This manual is designed so the policies may be used as written, or they may be easily adapted to a specific agency by using the CD-Rom that is provided with the manual. The content is written taking into consideration JCAHO standards, federal regulations, and current standards of practice for infection control.
The manual includes a detailed table of contents and numbered tabs for ease in finding specific policies. The manual format includes:
- The Infection Control Program
- Surveillance of Infections
- Infection Control Education
- Isolation
- Employee Health
- Patient Care Policies
- Department Policies
- OSHA Exposure Control Plans for Bloodborne
- Pathogens and Tuberculosis
- Performance Improvement
- References
Table of Contents
INFECTION CONTROL PROGRAM
Infection Control Program Overview
Job Description – Infection Control Practitioner
Infection Control Competency Assessment
Infection Control Committee
Authority of the Infection Control Committee
Sample Minutes Form
SURVEILLANCE OF INFECTIONS
Infection Control Surveillance
Healthcare-Associated Infection Summary Report by Patient Days
Infections by Device Days
Line Listing of Patient Infections
Definitions of Infections for Surveillance Activities
Infection Control Plan
Surveillance Plan
Reportable Diseases
Outbreak Investigation Form
Healthcare-Associated Infections and Sentinel Events
Healthcare-Associated Infections Reviewed as Sentinel Events
INFECTION CONTROL EDUCATION
Infection Control Orientation and Inservices
Infection Control Orientation Outline
OSHA Bloodborne Pathogens Standard Employee
Training Outline
Tuberculosis Employee Training Outline
Patient and Family Education for Infection Control and Infectious Diseases
ISOLATION FOR COMMUNICABLE DISEASES
Standard Precautions
Contact Precautions
Droplet Precautions
Airborne Precautions
Respiratory Protection for Airborne Diseases
Tasks/Operations Requiring Respiratory Protection
Respiratory Protection Exposure Determination
For Biological Agents (TB And Smallpox)
Compliance Monitoring
Staff Self-Evaluation of Infection Control Practices
Monitoring Compliance with Infection Control Policies
Handling and/or Disposing of Used Needles
Using Gloves
Clostridium Difficile
Methicillin-Resistant Staphylococcus Aureus (MRSA)
Vancomycin-Resistant Enterococcus (VRE)
EMPLOYEE HEALTH
Physical Assessment
Annual Tuberculosis Assessment (for use with staff who are PPD positive)
Reporting Employee Infections
Employee Infection Record
Summary of Important Recommendations and
Work Restrictions for Personnel with Infectious Diseases
Criteria for Determining Exposure to Communicable Disease
Management of Accidental Exposure to Communicable Diseases
Influenza Vaccine Informed Consent Form
Hepatitis B Immunization Program
Information on Hepatitis B and the Vaccine
Hepatitis B Immunization Consent or Declination
Tuberculosis Screening for Employees
Frequently Asked Questions: Tuberculosis and the PPD Tuberculin Skin Test
Post-Exposure Evaluation and Follow-Up
Bloodborne Pathogens Post-Exposure Evaluation and Follow-Up
Bloodborne Pathogens Post-Exposure Evaluation/
Healthcare Professional’s Written Opinion
Recommendations for Hepatitis B Prophylaxis
Following Percutaneous or Permucosal Exposure
Potential HIV Exposure
Consent for HIV Antibody Blood Test and Release of Information
Vaccine Recommendations
Pregnant Personnel
PATIENT CARE POLICIES
Animals in the Home
Bag Technique
Cleaning, Disinfection and Sterilization
Environmental Sampling
Feeding Syringes
Hand Hygiene
Immunizations: Influenza (Flu) Vaccination
of Patients, Staff, and Volunteers
Immunizations: Pneumococcal Vaccination (PPV) of Patients
Immunizations: Adverse Reactions
Infectious Waste Management
Intravenous Therapy
Use of Oxygen
Personal Hygiene
Pest Control
Collection of Specimens
Use of Thermometers
Suctioning and Care of Tracheostomies
Nasogastric/Gastrostomy Tube Feeding
Urinary Catheters
Prevention of Wound Infections
Wound Care/Treatment Guidelines
Wound Care Procedure for Major Wounds
DEPARTMENT POLICIES
Housekeeping Services
Vending Room (Canteen)
OSHA BLOODBORNE PATHOGENS
REGULATIONS
Bloodborne Pathogens Model Exposure Control Plan (ECP)
Program Administration
Employee Exposure Determination
Methods of Implementation and Control
Standard Precautions
Exposure Control Plan
Engineering Controls and Work Practices
Personal Protective Equipment
Housekeeping
Laundry
Labels
Hepatitis B Vaccination
Post-Exposure Evaluation and Follow-up
Administration of Post-Exposure Evaluation and Follow-up
Procedures for Evaluating the Circumstances Surrounding an Exposure Incident
Employee Training
Recordkeeping
Training Records
Medical Records
OSHA Recordkeeping
Sharps Injury Log
Sample Sharps Injury Log
Employee Input about Engineering and Work Practice Controls
TUBERCULOSIS CONTROL PLAN
Tuberculosis Control Plan
Tuberculosis Risk Assessment
Elements of a Tuberculosis Infection Control Program
Employee Tuberculosis Skin Testing Summary
Immunization and TB Skin Testing Record
Annual Tuberculosis Assessment
PERFORMANCE IMPROVEMENT
Supervisory Review
Infection Control Assessment of Agency Office
Compliance Rounds Forms:
Foley Catheters
Tube Feeding
Safer Sharps and Sharps Disposal
Standard Precautions
Documentation of Infections
Dressings/Wound Care
