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                                 Reid Hospital & Health Care Services
                                      Infection Control Manual
Table of Contents
Organization & Administration..........................................................................................4
  INFECTION CONTROL SCOPE OF SERVICES ....................................................................... 4
  HOSPITAL INFECTION CONTROL COMMITTEE SURVEILLANCE .............................................. 8
  CURRENT STATS ............................................................................................................ 9
Patient Surveillance .........................................................................................................9
  REPORTING OF COMMUNICABLE DISEASES TO THE PUBLIC HEALTH DEPARTMENT ............ 15
Infection Prevention .......................................................................................................16
  BODY SUBSTANCE ISOLATION ........................................................................................ 16
STOP SIGN ISOLATION FOR AIRBORNE COMMUNICABLE DISEASES ..................20
  CHICKENPOX EXPOSURE MANAGEMENT ......................................................................... 30
  MENINGOCOCCAL EXPOSURE MANAGEMENT................................................................... 31
  MANAGEMENT OF INTRAVASCULAR CATHETERS/ VASC COMMITTEE.................................. 32
  VISITOR POLICY FOR INFECTION CONTROL...................................................................... 32
  ANIMALS IN THE HOSPITAL ..................................................................................... 33
Occupational Medicine....................................................................................................28
  OCCUPATIONAL MEDICINE SERVICES SCOPE OF CARE .................................................... 34
  OCCUPATIONAL MEDICINE SERVICES SUMMARY .............................................................. 36
  WORK RESTRICTIONS FOR COMMUNICABLE DISEASES .................................................... 37
  MANAGEMENT OF BLOOD/BODY SUBSTANCE EXPOSURE ................................................. 40
Enviroment of Care ........................................................................................................40
  MATRIX OF PRECAUTIONS FOR CONSTRUCTION & RENOVATION ....................................... 41
  ENVIRONMENTAL SANITATION FOR INFECTION CONTROL ................................................. 44
  WASTE HANDLING: ....................................................................................................... 45
  CONTAINING, TRANSPORT AND DISPOSAL OF POTENTIALLY INFECTIOUS WASTE................ 45
  LAUNDRY HANDLING ..................................................................................................... 46
Disinfection & Sterilization..............................................................................................47
  CLEANING, DISINFECTION AND STERILIZATION OF PATIENT CARE EQUIPMENT ....................... 47
  TABLE 1: REPROCESSING OF MEDICAL DEVICES AND PATIENT CARE ITEMS ............................ 49
  MICROBIOLOGICAL SAMPLING ........................................................................................ 53
  TOY CLEANING ............................................................................................................. 53
Bloodborne Pathogens Exposure Control Plan ..............................................................42
  INTRODUCTION ........................................................................................................ 42
  EXPOSURE DETERMINATION...................................................................................42
  METHODS OF COMPLIANCE................................................................................................42
  BODY SUBSTANCE ISOLATION: ......................................................................................... 43
  ENGINEERING AND WORK PRACTICE CONTROLS ................................................ 44




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   Needle / Sharps Management ................................................................................. 44
   Safer Medical Devices............................................................................................. 45
   Handwashing .......................................................................................................... 46
   Mucous Membrane Exposure Prevention ............................................................... 46
   Transporting Laboratory Specimens ....................................................................... 46
   Equipment Servicing and Maintenance ................................................................... 46
   PERSONAL PROTECTIVE EQUIPMENT ............................................................... 46
   Gloves ..................................................................................................................... 47
   Protective Clothing .................................................................................................. 47
   Facewear ................................................................................................................ 47
   WORKSITE CONDITIONS ...................................................................................... 47
   Routine Environmental Cleaning and Disinfection .................................................. 47
   Spill Clean-up .......................................................................................................... 47
   Laundry ................................................................................................................... 47
   Waste Management ................................................................................................ 48
 HEPATITIS B VACCINATION ............................................................................................ 49
 POST-EXPOSURE EVALUATION AND FOLLOW -UP..............................................................49
   COMMUNICATION OF HAZARDS..........................................................................49
   BIOHAZARD SIGNS AND LABELS.........................................................................49
   TRAINING ............................................................................................................... 62
 APPENDIX 1:.............................................................................................................. 64
WASTE SEPARATION AND DISPOSAL..................................................................51,52
APPENDIX 2: CONTENT OUTLINE OF TRAINING.....................................................53
Reid Hospital Tuberculosis Exposure Control Plan...................................................54,61
 INTRODUCTION ............................................................................................................
 PERIODIC ASSESSMENT AND EXPOSURE DETERMINATION ....................................................
 METHODS OF COMPLIANCE ...............................................................................................
   Administrative Controls ...............................................................................................
   Engineering Controls ...................................................................................................
   Personal Respiratory Protection ..................................................................................
 POST EXPOSURE EVALUATION & FOLLOW -UP......................................................................
   APPENDIX 3:SCREENING FOR TUBERCULOSIS AND TUBERCULOSIS ..........62
                     INFECTION IN HIGH RISK POPULATIONS .................................... 62
   APPENDIX 4: PATIENT SCREENING LEVELS ..................................................... 63
   APPENDIX 5: GUIDELINES FOR INITIATION OF TB ISOLATION ........................ 64
   APPENDIX 6:GUIDELINES FOR DISCONTINUATION OF TB ISOLATION .......... 65
   APPENDIX 7: Respiratory Tuberculosis Isolation Room Negative
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            Pressure Monitoring ......................................................................... 66
APPENDIX 8: TB Management during a Code Blue............................................................67
APPENDIX 9: TUBERCULOSIS EXPOSURE MANAGEMENT .............................. 68
APPENDIX 10: N-95 Respirator Use at Reid Hospital ............................................ 69
APPENDIX 11: Outline for General Tuberculosis Education and Training .............. 92
APPENDIX 12: Resources for Consultation and Additional Information.................. 72
APPENDIX13: Infection Control Program Plan.........................................................73
APPENDIX14: Infection Control Risk Assessment..............................................78, 79
           Signature Page..................................................................................81




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                                                          Organization & Administration


                                                         Infection Control Scope of Services
The Infection Control Committee provides direction and oversight for the Infection Control Program (Infection Control Program Plan: Appendix 11). The
Infection Control Department is responsible for the development and coordination of the program. The Infection Control staff work in consultation with the
VP/CNO, and the Microbiologist and are directly supervised by the Chair of the Infection Control Committee.

Primary functions of the Infection Control Committee include:
 Infection Control Risk Assessment (Appendix 12) of facility and program needs.
 Development and implementation of infection control policies and procedures.
 Evaluation of surveillance information, infection prevention and control measures.
 Participation in accreditation and regulatory activities related to infection monitoring, prevention and control.
 Liaison with Occupational Medicine, Risk Management, Critical Care Council, Quality Department, Emergency Management,
    Environment of Care Guidelines, Clinical Valve Analysis Committee, and Safety Committees regarding infection control
    aspects.

Primary functions of the Infection Control Department include:
                                                                                   Internal
   Monitoring rates of hospital acquired infections (HAI’s) (nosocomial) and marker organism transmission.
   Identifying risk factors for HAIs.
   Participating in implementation of strategies to reduce the risk of hospital acquired infections to patients, visitors, healthcare providers, students, volunteers and
    others at the medical center.
   Infection Control and the Microbiology Department identify and investigate unusual clusters, exposures, or outbreaks of infectious diseases.
   Providing education, training and consultation to hospital staff on infection control and epidemiology.
   Acting as liaison with the units, clinics, departments and joint-venture services regarding infection control.
   Interacting routinely with Occupational Medicine, Risk Management, Quality Department, Environment of Care Guidelines, Product Evaluation, and Safety staff.
   Acts as a consultant to the Emergency Management Committee on issues concerning pandemics, weapons of mass destruction, bioterrorism, and the Infection
    Control Practitioner also serves as the Bioterrorism Coordinator for the hospital, etc.

                                                                                   External
   Liaison with the Public Health Department(s) regarding communicable diseases.
   Liaison to the Indiana District 6 (BT-6) Hospital Group.
   Liaison to the Wayne County Emergency Management Agency.
   Member of the Local Long-Term Care Infection Control Group.
   Networks and consults with infection control professionals at other facilities.
   Participates in infection control professional organization activities ( National APIC, APIC Indiana, Ohio APIC).
   Provides public education regarding infection control as needed.
   Participates in legislative activities that pertain to infection control.
   Contributes to research and share results in abstracts, publications, presentations (VHA Central).
   Attend annually the Association of Infection Control Professionals National Education Conference.

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                                                         HOSPITAL INFECTION CONTROL COMMITTEE

Purpose
At Reid Hospital, hospital wide infection control is a safety and quality assurance activity. The goal of the Hospital Infection Control Committee is to identify
and reduce the risks of acquiring and transmitting infections among patients, employees, physicians, other practitioners, contract workers, volunteers,
students, and visitors.

Function
A major function of the Committee is the review of infection control principles and practices for all hospital personnel. Other functions include reviewing trends
and other analyses of hospital acquired (nosocomial) infections and marker organism transmissions and advising on appropriate interventions; investigations
of outbreaks of infection; identification of patients at special risk for infection, and intervention, if possible, to prevent infection. The Committee approves the
type and scope of surveillance; approves actions to prevent or control infection based on surveillance reports of infections or exposures among patients or
staff; and reviews and approves policies and procedures related to infection and surveillance, prevention and control activities in the hospital. The Committee
also assists in the formulation and evaluation of policies and procedures governing the Occupational Medicine Department regarding exposures and
communicable diseases among employees.

Membership
The Hospital Infection Control Committee is appointed annually by the Infection Control Practitioner and includes representatives from the major departments,
i.e., Medicine, Surgery, Operating Room, Patient Care Services, Pharmacy, Laboratory, Quality Improvement, Risk Management, Administration,
Occupational Medicine and other representatives as needed and on a consultative basis.

Authority
In situations concerning communicable diseases, the Committee, through its chairperson, Infection Control Practitioner, administration and physician
members, has the authority to institute any appropriate control measures or studies when there is reason to believe that a danger exists to patients or
personnel. This authority and responsibility is understood and approved by the Medical Staff and Hospital Administration through the Medical Executive Board
of the hospital.


                                               INITIATION OF EMERGENCY INFECTION CONTROL MEASURES

POLICY: When there is a reasonable certainty of a contagious disease representing a danger to patients, visitors, or to hospital personnel, the Hospital
Infection Control Committee shall have the authority to institute appropriate infection control measures and evaluations.

PURPOSE: To protect patients, visitors, and hospital personnel from the hazards of infectious diseases acquired from others or the hospital environment.

IMPLEMENTATION: Identification and Reporting of the Hazard:
   1. The recognition and designation of patients with an infectious disease which might pose a threat to other patients, visitors, or hospital employees is
      the responsibility of personnel including physicians and nursing personnel responsible for the care of the patient.
   2. The INFECTION CONTROL MANUAL contains the criteria definitions and appropriate preventive measures. These are ordinarily initiated by the
      responsible physician, and/or on the advice of the Infection Control Practitioner or Chair of the Infection Control Committee.
   3. The Infection Control Practitioner is to be notified if there is a question of potential infectious hazard to patients, visitors, or hospital workers existing in
      the hospital environment.


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Initiation of Control Measures:
     1. The Chair of the Hospital Infection Control Committee and the Infection Control Practitioner render a judgment of whether such a hazard of potential
         danger is present.
     2. The existence of the infectious hazard and potential danger is discussed with involved physicians, nursing and other personnel.
     3. In this emergency situation, the Hospital Infection Control Committee, through the Chair and the Infection Control Practitioner, shall authorize and
         supervise initiation of the appropriate procedures to protect other patients and hospital personnel.



Initiation of Appropriate Evaluation:
     1. Measures to define the extent of the problem or to evaluate control procedures may include microbiologic studies of patients, hospital personnel, or
         the hospital environment.
     2. The Hospital Infection Control Committee, represented by the Chair and the Infection Control Practitioner shall have the authority to initiate
         appropriate studies.
     3. Costs of the studies mentioned above are the responsibility of the institution and not individual patient charges.


                                                       REID HOSPITAL & HEALTH CARE SERVICES
                                                      INFECTION CONTROL COMMITTEE MEMBERS


                                                        Infection Control Chair: William Black Jr., MD
                                                          Infection Control Practitioner: Greg Carter

Members                                  Representation
Jennifer Longnecker                      OR/ Surgery/PACU
Rhonda Lancaster                         Microbiology
Marilee Crosby                           Quality Improvement/Organizational Improvement
Amy Strain                               Infection Control Data Specialist
Angie Lake PharmD.                       Pharmacy
Vickie Bryant                            Environmental Services
Becky Stewart                            Occupational Medicine
Allyson Harrell                          Critical Care
Nancy Seal                               Emergency Department
Kay Cartwright                           Administration VP/CNO
Luanne Christofaro                       Outpatient Center
Christopher Neher, MD                    Orthopedic Surgery
Rhonda Matson                            Education
Jerry Swango                             Engineering
Annette Saylor                           Mother/Baby
Patti Graham                             Outpatient Surgery Center, Infection Control/Quality
Don Day                                  Oncology Unit
Kathy Stephens                           Respiratory Therapy
Trish Friedman                           Administrative Coordinator

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Ad hoc Members    Department
Jo Hill           Radiology
Jennifer Ehlers   Administration/Risk Management




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                                                       Hospital Infection Control Committee Surveillance

Surveillance is the systematic collection and analysis of information about hospital acquired infections, and dissemination of the results of the monitoring to
those who need to know. The purpose of monitoring is to determine various endemic rates of hospital acquired infections so that increases above that level
(epidemic) can be identified and investigated, and appropriate prevention strategies can be initiated.
The monitoring programs at Reid Hospital may include comprehensive surveillance for limited periods of time or targeted surveillance to describe infection
risk related to high-risk procedures, patient populations or locations within the hospital. Previous experience at Reid Hospital indicates that targeted
surveillance provides more useful information than attempts at a total surveillance program. Certain infections, e.g., bacteremias, or certain pathogens, e.g.,
MRSA, VRE, C.difficile may be monitored regularly.
The case finding methodology is laboratory-based surveillance combined with ward rounds, consultation with microbiology, incident reports and reports from
services, units, departments or clinics.
Data quality is insured by careful establishment of interrater reliability among the reviewers and by controlled re-review of a test population periodically.
Surveillance is the responsibility of the Infection Control Practitioner and staff, with the assistance and supervision of the Chair of the Infection Control
Committee.
Results of monitoring are reported periodically to the Infection Control Committee and to other departments or committees as indicated.

                                                              Infection Control Risk Analysis (ICRA)
Reid Hospital is a regional medical center providing a wide variety of services to vulnerable populations. The facilities are privately owned and governed by a
board of directors, which employs all the staff. Reid Hospital is a primary teaching site for nursing and radiology students from Reid Hospital, IUE and Ivy
Tech Health Sciences programs. Reid Hospital Services include:
       Level II adult and pediatric trauma center serving Wayne County Indiana and surrounding counties of East Central Indiana and West Central Ohio.

       Comprehensive health-care, providing high quality, state-of-the-art advanced health care for people from all walks of life including:

            o    Persons incarcerated in the Wayne County Jail

            o    Mentally ill patients, particularly those treated voluntary and involuntarily

            o    Persons with sexually transmitted diseases

            o    Substance abusers

            o    Indigents without third-party coverage

            o    Non-English speaking poor

            o    Victims of domestic violence

            o    Victims of sexual assault

       Clinical care for all patients.




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Current Stats

       Licensed beds: 235

       Employees: 1389

       Physicians: 135

       Average occupancy rate 64 percent in 2006.

       More than 54,000 Emergency Department visits in 2006.

       More than 12,444 inpatient admissions in 2006.

       87,000 outpatient visits in 2006.


Surveillance Background and Activities

Patient Surveillance
Outcome Surveillance: Infection

From 2000-2005, nosocomial surveillance was house-wide that were identified in the five years of comprehensive surveillance that concluded in 2005. This
surveillance scope included:
    1. All surgeries

    2. Infections from positive intravascular tip cultures;

    3. Bacteremias;

From 2006 to current, the scope of surveillance changed to include more detailed risk factors which included the 100K Lives Campaign and Centers for
Medicare/Medicaid (CMS) indicators; ventilator associated pneumonia in ICU patients (prevention strategies in the CDC nosocomial pneumonia prevention
guidelines were implemented), central-line bacteremia associated infections in all inpatients, foley catheter related urinary-tract infections in all patients. In
2006, reporting of surgery infections become more focused targeting high-volume high-risk cases (orthopedics), low-volume high-risk cases (Open-Heart). All
surgery infections were still looked at for trends and analysis. Post-discharge surgical surveillance began with 100% surgeon compliance. New tracking
forms were implemented to track all the infections by infection control and microbiology. The new form for tracking surgical infections, Central-line infections,
Foley-related UTI’s, ventilator-associated pneumonia, PICC-line infections, C-section infections, Nursery infections, and others was a spread sheet which
showed, at a glance, monthly rates, year-to-date rates, including Reid internal benchmark rates and national benchmark rates (NNIS) for comparison
purposes.

In the fall of 2006, spinal surgical wound infections were monitored and determined to be above the published CDC NNIS rates; Root cause analysis
determined the need to change skin prep and prep technique. Spinal surgical wound infections were again surveyed first quarter of 2007, and the results
indicated a rate below the CDC NNIS rates. Monitoring of surgical wound infection prevention practices are ongoing and include CMS indicators for
perioperative antibiotic prophylaxis administration.

Process Surveillance: Marker Organisms
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Marker organism surveillance was initiated at Reid Hospital in 2005 as an indicator of transmission risk for various categories of bacteria (gram positive, gram
negative, fungal). Marker organisms are generally unique or resistant versions of organisms that cause nosocomial infections in hospitalized patients.
Marker organisms surveyed have included colonization or infection at any site with the organism’s Methicillin-resistant Staphyloccus aureus (MRSA),
Vancomycin resistant Enterococcus (VRE), Clostridium difficile, or other resistant gram-negative rods. MRSA study at Reid Hospital and elsewhere have
identified organisms such as MRSA are likely to be acquired in a community setting; they are almost always considered to be nosocomial transmitted though.
The MRSA study began October of 2006 and will conclude October 2007. Before October 2006, Reid Hospital was averaging 2-4 MRSA nosocomial
infections per month, after the MRSA protocol was implemented not one nosocomial MRSA infection for the first five months and to date eight months later,
only one nosocomial MRSA infection has occurred. MRSA rates are published on the infection control intranet page under MRSA for all to review.



                                                                           Gram positive

Vancomycin resistant Enterococcus (VRE) monitoring began in late 1995. VRE positive patients are placed in an electronic database and on each
readmission placed in Contact isolation. VRE surveillance has continued to the present and is reported every other month at Infection Control Committee
meeting.

Clostridium difficile (C. diff) monitoring began in 2004. Known or suspected C. difficile patients are placed in Enteric and Contact Isolation using strict barrier
precautions and Handwashing is with soap and water only. The use of alcohol based hand sanitizers are not recommended for C. difficile cases.




                                                                              Fungal

Aspergillus monitoring is as needed as an indicator of environmental risk of nosocomial infection, especially related to renovation or construction activities and
highly compromised patients such as those with burns, major trauma, cancer, and HIV/AIDS. It will be monitored in preparation for and during the first year’s
habitation of the New Reid Hospital.

Process Surveillance: Hand Hygiene

Following publication of the CDC Hand Hygiene guidelines, surveillance of hand hygiene practices at Reid Hospital was initiated. Historical reference was
available from monitoring soap and hand sanitizer usage observations between 2000 -2005. With new evidence-based and best practice research Reid
Hospital initiated a peer-review staff monitoring survey form on hand hygiene in 2006 and current. The monitoring form includes surveillance by discipline and
by units/departments. Reid Hospital accepted this implementation as a national safety goal. By so doing, increased selection and placement of alcohol gel
sanitizer dispensers throughout the organization with input from staff and physicians on strategic locations. Monitoring is ongoing monthly with greater than
2500 observations per month. Within the first seven months of implementation Reid Hospital was able to show as hand hygiene compliance improved
infection rates decreased. For the last 12 months, to date, Reid Hospital has been in the green light status with greater than 90% hand hygiene compliance.

Staff Surveillance

Monitoring of staff for exposures is provided by Occupational Medicine and is reported every other month to the Infection Control Committee and monthly to
Employee Safety Committee and to other groups as needed.




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Cases of tuberculosis in patients and inadvertent employee exposures, results of tuberculosis screening in employees, blood/body fluid exposures and
outcomes have been monitored and reported at least monthly by Occupational Medicine. No known TB conversions from exposures have occurred at Reid
Hospital since 2004.

Surveillance of staff for other infectious diseases is coordinated between Occupational Medicine and Infection Control as the need arises. Examples of this
type of monitoring include mumps, C. difficile, influenza and influenza vaccination rates.

Disaster and other Public Health Surveillance

Bioterrorism related syndromic surveillance is ongoing.

By summer 2005, data based syndromic surveillance was established and is monitored continuously by infection control. Infection Control notifies Wayne
County Indiana Public Health of specific patient conditions or clusters that exceed established criteria or thresholds, and subsequent investigations are
coordinated between these groups as needed.

Reid Hospital provides communicable disease reporting, identified by the Public Health Department in the state of Indiana, monitoring of communicable
diseases is an ongoing surveillance activity and a data base is electronically stored by Reid Hospital Privacy Officer.

Infection Control Program Evaluation
In late 2005, an infection control survey was sent out to all areas as an organizational improvement initiative This initiative has provided additional
surveillance support, primarily through increased development of computer technology for automated surveillance in comparison of organism susceptibility
and antibiotic prescribing trends. In early 2006 a review of the overall Infection Control Program was begun to determine the efficiency and adequacy of
resources in relation to increased needs within and external to Reid Hospital. From the evaluation and review a 0.4 FTE was hired as an Infection Control
Data Input Specialist, 0.2 FTE was hired for clerical support. The beginning of 2007 saw the implementation of the first Infection Control interactive Intranet
Site.


                                                        DEFINITIONS OF NOSOCOMIAL INFECTIONS


In general, CDC Definitions for Nosocomial Infections are used to classify healthcare acquired infections. These definitions comprise 13 major categories and
48 specific sites. The 13 major infection categories cover urinary tract infection; surgical site infection; pneumonia; bloodstream infection; bone and joint
infection; central nervous system infection; cardiovascular system infection; eye, ear, nose, throat, or mouth infection; gastrointestinal system infection; lower
respiratory tract infection other than pneumonia; reproductive tract infection; skin and soft tissue infection; and systemic infection.

The definitions for the most frequently occurring sites of infection—urinary tract, surgical site, pneumonia, and bloodstream infections--- in hospitalized
patients are listed below. Colonization or inflammation is not classified as nosocomial infection. In some instances a specific definition related to a protocol
may be used. These definitions are provided in reports with findings. Classification of infections is for epidemiologic purposes and is not intended to define
clinical disease or to make therapeutic decisions.

For more information on nosocomial definitions and the National Nosocomial Infections Surveillance System reports visit the CDC National Center for
Infectious Diseases Division of Healthcare Quality Promotion web address:
http://www.cdc.gov/ncidod/dhqp/nnis_pubs.html



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Preventability or inevitability of an infection is not a consideration when determining whether it is hospital acquired. Surveillance definitions are not intended
to define clinical disease for the purpose of making therapeutic decisions. Some true infections will, therefore, be missed while other conditions may
erroneously be counted as infections.

Urinary Tract Infections
A symptomatic urinary tract infection must meet at least one of the following criteria:
     Patient has at least one of the following signs or symptoms with no other recognized cause: fever (>38 C), urgency, frequency, dysuria, or
       suprapubic tenderness and patient has a positive urine culture, that is, 10 microorganisms per cm or urine with no more than two species of
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       microorganisms.
     Patient has at least two of the following signs or symptoms with no other recognized cause: fever (>38 C), urgency, frequency, dysuria, or
       suprapubic tenderness and at least one of the following:
           1. positive dipstick for leukocyte esterase and/or nitrate
           2. pyuria (urine specimen with  10 wbc/mm or 3 wbc/high power field of unspun urine)
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           3. organisms seen on Gram stain of unspun urine
           4. at least two urine cultures with repeated isolation of the same uropathogen (gram-negative bacteria or S. saprophyticus) with 10 colonies/ml
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                in nonvoided specimens
           5. 10 colonies/ml of a single uropathogen (gram-negative bacteria or S. saprophyticus) in a patient being treated with an effective
                    5

                antimicrobial agent for a urinary tract infection
           6. physician diagnosis of a urinary tract infection
           7. physician institutes appropriate therapy for a urinary tract infection.
     Patient 1 year of age has at least one of the following signs or symptoms with no other recognized cause: fever (> 38 C), hypothermia (<37 C),
       apnea, bradycardia, dysuria, lethargy, or vomiting and patient has a positive urine culture, that is, 10 microorganisms per cm of urine with no more
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       than two species of microorganisms.
     Patient  1 year of age has at least one of the following signs or symptoms with no other recognized cause: fever (>38 C), hypothermia (<37 C),
       apnea, bradycardia, dysuria, lethargy, or vomiting and at least one of the following:
           1. positive dipstick for leukocyte esterase and/or nitrate
           2. pyuria (urine specimen with  10 wbc/mm or 3 wbc/high power field of unspun urine)
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           3. organisms seen on Gram stain of unspun urine
           4. at least two urine cultures with repeated isolation of the same uropathogen (gram-negative bacteria or S. saprophyticus) with 10 colonies/ml
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                in nonvoided specimens
           5. 10 colonies/ml of a single uropathogen (gram-negative bacteria or S. saprophyticus) in a patient being treated with an effective
                    5

                antimicrobial agent for a urinary tract infection
           6. physician diagnosis of a urinary tract infection
           7. Physician institutes appropriate therapy for a urinary tract infection.

Asymptomatic bacteriuria
An asymptomatic bacteriuria must meet at least one of the following criteria:
     Patient has had an indwelling urinary catheter within 7 days before the culture and patient has a positive urine culture, that is, 10 microorganisms
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              3
       per cm of urine with no more than two species of microorganisms and patient has no fever (>38 C), urgency, frequency, dysuria, or suprapubic
       tenderness.
     Patient has not had an indwelling urinary catheter within 7 days before the first positive culture and patient has no fever (>38 C), urgency, frequency,
       dysuria, or suprapubic tenderness.



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Other infections of the urinary tract
Other infections of the urinary tract must meet at least one of the following criteria:
    Patient has organisms isolated from culture of fluid (other than urine) or tissue from affected site.
    Patient has an abscess or other evidence of infection seen on direct examination, during a surgical operation, or during a histopathologic
        examination.
    Patient has at least two of the following signs or symptoms with no other recognized cause: fever (>38 C), localized pain, or localized tenderness at
        the involved site and at least one of the following:
             1. purulent drainage from affected site
             2. organisms cultured from blood that are compatible with suspected site of infection
             3. radiographic evidence of infection, e.g., abnormal ultrasound, CT scan, magnetic resonance imaging (MRI), or radiolabel scan (gallium,
                 technetium)
             4. Physician diagnosis of infection of the kidney, ureteer, bladder, urethra, or tissues surrounding the retroperitoneal or perinephric space.
             5. Physician institutes appropriate therapy for an infection of the kidney, ureter, bladder, urethra, or tissues surrounding the retroperitoneal or
                 perinephric space.
    Patient 1 year of age has at least one of the following signs or symptoms with no other recognized cause: fever (>38 C), hypothermia (<37 C),
        apnea, bradycardia, lethargy, or vomiting and at least one of the following:
             1. purulent drainage from affected site
             2. organisms cultured from blood that are compatible with suspected site of infection
             3. radiographic evidence of infection, e.g., abnormal ultrasound, CT scan, magnetic resonance imaging (MRI), or radiolabel scan (gallium,
                 technetium)
             4. physician diagnosis of infection of the kidney, ureter, bladder, urethra, or tissues surrounding the retroperitoneal or perinephric space
             5. Physician institutes appropriate therapy for an infection of the kidney, ureter, bladder, urethra, or tissues surrounding the retroperitoneal or
                 perinephric space.

Surgical site infection
A superficial SSI must meet the following criterion: Infection occurs within 30 days after the operative procedure and involves only skin and subcutaneous
tissue of the incision and patient has at least one of the following:
     1. purulent draining from the superficial incision
     2. organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision
     3. at least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat, and superficial incision is
         deliberately opened by surgeon, unless incision is culture-negative
     4. Diagnosis of superficial incisional SSI by the surgeon or attending physician.
The following are not counted as superficial surgical site infections:
      a stitch abscess (minimal inflammation and discharge confined to the points of suture penetration) as an infection
      a localized stab wound infection
      An infected burn wound. The incisional site infection involves or extends into the fascial and muscle layers (report as a deep incisional SSI).
      The infection involves both superficial and deep incision sites (report as a deep incisional SSI)

Deep incisional SSI
A deep incisional SSI must meet the following criterion:
Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to
be related to the operative procedure and involves deep soft tissues (e.g., fascial and muscle layers) of the incision and patient has at least one of the
following:
     1. Purulent drainage from the deep incision but not from the organ/space component of the surgical site.

                                                                                                                                                                      13
                                                                                                                                                          14
    2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms:
       fever (>38 C), or localized pain or tenderness, unless incision is culture-negative.
    3. an abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or
       radiologic examination
    4. diagnosis of a deep incisional SSI by a surgeon or attending physician

Surgical site infection (Organ/space)
An organ/space SSI involves any part of the body, excluding the skin incision, facia, or muscle layers, that is opened or manipulated during the operative
procedure. An organ/space SSI must meet the following criterion:
Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to
be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or
manipulated during the operative procedure and patient has at least one of the following:
    1. purulent drainage from a drain that is placed through a stab wound into the organ/space
    2. organisms isolated from an aseptically obtained culture or fluid or tissue in the organ/space
    3. an abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or
          radiologic examination
    4. diagnosis of an organ/space SSI by a surgeon or attending physician
Occasionally an organ/space infection drains through the incision. Such infection is considered a complication of the incision. Therefore, it is classified as a
deep incisional SSI.
The following are specific sites of an organ/space SSI:
Osteomyelitis, breast abscess or mastitis, myocardit’s or pericarditis, disc space, ear, mastoid, endometritis, endocarditis, eye (other than conjunctivitis), GI
tract, Intraabdominal (not specified elsewhere), intracranial (brain abscess or dura), joint or brusa, other infections of the lower respiratory tract, mediastintis,
meningitis (or bentriculitis), Oral cavity (mouth, tongue, or gums), other male or femal reproductive, other infections of the urinary tract, spinal abscess without
meningitis, sinusitis, upper respiratory trac (pharyngitis), arterial or venous infection, and vaginal cuff.

Pneumonia
Pneumonia must meet at least one of the following criteria:
    Patient has rales or dullness to percussion on physical examination of the chest and at least one of the following:
          1. new onset of purulent sputum or change in character of sputum
          2. organisms cultured from blood
          3. isolation of an etiologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy
    Patient has a chest radiographic examination that shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion and at least one of
      the following:
          1. new onset of purulent sputum or change in character of sputum
          2. organisms cultured from blood
          3. isolation of an etiologic agent from a specimen obtained by transtrachael aspirate, bronchial brushing, or biopsy
          4. isolation of virus from or detection of viral antigen in respiratory secretions
          5. diagnostic single antibody titer (lgM) or fourfold increase in paired sera (lgG) for pathogen
          6. Histopathologic evidence of pneumonia.
    Patient  1 year of age has at least two of the following signs or symptoms: apnea, tachypnea, bradycardia, wheezing, rhonchi, or cough and at least
      one of the following:
          1. increased production of respiratory secretions
          2. new onset of purulent sputum
          3. organisms cultured from blood or diagnostic single antibody titer (lgM) or fourfold increase in paired sera (lgG) for pathogen
          4. isolation of an etologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy
                                                                                                                                                                   14
                                                                                                                                                                  15
             5. isolation of virus or detection of viral antigen in respiratory secretions
             6. histopathology evidence of pneumonia
    Patient  1 year of age has a chest radiologic examination that shows new or progressive infiltrate, cavitation, consolidation, or pleural effusion and at
        least one of the following:
             1. increased production of respiratory secretions
             2. new onset of purulent sputum or change in character of sputum
             3. organisms cultured from blood or diagnostic single antibody titer (lgM) or fourfold increase in paired sera (lgG) for pathogen
             4. isolation of an etiologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy
             5. isolation of virus from or detection of viral antigen in respiratory secretions
             6. histopathology evidence of pneumonia
Expectorated sputum cultured is not useful in the diagnosis of pneumonia but may help identify the etiologic agent and provide useful antimicrobial
susceptibility data. Findings from serial chest x-rays may be more helpful than a single x-ray.

Laboratory-confirmed bloodstream infection
Laboratory-confirmed bloodstream infection must meet at least one of the following criteria:
      Patient has a recognized pathogen cultured from one or more blood cultures and organism cultured from blood is not related to an infection at another
          site.
      Patient has at least one of the following signs or symptoms: fever (>38, C), chills, or hypotension and at least one of the following:
               1. Common akin containment (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or morococci) is
                   cultured from two or more blood cultures drawn on separate occasions.
               2. common skin contaminate (e.g., diphtheroids, Bacillus sp., Propinobacterium sp., coagulase-negative staphylococci, or micrococci) is
                   cultured from at least one blood culture from a patient with an intravascular line, and the physician institutes appropriate antimicrobial therapy
               3. Positive antigen test on blood (e.g., H. influenzae, s. pneumoniae, N. menigitidis, or group B Streptococcus) and signs and symptoms and
                   positive laboratory results are not related to an infection at another site.
      Patient  1 year of age has at least one of the following signs or symptoms: fever (>38 C), hypothermia (<37 C), apnea, or bradycardia and at least
          one of the following:
               1. common skin containment (e.g., diphtheroids, Bacullus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is
                   cultured from two or more blood cultures drawn on separate occasions
               2. common skin contaminant (e.g., diphtheroids, Bacullus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is
                   cultured from at least one blood culture from a patient with an intravascular line, and physician institutes appropriate antimicrobial therapy
               3. Positive antigen test on blood (e.g., H. influenzae, S. pneumoniae, N. meningitides, or group B Streptococcus) and signs and symptoms and
                   positive laboratory results are not related to an infection at another site.
Report purulent phlebitis confirmed with a positive semiquantitive culture of a catheter tip. Report organisms cultured from blood as BSI-LCBI when no other
site of infection is evident. Pseudobacteremias are not nosocomial infections.

Reference:
CDC Guidelines for Detecting and Classifying Nosocomial Infections by Systemic Sites


                                  Reporting Of Communicable Diseases to the Public Health Department

POLICY:
All reportable diseases listed by the Indiana State Department of Public Health must be reported as required by law
http://www.state.in.us/isdh/publications/comm_dis_rule.pdf when diagnosis is confirmed.
The attending physician or designee is responsible for reporting via one of two routes:
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                                                                                                                                                                    16
       directly to the Public Health Department
       Indirectly by contacting the Infection Control Department to initiate a report.

PROCEDURE:
   1. Confirm that the disease is reportable by checking the listing, "Reportable Diseases" located on the infection control intranet site under government
      links, Indiana Department of Health. Or call Reid Hospital microbiology department and/or the emergency department.
   2. Contact by telephone 3493, infection control. Be prepared to provide information on diagnosis verification, patient data, treatment and known
      contacts, if requested.
   3. Alternatively, contact the Administrative Coordinator if infection control is unavailable, by dialing (o) for hospital operator and asking for the
      Administrative Coordinator/Nursing Supervisor or if you know their pager number via the paging system with the same information ready.



                                                      QUARANTINE POLICY FOR INFECTIOUS DISEASES

If a patient with active tuberculosis, not currently on treatment, states intent to leave or does leave the hospital, contact infection control and infection control
will alert the proper public health officials who will take proper action.




                                                                   Infection Prevention
                                                Body Substance Isolation and Transmission Based Precautions
                                                                          INTRODUCTION
For many years, "isolation" has been viewed as the cornerstone to a program of infection prevention and control. This concept was an outgrowth of the earlier
practice of placing patients with selected, diagnosed diseases in quarantine. However, in current hospital practice, we now know it is more reliable to provide
a high level of infection precautions for all patients, regardless of whether an infection has been diagnosed. This provides for prevention of infection.
Why is this? First of all, a system like the category isolation used in most hospitals is not initiated until the diagnosis of an infectious disease is suspected or
proven. The causative agent is always present in the affected body site or substance before the diagnosis is established. Thus, transmission may often occur
before isolation is begun.
Second, infectious diseases occur in a spectrum of forms, ranging from inapparent, unrecognized infection to mild, moderate or severe illness. Inapparent
infection may be clinically unrecognized, yet still be communicable. The higher incidence of serological markers for hepatitis B virus in health care workers
with frequent blood contact illustrates this point.
Third, isolation focuses on special techniques for only those body substances identified (cultured) as containing the infective agent. However, other
substances and sites are often handled without the awareness that they also may be colonized with the same microorganism. For instance, a patient with a
wound infected with Methicillin-resistant Staphylococcus aureus (MRSA) might also have the same organism in sputum, saliva, feces and on the skin.
Fourth, the majority of hospitalized patients with infection do not require "isolation" based on criteria in most guidelines. Yet, these infected or colonized
patients frequently serve as a source of microorganisms which are spread from them to other patients or personnel. The discrepancy between isolated and
non-isolated patients may give healthcare providers a false sense of security with non-isolated patients and promote a lesser standard of care.
                                                                             References:
Heymann DL, ―Control of Communicable Disease in Man‖, Am. Pub. Health Assoc., 18th ed., 2004.
Lynch P, Cummings MJ, Roberts PL, et al., Implementing and evaluating a system of generic infection precautions: Body substance isolation, Am J Infec
Control, 1990; 18:1-12.

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                                            ROOMMATE SELECTION FOR INFECTION PREVENTION
In an ideal world, every hospitalized patient would have a private room. However, in practice this does not always occur. These guidelines are provided as a
model for determining safe roommate combinations, which reduce the risk of transmission of organisms between patients and are most effective when
practiced with recommended body substance isolation barrier techniques. Personal hygiene, the ability to control body substances, is the most important
element to consider in roommate assignments. A patient may fit into more than one level. When placing a patient with a roommate, select the single highest
level that describes the patient.
L
E
V                  DEFINITION                                   EXAMPLES                   COMBINATIONS
E
L
  Patients making uneventful recovery from
  medical conditions, and who have no open         MI, diabetes, GI bleed, hypertension,   YES - 1,2,3
1
  skin sites, catheters, incontinence and who      ulcer disease, back pain                NO - 4
  do not fit into levels 2, 3, or 4
  *Oncology patients, preoperative patients
                                                   Cholecystectomy, appendectomy,
  and patients making uneventful recovery
                                                   orthopedic surgery, hysterectomy,
  from surgical procedures which entail no                                                 YES - 1,2
2                                                  vaginal deliveries, C-Section, chemo
  open drains, catheters or mechanical                                                     NO - 3,4
                                                   or radiation therapy, minor burns,
  respiratory assistance and who do not fit into
                                                   leukemia*, AIDS*
  levels 3 or 4
  Patients likely to be sources of large           Fecal/urinary incontinence, open
                                                                                           YES - 1
3 numbers of microorganisms, either infected       drains, major decubitus, extensive
                                                                                           NO - 2,3,4
  or colonized, and who do not fit into level 4    dermatitis, ventilator assistance
                                                   A) Measles, mumps, chickenpox,
                                                   rubella, pertusis, tuberculosis,
                                                   disseminated zoster, meningococcal
  A) Patients with communicable diseases
                                                   meningitis, plague, smallpox, SARS,
  spread through an airborne route or                                                      A) YES 4**
4                                                  diphtheria.
  B) Patients who consistently soil the                                                    B) NO 1,2,3,4
                                                   B) Major burns or containment of pus,
  environment with body substances
                                                   blood, urine, feces, sputum unable to
                                                   be accomplished by patient or
                                                   personnel
* Patients very susceptible to infections due to diminished responses such as post bone marrow transplant, AIDS or severe leukopenia may benefit from a
private room. "Protective/Neutropenic Isolation", the use of gown, gloves and masks are used at Reid Hospital to minimize and possibly reduce the incidence
of infection in compromised patients.

**Patients with the same airborne communicable disease may sometimes room together. For example, a patient with chickenpox may room with another
patient who has a history of chickenpox, herpes zoster, or has active varicella infection. Contact Infection Control at 3493 prior to placing patients with the
same airborne communicable disease together.

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                                                   BARRIER TECHNIQUES TO REDUCE INFECTION RISK
Most infection control situations are addressed in these general guidelines. These techniques are applied to all body substances from all patients, not only
those of patients with diagnosed infections since the presence of infectious organisms always precedes diagnosis. In general, contact with body substances
from patients, infected or uninfected, should be avoided. Gloves should be worn for all contacts with body substances, and when the amount or location of the
substance makes it difficult to keep clean, personnel should wear additional barriers to protect other body areas from contact. Hands are washed after gloves
and other barriers are removed.




PATIENT CONDITION              ALWAYS REQUIRES                      SOMETIMES REQUIRES
SPUTUM & ORAL                                                       Roommate restriction when pt or
SECRETIONS                                                          roommate has poor personal
    Suctioning (oral or       Wash hands after contact.            hygiene.*
      deep)                    Glove for sputum contact.
    coughing patients         Mask for suctioning/intubation.      Mask if pt is likely to cough or
                              Instruct pt in handwashing and       spit in your face, and you are within 3
    Intubation                disposal of sputum contained in      feet of the patient.
                               tissues.
                               Gown when soilage of clothing        Airborne Isolation/AFB Precautions
                               is likely.                           (STOP) if diagnosis of airborne
                                                                    communicable disease is
                                                                    suspected.**
LESION DRAINAGE                Wash hands after contact. Mask for
    open skin ulcers          water picking & working over large
    boils                     wounds.
    pustular lesions                                               Roommate restriction when drainage
    wounds                    Glove for contact with drainage or
                                                                    excessive or if patient or roommates
    wound infections          open wound.
                                                                    have poor personal hygiene.*
    open non-intact skin
    rashes                    Use "no touch" dressing technique.
                                                                    Special precautions for selected
    cellulitis                                                     patients with skin lesions that are
                               Gown when soilage of clothing
                                                                    manifestations of systemic infections
                               is likely
                                                                    such as chicken pox, measles, etc.**
                               .
                                                                    (See Infection Control intranet under
                               Bag soiled linen & dressings.
                                                                    Isolation for isolation placement
                                                                    guidelines)
                               Instruct pt in handwashing.

                               Cover draining wounds with
                               dressings.
URINE DRAINAGE                 Wash hands after contact.            Roommate restriction when patient or

                                                                                                                                                           18
                                                                                                                                                           19
                                 Glove for urine contact.                     roommate has poor personal
       urine incontinence       Use separate urine measurement               hygiene.*
       urinary fistula          devices for each patient.
       catheter drainage        Maintain sterile closed drainage
       specimen handling        system.
       output measure           Bag urine soaked linen & trash.
                                 Instruct pt in care of urine and
                                 handwashing.
 FECAL DRAINAGE                  Wash hands after contact.
      fecal incontinence        Glove for fecal contact.
                                                                        Roommate restriction when fecal
      ostomy drainage           Gown when soilage of clothing is
                                                                        soilage is excessive or if either patient
      gallbladder drainage likely.                                     or roommate has poor personal
      diarrhea due to any Bag heavily soiled linen & trash.            hygiene.*
         cause                   Instruct pt in care of feces and
                                 handwashing.
 BLOOD                           Wash hands after contact.
      GI bleeding               Glove for blood contact
                                                                        Roommate restriction when soilage is
      Serosanguinous            Gown when soilage of clothing
                                                                              excessive or if patient or
         drainage                is likely.
                                                                              roommate has poor personal
      CPR                       Bag bloody linen & trash.
                                                                              hygiene.*
      hemoptysis                Instruct patient in care of bloody
                                 discharge and handwashing.
 OTHER BODY                      Wash hands after contact.
 SUBSTANCES                      Glove for body substance contact.
      peritoneal fluid          Gown when soilage of clothing          Roommate restriction when soilage is
      vaginal discharge         likely.                                      excessive or if patient or
      joint fluid               Bag soaked or heavily soiled linen           roommate has poor personal
      CSF                       & trash.                                     hygiene.*
                                 Instruct patient in care of body
                                 substances and handwashing.
 COMPROMISED
 PATIENTS
                                                                        ***private room:
      Bone marrow
                                 Body Substance Isolation               Patients very compromised may
         transplant
                                                                              benefit from a private room.
      Leukemia
      AIDS
*PERSONAL HYGIENE: Personal hygiene is considered good if the patient does not consistently soil the environment with body substance, does cover the
mouth and nose when coughing and washes hands after soiling them. In seriously ill patients, the management of body substances is performed by
personnel; if body substances cannot be contained by the patient or personnel, consider the patient to have poor personal hygiene and restrict roommates
when indicated.
** See Isolation Signs section on the Infection Control Intranet for airborne communicable diseases & Tuberculosis Exposure Control Plan.
***Protective Isolation, the use of gowns, gloves and masks to enter a patient room is recommended at Reid Hospital.



                                                                                                                                                           19
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                                                ISOLATION FOR AIRBORNE COMMUNICABLE DISEASES:
                                                                          Isolation Sign
Whenever patients are believed to have diseases transmitted in whole or in part by the airborne route, they should be placed in "STOP Sign Isolation." A
STOP sign alert card is placed on the patient's door, the patient is placed in a private room or with an immune roommate, and all personnel or visitors must
check with the nurse before entering. The nurses are responsible for determining the immune status of persons wishing to enter the room. The nurses are
also responsible for instructing persons to mask when necessary, for example, masks for visitors entering the room of meningococcal meningitis patients or
TB patients.

PATIENT CONDITION                                  ALWAYS REQUIRES
DISEASES TRANSMITTED BY AIRBORNE                            Stop sign isolation
ROUTE                                                       Notify (3493)
    measles (rubeola)                                      Private room (immune roommate sometimes
    mumps                                                   acceptable)
    Influenza                                              Personnel who are immune to the disease, if
    chickenpox (varicella)                                  immunity is possible.
    disseminated zoster (varicella)                        Body Substance Isolation:
    rubella                                                 -handwashing after body substance contact
    tuberculosis                                            -glove for contact with body substance
    meningococcal meningitis**                              -gown if soilage of clothing is likely
    diphtheria, pharyngeal                                  -instruct patient regarding disease spread &
    whooping cough (Pertussis)                              Handwashing AND also use STOP Sign Isolation
    pneumonic plague
    smallpox, vaccinia, monkeypox
    SARS
    Viral hemorrhagic fevers


The following diseases are transmitted in whole or in part by the airborne route. Patients with these diseases need to be assigned to private rooms and have
a "STOP: AIRBORNE or AFB Isolation/Precaution" sign posted on the door. The door should remain closed. See Infection Control Intranet site under
―Isolation Signs‖
                    STOP SIGN ISOLATION FOR AIRBORNE COMMUNICABLE DISEASES
                                                                                                           Sign Mask Respirator Gown Immunity Negative
Disease (infectious           Duration of Airborne                           Comments
                                                                                                           Level                        *     pressure
      agent)                      Precautions
                                                                                                                                                room
Avian Influenza          Until 14 days after onset of All persons entering room wear a
(Type A virus variant)   symptoms. May vary in immune resporator. Healthcare providers who have
                         compromised persons.         had current influenza vaccination provide             3             X         X    Preferred      X
                                                      patient care whenever possible. Call
                                                      Infection Control (3493)
Chickenpox, VZV          Until all lesions are crusted       Only persons immune to chickenpox
(varicella zoster virus)                                     (varicella) can enter the room. Persons who    1                            required
                                                             are immune do not need to wear a mask
                                                                                                                                                               20
                                                                                                                                                        21
see also Herpes zoster                                      except for Body Substance Isolation
below                                                       purposes. Exposed susceptible patients &
                                                            staff should be quarantined (off work)
                                                            beginning 10 days after first exposure until
                                                            21 days after last exposure.
Diphtheria,              Until 2 cultures (from nose &      Persons who are not immune to diphtheria
Pharyngeal               throat) taken at least 24 hours    should wear a mask to enter the room.
(Corynebacterium         after cessation of antimicrobial   Report immediately to Public Health Dept.            1   X                  preferred
diphtheriae)             therapy are negative for           (973-9243). Call Infection Control (3493)
                         Corynebacterium diphtheriae.       immediately.
Hemorrhagic fevers       Variable. Contact               PAPRs and full body barriers required to
including:               Epidemiology/Infection Control. enter room. Report immediately to Public
Lassa fever                                              Health Dept. (973-9243). Physicians can call
Ebola virus                                              the State Health Dept. and/or CDC (404-                 3          X      X                X
Marburg virus                                            639-2888) for advice about management of
                                                         a suspected case. Call Infection Control
                                                         (3493) immediately.
Herpes zoster, VZV       Until all lesions are crusted.     Localized lesions in immunocompromised
(varicella zoster virus)                                    patients frequently become disseminated.
localized in                                                Because such dissemination is
immunocompromised                                           unpredictable, use precautions as for
patient, or                                                 disseminated diseases. Only persons who
disseminated in                                             are immune to chickenpox (varicella) can             1                      required
anyone                                                      enter the room. Patients with localized
                                                            herpes zoster (shingles) who are not
                                                            immunocompromised do not need STOP
                                                            sign isolation, but roommates and
                                                            healthcare providers should be immune.
Influenza A or B         Until 5 days after onset of        All persons entering room wear a surgical
Or Pandemic Flu          symptoms and clinical              mask. Healthcare providers who have had
                         improvement for adults; 7 days     current influenza vaccination provide patient
                                                                                                                 1   X                  preferred
                         for children. May vary in          care whenever possible. Call Infection
                         immune compromised persons.        Control (3493).




                                                                                                            Sign Mask Respirator Gown Immunity Negative
Disease (infectious          Duration of Airborne                          Comments
                                                                                                            Level                        *     pressure
      agent)                     Precautions
                                                                                                                                                 room
Measles, hard          For 4 days after start of rash,      Persons who are immune do not need to            1                         required
                                                                                                                                                        21
                                                                                                                                       22
measles               except in immunocompromised         wear a mask except for Body Substance
(rubeola virus)       patients, with whom precautions     Isolation purposes. Persons who are
                      should be maintained for duration   susceptible to measles can not enter the
                      of illness.                         room. Report immediately to Public Health
                                                          (973-9243). Call Infection Control (3493).
Meningococcal         For 24 hours after start of         All persons entering room wear a surgical
meningitis,           effective antibiotic therapy.       mask. Report immediately to: Call
bacteremia or                                             Infection Control (3493) and/or
pneumonia,                                                Occupational Medicine (3149). Close
                                                                                                       1   X
known or suspect.                                         contacts should be evaluated individually
(Neisseria                                                for appropriate antimicrobial prophylaxis
meningitidis)                                             ASAP.

Monkeypox             Until scabs have crusted and        PAPRs and full body barriers required to
(monkeypox virus)     dried.                              enter room. Report immediately to Public
                                                          Health (973-9243). Physicians can call the
                                                          State Health Dept. and/or CDC (404-639-      3       X   X               X
                                                          2888) for advice about management of a
                                                          suspected case. Call Infection Control
                                                          (3493) immediately.
Mumps, infectious     For 9 days after onset of           Persons who are not immune should not
parotitis             swelling.                           enter the room. Report immediately to        1
                                                                                                           X           preferred
                                                          Infection Control (3493).
Pertussis, whooping For 5 days after start of effective   All persons entering room wear a surgical
cough               therapy.                              mask. Report immediately to Infection
                                                                                                       1   X
(Bordetella                                               Control (3493) and Occupational Medicine
pertussis)                                                (3149).
Plague, Pneumonic     Until 3 days after appropriate      All persons entering room wear a surgical
(Yersinia pestis)     antibiotic therapy and clinical     mask. Report immediately to Public
                      improvement.                        Health (973-9243). Physicians can call the
                                                          State Health Dept. for advice about
                                                          management of a suspected case. Call         1   X
                                                          Infection Control (3493).




                                                                                                                                       22
                                                                                                                                                     23
                                                                                                           Sign Mask Respirator Gown Immunity Negative
Disease (infectious         Duration of Airborne                           Comments
                                                                                                           Level                        *     pressure
      agent)                    Precautions
                                                                                                                                                room
Rubella, German        Until 7 days after onset of rash.   Persons who are immune do not need to
Measles                                                    wear a mask except for Body Substance
(rubella virus)                                            Isolation purposes. Only persons who are
                                                                                                            1                        required
                                                           immune to rubella can enter the room.
                                                           Report immediately to Public Health (973-
                                                           9243). Call Infection Control (3493).
Smallpox (see          Until scabs have fallen off.        PAPRs and full body barriers required to
Smallpox Control                                           enter room. Call Infection Control (3493).
Plan)                                                      Report immediately to Public Health (973-
(variola virus)                                            9243). Physicians can call the State             3
                                                                                                                         X       X   preferred   X
                                                           Health Dept. and/or CDC (404-639-2888)
                                                           for advice about management of a
                                                           suspected case.
SARS (see SARS        Until 10 days after resolution of    N-95 Mask and full body barriers required
Control Plan under IC symptoms.                            to enter room. Call Infection Control
Intranet)                                                  (3493). Report immediately to Public
(coronavirus)                                              Health (973-9243). Physicians can call           3
                                                                                                                         X       X               X
                                                           the State Health Dept. and/or CDC (404-
                                                           639-2888) for advice about management
                                                           of a suspected case.
Tuberculosis           For patients confirmed with         N-95 masks are worn by persons entering
Pulmonary, confirmed   pulmonary TB, apply                 the isolation room and when transporting
or suspect (see TB     precautions until patient is        patients with confirmed TB place a
Exposure Control       improving and sputum smear is       surgical mask on the patient. Visitors also
Plan Under IC          negative x3, or patient cannot      use N-95 respirator mask. Call Infection
Intranet               produce sputum or positive AFB      Control (3493). Infection Control will report    2            X                       X
(Mycobacterium         smear is culture negative after 6   to Public Health (973-9243) when
tuberculosis)          weeks. To rule out TB, 2            confirmed.
                       negative AFB smears
                       (expectorated, induced or
                       combined) are needed.
Vaccinia, progressive, Variable. Contact Infection         All persons entering room wear a surgical
generalized, severe Control (3493)                         mask and body barriers. Report
(vaccinia virus)                                           immediately to Public Health (973-9243).
                                                           Physicians can call the State Health Dept.       3            X       X   preferred   X
                                                           and/or CDC (404-639-2888) for advice
                                                           about management of a suspected case.
                                                           Call Infection Control (3493).
*Immunity by natural infection or vaccination is either required or preferred for persons entering the room. For preferred immunity diseases, in
which only susceptible healthcare providers are available, a mask should be worn.
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                                                   SUSCEPTIBILITY AND COMMUNICABLE DISEASES
Certain diseases are transmitted either in part or entirely by the airborne route. Some of these are the usual childhood diseases such as measles, mumps,
rubella, and chickenpox. The remainder are infectious diseases more often seen in adults who are known to be spread by contact but which may also have an
airborne component. These include whooping cough, pharyngeal diphtheria or herpes zoster (shingles). A person who is susceptible has little or no
resistance to the disease, and should avoid contact with body substances and sharing of enclosed air space with individuals known to have that disease. A
non-susceptible person is immune. Some people may lose their immune response through age or disease.
The following table is designed to assist you in determining individual susceptibility to specific airborne diseases.


          YOU MAY BE SUSCEPTIBLE TO                                               IF YOU HAVE NEVER HAD

                                                Chickenpox, Varicella
          Chickenpox
                                                Herpes zoster (Shingles), Varicella (chickenpox) vaccine

          Influenza                             Most current Influenza vaccination or illness

                                                Diphtheria vaccination (DPT/DtaP in childhood & diphtheria or Td boosters in adults every 10
          Diphtheria, pharyngeal
                                                years)

                                                Measles
          Measles (rubeola)                     Measles vaccination (MMR series plus booster)
                                                Positive serology for measles (rubeola)

                                                Mumps
          Mumps                                 Mumps vaccination (MMR series)
                                                Positive serology for Mumps

                                                Pertussis (Whooping cough)
          Pertussis (Whooping cough)            Pertussis vaccination (DPT in childhood) . Individuals between the ages of 11 and 64
                                                should receive one time dose of Tdap

                                                Rubella
          Rubella                               Rubella vaccination (MMR series)
                                                Positive serology for Rubella

                                                Smallpox
          Smallpox, Monkeypox, Vaccinia
                                                Smallpox vaccination (vaccina vaccine)


                                           SUMMARY OF KEY ELEMENTS OF BODY SUBSTANCE ISOLATION:
                                           REID HOSPITALS UNIVERSAL/STANDARD PRECAUTIONS SYSTEM
Infection precautions place a barrier of plastic (gloves), fabric (gowns) or paper (masks) between potentially infectious body substances and the caregiver. All
humans have potentially infectious agents in pus, feces and sputum/saliva. Many people also have potentially infectious agents in blood, urine and other body

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fluids, tissues and substances. Precautions to prevent transmission of these potentially infectious agents are practiced with all patients, not only those who
have diagnosed infections.

Protection of both patients and healthcare providers must be provided when using infection precautions. Whenever precautions are used to protect healthcare
providers (such as gloving for touching a patient's mucous membranes), the impact on the patient must be considered and protection of both accomplished
(putting on clean or sterile gloves immediately before touching the patient's mucous membranes).

At Reid Hospital, Body Substance Isolation (BSI) is the universal standard contact precautions system for preventing contact spread of infectious agents
when caring for all patients. For patients with airborne communicable diseases of rubeola (measles), mumps, rubella (German measles), Varicella
(chickenpox), meningococal meningitis, pertussis (whooping cough), pneumonic plague, and influenza, "STOP ISOLATION (Level 1) Airborne Communicable
Diseases" signs are used to identify the rooms of these patients. For patients with tuberculosis, "STOP ISOLATION (Level 2) AFB Communicable Diseases"
with a respirator requirement (only respirator fitted and trained persons enter room) is used. For highly communicable diseases easily transmitted by both air
and contact, ―Stop ISOLATION (Level 3) Airborne, AFB and Contact Isolation‖ is used.

A consistent approach to managing all body substances, including blood, from all patients is essential to prevent transmission of infectious agents. The
following practices are used for all patients at all times to prevent transmission of infections to both patients and healthcare providers:

1. GLOVES: Healthcare providers put on clean or sterile gloves just before contact with mucous membranes or non-intact skin of all patients. When direct
contact with any moist body fluid or substance (blood, pus, sputum, urine, feces, saliva, etc.) from any patient is likely, gloves are worn. Personnel gathering
trash wear heavy-duty gloves. Personnel who hand-clean soiled items and equipment wear gloves. Hypoallergenic, non-latex, and powderless gloves and
cotton glove liners are available.

2. BODYWEAR: When soilage of clothing or bare skin by body substances is anticipated, a gown or apron is worn. If a gown or apron becomes penetrated by
body substances, it is removed immediately or as soon as possible.

3. FACEWEAR: When splattering of body substances to the face (to the facial skin, eyes, nose, mouth) is anticipated (e.g., coughing patient who does not
cover mouth or nose, for intubating or suctioning patients), appropriate facewear is worn. Face wear includes glasses/goggles with sideshields, masks
with/without eyeshields, and faceshields. Appropriate facewear is also worn to protect patients from respiratory secretions of healthcare providers, e.g. for
changing dressings on a large wound and for central line insertion. If you are susceptible to an airborne communicable disease, such as chicken pox or
measles, do not have contact with patients known to have these infectious diseases; wearing a mask is not an effective prevention strategy. For tuberculosis,
smallpox, and SARS, N-95 respirator masks are worn when entering isolation areas (see Bioterrorism, SARS, and Tuberculosis Exposure Control Plans).

4. OTHER PERSONAL PROTECTIVE EQUIPMENT: Surgical caps, hair covers, hoods, possible leggings, possible arm shields, boots and shoe covers are
worn when contact with body substances to those body areas is anticipated.

5. HAND HYGIENE: Hand hygiene is done immediately before and after contact with a patient, between contacts with different patients, when hands are
soiled, and immediately after gloves have been removed. Hand washing with soap and water is done immediately or as soon as possible following accidental
contact of any body area (skin) with any body substance. For visibly clean hands, hand hygiene using alcohol based handcleansing gels may be done for
hand sanitizing.

6. SIGNAGE: Isolation signs are used to remind staff of infection precautions are located in all patient care areas. In addition, ―Isolation Signs‖ are used to
identify rooms of patients with communicable diseases.

7. LABORATORY SPECIMENS: Laboratory specimens are handled as if they all contained infectious agents. Specimens are placed inside plastic, biohazard
labeled, bags before transport to the laboratory. Gloves are not required for transporting bagged laboratory specimens but transporting personnel should
wash and/or santize their hands after delivery. The outside of specimen containers should be clean; visibly soiled containers may be rejected by the
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laboratory. Refrigerators or freezers used to store body substance specimens are marked with "biohazard" signs.
8. REUSEABLE ITEMS: Handling and reprocessing practices are consistent for soiled, reusable articles and equipment, that is, all are treated as if infectious
agents are present. Small, soiled instruments and equipment are placed in marked containers located in the dirty utility rooms. Central Processing,
Respiratory Care and other personnel glove to remove and transport soiled items. Reusable articles and instruments are cleaned, disinfected and/or sterilized
in a consistent manner depending on their use, not on identification of infection in a particular patient. During cleaning of reusable sharps, personnel do not
reach by hand into the containers where these sharps have been placed for soaking; instead a strainer, forceps or other mechanical tool is used for removing
sharp instruments.
9. DISPOSABLE ITEMS: Disposable dishes are not necessary for patients with communicable diseases Single use devices are sometimes remanufactured
by a contracted entity for Reid Hospital. However, if these devices must meet the same regulatory requirements as the original manufacturer and Infection
Control must be consulted for approval (See administrative policy 33A).
10. SHARPS: Needles and other sharps (razors, glass, scalpels, etc.) are placed in puncture resistant biohazard labeled containers. Recapping used needles
is avoided whenever possible. When recapping is necessary, a one-handed safe recapping technique or mechanical recapping device is used (see
Bloodborne Pathogens Exposure Control Plan). Two handed recapping is not done. Used needles are not bent, broken, clipped or otherwise manipulated by
hand. If a needle needs to be removed from a syringe, a forceps or other tool is used. For intravenous therapy, a needleless delivery system is routinely used.
Safer medical devices to reduce or eliminate potential blood exposure are evaluated in the Products Standardization Committee routinely and upon request.
Contact Materials Management if you want a safer device evaluated or Materials Management and/or hospital Safety Officer if you have concerns about the
safety of a practice or device in use.
11. EXPOSURE: Lacerations or punctures with contaminated sharps or splash/splatter of body substances to a mucous membrane are exposures. Contact
Occupational Medicine or go to the Emergency Department immediately for follow-up. Flushing with water is done immediately following accidental contact of
mucous membranes (eyes, nose, mouth, etc.) with any body substance.
12. LINEN: Soiled linen is bagged in standard plastic bags supplied by the laundry at the point of use; special colored bags to identify ―isolation‖ linen are not
used since all soiled linen is considered ―isolation‖ laundry. Transporters wear gloves and laundry workers glove and gown when handling all soiled linen. For
patient clothing infested with lice or scabies, plastic bags are used for clothing storage and sent to laundry immediately for processing with patient label on
outside of laundry bag.

13. TRASH: General waste is placed into plastic-lined cans. Environmental Services personnel wear gloves to collect and transport waste. Waste from
patient care areas with body substances in an absorbed form is not considered infectious/biomedical waste; examples of this type of waste include gloves,
gowns, masks, dressings, and emptied body substance collection containers. These items are placed into plastic bio-hazard bags, collected with the general
waste and transported for processing. Infectious/biomedical wastes (see Waste Management section for definitions) are handled in a separate waste system.
Infectious/biomedical wastes are placed in special containers in the dirty utility rooms, collected and transported to a holding area, boxed and transported
offsite for final disposal by a biomedical waste-handling contractor. A listing of regulated/infectious/biomedical waste can be found Section IV of the Infection
Control Manual.

14. HOUSEKEEPING: Cleaning of patient rooms, laboratory areas and other clinical areas are performed in a standard and consistent manner. Prompt
cleanup of body substance spills is done by gloved personnel using an approved hospital disinfectant and safe procedure. Cleanup of broken glass is not
done by hand; a dustpan and broom or other tools are used. Disinfectant and spill clean-up equipment are available in the custodian closets or from
Environmental Services.

15. PRIVATE ROOMS: Private rooms are used for patients with airborne communicable diseases and for patients who consistently soil the room and articles
in the room with body substances. Private rooms may be requested by physicians for patients who are severely immunocompromised and this request will be
accommodated if a room is available (see Roommate Selection table in Infection Prevention Section).

16. ROOMMATE SELECTION: Patients may have roommates when both roommates practice good personal hygiene and neither roommate has an infection
which requires a private room (see Roommate Selection section). Good personal hygiene is defined as patient behavior which does not soil articles in the
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room with blood, pus, feces, urine or oral secretions. When the patient's personal hygiene cannot be accurately assessed or is questionable, a private room
may be indicated.

17. PATIENT TRANSPORTATION: Patients with diseases transmitted by the airborne route (Stop Sign Isolation) should not be transported unnecessarily to
other areas or departments, or leave the isolation room. If the isolated patient's recuperation and treatment would be compromised by examinations,
procedures, and treatments performed in the patient's room, then the patient may be transported from the isolation room to other departments, if these
patients are transported, the patient will wear a surgical mask and the transporter, if possible, should be immune to the disease. The receiving department
and Transportation should be notified in advance by nursing so that immune personnel can be selected for performing the procedure (see Susceptibility and
Communicable Diseases). For information on the length of time the patient will need isolation, see the infection control intranet site under isolation
precautions Types and duration of isolation or call the infection control department (3493). If infection control is not available, call the Administrative
Coordinator.

18. PATIENT TEACHING: All patients should be taught that potentially infectious agents are present in their body substances and that they may be
susceptible to infections from others. Hand, respiratory, and good personal hygiene should be emphasized for their protection and the protection of others.




HAND HYGIENE

PURPOSE:

Hand hygiene is important to aid in the prevention of contamination and cross transmission of microorganisms among patients and employees. Clean hands
protect both patients and healthcare providers.

POLICY:

    1. Maintain intact skin on hands. Use water-based lotions and creams to prevent dryness or irritation. Personal products may be used (medications,
       ointments, etc.) to maintain healthy hand skin but should not be shared with others.
    2. Do not wear artificial nails or extenders when providing patient care (see administrative policy 13).
    3. Hands are clean when providing patient care.


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  4.   Hands can be cleaned by handwashing using the sink with soap and water, by using alcohol gel sanitizers, or by using for hand use only antimicrobial
       impregnated towelettes.
  5.   Soiled hands are washed at the sink with soap and water.
  6.   Visibly clean hands can be sanitized by using the alcohol based gel or foam products.
  7.   Clean hands:
           a. Before and after touching any patients, devices on a patient, or items at the patients bedside and room.
           b. Before gloving for sterile procedures (IV, urinary catheter insertion)
           c. After removing gloves and other personal protective equipment
           d. After using restroom facilities
           e. Before eating
           f. Before touching your mucous membranes (inserting contacts, applying lip products, etc)




EQUIPMENT:

       For handwashing:
              Plain soap or antiseptic soap
              Sink with running water
              Paper towels for drying

       For hand sanitizing or for cleaning soiled hands when sink not available:
              Alcohol-based gel sanitizer

PROCEDURE:

       For handwashing:
                 1. Wet hands and apply plain or antiseptic soap.
                 2. Wash using friction to all surfaces of hand, including under fingernails for at least 15-20 seconds.
                 3. Rinse hands under running water.
                 4. Dry hands and then use a clean paper towel to turn faucets off.
                 5. Avoid using hot water because it may increase the risk of dermatitis.

       For hand sanitizing:
                  1. Apply alcohol based gel or foam to palm of hand and rub hands together, covering all surfaces of the hands and fingers, until hands
                       are dry.
                  2. Some alcohol based gel or foam products suggest washing with soap and water after every 10-15 uses of the products to remove
                       buildup.




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                              MANAGEMENT OF EMPLOYEES AND PATIENTS EXPOSED TO COMMUNICABLE DISEASES
If a patient, employee or visitor is suspected of having an airborne communicable disease, employees should notify Occupational Medicine (3149) or Infection
Control (3493) immediately. Visitors should be restricted from visiting patients within the hospital. The following steps shall be taken by the physicians, nurses,
charge nurses, Unit Directors, infection control, Occupational Medicine, and others as deemed necessary:

1. Confirm the diagnosis (MD, Nursing)

2. Isolate the case (Nursing, MD)

3. Determine period of infectivity (MD, Nursing, IC, OM)

4. List all patient contacts; notify physicians caring for patients who are not immune (Nursing develops list for IC

   follow-up)

5. List all personnel contacts (Nursing develops list for OM follow-up)

6 Obtain specimens for serologic testing (coordinated by Occupational Medicine or Infection Control)

       patients - reports sent to chart and respective physicians

       personnel - reports sent to Occupational Medicine

7. Restrict exposed persons who are susceptible (Infection Control & Occupational Medicine coordinate with directors of       affected areas)

8. Administer prophylaxis if needed and available.

9. Evaluate exposures for secondary cases.

10. Report findings to Infection Control Committee.




                                                              Examples of Exposure Management
                             Disease                   Mode of             Restrictions/       Prophylaxis
                                                       Transmission        Isolation
                             Varicella                 Droplet spread,     Days 10-21 after    VZIG to high risk individuals
                             (Chickenpox)              secretions          exposure or until   early (within 96 hours)
                                                                           lesions are all dry
                                                                           and crusted

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                            Rubella (German           Droplet spread,        Days 7-23 after         Vaccinate promptly
                            Measles)                  nasopharyngeal         exposure or until 5
                                                      secretions, urine,     days after rash
                                                      blood, feces           appears
                            Rubeola (Measles)         Droplet spread,        7-14 days or until 4    Vaccinate promptly
                                                      nasal or throat        days after rash
                                                      secretions             appears
                            Diphtheria                Nasal and oral         If disease develops     Diphtheria toxoid vaccine with
                                                      secretions, lesion                             boosters every 7-10 yrs;
                                                      drainage                                       erythromycin or penicillin for
                                                                                                     unimmunized exposed persons
                                                                                                     promptly and within 10 days
                            Tuberculosis              droplet nuceli         If active pulmonary     Exposure screening and follow-
                                                                             disease is present      ups of contacts by
                                                                                                     Occupational Medicine,
                                                                                                     Infection Control and Wayne
                                                                                                     County Public Health
                            Pertussis (Whooping       Droplet spread,        Until 5 days after          One time dose of Tdap
                            cough)                    nasal or throat        onset of symptoms       Amantadine or Oseltamivir.
                                                      secretions                                     Consult with OCC Medicine or
                                                                                                     Infection Control.
                            Influenza                 Droplet spread, oral or nasal secretions.

                                                             Chickenpox Exposure Management
Chickenpox (Varicella) is a very infectious airborne communicable disease that can be serious or fatal in persons with poorly functioning immune systems
(leukemia or other white cell disorders, burns, cancer chemotherapy or steroids, or other immunosuppressive disorders). Major effects of primary chickenpox
can be reduced by Varicella Zoster Immune Globulin (VZIG) if it is administered within 96 hours of exposure. The purpose of this protocol is to outline the
steps necessary to identify, treat and isolate exposed patients and employees within the effective time period. The steps in the protocol are listed in the order
they should occur. Responsibility for executing each step is suggested and is a coordinated effort*.

*Notify Occupational Medicine (3149) or Infection Control Department immediately (3493) for cases of suspected chickenpox. After normal office hours, the
hospital operator will contact the Infection Control Practitioner (ICP).

1. CONFIRM THE DIAGNOSIS (MD, ICP, OM)

Be sure the suspected case has been diagnosed correctly. Patients with disseminated Zoster (shingles, reactivated chickenpox infection) have many lesions,
but do not have the virus in their saliva as do people with chickenpox, and are infectious only by direct contact rather than airborne transmission.

2. ISOLATE THE CASE (MD, Nursing)

Place the patient in a private room with the door closed or with a roommate known to have had chickenpox. Place a "STOP ISOLATION SIGN‖- Airborne
Precautions sign on the door. Personnel who have not had chickenpox should not enter the room and the patient should not leave the room unnecessarily.
Visitors who may be susceptible have their risk of chickenpox explained before they enter the room.

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3. DETERMINE THE PERIOD OF INFECTIVITY (MD, Nursing, ICP, OM)

To determine the period of infectivity, count back 4 days from the date the first lesion appeared. All people who had face-to-face contact with the patient or
shared airspace for more than 30 minutes are considered exposed. Consider the case infectious until 6 days after the last lesions appeared or until the
lesions are crusted and dry, whichever comes last.

4. LIST ALL PATIENT CONTACTS (Nursing develops list for ICP follow-up)

Nurse Managers or charge nurses may delegate this step, but is must be done immediately. List all patients who meet the exposure definition. Interview each
one asking these questions: "Have you ever had chickenpox?" If yes, consider them immune. If no, ask, "Have you had siblings or children who had
chickenpox while you lived together?" If yes, consider them immune. If history of two doses of vaccine, consider them immune, If no, immunity will have to be
determined by serologic screening.

5. NOTIFY PHYSICIANS CARING FOR PATIENTS WHO ARE NOT IMMUNE (MD, Nursing, ICP)

Notify the physicians promptly if their patients are susceptible or do not remember, particularly if VZIG will need to be ordered from the Pharmacy. Physicians
determine if patients need VZIG.

6. LIST ALL PERSONNEL CONTACTS (Nursing develops list for Occupational Medicine follow-up)

As with patient interviews, the task may be delegated. The Occupational Medicine Nurse may assist with the interviews or may assign unit
directors/managers, depending on the nature and extent of the exposure. If the patient has been to the other units, clinics or departments, notify Occupational
Medicine of the locations.

7. OBTAIN SPECIMENS FOR SEROLOGIC TESTING (Coordinated by Infection Control, Occupational Medicine)

Blood specimens (7 ml, red top tube) may be ordered and drawn by Occupational Medicine, nurses, house staff or laboratory.

Request results to be reported to patients' physicians or to Occupational Medicine. Physicians may consult with William Black Jr., Chair, Infection Control
Committee.

8. RESTRICT EXPOSED PERSONS WHO ARE SUSCEPTIBLE (Infection Control & Occupational Medicine coordinate with unit directors/managers
of affected areas)

Restrict exposed employees and visitors from the hospital from day 10 after FIRST exposure through day 21 after LAST exposure, even if they have received
VZIG. Place exposed, susceptible patients in Airborne/Contact isolation, a private room or semi-room with an immune roommate, cared for by immune
personnel from day 10 through day 21, even if they have received VZIG.

                                            Meningococcal (Pneumonia or Meningitis) Exposure Management
PURPOSE: To decrease the risk of acquiring meningococcal infection in staff and others with well-defined, close patient contact including:

    1. Persons who have administered mouth-to-mouth resuscitation to a patient with untreated meningococcal disease.

    2. Close contact (equal to or less than 3 feet) to a patient with untreated meningococcal tracheobronchitis or pneumonia who is coughing or is on a
       ventilator.

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PROCEDURE:

    1. The Microbiology Laboratory, Physician or Nursing notifies Infection Control or Occupational Medicine of suspected or confirmed case. Infection
       Control or Occupational Medicine or may also consult with the Chair of the Infection Control Committee to confirm the need for post exposure follow-
       up.

    2. Nursing, Occupational Medicine and Infection Control staff identify contacts of the untreated case who meet the criteria above, including staff, visitors,
       family members and significant others.

    3. Provide prophylaxis as soon as possible, preferably within 48 hours of exposure. No prophylaxis is warranted if more than 7 days have elapsed since
       exposure. Occupational Medicine is responsible for providing prophylaxis for staff and others working in the hospital. Physicians, Nursing and
       Infection Control are responsible for referring other contacts to the Emergency Department for exposure and/or illness assessment and prophylaxis.
       Infection Control is responsible for coordinating with the Public Health Department to ensure rapid identification and prophylaxis of all close contacts.



    4. For staff, a prescription for an appropriate prophylactic antibiotic is ordered by the Occupational Medicine Physician and available through the
       Pharmacy. Cost is covered by the hospital.

    5. Employees are advised to return promptly to the Occupational medicine or Emergency Department for fever or headache developing within 10 days
       of exposure.



                                                       Management of Intravascular Catheters
OBJECTIVE: To promote safe and uniform management of intravascular catheters in all patients
                                      (Refer to Nursing Manual Policies # 18, 19, 129, 130, 131, 133, and 134)



                                                           Visitor Policy for Infection Control

The support offered to patients by visitors is of great importance in their recovery and well being. A few simple principles will ensure the visitor’s and the
patient’s safety from exposure to communicable diseases.


A. General Policy
    1. Visitors with uncontrolled symptoms of coughing, sneezing, or diarrhea should refrain from visiting. Other ways of communicating with the patient
       during this time include telephone and written notes.
    2. Any person with signs of a serious communicable disease, including tuberculosis, measles, chickenpox, shingles, meningitis, or pertussis, is not
       permitted to visit the hospital until the infection has resolved or the person is no longer potentially contagious. A cold is not included as a serious
       communicable disease.
    3. Before touching any patient, hands should be freshly washed and/or sanitized. Studies of viral infections have documented that infections can be
       spread by hands, including spread of respiratory infections by sneezing and coughing into hands.

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    4. Visitors should follow any recommended precautions to avoid spreading potentially infectious organisms to and from the patient. At Reid Hospital,
       Standard/Universal Precautions are used for all patients.
    5. Fresh flowers or plants have microorganisms on plants, flowers or in the soil and water surrounding them. These are not permitted in the recovery or
       intensive care unit rooms and in some cancer patient rooms. Consult with the physician and/or staff for severely immunodeficient patients to
       determine if flowers or plants might pose a risk of infection for that patient.


B. Visitation by Children Under 12 Years of Age
    1. Any unimmunized child exposed to or with signs of a serious communicable disease, including measles, mumps, chickenpox, meningococcal
        meningitis, or pertussis (whooping cough), is not permitted to visit the hospital until the incubation period is exceeded or the infection has resolved. As
        long as the child is potentially contagious, hospital visitation is prohibited. A cold is not included as a serious communicable disease.
    2. Children who have received oral polio vaccine within the past month may not visit unimmunized children who are hospitalized.
    3. During community outbreaks of vaccine preventable childhood diseases, unimmunized children will not be permitted to visit areas where high risk
        patients are clustered such as in PPCU.
    4. Children are not routinely permitted in areas where the environment may be contaminated with pathogenic microorganisms, blood or other body
        substances. These areas include the operating room, laboratory, and morgue areas.
    5. Children visiting the hospital should be accompanied by a supervising adult to ensure that the child is not accessing hazards such as trash cans,
        soiled linen bags, and sharps containers.
    6. The supervising physician, unit director, Administrative Coordinator, or Infection Control Practitioner must approve exceptions to these guidelines.
        Exceptions must not put patients or others at risk of acquiring infection.
    7. Additional policies on visitation can be found in the Administrative Policy Manual, Visitors Policy 7 and/or any unit specific policies.




                                                                  ANIMALS IN THE HOSPITAL


PURPOSE: The purpose of this policy is to govern the potential occurrence of animals in the hospital for the purpose of maintaining order, preventing
transmission of potential zoonoses, and to provide guidance for staff and visitors who may be involved in situations in which animals are present. While
unlikely, transmission of diseases from pet animals to hospital patients or staff is theoretically possible. Conditions which have the potential to be transmitted
include, but may not be limited to, ecto and endo parasites of dogs, such as fleas, round worms, and ringworm, toxoplasmosis in cats, Chlamydia psittaci in
birds and salmonella from turtles and fowl. In addition, animals may also initiate allergic reactions in some people.

DEFINITIONS:
    Service Animals: Service animals are not pets. A Service animal is trained to assist or accommodate an individual with a disability or impairment.
       Washington law does not require that an accredited school train the Service Animal. Thus, owners may train their own animals and request
       accommodations.




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         Therapy Animals: Therapy Animals are not pets. A Therapy Animal is a suitably trained dog that provides a therapeutic benefit to patients. Therapy
          Animals are used for Animal Assisted Therapy (AAT), which is a therapeutic intervention using a certified Therapy Animal to assist in the therapeutic
          process. Therapy Animals are certified for their work or are in training. Only a trained AAT handler handles therapy Animals.
      Pets: Pets are patient-owned animals that are not trained for a specific therapeutic purpose or to assist a person with a disability. Pet Visits are visits
          by suitable patient-owned domesticated animals in the hospital premises setting.
POLICY:
Animals not permitted on hospital premises include: reptiles, birds, rodents, arachnids, rabbits, raccoons or wild animals. In general, pet animals will be
excluded from the hospital buildings unless there is a legitimate reason for them to be there. Such reasons are presently limited to:
     1. Guide dogs for the blind and hearing impaired.
     2. Service dogs for other handicapped individuals whose presence is required for the benefit of the patient, visitor, or staff member.
     3. Pet Therapy animals engaged in animals assisted activities. At the present time these are limited to dogs.
     4. In the very limited number of cases where a patient's welfare is judged to be significantly enhanced by the presence of this pet, upon the
          recommendation of his physician, and with the explicit agreement of infection control and the nursing staff of the unit where the animal will be present,
          an exception to the exclusion policy may be granted.
A trained handler or owner must accompany the animal at all times. A therapy or guide dog must have a responsible adult present who will be responsible for
feeding, watering, toileting and exercising the dog, and may be held responsible for the dog's behavior, and health condition.
Any animal not clean and in apparent ill health, or found to harbor external parasites, may be excluded at the discretion of any staff member responsible for
the care of patients. Immunizations must be current and documentation of such must be available on request. Such vaccinations will include: Rabies, Canine
Distemper, Canine Parainfluenza, Canine Adenovirus type 1 and 2, Canine Leptospirosis, Canine Parvovirus, Canine Coronavirus, and Bordetella.
All animals will be restricted to the area of the hospital where their presence is required. The rights of all other patients, visitors, and staff not to have contact
with the animal will be respected at all times. At no time will the animal be allowed to run loose or cause a disturbance. Any animal posing a threat to
patients, visitors, or staff because of odor, noise, health, temperament, or behavior will be removed from the premises.
In the event that an "accident" occurs, the owner/handler shall request assistance from the staff for appropriate disposal of animal waste. Soiled areas will be
treated by Environmental Services using the standard method of cleaning and disinfection. The presence of animals in the hospital shall not lessen the
standard of housekeeping or contribute to an objectionable odor.
Should an "incident" occur (scratch, bite, allergic reaction, etc.) standard hospital injury protocols will be implemented and the Charge Nurse will complete and
file an "occurrence report".
All persons handling animals or animal product shall practice proper and frequent handwashing.
The Infection Control Committee must approve any pet therapy programs at Reid Hospital.
Handlers of therapy dogs must undergo employee or volunteer orientation, whatever is appropriate.
Approved therapy dogs must have a health certificate provided by a licensed veterinarian within the past 6 months. This examination must include a fecal
check, teeth and gum check, blood analysis, and cardiopulmonary exam. In addition, the animal must be certified free of infection, contagious disease, or
dermatological conditions, including external parasites. These records will be maintained by the pet therapy organization and must be available on demand.
REFERENCE: Delta Society of Hospital Programs
CROSS-REFERENCE: Reid Hospital Administrative Policy & Procedures Manual


                                                            Occupational Medicine (OM)
                                                         Occupational Medicine Scope of Care/Service
The Occupational Medicine provides services and participates in administrative activities that promote and enhance a safe environment for workers and
clientele within the physical campus and/or for the programs as assigned by Reid Hospital.
A. Types and ages of patients served:

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The following persons are eligible for Employee Health Services: Reid does not pay for services provided to faculty, students, or other agency
employees. OM can offer to provide pre-placement services at the expense to their agency...

      Employees and Faculty of Reid Hospital (Full time, part time, per diem and temporary)
      Students of affiliated teaching programs**
      Other agencies who have employees located within Reid Hospital buildings*
      Volunteers of Reid Hospital and its affiliated programs**
   *General services such as TB screening, routine immunizations, minor first aid, and certain post-infectious disease exposure protocols are available.
   Restrictions, however, may govern extent workers’ compensation-related care, depending on the employing agency.
   **Students and volunteers are required to have prerequisite immunizations and screening exams administered by and documented with outside agencies,
   and completed prior to any affiliation with Reid Hospital, as stated in the agency’s affiliation agreement with Education.
B. Methods used to assess and meet service needs
   The OM in conjunction with the Infection Control Committee, the Safety Committee, Reid Hospital administration, and the OM Director, establishes a
   structure for:
      defining health screening standards for employees,
      implementing immunization and medical surveillance programs
      providing assessment, direct care and/or medical triage of work related injuries and illness
      maintaining a confidential employee health record keeping system
      evaluating occupational hazard risk and determining strategies for risk reduction
      coordinating and providing health promotion activities for Reid Hospital personnel
      Representing the organization on internal and external committees, educational activities, and task forces.
C. Scope of Service
   The OM performs or provides the following services:
      Evaluation of immunity to specified communicable diseases and tuberculosis screening for new and existing volunteers, employees and faculty.
      Immunizations, periodic screening and medical surveillance and exposure management for specified communicable diseases.
      Minor first aid and/or triage to appropriate healthcare professional for work related illness/injury, and related psycho-social sequelae.
      Assessment of work environment for health related hazards.
      Development, coordination, and implementation of health promotion and wellness activities for employees.
      Instruction and consultation for occupational health related topics.
D. The appropriateness, clinical necessity, and timeliness of support services provided directly by the hospital or through referral sources
   Affiliated support structure:
   Clinical support is provided through, but not limited to: the Occupational Medicine Medical Director, Emergency Department, and Occupational Medicine,
   Infection Control, and the Wayne County Public Health Department. Social services and employee assistance programs are available through Reid
   Hospital and the Employee Assistance Program.
   Consultation for administrative/policy issues is provided by the appropriate department or committee structure, such as Infection Control Committee and
   Safety Committee under the guidance of the VP for Clinical Support Services.
E. The availability of necessary staff:
   OM professional nursing staff has specific training, experience, and demonstrated competency for performing assessments and effecting appropriate
   triage of clinical and administrative areas listed above. The Medical Director has oversight of clinical protocols and is responsible for pharmaceutical
   prescription signature.
F. The extent to which the level of care or service provided meets patients’ needs:
   Comprehensive services, ranging from health promotion strategies, emotional, mental health, and social services, through Level III trauma care are
   available via the referral and clinical support system.
G. Recognized Standards of Practice:

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   The following organizations have published standards from which the OM derives its scope of services:
     American Association for Occupational Health Nursing;
     Centers for Disease Control and Prevention, including National Institute for Occupational Safety; and Health, and Advisory Committee on
        Immunization Practices.
     Occupational Safety and Health Administration;
     Healthcare Facilities Accreditation Program (HFAP)
     Joint Commission for Accreditation of Health Care Organizations (JCAHO); and
     State of Indiana Administrative Code, and the Indiana State Department of Health.


                                                           Occupational Medicine Services Summary
OFFICE LOCATION: Basement PHONE: 3149
The following is a summary of services offered to employees through Occupational Medicine at Reid Hospital. These services are available to all employees
and volunteers. Students are eligible for first aid and exposure management; other services may be referred to appropriate providers. Prescriptions for
prophylactic drug therapies for work related communicable disease exposures are available as needed.

                                             COMMUNICABLE DISEASE SCREENING AND PREVENTION
                Tuberculosis screening
                PPD skin testing                                                at hire
                                                                                annually for low risk areas
                                                                                semiannually for high risk areas
                                                                                following exposure to active case
                Chest x-ray
                                                                                at hire for skin test reactors who have positive ―yes‖
                                                                                 answers on questionnaire

                                                                                if symptomatic for TB
                                                                    
                Vaccinations                                                    For all employees at risk for blood/body fluid exposure
                 Hepatitis B screening and immunization
                Diphtheria                                                      all employees are to have current immune status for the
                Influenza                                                        vaccine preventable diseases listed
                Mumps                                                           influenza vaccine is encouraged and offered to employees
                Rubella                                                          each fall
                Rubeola                                                         on request and as needed for communicable disease
                Tetanus                                                          exposure management
                Titers
                Hepatitis
                Rubella                                                         on request and as needed for communicable disease
                Rubeola                                                          exposure management
                Varicella

WORK RELATED INJURIES
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       First aid for minor injuries.
       Referral available for more serious injuries.
       Information, counseling, referral for minor non work-related illness or injury.


                                                    REPORTING WORK RELATED INJURIES/ILLNESSES
                           What to do if you’re injured on the job?                 What’s available at Reid Hospital?
                           Notify your supervisor of injury: Ask yourself if you    First aid for minor injuries is available through the
                           would go to the Emergency Department or your             Occupational Medicine office (3149), Mondays
                           family doctor if this occurred at home. If yes, then     through Fridays, 0700 to 1630. Injuries requiring
                           go to Occupational Medicine or Emergency                 extensive care or occurring after OM hours may
                           Department. Exception all bloodborne pathogen            be seen in the Emergency Department, 24 hours
                           exposures should seek medical attention ASAP.            a day, 7 days a week.
                           Report your injury and how it happened to your           Complete ―Incident Report‖ form which is available
                           manager immediately after seeking care.                  through your department. Managers are to
                                                                                    forward the report to Human Resources and Reid
                                                                                    Hospital Safety Officer within 24 hours.
                                                                                    Further information concerning industrial
                                                                                    insurance following a work-related injury or
                                                                                    disease is available from Human Resources
                                                                                    representative.




                                              Work Restrictions for Communicable Diseases
PURPOSE: To prevent nosocomial spread of communicable diseases to patients and staff within Reid Hospital from staff with contagious illnesses.

POLICY: Persons with communicable diseases or who are susceptible and exposed to communicable disease shall be restricted from direct contact with
patients when:
    1. Transmission of the disease to the recipients of care or others in the workplace can occur in that particular job environment; and
    2. The disease can cause serious illness.
INCLUSIONS: Reid Hospital staff, students, volunteers, and all persons who work within the hospital Buildings.

Occupational Medicine staff (3149), Infection Control staff (3493), should be consulted if there are questions concerning the safety of allowing a person to
return to work. Guidelines for managing employees are listed below. Please note that there are two sections--one for employees with communicable
illnesses and the other for employees exposed to a communicable disease to which they are susceptible.



                       SECTION I. EMPLOYEES WITH COMMUNICABLE ILLNESS



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Employees may not work in the hospital environment during the known period of communicability for:
Duration of Restriction:




Chickenpox (Varicella zoster)                                  Until all vesicles are dried and crusted.
Shingles (Herpes zoster)                                       Patient contact is limited to immune
                                                               patients and lesions are covered.
Measles (Rubeola, hard measles)                                Until 4 days after rash appears.
Mumps                                                          For 9 days after onset of swelling; less if
                                                               swelling has subsided.
Rubella (German measles)                                       Until 5 days after rash appears.
Scabies or Pediculosis                                         Until 24 hours after initiation of appropriate
                                                               treatment.
Pink Eye                                                       Until 24 hours after initiation of appropriate
                                                               treatment.
Tuberculosis                                                   Until receiving appropriate therapy and
                                                               clinical improvement. The employee health
                                                               physician consultant shall review the case
                                                               prior to allowing the employee to return to
                                                               work.

                              Employees may or may not require work restriction
                                 due to specific acute infections or carrier states.
Group A Streptococcus                                          Evaluation by OM or IC is necessary
Staphylococcus, coagulase positive
Acute hepatitis B, or HBsAg positive                           Individual evaluation by OM or IC. Work restriction
Acute hepatitis C                                              will depend upon the employee's hygiene and
HIV positive or AIDS                                           preventing his/her blood and other body fluids from
                                                               contacting others.
Neisseria meningitidis (meningococcus)                         No restriction for treatment of carrier state required;
                                                               for acute meningococcal disease, including
                                                               meningitis, employees would be too ill to work.
Amebiasis, Salmonella,                                         Food handlers are restricted. In other health care
Campylobacter, Shigella,                                       workers, evaluation by OM or IC is necessary.
Cholera, Worms/Parasites
Hepatitis A
Employees must be evaluated by OM, IC or their private physician regarding their work area if they have certain
signs or symptoms of the following conditions:




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Diarrhea
Draining abscesses, boils
Exudative dermatitis
Herpes simplex (whitlow, stomatitis)
Uncontrolled respiratory symptoms/infections
Impetigo
Influenza
Pertussis




                                                           SUSCEPTIBLE EMPLOYEES
                   Exposure of susceptible employees to specific communicable diseases may require restriction from work during
                   the incubation period, for example:
                   Chickenpox, Varicella                                                     Incubation period is 13-21 days
                                                                                             after exposure; restriction would be
                                                                                             from day 10 after first exposure thru
                                                                                             day 21 after last exposure or, if
                                                                                             disease develops, until the last crop
                                                                                             of vesicles is dried and crusted.
                   Measles, Rubeola                                                          Incubation period is 7-18 days;
                                                                                             restriction would be from day 7 after
                                                                                             first exposure to day 14 after last
                                                                                             exposure; if disease develops, until
                                                                                             4 days after onset of rash. Live
                                                                                             vaccine given to susceptibles within
                                                                                             72 hours of exposure may prevent
                                                                                             illness.
                   Mumps                                                                     Incubation period is about 14 to 21
                                                                                             days: restriction would be from 12
                                                                                             until 21 days after exposure; if
                                                                                             disease develops, for 9 days after
                                                                                             onset of parotid gland swelling, but
                                                                                             less if swelling has subsided.
                                                                                             Immunization of susceptibles
                                                                                             following exposure is of uncertain
                                                                                             value.
                   Rubella                                                                   Incubation period is 14-23 days;
                                                                                             restriction would be from day 7 after
                                                                                             exposure through day 23; if disease
                                                                                             develops, until 4 days after rash
                                                                                             appears.


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REFERENCE:
                                                                                      th
Control of Communicable Diseases Manual. American Public Health Association, 18 Edition




                                                      Management of Blood/Body Substance Exposure
Exposure to blood or body fluids/substances is a serious occupational hazard. Immediate reporting of these events allows for appropriate risk assessment,
counseling and initiation of post exposure prophylaxis (PEP). Reid Hospital follows guidelines set forth by the Centers for Disease Control.
PROCEDURE:
   1. Wash area immediately. Use water and appropriate cleansing solution. Mild non irritating soap or antibacterial scrub is used on skin. If splashed in
        eyes or mucous membranes, flush area with saline or non irritating solution. Do not use harsh agents which may cause additional injury to tissues.
   2. Seek care immediately through the OCCUPATIONAL MEDICINE or the EMERGENCY DEPARTMENT. Prophylactic medications are most likely to
        be effective when treatment is started within the first few hours after exposure.
                                                              st
        Emergency Department (when OM not available) 1 Floor Hospital
   3. Verbally report the exposure immediately to the Charge person and Occupational Medicine at 3149. Leave a confidential message, giving your name,
        date of injury, name and location of the source patient, and phone number where you can be reached.
   4. Confidential counseling, treatment and testing are provided at no cost to the exposed person and the source patient. Source patient counseling and
        testing will not be done until the exposed person has notified their Charge person, unit director, infection control and/or nursing supervisor on-call.
        This assures that appropriate and legal counseling, consent and test notification are completed*, and that the source patient is not billed.
   5. Complete the ―Occurrence Report ―form. All follow-up care is provided through the OM.




                                                                 Environment of Care
PURPOSE: To provide a hygienic environment for patients, staff and other individuals in the hospital and reduce transmission of microorganisms in newly
constructed and existing environments of care. This is part of the broader purpose of providing a safe, functional, supportive, and effective environment of
care. Included in this section are infection control policies regarding risk assessment and reduction during construction and renovation, environmental
sanitation, laundry handling, and managing regulated biohazardous waste.

POLICY: The Infection Control Committee provides a liaison with the Environment Services (ES) by having them serve as a member of the Infection Control
Committee and in activities related to process and outcome monitoring, and makes recommendations for improvement in infection control related to
environmental issues.
Activities include, but are not limited to, risk assessment and participation in contractor meetings during construction and renovation, EOC rounds, and utilities
monitoring such as air quality monitoring. A matrix for infection control risk assessment and precautions for construction and renovation has been jointly
developed and adopted with the Engineering and Maintenance Department.




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                                                         Infection Control Risk Assessment (ICRA)

                                                 Matrix of Precautions for Construction & Renovation
Step One:
Using the following table, identify the Type of Construction Project Activity (Type A-D)

                   Inspection and Non-Invasive Activities.
                   Includes, but is not limited to:

                   feet
     Type A

                       not generate dust or require cutting of walls or access to ceilings other
                       than for visual inspection.
                   Small scale, short duration activities which create minimal dust
                   Includes, but is not limited to:
     Type B

                                                       e dust migration can be controlled.
                   Work that generates a moderate to high level of dust or requires
                   demolition or removal of any fixed building components or assemblies
                   Includes, but is not limited to:
                                                                    ing
    Type C                         floor coverings, ceiling tiles and casework




                   Major demolition and construction projects
                   Includes, but is not limited to:
    Type D



Step Two:

Using the following table, identify the Patient Risk Groups that will be affected.
If more than one risk group will be affected, select the higher risk group:

  Low Risk           Medium Risk                 High Risk                   Highest Risk
Office areas
                                                                         immunocompromised
                                                                         patients

                                              (specimen)
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                                                                                                                                                             42


                  Therapy

                                                                              pressureisolation rooms
                                                 Care Unit

                                                                              including C-section
                                                                              rooms



Step Three: Match the

      Patient Risk Group (Low, Medium, High, Highest) with the planned …
      Construction Project Type (A, B, C, D) on the following matrix, to find the …
      Class of Precautions (I, II, III or IV) or level of infection control activities required.
      Class I-IV or Color-Coded Precautions are delineated on the following page.



                                           Construction Project Type
 Patient Risk Group          TYPE A           TYPE B             TYPE C                     TYPE D
LOW Risk Group                  I                 II                 II                      III/IV
MEDIUM Risk Group               I                 II                III                        IV
HIGH Risk Group                 I                 II              III/IV                       IV
HIGHEST Risk Group             II              III/IV             III/IV                       IV

Note: Infection Control approval will be required when the Construction Activity and Risk Level indicate that Class III or Class IV control procedures are
necessary.




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                                                                                                              43
                                             Description of Required Infection Control Precautions by Class

                During Construction Project                    Upon Completion of Project
        1. Execute work by methods to minimize              1. Wipe work surfaces with disinfectant.
           raising dust from construction operations.       2. Wet mop and/or vacuum with HEPA
Class
        2. Immediately replace a ceiling tile displaced        filtered vacuum before leaving work
  I
           for visual inspection                               area.

        1. Provide active means to prevent airborne         1. Wipe work surfaces with disinfectant.
           dust from dispersing into atmosphere.            2. Contain construction waste before
        2. Water mist work surfaces to control dust            transport in tightly covered
           while cutting.                                      containers.
Class   3. Seal unused doors with duct tape.                3. Wet mop and/or vacuum with HEPA
  II    4. Block off and seal air vents.                       filtered vacuum before leaving work
        5. Place dust mat at entrance and exit of work         area.
           area                                             4. Remove isolation of HVAC system in
        6. Remove or isolate HVAC system in areas              areas where work is being
           where work is being performed.                      performed.
        1. Remove or Isolate HVAC system in area            1. Do not remove barriers from work
           where work is being done to prevent                 area until completed project is
           contamination of duct system.                       inspected by the owner’s Safety
        2. Complete all critical barriers i.e. sheetrock,      Department and Infection Control
           plywood, plastic, to seal area from non work        Department and thoroughly cleaned
           area or implement control cube method               by the owner’s Environmental
           (cart with plastic covering and sealed              Services Department.
           connection to work site with HEPA vacuum         2. Remove barrier materials carefully to
Class
           for vacuuming prior to exit) before                 minimize spreading of dirt and debris
  III
           construction begins.                                associated with construction.
        3. Maintain negative air pressure within work       3. Vacuum work area with HEPA
           site utilizing HEPA equipped air filtration         filtered vacuums.
           units.                                           4. Wet mop area with disinfectant.
        4. Contain construction waste before transport      5. Remove isolation of HVAC system in
           in tightly covered containers.                      areas where work is being
        5. Cover transport receptacles or carts. Tape          performed.
           covering unless solid lid.




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          1. Isolate HVAC system in area where work is        1. Remove barrier material carefully to
             being done to prevent contamination of duct         minimize spreading of dirt and debris
             system.                                             associated with construction.
          2. Complete all critical barriers i.e. sheetrock,   2. Contain construction waste before
             plywood, plastic, to seal area from non work        transport in tightly covered
             area or implement control cube method               containers.
             (cart with plastic covering and sealed           3. Cover transport receptacles or carts.
             connection to work site with HEPA vacuum            Tape covering unless solid lid
             for vacuuming prior to exit) before              4. Vacuum work area with HEPA
             construction begins.                                filtered vacuums.
          3. Maintain negative air pressure within work       5. Wet mop area with disinfectant.
             site utilizing HEPA equipped air filtration      6. Remove isolation of HVAC system in
             units.                                              areas where work is being
          4. Seal holes, pipes, conduits, and punctures          performed.
             appropriately.
Class     5. Construct anteroom and require all
 IV          personnel to pass through this room so they
             can be vacuumed using a HEPA vacuum
             cleaner before leaving work site or they can
             wear cloth or paper coveralls that are
             removed each time they leave the work
             site.
          6. All personnel entering work site are required
             to wear shoe covers. Shoe covers must be
             changed each time the worker exits the
             work area.
          7. Do not remove barriers from work area until
             completed project is inspected by the
             owner’s Safety Department and Infection
             Control Department and thoroughly cleaned
             by the owner’s Environmental Services
             Department.




                                              Environmental Sanitation for Infection Control
POLICY:
Routine Cleaning: Cleaning methods for removal of soil are generally adequate for routine environmental cleaning. Since microorganisms are normal
contaminants of the environment, extraordinary attempts to disinfect or sterilize wall, floors and other surfaces are not indicated unless there is an association
made with transmission of infections to patients or staff. In general, environmental cleaning is the responsibility of the Environmental Services (ES)
Department.



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Schedules: Carpets are vacuumed regularly with machines designed to efficiently filter discharged air (HEPA), cleaned if spills occur and shampooed
whenever a thorough cleaning is indicated. Terminal cleaning of walls, blinds and curtains is done at routinely scheduled intervals or when they are visibly
soiled. Disinfectant fogging is not done.
Environmental Services maintains schedules for routine area cleaning including floors, walls, curtains, rugs, windows, fans and surfaces in each area.
Equipment and environmental and working surfaces are cleaned and decontaminated after contact with blood or other body substances using an approved
environmental disinfectant. All bins, pails, cans and similar receptacles intended for general and infectious waste are decontaminated on a regular schedule
or as soon as possible if visibly soiled.

Spill Clean-up: Clean-up of spills or other environmental soilage with blood and other body substances is done as soon as possible by gloved personnel
using an approved and appropriate environmental disinfectant. When the spill involves sharps or broken glass, it is done using appropriate tools such as a
dustpan and brush, forceps or tongs. Clean-up supplies are available in the custodial closets or other designated locations in each work area or from
Environmental Services personnel.



Approved Environmental Disinfectants: A hospital grade, environmental disinfectant-detergent, registered with the EPA, is used for cleaning environmental
surfaces. Manufacturers' instructions for use and dilution are followed. The Infection Control Committee approves the generic type of disinfectant for general
hospital wide use. The current approved generic type of disinfectant is a quaternary ammonium compound. Other types of environmental disinfectants can be
used with the consultation and approval of the Infection Control Practitioner. Approved environmental disinfectants are available from Environmental
Services.




Consultation: The Infection Control Department provides consultation regarding any major change in cleaning products or techniques. Consultation
regarding selection of an appropriate environmental disinfectant can be done upon request through the Environmental Service and Infection Control
Departments.

RESPONSIBILITY: All departments involved are responsible for implementing this policy in conjunction with the hospital Environmental Services Department.

REFERENCE: Environmental Service Department Policies




                                                    Waste Handling:
                            Containing, Transport and Disposal of Potentially Infectious Waste

POLICY: Wastes which present a potential infection hazard to hospital waste handlers, patients, staff and the general public shall be identified, handled, and
disposed of in a safe manner consistent with the recommendations of regulatory and advisory agencies.




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Biohazardous Waste Definitions: A variety of terms are used by federal, state, county and city regulatory agencies to describe hospital waste. These terms
include regulated waste, biomedical waste, infectious waste, and general medical waste. Reid Hospital contracts for infectious/biomedical waste
transportation and treatment to ensure appropriate disposal. This contract covers Reid’s wastes, which are consistent with the Indiana Administrative Code
(IAC) definitions of regulated, biomedical waste including:

1. Cultures and stocks of etiologic agents, clinical specimens & containers, culture dishes, devices used to transfer, inoculate and mix cultures, and waste that
has come into contact with specimens from the laboratory (excluding computer paper).

2. Pathological waste including waste human source biopsy materials, tissues and anatomical parts that emanate from surgery, obstetrical procedures and
autopsy. If Leeches have been used for patient debridment procedures and placed in alcohol afterwards, are included. Pathological waste does not include
teeth, human corpses, remains, and anatomical parts that are intended for internment or cremation.

3. Discarded live and attenuated vaccines and wastes from production of biologicals and serums.

4. Blood, blood products and other body fluids in free flowing form, including containers that are difficult to empty into the sanitary sewer system (such as
1000 cc vacutainer bottles with centesis fluids or blood transfusion bags/IV tubing with visible blood). These containers with liquid body fluids are carefully
placed into the large, red-bag lined, and "biohazard" marked waste cans located in the dirty utility rooms. A solidifier is added to the container when free
flowing liquid is visible.


5. Needles and sharps waste (capable of causing punctures or injury) including needles, syringes with needles attached, IV tubing with needles attached,
glass specimen tubes, razors, scalpel blades and lancets. Needles and sharps waste are disposed of into rigid, biohazard labeled, plastic containers by the
user. Sharps containers are assessed by Environmental Services, Nursing and other departmental staff and replaced when near full; used sharps containers
are placed into the dirty utility rooms for pick-up by Environmental Services staff.

6. Waste with body substances, which are fully absorbed by other waste materials (except those listed above in 1-7) is not classified as infectious waste and
can be disposed of in the general waste stream. All waste is bagged securely to prevent leaking. Any non-radioactive liquid patient waste may be disposed of
into the sanitary sewer system (such as blood, urine or dialysate fluids). Waste collection and disposal is the responsibility of the Environmental Services
Department according to approved procedures. Waste handlers and transporters wear gloves when handling wastes. A list is posted in the soiled utility
rooms near the regulated waste containers which identifies waste requiring special disposal.




                                                                     Laundry Handling

POLICY: Methods of handling clean laundry ensure that cleanliness is maintained. All used laundry is handled so that exposure associated with containing,
transporting and handling is eliminated. Laundry is reprocessed and distributed by Reid Hospital Laundry.

PROCEDURE:
1. All dry, used laundry is bagged in standard laundry bags available from Reid’s laundry.

2. All soiled laundry is bagged in the work areas where is was used, placed in the dirty utility rooms, collected from there and transported by gloved Linen
Service personnel to a "biohazard" marked holding area.

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3. All clean laundry carts in the holding areas are plastic/nylon covered.

4. Clean and soiled laundry is kept separated to prevent contamination of the clean from the soiled laundry.



                                                                STORAGE UNDER SINKS
POLICY: Storage space under sinks cannot be utilized to store items. Moisture or contamination presents a risk of infection to patients if patient items were
stored there.

PROCEDURE:
1. Equipment and supplies used for patient care or diagnostic purposes are NOT stored under sinks.

2. In the event of a leak, call engineering immediately.



                                                           Disinfection & Sterilization
                                     Cleaning, Disinfection and Sterilization of Patient Care Equipment
POLICY:
The goal of reprocessing shared patient care equipment is to achieve a level of cleaning, disinfection or sterilization which eliminates the risk of these objects
as the source of microorganisms causing infections. Decisions regarding cleaning, disinfecting or sterilizing patient care equipment/supplies are based on the
potential risk of infection associated with their use. "Table 1. Reprocessing of Medical Devices and Patient Care Items," provides direction for these decisions.
Information of specific methods can be found in "Table 2. Methods of Sterilization and Disinfection." Consultation with the Infection Control Department is also
available at 3493.

PROCEDURE:
CLEANING:
All objects to be disinfected or sterilized should first be thoroughly cleaned to remove all organic matter and other residue. Cleaning can be done manually
(using friction) or mechanically (ultrasonic cleaners, washer-sterilizers). Whenever possible, cleaning in a washer is preferred. Manual cleaning is done by
gloved personnel. Hinged items and items with lumens take special attention and inspection to ensure that debris has been removed. Sharp objects (such as
scalpels, needles, blades, etc.) that are immersed during cleaning, are removed from the soaking solution using a strainer-type lifter, forceps or other tool, not
by reaching into the solution by hand.
INDICATIONS FOR STERILIZATION AND HIGH-LEVEL DISINFECTION:
1. Critical medical devices or patient care equipment that enter normally sterile tissue, the vascular system or through which blood flows are subjected to a
sterilization procedure before each use.
2. Scopes, such as laparoscopes, arthroscopes and other fiberoptics that enter normally sterile tissue are subjected to a sterilization procedure before each
use. Accessories designed to break mucosal surfaces, such as biopsy forceps or snares, are sterilized.
3. Equipment that touches mucous membranes, e.g., endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment,
receives high-level disinfection at a minimum.
4. Items that are sheathed during use, such as vaginal probes covered with condoms; reduce the level of microbial contamination. However, these items
must still receive high level disinfection between patients since the sheaths and condoms may fail.
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                                                                                                                                                               48
5. Sterile water is used to rinse items following cold soak sterilization (chemical soak). Tap water may be used to rinse items following cold chemical soaking
for high level disinfection. When tap water is used to rinse off chemical soak solutions used in high level disinfection of scopes, these scopes have a 70%
alcohol rinse following the tap water rinse, and forced air is used to dry lumens.
6. Noncritical patient care surfaces (bedrails, overbed tables) and equipment (stethoscopes, hammars) that touches intact skin receives low level disinfection
when visibly soiled and before use by another patient.
7. To eliminate the chance of disinfection contamination, certain control measures are implemented. The disinfectant is prepared correctly to achieve the
manufacturer’s recommended use-dilution. Preparation is done using clean containers and in a clean work area.

METHODS OF STERILIZATION:
1. Whenever sterilization is indicated, a steam sterilizer is used unless the object to be sterilized will be damaged by heat, pressure, or moisture or is
otherwise inappropriate for steam sterilization. In this case, another acceptable method of sterilization is used, e.g., cold chemical soak sterilization, Steris
system or Sterrad autoclave. Cold chemical soak and Steris System 1 are high level disinfection.
2. Flash sterilization (270 F or 132 C for 3 minutes in a gravity displacement steam sterilizer) is not recommended for implantable items and should only be
used for emergent needs. For implants that are flash sterilized, a biological indicator is used for each implant load. (AAMI, AORN)

MONITORING OF STERILIZERS:
  1. Each load is monitored with mechanical and chemical indicators. If the mechanical or chemical indicators suggest inadequate monitoring, the items
     are not used until adequately sterilized.
  2. All high vac, pre-vac and gravity steam sterilizers are monitored at least once a week with commercial preparations of spores intended specifically for
     that type of sterilizer (i.e., Geobacillus stearothermophilus for steam sterilizers and Bacillus atropheus (formerly Bacillus subtilis) for ethylene oxide
     and dry heat sterilizers).
  3. Biological testing is run daily for the Serrad. (AAMI, AORN)
  4. Biological testing is run weekly for the Steris System 1 Processors. Chemical indicators are run with each load and system diagnostics are completed
     daily, when in use, prior to the first load.
  5. Every autoclave load which contains an implantable device is monitored using a biological indicator. Documentation is maintained of implantable
     devices placed in specific patients.
  6. If spores are not killed in routine spore tests, the sterilizer is immediately shut down, checked for proper use and function, and in conjunction with
     Engineering, and the spore test repeated. The sterilizer is not used until spore testing is negative. Objects, other than implantable objects, do not
     need to be recalled because of a single positive spore test unless the sterilizer or the sterilization procedure is defective.
  7. If spore tests remain positive, use of the sterilizer is discontinued until it is serviced.

USE AND PREVENTIVE MAINTENANCE:
Manufacturers' instructions are followed for use and maintenance of mechanical cleaning equipment and sterilizers. Preventive maintenance is performed on
sterilizers by qualified personnel and guided by the manufacturer’s instructions.

STORAGE AND USE OF STERILE ITEMS:
1. Storage areas for clean and sterile items provide protection against dust, moisture, insects and temperature and humidity extremes. These items are
stored so that the packaging is not compromised (punctured, bent, etc.).
2. Sterilized items without expiration dates can be used unless its sterility is questionable, e.g., the package is punctured, torn or wet (event related shelf life).
Items with expiration dates are not used if the expiration date has passed.

REPROCESSING SINGLE-USE OR DISPOSABLE ITEMS:
Single use devices are reprocessed by Reid Hospital using a third-party reprocessor (See Administrative Policy 33). They are reprocessed by contractors
who provide reprocessing of disposables service according to the FDA enforcement document for single-use devices.
RESPONSIBILITY:

                                                                                                                                                                    48
                                                                                                                                                               49
All department managers involved are responsible for implementing this policy as it relates to their area of service and as specified by the following Tables 1
and 2. Consultation regarding proper cleaning, disinfection and sterilization is available from Infection Control at 3493.

TABLE 1: REPROCESSING OF MEDICAL DEVICES AND PATIENT CARE ITEMS
Classification/Example Process/ Product               Procedure                           Comment
Critical - enters sterile tissue or vascular system
Sterilized in the hospital Sterilization: Autoclave   1. Thoroughly clean objects and Sterilization
Example: Surgical             or prolonged contact    wrap or package for sterilization. processes are
instruments and devices; with sporocidal              2. Follow manufacturer's             designed to have a
trays and sets; implants chemical (EPA sterilant/     instructions for use of each         wide margin of
                              disinfectant)           sterilizer or use recommended        safety. If spores are
                                                      chemical soak protocol.              not killed, the
                                                      3. Monitor time-temperature          sterilizer should be
                                                      charts.                              checked for proper
                                                      4. Use commercial spore              use and function; if
                                                      preparations to monitor sterilizers. spore tests remain
                                                      5. Inspect package for integrity     positive,
                                                      and for exposure of sterility        discontinue use of
                                                      indicator before use.                the sterilizer until
                                                      6. Use before maximum safe           properly serviced.
                                                      storage time has expired if          Maximum safe
                                                      applicable.                          storage time of
                                                                                           items processed in
                                                                                           the hospital varies
                                                                                           according to type of
                                                                                           package or
                                                                                           wrapping
                                                                                           material(s) used;
                                                                                           follow
                                                                                           manufacturer's
                                                                                           instructions for use
                                                                                           and storage times.
Purchased as sterile                                  1. Store in safe, clean area.        Materials
Example: Intravenous                                  2. Inspect package for integrity     Management and
fluids; irrigation fluids;                            before use.                          Infection Control
normal saline; trays and                              3. Use before expiration date if     Department will
sets                                                  one is given.                        notify the Food and
                                                      4. Notify infection control if       Drug
                                                      circumstances suggest infection Administration,
                                                      related to use of the item.          local and state
                                                                                           health departments
                                                                                           and CDC if intrinsic
                                                                                           contamination is
                                                                                           suspected.

                                                                                                                                                              49
                                                                                                                    50


Semicritical - touches mucous membranes/open skin
Should be free of          High to intermediate     1. Sterilize or follow a protocol for   Bacterial spores
vegetative bacteria. May level disinfection:        high-level disinfection.                may survive after
be subjected to high-      Pasteurization or short 2. Bag and store in safe, clean          high-level
level disinfection rather contact with sporocidal area.                                     disinfection, but
than sterilization process chemical (EPA sterilant/ 3. Conduct quality control              these usually are
Example: Respiratory       disinfectant) with label monitoring after any important          not pathogenic.
therapy equipment;         claim for tuberculocidal changes in the disinfection             Microbiologic
flexible endoscopes;       activity                 process.                                sampling can verify
laryngoscopes;                                                                              that a high-level
endotracheal tubes; and                                                                     disinfection process
other similar instruments                                                                   has resulted in
                                                                                            destruction of
                                                                                            vegetative bacteria;
                                                                                            however, this
                                                                                            sampling is not
                                                                                            routinely
                                                                                            recommended.
Non-critical - touches intact skin
Usually contaminated       Low-level disinfection:   1. Follow a protocol for cleaning       Items and the
with some bacteria         Hospital or               or, if necessary, a low-level          environment are
Example: Bedpans;          environmental             disinfection process. Wear             cleaned when
crutches; rails; EKG       disinfectant.             gloves for cleaning.                   visibly soiled and
leads; stethoscopes;                                 2. Follow manufacturer’s               on a regular basis.
tabletops; exam tables                               instruction for use-dilution and
                                                     replace with fresh solution
                                                     frequently.



                                                 TABLE 2: METHODS OF STERILIZATION AND DISINFECTION

                             Sterilization      Disinfection
                           Critical items (will High level (semi-      Intermediate      Low level (non-critical
                            enter tissue or     critical items: will    level (some       items: will come in
                          vascular system or come in contact           semi-critical    contact with intact skin)
                                                                               a
                        blood will flow through with mucous              items and
                                  them            membrane or            non-critical
                                                 non-intact skin)           items)

Object                   Procedure Exposure Procedure                    Procedure Procedure (exposure
                                   time (hr) (exposure time              (exposure time ≤ 10 min)

                                                                                                                    50
                                                                             51
                                          12-30 min at 20°C) time ≤ 10
                                                             min)
                                                                    5
Smooth, hard surface          A    MR             D               J      K
1,4
                              B    MR             E               K      L
                              C    MR             F               M      M
                              D    10 h           H               N      N
                                                   6
                              E     NA            I                      O
                              F     6h            J
                              G   12 m,
                              H   55°C
                                  3-8 h
      Rubber tubing and       A    MR             D
                  3,4
        catheters             B    MR             E
                              C    MR             F
                              D    10 h           H
                                                   6
                              E     NA            I
                              F     6h            J
                              G   12 m,
                              H   55°C
                                  3-8 h
  Polyethylene tubing         A    MR             D
                 3,4,7
   and catheters              B    MR             E
                              C    MR             F
                              D    10 h           H
                              E     NA
                              F     6h
                              G   12 m,
                              H   55°C
                                  3-8 h
                          4
 Lensed instruments           B    MR             D
                              C    MR             E
                              D    10 h           F
                              E     NA            H
                              F     6h
                              G   12m,
                              H   55°C
                                  3-8 h
                                                                  8
  Thermometers (oral                                             K
                 8
     and rectal)




                                                                             51
                                                                                                                                                               52
                         4
    Hinged instruments       A                            D
                             B                            E
                             C                            F
                             D                            H
                                                           6
                             E                            I
                             F                            J
                             G
                             H
Modified from Rutala WA. Weber DJ and the Healthcare Infection Control Practices Advisory Committee . In: CDC Draft Guideline for Disinfection and
Sterilization in Healthcare Facilities, Federal Register, April 30, 2002.


A. Heat sterilization, including steam or hot air (see manufacturer's recommendations)
B. Ethylene oxide gas (see manufacturer's recommendations)
C. Hydrogen peroxide gas plasma (see manufacturer’s recommendations).
D. Glutaraldehyde-based formulations (>2%) Caution should be exercised with all glutaraldehyde formulation when further in-use dilution is anticipated.)
E. Ortho-phthaladehyde 0.55%
F. Hydrogen peroxide 7.5% (will corrode copper, zinc and brass)
G. Peracetic acid, concentration variable but <1% is sporicidal.
H. Hydrogen peroxide 7.35% and peracetic acid 0.23%; hydrogen peroxide 1% and paracetic acid 0.08% (will corrode metal instruments)
                             o
I. Wet pasteurization at 70 C for 30 minutes after detergent cleaning
J. Sodium hypochlorite (5.25% household bleach diluted 1:50 provides 1000 ppm available chlorine; will corrode metal instruments)
K. Ethyl or isopropyl alcohol (70% to 90%)
L. Sodium hypochlorite (5.25% household bleach diluted 1:500 provides 100 ppm available chlorine)
M. Phenolic germicidal detergent solution (follow product label for use-dilution)
N. Iodophor germicidal detergent solution (follow product label for use-dilution)
O. Quaternary ammonium germicidal detergent solution (follow product label for use-dilution)
MR, Manufacturer's Recommendation
NA Not applicable
1
  See text for discussion of hydrotherapy.
2
  The longer the exposure to a disinfectant, the more likely it is that all microorganisms will be eliminated. Ten minutes exposure is not adequate to disinfect
many objects, especially those which are difficult to clean, because they have narrow channels or other areas that can harbor organic material and bacteria.
Twenty minutes exposure at 20° C is the minimum time needed to reliably kill M. tuberculosis and other nontuberculous mycobacteria with a 2%
glutaraldehyde. With the exception of 2% glutaraldehydes, follow the FDA-cleared high-level disinfection claim. Some high-level disinfectants have a
reduced exposure time (e.g., ortho-phthalaldehyde at 12 minutes at 20°C) because of their rapid activity against mycobacteria or reduced exposure time due
to increased mcobactericidal activity at elevated temperature (2.5% glutaraldeyde at 5 minutes at 35°C).
3
  Tubing must be completely filled for disinfection; care must be taken to avoid entrapment of air bubbles during immersion.
4
   Material compatibility should be investigated when appropriate.
5
  Used in laboratory where cultures or concentrated preparations or microorganisms have spilled. This solution may corrode some surfaces.
6
  Pasteurization (washer disinfector) of respiratory therapy and anesthesia equipment is a recognized alternative to high-level disinfection. Some data
challenge the efficacy of some pasteurization units.
7
  Thermostability should be investigated when indicated.
8
  Do not mix rectal and oral thermometers at any stage of handling or processing.

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                                                                                                                                                                  53
                                                                Microbiological Sampling
POLICY:
1. Routine environmental culturing of air and environmental surfaces is not done.
2. Monthly sampling of water used to prepare dialysis fluid is monitored by The Dialysis Center, who receives, evaluates and interprets sampling results. Reid
Hospital Microbiology may provide laboratory services.
3. Microbiologic sampling, when indicated, is done as part of an epidemiological investigation.
4. Routine microbiologic sampling of patient-care objects purchased as sterile is not recommended. If contamination of a commercial product sold as sterile is
suspected, Infection Control is notified, suspected lot numbers are recorded and items from suspected lots are segregated and not used. The Infection
Control Committee, Microbiologist, or designee of the infection control chair makes decisions regarding microbiological assays and notification of outside
agencies (e.g. FDA, CDC, etc.).


                                                                        Toy Cleaning
POLICY:
1. Children who do not have airborne communicable diseases (e.g. measles, mumps, rubella, pertussis, chickenpox, influenza, TB), may use playroom toys
(ED)(Rehab)(PPCU). Playrooms are cleaned daily. Area staff and Environmental Services staff share the cleaning responsibilities for playrooms and large
toys (e.g., slides, castles, gym mats, toys, etc.).
2. Toys are shared between patients and toy washing is done daily by area staff using soap and water or a non-toxic disinfectant.
3. Individual toys belonging to the child are kept with the patient in the patient's room and are cared for by family and staff. These toys are not shared with
other patients.

PROCEDURE:
1. Dirty toys are separated into three categories
          a) Immersible toys have no moving parts, no hollow spaces and a non-porous surface. They will not soak up water into closed cracks or spaces
          (e.g. Lego's, stacking cups).
          b) Non-Immersible toys have inside spaces, small openings or hinges (e.g. dolls, cars) or are too large to be immersed (e.g. slides, etc...).
          c) Uncleanable toys soak up water and are damaged by immersion (e.g. games, books, puzzles, activity books, crayons, stuffed animals).
2. Immerse, surface wash, and rinse immersible toys
3. Wipe surface of non-immersible toy, using a washcloth. Wipe the surface thoroughly and clean all the nooks and crannies.
4. Uncleanable toys are discarded if soiled or wiped down with a damp cloth and ultimately sent home with child.
5. Dry and replace toys in exam and/ or waiting rooms.




      Bloodborne Pathogens “Exposure Control Plan” – See Infection Control Intranet Site

INTRODUCTION
On December 6, 1991, the Occupational Safety and Health Administration (OSHA) published a final rule on Bloodborne Pathogens effective March 1992 (29
CFR 1910.1030). Washington State Department of Labor and Industries adopted similar requirements in May 1992 (WAC 296-6208001). Copies of the
federal Bloodborne Pathogens Standard and the state regulation, WAC: Part J, "Biological Agents" are available at these websites online. In November 1999,
a NIOSH Alert, ―Preventing Needlestick Injuries in Heath Care Settings‖ was published to promote use of improved engineering controls to reduce needlestick
                                                                                                                                                                  53
                                                                                                                                                               54
injuries. Ultimately, the Needlestick Safety & Prevention Act was signed and a revised national standard was published in the Federal Registry effective April
2001.
The purpose of these rules and regulations is to minimize or eliminate occupational exposure by healthcare workers to bloodborne infectious agents such as
HIV, hepatitis B, and hepatitis C. This rule applies to all HMC employees and volunteers who may be exposed to blood or other potentially infectious materials
in the workplace. Occupational exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially
infectious materials that may result from the performance of an employee's regular work duties.
This plan summarizes the elements of the infection control and Occupation Medicine programs that are important in reducing or eliminating occupational
exposure. A combination of engineering and work practice controls, use of personal protective clothing and equipment, training, and medical surveillance are
effective strategies and are outlined in this plan. Additional details may be found in other sections of the Infection Control Manual located on the Infection
Control Intranet Site under ―Exposure Control Plan‖ or in department-specific policy and procedure manuals.
This plan is updated annually using feedback and input from staff as needed, incident report summaries, consultations with Infection Control, Occupation
Medicine, Risk Management, and Safety, and referrals from committees, departments, clinics, or units.
Blood exposure incident reports are summarized annually for identification of prevention strategies and quarterly for product evaluation purposes. These
summaries are reviewed and evaluation of products and techniques that eliminate or minimize the use of needles and sharps is ongoing through the Product
Evaluation, Infection Control, Quality Assessment, and Safety Committees. Documentation of consideration and implementation of safer medical devices can
be found in the Product Evaluation Committee minutes.
Consultation on the Bloodborne Pathogens Standard as it relates to Reid Hospital is available through the Infection Control Office (3493), Infection Control
Intranet Site, or Occupational Medicine (3446).

BODY SUBSTANCE ISOLATION:
Universal Precautions + Standard Precautions
Summary of Key Elements of Body Substance Isolation (BSI)
Infection precautions place a barrier of plastic, rubber or other material (gloves), fabric (gowns), or paper (masks) between potentially infectious body
substances and the caregiver. All humans have potentially infectious agents in pus, feces, and sputum/saliva. Many people also have potentially infectious
pathogens in blood, urine, and other body fluids, tissues, and substances. Precautions to prevent transmission of these potentially infectious agents are
practiced with all patients, not only those who have diagnosed infections.
Effective infection control precautions provide protection to both patients and healthcare providers. Whenever precautions are used to protect healthcare
providers (i.e., gloving for touching a patient's mucous membranes), the impact on the patient must be considered and protection of both accomplished (i.e.,
using fresh clean or sterile gloves immediately before touching the patient's mucous membranes).
At Reid Hospital, Body Substance Isolation (BSI) has been adopted as the universal and standard precautions system. BSI signs are displayed throughout
the hospital to remind staff and Reid Hospital volunteers that all patients are in Body Substance Isolation. BSI signs are located in, but not limited to:
      Patient rooms;
      Patient clinical areas;
      Departments that provide direct patient care;
      Restrooms;
      Departments and areas that provide patient support services and handle body substances.
No other special signage is used for patients diagnosed with touch-contact spread infections. Stop - Airborne isolation/precaution signs are used to identify
the rooms of patients with airborne communicable diseases such as tuberculosis or chickenpox.
This consistent approach to managing all body substances, including blood, from all patients is essential to prevent transmission of all infectious agents. The
following practices are used for all patients at all times to prevent transmission of infectious pathogens to patients and to healthcare workers:
      Healthcare providers put on clean or sterile gloves just before contact with mucous membranes or non-intact skin for all patients. When direct contact
         with moist body substances (blood, pus, sputum, urine, feces, saliva, etc.) from any patient is likely, gloves are worn. Personnel gathering trash and
         personnel who hand-clean soiled items and equipment wear heavy latex gloves or suitable alternative gloves.

                                                                                                                                                              54
                                                                                                                                                          55
   When soilage of clothing or bare skin by body substances is anticipated, a gown or apron is worn. If a gown or apron becomes penetrated by body
    substances, it is removed immediately or as soon as possible. Selection of body covering is based on anticipated volume of body substance, duration
    of contact, and rubbing/friction of body substance into the covering.
   When splattering of body substances to the face is anticipated (to facial skin, eyes, nose, mouth), appropriate facewear is worn. When splatter to the
    face is expected, it is important to cover the face entirely. Facewear includes full-face shields, glasses/goggles with sideshields, masks with upper
    faceshields. Facewear is needed during open suctioning, wound irrigation, and when draining body fluid collection containers.
   Surgical caps, hair covers, hoods, leggings, arm shields, boots, and shoe covers are worn when contact with body substances to those body areas is
    highly anticipated. Upper body areas which may need covering during splashing procedures (i.e., jet spray irrigation, etc.) include the face, neck,
    ears, under the chin, arms, and legs. Some procedures (i.e., large volume irrigation) may result in body areas below the knees becoming soaked and
    require adequate protective barriers. Open toed shoes or shoes with holes (CROCS) in surgery or patient care areas are not allowed due to the
    potential of exposure to skin from blood or other potentially infectious material (OPIM).
   Handwashing remains the most effective yet most often overlooked method of infection control and is done:
         After handling used equipment;
         Between contacts with different patients;
         After using the bathroom;
         When hands are soiled;
         Before eating;
         Immediately after gloves or other barriers have been removed. Handwashing after glove removal is important since some gloves may have
             undetected holes and may not completely prevent hand contamination.
         Handwashing can be done using soap and running water or by using an alcohol based hand cleanser provided in the clinical areas. Alcohol
             gels/foam should not be used when hands are soiled. If hands are soiled, they should be washed with soap and water for a minimum of 15-20
             seconds.
   Following accidental contact exposure of any body substance to the employee(s):
         Skin: Wash the exposed area immediately, or as soon as reasonably possible, with soap and running water for at least 30 seconds. If skin is
             not intact and was exposed to blood, report to Occupational Medicine or the Emergency Department.
         Eyes or other mucous membranes: Flush with normal saline or water immediately or as soon as reasonably possible for at least 30 seconds.
             Report body substance exposures to Occupational Medicine or the Emergency Department.
   Needles and other sharps are handled in such a way that injury is avoided. See Exposure Control Plan.
   Laboratory specimens are handled as if they all contained infectious agents:
         Specimens are placed inside plastic, biohazard-labeled bags before transport to the laboratory. The outside of the specimen bag/container
             should be clean.
         Any specimens transported through the pneumatic tube system are placed in rigid, biohazard-labeled carrier containers.
         Refrigerators or freezers used to store body substance specimens are identified with biohazard signs.
   Handling and reprocessing practices are consistent for all soiled articles and equipment. All such articles and equipment are treated as if infectious
    agents are present.
         Soiled instruments and equipment are placed in biohazard-labeled containers located in the dirty utility rooms.
         Central Processing, Respiratory Care and other personnel use appropriate gloves to remove and transport used or soiled items.
         When reusable sharps are soaked for cleaning, strainers or baskets (designed to prevent a person from having to reach into the container
             blindly to remove the sharp) are used.
   Handling and transporting of soiled and/or wet linen:
         Soiled linen is bagged in standard cloth linen bags at the point of use.
         Wet linen that is likely to leak through cloth bags is first placed into a plastic leakproof bag, then into a cloth linen bag that identifies it as
             laundry.

                                                                                                                                                          55
                                                                                                                                                                  56
                Patient clothing infested with lice or scabies are placed in plastic bags to contain the parasites and labeled with patient identification and sent
                 to laundry.
             Laundry Department: Transporters wear gloves and laundry workers glove and gown when handling all soiled linen.
       Handling and transporting of waste:
             General waste is placed into plastic trash bags, environmental services picks-up and transports to the dirty dock for contractor pick-up.
                 Waste from patient care areas with body substances in an absorbed form is considered to be general waste if it is in a leakproof bag, i.e.,
                 gloves, gowns, masks, dressings, emptied collection containers, etc. These items are placed into waste containers, collected with the general
                 waste.
             Infectious/biomedical wastes (defined in the Waste Management section) are handled in a separate waste system; infectious/biomedical
                 waste is placed in special biohazard labeled bags (containers) in the dirty utility rooms, collected by environmental services and transported
                 to a holding area, boxed and transported offsite by a biomedical waste handling contractor.
       Cleaning of patient rooms, laboratory areas, and other clinical areas is performed in a standard and consistent manner. Disinfectant and spill clean-up
        equipment are available from Environmental Services.
             Prompt cleanup of Blood/body substance spills is done by gloved personnel using a germicidal disinfectant and safe procedure.
             Cleanup of broken glass is not done by hand; a dust pan and broom are used.
       Private rooms are used for patients with airborne communicable diseases and for patients who consistently soil the room and articles in the room with
        infectious body substances.

                                                ENGINEERING and WORK PRACTICE CONTROLS
Engineering Controls are measures that isolate or remove a bloodborne hazard, and includes self sheathing needles and needle devices that contain built-in
safety features, or non-needle sharps such as needleless IV systems.

Needle / Sharps Management
Needles and sharp objects are handled to minimize risk of inadvertent puncture or other injuries. All used sharps are considered contaminated with potentially
infectious materials.
     Patient Notification. Let patients know what is about to happen and what you want them to do or not do. Sudden movements from startled patients
         adds to the risk of injury.
     Recapping and handling of used needles. Routine recapping of used needles is avoided. In certain situations, such as serial injections from the
         same syringe, recapping is safer than leaving the needle uncapped. Whenever recapping is necessary, it is done using a one-handed recapping
         technique or a recapping mechanical device.
     Used needles and other sharps are not cut, bent, sheared, broken, removed, or otherwise manipulated by hand. If a used needle needs to be
         removed from a syringe, forceps or other sharps removal devices are to be used. It is not necessary to change needles during blood culturing.
     Passing of needles. For procedures which involve passing of needles or other sharps, the passer places the sharp on a surface or neutral zone
         (tray, basin, etc.) for the recipient to pick up rather than use hand-to-hand passing. If this is not possible, then visual or verbal communication is used
         before passing.
     Suturing technique. Individual suturing technique should be assessed for injury potential and revisions considered, i.e., cutting off needles before
         tying suture knots; eliminating first finger guiding of the suture needle through tissue, etc..
     Reusable sharps. Reusable, contaminated sharps are gathered for reprocessing in puncture resistant, leakproof, biohazard-labeled containers.
         During cleaning of reusable sharps, personnel do not reach by hand into the containers where these sharps have been placed for soaking; use
         strainers, baskets, or tools to remove sharps.
     Disposal of Sharps. All used sharp objects are separated from general waste by placing them into special puncture resistant, red or biohazard-
         labeled, leakproof containers located near the point of use. When 3/4 full, or at manufacturer’s ―fill-Line‖, these sharps containers are sealed,
         replaced, and transported to the infectious/biomedical waste holding area. It is important to keep track of, and properly dispose of needles/sharps,

                                                                                                                                                                  56
                                                                                                                                                                 57
        especially during intense and/or busy procedures (CPR, major trauma, etc.). Do not dispose of sharps in waste cans or leave them hidden under
        drapes, in pockets, under patients, in beds/stretchers, counter tops, or window seals, etc..

                                                                   Safer Medical Devices
Certain safer medical devices are available through purchasing and recommended for use, including resheathing butterflys, self-contained lancets, and self-
sheathing needled syringes. For patient intravenous therapy, a needleless delivery system is routinely used. Needles should not be used to access the
needleless IV delivery system as this may increase the risk of needle-stick injury.
Self-sheathing needles are available and are useful in areas where sharps containers may not be immediately accessible (i.e., psychiatric unit patient rooms).
Self-sheathing needles, such as butterfly needles, can still cause needlesticks before the safety feature is engaged.
As new and safer medical devices become available from manufacturers (i.e., needleless IV systems), assessment of the benefit of these devices and
decisions regarding their systematic implementation are managed through the Product Evaluation Committee (Clinical Value Analysis Committee) routinely on
a monthly basis and as needed. The Product Evaluation Committee is composed of non-managerial clinical staff including Patient Care Services, Radiology,
Laboratory as well as Occupational Medicine and Infection Control Staff. If you have safer product alternatives to suggest, safer work practice ideas, or to
report problems with any safety device or other needlestick hazard, contact product evaluation representative, Occupational Medicine, or Infection Control
representative(s).

                                                                        Handwashing
Handwashing facilities are readily accessible in patient care areas and in bathrooms. Plain soap or an antiseptic soap are available at each sink. Proper
handwashing includes the use of running water allowing the water to run distally down the arm or hand, soap, and a friction-creating technique making sure to
clean all surfaces of the hands and fingers. Hands should be washed:
     Before and after patient contact.
     After handling used equipment.
     After using the bathroom.
     Before eating.
     After gloves and other barriers have been removed.
     Whenever the hands are soiled. If hands are inadvertently soiled with body substances (i.e., glove tear during surgery), handwashing is done as soon
         as reasonably possible.
Alcohol based gel/foam is also available for hand cleansing and can be used except when hands are soiled.
When handwashing facilities are not available (i.e., in mobile medical emergency ), an antiseptic hand cleanser or towelette containing an alcohol based
solution may be used to clean the hands.
Occupational Medicine or Infection Control staff are available to evaluate and provide direction on potential work restrictions for employees with broken skin or
hand dermatitis.

Mucous Membrane Exposure Prevention
To avoid accidental inoculation of mucous membranes with blood and body substances, certain activities are not done in work areas where there is a
reasonable likelihood of occupational exposure. Eating, drinking, smoking, applying cosmetics or lip balm, handling contact lenses, and other activities that
involve placing any article in the employee's mouth, eyes, or nose are not done in these work areas.
Examples of such work areas include laboratory benches, patient bedsides in the ICUs, patient rooms during touch-contact patient care, operating and
recovery rooms, dirty utility areas, housekeeping closets, and other similar areas.
Procedures involving blood or other body substances are done in such a way that minimizes or eliminates spraying, splashing, splattering, or generation of
aerosol droplets of these substances. When possible, engineering controls, such as biological safety cabinets, protective splatter shields, air filters, centrifuge
covers, and capture ventilation on equipment are used in areas performing these procedures.


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Mouth pipetting or mouth suctioning of blood or other body substances is prohibited. In CPR situations, resuscitation bags, pocket masks and other ventilation
devices are used to eliminate the need for direct healthcare provider mouth-to-patient mouth contact during CPR ventilation. Resuscitation items are available
on all crash carts and in other designated locations in patient areas.

                                                       Transporting Laboratory Specimens
       Collection and transportation of specimens. Specimens of blood or other body substances are placed in primary, puncture-resistant, leakproof
        containers during collection, handling and processing in the laboratory. The primary specimen container is placed inside a biohazard-labeled plastic
        bag and sealed. The requisition is attached to the outer part of the bag. Any specimens transported through the pneumatic tube system are placed in
        rigid, biohazard-labeled carriers and properly cushioned with foam for transport to the laboratories.
       Personal protection during transportation. Gloves are not necessary for specimen transport since the specimen has been gloved by the plastic
        bag and the outside of the bag is considered clean.
       Transportation of specimens outside of Reid Hospital. All specimens of blood or body substances are properly packaged for shipment by mail or
        courier service. Information on proper packaging of specimens or other biohazardous material is available from Laboratory (3134).

                                                      Equipment Servicing and Maintenance
All equipment that has been used on patients or in patient care areas is considered contaminated. This equipment should be kept in a controlled access area
until it has been decontaminated.
      Within Reid Hospital (i.e., Central Processing, Bio-Medical Engineering, Respiratory Care, Laboratory Medicine, etc.) equipment which may be
          contaminated with blood or other body substances is decontaminated prior to servicing unless decontamination is not possible.
      All equipment contractors that provide cleaning as part of contracted services receive an initial written notification from Materials Management that,
          when the equipment or a portion of the equipment is discontinued, serviced, or shipped, it must be handled as contaminated and appropriate infection
          control precautions used.

                                                      PERSONAL PROTECTIVE EQUIPMENT
Personal protective equipment (PPE) is any barrier worn by healthcare providers to eliminate direct touch contact with body substances. PPE is selected by
the healthcare provider as appropriate to the task and procedure. To be appropriate, PPE must prevent blood or other body fluids/substances from soaking
through to the user's clothes, skin, eyes, nose, mouth, or other mucous membranes under normal conditions of use and for the duration of time for which the
PPE will be used.
PPE includes, but is not limited to, gloves, gowns, aprons, laboratory coats, faceshields, masks, and eyewear. Appropriate PPE in a variety of sizes and
materials is readily accessible in the work area or is issued to a health care provider. PPE is provided, cleaned, laundered, repaired, replaced, and/or
disposed of by Reid Hospital at no cost to the healthcare provider.
Disposable PPE is removed immediately following completion of the task or procedure and discarded into the general waste. Reusable PPE (i.e., cloth
gowns) are placed into laundry bags following removal. Healthcare providers do not take home PPE’s which is soiled with blood or other body substances for
cleaning or laundering.
A list of stocked PPE at Reid Hospital that are available routinely or by special order is available from Materials Management. Latex-free gloves and other
PPE are available upon request. Materials Management maintains a list of the latex-containing or latex-free status of all stocked items. Assistance with
purchase of these items is provided through Material Management.

Gloves
Gloves provide a barrier between the hand and contamination. Gloves are put on:
     Immediately before contact with any patient's mucous membranes.
     Immediately before contact with any patient's non-intact skin.
     When performing vascular access procedures.
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      Any contact with moist body substances.
      When handling or touching surfaces or items contaminated with body substances.
Hands should be thoroughly dry before donning latex gloves as additional moisture due to perspiration inside the glove has been shown to decrease the
barrier integrity of latex, especially during extended wear. Whenever possible, latex gloves should not be worn for longer than two (2) hour at a time. Vinyl and
Nitrile gloves are also available.
If gloves become torn, punctured, or the barrier ability is compromised, they are replaced as soon as possible. Disposable gloves are not washed or
decontaminated for reuse. Utility gloves can be decontaminated for reuse if they are intact. Utility gloves which are torn, punctured, or deteriorated are
discarded.
Cotton glove liners are available at any employee's request. In response to the increase in latex allergic reactions associated with aerosolized glove powder,
HMC now purchases only powder-free gloves. For individuals with allergies or sensitivities to glove materials, alternate latex-free gloves are available through
Materials Management.
Occupational Medicine is available to any employee or volunteer for evaluation of dermatologic or systemic reactions which appear to be related to glove
usage.

Protective Clothing
Disposable gowns and aprons, reusable gowns, laboratory coats, and other protective clothing (i.e., hair covers, shoe covers, leggings) are available in the
work areas and are worn when exposure of healthcare provider clothing or skin is anticipated.

Facewear
When splash, splatter, spray, or droplet aerosols of blood and other body substances is likely to occur, face protection is worn. Available face protection
includes masks with and without eyeshields, plastic faceshields, and glasses/goggles with sideshields.

                                                                WORKSITE CONDITIONS

Routine Environmental Cleaning and Disinfection
The primary responsibility for maintaining the worksite in a clean and sanitary condition rests with the Environmental Services Department. However,
sometimes this responsibility is shared with each department and with other healthcare providers. For example, in the Laboratories, Environmental Services
personnel routinely clean floors, windows, and walls, while Laboratory personnel clean work countertops and refrigerators.
Environmental Services maintains schedules for routine area cleaning including floors, walls, curtains, carpets, windows, and surfaces in each area. All bins,
pails, cans, and similar receptacles intended for general and infectious waste are decontaminated on a regular schedule or as soon as possible if visibly
soiled.
Equipment, environmental, and working surfaces are cleaned and decontaminated after contact with blood or other body substances using an approved
environmental disinfectant. Approved environmental disinfectants are available from Environmental Services. For general purposes, the approved
environmental disinfectant is a generic quaternary ammonium compound. Consultation regarding selection of an appropriate environmental disinfectant can
be done upon request through the Environmental Services or the Infection Control Department.
Protective coverings, such as plastic wrap, aluminum foil, or fluid-proof absorbent paper may be used to cover equipment and environmental surfaces; they
are replaced when visible soilage is present and at regular intervals.

Spill Clean-up
Clean-up of spills or other environmental soilage with blood and other body substances is done as soon as possible by gloved personnel using an approved
environmental disinfectant. When the spill involves sharps or broken glass, it is done using appropriate tools such as a dust pan and brush, forceps, or tongs.
Clean-up supplies are available in the custodial closets or other designated locations in each work area or from Environmental Services personnel.

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Laundry
All used laundry is handled as contaminated. Used, soiled laundry is not shaken out but is rolled and handled with minimum agitation. All soiled laundry is
bagged in the work areas where it was used and placed in the dirty utility rooms.
      All dry, used laundry is bagged in standard laundry bags available from consolidated Shared Laundry Services.
      Heavy, wet laundry is placed into plastic, leak-proof bags and then placed in the standard cloth laundry bags.
      Linen that is wet and cannot be absorbed by the surrounding dry linen, and thus leaks through the cloth bag, is first bagged in plastic and then placed
        into a standard cloth laundry bag to identify it as linen.
Bagged, soiled laundry is collected from the dirty utility rooms by gloved Environmental Services personnel and sent via chute or transported to a biohazard-
marked holding area on the dirty dock. All laundry carts in the basement areas are plastic covered. All linen is processed by Reid Hospital Laundry Services.


                                                              STORAGE UNDER SINKS
POLICY: Storage space under sinks can be utilized to store items for which moisture or contamination does not present a risk of infection to patients.
PROCEDURE:
    1. Equipment and supplies used for patient care or diagnostic purposes are NOT stored under sinks.

    2. In the event of a leak, items stored under the sink are discarded and/or cleaned with a disinfectant by gloved personnel(must be cleanable).

Waste Management
Wastes which present a potential infectious exposure hazard to hospital waste handlers, and the general public, are identified, handled, and disposed of in a
safe manner consistent with the recommendations of advisory and federal/state regulatory agencies. A variety of terms are used by federal, state, county, and
city regulatory agencies to describe hospital waste. These terms include regulated waste, biomedical waste, infectious waste, and general medical waste.
Reid Hospital contracts with private companies for infectious/biomedical waste transportation and treatment to ensure appropriate disposal. This contract
covers Reid Hospital wastes which are consistent with the Indiana Administrative Code (IAC) definitions of regulated, infectious/biomedical waste including:
      Laboratory and specimen materials, including:
              Cultures and stocks of etiologic agents.
              Clinical specimens and containers.
              Culture dishes.
              Devices used to transfer, inoculate, and mix cultures.
              Waste that has come into contact with specimens from the laboratory (excluding computer paper).
      Pathological wastes, including:
              Waste human source biopsy materials.
              Tissues and anatomical parts that emanate from surgery, obstetrical procedures, and autopsy.
              Leeches that have been used for patient debridment procedures.
              Pathological waste does not include teeth, human corpses, remains, and anatomical parts that are intended for internment or cremation.
      Discarded live and attenuated vaccines and wastes from production of biologicals and serums.
      Blood, blood products and other body fluids in free flowing form are discarded in their containers into the large, red-bag lined, biohazard-labeled
         waste cans located in the dirty utility rooms. Such containers with liquid body fluids include, but are not limited to:
              Large (1000cc) vacutainer bottles with paracentesis fluids.
              Blood transfusion bags.
              IV tubing with visible blood.
      Needles and sharps waste (capable of causing punctures or injury) management:

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                Needles and sharps waste are discarded into rigid, biohazard-labeled, plastic sharps containers by the user. These wastes include, but are
                 not limited to:
                       Needles and syringes with needles attached.
                       IV tubing with needles attached.
                       Glass specimen tubes.
                       Scalpel blades.
                       Lancets.
              Sharps containers are assessed by environmental services, nursing and other departmental staff and replaced when 3/4 full or to
                 Manufacturer’s ―fill-Line‖. Used sharps containers are placed into the dirty utility rooms for pick-up by Environmental Services staff.
              Needles and other sharps which do not fit into regular sharps containers are placed into the large, red-bag lined, rigid, biohazard-labeled
                 containers located in the dirty utility rooms.
     Waste from patients with the following diseases is not transported or disposed of by private contractors unless it has been pre-treated. These wastes
        are autoclaved prior to disposal. These diseases include:
              anthrax (Bacillus anthracis)
              plague (Yersinia pestis)
              rabies (Rabies virus)
              smallpox
              viral hemorrhagic fevers (Lassa, Ebola, Marburg, Argentine, Bolivian, Crimean-Congo viruses)
              other rare and unusual infectious diseases classified as Biosafety Level 4.
     Liquid patient waste is discarded into the sanitary sewer system whenever possible (any non-radioactive body fluids such as blood, urine, or dialysate
        fluids).
Waste collection and disposal is the responsibility of the Environmental Services Department according to approved procedures. Waste handlers and
transporters wear gloves when handling wastes. A listing of infectious wastes and regular wastes can be found in (Appendix 1).




                                                                Hepatitis B Vaccination

Hepatitis B virus (HBV) vaccine is available at no cost to all Reid Hospital Patient Care Providers, and/or others who have potential for occupational exposure.
The vaccination series is offered initially at the time of new employee orientation and remains available at any time that the Occupational Medicine is open.
Hepatitis B antibody testing is available, but is not required as a pre-requisite to receiving the HBV vaccine.
HBV vaccine is recommended for Patient Care Providers, and/or others with potential occupational exposure. Healthcare workers who decline the vaccine are
required to sign a waiver. The vaccine remains available throughout the duration of the healthcare worker's employment at Reid Hospital if, at a later time, the
healthcare worker decides to accept it.
All employees are required to complete an "Immunization Health History". Information on past infection or immunization for hepatitis B virus and other
infectious diseases is recorded and kept on file with Occupational Medicine. Occupational Medicine records are maintained confidentially. A summary of
services which are available to employees is located in the Occupational Medicine section of this Infection Control Manual.

                                                     Post-Exposure Evaluation and Follow-Up
Whenever an exposure incident occurs, it is the responsibility of the employee to act immediately and to initiate evaluation and follow-up by going to
Occupational Medicine (3446), or the Emergency Department when Occupational Medicine is closed. Information on initial and follow-up procedures to be
followed after an exposure incident is posted on the Infection Control Intranet Site under Exposure Control Plan.


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                                                                    Employee Follow-up
When an exposure incident occurs, confidential post-exposure counseling and testing of the exposed employee is arranged for and/or provided by the
Occupational Medicine. Collection of the exposed healthcare worker's blood for hepatitis B (HBV), hepatitis C (HCV), and HIV is accomplished as soon as
feasible and tested with informed consent and pre-test counseling.
All individual Employee Health records are kept confidential and are not disclosed or reported without the employee's written consent to any person except as
required by law. These records are maintained for at least the duration of employment plus 30 years. A sharps injury log is maintained by Occupational
Medicine/Human Resources to ensure employee privacy and to document type and brand of device involved, location of the incident, and a description of the
incident.
Occupational Medicine medical records are provided upon request for examination and copying to the subject employee, to anyone having written consent of
the subject employee and to appropriate regulatory agency representatives.

                                                          Source Patient/Individual Follow-up
Post-exposure procedures involving the source patient is arranged by Occupational Medicine, Infection Control, Administrative Coordinator, Unit Director,
Charge Nurse, and/or patient care RN including pre-test counseling, consenting, and confidential HBV, HCV, and HIV testing. If the HBV, HCV, and/or HIV
status of the source patient is already known, further testing is not necessary. Results of the source patient's tests are made available to the exposed
employee and the employee is informed of pertinent regulations and laws concerning disclosure of the identity and infectious status of the source individual.
Additional details of post-exposure evaluation and follow-up can be found in Occupational Medicine section of this Infection Control Manual and on the
Infection Control Intranet Site under ―Exposure Control Plan‖.

                                                            COMMUNICATION OF HAZARDS
CONSULTATION REGARDING COMMUNICATION HAZARDS
When a communication hazards issue or concern is identified, the Unit Director, area Manager or Supervisor should be initially notified for resolution. If
resolution is not obtained, consultation with the hospital’s Safety Officer (3194), Occupational Medicine (3446), or Environmental Services (3062) is available.
Referral to the appropriate committee, including Infection Control, Safety, Clinical Value Analysis, or Risk Management are also options available to
employees.

BIOHAZARD SIGNS AND LABELS
Biohazard warning labels are attached to:
     Containers for regulated wastes.
     Refrigerators, freezers, or other storage areas containing specimens.
     Containers used to mail or ship potentially infectious materials.
Biohazard labels are either an integral part of the container or are affixed to the container by string, wire, adhesive, or other method that prevents their loss or
unintentional removal.
Biohazard labels include the universal biohazard symbol and are fluorescent orange or orange-red with lettering and/or symbols in a contrasting color. These
labels are not required for:
     Units of blood or blood components or blood products intended for transfusion or other clinical use.
     Individual containers of blood or other body substances that are placed in a larger, labeled container during storage, transport, shipment, or disposal.

TRAINING
All employees with occupational exposure are required to participate in training provided at no cost to the employee and during working hours. This training is
done at the time of new employee orientation and SynQuest Training annually thereafter. Additional training is provided when changes, such as addition or
modification of tasks or procedures, occurs. Additional training is limited to addressing the new exposures created. Material appropriate in content and
vocabulary to the educational level, literacy, and language skills of employees is provided. The Infection Control staff is available for consultation with
directors/managers regarding training content and presentations. An outline of training content can be found in Appendix 2.
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The person conducting the training is knowledgeable in the subject matter contained in the training program as it relates to Reid Hospital. Unit Directors,
department managers and service-line chiefs who have received bloodborne pathogen training provided by Reid Hospital’s Infection Control Department,
and/or Education Department are qualified to provide training to the staff.

                                                                Training Record-Keeping
Training records are maintained by the area manager and include the dates of training, summary of training content, names and qualifications of persons
conducting the training, and names and job titles of all attendees. All training records are maintained for 3 years from the date on which the training occurred.
Training records are monitored by the Education Department.
Training records are available upon request for examination and copying to employees, to employee representatives, and to authorized regulatory agency
representatives.




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                                                                       APPENDIX 1:

                                    REID HOSPITAL & HEALTH CARE SERVICES
                                        WASTE SEGREGATION GUIDELINES
  REGULATED MEDICAL                 CHEMOTHERAPY WASTE            SOLID WASTE                  HAZARDOUS WASTE
                                      All Tissue and Trace
           WASTE                             Chemo                    (TRASH)
                                         Yellow label for
                                           incineration
     Red Biohazard Bag               Chemotherapy Sharps       Clear, Gray or Brown              Hazardous Waste
                                        Container or Bag                Bags                        Container
Blood/blood products & OPIM       Trace/empty contaminated    Examples:                        Examples:
Examples:                         items generated in the
      NO FREE LIQUIDS             preparation and             Paper or plastic
         ACCEPTED                 administration              wrappers                         Outdated/unused
OPIM in liquid/semi liquid        of antineoplastic/cytotoxic                                  chemotherapy drugs
state                             drugs                       packaging, boxes,                (bulk)
if compressed; PIM caked          are considered to be
with                              residually                  computer paper, office
dried blood capable of
releasing                         contaminated                       waste                     Certain pharmaceuticals
during handling such as,
soiled                            Examples:
                                                                     Unused medical
disposable, i.e. bloody gauze,    Chemo IV tubing                    products                  Used solvents, stains,
dressings, lap pads, OB and                                          & supplies                paints & thinner
surgical peri-pads and gloves     Empty bags/bottles
                                                                     PPE (worn but not
                                                                     soiled)                   Chemicals such as
                                                                                               formaldehyde &
Amy amount of blood/body          Empty drug vials                                             formalin,
fluid in containers, catheters,                                      Food products and         acetone, toluene,
or                                                                   waste                     mercury
tubes with fluid blood or blood   Spill clean up materials or kits   (soda cans, paper cups,   fixatives, alcohol,
products not discarded or                                            plastic utensils)         disinfectants & chemical
flushed i.e., blood sets,
suction                           HEPA filters from Pharmacy                                   sterilizing agents
canisters & drainage sets         laminar air flow hood              Empty IV bags, bottles,
                                                                     and tubing without        Drums or other
                                                                     needles                   containers
Dialyzers & tubing                Needles and syringes                                         with "hazardous" label
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                                                                 Empty urine cups, stool
                                                                 containers, Foley bags
Microbiology lab specimens,    Gowns                             or                         Radioactive material
used culture plates, tubes,                                      tubing, diapers, chux
bottles & devices              Gloves
                                                                 Exam & cleaning gloves        Universal Waste
Clear specimen bags with the   Masks
biohazard symbol                                                 Empty collection bottles   Rechargeable/recyclable
                               Barriers                          & bags                     batteries
Placentas and surgical
specimens                      Placentas and surgical            Sanitary napkins &         Fluorescent light bulbs
                               specimens are yellow labeled      tampons (personal)
Blood spill clean up           for incineration prior to being
                                                                 Disposable paper
materials                      sent off-site                     drapes,
                                                                 lab coats, paper towels,
    Sharps Containers                                            band aids
NO FREE LIQUIDS
                                                                 Disposable basins,
                                                                 bedpans, urinals (with
Needles and syringes                                             no
                                                                 (visible blood)
Scalpel blades & lancets
                                                                 Non-mercury batteries
Glass pipettes, slides
and tubes                                                        Empty aerosol pressure
                                                                 cans
Broken contaminated glass

Staples and guide wires

Disposable suture sets and
       biopsy forceps

Electrocautery tips




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                                                                      APPENDIX 2:
                                                                 CONTENT OUTLINE OF TRAINING
I. OSHA Rules and Regulations on Bloodborne Pathogens
II. Bloodborne infectious diseases (Hepatitis B, Hepatitis C, HIV) Health Care Workers could be exposed to.
III. Exposure Control Plan
         A. Location and availability
         B. Identification of tasks/activities that may involve exposure to blood and body substances.
         C. Effective measures for eliminating or reducing exposure risks.
                  1. Personal Protective Equipment (PPE)
                           a. Appropriate selection for use
                           b. Types and availability
                           c. Decontamination and disposal
                  2. Engineering controls
                           a. Handwashing facilities
                           b. Sharps: disposal containers, recapping devices, resheathing needles and butterflys
                           c. Needleless IV systems
                           d. Other safer medical devices
                  3. Work practice controls to protect employees
                  4. Limitations of PPE, devices, and practices
         D. Hepatitis B vaccination
                  1. Availability, efficacy, safety
         E. Post-exposure management
                  1. Exposure definition
                  2. Immediate actions
                  3. Follow-up actions
                  4. Reporting and record-keeping
         F. Signs and Labels
                  1. Body Substance Isolation signs
                  2. Isolation signs
                  2. Biohazard symbol and color
IV. Questions and answers




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     Reid Hospital Tuberculosis Exposure Control Plan ( Found on the Infection Control Intranet Site                            under “TB Control Plan”)

INTRODUCTION
From 1985 to 1993, the number of persons newly diagnosed with active tuberculosis (TB) in the United States population increased by 20 percent, reversing
a previous 30 year downward trend. The number of newly diagnosed cases in Wayne County of Pulmonary infectious tuberculosis has been zero for the last
three years from the time of the revision of this manual. The CDC estimates that up to 13 million US adults are infected with TB. It is estimated that, in time,
over one million of these individuals may develop active TB disease and may transmit the infection to others. While the number of reported cases of TB has
very slowly begun to decline nationally since 1993, the number of active cases in some areas continues to rise.

The emergence of multi-drug resistant TB strains (MDRTB) has contributed to the seriousness of the problem by introducing organisms resistant to the two
previously most effective drugs used for preventing and treating TB, isoniazid and rifampin. MDRTB is often fatal, and has been documented in outbreaks in
hospitals in Atlanta, Miami, New York City, and New Jersey, as well as other health care settings.

Nosocomial transmission of TB to both patients and health care workers has resulted in deaths, especially in those who are immunocompromised. Of great
concern is the occupational exposure of more than five million US workers who are exposed to TB in the course of their work in hospitals, homeless shelters,
nursing homes, and other work settings. The risk of infection to workers who are occupationally exposed is estimated to be as high as 10 times the risk to the
general population.

                                                            Tuberculosis Infection and Disease
The organism that causes TB - Mycobacterium tuberculosis - is carried in airborne particles, called "droplet nuclei", that can be generated when a person with
pulmonary or laryngeal TB sneezes, coughs, speaks or sings. For persons with extrapulmonary TB, droplet nuclei can be formed when aerosolizing
procedures are done such as jet water picking of an abscess infected with M. tuberculosis. The droplet nuclei are so small (1-5 microns) that normal air
currents keep them airborne and can spread them throughout a building.

TB infection occurs when a person inhales droplet nuclei and the M. tuberculosis bacilli settles in the alveoli of the lungs and spreads through the body in the
lymphatic system and the bloodstream. Two to ten weeks after infection, the immune system of healthy persons responds and limits further multiplication and
spread of the TB bacilli. At this point a person is infected and most will have developed a positive PPD skin test reaction.

A small number of newly infected people (less than 1%) will rapidly progress to clinical illness after exposure. Another group of infected people (about 5%) will
develop clinical illness within 2 years after exposure and overall, 10% of infected people will develop active disease sometime over their lifetime.

For people who are immunocompromised, such as those who have HIV infection, cancer, diabetes, or those who receive chemotherapy, radiation therapy or
systemic steroids, the risk of progressing to active TB rapidly is greatly increased and the risk of developing active disease rises to approximately 7-10% per
year.

                                                        Response to Tuberculosis in Healthcare Facilities
In response to the rising trend of TB in the United States, the Occupational Safety and Health Administration (OSHA) implemented, in 1993, nationwide
enforcement procedures aimed at controlling the transmission of TB in certain work settings, including health care settings. These enforcement regulations,
revised in 1996 and based on the Centers for Disease Control's recommendations: "Guidelines for Preventing the Transmission of Mycobacterium
tuberculosis in Health Care Facilities, 1994", were intended as an interim measure while OSHA continued its effort at developing a permanent standard.

In 2003, OSHA withdrew its proposed standard on Occupational Exposure to TB because of the steady decline in the rate of TB since 1993 and substantial
compliance by health care facilities with CDC guidelines.
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This Reid Hospital Tuberculosis Control Plan has been reviewed and revised to reflect CDC recommendations to prevent and control the transmission of
tuberculosis in the workplace. The prevention and control guidelines are enforced by OSHA, HFAP, JCAHO, Indiana Occupational Safety and Health
Administration (IOSHA), and Indiana State Department of Health (ISDH), as will be the TB Standard when finalized and promulgated into law.
In general, the CDC guidelines, OSHA's Proposed Standard, and the enforcement regulations all emphasize the importance of a hierarchy of control
measures ranked in priority as:

    1. Administrative Controls
    2. Engineering Controls
    3. Personal Respiratory Protection

Healthcare facilities must develop a written TB exposure control plan based on a risk assessment of TB among patients and healthcare workers in each
facility. Early identification and management of persons with TB, a purified protein derivative (PPD) skin testing program and healthcare worker education are
essential components of the plan.
This Reid Hospital Tuberculosis Control Plan summarizes the elements of the infection control and Occupational Medicine programs that are important in
reducing or eliminating occupational exposure to tuberculosis at Reid Hospital. Additional details may be found in department, unit, or clinic specific policy and
procedure manuals in relevant areas. This plan is updated annually using regulatory and accreditation information, feedback and input from staff, incident
report summaries, claims data, consultations with Microbiology, Wayne County Health Department, Occupational Medicine, Employee Safety Committe as
well as referrals from committees, departments, units or clinics. The efficacy of both the exposure control plan and the respiratory protection program is
monitored by review of incident reports and PPD conversion investigations. The Infection Control Committee is responsible for review, compilation, revisions
and distribution of this plan. Copies of the plan are available in the online hospital Infection Control Manual or in hard copy from the Infection Control
Department (3493).


                                                     Periodic Assessment And Exposure Determination
                                                              Tuberculosis Patients at Reid Hospital
Each year since 2005, 1-3 patients have been confirmed with atypical-tuberculosis (avium, chelonei, and kansasii), not active M tuberculosis pulmonary
disease. Information on TB in patients at Reid Hospital is maintained Microbiology and the Infection Control Departments and is periodically summarized and
reviewed by the Infection Control, the Medical Staff Quality Improvement and Safety Committees. This summary is prepared as needed and provides
information on patients with confirmed tuberculosis disease who receive services at Reid Hospital as inpatients and outpatients. Summary information
includes number of patients, patient characteristics, locations within the hospital, and anti-tuberculosis drug susceptibilities.

                                                   PPD (TB) Skin Test Evaluation and Screening of Employees
Initial tuberculosis screening evaluation, periodic screening, and follow-up are provided at no cost to employees. Initial tuberculosis screening is required of all
new employees at the time of employment, and must be completed within the first two weeks of employment. Screening is available at new employee
orientation or through Occupational Medicine (OM).

Employees who are PPD positive and have not had adequate preventive therapy are required to report any TB symptoms to Occupational Medicine.
Employees found to have a significant positive PPD skin test reaction with signs and/or symptoms of active TB disease will be removed from the workplace
and remain off work until determined to be non-infectious. Employees with new significant PPD skin test reactions will be referred to their family physicians for
further evaluation and treatment if necessary.




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Anergy testing will be done if indicated (i.e., employee reports being immunocompromised for any reason) and only for employees whose TB skin test status
is not known to be positive. An initial two-step testing procedure is used for each new employee who has not been previously skin tested and/or for whom a
negative test cannot be documented within the past twelve (12) months. If documentation is provided to OM that the employee has had a negative skin test
within the past twelve (12) months, that test may be utilized as the initial step in the two-step testing procedure. (Current ISDH recommendations require two-
step testing for all new employees). Termination PPD skin testing is available on a voluntary basis to employees who present to the OM within two (2) weeks,
but not less than one (1) week prior to their last day of work at Reid Hospital.

Information on PPD skin testing and results is periodically summarized by the and presented to the Infection Control and Safety Committees. This information
is used to assess the efficacy of the respiratory protection program and to assess the incidence of unknown exposures which lead to skin test conversions.
Positive PPD results are assessed and categorized as non-occupational related or as possible/probable occupational conversions. Employees with possible
or probable occupational conversions are interviewed and evaluated individually by Occupational Medicine to determine the likely means of exposure. PPD
skin test conversions that are determined to be occupationally related are recorded in the OSHA 200 log.

Employees are determined to be in high risk or non-high risk categories of potential TB exposure depending on the expected level of contact with TB patients
and the expected duties performed within the employees job classification. (See section: Determination of Healthcare Provider Exposure Risk). Employees of
Reid Hospital will receive PPD skin testing annually. Employees who have skin-test conversions due to occupational exposure will be temporarily considered
high risk for that period of time and will be retested at six (6) months and as needed. Employees at occupational risk of TB exposure who have previously
documented positive PPD results will be periodically evaluated by Occupational Medicine.


                                                   Determination of Healthcare Provider Exposure Risk
This exposure determination is based on a reasonable expectation of occupational exposure to tuberculosis at Reid Hospital as part of job performance.
Persons with reasonable expectation of occupational exposure are provided with TB training, screened routinely for TB infection or disease and provided with
NIOSH approved respirators in compliance with the OSHA enforcement policies and OSHA's Proposed Standard for Occupational Exposure to TB, which
include requirements for respiratory protection.

In accordance with OHSA's determination of high risk categories for potential exposure to TB, employees whose normal work duties include the following
tasks are considered high-risk:

       Enter TB isolation rooms. Rooms equipped to handle TB isolation patients are: ED, PPCU, ICU/CVU

Employees who may be at risk include but are not limited to:
                       Nursing Staff
                                                                             Medical Staff
                       Public Safety
                                                                             Social Workers
                       Engineering & Maintenance
                                                                             Pastoral Care
                       Physical Therapy/Rehab Services
                                                                             EEG
                       Nutrition & Food Services
                                                                             EKG
                       Occupational Therapy
                                                                             Physicians
                       Radiology
                                                                             Environmental Services
                       Transportation
                                                                             Laboratory Services
                       Respiratory Care

       Perform or are present during the performance of high-hazard procedures. High-hazard procedures are to be performed in a TB isolation room.
        Such procedures may include:
       Cough-inducing procedures:
                                                                                                                                                             70
                                                                                                                                                                 71
     Bronchoscopy Procedures
     Respiratory Care Procedures (sputum induction)
     Other aerosolizing procedures:
     Operating Room Procedures (TB abscess irrigation; lung resection for TB)(Last case of the day if possible)
     Pathology Procedures (centrifuging specimens, bone sawing)
    Transport, or are present during the transport, of patients with confirmed or suspected TB in an enclosed vehicle, ambulance, or helicopter.
     In elevators if the patient is unmasked, not ventilated, and coughing
     Work in a high risk intake area where early identification procedures are performed.

Procedures performed on patients with known or strongly suspected active tuberculosis should not be considered a mandatory training opportunity for
medical, nursing and respiratory care students nor should they be required to enter TB isolation rooms.

Whenever possible, without compromising patient care or expected outcomes, employee exposure in TB isolation rooms should be minimized by:

       Combining tasks to limit the number of entries into the room;
       Limiting the number of employees who must enter an TB isolation room;
       Delaying elective transportation of TB patients;
       Delaying elective high hazard procedures or surgery until the patient is determined to be non-infectious.

    It is expected that the following staff should not require entrance into TB isolation rooms: Admitting Department, Materials Management, Dietary Aides .
    Under normal circumstances, staff providing immediate care required by the patient, staff who clean and/or maintain the room environment, and approved
    patient visitors are allowed to enter into TB isolation rooms occupied by patients with active or suspected TB. Nursing staff can provide venipuncture for
    laboratory studies if lab personnel have not been fit-tested, delivery of meal trays and other activities for the purpose of reducing the total number of staff
    who enter the room.


                                                                    Methods Of Compliance

                                                                    Administrative Controls

                                             SCREENING FOR TUBERCULOSIS IN HIGH RISK POPULATIONS
The CDC's Advisory Committee for Elimination of Tuberculosis recommends that certain high risk groups be screened for TB (Appendix 1). These
recommendations are endorsed by the Infection Control Committee Reid Hospital although the final decision for screening of any individual patient lies with
the primary physician. Decisions regarding individual patient screening for TB are made according to standard medical practice by the physician. Consultation
regarding TB screening, diagnosis, drug therapy and medical management is available through the Pulmonary Diseases Teams and/or the Infection Control
Practitioner. Inpatient PPD skin test administration and reading is provided by trained nursing staff Sputum induction is available from Respiratory Care.

                                                                   PATIENT SCREENING LEVELS
In order to promptly identify patients at risk of transmitting TB who receive services at Reid Hospital as inpatients or outpatients, patients with suspected or
confirmed TB are to be isolated in a TB isolation room as soon as possible. The scope of screening patients for TB includes all initial entry areas of Reid
Hospital for patients such as ambulatory care clinics, Emergency Department, Wound Center, and admitting department. Each level of screening is based on
the role of the healthcare worker with patients and subsequent actions for confining transmission. Appendix 2 provides more details on each level.
LEVEL 1 - Initial contact with a coughing patient - encourage patient to cover cough. Tissues are available in all waiting areas. Signs are posted in waiting
             areas encouraging use of tissues when coughing.
                                                                                                                                                                 71
                                                                                                                                                               72
LEVEL 2 - Health assessment for TB risk factor history - if risk factors present, remove patient from traffic area to designated holding area as soon as
          possible of identification.
LEVEL 3 - Medical assessment for TB - diagnostic testing, isolation decisions.
LEVEL 4 - Follow-up assessment to verify or exclude TB - laboratory confirmation, exposure follow-up if indicated.

                                          EVALUATION AND MANAGEMENT OF THE PATIENT WITH POSSIBLE TB
                                                                  FOR ISOLATION IN A TB ROOM
Algorithms for evaluation and management of patients with possible TB presenting to the Emergency Department/patient care units have been developed
through the Infection Control Committee and are used in conjunction with the Patient Screening Levels. Early consideration of TB in the differential diagnosis
is essential to prompt identification and initiation of control measures. When a patient is determined to need hospitalization and active, pulmonary TB is a
concern, isolation in a TB isolation room is indicated (see Appendix 3). The "Rule Out TB" Clinical Pathway is also initiated at this time.

Decisions to discontinue TB isolation after active TB has been confirmed are made by the medical attending staff based on the algorithm presented in
Appendix 4. Patients who have been receiving treatment for their active TB may be removed from TB isolation when there is clinical improvement and one of
the following:

       Patient asymptomatic after two or more weeks of effective TB drug treatment;
       3 spontaneously produced sputa collected on different days are AFB smear negative (concentrated specimen);
       1 induced sputum is AFB smear negative (concentrated specimen).
       The patient is no longer able to produce a sputum specimen.
       A positive AFB sputum smear is culture negative after 6 weeks.

In situations where there is disagreement with isolation decisions, the Infection Control Practitioner, the Chair of the Infection Control Committee, Safety
Officer, or a designee should be consulted for resolution. (See Appendix 10)



CODE BLUE MANAGEMENT OF TB ISOLATION PATIENTS
The first priority of the Code 99 responding team is the evaluation, care and attempted resuscitation of the patient in TB respiratory isolation, while also
maintaining adequate protection of healthcare workers (Appendix 5). N-95 respirators are made available to the code 99 team. Every effort should be made to
wear these respirators during the code. An Ambu bag with microbial filter attached is stored on each unit's Code 99 cart and in each isolation unit's respiratory
supply closet.
The number of people in the room is kept to the minimum required to care for the patient. During a code, nursing will notify all respondents of the patient's TB
isolation status, restrict the number of staff in the room to only Code 99 team members, and provide and insure that all participants wear appropriate
respirators. If TB isolation was not able to be adequately maintained, consultation between members of the responding team and Occupational Medicine is
done regarding the determination of exposure and necessity for any follow-up. (Appendix 6)


                                                     TRANSPORTATION OF TB ISOLATION PATIENTS
Patients with suspected or known active (infectious) pulmonary TB should not be transported unnecessarily to other areas or departments, or leave the
isolation room. For example, a TB patient needing a chest x-ray should have a portable done in the isolation room. If the isolated patient's recuperation and
treatment would be compromised by examinations, procedures, and treatments performed in the patient's room, then the patient may be transported from the
isolation room to other departments with appropriate respiratory protection (surgical mask) on the patient, and on arrival N-95 respirators for staff.



                                                                                                                                                               72
                                                                                                                                                               73
The receiving department and Transportation Service should be notified in advance. The sending unit/clinic notifies the receiving procedure department staff
that a TB isolation patient is being transported to them and will require immediate placement upon arrival in the procedure room. If suspected or known TB
patients are transported, the patient should wear a mask (surgical, not a respirator). The patient is instructed to keep the mask on (over nose and mouth) at
all times during transport to and from the procedure room. If the patient is on mechanical ventilation, a mask on the patient is not needed due to the microbial
filter on the Ambu bag used in transport.

The transporter wears an N-95 respirator when entering the TB isolation room to begin the transport process and when confined with the patient in the
elevator wear N-95 or in other enclosed spaces (Unless the patient is wearing a surgical mask, then the transporter does not need to wear the respirator). Do
not allow any non-essential personnel not caring for the patient onto the elevator. The N-95 respirator is removed while transporting the patient in open areas
such as hallways (as long as the patient is wearing a surgical mask) if not, the transporter must continue to wear the N-95 respirator.
Employees who transport, or are present during the vehicular transport, of patients with confirmed or suspected TB are to wear respiratory protection while in
the enclosed vehicle (ambulance, helicopter).

                                                       RADIOLOGY SCREENING FOR TUBERCULOSIS
Posterior-anterior and lateral chest radiographs are routinely evaluated by the radiologist for presence of pulmonary tuberculosis. Radiology services are
available in the Emergency Department 24 hours daily, and in Main Radiology during operating hours. The primary physician is notified immediately by the
radiologist if active pulmonary TB is suspected. If extensive active cavitary disease is identified, the Infection Control Department is also notified by Radiology.

Inpatient chest x-rays are portable and done in the TB/AFB isolation patient room. If portable x-ray results are inadequate and additional views are needed,
the patient is transported to Radiology per transportation requirements stated above. Whenever possible, procedures done in Radiology for TB patients are
scheduled last to facilitate adequate ventilation of the procedure room following the procedure.




                                                            LABORATORY CONTROL MEASURES
Laboratory Workplace Controls
In accordance with CDC/NIH Biosafety in Microbiological and Biomedical Laboratories recommendations, Reid Hospital laboratory shall operate with
Biosafety Level 3 containment procedures. The laboratory director is responsible for the determination and documentation of the appropriate biosafety level
required by the activities and occupational hazards in the laboratory and the maintenance of the appropriate associated safety compliance procedures.
Specific laboratory workplace control measures to prevent or minimize occupational exposure to TB are described in detail in the Laboratory Manual.
Laboratory waste contaminated with M. tuberculosis is decontaminated by autoclave prior to leaving the laboratory.

Acid-Fast Bacilli (AFB) Cultures and Smears
Specimens must be concentrated for reliable AFB smear results. Routine AFB processing involves decontamination and concentration of the entire specimen
for AFB culture and smear. Alternatively, a portion of the specimen may be concentrated by a new cytospin method for AFB smear only. This method enables
the laboratory to provide same day smear results for late-arriving specimens that cannot be processed until the following day.

The following services are currently available for detection of mycobacterium by smear 7 days a week:
    Routine AFB smear (with culture) - results are available by 4 pm for specimens received in the laboratory by 9 am.
    Special request cytospin AFB smear - results are available by 4 pm for specimens received in the laboratory by 2 pm.
    After 2 pm daily, direct (not concentrated) AFB smears are available as a STAT request only and are available for the physician to read within one
         hour. This is an insensitive procedure and should not influence decisions to release a patient from TB isolation.
    AMTD for AFB smear positive specimens can be sent to the state laboratory by request.


                                                                                                                                                                 73
                                                                                                                                                                 74

                                                          Mycobacterium tuberculosis Positive Cultures
When a specimen is processed for AFB and Mycobacterium tuberculosis is identified in culture, the laboratory notifies the primary physician, Nursing Unit and
the Infection Control Department. In addition, a written update of ongoing positive AFB smear and culture results is routinely sent to Infection Control.
Subcultures of initial isolates for M. tuberculosis are submitted by the Microbiology Laboratory to the state reference laboratory in compliance with ISDH
recommendations.
Positive cultures will be reported to the Wayne County Health Department by Infection Control.

Engineering Controls
                                                             TUBERCULOSIS ISOLATION ROOMS
Indiana State Codes require that existing TB/AFB isolation rooms at Reid Hospital have at least 6 air changes per hour, with 2 being fresh air changes.
Additionally, each TB isolation room has a pressure monitor located outside the door which continuously checks and automatically adjusts the ventilation so
that correct TB isolation room conditions are ensured. These monitors have a control system which varies the supply of air to the room to maintain a negative
pressure with respect to the adjacent space. Ventilated air from TB isolation rooms is exhausted directly to the outside.

TB isolation rooms are used for patients suspected or known to have pulmonary TB, and for high-hazard procedures performed by Physicians and
Respiratory Care, such as sputum induction for AFB specimens or bronchoscopy. Currently, there are 4 patient-care TB isolation rooms at Reid Hospital: 1 in
Emergency Department, 2 in the ICUs, 1 in PPCU Although no patient care activities take place in the AFB Laboratory the lab is designated for culturing of M.
tuberculosis and is thus environmentally engineered with appropriate ventilation and equipment for the protection of lab employees.

When a TB/AFB isolation room vacated by a confirmed or suspected TB patient, unless the patient has been medically determined to be non-infectious, the
room is to be ventilated for a removal efficiency of 99.9% before permitting entry without respiratory protection (60 minutes). The isolation sign will remain on
the room until the completion of adequate ventilation decontamination and cleaning, the sign will then be removed by environmental services and returned to
the nursing staff.

When all TB/AFB isolation rooms are in use by patients with rule out or known TB, any potential TB admissions will be diverted to another appropriate facility
per the High Census and Patient Transfer Policies in the Reid Hospital Administrative Policy Manual. Central Scheduling or Administrative Coordinator (for
evenings, nights and weekends) coordinates use of the TB /AFB isolation rooms.



                                        TUBERCULOSIS ISOLATION ROOM PRESSURE MONITOR AND CONTROL

Engineering is notified when a patient is in AFB Isolation and the room is monitored daily and logged for negative pressure by engineering. On weekends
nursing staff shall measure negative pressure daily using the manual ―tissue methology‖ and if the tissue blows inwardly report this to the engineer on-call.

       The room door to the corridor and the windows are closed.
       An ambu bag and microbial filter is stored on each unit's Crash cart.
       An ambu bag and microbial filter is stored in each unit's respiratory supply closet.

If a utility failure in the TB isolation room is identified while a TB patient is present in the room Nursing notifies the Engineering Department who provides rapid
evaluation and repairs as needed. If the room cannot be returned to proper functioning shortly, the patient is moved to another available TB negative pressure
isolation room.



                                                                                                                                                                 74
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Engineering is responsible for assuring conformance with TB isolation room standards when patients with suspected or confirmed TB are present in the TB
isolation room.

The Engineering Department is responsible for inspection, performance monitoring and urgent/routine maintenance of the TB isolation room ventilation, any
negative pressure monitors in accordance with pertinent regulations. Details of the management plan for ventilation systems and for ongoing routine
maintenance can be found in the Engineering-specific TB exposure control plan.

In the event that a ventilation fan system fails to maintain a TB isolation room at proper negative pressure, the isolation patient in the non-functioning room is
transferred to an alternate isolation room with a functioning ventilation system.

Personal Respiratory Protection
N-95 respirators are used by all staff and other healthcare providers who enter TB/AFB isolation rooms or who perform cough-inducing or aerosol generating
procedures, or other high hazard procedures on patients with risk factors for TB. N-95 use by other staff is not required because of patient TB health
screening efforts occurring at intake areas (Emergency Department, Ambulatory Surgery, Radiology) and, as appropriate, throughout the patient's inpatient
stay. If staff in areas without TB isolation rooms identify a patient whose history and physical findings suggest TB, refer to the action steps outlined in Level 2
and 3 screening in Appendix 2.


                                                                   TYPES OF RESPIRATORS
When providing care to patients with known or suspected infectious TB, the standard respirator worn by the healthcare worker is an N-95 respirator or
greater. The respirators are distributed to healthcare workers through their department, service, or unit directors.

Persons entering the rooms of patients with TB are kept to a minimum without compromising patient care. N-95’s are available for essential personnel who
have been medically cleared and fit tested who must enter the rooms of patients with suspected or confirmed infectious TB, including entry for high hazard
procedures.

For TB patient visitors who need to enter the TB isolation room, nursing staff will provide N-95 mask along with visitor instructions on use.

Children (12 years old and under) are restriced from entering TB isolation rooms to visit. Exceptions to this may be made by the supervising physician, unit
director, Infection Control Practitioner , or medical director and must not put visitors and/or others at risk of acquiring infection.


                                                       RESPIRATOR FIT TESTING AND FIT CHECKING

Employees experiencing difficulty breathing or other medical difficulties performing their job duties while wearing a respirator are to report to Occupational
Medicine or Emergency Department for evaluation.

                                                           RESPIRATOR EDUCATION AND TRAINING
Respirator training must be provided by a knowledgeable trainer to all potential respirator wearers. Training includes reasons for wearing the respirator,
limitations of the respirator, proper use and storage, flow-checking procedures to ensure adequate air flow, and the potential risks with non-compliance.
Managers are responsible for maintaining a record of everyone in their department who needs annual fit-testing. Occupational Medicine is responsible for
training and maintaining documentation of respiratory protection education and training. Appendices 8 and 9 provide basic training information and a sample
post-training test on PAPRs. Additional education aids and resources on respirators are available through Education and Occupational Medicine.



                                                                                                                                                                  75
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                                                              Post Exposure Evaluation & Follow-Up
                                                                         Contact Investigation
A potential TB exposure occurs when infection control precautions have not been taken for a person with infectious TB. Unit Directors/Department Managers
assist in identification of potentially exposed patients and staff for exposures occurring in their respective areas. Determination of whether an actual exposure
occurred to an individual is made by Occupational Medicine, Infection Control, or medical staff and includes assessment for:

       Potential exposure to the exhaled air of an individual with suspected or confirmed TB who is AFB smear positive, or
       Exposure to a high hazard procedure which has the potential to generate potentially infectious droplet nuclei (such as bronchoscopy, bone sawing in
        autopsy, intubation or jet spraying).

Follow-up management of healthcare workers, other Reid Hospital employees, or volunteers who experience a TB exposure incident is done by Occupational
Medicine. Urgent follow-up is not needed for TB exposure. When an employee suspects that they have been exposed to TB, contact Occupational Medicine
when this service is next open. An "Incident Report" is completed when TB exposure is suspected. Follow-up confirmation for reports of suspected TB
exposures is done by Ocupational Medicine and/or Infection Control.

Follow-up of patients who experience a TB exposure incident is conducted by the primary physician or the Public Health Department. The Infection Control
Department coordinates and monitors follow-up of patient exposures and communicates with Public Health and the primary physician as needed.

Consultation regarding post-exposure evaluation and follow-up of patients, healthcare workers, or other employees is available through Occupational
Medicine, Infection Control and the Public Health Department.
Specific TB exposure follow-up procedures are detailed in Appendix 6, "Tuberculosis Exposure Management".

                                                                       Incident Investigation
Exposure incidents which result in a PPD skin test conversion will be investigated by Occupational Medicine. The specific circumstances surrounding the
exposure and the conversion will be evaluated and documented (i.e., failure of engineering controls or work practices) and recommendations, which may
include additional training if indicated, will be made to prevent such occurrences in the future.



                                                            Public Health Department Reporting
Infection Control and/or diagnosing physician is responsible for tuberculosis case reporting to the Wayne County Public Health Deaprtment in compliance with
ISDH state regulations of reporting a communicable disease. This would include patients who are being empirically treated for active TB, patients with positive
AFB smears or cultures, or patients with presumptive active TB. In addition, the Microbiology Laboratory is responsible for submitting positive specimens for
M. tuberculosis to the state reference laboratory.

                                                                   Education and Training
All newly employed healthcare workers receive basic education and training on TB transmission, signs and symptoms, medical surveillance and therapy, Reid
Hospital specific TB experience including information on the TB patient population and Reid Hospital specific infection control precautions (Appendix 9).
Generic education is provided in New Employee Orientation followed by department/unit/service specific training. In addition, education and training regarding
respirators is required and provided by the department, service or unit. TB and respiratory protection training updates occur annually as part of annual training
activities. Education is coordinated and documented by Occupational Medicine and/or area managers. A SynQuest Training module is available on-line and
in the Education Department for Reid Hospital staff who provide services to TB isolation patients.
Retraining will be provided to any employee on any topic(s) contained in this Tuberculosis Exposure Control Plan in which specific knowledge and skills
necessary for the employee's ability to perform work duties in a manner which provides protection to both self and patients.

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Contract workers are informed by Engineering of any potential exposure to TB contaminated air spaces. Contractors are informed by the specific
unit/department managers if there is a need to enter a TB isolation area. Education- It should be up to the company to provide medical clearance, fit testing
and PPE to contract workers and training are provided to contract workers by Engineering and/or Infection Control.


                                                       Consultation Regarding TB and Infection Control
For questions or concerns related to infection control, exposures or respiratory protection, the Infection Control and Occupational Medicine Departments are
available. For issues of conflicting medical opinion, consultation with the Infection Control Committee can be done through the Chair. Appendix 10 provides
information on resources available for concerns regarding this exposure control plan and management of tuberculosis at Reid Hospital.




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                                                                          APPENDIX 3:




                                                         SCREENING FOR TUBERCULOSIS



The Advisory Committee for Elimination of Tuberculosis (CDC/ACET, MMWR 1990) recommends that the following high risk groups be screened for TB:

Screening Methods
1. TB skin testing - Mantoux test
2. CXR and sputum smear - only when the objective is intended to identify persons with current pulmonary disease and when the administration of preventive therapy to
infected persons is not possible (e.g., among the homeless).




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                                                                          Appendix 4
                                                                    PATIENT SCREENING LEVELS
These screening levels are presented as guidelines for HMC staff in identifying and assessing patients for Tuberculosis potential. Level 1 activities can be
performed by staff identified in all 4 levels. Level 2 activities can also be performed by staff identified in Level 3. Level 3 & 4 activities are restricted to those
staff specifically identified.
LEVEL 1              Initial Patient Contact

        Reception personnel, USC/Patient Services Representative, Patient Care
  WHO: Coordinators, Social Workers, Admitting Personnel, any health care provider who has initial
        patient contact.
  TYPE: Identify coughing patients and provide tissues to cover cough.
        1. Give patient a tissue pack and paper bag for disposal.
        2. Instruct patient to use tissues to cover mouth when coughing.
        3. Ask:
              "How long have you had that cough?"
  ACTIO
                 (If response is more than 2 weeks, proceed to the following question):
  NS:
              "Are you seeing the doctor for your cough?"
                 (If response is yes):
        4. Inform Level 2 provider immediately of above responses.


LEVEL 2           Health Assessment

        RNs, Health Care Specialists, Radiology staff, Nurse Practitioners, Physician Assistants,
  WHO:
        Medical Students, Respiratory Therapists, Resident and Attending Physician.
  TYPE: Gather information on risk factors for TB by interview and taking history.
                                                                                                                                                                     79
                                                                                                               80
      1. Provide tissues and reinforce to the patient to cover mouth when coughing.
      2. Provide a surgical mask or dust-mist mask to patient and request patient to wear it if unable
      to cover mouth with tissue during cough.
 ACTI
      3. Remove patient from common waiting/public areas within five (5) hours of identifying
 ONS:
      suspecting tuberculosis.
      4. Notify medical staff to do further assessment for TB as soon as possible.


LEVEL 3         Medical Assessment

 WHO: Medical staff, attending and resident physicians.
       Tentative diagnosis or decision on the likelihood of active pulmonary TB (based on Algorithm for
 TYPE:
       Initiation of TB Isolation, Appendix 3).

LEVEL 4           Follow-Up Assessment

 WHO:     Epidemiology/Infection Control, Microbiology Laboratory, Resident and Attending physicians.
          Follow-up with smear and culture results.
 TYPE:
          Evaluate treatment options.
          1. For inpatients: Microbiology laboratory will contact Epidemiology/Infection Control, Physician,
          or Nursing Unit if positive AFB smear and/or M. tuberculosis culture result.
          2. For outpatients or discharged patients: Microbiology contacts Epidemiology/Infection
          Control.
          3. Maintain or discontinue "STOP-Airborne Communicable Disease" sign for inpatients (based on
 ACTIONS:
          Algorithm for Discontinuing TB Isolation, Appendix 4).
          4. Epidemiology/Infection Control verifies reporting of the case to the Public Health Department.




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Evaluation and Management of the Patient with Possible TB Presenting to Reid Hospital

            APPENDIX 5: GUIDELINES FOR INITIATION OF TB ISOLATION




                                                                                        81
                                                                                                                        82

               Patient with a                                                    Initiate Level 2 Screening
                   Cough




               Provide tissues




                                           YES
         Initiate Level 1 Screening


                                                                        Is one of the following risk factors present?
                                                                               -recent (2yrs) exposure to TB




                                                 YES
                                                                              -known recent PPD conversion
                  Cough
                                                                                 -high-risk Native American
               present for >
                                                                                   -immunocompromised
                 2 weeks
                                                                                     -high-risk immigrant
                                                                                      -fever/night sweats
                                                                                      -recent weight loss
                                                                                      -previous hx of TB
                                          NO
                    NO




                                                                                         -hemoptysis



                Continued
              evaluation TB
                clinically




                                                                                             YES
                indicated


                                                                                Initiate Level 3 Screening
                                                                             Place surgical mask on patient if
                                                                             unable to use tissues or place in
                    NO




                                                       NO                                isolation



           Isolation not required
                                                                                     Is the chest x-ray
                                                                                   suggestive of TB?**
                                                                                    or is there a concer
                                                                                    for laryngeal TB?




                                                                                            YES



                                      Outpatient evaluation and care                     Need for
                                        Contact PHP TB Clinic          NO             hospitalization
                                                                                            YES




                                                                                                                        82
** Chest X-ray patterns typical of TB in an immunocompetent host:
   -upper lobe infiltrative, cavitary or fibrocavitary disease               Place in TB isolation to R/O TB
   -lower lobe pneumonic process with hilar adenopathy
                                                 83
                 APPENDIX 6:

GUIDELINES FOR DISCONTINUATION OF TB ISOLATION




                                                 83
84




84
85




85
                                                                                                                            86



                                                                    APPENDIX 7:
                                          Respiratory Tuberculosis Isolation Room Negative Pressure Monitoring
              To assure a continuous negative air pressure relationship between patient rooms used for
Purpose
              Respiratory TB Isolation and adjacent public spaces.
Performed
              Engineering Mon-Fri and/or Nursing staff on the weekends
by:
              Metered Test-Mon-Fri. with a Alnor Velometer.
Equipment:
              Tissue Test-Weekends
              1. Patients ordered into Respiratory TB Isolation are placed in rooms with negative pressure in
              respect to adjacent space, at least 6 air changes per hour.
Policies:
              2. When a patient requires Respiratory TB Isolation, the negative air pressure relationship of
              the room must be documented daily.
Cross         Indiana Administrative Code, Infection Control Manual, Tuberculosis Control Plan.
References:

                          Planned Actions                                                            Key Information

                         1. Inform patient
                         of isolation
                         orders and need
                         to stay in room
                         with doors and
                         windows closed.
                         a. Document
                         teaching
                         2. Monitor and
                         document room
                         pressure on
                         Respiratory       1. Meter used to determine airflow direction is an Alnor Velometer-Engineering
                         Isolation Room 2. Tissue Method by Nurses
                         Log once a day,
                         at consistent
                         time.
                         3. Call
                         Engineering
                         for
                         service.(2034)
                         or through the
                         operator) for
                         room
                         maintainence
                                                                                                                            86
                                                                                                                 87
problems

5. In case of
instrument
malfunction:
a. Double check
                   a. If tissue flutters into room, air pressure remains negative. (Flowing from corridor into
the air flow by
                   room.)
holding a tissue
                   b. Maintenance & Engineering is responsible for routine calibration, testing,
in front of the
                   maintenance and repair.
door.
b. Call
Maintenance &
Engineering.




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                                                                 APPENDIX 8:
                                            ADDENDUM TO Reid Hospital CODE BLUE POLICY
                                      Recommendations for Code Blue Responses for Patients in Airborne
                                              Communicable Disease (Respiratory) Isolation

8. The first priority of the responding team is the evaluation, care, and attempted resuscitation of the patient in respiratory isolation, while also
    maintaining adequate protection of health care workers.
9. NIOSH-approved, N-95 respirators are available outside the isolation rooms and should be worn by all responders going into the patient’s room
    during a Code Blue.
10. The minimum number of people required to care for the patient should be in the patient's room. All others should be asked to leave the room, unless
    extenuating circumstances dictate otherwise.

      Suggested attendance:
      Anesthesiologist
      ICU/CVU Nurses
      Physician(s)
      Respiratory Care
      Unit Nurses
      Other RNs from the patient's unit
      Pharmacist
      Unit Director
      Administrative Coordinator
5.    Everyone in the room should be made aware of the patient's respiratory isolation.
6.    Every attempt should be made by those in the room to wear proper respirators.
7.    Every attempt should be made keep the door to the room closed. One person should be placed at the door to hand materials/labs back and forth as
      needed.
8.    The Lab/ ABG trays should remain outside the room. Labs and results should be passed in and out of the room.
9.    If respiratory isolation can not be adequately maintained, consultation should occur between members of the responding team and Occupational
      Medicine or Infection Control regarding the necessity for any appropriate follow-up.
10.   The Unit Director/Charge Nurse/Administrative Coordinator present at the Code Blue is responsible for carrying out items 4 - 9 above.




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                                                                      APPENDIX 9:

                                                   TUBERCULOSIS EXPOSURE MANAGEMENT
PURPOSE:
To protect Reid Hospital employees and patients by preventing potential spread of tuberculosis.
PROCEDURES and DEFINITIONS:
The Occupational Medicine (OM) will be notified as soon as is reasonably possible after an employee exposure to tuberculosis has been identified. The
supervisor of the affected area shall provide the OM nurse(s) with the name and hospital number of the index case (person with active disease), the dates of
exposure and the names of employees and patients potentially exposed.
Exposures to patients are to be reported to the Infection Control Department.
PPD skin tests:
5TU units-PPD (intermediate strength purified protein derivative, injected intradermally (Mantoux).
Determination of PPD Reaction:
  PPD Reaction                      Determination of Reaction
                                         Immunocompetent                Immunocompromised
  0-4 mm induration                 negative                         unreliable; test with controls
  5-9 mm induration                 questionable; retest in 4-6      positive
                                    weeks
  >9 mm induration                  significant positive             significant positive
Baseline Testing:
All persons exposed should receive a baseline PPD skin test unless:
       they had a documented negative PPD test within 3 months, in which case this will be considered the baseline, or
       they have had a documented positive PPD skin test in the past.
PPD skin tests will be read at 48-72 hours after initial administration and significant reactions will be measured and recorded in millimeters of induration and
erythema. Persons with significant reactions shall be referred to Occupational Medicine. These persons, however will not be considered to have converted
from the exposure unless the exposure was more than 6 weeks prior to testing.
It is the responsibility of the employee to return for PPD test reading at 48-72 hours or as advised by Occupational Medicine will coordinate baseline and
follow-up testing with the patient's primary care provider or physician.
Follow-Up Testing and Documentation
       PPD skin testing will be repeated on all exposed persons with negative baseline tests at 10-12 weeks after the exposure.
       All employee PPD tests and results are recorded on the employee's health record and maintained confidentially with the Occupational Medicine.
       Persons with significant reactions to retesting will be referred to Occupational Medicine for further evaluation and treatment.
       Employees will receive a written opinion from the Occupational Medicine Nurse or the physician within 15 days of the completion of all medical
          evaluations pertaining to an exposure incident. For exposure incidents that require retesting in 10-12 weeks, the written opinion will be forthcoming
          following the reading of the follow-up PPD skin test. A copy of the written opinion will be maintained in the employee's confidential records with the
          Occupational Medicine. The written opinion will be limited to:
       The employee's skin test status;
       The employee's infectivity status;
       A statement that the employee has been informed of the results of the medical evaluation;
       A statement that the employee has been told about any medical conditions resulting from exposure to TB that require further evaluation or treatment;
          and
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   Recommendations for medical removal or work restrictions and the physician's or Occupational Medicine Nurse’s professional opinion regarding the
    employee's ability to wear a respirator.




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                                                      N-95 Respirator Use at Reid Hospital
                                                                    Appendix 10

What is a N-95 respirator mask?
> A filtered respirator disposable mask filtering 1-5 micron particles in size.
> A N-95 is Reid Hospital’s standard for use with active or rule-out TB patients
What are the limits of a PAPR?
> Used for filtering particles from the air
> Do not protect you from noxious gases or vapors
> They do not supply oxygen in an oxygen-deficient environment
Answers to procedural questions should be found in your departmental TB exposure control plan. This plan should contain:
> Who needs to wear N-95’s or Half-Mask respirators
> When you should be wearing an approved respirator
> How you should wear your respirator
> Where you can get a respirator if your department does not have any

                                           Key Points of N-95 and Half-Mask Respirator Use at Reid Hospital


      Perform the fit check each time you don the respirator.

                                                                    N-95 Respirator




                                                                  Half-Mask Respirator




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                                           Outline for General Tuberculosis Education and Training
                                                                     Appendix 11

I.     The TB Bacilli and Transmission of TB
       A. TB infection versus disease
          1. Causative agent - M. tuberculosis
          2. Atypical M. tuberculosis strains
          3. Multi drug resistant TB strains
          4. Characteristic signs and symptoms
          5. In healthy versus immunocompromised persons
       B. Risk factors for TB infection and disease development
          1. Personal risk factors
       C. Epidemiology of TB in the community and in Reid Hospital
          1. Transmission - airborne, aerosol, needlestick
          2. Infectiousness with active disease
          3. Reinfection in persons with positive PPD skin test
          4. Impact of heat, sunlight (UV-C), air dilution on M. tuberculosis
II.    Prevention: Administrative Controls
       A. Patient population screening
          1. Signs & symptoms, history, PPD status, chest x-rays, smear & culture
          2. Triage to isolation rooms & maintenance of TB isolation, room signage
       B. Employee risk determination
          1. Employee tuberculosis screening
       C. PPD skin tests, chest x-rays, smear & culture
          1. Reporting and follow-up of signs/symptoms
          2. Follow-Up of positive skin tests
       D. Reporting and follow-up of exposures
          1. Reporting of active TB to the Public Health Department
          2. Anti-tuberculosis drug therapy
          3. Prophylaxis of infection
          4. Treatment of disease
          5. Visitor management
III.   Prevention: Engineering Controls
       A. TB isolation rooms
          1. Air changes, any ultraviolet lights, air flow monitoring
          2. Locations of TB/AFB isolation rooms
       B. High hazard procedure rooms (Bronchscopy)
IV.    Prevention: Respiratory Protection
       A. Particulate respirator types in use at Reid Hospital
          1. N-95 Respirators
          2. Half-Mask Respirators and screw on filter canisters
          3. Availability, use and storage
V.     Location of References
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                                            93
A. Reid Hospital TB Exposure Control Plan
B. Respiratory Protection Plan




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                                  Resources for Consultation and Additional Information
                                                     Appendix 12

For questions about:               Contact:                Phone

acquiring a N-95 Mask      Unit/dept. based/Material
                                 Management
N-95 Fit-Testing            Occupational Medicine
AFB smear & culture        Microbiology/Laboratory
results
chest x-ray reading                 Radiology
clinical education              Education Dept.
                         Infection Control Intranet Site
Exposure Control Plan           Infection Control          3493

isolation management     Infection Control Intranet Site
issues                        Isolation Guidelines         3493


inpatient PPD
placement                   Education Department

Employee PPDs,
respiratory protection      Occupational Medicine
information
negative pressure
ventilation                       Engineering
malfunctioning
Daily Negative
Pressure Room                     Engineering
Monitoring when TB
patient is admitted
sputum induction               Respiratory Care

TB case reporting              Infection Control           3493
                                 Admissions;
TB isolation room use:    Administrative Coordinator
admission & procedure    (evenings, nights, weekends,
scheduling                         holidays)

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                                                                 95

Acquireing TB Isolation    Found on Infection Control
room sign                 Intranet Site under Isolation   3493
                                      Signs




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                                                          Appendix 13




                                          Reid Hospital Infection Control Program Plan
                                                               2007

Reid Hospital is a 233 bed acute care rural hospital. The facility is located approximately 2 miles west of the Ohio/Indiana border
along interstate 70, exit 151. It serves the community at large as well as a large Medicare and indigent population in Wayne
County, Indiana and the surrounding counties of Indiana and Ohio.

The facility includes a level III trauma Emergency Department and an 18 bed intensive care unit which serves adult and pediatric
populations. The hospital has a pediatric unit for children (newborn through teenager). The hospital also includes 2 adult
psychiatric units and 1 Obstetrics’ unit and newborn nursery.

Reid Hospital employs approximately 1,500 people and benefits from the services of 524 community volunteers. The Medical Staff
includes 177 members, 88 percent of whom are board certified in their specialty. The physicians provide care in nearly 40
specialties and sub-specialties of medicine.


Program Organizational Structure

The Department of Infection Control is managed by a board certified infection control trained professional (ICP).
The ICP interfaces with all departments and services of Reid Hospital including Medical Staff, hospital committees, national, state,
county, and local agencies, accreditation programs, and regulatory agencies.
The program is monitored by an Infection Control Committee which meets at least 4 times a year and chaired by a physician
appointed by the medical staff. The committee consists of key hospital members from physicians, administration, pharmacy,
microbiology, nursing, surgery, heart services, environmental services, mother/baby, intensive care, education, tech services,
central processing, plant engineering, employee health and other adhoc members as needed.
The committee has the authority, with consultation from Medical Executive Committee and administration to implement emergency
measures to prevent and/or control outbreaks or epidemics.
The program plan is reviewed and/or revised on an annual basis as needed and approved by the committee.
The hospital provides for the ICP annual continuing education provided by the ICP’s national and state Association of Infection
Control Professionals (APIC).
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Monthly scientific periodicals are circulated into the department by the medical library as part of the continuing education program.




Infection Control Goals and Responsibilities

The goal of the infection control program is to reduce the risk of acquisition of healthcare acquired infections in patients and
occupationally acquired infections in healthcare workers. The department under the guidance of the Chair of the Committee, Chief
Nursing Officer, and IC Practitioner achieve this by:

   A.     Working with the various safety and quality department improvement programs in the hospital.

        The ICP participates on:
         Patient Safety Committee
         Employee Safety Committee
         Critical Care Practice Council
         Product Evaluation Committee
         Emergency Management Committee
         Co-Chairs Hospital Emergency Incident Command System (HEICS) Sub-Committee
         Co-Chairs MRSA Task Force
         Adjunct member to other committee and task force as needed
         Chair- of the Pandemic Influenza Task Force

   B. Outside ICP participation:
       Indiana District 6 Bioterrorism Task Force
       Indiana Voluntary Hospital Association (VHA) Infection Control Committee member
       Ohio Association of Infection Control Professionals, Greater Cincinnati/Dayton Chapter
       Indiana Association of Infection Control Professionals
       National Association of Infection Control Professionals
       International Association Of Infection Control Professionals

   C. Performs on-going risk assessments to identify the risk for transmission and acquisition of infectious agents in the hospital
      and to prevent emerging infectious diseases from entering the hospital.
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      The ICP and manager of Employee Health, in collaboration, establish protocols for occupational exposures to patient’s
       blood and body fluids.
      Plans are continually being written, revised, and educated for emerging infectious diseases such as SARS and Avian
       influenza.

D. Using an epidemiological approach for surveillance, data collection and trend analysis:
    House-wide surveillance is accomplished, but not limited to, a microbiology software program and reported to the
      infection control committee by the hospital microbiologist. Surveillance criteria include Centers for Disease Control and
      Prevention Guidelines and definitions. This data also includes resistant-organisms, C. difficile, and VRE infections (VRE
      patients are electronically tracked from admission-to-admission using the SMS software system). Appropriate control
      measures are applied at any given time as needed for any infectious or communicable disease. The ICP works very
      closely with local nursing homes on patient placement issues of infection control concern.
    More focused surveillance includes, but not limited to, C-sections, nursery infections, ventilator associated pneumonia,
      catheter-related blood stream infections, PICC- line infections and catheter-related urinary tract infections.
    Focused surgery infection surveillance includes, but not limited to, CABG, Total Knee, and Total Hip infections. National
      Nosocomial Infection Surveillance (NNIS) benchmarks are used as a measurement tool. Base-line hospital historical
      data is also used as a measurement tool.
    All data is shared with hospital units, Quality Committee, and Medical Executive Committee.
    Handwashing compliance is monitored on a monthly basis using a peer review form. Forms are then sent to infection
      control and tabulated. Data is shared with hospital units, administration, Quality Committee, Infection Control, Patient
      Safety, and Medical Executive Committees. Increased waterless hand cleanser dispensers have been added hospital-
      wide to assist in Handwashing compliance.

E. Developing and implementing infection control policies:
    Policies are developed with input from the appropriate departments and services in the hospital. Infection control policies
     are developed by a collaborate effort between clinical, administrative, and infection control staff. Policies are presented
     to the infection control committee for approval. Policies can be found on the intranet under administration infection
     control icon.

F. Working with hospital leadership to effectively design and implement the infection control program:
    The ICP reports directly to the Vice President/Chief Nursing Officer.
    This allows for more informed and effective decision making.
    The department is also afforded the opportunity to provide consultation to leadership on topics such as Avian Influenza
     and other emerging infectious diseases that may effect the management of the hospital and share new laws that impact
     on protection from bloodborne pathogens and mandatory reporting of infectious diseases.



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G. Working with local and regional public health authorities to integrate the efforts for control of infections in the hospital and
   community.
    The local health district is an adhoc member of the infection control committee.
    Local emergency management and local health officials are represented on the emergency management committee.
    The ICP collaborates with the local health department on their Pandemic Influenza Plan and Bioterrorism Plan
      development.
    Education is offered and provided to the local law enforcement agencies on bloodborne and airborne pathogens and
      other emerging infectious and communicable diseases.
    Work with local public health on responding to a large volume of patients that need to be admitted due to infectious
      diseases.

H. Isolation/Precautions:
    The hospital uses Center for Disease Control transmission based, isolation/precautions criteria for communicable and
       infectious disease patient placement.

I. Reportable Communicable Diseases:
    The ICP will report, as required by Indiana Administrative Code-410IAC 3.1-2-18, any communicable diseases.

J. Respiratory Protection Program
    Collaboration between occupational health and infection control in the development of the respiratory protection plan.
    An annual TB risk assessment is performed by infection control in collaboration with local public health department.
    Wayne County has a very low prevalence of Tuberculosis (TB).
    No hospital worker TB skin conversions have been associated with occupational exposure.
    Respiratory Hygiene stations are found in each registration areas for the general public.

K. Environmental Rounds
    Environmental rounds are performed in the clinical areas by the ICP and/or unit/department managers at least bi-weekly
      and as needed so that the overall environment shall be sanitary to avoid sources and transmission of disease and
      infection.
    Feedback on opportunities for improvement is given to unit/department managers for follow-up.

L. Sterilization and Disinfectant
    The ICP evaluates and makes recommendations, in collaboration with Environmental Services and Central Sterile
      Processing, regarding any change in chemical solutions for sterilization and/or other cleaning products.
    The ICP consultants with departments in regards to provision, cleaning, and disinfection of patient care equipment.
      Departments should follow manufacturer’s recommendation for any dilution formula and any mixture prepared for
      cleaning.
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M. Comply with National Safety Goals
    Handwashing and artificial nails are addressed in our policies.
    Infection Control reviews all death reports
    Infection Control and the hospital complies with the Centers for Medicare/Medicaid Campaign – Surgical Infection
     Prevention Program (SIPP) and the Surgical Care Improvement Program (SCIP) and The Hospital Acquired Infections
     Program (HAI) – part of the 100K Lives Campaign.


N. Employee Health/Occupational (OCC) Health
      Infection Control works very closely with Employee/Occ Health department to prevent occupationally acquired
        diseases.
      Emphasis is placed on prevention from bloodborne pathogens, Hepatitis B vaccination, and annual influenza
        vaccination.
      Exposure incidents are followed-up by Occ Health.

O. Outbreak Investigations
    Each outbreak is investigated and control measures are implemented.
    Investigative techniques include development of case definitions, case findings, development and analysis of line listing,
      point prevalence culture surveys of patients, staff and/or environment as needed.
    Development and analysis of epidemic curve
    Observation of healthcare worker care techniques and performance of case-control study
    Interventions for control are developed and implemented quickly as possible.

P. Education Provided by Infection Control
    Education of employees in the prevention of hospital-acquired infections in patients and occupationally acquired
     infections in healthcare workers is provided by the Infection Control Practitioner and computer based training modules
     during General Hospital Orientation of new employees and annually and as needed to staff.
    Education is provided on universal/standard precautions, bloodborne pathogens, transmission based precautions, and
     airborne diseases such as tuberculosis.
    Department specific education is given at the request of the department and/or as a request by the ICP for the
     department.


Q. Quality Improvement
    Infection Control will report quality indicator initiatives, as assigned, to the Quality department.
    Handwashing Compliance is Infection Control’s QI initiative for 2006-2007.
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                                                               Appendix 14




Reid Hospital & Health Care Services

2007 Infection Control Risk Assessment Hazard Scoring Matrix

           Element               Probability                     Risk/ Impact                        *Risk Factor     Actions, Monitoring, Mitigation and
                                                                Severity Rating                       Severity of              Remediation Activities
                                 4-Frequent   Patients                    Staff                                   IC= Infection Control Activity
                                                                                                         Effect   P = Policy
                                 3-Occasional 4-Catastrophic Event        4-Catastrophic Event
                                              3- Major Event              3- Major Event                           PI = Process Improvement
                                 2-Uncommon 2- Moderate Event             2- Moderate Event                        QC = Quality Control Activity
                                 1-Remote     1- Minor Event              1- Minor Event                           PG = Nursing Practice Group
                                                0 -none/ non applicable   0 - none/ non applicable                 (Committees/Processes as noted)
  Device related infections in
  ICU                                  4                   1                          0                   4                            IC/QC
  Targeted surgical site
  infections                           4                   2                          0                   8                            IC/QC
  Antibiotic resistant
  organisms of epidemiologic           4                   2                          0                   8                   Microbiology/Pharmacy
  significance
  Communicable disease
  reporting                            4                   2                          0                   8                              IC
  Needlestick/Blood/body fluid
  exposure (staff)                     3                   0                          1                   3                           Occ Med
  Needlestick/Blood/body fluid
  exposure (patient)                   1                   1                          1                   2                    IC/Risk Management
  Communicable disease

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          Element              Probability                          Risk/ Impact                           *Risk Factor     Actions, Monitoring, Mitigation and
                                                                   Severity Rating                          Severity of              Remediation Activities
                               4-Frequent   Patients                          Staff                                     IC= Infection Control Activity
                                                                                                               Effect   P = Policy
                               3-Occasional 4-Catastrophic Event              4-Catastrophic Event
                                            3- Major Event                    3- Major Event                                  PI = Process Improvement
                               2-Uncommon 2- Moderate Event                   2- Moderate Event                               QC = Quality Control Activity
                               1-Remote     1- Minor Event                    1- Minor Event                                  PG = Nursing Practice Group
                                                   0 -none/ non applicable    0 - none/ non applicable                        (Committees/Processes as noted)
exposure (staff)                       2                       0                          1                       2                               OCC Med/IC
Communicable disease
exposure (patient)                     1                       0                          0                       0                                   IC
Annual TB assessment                   4                       0                          0                       0                                   IC
Influenza vaccination of
employees                              3                       0                          3                       9                               OCC Med/IC


Naturally Occurring Events
(Human, Natural,
Technological, &                       2                 1-Flooding                  1-Flooding                   2               Emergency Management Committee
Hazardous)                                                                                                                                     (HVA)
Epidemic (bio-terrorism)               1                       0                          0                       0                            IC/ED
Standard/Isolation Prec.               4                       2                          3                      20                              IC
Construction hazards                   3                       1                          1                       6                     IC/Plant Engineering
Environmental rounds                   4                       3                          3                      24                              IC
                 *To score the risk factors multiply the probability by the risk/impact rating. The higher the score, the greater the priority.




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