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Infection Control Plan 2014
INFECTION
CONTROL
PLAN
June 17, 2014
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Infection Control Plan 2014
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Infection Control Plan 2014
TABLE OF CONTENTS
Page Section Title
Note: If you click on a title, it will take you to the page.
Section 1:
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Purpose
Section 2:
Employee Guidelines
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2.1
Universal/Bloodborne Pathogens Precautions
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2.2
Hand Washing
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2.3
Hand Washing Facilities
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2.4
Use of Gloves/Barrier Precautions
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2.5
Provision of Personal Protective Equipment
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2.6
Safety-Engineered Sharps
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2.7
Sharps Containers
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2.8
Employee Immunizations
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2.9
Employer Provision of Vaccines
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2.10 Employee TB Skin Testing
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2.11 Orientation of Employees
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2.12 Employer Provision of Staff Orientation
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2.13 Post Exposure Management for Occupational Exposure to Blood or Other
Potentially Infectious Materials (OPIM)
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2.14 Employer Provision of Post Exposure Management
Section 3:
Sterilization and Disinfection of Clinic Equipment
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3.1
Counters/Sinks/Tables/Trays
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3.2
Routine Schedule for Cleaning and Disinfection
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3.3
Cleaning Up Blood and/or Body Secretion Spills
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3.4
Use of Chemical Germicides
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3.5
Exam Tables
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3.6
Thermometers
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3.7
Devices Used in Procedures Involving Blood
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3.8
Vaginal Speculum
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3.9
TB Sputum-Collection Equipment
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3.10 Otoscope/Ophthalmoscope
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3.11 Blood-Pressure Equipment
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3.12 Autoclave Operation/ Autoclave
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3.13
3.14
3.15
Refrigerators and Freezers
Hazard Communication for Contaminated Equipment
Equipment in University Health Services
Section 4:
Disposal of Regulated Medical Waste
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4.1
Management of Medical Waste
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4.2
Sharps Collection
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4.3
Collection of Other Regulated Medical Waste
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4.4
Waste Treatment and Disposal Methods
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4.5
Record-Keeping Requirements
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4.6
Non-Infectious Clinic Waste and Office Waste
Section 5:
Isolation of Potentially Infectious Patients
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5.1
Identification/Isolation of Potentially Infectious Patients
Section 6:
Storage and Handling of Equipment, Supplies, and Biological Specimens
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6.1
Equipment and Supplies
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6.2
Sterile Equipment
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6.3
Specimen Storage, Handling, and Transport
Section 7:
Miscellaneous Activities in Clinic Settings
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7.1
Laundry
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7.2
Food
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7.3
Post-Exposure Management
Section 8:
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OSHA Standards
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Infection Control Plan 2014
SECTION 1:
Purpose of This Manual
This Infection Control Plan has been established to:
1. Provide guidelines, procedures, and an exposure control plan to University of Notre
Dame Health Services (UHS).
2. Serve as a resource for UHS employees for preventing the spread of infectious diseases.
3. Promote safer work practices in caring for patients.
4. Serve as a resource for accessing current state and federal laws and recommendations
related to employee health and facility infection control.
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Infection Control Plan 2014
Section 2
Employee Guidelines
2.1
Universal/Bloodborne Pathogens Precautions
Universal/ Bloodborne Pathogens precautions will be observed by considering all blood and
body fluids as potentially infectious (OSHA Standards). New elements of the OSHA standards
include Respiratory Hygiene/Cough Etiquette and Safe Injection Practices.
Reference from the Centers for Disease Control:
2007 Guideline for Isolation Precautions(current): Preventing Transmission of Infectious Agents
in Healthcare Settings. Download the complete PDF version
2.2
Hand Washing
All staff must observe good personal hygiene, which includes hand washing. Staff should wash
hands before and after each patient contact; before donning and after removing gloves or
other personal protective equipment; before preparing and after administering medications or
injections; after handling objects contaminated with blood or other potentially infectious
materials; after using the toilet, blowing your nose, or covering a sneeze or cough; and before
eating, drinking, or handling food.
2.3
Hand-Washing Facilities
Note: Proper hand hygiene is the single most important means of preventing the spread
of infection!
All established clinics must be equipped with hand-washing facilities which are readily
accessible to employees.
Procedure
1. If possible, remove jewelry from hands and wrists. Only a minimum amount of
jewelry should be worn during clinic care.
2. If hands are not soiled with organic debris, use an instant hand sanitizer with at least
60% alcohol. Many studies have shown that 60 to 90% alcohol based hand rub is
more effective and better tolerated than soap and water.
3. If hands are visibly soiled, wet hands under running water. Lather hands well with
soap, hand antiseptic, or surface antiseptic from a dispenser. Wash fingers, in
between the fingers, under the fingernails, palms, backs of hands, and wrists, for 15
seconds. Bar soap should be used only if soap dispensers are unavailable. It has
been proven that bar soap can harbor bacteria if left undrained. If bar soap is to be
used, provide a self-draining soap dish. Run water over the soap briefly before
replacing it in the soap dish.
4. Remove and clean the inside and outside of the soap dispenser when it needs to be
refilled. Keep it free of soap build-up.
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5.
6.
7.
8.
Rinse hands thoroughly.
Dry hands with paper towels.
Use paper towels to turn off the faucet.
Apply hand lotion as needed. Frequent hand cleansing removes skin oil. Using a
hand lotion will lubricate the skin and prevent excessive drying and chapping.
Remember to wash hands and any other skin surface with soap and water, or flush mucous
membranes with water immediately or as soon as feasible following direct contact with blood
or other body substances. Report mucous membrane or non-intact skin contact with blood or
other body substances to your supervisor immediately! (See Post-exposure Management for
Occupational Exposure to Blood or Other Potentially Infectious Materials [OPIM] in UHS Risk
Management and Safety Plan)
2.4
Use of Gloves/Barrier Precautions
Gloves shall be worn when it can be reasonably anticipated the healthcare worker may have
hand contact with blood, semen, vaginal secretions, urine, feces, saliva, sputum, vomitus, or
any body substance.
Note: Throughout the manual, unless otherwise specified, the term “gloves” will refer to
disposable synthetic examination gloves. Latex gloves shall not be used.
Procedure
Gloves shall be used for all procedures where exposure to blood or body substances is
expected, including patient care, cleaning equipment and environmental surfaces directly
contaminated with such substances, or during any vascular access procedure.
1. Disposable gloves will be made available for all staff to wear when contact with body
substances is expected. Vascular access procedures include such things as starting an
IV, phlebotomy, and finger or heel sticks. It is optional when giving injections.
2. It is recommended that gloves be worn on both hands. When both hands are gloved, be
careful not to contaminate equipment and surfaces while performing patient exams.
3. If cross-contamination of surfaces and equipment is anticipated, one hand should
remain ungloved and not be used to perform the exam.
4. Washing gloves with soap may cause “wicking” (i.e., the enhanced penetration of fluids
through undetected holes in the gloves). Disinfecting agents will lead to glove
deterioration.
5. If the gloves become torn or punctured, discard them and put on a new pair. Gloves
should be checked for tears and should not replace hand washing.
6. If breaks in the skin are present on the hands, additional coverings may be worn under
the gloves. Glove liners, bandages, gauze, or finger cots can help minimize hand
irritations.
7. For environmental cleaning purposes, heavier reusable household gloves may be used.
They can be washed with soap and water after use and hung to dry. Lightweight
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examination gloves do not hold up under prolonged exposure to disinfection
procedures.
8. Discard the household gloves if they are cracked, peeling, torn, or punctured, or show
other signs of deterioration.
Note: The use of gloves is not intended to replace good hand-washing practices;
rather, it is meant to support and supplement hand washing.
Key to Abbreviations Used
Y = Yes (glove use is mandatory for the procedure)
N = No (glove use is not required)
O = Optional (gloves may be worn, but are not required
Table 1: Procedures and Expected Glove Use
1. Drawing blood
2. Doing finger or heel sticks
3. Giving injections
4. Taking temperatures
5. Testing urine with dipsticks
6. Doing pap smears and testing for sexually transmitted
diseases
7. Pelvic and/or rectal exams
8. Taking blood pressure
9. Taking heights, weights
10. Doing breast exams
11. Doing an oral exam
12. Handling/preparing lab specimens
Y
Y
O
N
Y
Y
Y
N
N
N
Y
Y
Infection Control Techniques
1. Thoroughly wash hands with soap and running water for at least 15 seconds before
and after:
• each contact with each patient,
• handling a specimen,
• contact with a potentially contaminated surface, or
• use of personal protective equipment.
2. Wear personal protective equipment appropriate to the task being performed.
3. Healthcare workers who have exudative lesions/weeping dermatitis or open sores
should cover wounds, if possible, and refrain from direct patient care until the condition
resolves.
4. Change clothing splashed with blood or body fluids as quickly as feasible.
5. Remember that gloves will not provide protection against needle sticks or other
percutaneous injuries. Gloves will, however, help to reduce the amount of blood or
body substance entering into the wound, when the needle penetrates the glove.
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Safe injection Practices
Further attention to patient protection is also needed as evidenced by continued outbreaks in
ambulatory settings resulting from unsafe injection practices. Unsafe practices that have led to
patient harm include:
1. use of a single syringe, with or without the same needle, to administer medication to
multiple patients,
2. reinsertion of a used syringe, with or without the same needle, into a medication vial
or solution container (e.g., saline bag) to obtain additional medication for a single
patient and then using that vial or solution container for subsequent patients,
.
3 preparation of medications in close proximity to contaminated supplies or equipment.
Key recommendations for safe injection practices in ambulatory care settings:
1. Use aseptic technique when preparing and administering medications
2. Cleanse the access diaphragms of medication vials with 70% alcohol pad or wipe before
inserting a device into the vial
3. Never administer medications from the same syringe to multiple patients, even if the
needle is changed or the injection is administered through an intervening length of
intravenous tubing
4. Do not reuse a syringe to enter a medication vial or solution
5. Do not administer medications from single-dose or single-use vials, ampoules, or bags or
bottles of intravenous solution to more than one patient
6. Do not use fluid infusion or administration sets (e.g., intravenous tubing) for more than
one patient
7. Dedicate multi-dose vials to a single patient whenever possible. If multi-dose vials will
be used for more than one patient, they should be restricted to a centralized medication
area and should not enter the immediate patient treatment area (e.g., operating room,
patient room/cubicle)
8. Dispose of used syringes and needles at the point of use in a sharps container that is
closable, puncture-resistant, and leak-proof.
9. Adhere to federal and state requirements for protection from exposure to bloodborne
pathogens.
2.5
Provision of Personal Protective Equipment
The employer shall provide, at no cost to the employee, necessary personal protective
equipment and clean or replace such items as needed.
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Table 2: Examples of Personal Protective Equipment for Protection from
Occupational Exposure to Blood and Body Fluids
Task/Activity
Glove
Gown
Bleeding control for spurting blood
Blood drawing
Handling and cleaning contaminated
instruments/equipment
Giving an injection
Measuring Blood Pressure
Measuring Temperature
Yes
Yes
Yes
Yes
No
Optional
Protective Eye
Wear
Yes
Yes
No
No
Optional Optional
No
No
No
No
No
No
No
No
No
2.6
Mask
No
No
No
Safety-Engineered Sharps
Employee will use recommended safety-engineered sharps devices.
2.7
Sharps Containers
Employees will immediately, or as soon as possible, dispose of contaminated sharps into an
appropriate container that is placed close to work area. (See Bloodborne Pathogens Protection
Plan on the ND Risk Management website.)
2.8
Employee Immunizations
All employees will be in compliance with established departmental policies regarding
immunizations and TB skin tests. (See UND Risk Management and Safety Policy in the UHS Risk
Management Manual)
2.9
Employer Provision of Vaccines
Refer to the Administrative Policy “Immunizations and Tuberculosis Screening for Employees”
2.10
Employee TB Skin Testing
University Health Services will provide employees who have worksite risk of exposure to
Tuberculosis (TB): skin testing at specified intervals; appropriate user-tested masks; referral and
post exposure follow-up treatment as needed.
Refer to Policy “Immunizations and Tuberculosis Screening for Employees”
2.11
Orientation of Employees
All employees with the potential for occupational exposure will be oriented to infection control
guidelines within 10 days of employment, as changes occur in policies and practices concerning
infection control, and annually thereafter. Documentation of training will be maintained in the
employee’s personnel file.
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2.12
Employer Provision of Staff Orientation
Staff orientation shall be provided during normal working hours, at no cost to the employees.
Procedure
All employees should be informed about the
risks of significant infection they are
exposed to in the occupational setting.
Supervisors will ensure that training
sessions are provided to review these
infection control guidelines with new
employees at their initial assignment and
annually thereafter.
Employees should understand:
Key Points
Presentation of the information will be
geared to the level of the employee.
General principles of infection control will
be included in the discussion.
a. the routes of transmission of various
infectious diseases, especially those for
bloodborne diseases such as hepatitis B
and C and HIV/AIDS
b. other relevant epidemiologic aspects of
occupationally-acquired infectious
diseases;
c. the department’s bloodborne pathogen
exposure control plan as outlined in this
manual;
d. the “OSHA Bloodborne Pathogens
Standard”;
Refer to the:
“OSHA Standards.”,
IN Guidelines For The Prevention Of
Bloodborne Pathogen Disease Transmission
During Student Activities
“Indiana ISDH Bloodborne Pathogen
Information”
UND Risk Management’s Bloodborne
Pathogen Exposure Control Plan.
e. the basic principles of standard
precautions, and the uses and
limitations
of personal protective equipment;
From the CDC Website:
f. strategies to reduce occupational
exposure including the use of
engineering
controls and work practice controls, and
safety-engineered sharps devices ;
Occupational Exposure
Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations
for Postexposure Prophylaxis
MMWR 2001;56(RR-11)
g. how to dispose of potentially infectious
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waste, contaminated clothing,
equipment,
sharps, and other items such as glove,
etc.
National Clinicians Post-Exposure Prophylaxis
Hotline (PEPline)
Hotline providing clinicians with 24-hour
guidance on managing occupational
exposures to HIV, viral hepatitis, and other
h. the protective action to take in the event bloodborne pathogens
of spills or personal exposure to tissue
Non-occupational Exposure
fluids, and the appropriate reporting
measures;
Postexposure Prophylaxis to Prevent
Hepatitis B Virus Infection
i. We will follow the UND Risk
MMWR 2006,56(RR-16), Appendix B
Management Post Exposure Policy for
reporting and managing needle-sticks and
other direct exposures to blood and other
potentially infectious materials;
j. the signs, labels, or color-coding
regarding hazard communications.
Staff should be trained in the use of safetyengineered sharps device.
Employees at risk should be provided
tuberculosis education that includes annual
respiratory devices; TB disease signs and
symptoms, screening, transmission, and
management
Staff should be given information on how to
access and use Material Safety Data Sheets
(MSDS) for the safe use of chemicals for
cleaning and disinfection.
Training records shall be kept to document
training received.
Information to be recorded shall include:
a. the date(s) of the session
b. the name(s) and qualifications of the
person conducting the training
c. the names and employee identifiers
of all the persons attending the training
session will be stored in a secure file.
Training sessions must include an
opportunity for discussion or a
question/answer period.
Records will be kept on file by the UHS
Director.
Videos/DVD’s may be used for training.
However, a method for answering questions
must be in place.
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2.13 Post-Exposure Management for Occupational Exposure to
Blood or Other Potentially Infectious Materials (OPIM)
All accidental exposures of employees or patients to blood, blood products, secretions,
or other body substances via percutaneous, parenteral, or mucosal routes shall be reported
immediately, and appropriate post-exposure evaluation/treatment initiated. Refer to the
Worker Compensation information and forms from the University’s Risk Management Office .
2.14 Employer Provision of Post-Exposure Management
The employer shall ensure that all medical evaluations, procedures, prophylaxes, and
counseling are made available at no cost to the employee and at a reasonable time/place.
A licensed healthcare professional will evaluate the exposure and recommend treatment
and follow-up as indicated.
Procedure
All employees should be aware of the risks of
acquiring an infection from occupational
exposure in a healthcare setting. Refer to
“Orientation of Employees” in this manual
All accidental exposures of employees to
patient blood or body substances shall be
reported to the employee’s direct supervisor
immediately.
Regardless of the source of exposure, first aid
consists of washing exposed skin site with
soap and water or irrigation of exposed eyes
with clean water/saline/sterile irrigant.
The UHS Staff will be expected to be familiar
with and responsible for following the UHS
Adverse event policy.
The employee’s supervisor or designee is
responsible for coordination of postexposure management.
Key Points
Exposure of bloodborne pathogens is defined
as parenteral (needlestick or other punctures
of the skin with a used needle or other sharp
item), mucous membrane (splatters/aerosols
into the eyes, nose, or mouth), or direct
contamination of an open wound or nonintact skin with a body substance.
If the direct supervisor is unavailable, the
incident shall be reported to the next
available supervisor or authorized person
(e.g., UHS on-call administrator).
Refer to “Adverse Events Policy” and the
“Adverse Events Report” in the UHS
Administration Policies
Refer to “Post Exposure Evaluation and
Follow-up” in the ND Risk Management
Bloodborne Pathogens.
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Document the route(s) of exposure and the
circumstances under which the exposure
incident occurred.
The employee may refuse all or part of the
recommended post-exposure management
procedures. Document which step of the
process was refused, and have this signed by
both the employee and supervisor. Attach
this documentation to the appropriate postexposure form specific for bloodborne
pathogens.
Test results should remain strictly
confidential
and be filed in the employee’s health record.
Employee health records will be maintained
at the ND Wellness Center.
Refer to “Post Exposure Evaluation and
Follow-up” in the ND Risk Management
Bloodborne Pathogens Policy. For Forms,
refer to UND Risk Management.
Any test, treatment, or follow-up procedure
should be documented, but serologic test
results should not be put into the employee’s
personnel file.
Incident report will be maintained in the
Notre Dame Office of Risk Management.
Current Estimates — Risk of Becoming Infected After a Single
Needle stick From a Known Positive Source
Hepatitis B:
Hepatitis C:
HIV:
2%–40%
1.8%
0.3%
Source: Updated U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to HBV, HCV and HIV and Recommendations for Postexposure Prophylaxis,
Centers for (cont.) Disease Control (CDC) Morbidity and Mortality Weekly Report (MMWR)
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SECTION 3:
Sterilization and Disinfection of Clinic Equipment
3.1
Counters/Sinks/Tables/Trays
All counter tops, sinks, trays, and table tops in patient care areas must be made of
impervious materials and should be cleaned with a disinfectant-detergent registered by the U.S.
Environmental Protection Agency (EPA). Surfaces which are likely to be contaminated with
blood or body fluids will be cleaned daily, and must be cleaned and disinfected after
contamination.
3.2
Routine Schedule for Cleaning and Disinfection
The facility will maintain a written schedule for cleaning and disinfection, outlining the
surfaces and areas to be cleaned, the cleaners or disinfectants used, and the employees
involved in the process. Refer to “UHS Cleaning Schedule” in this Manual.
Procedure
Clean environmental surfaces with a
disinfectant-detergent registered by the EPA.
If using a spray disinfectant, leave the
disinfectant on the surface for the required
length of time and then wash off and let dry
according to the manufacturer’s directive.
Wear gloves while cleaning.
Key Points
When using an EPA-registered disinfectantdetergent, follow the manufacturer’s
instructions for use.
When spraying, wear mask and eye
protection. Do not use spray when patients
are present.
Reusable gloves should be inspected for tears
or holes before using. They should be washed
with soap and water and hung to dry after
use. Replace the gloves if they are cracked,
peeling, torn, etc.
Maintain and consult current “Material
Material Safety and Data Sheets (MSDS) can
Safety and Data Sheets” (MSDS)on all
be found on the UND Risk Management’s
products in order to determine the
website
appropriate precautions and to prevent
hazardous conditions during product
applications.
Note: For a current listing of chemical disinfectants and sterilants registered by the U.S.
Environmental Protection Agency, refer to the OSHA website at Indiana.gov, or the University
of Notre Dame Risk Management (631-5037).
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3.3
Cleaning Up Blood and/or Body Secretion Spills
Spills will be cleaned immediately or as soon as feasible, using the appropriate EPA-registered
disinfectant.
3.4
Use of Chemical Germicides
Chemical germicides that are registered by the EPA as “hospital disinfectants” and are
tuberculocidal are to be used to clean up spills of blood or body secretions. Those
disinfectant-detergent formulations not designated as “hospital disinfectants” should
be reserved for general cleaning of environmental surfaces. Follow the manufacturer’s
instructions for using any EPA disinfectants. The procedures below address cleaning spills.
Procedure
Use household gloves.
Take care not to splash the blood or body
secretions into your mouth or eyes. If the
circumstances are such that aerosolization
may occur, a mask and goggles must be
worn.
Use of chlorine bleach is against the UND
Building Services Policy.
Remove the majority of the spill with
disposable absorbent toweling. Place
contaminated towels in red BIOHAZARD bag,
and add absorbent material to the bag as
needed. Dispose of in waste receptacles
marked with the BIOHAZARD label.
When dealing with a large spill, reapply
disinfectant directly to the cleaned spill area,
then remove with absorbent toweling.
After spill cleanup, hands should be washed
with soap and water.
Key Points
Due to potential hazards, such as mixture
with other chemicals as well as being
corrosive. When using any disinfectant in
concentrated form or in large amounts (such
as with spill cleanup), always make sure the
area is well ventilated.
BIOHAZARD bags are located on the
housekeeper’s carts and in the Soiled Utility
rooms on the first and second floor.
Follow ND Risk Management’s policy on
“Waste Treatment and Disposal Methods”
for procedure for removal of contaminated
waste.
Examples of absorbent material added to the
bags include additional paper towels or kitty
litter.
Longer contact times are required when
more organic matter is present.
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Commercial blood spill clean-up kits may also
be used, following manufacturer’s directions.
Located in the housekeeper’s closets and the
Soiled Utility Rooms on the first and second
floors.
Note: General information on sterilization and disinfection can be found in this manual
under “Principles of Sterilization and Disinfection.
3.5 Exam Tables
All exam tables should be cleaned daily with an appropriate disinfectant solution, and
disposable coverings for exam surfaces should be used.
Procedures
Key Points
Table paper or absorbent pads will be
Surface disinfection between patients is not
changed on all exam tables after each patient necessary if NOT contaminated with
by the nursing staff.
secretions, excretions, and/or blood.
Table paper or absorbent pads with no visible If the paper or absorbent pad becomes
contaminated, the soiled covering must be
soil or body fluids can be discarded with
discarded in waste containers identified with the
routine solid waste.
BIOHAZARD symbol.
Wear gloves during this cleaning procedure
If the table becomes soiled, remove obvious
organic soil with disposable towels and follow
instructions in “Cleaning Up Blood and/or
Body Secretions” located in this manual.
All exam tables should be cleaned by the
Clinic Staff following the last patient at the
end of each clinic day. An appropriate EPAregistered low-level disinfectant-detergent
should be used for noncritical medical
equipment according to the manufacturer’s
directive.
Refer to “Counters/Sinks/Tables/Trays” in
this manual for sterilization and disinfection.
3.6
Thermometers
Digital and ear thermometers must be cleaned according to the manufacturer’s instructions.
Digital and Other (Such as Ear) Thermometers
Procedure
Key Points
When using thermometers with disposable
sleeves or sheaths, use a new sleeve or
sheath with each patient.
Follow manufacturer’s instructions for
cleaning.
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3.7
Devices Used in Procedures Involving Blood
All devices used in procedures involving blood shall be cleaned, disinfected, or discarded
after each use, as directed below.
Procedure
A. Automatic Lancet Devices
1. Only safety-engineered disposal
lancets
should be used. Contaminated lancets
should be deposited in appropriate
containers immediately after use.
B. Vacutainer Sleeves
1. Vacutainer sleeves (blood tube
holders)
are to be used only one time because
they are reported to have 50-80%
contamination after one use and because the health worker is put at risk
of a sharps injury during removal of
the contaminated needle.
C. Other Safety-Engineered Devices
1. Plastic blood tubes should be used.
2. Safety engineered syringes and
needles
should be used.
D. Glucometers
1. Disinfection and cleaning of the
Glucometers should be according
to the manufacturer’s guidelines
with an EPA-approved disinfectant.
3.8
Key Points
Sharps containers should be placed close to
work area and not overfilled. (Three-fourths is
considered full.)
Glucometers and other environmental
surfaces should be cleaned regularly and
whenever contamination with blood or body
fluid occurs.
Vaginal Speculum
Reusable speculum will be cleaned and autoclaved or receive high-level disinfection as
outlined, after each use. Disposable speculum will be discarded after use.
3.9
TB Sputum-Collection Equipment
All sputum-collection equipment will be disinfected after each use as outlined.
Procedure
Key Points
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1. Self-collected sputum specimens brought
to UHS will require a sputum specimen
collection cup and a mask for the
healthcare provider.
2. The normal UHS disinfectant is used to
clean or disinfect floors and walls.
3.10
Otoscope/Ophthalmoscope
The plastic attachments are to be cleaned and disinfected after each use as outlined.
Procedure
1. After the piece is removed from the instrument, clean off visible organic
matter with a cotton swab. Wash the
piece with soap and water, then dry.
Key Points
Certain substances, such as pus and blood,
neutralize disinfectant. Soap and water
assure
emulsification and dispersion of these
substances. Drying assures there is no
dilution of the disinfectant from water left on
pieces.
2. Place the cleaned piece(s) in disinfectant
solution for 10 minutes.
3. Remove the pieces from the Betadine
solution rinse well with water, dry, and
store in a dry container.
4. Use disposable speculum for ear and nose These may be discarded as routine clinic
exams. Discard speculum after completing waste, provided that there is no visible blood
each patient’s exam.
present on the speculum. If blood is present,
these should be discarded into a waste
receptacle marked with the BIOHAZARD
label.
3.11 Blood-Pressure Equipment
Stethoscope earpieces should be cleaned after each use unless only one person is using the
stethoscope. Blood-pressure cuffs should be kept clean and free from obvious debris.
Procedure
1. Earpieces on stethoscopes should be
cleaned with 70% alcohol pad or wipe
each time a different person uses the
stethoscope.
Key Points
Ideally, the earpieces should be washed with
soap and water first to remove obvious
debris. This may not be practical in most
situations. An alternative procedure would
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be to use a cotton swab to remove visible
organic material and follow with alcohol.
2. The bell of the stethoscope should be
wiped with 70% alcohol pad or wipe after
use with each patient.
3. Wash the blood-pressure cuffs when they
become soiled with body substance.
4. Blood-pressure cuffs may be washed in
regular laundry detergent after first
removing the bladder. The cuffs can be
soaked in a sink with detergent and
washed
in a machine.
3.12 Autoclave Operation /Monitoring
The autoclave will be operated and maintained according to the manufacturer’s instructions.
The autoclave will be monitored according to the manufacturer’s instructions to determine that
it is functioning properly (i.e., achieving sterile conditions).
Refer to: INSTRUMENT PROCESSING AND STERILIZATION Policy with Procedure in the Clinical
Policies.
3.13 Refrigerators and Freezers
Refrigerators and freezers used to store or contain blood or other potentially infectious
materials (OPIM) must have a fluorescent orange or orange-red warning label including the
BIOHAZARD symbol and word in a contrasting color. These refrigerators and freezers must not
be used for food storage or vaccine storage.
BIOHAZARD Symbol for Refrigerators Containing Blood and OPIM
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Procedure
Refrigerators should be kept clean at all
times.
They can be wiped out with liquid dish soap
and warm water.
Key Points
Refrigerators and freezers used to store
vaccine, serum, blood or other potentially
infectious materials are cleaned by nursing
staff according to a schedule posted on the
refrigerator.
Refrigerator should be kept at appropriate
storage temperature.
3.14 Equipment in University Health Services
Any equipment that becomes contaminated with blood or OPIM must be decontaminated.
Table for Cleaning Equipment in University Health Services
Procedure
If any piece of clinic equipment becomes
contaminated, it should be cleaned/
disinfected as soon as it is practical to do so.
Key Points
Any cleaners or disinfectants used must be
compatible with the surface to be cleaned.
Follow manufacturer’s instructions for
cleaning delicate equipment.
3.15 Hazard Communication for Contaminated Equipment
BIOHAZARD signs or labels must be posted on contaminated equipment if the equipment
cannot be decontaminated immediately.
Procedure
If an instrument/equipment cannot be
readily cleaned after contamination with
blood or OPIM, a BIOHAZARD sign and label
must be posted on the instrument prior to
cleanup.
The BIOHAZARD sign and label must be
attached to contaminated equipment that
requires disassembly for the cleaning/
disinfecting process or for repairs.
Key Points
The sign must be readily visible and must
indicate which parts of the instrument are
contaminated. Contact Risk Management for
biohazard signs or labels.
This is important to alert all who handle the
equipment, especially off-site repair technicians, as to the nature and extent of the
contamination.
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Section 4:
Disposal of Regulated Medical Waste
4.1
Management of Medical Waste
Medical waste generated within the facility which has a high potential risk for causing
infection if improperly handled or treated will be managed in accordance with:
1. The University of Notre Dame Department of Risk Management and Safety policies
regarding the management of medical waste will be followed.
UND Risk Management Guidelines_for_the_collection and disposal of infectious waste
2. OSHA standard Occupational Exposure to Bloodborne Pathogens; Formal Rule
1910.1030(see Appendix C) as a good practice standard 29 CFR
4.2
Sharps Collection
Contaminated Sharps Container
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Procedure
1. Sharps containers shall be punctureresistant, closable, leak-proof on sides
and bottom, color-coded or labeled
clearly with the BIOHAZARD symbol.
2. Sharps containers will be placed in
clinic settings. All sharps will be placed
in these containers immediately after
use.
3. Contaminated needles shall not be
recapped, bent, sheared, broken, or
separated by hand from syringes.
Needles and syringes must be
discarded into the sharps container as
a unit.
4. Broken glassware shall not be picked
up directly by hand. Use appropriate
mechanical means.
5. Sharps containers will be replaced
when they are ¾ full.
6. Sharps must be placed in a marked,
puncture resistant rigid container
designed for sharps. If the container
is not leakproof as defined in 49 Code
of Federal Regulations 173.23(f), the
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Key Points
The BIOHAZARD label must be predominately
fluorescent orange or orange-red with letters
or symbols in a contrasting color.
Place the containers in the areas where
sharps are used. When not in use, these
containers must be placed out of the reach of
any unauthorized personnel.
Twisting, bending, or separating
contaminated needles by hand increases the
possibility of injury and occupational
exposure. One-handed disposal of sharps is
recommended.
Decontaminate and wash equipment as
needed after use in picking up contaminated
glass.
Sharps containers must be kept upright,
replaced routinely, and not be overfilled.
Indiana Commission on Environmental
Quality regulations.
Infection Control Plan 2014
container must be placed in a plastic
bag that is marked with a BIOHAZARD
color-coded symbol.
Note! Under no circumstance will hand entry into puncture resistant containers for sharps be
allowed.
4.3
Collection of Other Regulated Medical Waste
The University of Notre Dame Department of Risk Management and Safety policies regarding
the management of medical waste will be followed.
UND Risk Management Guidelines_for_the_collection and disposal of infectious waste
Procedure
1. All other regulated waste shall be
placed in containers which are
closable and constructed to contain
all contents and prevent leakage of
fluids during handling, storage,
transport, and shipping.
2. Containers must be labeled or colorcoded in accordance with paragraph
(g)(1)(i) of the Bloodborne Pathogen
Standard (see OSHA Standard in this
manual.)
3. Containers must be closed prior to
removal to prevent spillage or
protrusion of contents during
handling, storage, transport, or
shipping.
4. If outside contamination of the
regulated waste container occurs, it
shall be placed in a second
container which meets the same
specifications as the first.
5. Clinical personnel, not janitorial
staff, shall manage the proper disposal of sharps and other regulatory medical waste.
Key Points
Receptacles designated for special waste
should be set up in the clinics, readily
accessible for staff use.
The BIOHAZARD label must be predominately
fluorescent orange or orange-red with letters
or symbols in a contrasting color. A red bag
or container may substitute for labels.
Wear gloves and use mechanical devices as
necessary to prevent contaminating or
injuring the hands.
Janitorial staff should be trained to recognize
medical waste containers and know that
clinical personnel will manage the medical
waste.
Note: Sharps containers and other medical waste awaiting transport must be kept in a secure
location.
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Infection Control Plan 2014
4.4
Waste Treatment and Disposal Methods
All regulated medical waste shall be treated as outlined below.
Note: Sharps containers and other regulated medical waste are required to be released
only to registered transporters of untreated medical waste. Please refer to the UHS Risk
Management and Safety Manual.
Treatment Methods for Microbiological Waste
Procedure
Key Points
1. Remove pathological waste in glass
Follow the procedures for treatment and
tubes.
disposal of sharps.
2. Place in puncture-resistant containers
for treatment
3. Treat using steam sterilization,
chemical disinfection, or
encapsulation.
4. Follow disposal procedures for sharps.
4.5
Record-Keeping Requirements
Record keeping will follow UND Risk Management Guidelines_for_the_collection and disposal
of infectious waste.
4.6
Non-Infectious Clinic Waste and Office Waste
Waste which is generated within the facility and which does not have a high potential for
causing infection does not require special precautions for handling and disposal.
Note: Urine dipsticks and empty urine-specimen cups may be placed in the regular trash.
These items do not meet the definition of special waste from healthcare-related
facilities or OSHA’s definition of a bloodborne pathogen.
Non-Infectious Waste Table
Procedure
1. Exam rooms, clinic areas, and
laboratories should have trash cans
lined with heavy-duty plastic trash
bags.
Key Points
Heavy duty bags are used to contain
absorbent towels and other disposable clinic
supplies stained with small amounts of blood
or other organic debris.
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Infection Control Plan 2014
2. All clinic waste that has not been
identified as potentially infectious
should be placed into lined trash cans.
All clinic waste that has been
identified as potentially infectious
should be placed into hazardous
waste (red) lined trash cans.
Disposable items such as paper gowns, drape
sheets, exam-table paper, applicators, swabs,
tongue blades, used dressings and bandages,
urine dipsticks, disposable gloves, cotton
balls, and disposable speculums if
contaminated with blood or other potentially
infectious materials, fall into the hazardous
waste category.
Removal of non-infectious waste from clinic
areas may be assigned to the janitorial staff.
Make certain that both the clinic personnel
and janitorial staff understand that no one is
to reach directly into clinic trash receptacles
with their bare hands.
This non-infectious waste may be placed with
the regular trash.
This should be done as soon as possible.
3. Clinic trash cans, when filled, should
be emptied by taking the plastic-bag
lining and the receptacle out with the
trash as a unit. Add a new plastic bag
to the trash can.
4. If the waste receptacle becomes
contaminated, clean and disinfect it
using an approved solution.
Section 5:
Isolation of Potentially Infectious Patients
5.1
Identification/Isolation of Potentially Infectious Patients
In an effort to prevent the transmission of disease, patients with a suspected or confirmed
infectious disease that is transmitted by droplet spread or direct contact will be isolated
from the general clinic population.
Procedure
1. All staff in the clinic should have a
basic knowledge of the common
commun-icable diseases that may be
present in the clinic. Patients
Key Point
This information should be included as part
of the employee’s orientation program. See
“Orientation of Employees” In Risk
Management Manual.
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Infection Control Plan 2014
suspected of having any of the
following illnesses should be isolated:
• Bacterial meningitis
• Chickenpox
• Diphtheria
• Gastroenteritis
• Influenza
• Measles
• Mumps
• Pertussis
• Rashes of unknown source
• Rubella
• Tuberculosis
• Upper respiratory infections
(especially with fever and productive cough)
2. When a patient suspected of having
one of the above illnesses comes to
the clinic, the nurse in charge should
be notified, and the patient should be
taken out of the waiting room immediately and put in an exam room or
office away from other patients.
Patients who are coughing are
required to wear a mask.
It is not intended that clinic staff diagnose
illness, but rather that they should be aware
of indications that the patients may be infectious. Clerical and other support staff
should tell the nurse in charge if they suspect
a patient is infectious.
Section 6:
Storage and Handling of Equipment, Supplies, and Biological
Specimens
6.1
Equipment and Supplies
All equipment and supplies, including those in boxes, will be stored in properly
designated storage areas.
6.2
Sterile Instruments
All expiration dates on sterile instruments will be checked on daily basis as supplies are
restocked.
6.3
Specimen Storage, Handling, and Transport
Laboratory specimens of blood or other potentially infectious materials (OPIM) shall be
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Infection Control Plan 2014
handled in accordance with the provisions of the OSHA Bloodborne Pathogens standard
(see “OSHA Standards in this Manual”).
Section 7:
Miscellaneous Activities in Clinic Settings
7.1
Laundry
Reusable personal protective equipment made of cloth will be cleaned and repaired at no cost
to the employee.
Procedure
1. Reusable personal protective
equipment made of cloth will be
laundered and repaired, as needed, at
no cost to the employee.
2. A container that is labeled with the
BIOHAZARD symbol and word, or
color-coded, must be available to col-
Key Points
If the contaminated clothing is wet and
leakage is possible, the container must be
leak-proof.
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lect clothing/patient gowns with
blood or OPIM.
3. Employees will use universal precautions when handling contaminated laundry.
4. Contaminated Laundry shall be placed
in red bio-hazard bags and sent to the
Notre Dame Laundry.
7.2
Gloves and other personal protective equipment are necessary when handling contaminated laundry.
Food
Employee food will be stored separately from vaccines, medications, and specimens.
Procedure
1. Food and biological specimens will
not be stored in the same
refrigerator. Food cannot be stored in
a refrigerator along with specimens.
2. Food shall not be eaten in the clinic,
at nursing stations, receptionist desks,
or laboratory areas.
7.3
Key Points
See “OSHA Standards” in this manual.
The following activities are also not
permitted in these areas:
 smoking or drinking
 applying cosmetics or lip balm
 handling contact lenses
Post-Exposure Management:
Please refer to the University of Notre Dame Risk Management and Safety Department Policy
found in the University Health Services Risk Management section of this manual.
Refer to Worker Compensation Information on the UND Risk Management website.
8. OSHA STANDARDS
Information about the OSHA Standards can be found on the United States Department of Labor
website at: http://www.osha.gov/html/a-z-index.html
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