risk and risk
reduction methods.
2. The program is committed to preventing adverse outcomes such as healthcare-associated
infections and their related events, improving patient care by providing staff education
and support, minimizing occupational hazards associated with the delivery of health care
and fostering evidence-based decision making.
B) Infection Prevention Program Description
1. The Infection Prevention Program is a multidisciplinary, systematic approach to quality
patient care that emphasizes risk reduction of disease transmission in a homecare
environment using sound epidemiological principles.
2. The program focuses on reducing the risk of acquired or transmitted infections for
employees and patients.
C) Program Authority and Responsibility
1. The Infection Prevention Committee is comprised of PHS employees. Acting as liaisons for
staff and patients, members of the committee present questions and concerns related to
infection prevention for discussion and resolution. The committee is responsible for
implementation of infection prevention measures by developing policy, creating tools, and
training staff and patients.
2. PHS Infection Prevention Medical Director and Patient Safety Coordinator:
2.1.
Provides direction and support for the Infection Prevention Program.
2.2.
Provides direction and support to the Managing Director of Human Resources.
2.3.
Initiates action in matters of infection prevention as necessary.
2.4.
Collaborates with the Infection Prevention Committee for review and analysis of
data, scope of surveillance activities, and policies and procedures related to the
infection prevention program.
2.5.
Directs and coordinates the Infection Prevention program maintaining practice
standards.
2.6.
Identifies and assesses patient needs, program design and implementation,
development of surveillance plans and program evaluation.
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2.7.
Serves as an educational resource and liaison to public health and emergency
preparedness.
2.8.
Assists with analysis and interpretation of collected infection prevention data.
2.9.
Investigates and surveys suspected outbreaks of infection.
2.10. Plans, implements and evaluates infection prevention measures.
2.11. Educates patients, families, caregivers, and PHS staff about infection risk and
prevention methods.
2.12. Manages infection prevention activities.
2.13. Provides consultation on infection risk assessment and prevention strategies.
Responsible Personnel
 Surveillance, prevention and control of infection is the responsibility of every PHS
employee.

Employees with frequent exposure: RN’s, RCP’s, Dietitians, Medical Social Worker, Clinical
Specialists, Service Specialists, Equipment Processing personnel.

Employees with infrequent exposure: Office Personnel, Pharm D’s, RPh’s, Pharmacy
Technicians, Warehouse personnel
A) Scope of Services
1. PHS provides quality services to the medically fragile child in the homecare setting. The
PHS Infection Prevention Program is divided into three functional groups of routine
activities that address the integrated facets of risk assessment, surveillance,
identification, reporting, prevention and control, consultation, and education.
1.1. Employee-Related Infection Prevention Procedures



Surveillance and reporting procedures
Bloodborne pathogen exposure procedures
Employee immunization procedures
1.2. Patient-Related Infection Prevention Procedures





Surveillance
Identification
Reporting
Prevention and control
Immunization reporting
1.3. Patient Care/ Infection Prevention Procedures








Safety procedures
Standard precautions
Handling of sharps and potentially hazardous blood/body fluids
Patient care procedures
Employee training
Hand hygiene
Personal protective equipment
Labeling of hazardous waste
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Cleaning of non-disposable equipment used in a home
Transporting clean and dirty equipment
Patient education on infection prevention



2. The PHS Infection Prevention Program includes:

Identification, management, and follow up of persons with transmissible diseases.

Identification of specific infections in patients which are present on admission or
which occur after admission, and identified infection in staff that are present on
employment or which occur as a result of exposure.

Management of identified risk.

Measurement and monitoring of program effectiveness and, when indicated, expand
activities associated with health and safety and quality improvement.
3. Risk Assessment—the determination of value of risk related to a concrete situation and a
recognized threat or hazard. Risk assessment requires calculations of two components of
risk: the magnitude of the potential loss, and the probability that the loss will occur. A
risk assessment acts as a basis for our annual infection prevention plan, identifies at risk
populations at PHS, assists in focusing surveillance efforts, and meets regulatory
requirements.
Surveillance
Activity
Rationale
Reporting Mechanism
Hand Hygiene
-Hand hygiene is the number one
prevention activity for reducing the
risk of infection.
-Ride-alongs and/or tracers - direct
observation
Equipment/supply
Bag technique
-High potential for adverse outcomes
-Reported to managers and Infection
Prevention Committee
-High potential for prevention
-Learning Block-competency evaluation
-Potential for adverse outcomes
-Ride-alongs, tracers, and direct
observation
-Potential for transmission
-High potential for prevention
-Reported to managers and Infection
Prevention Committee
-Learning Block-competency evaluation
CLA-BSI
-High potential for adverse outcomes
-High potential for prevention
-Rate per 1,000 central venous catheter
days monitored
-Reported to Infection Prevention
Committee
-Learning Block-competency evaluation
-1,2,3 Infection Free Program-caregiver
competency evaluation
TB
-High potential for adverse outcomes
-High potential for exposure
-Follow up monitoring after problem
identification
-High potential for prevention
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- Required employee TB skin testing done
only upon hire. This is arranged through
HR.
-Reported to Infection Prevention
Committee
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Multi-drug Resistant
Organisms
-High potential for adverse outcomes
-Reported to Infection Prevention
Committee
-Potential for prevention of
transmission
-Learning Block-competency evaluation
Sentinel Events
-High potential for adverse outcomes
-A Root Cause Analysis is conducted on all
Sentinel Events
Review/revise
Infection Prevention
evaluation Program
-Must be consistent with current
Standards of Care: regulatory, clinical,
environmental, etc.
-Reviewed and approved by Infection
Prevention Committee
Warehouse/
-High potential for adverse outcomes
Biomed Committee
Surveillance activity
-Potential for prevention of adverse
outcomes
-Reviewed by Infection Prevention
Committee
-Learning Block-competency evaluation
-Learning Block-competency evaluation
-Direct observation and tracers.
Immunization
Employee
-Moderate potential for adverse
outcomes
-Reviewed by Infection Prevention
Committee
Hepatitis
-High potential for transmission
Influenza
-High potential for absenteeism
-Employees followed by Human Resources
and Infection Prevention Committee
-High potential for prevention
Employee Exposure
Infection
-High potential for adverse outcomes
-Followed by Human Resources and
Infection Prevention Committee
-High potential for prevention
-Learning Block-competency evaluation
4. Risk Prioritization—determines whether a known or potential risk is likely to occur, if it will
be significant should it occur, whether we have a prevention plan established and are
adequately prepared to handle an occurrence so that the negative effects are eliminated
or minimized.
Event/Activity
Program
Probability
Risk Will Occur
Risk/Impact Severity
Rating
Risk Factor
Current
System in
place?
4 - Sentinel Event
3 - Major Event
(Permanent loss of
function)
4 - Frequent
3 - Occasional
2 - Uncommon
1 - Remote
2 - Moderate Event
(No permanent
impairment Temporary)
1 - Minor Event
(No loss of function)
Multiply the highest
risk/impact rating and
the probability risk to
get the risk factor
Y - Yes
N - No
0 - Non-Applicable
Patient
Staff
Hand Hygiene
4
3
3
12
Y
Bag Technique
4
2
2
8
Y
CLA-BSI
4
4
0
16
Y
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TB
2
4
4
8
Y
Multi-Drug Resistant
Organisms
4
3
3
12
Y
Sentinel Events
3
4
0
12
Y
Employee Exposures
3
0
4
12
Y
Employee Vaccination
3
0
2
6
Y
Standard Precautions
4
3
3
12
Y
Pandemic Planning
1
4
4
4
Y
B) Employee-Related Infection Prevention Procedures
1. Surveillance and Reporting Procedures
1.1. Data on staff infections will be collected by the PHS Managing Director of Human
Capital using the Infection Prevention Log. This information is analyzed, assessed
and interpreted for improved patient safety and employee health.
1.2. As healthcare workers, PHS employees must help to ensure the health and safety of
PHS patients and employees. If you are diagnosed with any of the communicable
diseases listed by the MN Health Department document “Communicable Disease Rule,
Chapter 4605, section: 4605.7040 Disease and Reports; Isolate Submissions”; you
have a responsibility to report such infection to the PHS Human Resources
department. Such a report will be held in confidence as long as such confidential
treatment does not endanger our employees’ or patients’ safety. In addition, PHS
will not use this report in any discriminatory manner nor will PHS take disciplinary
action based on it. The PHS HR department and PHS Infection Preventionist will;

Advise employees of required work restrictions.

Use this information from employee infection reports to identify employee
infection outbreaks.

Compare this data to patient infection data to identify any potential correlation.
Acute Diseases
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Chronic diseases
and/or colonizations
Chicken pox
CMV
Influenza
MRSA
Measles
MSSA
Mumps
VRE
Pertussis
Hepatitis B
RSV
Hepatitis C
Rubella
HIV
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MRSA Infection
TB
MSSA Infection
Pseudomonas
Pneumonia
Other
Hepatitis A
C-diff
Other
1.3. Tracking will be done by completing the Infection Prevention Log which will be kept in
a separate file, to protect confidentiality. The medically certified infections tracked
include (are based on the Communicable Disease Reporting Rule maintained by MN
Dept. of Health which is current as of September 13, 2005):

The following are not recorded in our clinical database but, because they are
highly contagious, should be reported by the infected employee:
Meningitis
Group A Strep
Staph Lesions
Shingles
Scabies
IMPORTANT! For the most current listing of communicable reportable diseases, see
the MN website at:
http://www.health.state.mn.us/divs/idepc/dtopics/reportable/rule/rule.html. Staff
with communicable diseases that must be reported to state health officials will be
reported by their physician or clinic.
1.4. Trends identified on the logs will be reported quarterly at the Infection Prevention
Committee meeting.
2. Bloodborne Pathogen Exposures Procedures
2.1. Bloodborne Pathogen Exposure
2.1.1. Bloodborne Pathogen Exposures will be handled according to the procedures
delineated in OSHA’s bloodborne pathogen’s standard, to ensure employee and
patient safety.
2.1.2. A bloodborne-pathogen exposure is defined as a specific eye, mouth or other
mucous membrane, non-intact skin, parenteral contact with blood or other
potentially infectious materials that results from the performance of an
employee’s duties, such as a puncture from a contaminated sharp.
2.1.3. The PHS Managing Director of Human Capital and/or Medical Director will ensure
that a request is made for testing of the source individual’s blood for any
bloodborne pathogens.
2.1.4. The PHS Managing Director of Human Capital and/or Medical Director will
provide, to the PHS designated clinic or clinic of employee’s choosing, a
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description of the affected employee’s job duties as they relate to the incident, a
report of the specific exposure (including route of exposure), relevant employee
medical records (including hepatitis B vaccination status) and results of the
source individual’s blood tests, if available.
2.1.5. The designated clinic must then collect a blood sample from the exposed
employee and test it for HBV and HIV serological status. If the employee does
not give consent for HIV baseline testing, the employee’s blood sample must be
kept for at least 90 days. If, during this time, the employee elects to have the
baseline sample tested, testing shall be performed as soon as feasible.
2.1.6. The results of the source individual’s blood tests are confidential. As soon as
possible, however, the test results of the source individual’s blood must be
made available to the exposed employee through consultation with our clinic.
2.1.7. Following post-exposure evaluation, the PHS Managing Director of Human
Capital and/or Medical Director will ensure that the clinic provides a written
opinion to PHS. This opinion should be limited to a statement that the employee
has been informed of the results of the evaluation and told of the need, if any,
for further evaluation or treatment. The PHS Managing Director of Human
Capital must provide a copy of this written opinion to the employee within 15
days. This is the only information that should be shared with PHS by the clinic.
All other employee medical records are confidential.
2.1.8. The Exposure Incident Report Form will be completed by the PHS Managing
Director of Human Capital and/or Medical Director.
IMPORTANT! Check OSHA website to ensure most current information
http://www.osha.gov/needlesticks/needlesticks-regtxtrev.html
3. Employee Immunizations Procedures
3.1. All employees will be offered the Influenza vaccine every fall, availability permitting.
3.1.1. PHS’ goal is to align with the HP 2020 goal of increasing the percentage of
Health Care Workers (clinical staff) who are vaccinated annually against
seasonal influenza to 90% by 2020.
3.1.1.1. In an attempt to achieve this goal, PHS will annually educate staff about
the influenza vaccine; non-vaccine control and prevention measures; and
the diagnosis, transmission, and impact of influenza (The Joint
Commission Standard IC.02.04.01, Element of Performance 2).
3.1.2. Methodology in determining PHS Annual Influenza vaccination rates:
3.1.2.1. HR department will send out a form for employees to complete which
asks if they have received or declined the Influenza vaccination.
3.1.2.2. Patient Safety Coordinator will monitor the responses and the employees
who choose to decline the vaccine will be asked to classify the reason for
declining. Reasons include:
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
Vaccination is too expensive

Severe reaction to the vaccine in the past

Anaphylaxis allergy to eggs

Personal (i.e. Vaccine doesn’t work): Employee does not need to
explain what their personal reason is to PHS.
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3.1.2.3. At the end of January, Patient Safety Coordinator will accumulate
responses and update the Infection Prevention Committee and Senior
Team members on what percentage of PHS employees received the
Influenza vaccination.
3.2. All employees will be offered the Hepatitis B vaccine within 10 working days of initial
assignment. If the employee consents to receive the Hepatitis B vaccine, then the
series will be given. If the employee refuses the Hepatitis B vaccine a waiver will be
signed and kept in the employee file located in Human Resources. Any employee
who has received the Hepatitis B series will have a titer drawn. If the titer is low,
current Minnesota Department of Health recommendations will be followed.
All clinical employees will be given a PPD Skin test upon hire, which is arranged
through HR. All new clinical employees to PHS will have the option to do PPD skin
testing or QuantiFERON blood test. If the new clinical employee has a positive test,
they will be referred to their primary physician for evaluation.
C) Patient Related Infection Prevention
1. Surveillance Procedures
1.1. Data on patients’ infections is collected internally by the Infection Control Committee
to identify any trends and/or changes in trends. If trends are noted, this information
is analyzed, assessed and interpreted for potential improvement of patient care on a
semi annual basis. Outside experts will be used as necessary with analysis,
assessment and interpretation of data.
2. Identification Procedures
2.1. The following are infectious / communicable diseases currently recorded in our clinical
database. However, this list is not exhaustive:
Acute Diseases
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Chicken pox
Chronic diseases
and/or colonizations
CMV
Influenza
MRSA
Measles
MSSA
Mumps
VRE
Pertussis
Hepatitis B
RSV
Hepatitis C
Rubella
HIV
MRSA Infection
TB
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MSSA Infection
Pseudomonas
Pneumonia
Other
Hepatitis A
C-diff
Other
2.2. Infusion Services will track central line associated blood stream infections and review
twice a year.
2.3. Clinicians will immediately report active infections in the Electronic Health Record.
2.3.1. Any patient who has a transmissible infection that requires contact precautions,
an Alert on the patient’s account will be entered so that all employees are aware
and can take special precautions before completing a home visit.
3. Investigating Outbreaks
3.1. All clinicians are responsible for reporting and documenting communicable/infectious
diseases.
3.2. Surveillance (monitoring trends and detecting outbreaks) for communicable/
infectious diseases is collected by clinical staff and reviewed by the Infection
Prevention Committee quarterly.
3.3. The PHS Infection Prevention Committee will investigate outbreaks as defined by
surveillance and identification procedures.
3.3.1. All detected outbreaks will be identified as a sentinel event, initiating an analysis
of the event to determine the root cause(s) and the formulation of an action
plan to manage, contain, and avoid the recurrence of the communicable/
infectious outbreak.
3.4. The Minnesota Department of Health, patient’s physician, and other health care
providers will be utilized as resources to assist with appropriate management and
containment measures of the outbreak.
4. Reporting Procedures
4.1. Patients with communicable diseases that must be reported to state health officials
will be reported by the patient’s physician or the primary healthcare provider.
4.1.1. The Report of Infectious/Communicable Disease Form will be completed by the
PHS Managing Director of Human Capital or PHS Medical Director.
4.1.2. IMPORTANT! For the most current listing of communicable reportable
diseases, see the MN website:
http://www.health.state.mn.us/divs/idepc/dtopics/reportable/rule/rule.html.
5. Prevention Procedures
5.1. PHS employees will practice appropriate infection prevention measures in all care
provided in the home.
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5.2. Any staff assigned to a potentially infectious case will follow appropriate precautions.
If the staff has questions regarding appropriate precautions, they will contact a
clinical manager and/or Medical Director.
5.3. Standard precautions will be followed by all direct care personnel. All patients are to
be considered potentially infected with HIV and/or other bloodborne pathogens.
5.4. Special precautions will be utilized for patients with known multiple drug resistant
bacteria, i.e. VRE (Vancomycin Resistant Enterococcus) and MRSA (Methicillin
Resistant Staph Aureus).
5.4.1. When a patient is admitted to PHS for services, the admitting clinician will obtain
a history including any positive cultures of MRSA and/or VRE. The positive
history will be documented in the Electronic Health Record.
5.4.2. All clinicians will follow standard precautions as they do with all patients.
5.4.3. Whenever possible, patients who are known to be positive for VRE or MRSA will
be scheduled at the end of the day to minimize the potential for transmission to
other patients.
5.5. Tuberculosis Precautions
5.5.1. All clinicians will follow standard precautions when caring for a patient with
suspected or confirmed infectious TB.
5.5.2. An N95 disposable, respirator mask shall be worn by all clinicians entering the
homes of and providing care for patients with suspected or confirmed infectious
TB disease.
5.5.3. N95 respirator masks will be mask-fit tested to each clinician prior to entering
the home of a patient or family member with suspected or confirmed active
infectious TB disease.
5.5.4. Patients, caregivers and household members will be educated regarding the
importance of taking medications, respiratory hygiene, cough etiquette
procedures and proper medical evaluation.
5.5.5. The determination of when it is safe to discontinue wearing of the N95 respirator
mask in the home of a patient with suspected or confirmed infectious TB is
based on the provision of appropriate therapy, improvement of signs and
symptoms, and the results of three sputum smears for acid-fast bacilli are
negative on three consecutive days. At lease one specimen should be collected
early in the morning.
5.5.6. Equipment that comes back to PHS from known or suspected TB cases will be
quarantined for 3 months.
D) Patient Care/Infection Prevention
1. Safety Procedures
1.1. Staff will adhere to appropriate safety measures in all client care procedures.
1.2. All incidents/accidents will be reported to the employee’s immediate supervisor and
Managing Director of Human Resources.
1.3. Employees will practice basic home safety and appropriate infection prevention
measures in all care provided in the home and clinic settings.
1.4. Measures will be taken to prevent and identify infections.
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1.5. Employees will follow health and dress code policies established.
1.6. All staff doing patient care or at risk for exposure will be instructed on the
precautions to take.
1.7. Standard precautions will be followed by all direct care personnel.
2. Handling of Sharps and Potentially Hazardous Blood/Body Fluids
2.1. Lab specimens will be placed in a plastic bag that has a biohazard label and then
placed inside a rigid, puncture-resistant container (that also has a biohazard label)
for transport.
2.2. Puncture-resistant containers will be available for disposal of needles and other
sharps.
2.3. Disposable needles, any sharp items or other potentially infectious waste materials
(syringe of blood) that are not disposed of in the patient’s sharps container will be
returned to PHS and placed in large Sharps barrel for disposal.
2.4. PHS patients will be provided with a puncture-resistant container and instructions for
disposal of needles and other sharps (Sharps Disposal by Mail System).
2.5. PHS will review the use of safe medical devices and sharps per the Annual Safer
Sharps Evaluation policy.
3. Patient Care Procedures
3.1. If dealing with a patient with an open wound, cut or lesion, employee will provide
care utilizing standard precautions.
3.2. Ventilation devices will be available for use in the event of need for mouth-to-mouth
resuscitation.
3.3. Mouth pipetting/suctioning of blood or other potentially infectious materials is
strongly discouraged and is for emergency use only in the event the patient’s suction
equipment is inoperable and the patient requires suctioning to maintain a patent
airway.
3.4. Clinicians verify that open containers of sterile water and saline are marked with a
disposal date. All open containers are disposed of after 24 hours unless the patient,
family, or nursing agency providing care in the home indicates otherwise.
3.5. PHS recommends that open pour containers of sterile water and saline are not used
for multiple patients.
4. Employee Training
4.1. All employees who have an occupational risk of exposure to infectious materials will
be provided a training program on infection prevention. Training will be provided
during orientation and prior to assignment of tasks which pose a risk of exposure to
infectious materials. Training will be repeated annually thereafter.
4.2. Additional training will be provided as changes in tasks, procedures, and regulations
occur.
4.3. All training will be at a level of understanding of employee.
4.4. Content of training will include but not limited to:
4.4.1.
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Infection prevention and common terms
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4.4.2.
Growth conditions and mode of transportation of microorganisms and
measures to preventing infection via this information
4.4.3.
How HIV and Hepatitis viruses are transmitted and actions to minimize own
risk:
4.4.4.
HIV disease processes
Signs and symptoms
Transmission
Use of standard precautions
High risk activities
Prevention recommendations
4.4.5.
Effective hand hygiene and use of personal protective equipment
4.4.6.
Methods of waste management
4.4.7.
Current OSHA regulation requirements
4.4.8.
PHS exposure prevention plan
4.4.9.
Degree of occupational exposure with each job description
4.4.10.
Work practice preventions and risk management measures
4.4.11.
Incident reporting and safety measures.
4.5. Employee will receive instruction on Hepatitis B vaccine and other immunizations, as
indicated.
4.6. Employee will be given an opportunity for interactive questions and answers on
infection prevention regulations and requirements during departmental orientation.
4.7. Training records will be maintained on employees and kept for at least three years
after training session. Record will contain date of session, instructor and content of
session.
5. Hand Hygiene Procedures
5.1. Wash hands with liquid soap (antimicrobial preferred, otherwise nonantimicrobial)
and hand dry with a disposable towel or clean cloth towel every time
5.1.1.
hands are visibly soiled
5.1.2.
after contact with blood and body fluids or excretions, mucous membranes,
non-intact skin, and wound dressings
5.1.3.
if there is Clostridium Difficile suspected or confirmed in the home
5.2. Cleanse hands with an alcohol-based hand sanitizer or wash hands with liquid soap
(antimicrobial recommended, otherwise nonantimicrobial) and water and dry with a
disposable towel or a clean cloth towel every time for routine decontamination:
5.2.1.
upon entering a patient’s home
5.2.2.
before performing procedures involving medical devices or open wounds,
with gloves worn as necessary
5.2.3.
after performing procedures where hands may have become contaminated,
such as changing dressings or suctioning the patient or coming into contact
with blood and body fluids or excretions, mucous membranes, or non-intact
skin
5.2.4.
anytime the hands may have been contaminated such as emptying bedpans
or suction bottles
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5.2.5.
before and after removing gloves
5.2.6.
when performing care and moving from a contaminated body site to a clean
site
5.2.7.
before entering the clean area of clinician’s supply/equipment bag
5.3. Other hand hygiene issues
5.3.1.
Efforts should be made to maintain a clean environment, especially for
frequently touched surfaces, such as medical equipment, and surfaces that
come into direct contact with the patient’s skin.
5.3.2.
Do not add soap or alcohol based hand sanitizer to a partially empty
dispenser. This can lead to bacterial contamination of soap or sanitizer.
5.3.3.
Do not wear artificial fingernails or extenders when having direct contact with
patients at high risk.
5.3.4.
Antimicrobial impregnated wipes are not considered an effective alternative
to soap and water or alcohol based hand gel for hand hygiene.
5.3.5.
Check the expiration dates on alcohol based hand sanitizers and store within
the appropriate temperature range.
Proper Hand Hygiene Technique
Alcohol based sanitizer
1. Apply product to palm of one hand and rub hands together, covering all surfaces of
hands and fingers, until hands are dry. NOTE! Hands must be completely dry
after using an alcohol-based sanitizer to avoid a fire / burn hazard.
2. Follow the manufacturer’s recommendations regarding how much to use.
Soap and water
1. Wet hands with water, apply amount of product recommended by the manufacturer,
and rub hands together vigorously for at least 20 seconds, covering all surfaces of
the hands and fingers.
2. Rinse hands with water and dry thoroughly with a disposable towel.
3. Use the towel to turn off the faucet.
4. Avoid using hot water because repeated exposure to hot water may increase the risk
of dermatitis.
6. Protective Barriers
6.1. PHS will provide personal protective equipment to all employees who may come into
contact with blood or other potentially infectious body fluids.
6.2. PHS will provide employees a personal protective equipment (PPE) kit containing
gloves, face shields, masks, gown/clothing coverings, hair nets, booties,
CPR/ventilation mask (if employee is CPR certified) and red biohazard bags. Supplies
of these items will be maintained in the agency office and the employee is responsible
for maintaining their own personal protective equipment kit.
6.3. The PPE kit is to be returned to PHS upon employee termination.
6.4. Employees will be given instruction on use of the PPE kit and its supplies upon
employment and annually thereafter.
Last Revised: 1/29/2015
Last Reviewed: 1/13/2014
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6.5. All used personal protective equipment shall be properly disposed of before leaving
the client’s home.
6.6. The type of protective barrier should be appropriate to the procedure being
performed and the type of exposure anticipated.
6.7. When contact with blood/body fluids is anticipated, protective barriers are to be worn
(gloves, mask, protective eyewear and/or gowns).
7. Use of Gloves
7.1. Use of gloves can reduce risk of contact with bloodborne pathogens but do not
prevent penetrating injuries. Gloves must be replaced as soon as possible if torn or
punctured.
7.2. Latex free and/or vinyl gloves are available to all employees for patient care
procedures.
7.3. Hand hygiene should be practiced before applying and after removing gloves.
7.4. Gloves must be changed between client contacts. Gloves should be disposed of
immediately after use.
7.5. Gloves must be worn when:
7.5.1. Employee comes in contact with blood/body fluids, mucous membranes or nonintact skin (for example, carrying un-diapered child).
7.5.2. Employee has cuts, abrasions, chapped skin or dermatitis on hands.
7.5.3. Performing invasive procedures such as venipunctures, procedures involving
vascular access, catheterization, etc.
7.5.4. Disinfection procedures are performed.
7.5.5. Handling supplies or equipment that may come in contact with mucous
membranes (for example, nasal cannula).
8. Labeling of Hazardous Waste
8.1. Warning labels must be affixed to any container containing blood or potentially
infectious or hazardous material that is taken from the patient’s home. The following
items will carry a “biohazardous” label or be contained in a red (orange-red)
container:
8.1.1.
Container with sharps
8.1.2.
Specimen containers with blood or other potentially hazardous materials
8.1.3.
Biohazard labels or red bags are available to staff who have the potential for
handling hazardous materials.
8.2. Contaminated equipment being transported to PHS for disinfection procedures must
be bagged in an opaque plastic bag.
9. Cleaning of Non-Disposable Equipment Used In a Home
9.1. All non-disposable equipment that comes in contact with a patient or their equipment
should be wiped off with an appropriate disinfectant wipe (PDI wipes). Clorox
disinfecting wipes are not appropriate for use on home care equipment.
9.2. To prevent skin irritation wash hands thoroughly with soap and water after using PDI
wipes or wear gloves when using PDI wipes.
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Last Reviewed: 1/13/2014
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9.3. Equipment is placed back into the clinician’s supply/equipment bag only after being
cleaned and air-dried.
9.4. Bags should either be placed on a clean, disposable barrier while in the patient’s
home or cleaned upon leaving the home with an appropriate disinfectant wipe.
9.5. The clean section of a clinician’s bag should be kept closed while in the patient’s
home.
9.6. The clinician must perform hand hygiene every time the clean section of their
supply/equipment bag is accessed.
9.7. The cleanliness of all clinician supply/equipment bags must be maintained.
9.8. The cleanliness off all electronic devices including laptop computers must be
maintained.
10.Transporting Clean and Dirty Equipment
10.1. All equipment picked up from a patient’s home is considered dirty and must be
bagged using non-sterile gloves by appropriate personnel and put into an opaque
plastic bag.
10.2. All clean equipment will be bagged in clear plastic bags (equipment leaving the
office, or carried in RN, RCP, Clinical Assistant or Service Specialist vehicle).
10.3. The RCP/RN/Clinical Assistant/Service Specialist must remove gloves and clean
hands following the handling of dirty equipment with soap and water or hand
sanitizer.
10.4. All dirty equipment should be secured and set apart from clean equipment in that
part of the RCP/RN/Clinical Assistant/Service Specialist vehicle that has been set
aside for dirty equipment.
10.5. All dirty equipment must be brought into the “dirty room” of the Equipment
Processing Center.
10.6. Clean equipment returned from the field should also pass through the dirty room.
11.Patient Education on Infection Prevention
11.1. Patient education will include the following safety/infection prevention education:
11.1.1.
Safe use of medical equipment in the home
11.1.2.
Safe handling/disposal of needles and hazardous waste
11.1.3.
Safe management of all medications
11.1.4.
Hand hygiene and proper disposal of contaminated supplies/waste
11.2. Patient and/or caregiver understanding of infection prevention will be monitored on
an ongoing basis and reinforcement of instruction provided as needed.
11.3. Patient and/or caregiver will be taught signs and symptoms of infection that need
to be reported to their physician.
11.4. Staff will instruct patient and/or caregiver in good infection prevention measures
such as hand hygiene, waste management, disinfection procedures, proper dressing
procedure, and other ways to decrease spread of infections.
11.5. Infection prevention education will be documented in the Electronic Medical Record.
Last Revised: 1/29/2015
Last Reviewed: 1/13/2014
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E) Compliance Monitors
1. Each manager is responsible for monitoring compliance with PHS Infection Prevention
policies.
2. Deviation from policies and procedures are dealt with according to the Infection
Prevention Committee.
3. Observations of deviation from policy, made during surveillance, are reported to the
department manager.
References
Plan of the Infection Control Department of Slidell Memorial Hospital, section of Surveillance,
Prevention, and Control of Infection, Policy Number IC-020
EPI:101 The Fundamentals of Infection, Surveillance, Prevention and Control, APIC 2008
APIC Text of Infection Control and Epidemiology, 3rd Edition 2009
Rhinehart, Emily and Friedman, Mary M., Infection Control in Home Care, APIC 2006
Minnesota Department of Health
Centers of Disease Control and Prevention
Occupational Safety and Health Administration
Brown, D.G., Skylis, T.P., Sulisz, C.A., Freidman, C., and Richter, D.K. Sterile Water and Saline
Solution: Potential Reservoirs of Nosocomial Infection. American Journal of Infection Control.
13(1):35-9, 1985. Retrieved from APIC July 5, 2012.
Joint Commission Standard on Infection Prevention and Control. Standard IC.02.04.01,
Elements of Performance 4-6.
Follow-Up Responsibilities
PHS Medical Director
Last Revised: 1/29/2015
Last Reviewed: 1/13/2014
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