Download WHS – Infection control policy template

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Disclaimer
The suggested template is intended for use as a guide of a general nature only and
may not be relevant to particular practices, patients or circumstances. Persons
implementing any recommendations contained in this publication must exercise their
own independent skill or judgment or seek appropriate professional advice relevant to
their own particular practice. Compliance with any recommendations will not in any way
guarantee discharge of the duty of care owed to patients and others coming into
contact with the health professional or practice. This publication is not comprehensive
and does not constitute legal advice. You should seek legal or other professional
advice before relying on any content, and practice proper clinical decision making with
regard to the individual circumstances. Avant is not responsible to you or anyone else
for any loss suffered in connection with the use of this information. Information is only
current at the date initially published.
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WHS – Infection control policy
template
The following are proposed for use in a policies and procedures manual, adapted to
suit individual requirements:
Vaccinations for practice members
Working in the health care industry exposes staff to disease. Staff are educated on
infection prevention and control guidelines to protect themselves against disease.
All staff members are responsible for their own wellbeing. However, the practice offers
the following routine immunisation to all practice members:
 Diphtheria-tetanus
 Rubella
 Hepatitis B
 Sabin
 Influenza
 Pneumococcal
 Varicella
 Measles for those aged 18 – 30
 Meningitis C
A record of immunisation status is kept on individual staff member files indicating
name, date, titre levels (where appropriate), booster due, who by, batch #, etc. The
practice manager keeps a composite list of booster due dates and informs staff.
Advice should be sought from an infectious diseases expert when staff members have
contracted a communicable disease.
Blood and body substance spills
Spill kit is kept … (e.g. under sink in store room)
All practice members are trained in the safe management of a contaminated waste
spill. They understand the concept of removing the spill, decontaminating the area and
safe disposal of waste.
Carpets:
 Confine and contain the spill and clean up as soon as possible using the spill -kit.
 Wear gloves, gown, mask and goggles.
 Absorb excess blood or body substance spill with paper hand towel and discard
in contaminated waste bag.
 Soiled carpet to be cleaned with neutral detergent and water and shampooed
using carpet cleaner as soon as possible.
 Dispose of all wastes in contaminated waste bag, seal and arrange for collection.
 Restock spill kit.
Non-carpeted areas:
 Confine and contain the spill and clean up as soon as possible using the spill kit.
 Wear gloves, gown, mask and goggles.
 Absorb blood and body substance spill from surface using paper towel or
absorbent granules and discard in contaminated waste bag
 Clean the area with neutral detergent.
 Dispose of all wastes in contaminated waste bag, seal and arrange for collection.
 Ensure floor is dry.
 Restock spill kit.
Blood and body substance exposure
All staff members are aware and trained in the process for dealing with blood or body
fluid exposure.
The practice manager is responsible for managing this process and is required to
inform all staff members of the potential risks with needle stick and sharp injury. A
needle stick injury follow-up protocol should be visible in procedure rooms as well as in
the policy and procedure manual.
The practice manager is responsible for maintaining and updating this policy.
Any staff member exposed to blood or body substances is required to report this
incident immediately to the practice manager and complete an incident form.
The staff member is required to give informed consent for testing for HIV and hepatitis
C and B. The results of these tests are confidential. All the required paperwork is to be
completed in compliance with state-based health legislation.
If the source is known, test for HIV and hepatitis C and B with informed consent.
If the source is not known to be HIV, hepatitis C or B positive contact a doctor or the
sexually transmitted diseases clinic for instructions.
Counselling is offered and recommended for the staff member and the source patient if
testing is done.
Follow-up blood tests will be provided by the practice.
The results from any tests are confidential and the staff member receives them directly.
These results are also forwarded to the referring practitioner. The staff member is
under no obligation to inform the practice of the results.
The practice manager completes any insurance advice form required by the workers’
compensation insurer.
Sharps injury management
To reduce incidence of sharps injury:
 All sharp objects, including needles, syringes and blood glucose lancets are
deposited into the approved yellow rigid containers.
 Keep containers out of children’s reach – not on the floor.
 Needles are never recapped, purposely bent, broken removed from disposable
syringes or otherwise manipulated by handling.
 When the sharps container becomes three-quarters full it is sealed. Sharps
containers are collected by (company name) weekly.
 Notices on sharps injury procedures are posted in all areas of the practice
Example of notice for sharps injury:
Immediate treatment for sharps injury:
• Wash the affected area thoroughly with soapy water
• Report incident to employer – consent to be gained from patient if the identity is
known.
• Make appointment with doctor for counselling and blood tests
Cleaning
A regular cleaning and maintenance schedule is necessary to maintain a safe and
clean environment.
The premises must be cleaned frequently, thoroughly and with the appropriate
chemicals, to minimise infection transmission and offer a safe workplace. Neutral
detergent is recommended for all general cleaning. Disinfectants are only
recommended in the presence of most-resistant organism (including C. difficile) or
other infectious agents requiring transmission-based precautions. The surface/items
should be physically cleaned with a detergent solution, followed or combined with a
TGA-registered disinfectant with label claims specifying its effectiveness against
specific infectious organisms.
A contract cleaner is employed to clean three times a week after business hours. They
will be provided with a rear door key and the security code allowing access. They must
also sign a confidentiality agreement. All contract cleaners are cognisant of health care
cleaning requirements, including the use of colour-coded cleaning equipment.
All practice members will continually assess the contractor’s performance. The practice
manager will perform monthly inspections with the contractor. Any problems should be
reported to the practice manager. The contract cleaner will report directly, and be
answerable to, the practice manager.
Contractors’ duties will be as follows:
 Vacuum all floors
 Empty all bins (excluding those lined with yellow contaminated waste bags)
 Take out garbage on **** evening
Using the appropriate cleaning agent supplied by the practice:
 Clean all internal windows and unbarred external windows
 Clean toilets
 Clean basins in all rooms
 Wipe over all seats and beds
 Sweep and mop all vinyl and tiled floors (do not polish)
 Clean staff bathroom and shower
 Wipe over all furniture (excluding computer keyboards and screens)
 Dust all surfaces
 High dusting (e.g. top of curtain rails)
 Mop heads and cleaning cloths are to be laundered after use and stored dry.
The neutral detergent for all general cleaning is purchased by the surgery and kept in
the cleaner’s storeroom.
The contractors are expected to wear heavy-duty gloves while cleaning.
The contractors wash children’s toys on the Friday of each week.
No sharps or instruments are to be touched by the contractors. The practice manager
is to be informed via the communication book should any sharps or instruments be left
exposed.
A communication book is kept in the practice manager’s office for any specific
instructions for the contractors.
Contact details for the cleaner are: XXXXX
Waste removal
Waste management and removal of clinical waste are important in the control of
infection and contamination.
‘Clinical waste’ is any matter that is soiled with any body substances.
Clinical waste is disposed of by approved waste contractors, in accordance with
Australian Standards and local government regulations.
All clinical waste is placed into a yellow clinical waste bag as soon as possible after
generation. This bag is sealed and placed in a locked collection bin, located either
securely in outside collection area or in a locked room, to prevent public access. The
secure clinical waste is collected weekly by an authorised waste management
contractor who complies with EPA Standards.
(Company name) collects the clinical waste on Friday of each week.
The waste is tracked and transported to a clinical waste high temperature incineration
facility governed by … (The company transporting the waste can provide this
information, e.g. NSW EPA regulation license number …).
Sterilising and disinfecting
Risk of infection and cross contamination is minimised if practice members are trained
in infection prevention and control and sterilisation and disinfection techniques. This
training/education will be recorded in personnel files.
Adequately decontaminating, disinfecting and/or sterilising all reusable medical
equipment minimises the risk of cross infection.
Appropriate cleaning and decontaminating all practice equipment and the practice
environment controls the possibility of infection spread.
Wearing protective clothing (gloves, impervious gowns, eye protections and hair
covering) during these processes reduces the risks and ensures the safety of practice
members.
Disposing of both clinical and non-clinical waste in a methodical manner, and ensuring
this is done regularly, also minimises the risk of infection spread.
Example cleaning schedule
Area
Vacuum carpets
Daily
Yes
Weekly
Monthly
Quarterly
As reqd
Mop linoleum areas
Yes
Damp wipe desk tops and
sinks
Yes
Empty clinical waste bins
Yes
Remove full sharps containers
Yes
Empty waste paper bins
Yes
Clean windows
Yes
Wipe marks from walls
Clean toilets
Clean kitchen fridge
Steam clean carpets
Yes
Yes
Yes
Yes