policies and protocols for infection control, the prevention of infection, the ability to demonstrate extreme measures are taken to prevent the cause of infection in and around the workplace. This protocol is geared more towards the surgical setting but can be customized to meet any health care setting as most of them are universal precautions based policies.
Infection Control Program Policy # 0126 Effective: Reviewed: Revised: 1. POLICY. 1.1 The Center ahs established an Infection Control program which is facility- wide, involving both the Medical Staff and the employees of the facility. 2. GOAL. 2.1 It is the goal of the Center to provide the highest quality of patient care, including a safe and effective system for the surveillance, prevention and control of infections. The Governing Body of the Center oversees all activities of the Center and therefore may make recommendations, institute surveillance or control measures, if needed. 3. LEADERSHIP INVOLVEMENT. 3.1 The Governing Body reviews all reports of post-operative infections, including surgical site infections and/or device-related infections. The Governing Body also reviews all proposed policies and procedures. The Director of Nursing attends all meetings and acts as the designated Infection Control Coordinator of the Center 4. PROGRAM ELEMENTS. 4.1 Center staff are in-serviced upon hire and at least annually thereafter on infection control measures. The Center will report any communicable diseases or incidents of infections involving antibiotic-resistant organisms to the local health department. 4.2 Peer review of Medical Staff physician/podiatrists includes statistical data on outcomes including post-operative infections. This review is ongoing and is presented quarterly for each physician and at the time of their two-year reappointment procedure. Credentialing of physicians is the responsibility of the Governing Body. 4.3 Routine monitoring of patients is accomplished on a monthly basis to determine if any post-operative infections have been noted. If reported, a Post-Operative Infection Report is initiated by the Coordinator and is forwarded to the Administrator for review and presentation to the Governing Body. In addition, Report for all reported infections will be completed. 4.4 The Quality Council also serves as the Infection Control Committee, and any problems, policy or procedure changes, new equipment acquisition, in- service education, cost savings, significant employee illness, etc., Page 1 of 3 related to infection control and prevention are presented and forwarded to the Administrator for presentation to the Governing Body. 4.5 All activities related to infection control are communicated to the Governing Body on a quarterly basis, or more frequently as needed. An annual summary will be completed as to the infection control activities for the previous year and reported to the Governing Body. 4.6 The Coordinator will also compile information related to the sterilization process of the instruments within the facility and report this to the Governing Body quarterly. This information should contain information related to the sterility of the instrumentation completed within the facility. (See Form SD-1 DOC) 5. INFECTION CONTROL PHYSICIAN FOLLOW-UP. Thos mechanisms are used in order to manage an effective Infection Control program at the Center. 5.1 Post-Operative Telephone Call – At the time of the telephone call post- operatively, the patient will be asked specific questions regarding his incision (i.e. swelling, redness, heat, etc.) 5.1.1 If, at this time, the nurse believes there are symptoms of an infection present, the patient will be instructed to call his physician immediately. The Director of Nursing or Infection Control Coordinator will also be notified immediately so that sterile supplies and equipment used for the case as well as the OR can be checked. 5.2 Post-Operative Infection Report – A second mechanism has been devised to further track post-operative infections. 5.2.1 Each month the Infection Control Coordinator will mail to each physician’s office a list of patients done the previous month, request if an infection has been noted. 5.2.2 The questionnaire is returned to the Center for review, if the physician does not return his/her questionnaire, additional methods should be used to obtain this information. 5.2.3 A mechanism has been devised to monitor the return of all questionnaires sent to the physician’s offices. If physicians remain non-compliant, this will be reported to the Governing Body and reflected in the credentialing process. 5.3 Reported Infections. 5.3.1 When an infection is reported to the Director of Nursing or Infection Control Coordinator, the Post-Operative Infection Report form will be completed and actions taken documented. This form will be presented to the Governing Body for further action. 5.3.2 Definitions for an infection should be followed per the CDC guidelines of “Surgical Site Infections”. 5.3.3 Following the review of the Infection Report by the Quality Council, the information (including the original Post-Operative Infection Report form and attached documentation) will be maintained with a Log of Post- Operative Infection Reports. 5.3.4 An incident report will be completed for each infection and statistics compiled and reported on the monthly Risk Management Report. (Report the infection on the month that the individual infection was discovered/reported, not the month in which the date or surgery occurred. 6. APPLICABLE FORMS. 6.1 Post-Operative Infection Report 6.2 Post-Operative Infection Trend. Page 2 of 3 6.3 Sterilization Report. 6.4 Post-Operative Infection Summary. 7. REFERENCES. 7.1 Risk Management Policy. Page 3 of 3
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