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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. Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 1 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 2 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service - Required employee TB skin testing done only upon hire. This is arranged through HR. -Reported to Infection Prevention Committee 3 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 4 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service Chronic diseases and/or colonizations Chicken pox CMV Influenza MRSA Measles MSSA Mumps VRE Pertussis Hepatitis B RSV Hepatitis C Rubella HIV 5 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 6 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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: Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 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. 7 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 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 8 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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. Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 9 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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. Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 10 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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. Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service Infection prevention and common terms 11 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 12 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 © Pediatric Home Service 13 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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. Last Revised: 1/29/2015 Last Reviewed: 1/13/2014 © Pediatric Home Service 14 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 © Pediatric Home Service 15 of 16 398 - Infection Prevention Program Infection Prevention Program – Policy 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 © Pediatric Home Service 16 of 16 398 - Infection Prevention Program