Download Infection Control Plan - MidWest Clinicians` Network

CHERRY STREET HEALTH SERVICES
POLICY AND PROCEDURE
SUBJECT: INFECTION CONTROL PLAN
POLICY:
Cherry Street Health Services (CSHS) is committed to providing a safe and efficient working
environment for all employees. All employees have a right to know about health hazards associated
with their work. Education and inservice training will enable employees to make knowledgeable
decisions about any personal risks of employment. The Safety and Infection Control Manual will
include policies, procedures, and responsibilities designed to make employees aware of hazards in
the work place and to train employees in appropriate and safe working conditions.
CSHS has assigned the responsibility, authority and accountability for safety to all management and
supervisory personnel. Accident prevention is the primary objective of a “hazard-free” work place.
To accomplish this, CSHS folllows these federal and state regulations:
1) OSHA’s Occupational Exposure to Hazardous Chemicals in Laboratories
2) 2) OSHA’s Occupational Exposure to Blood Borne Pathogens.
These regulations, along with prudent infection control measures, will be the primary components
of the Safety and Infection Control Manual.
A hazard-free work place is everyone’s responsibility. All employees must continuously work
together to promote a safe work place. Management and supervisory personnel will consistently
enforce all policies and procedures. Each employee will have the responsibility of performing their
own work in a safe and efficient manner and to report unsafe acts or conditions to their supervisor.
I.
OBJECTIVES
A.
Safe work methods will be developed and maintained. All employees will be
appropriately trained in these methods.
B.
Chemical management requirements will be covered by the Safety and Infection
Control Manual.
1.
Implementation of procedures and work practices that protect employees
from health hazards associated with chemicals used by this organization.
2.
Maintain employee exposures below permissible exposure limits for OSHA
regulated substances.
C.
Exposure Control Plan requirements will be covered by the Safety and Infection
Control Manual.
Infection control plan
Page 1
6/95
6/96
6/98
6/99
8/00
7/05
1.
Exposure determination will be listed by job title descriptions for all job
classifications that are determined to be a Risk Category I, Category II or
Category III. *Refer to Form IC - 1A for the organizations personnel risk
categories.
2. Methods of compliance will be through the practice of universal precautions,
Personal Protective Equipment (PPE) and engineering controls, handwashing
practices, sharps precautions, hazardous waste disposal and decontamination
procedures.
D. All employees needing medical attention will use the employee health services available
through Spectrum Health. All medical examinations and consultations will be
performed without cost to the employee, without loss of pay, and in a reasonable
time. This service must not be misconstrued as an employee’s personal physician.
This service is for exposure incidents due to a hazardous chemical, blood borne
pathogen, or other workplace occurrence.
III.
GLOSSARY
A.
Chemical
1.
Carcinogen: a substance capable of causing cancer.
2.
Combustable: able to catch on fire and burn.
3.
D.O.T: Department of Transportation.
4.
EPA: Environmental Protection Agency.
5.
Flammable: capable of being easily ignited and of burning with extreme
rapidity.
6.
Laboratory scale: work with chemicals that can easily and safely be
manipuIated by one person, excluding the commercial production of
chemicals for sale.
7.
Laboratory use: a work place where relatively small quantities of hazardous
chemicals are used on a non-production basis.
8.
MSDS: Material Safaty Data sheets.
9.
OSHA: Occupational Safety and Health Administration - The regulatory
branch of the Department of Labor concerned with employee safety and
health.
10.
PEL: Permissisle Exposure Limit. This is the legally allowed concentration
in work place that is considered a safe level of exposure for an 8 hour shift,
40 hours per week.
B.
Blood Borne Pathogens
Infection control plan
Page 2
6/95
6/96
6/98
6/99
8/00
7/05
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Infection control plan
Page 3
6/95
6/96
6/98
6/99
8/00
7/05
Blood: human blood, human blood components, and products made from
human blood.
Blood borne pathogens: pathogenic microorganisms that are present in
human blood and can cause disease in humans. These pathogens include, but
are not limited to Hepatitis B Virus (HBV) and Human Immunodeficiency
Virus (HIV).
Contaminated: the presence or the reasonably anticipated presence of blood
or other potentially infectious materials on an item or surface.
Decontaminated: the use of physical or chemical means to remove,
inactivate, or destroy blood borne pathogens on a surface or item to the point
where they are no longer capable of transmitting infectious particles and the
surface or item is rendered safe for handling, use, or disposal.
Engineering controls: controls (i.e. sharps disposal containers, self-sheathing
needles) that isolate or remove the blood borne pathogen hazards from the
workplace.
Exposure Incident: a specific eye, mouth, or other mucous membrane, nonintact skin, or parenteral contact with blood or other potentially infectious
materials that results from the performance of an employee’s duties.
Occupational Exposure: reasonably anticipated skin, eye, mucous membrane,
or parenteral contact with blood or other potentially infectious material that
may result from the performance of an employee’s duties.
Other Potentially Infectious Materials
a.
The following human body fluids: semen, vaginal excretions,
cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid,
peritoneal fluid, amniotic fluid, saliva in dental procedures, any body
fluid that is visibly contaminated with blood, and all body fluids in
situations where it is impossible to differentiate between body fluids.
b.
Any unfixed or unpreserved tissue or organ (other than intact skin)
from a human (living or dead).
Parenteral: piercing mucous membranes or the skin barrier through such
events as needlesticks, human bites, cuts, and abrasions.
Personal Protection Equipment (PPE): specialized clothing or equipment
worn by an employee for protection against a hazard. General work clothes
(e.g., uniforms, pants, shirts or blouses) not intended to function as protection
against a hazard are not considered to be PPE.
Source Individual: any human body or organ part living or dead, whose
blood or other potentially infectious fluid or organ may be a source of
occupational exposure to the employee.
12.
IV.
Universal Precautions: an approach to infection control. According to the
concept of univeral precautions, all human blood and certain human body
fluids are treated as if known to be infectious for HIV, HVB, or other blood
borne pathogens.
13.
Work Practice Controls: controls that reduce the likelihood of exposure by
altering the manner in which a task is performed (e.g., prohibiting recapping
of needles by a two-handed technique).
RESPONSIBILITIES
A.
Safety Committee: The objective of this committee is to maintain a “hazard-free”
workplace for the organization. The committee will be chaired by the Operations
Director . The committee will meet monthly to review any incidents and annually
review all policies and procedures developed. The Safety Committee has the
following responsibilities:
1.
Work with administration and other key personnel to develop and implement
appropriate policies and practices.
2.
Certify the performance of protective equipment.
3.
Identify, monitor procurement, use and disposal of hazardous chemicals and
blood borne pathogens in the work place.
4.
Know current regulations that impact the work place.
5.
Always search for new methods to improve policies and procedures
developed.
6.
Review infection control and safety surveys.
B.
Operations Director/Executive Director
1.
Responsible for providing a “hazard-free” environment for all patients and
personnel.
2.
Aware of potential hazards in the organization and appropriate precautionary
measures are implemented.
3.
Communication with practice physicians and other key personnel on any
changes in policies and procedures.
C.
Facility Managers
1.
Responsible for providing a “hazard-free” environment for all patients and
personnel.
2.
Communication with Operations/Executive Director, etc.
3.
Provide formal safety inspections monthly and a semi annual risk assessment
inspection of all clinical sites. Reports to be submitted to the safety
committee.
4.
Know current regulations.
D.
Clinical Coordinators/ Supervisor(s)
1.
Works closely with Facility Managers in the administration of Safety
Infection control plan
Page 4
6/95
6/96
6/98
6/99
8/00
7/05
V.
and Infection Control program. Specifically identifies needs of the
department or site.
2.
Is a member of Safety Committee. Participates in the development and
implementation of new policies and procedures as needs change.
E.
Employees
1.
Employees are asked to utilize safety procedures implemented for protection
for everyone.
2.
All employees have the responsibility to be aware of hazards, and follow
policies and procedures designed to protect them.
3.
Report all incidents or accidents so that steps may be taken to prevent a
reoccurrence.
All employees must be aware that protective clothing and equipment alone
offer minimal protection. It is extremely important to follow all policies and
procedures contained in this manual.
MANAGEMENT OF HBV, HIV, AND MICROORGANISMS
A.
Universal Precautions: Universal precautions require health care workers (HCW) to
assume that all body fluids are potentially infected with HBV, HIV, or other blood
borne pathogens, and to use personal protective equipment, work practice controls,
prudent infection control measures and common sense to prevent parenteral, mucous
membrane, and non-intact skin exposure to blood and all body fluids.
B.
The following is a list of other potentially infectious materials: semen, vaginal
secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid,
peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid visisly
contaminated with blood, and all body fluids in situations where it is difficult or
impossible to differentiate between body fluids.
Modes of Transmission
1.
Microorganisms: are transmitted by several routes, and the same
microorganisms may be transmitted by more than one route. For instance,
Varicella-Zoster virus (Chicken Pox) can spread by either the airborne route
or by direct contact. There are four main routes of transmission: contact,
vehicle, airborne, and vectorborne.
2.
Contact transmission: This mode of transmission is the most important and
frequent cause of nosocomial infections and can be further classified by three
subgroups: direct contact, indirect contact and droplet contact.
a.
Direct contact: This involves direct physical transfer between a
susceptible host and an infected or colonized person (e.g., initial
examinations, suturing, dressing wounds, venipunctures, or other
procedures that require direct personal contact.
Infection control plan
Page 5
6/95
6/96
6/98
6/99
8/00
7/05
b.
3.
4.
5.
6.
Infection control plan
Page 6
6/95
6/96
6/98
6/99
8/00
7/05
Indirect contact: This involves personal contact of the susceptible
host with a contaminated intermediate object, usually an inanimate
object.
c.
Droplet contact: This involves infectious agents that may come in
contact with conjunctivae, nose, or mouth of a susceptible person as a
result of coughing, sneezing, or talking with an infected person who
has clinical disease or is a carrier of the organism. This is considered
“contact” transmission, rather than airborne, since droplets usually
travel no more than about 3 (three) feet.
Vehicle Transmission: the vehicle route applies to diseases transmitted
through the use of contaminated items.
a.
Food, such as in Salmonella.
b.
Water, such as in Legionellosis.
c.
Drugs, such as in bacteremia resulting from infusion of a
contaminated infusion product.
d.
Blood, such as in Hepatitis B, or Hepatitis C
Airborne Transmission: This occurs by dissemination of either droplet nuclei
(residues of evaporated droplets that may remain suspended in the air for long
periods of time) or dust particles in the air containing the infectious agent.
Organisms carried in this manner can be widely dispersed by air currents
before being inhaled by or deposited on the susceptible host.
Vectorborne Transmission: This mode is of greater concern in tropical
countries, for example, with mosquito transmitted Malaria. It is of little
significance in the United States.
HBV and HIV can be transmitted by direct contact, indirect contact, fecaloral transmission, and airborne transmission.
a.
Direct contact
1)
The transfer of blood borne pathogens or other infectious
agents may occur through accidental needlesticks, broken
glass, scalpel cuts, etc.
2)
Transfer of blood borne pathogens or other infectious agents
has occurred through pre-existing minute scratches, abrasions,
burns, weeping or exudative skin lesions, etc.
3)
Contamination of mucosal surfaces with blood borne
pathogens, or other infectious agents as may occur with mouth
pipetting, splashes, spattering, or conjunctival contact.
b.
Indirect Contact
1)
HBV can be transmitted indirectly from common surfaces
such as examination tables, patient beds, patient personal
C.
items, laboratory counter tops, test tubes, lab instruments, and
other surfaces contaminated with infectious blood, blood
products, or body fluids. Transfer to the skin or mucous
membranes is typically by hand contact.
2)
Nail biting, application of cosmetics, eating and other hand-tonose, hand-to-mouth, and hand-to eye actions may contribute
to indirect transmission.
c.
Fecal-Oral transmission: The fecal-oral route does not appear to be an
efficient mode of transmission of either HBV or HIV. Therefore,
routine precautions used in handling of feces are adequate to prevent
transmission of HBV or HIV. Fecal-oral transmission may pose a
hazard for Hepatitis A Virus infection.
d.
Airborne Transmission
l)
Airborne transmission of HBV and HIV through inhaled
aerosol has been hypothesized; thus far, none have been
documented.
2)
Splashing, splattering, centrifuge accidents, and removal of
rubber stoppers from tubes can produce large or small droplets
that may be transferred into the mouth, eyes or onto breaks in
the skin surface. This is not an example of airborne
transmission by aerosol, but rather transmission by direct
droplet contact.
Preventing HBV, HIV and Microorganism transmission in the clinical setting: if at
all possible, employees need to attempt to identify patients suspected of having
diseases that are spread by airborne transmission. This will include childhood
diseases, influenza, and TB. Diseases other than those that are not classified as
airborne should not pose a threat to patients in the waiting room.
1.
Practice universal precautions.
2.
Handwashing techniques and guidelines will be followed by all employees.
3.
The organization facilities will be maintained in a clean and sanitary
condition. All employees will follow housekeeping guidelines.
4.
Grossly contaminated equipment, work surfaces, examination rooms, spills,
leakage, etc., will be immediately decontaminated.
5.
All employees will use appropriate PPE as detertermined by the Safety
Committee for that particular task.
6.
All infectious waste shall be segregated and packaged as recommended.
7.
To prevent needlestick injuries, needles should never be recapped, separated
from syringes, or manipulated by hand in any way. (Exception: allergy
injections - double needle technique recommended; also if the needle is
Infection control plan
Page 7
6/95
6/96
6/98
6/99
8/00
7/05
contaminated when preparing injections and tubex administration kits i.e.
dental anesthesia and IM Penicillin administraton in medical)
8.
Devices, such as sharps or glass pipettes should be placed in punctureresistant and leakproof containers and will be labeled with the Biohazard
symbol.
9.
Mouth pipetting/suctioning of any substance is prohibited.
*Refer to Form IC for the organization’s housekeeping schedule.
VI.
RISK CATEGORY CLASSIFICATION SYSTEM
Job positions at the organization were reviewed for their probability of performing work
tasks that may cause exposures to blood, body fluids, or tissues. Consideration has been
given to tasks that may be performed by positions in the facility that would not be a-part of
the normal position requirements. Categories apply to physicians, all employees’ students,
contractors, or others who may be called upon to perform tasks within the facility.
A.
Category I: This category includes positions which are required to perform
procedures or other job related tasks that involve an inherent potential for mucous
membrane or skin contact with blood, body fluids, tissues or a potential for spills or
splashes of them. The use of appropriate protective measures is required for each
Category I position.Personnel who are considered in this category may be:
1.
Any individual who administers any type of direct patient care.
2.
Any individual who handles items that may come in contact with blood or
body fluids.
3.
Any individual who handles blood, body fluids or tissue.
4.
Employees who fall into Category I are as follows:
•
Physicians
•
Registered Nurses
•
Nursing Assistants/Medical Assistants
•
Soiled Linen Handlers ( housekeeping)
•
Dentists
•
Hygienist
•
Dental Assistants
•
Opthamology tech’s
•
Optometrist
•
Registered Dietician
•
WIC clerks
•
Licensed Practical Nurse’s
•
Lab or X-Ray personnel
Infection control plan
Page 8
6/95
6/96
6/98
6/99
8/00
7/05
•
B.
VII.
Bio-hazard Waste Handlers
Category II: This category includes those staff whose normal work routine involves
no exposure to blood, body fluids, tissues, but exposure may be required as a
condition of employment. Appropriate protective measures should be readily
available to every employee engaged in Category II tasks. Employees who fall into
Category II are as follows:
•
Medical Office Assistant/Receptionist
•
Office Clerks
•
Social Workers
•
Facility Mangers / Supervisors
•
General Maintenance Workers
C.
Category III: The normal work routine involves no exposure to blood, body fluid, or
tissues. Persons who perform these duties are not called upon as part of their
employment to perform or assist in emergency medical care or to be potentially
exposed in some other way. Category III employees are as follows:
•
Accounting/Finance,
•
Clerical, and
•
Data Procsssing Personnel
•
MIS staff
•
Translators
•
Administrators
D.
Documented Evidence of Employee Categories: All individuals performing
procedures or tasks within the organization shall have documented evidence that they
are aware of which category their duties shall-place them in.
1.
This documentation shall include a clear understanding of the proper use of
personal protective clothing and equipment.
2.
For Category I or Category II employees, the location of this clothing and
equipment is identfied and is continually maintained for their use.
STANDARD OPERATING PROCEDURES
A.
The organization has identified the following substances and procedures as
hazardous:
1.
Cleaning Germicides, disenfectants and cleaners
2..
Instrumentation Reagents
3.
Prepackaged Reagent kits (Pregnancy, Strep A, and Mono),
4.
Use of Sharps,
5.
Medical Procedures,
6.
Hazardous Waste
7.
X-ray chemicals (Cleaning & mixing chemicals of X-Ray processor).
Infection control plan
Page 9
6/95
6/96
6/98
6/99
8/00
7/05
B.
C.
D.
The hazards listed present eye, skin and respiratory hazards. The procedures listed
can present specific eye, mouth, other mucous membranes, non-intact skin, or
parenteral contact with blood or other potentially infectious materials. All employees
will use the following protocol when working with these hazards.
Bleach: Target organs: eye, skin, and lungs.
1.
PPE required and usage
a.
Protective eyewear/mask combinatlon or full face shield, gloves and
laboratory coat.
b.
PPE will be worn during preparation and usage.
c.
MSDS: Material Safety Data Sheets located at each clinical site.
2.
Preparation and Storage
a.
Refer to decontamination procedure located and engineering practices
b.
Undiluted bleach is stored at room temperature in the supply closet.
Store in cool, dry place.
c.
Do not reuse empty bleach containers.
Germicides: Byrex, Dispatch, Sklar Kleen, Sporox, Cavicide, Omini Cleaner,
Isopropyl Alcohol, Hydrogen Peroxide, Povidone solution, Phisodex, Lysol
disinfectant spray, and Citrace Spray. Target organs: eyes, skin and lungs.
1.
PPE required and usage
a.
Protective eye wear/mask combination or full face shield, gloves and
laboratory coat.
b.
PPE will be worn during preparation and usage.
c.
MSDS: Material Safety Data sheets are located at each facility. This
facility stores the MSDS sheets posted at each center for location
2.
Preparation and storage
a.
Follow manufacturer’s directions for usage. Store in original
container.
b.
Store at room temperature in supply closet.
MSDS sheet locations are listed on staff bulliten boards and lab areas located in each
facility.
G.
Prepackaged Reagent Test Kits: Target Organs--Eyes and skin
1.
The chemicals used in these test kits are in such small quantities that they
pose very minimal risk for employees.
2.
PPE Required and Usage
a.
Protective eyewear/mask combination or full face shield, gloves, and
laboratory coat.
Infection control plan
Page 10
6/95
6/96
6/98
6/99
8/00
7/05
b.
H.
I.
J.
Laboratory coats and gloves are required if upon receipt a test kit is
damaged or is leaking. Otherwise, all PPE is required during testing
procedure.
c.
MSDS: Material Safety Data sheets are located at each facility.
3.
Preparation and Storage: Refer to laboratory procedure manual for directions
for each test kit.
Sharps Protocol: Target Organs--Eyes and Skin
1.
PPE Required and Usage
a.
Protective eyewear or full face shield gloves and laboratory coat.
b.
PPE will be worn at all times during phlebotomy procedures.
2.
Preparation and Disposal
3.
Refer to laboratory procedure manual for instructions on phlebotomy
procedures.
4.
All contaminated sharps will be disposed at the closest possible puncture
resistent sharps container from its place of generation.
5.
Biohazardous sharps containers will be disposed of when they are threequarters (75%) full.
Medical Procedures: Target Organs: Eyes, Skin, and Mucous Membranes
1.
PPE Required and Usage
2.
Laboratory coats and gloves will be worn during the following procedures:
ear, nose, and throat exams, as well as oral temperature monitoring.
3.
Protective eyewear/mask combination or full face shield, gloves, and
laboratory coat will be worn during the following procedures: mole and
lesion removal, suturing, pelvic and rectal exams, and any emergency/trauma
situation.
4.
PPE is not required in the following procedures: blood pressure check, pulse,
height, weight and charting patient information.
Hazardous Waste: The organization utilizes the services of
SteriCycle
Name of Waste Management Vendor
13975 Polo Trail Drive Suite 201
Street Address
Lake Forest Illinois 60045
Infection control plan
Page 11
6/95
6/96
6/98
6/99
8/00
7/05
( 800) 457-9167
City/State/ZIP
1.
2.
3.
4.
Infection control plan
Page 12
6/95
6/96
6/98
6/99
8/00
7/05
Definition of Hazardous Waste: any material which is generated in the health
care community in the diagnosis, treatment, immunization, or in the care of
human beings.
a.
Sharps: Any object that may cause puncture or cuts, including but not
limited to: needles, syringes, lancets, broken glass, and scalpel blades.
b.
Microbiologicals--specimens, cultures discarded live and attenuated
vaccines; culture dishes/devices used to transfer, inoculate, will be
discarded in the red sharps containers).
c.
Blood and Blood Products: all waste, unabsorbed human blood or
blood products, including but not limited to serum, plasma, and other
components of blood, and visiby bloody body fluids such as suctioned
fluids, excretions, and secretions.
d.
Pathological waste: all teeth, tissue from biopsy and removal.
Medical Waste Segregation
a.
Segregate infectious waste from other waste at point of generation.
b.
20cc or greater bulk of human blood and blood products (synovial
fluid, vaginal fluid, cerebrospinal fluid, etc.) and absorbent items that
are “super saturated,” or freely dripping or if lightly sqeezed will
release contents.
c.
Sharps (scalpel blades, syringes, needles, test tubes, slides, disposable
speculums, and broken glass) should be placed in rigid, puncture
resistent containers.
d.
Urine specimens may be discarded into the sewer. Used urine cups
should be placed in solid waste.
Storage
a. Waste must be properly packaged in a red bio-hazard bag, sealed and
placed in the designated cardboard receptacle and stored in the designated
area of each building site with a hazard warning clearly marking the area.
b. Sites that generate small quantites of waste and transport waste to larger
facilities must prperly package waste in a double biohazard bag, seal and
place in a trunk of a car.
Spill Procedure: The spill kit is located at each site and is accessible to all
staff members. If a spill were to occur, proceed as follows:
a.
Minimize patient and staff contact with spill area.
b.
Sprinkle chlorasorb around the perimeter of the spill with an even
coating. Let area stand until absorbed.
c.
The following PPE must be worn: disposible gown, gloves, eye
protection if indicated.
c. Use shovel to scoop solids and absorbed powder. Place in bio-hazard bag
or decontaminate.
d. Spray Tor Aerosol to clean the area. Allow to stand for 10 minutes then
wipe with absorbent towel. Place soiled towel into red plastic bag. Place
any broken glass or sharps into puncture resistant container. Put sharps
container into bag.
e.
Place gloves and disposible gown in biohazard bag.
f.
Tie off bag and place in an appropriate waste container.
g.
Restock spill kit.
5.
Recordkeeping
a.
Bio-hazard waste is disposed of by our waste management vendor.
The manifest copies are kept on file at each clinic site.
b.
All records will be retained for three years.
J.
X-Ray chemicals & cleaning of X-Ray processor, developer, and fixer
1.
Target organs: Eyes, Skin, and Lungs
2.
PPE Required and Usage
a.
Protective eyewear/mask combination or full face shield, gloves and
laboratory coat.
b.
PPE will be worn during preparation and usage, also in cleaning the
X-ray processor.
c.
MSDS: Material Safety Data sheets are located at each facility.
Preparation and Storage
a.
Refer to MSDS decontamination procedure listed in manual .
b.
chemicals are stored in the cabinet in the dark room within the x-ray
area. The containers are to be disposed in accordance with
manufacturer’s specifications.
c.
The exhaust fan is to be on at all times during the operation and
cleaning of the x-ray processor.
K.
Laundry Policy
1.
Laundry contaminated with blood or other potentially infectious materials
will be handled as little as possible. This laundry will be placed in color
coded red bags at the location where it is used. Laundry will not be sorted or
reused in this area.
2.
Laundry at this facility is cleaned by Valley Cleaners. All laundry is placed
in color coded red bags indicating potentially infectious material may be
present.
VIII. General Safety Procedures
Infection control plan
Page 13
6/95
6/96
6/98
6/99
8/00
7/05
A.
IX.
Eye Contact: Promptly flush eye with water for a prolonged period (15 minutes) at
the eyewash station and seek medical attention.
B.
Skin Contact: Promptly flush the affected area with water and remove contaminated
clothing. If symptoms persist after washing, seek medical attention.
C.
Clean Up Spills Promptly
1.
Bleach or Germicides: If spilled, gloves, laboratory coat and full face shield
will be worn during clean up. Toweling used can be disposed of in the
regular trash receptacle. Rinse thoroughly with water and dry completely.
2.
Instrument Reagents and Test Kits: If spilled, gloves, laboratory coat and full
face shield will be worn during clean up. Toweling used should be disposed
of in a bio-hazard waste receptacle. Rinse thoroughly with water and dry
completely. Make sure broken reagent containers thatare made of glass are
disposed of in puncture resistant bio-hazard containers.
D.
Labels and Signs: Universal bio-hazard symbols will be placed on all refrigerators
used to store laboratory reagents, controls, specimens, and storage area for medical
waste. While the organization follows universal precautions for handling of all
specimens, but we feel these signs are necesssry for our patients’ protection as well.
Engineering and Work Practice Control
A.
Eyewash Fountains
1.
Inspected every month by practice employees.
B.
Handwashing
1.
Handwashing will be done before and after contact with each patient, using
the restroom, eating, and drinking.
2.
It is mandatory that all employees wash their hands with soap and water as
soon as possible after removal of gloves or other PPE. All employees that
have contact of any body area with potential infectious agent shall wash areas
immediately.
3.
The following handwashing protocol will be used by all employees:
a.
Wet hands under moderate stream of water at a comfortable
temperature.
b.
Dispense approximately 5 ml of lotion soap into cupped hands.
c.
Wash hands and wrists vigorously for 20 seconds.
1)
Use a rotary motion and friction to the palms, back of hands,
between fingers, and wrists.
2)
Hold the hands higher than the elbows.
3)
Rinse the wrists and hands thoroughly with running water.
Hold hands so water flows from wrist, to hands, and off finger
tips.
Infection control plan
Page 14
6/95
6/96
6/98
6/99
8/00
7/05
4)
C.
Dry the arms and hands thoroughly with a paper towel. Hold
the hands higher than the elbows.
d.
Hand Control Faucets: Since faucets are considered contaminated,
always turn faucet off with paper towel.
Special considerations:
1)
Hold hands away from the side of the sink.
2)
Avoid splashing your uniform or PPE.
3)
Avoid rings and cracked or chipped nail polish, since it makes
it difficult to remove organisms.
Decontamination: All spills should be wiped up immediately. The following
procedure is used for the decontamination of blood spills. For large spills, see spill
kit procedure.
1.
Wear heavyweight puncture resistant gloves and a gown.
2.
Absorb the blood with disposable towels.
3.
Sprinkle chorasorb on the spill site of all visible blood. Let it sit until all fluid
is absorbed.
3. Place all disposable materials used to decontaminate the spill into a bio-hazard
container. Handle the material in the same manner as other infectious waste.
4. If the spill site is bleach reisistant may use dispatch spray. The time of exposure
to solution may be brief inactivates HBV in 10 minutes and HIV in 2 minutes. If
the spill has been adequately decontaminated before disinfection, the spill may
be blotted up with disposable absorbent towels immediately after the spill area
has been soaked.
Bleach solutions are less effective in the presence of high concentration of protein.
Therefore, remove as much liquid blood or serum as possible before
contamination. If a surface or medical device is contaminated with dried blood,
remove all of it before disinfection. The dried blood should be wet and softened
with dispatch spray before being scraped off to prevent scattering potentially
infectious material and to facilitate complete removal. If complete removal is not
possible, expose the surface to dispatch spray for a longer time (20-30 minutes
may be necessary).
For large spills of culture or concentrated infectious agents, the spill should first
be flooded with a disinfectant, then dispatch spray is added and then allowed to
stand for 10 minutes before being decontaminated as outlined above.
Counters will be cleaned weekly with dispatch or Byrex spray and wiped
between each patient with a cloth. Examination tables will be cleaned weekly
Infection control plan
Page 15
6/95
6/96
6/98
6/99
8/00
7/05
D.
E..
G.
H.
X.
with dispatch solution and wiped between each patients. New examination
table paper will be provided for each patient. A blue pad will be placed under
the table paper during all pelvic examinations to prevent contamination of the
exam table.
Autoclave
1.
Cleaned every month with Omni cleaner according to manufacturer’s
specifications.
2.
Soak filter in full strength Omni cleaner for 24 hours rinse and replace.
X-Ray Processor
1.
Cleaned monthly (see agreement-Kent Radiology)
2.
PPE equipment to be used during cleaning and mixing of chemicals.
Instrument Tray
See procedure for instrument decontaimination process
Policy for minimizing risk of transmission of AIDS during actual CPR:
No tranamission of hepatitis B virus (HBV) infection during mouth-to-mouth
resuscitation has been documented. However, because of the theoretical risk of
salivary transmission of HIV during mouth-to-mouth resuscitation, special attention
should be given to the use of disposable airway equipment or resuscitation bags and
the wearing of gloves when in contact with blood or other body fluids. Resuscitation
equipment and devices known or suspected to be contaminated with blood or other
body fluids will be thoroughly cleaned and disinfected after each use. Clear plastic
face masks with one-way valves are available for use during mouth-to-mouth
ventilation. These masks provide diversion of the victim‘s exhaled gas away from
the rescuer and may be used by health-care providers and public safety personnel
properly trained in their use during two-person rescue, in place of mouth-to mouth
ventilation. The need for and effectiveness of this adjunct in preventing transmission
of an infectious disease during mouth-to-mouth ventilation are unknown. If this type
of device is to be used as reassurance to the rescuer that a potential risk might be
minimized, the rescuer must be adequately trained in its use, especially with respect
to making an adequate seal on the face and maintaining a patient airway. Such a
device requires two hands to secure a proper face seal and to maintain an open
airway. As an additional precaution, the rescuer should elect to wear gloves because
saliva or blood on the victim’s mouth or face may be transformed to the rescuers
hands.
Personal Protective Equipment (PPE)
A.
Purpose: The purpose of PPE is to prevent blood or other potentially infectious
materials passing through to or reaching the employees work clothes, street clothes,
Infection control plan
Page 16
6/95
6/96
6/98
6/99
8/00
7/05
B.
undergarments, skin, eyes, mouth or other mucous membranes under normal
conditions of use for the duration of time which the protective equipment will be
used.
1.
PPE will be provided for all employees at no cost to them. The Safety
Committee has specified that the following equipment will be utilized by all
employees.
2.
Protective eyewear/mask combination.
3.
Full face shields
4.
Gloves: Single use, disposable type. Hypoallergeric gloves will be available
to employees that develop allergies to the latex. Utility gloves will be
provided for housekeeping procedures and mixing of chemicals.
5.
Impervious laboratory coats and aprons
Accessibility
1.
The organization will provide appropriately sized PPE that is accessible to all
employees.
2.
Disposal, repair and replacement of PPE will be the responsibility of the
practice. Employees are asked to be prudent with their use of safety
equipment. All employees must use PPE as needed, but must not be
wasteful.
3.
All PPE will be removed and properly stored prior to leaving the facility.
a.
Laboratory coats, aprons, face shields, and protective eyewear/mask
combinations must be disposed of in a designated biohazard container
if contaminated.
b.
PPE that has not been contaminated but is torn, dirty, or has lost
effectiveness to provide protection may be discarded in solid waste
container designated for noncontaminated PPE.
c.
Contaminated gloves may be disposed in the nearest bio-hazard
container.
4.
PPE will be used in the following conditions:
a.
Gloves will be worn when it can be reasonably anticipated that the
employee will have had contact with blood or other infectious
materials. Gloves will be disposable, single use type. They will not
be washed or decontaminated for reuse.
b.
Face and eye protection will be provided by a full face shield or
eyewear/mask combination. This type of PPE will be worn whenever
splashes, spray, splatter, or droplets of blood or other potentially
infectious materials may be generated and eye, or nose, mouth
contamination can be reasonably anticipated.
Infection control plan
Page 17
6/95
6/96
6/98
6/99
8/00
7/05
c.
XI.
Laboratory coats and aprons will be of impervious material.
Therefore, employees work clothes, street clothes, and undergarments
will be protected.
Occupational Exposure
A.
Chemical Exposure - Definition
1.
Whenever signs and symptoms associated with a hazardous chemical
develops.
2.
Whenever an event takes place in the work area such as a spill, splash, or leak
resulting in a hazardous chemical exposure.
B.
Action - The organization will provide the following information to the employee
and the attending physician:
1.
The identity of the hazardous chemical to which the employee may have been
exposed.
2.
A description of the signs and symptoms of exposure.
3.
A copy of the MSDS for the chemical involved.
4.
A copy of the regulation.
5.
The organization will provide a written opinion that will not reveal specific
findings of diagnosis unrelated to the exposure but will include:
a.
Any recommendations for further follow up.
b.
Results of the medical examination and any associated test results.
c.
Any medical conditions that may be revealed in the course of the
examination that may place the employee at increased risk as a result
of an exposure in the work place.
d.
A statement by the physician that the employee has been informed of
the consultation/examination result and any medical condition that
may require further examination or treatment.
B.
Blood Borne Pathogen: Exposure incident is defined as a specific eye, mouth, or
other mucous membrane, non-intact skin or parenteral contact with blood or other
potentially infectious materials that results from the performance of an employee’s
duties.
1.
Hepatitis Exposure Policy Employees who receive a puncture wound from a
contaminated sharp or splashes to the mucous membrane from blood or body
fluids are to be reported to the Safety Officer to ensure that employees
exposed to Hepatitis receive prophylactic treatment if needed.
a.
Exposure: Significant exposure to Hepatitis is defined as follows and
is an indication for prophylactic treatment:
1)
Direct blood exposure (accidental needle stick, blood or an
open wound)
2)
Oral ingestion
Infection control plan
Page 18
6/95
6/96
6/98
6/99
8/00
7/05
3)
2.
Infection control plan
Page 19
6/95
6/96
6/98
6/99
8/00
7/05
Direct mucous membrane contact (accidental splashing of
serum, blood or body fluids in the eye or other mucous
membrane)
4)
Direct oral contamination by a patient‘s excrete (feces, urine,
etc.)
b.
Send employee to Spectrum Health Occupational
medicene downtown.
2) Hepatitis B
a)
The employee is to be referred to Spectrum Health
Occupational medicene for exposures.
b)
Prophylaxis is to be provided, according to current
CDC recommendations, by the organization free of
charge.
c)
CDC Recommendations are: (For those who have no
imunity - active or passive)
•
A single dose of HBlg is to be given as soon as
possible after exposure.
•
The first dose of Hepatits B vaccine is to be
given in the deltoid muscle as soon as possible,
but within 7 days of exposure.
•
The second dose of vaccine is to be given in
one month and the third and last dose is to be
given in 6 months.
d)
Hepatitis B surface antibody is to be done before the
administration of medications and again 2 months after
completion of the series of vaccine.
d)
Non-specific: if the exposure is significant, the
employee is to be given Hepatitis A prophylaxis.
e)
Dosages
•
Immune Serum Globulin: 0.03 ml/kg body
weight
•
HBlg (Human): 0.06 ml/kg body weight
HIV Exposure Policy: Employees are sent ot Spectrum Health Occupational
Medicene Clinic .
a.
To ascertain thorough internal serological testing if the exposed
employee has contracted the virus.
b.
To counsel employees who have significant exposure to HIV.
c.
Procedure
1)
3.
Employees who incur a significant exposure to HIV are to
have an employee incident/injury report form completed by
the immediate supervisor and involved employee and
submitted to the Operations Director.
2)
Significant exposure is defined as:
a)
Direct blood exposure/needle puncture
b)
Oral ingestion
c)
Direct mucous membrane contact
3)
Serological testing for evidence of HIV antibody is to be done
as soon as possible after the exposure. If negative, the
employee is to be retested in 6 weeks and at 3, 6, and 12
month intervals following exposure through occupational
medicene clinic.
4)
Counseling about the risk of infection is to be done by
Spectrum Health Occupational Medicene Clinic. The
recommendations of the Public Health Service include:
a)
Refrain from donating blood.
b)
Avoid exchange of saliva and/or deep kissing.
c)
Use condoms during sexual intercourse.
The organization will provide the following information to the employee and
the attending physician
a.
Documentation of the route(s) of exposure and circumstances under
which the exposure incident occurred.
b.
Identification and documentation of the source individual, unless the
employer can establish that identification is infeasible or prohibited by
federal, state or local law.
1)
The source individual‘s blood shall be tested as soon as
possible after consent is obtained in order to determine HBV
and HIV infectivity. If source is known to be MBV or HIV
positive, testing need not be repeated.
2)
Results of source individual’s testing will be made available to
exposed employee.
d.
Infection control plan
Page 20
6/95
6/96
6/98
6/99
8/00
7/05
Exposed employee’s blood shall be collected as soon as feasible and
tested after consent is obtained. If employee consents to baseline
blood collection, but does not give consent at the time for HIV
serologic testing, the sample shall be preserved for at least 90 days. If
within 90 days of the exposure incident, the employee elects to have
the baseline sample tested, such testing shall be done as soon as
XII.
feasible. If negative, blood will be collected again in 6 weeks, 3
months, 6 months and 12 months intervals following exposure.
e.
HBV status: The organization will provide a record of all
vaccinations given including non-responder status, Hepatitis B surface
antibody status, or any reason that is medically indicated for not
receiving the vaccination.
f.
Health care professionals written opinion: Spectrum Health will
provide the employee with a copy of the evaluating physician’s
opinion of his/her status to incude:
1)
HBV status
2)
Employee has been informed of any medical conditions
resulting from the exposure incident.
3)
All other findings or diagnosis shall remain confidential.
g.
Medical Records: The organization will maintain an accurate record
for each employee with an occupational exposure. The records will
include:
1)
Social security number
2)
HBV status and dates of vaccination
3)
Copy of all results, examinations, medical testing, and follow
up procedure.
4)
Employers copy of written opinion of evaluating physician.
5)
The organization ensures the confidentiality of employee
medical records and will not disclose or report any information
without the employee’s written consent.
6)
The organization will maintain these records for at least the
duration of employment plus 30 years.
Refer to Appendix D for the following documents:
•
EC - 1.3C Occupational Occurrence Report Form
•
IC - 1E Hepatitis B Vaccine Consent Form
•
IC - 1F Hepatitis B Vaccine Decline Form
•
IC - 1G Exposure Consent
•
IC - 1H Needle Stick Exposure Protocol
Education and Training
A.
New Employee Orientation: All new employees will be appropriately oriented and
instructed on the organization’s Environment of Care and Infection Control programs
at the time they are hired. This orientation is recorded in the employee’s personnel
file. Initial orientation will include the following:
1.
Fire safety and emergency evacuation of facilities.
Infection control plan
Page 21
6/95
6/96
6/98
6/99
8/00
7/05
2.
B.
Location and summary of the Federal Register 29 CFR Part 1910.
Occupational Exposure to Hazardous Chemicals in Laboratories and 29 CFR
Part 1910.1030. occupational Exposure to Blood Borne Pathogens. Both
standards are final rules.
3.
Explanation of how Safety and Infection Control manual meets the
requirements of the Chemical Hygiene Plan and the Exposure Control Plan.
4.
Explanation of risk categories, and determination of which category new
employees’ responsibilities place them.
a.
Actions taken if unplanned category tasks are encountered.
b.
Work practices and protective equipment available to employee.
c.
Location and proper use of protective clothing and equipment; and the
proper removal, handling, and decontamination of equipment.
d.
Limitations of protective clothing and equipment.
5.
Identification and location of hazards. Explanation of use, storage, and
Material Safety Data Sheets.
6.
Appropriate reporting procedures in the event of spills or personal exposure
to fluids or tissues and medical monitors associated with exposures.
7.
Epidemiology, symptoms, and modes of transmission of blood borne
diseases.
8.
Explanation of exposure incident reporting, method of reporting, and post
exposure medical follow up evaluation.
Inservice/Continuing Education
1.
All employees are required to review the Environment of Care and Infection
Control Plan annually. Attendance at inservice meetings is mandatory and
recorded.
2.
Any additions, deletions, revisions, or new policies made to the Safety and
Infection Control manual must be communicated to all employees through
inservice education.
3.
All employees will participate annually in continuing education and inservice
training.
4.
Training records will be maintained for three years.
Infection control plan
Page 22
6/95
6/96
6/98
6/99
8/00
7/05
OCCUPATIONAL OCCURRENCE REPORT FORM
SECTION I
Employee:
SS#:
Date of Occurrence:
Time:
DOB:
am/PM
Location:
Reported to Supervisor:
Signature
Print Name of Supervisor
SECTION II
Type Occurrence:
Details of Occurrence:
Infection control plan
Page 23
6/95
6/96
6/98
6/99
8/00
7/05
Blood Borne Pathogen Exposure
Chemical Exposure
Other
Eye, mouth, nose, mucous membrane
Acid
Fracture
Non-intact skin (sore, wounds, etc.)
Base
Sprain
Needle Stick/Sharps
Carcinogen
Miscellaneous
Other
Other
Instructions to Prevent Further Occurrences:
Employee/Date
SECTION III
Safety Officer/Date
For Blood Borne Pathogen Exposure
Source Individual
Source Unknown/Status Unknown
Source Known/HIV & HBV Status Unknown
Patient Record or ID#
SECTION IV
Physician
For Blood Borne Pathogen Exposure
Does the source individual have a positive test for infectious disease?
Yes
No
If yes, please describe:
Source individual refuses to consent to testing.
Physician Signature
Infection control plan
Page 24
6/95
6/96
6/98
6/99
8/00
7/05
Date
(Page 2)
SECTION V
HBV Status:
Seroconversion:
Series Initiated
Second Shot
Third Shot
Hepatitis B - Surface Antibody
(result)
SECTION VI
(date)
Medical Examination & Consultation
Physician Information:
Name:
Phone:
Address:
Date of Employee Examination:
Recommendations, treatment comments:
Follow-up necessary?
Yes
No
If Yes, Date:
Physician
SECTION VII
Time:
Date
Employee Consent for Baseline Testing for HBV and/or HIV
I
(employee name) understand and agree with the information contained in this
occupational occurrence report form. On
, I have given
consent to baseline
blood collection and testing for the following tests:
. I understand the
collection and testing will be done confidentially. All laboratory results will only be released to the physician performing the medical exam and
consultation unless I give written consent for them to be released elsewhere.
I
(employee name) consent to baseline blood collection. I decline testing of the
following at this time:
. I understand that I may elect to have
above tests performed within 90 days of my baseline collection.
Comments:
Employee/Date
Infection control plan
Page 25
6/95
6/96
6/98
6/99
8/00
7/05
Witness/Date
CLASSIFICATION SYSTEM FOR EVALUATING POTENTIAL EXPOSURE
TO BLOOD AND BLOOD-BORNE PATHOGENS
A.
CATEGORY I: Tasks that involve exposure to blood, body fluids or tissues.
1.
2.
3
B.
CATEGORY II: Tasks that involve no exposure to blood, body fluids or tissues, but employment
may require performing unplanned Category I tasks.
1.
2.
C.



Includes positions which are required to perform procedures or other job-related tasks that
involve an inherent potential for mucous membrane or skin contact with blood, body fluids,
or tissues or a potential for spills or splashes of them. The use of appropriate protective
measures is required for each Category I position.
Gloves, mask, safety glasses, protective clothes covers (head cover, plastic apron or cover
gown, shoe covers) are to be worn appropriately according to the type of procedure or tasks.
Probable or suspected exposure must be considered by the individual when judging the
extent of personal protective clothing and equipment that should be worn.
Personnel who are considered in this category may be:
Any individual who administers any type of direct patient care.
Any individual who handles items that may have come in contact with blood or body fluids.
Any individual who handles blood, body fluids or tissues.
The normal work routine of these positions involves no exposure to blood, body fluids or
tissues but exposure or potential exposure may be required as a condition of employment.
Appropriate protective measures are readily available to every employee engaged in
Category II tasks.
Personal protective clothing and equipment shall be available to this individual that is
appropriate for the tasks they may be asked to perform.
CATEGORY III: Tasks that involve no exposure to blood or body fluids, or tissues. Category I
tasks are not a condition of employment.
The normal work routine of these positions involves no exposure to blood, body fluid, or tissues.
Persons who perform these duties are not called upon as part of their employment to be potentially
exposed in some other way. Tasks that involve handling of implements or utensils, use of public or
shared bathroom facilities or telephones and personal contacts such as handshaking are Category III
tasks.
D.
DOCUMENTED EVIDENCE OF EMPLOYEE CATEGORY: All individuals performing
procedures or tasks within the facility shall have documented evidence that they are aware of which
category their duties shall place them. This documentation shall include a clear understanding of the
proper use of personal protective clothing and equipment and where this clothing and equipment is
maintained for their use, if they are in Category I or Category II. All employees shall receive
training in Universal Precautions and barrier protection techniques.
Infection control plan
Page 26
6/95
6/96
6/98
6/99
8/00
7/05
OSHA CATEGORY CLASSIFICATION
Employee Name
Department
Job Title/Positlon
CATEGORY I
I
understand that the duties that are required of me in my job position places
me in Category I. I have a thorough knowledge of the proper use of personal protective clothing and
equipment and where the clothing and equipment is maintained throughout the facility. I have received
education and training in Universal Precautions, barrier protection techniques and modes of transmission of
blood-borne pathogens.
SIGNATURE
DATE
CATEGORY II
I __________________________________ understand that the duties that are required of me in my position
places me in Category II but I may be required to perform unplanned Category I duties. If I have to perform
unplanned Category I duties I have a thorough knowledge of the proper use of personal protective clothing
and equipment and where the clothing and equipment is maintained throughout the facility. I have received
education/training in Universal Precautions, barrier protection techniques and modes of transmission of
blood-borne pathogens.
SIGNATURE
DATE
CATEGORY III
I
understand that the duties that are required of me in my position places me in Category III and I will not
have to perform duties that will require the use of personal protective clothing or equipment. I have received
education/training in Universal Precautions and modes of transmission of blood-borne pathogens.
SIGNATURE
Infection control plan
Page 27
6/95
6/96
6/98
6/99
8/00
7/05
DATE
CLASSIFICATION VERIFICATION
I have reviewed the job tasks of this position with
classification to be correct.
CLINICAL MANAGER
Infection control plan
Page 28
6/95
6/96
6/98
6/99
8/00
7/05
and
DATE
verify
this
REQUIREMENTS FOR CONTRACTED HOUSEKEEPING SERVICES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Provide Hepatitis B Vaccine for their employees or have documented declination
form signed.
Wear utility gloves when cleaning. Use gown and mask if danger of splash or
spills.
Vacuum carpet at each cleaning session.
Mop floors with a 1:100 solution of household bleach.
Clean bathrooms with a 1:100 solution of household bleach.
Clean examination tables at each cleaning session with a 1:100 solution of
household bleach.
Clean counters at each cleaning session with a 1:100 solution of household bleach.
Clean doorknobs at each cleaning session with a 1:100 solution of household
bleach.
Clean the portable lights and the lights that are mounted on the wall at each
cleaning session with a 1:100 solution of household bleach.
Do not handle or empty the infectious waste containers. This will be done by
clinic staff.
Notify the infectious waste coordinator if you see any contaminated object (used
needles, instruments, etc) that has not been disposed of properly.
Make a special attempt at replacing items on the examination room counters, as
closely as possible where you found them.
Notify clinic personnel of any items needed for cleaning.
Wipe outside of regular trash cans at each cleaning session with a 1:100 solution
of household bleach.
Clean inside of trash cans monthly with a 1:100 solution of household bleach.
Wipe down chairs in halls and exam rooms. Also waiting rooms with 1:100
solution of household bleach weekly.
Janitorial services to be rendered daily.
Shampoo carpet annually.
Infection control plan
Page 29
6/95
6/96
6/98
6/99
8/00
7/05
EXPOSURE CONSENT FORM
I understand that my blood sample was involved in a laboratory accident. At this time I give my
consent to
to perform Human
Immunodeficiency Virus (HIV) and Hepatitis B Surface Antigen testing in order to determine
prophylactic treatment of our healthcare worker(s).
I underetand that if my HIV results are positive that the testing laboratory may be required by
law to report all positive HIV s to the Department of Public Health or other state agency. All test
results will be handled in a confidential manner.
Patients Signature
Date
Witness
Date
Infection control plan
Page 30
6/95
6/96
6/98
6/99
8/00
7/05
Form IC - 1H
NEEDLE STICK/EXPOSURE PROTOCOL
I.
Supervisor / Facility Managers refers employee to Spectrum Health Occupational Health.
The employee will complete an Occurrence Report and forward it to their immediate
supervisor. The employee will be referred to occupational medicene .
II.
Substantiate exposure:
A.
Contaminated needle or injury from sharps
B.
Blood or certain body fluids to non-intact skin (chapped abraded, or afflicted with
dermatitis).
C.
Blood or certain body fluids to mucous membranes, mouth nose, or eyes.
III.
Evaluate contaminating source:
.
Source known/HIV and HBV
1.
Test source for HIV and HBV: Test for HBV only if employee is
unvaccinated or a non-responder. If positive, give employee HBV vaccine
one immediately and initiate Hepatitis B vaccine series.
2.
Treat employee for HIV and HBV.
3.
If source is HIV positive, high risk, or refuses tests, test employee at the
time of exposure for HIV and retest at 6 weeks, 3 months, 6 months and 12
months.
NOTE:
Employee and source individual must consent to testing.
Employee must consent to prophylactic treatment if indicated.
Results to be forwarded to Occupational medicene at Spectrum Health. Results are
placed in confidential health record with follow up plan suggested by occupational
medicene. Employees will be asked to follow up with Occupational medicene at
Spectrum Health as deterined by occupational medicene clinic.
Infection control plan
Page 31
6/95
6/96
6/98
6/99
8/00
7/05
Protocol for Disposing of Infectious Waste
I.
Infectious waste is defined as “any material which is generated in the health care
community in the diagnosis, treatment, immunization, or care of human beings.”
II.
Disposing of Infectious Waste
A.
B.
C.
Any used or discarded article that may cause punctures or cuts, including but not
limited to: needles, syringes, lancets, tubes of blood, broken glass, and scalpel
blades are to be discarded in sharps containers.
All waste, unabsorbed human blood, blood products, or absorbed blood when the
absorbent is supersaturated, including but not limited to: serum, plasma, and other
components of blood and visibly bloody body fluids are to be disposed of in either
the sharps containers or the red infectious waste bags.
Specimens, cultures, and stacks of etiological agents, including but not limited to:
waste which has been exposed to human pathogens in the production of
biologicals; and culture dishes/devices used to transfer, inoculate, and mix
cultures will be placed in the infectious waste containers.
III.
Gloves are to be worn while handling infectious waste items.
IV.
Infectious waste containers will be picked up by
NAME
Stericycle Inc
ADDRESS
2695 Elmridge NW
Walker Michigan 49544
Phone: 616 454-9405
Infection control plan
Page 32
6/95
6/96
6/98
6/99
8/00
7/05