Infection Control Program Policy # 0126
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.
2.1 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
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.,
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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
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.
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6.3 Sterilization Report.
6.4 Post-Operative Infection Summary.
7.1 Risk Management Policy.
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