LLUBMC Department Participation in Infection Control

Adjunctive Therapy

• Patient Care Practices:
  Adjunctive Therapy is responsible for recreational and occupational therapy for inpatients.
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing Hand hygiene
    • Following Standard and Transmission-base Precautions per policy M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9, Management of Wastes and Hazardous Materials
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  Adjunctive Therapy adheres to housewide and department specific Infection Control policies and procedures.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology and Infection Prevention include:
  • New employee orientation and B.L.U.E.
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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Admitting

• Patient Care Practices:
  The Admitting department is responsible for the admission process of the patient 24 hours a day. They handle patient possessions and interview patients in the Admitting office and patient rooms.
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing hand hygiene
    • Following Standard and Transmission-based Precautions per policy M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9, Management of Wastes and Hazardous Material
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to biohazardous waste
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  The Admitting department adheres to housewide and department specific Infection Control policies and procedures.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology include:
  • New employee orientation and B.L.U.E.
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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Ancillary

• Patient Care Practices:
  Ancillary services have direct and indirect patient contacts.
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing hand hygiene
    • Following Standard and Transmission-based Precautions per policy M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9, Management of Wastes and Hazardous Material
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to biohazardous waste
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  The Ancillary departments adhere to housewide and department specific Infection Control policies and procedures. Any individual departmental policies and procedures that include infection control issues are submitted to Clinical Epidemiology/Infection Control Committee (ICC) for approval at least tri-annually.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology include:
  • New employee orientation and B.L.U.E.
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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Engineering Services

• Patient Care Practices:
  Engineering Services provides consultative service to the Committee of the Whole regarding ventilation and plumbing issues. Management of sewage spills with appropriate traffic control.
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing hand hygiene
    • Following Standard and Transmission-based Precautions per policy M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9, Management of Wastes and Hazardous Material
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to biohazardous waste
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  All housewide Infection Control (IC) policies and procedures are adhered to, as well as specific departmental policies and procedures related to IC. All departmental IC policies and procedures are submitted to the Committee of the Whole/Clinical Epidemiology for approval at least tri-annually. Clinical Epidemiology and appropriate departments are notified when water is shut off. Clinical Epidemiology is involved whenever a sewage spill may affect patient care areas or access routes.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology include:
  • New employee orientation and B.L.U.E.
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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Environmental Services

• Patient Care Practices:
  Environmental Services is responsible for the hygiene and aesthetic cleanliness of the Medical Center, as well as the internal physical environment including its fixtures and furnishings. They are responsible for the transport of medical waste including biohazardous and sharps waste to appropriate storage areas. Rodent and pest control is a contracted service.
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing hand hygiene
    • Following Standard and Transmission-based Precautions per policy M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9, Management of Wastes and Hazardous Material
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to biohazardous waste
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  The Environmental Services department adheres to housewide and department specific Infection Control policies and procedures. Individual departmental policies and procedures that include infection control issues are submitted to Clinical Epidemiology/Committee of the Whole for approval at least tri-annually. Changes in environmental cleaning procedures or solutions are cleared through the Committee of the Whole. A periodic review of environmental disinfectants being used is presented to the Committee of the Whole for continued approval.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology includes:
  • New employee orientation and B.L.U.E.
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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Nursing

• Patient Care Practices:
  Nursing provides direct patient care, initial and ongoing physical assessment of patients for infections, patient education regarding Infection Control (IC), and collection of specimens. Nursing activities involve handling of blood and body fluids (e.g. nasopharyngeal suctioning, emptying urinary and other bags used for collection of blood or body fluids, dressing changes, etc).
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing hand hygiene
    • Following Standard and Transmission-based Precautions per policy M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9, Management of Wastes and Hazardous Material
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to biohazardous waste
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  All housewide IC policies and procedures are adhered to, as well as specific departmental policies and procedures related to IC. Nursing assigns patient rooms and develops patient care plans according to IC needs.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology includes:
  • New employee orientation and B.L.U.E.
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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Nutritional Services

• Patient Care Practices:
  Nutritional Services provides nutrition services to hospitalized patients. Food is also provided to visitors, employees, and physicians through hospital cafeteria and catering services. Food is stored, prepared, and served at proper temperature in a safe and sanitary environment. They also monitor vending machines.
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing hand hygiene
    • Following Standard and Transmission-based Precautions per policy M-50
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  All housewide Infection Control (IC) policies and procedures are adhered to, as well as specific departmental policies and procedures related to IC. Nutritional Services reports food-borne illness to Clinical Epidemiology [M-93], checks and cleans vending machines, and submits departmental IC policies and procedures to Clinical Epidemiology/Committee of the Whole for approval at least tri-annually.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology includes:
  • New employee orientation and B.L.U.E.
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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Pharmacy

• Patient Care Practices:
  The Pharmacy provides medications to all patient care areas including emergency medications, assures medications are not outdated, monitors antimicrobial therapy, and assures that parenteral fluids are prepared under aseptic technique.
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing hand hygiene
    • Following Standard and Transmission-based Precautions per policy M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9, Management of Wastes and Hazardous Material
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to biohazardous waste
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  All house-wide Infection Control (IC) policies and procedures are adhered to, as well as specific departmental policies and procedures related to IC. Personnel are instructed in aseptic technique and use of laminar and horizontal flow hoods if this is part of their job. Medication is rotated and outdated medication is discarded. Submits daily list of patients who are currently receiving antibiotic therapy to Clinical Epidemiology. Departmental IC policies and procedures are submitted to Clinical Epidemiology/Committee of the Whole for approval at least tri-annually.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology includes:
  • New employee orientation and B.L.U.E.
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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Social Services and Case Management

• Patient Care Practices:
  Social Services provides Social Service assessment including patient/family counseling that involves case work, family services, and crisis intervention. They are also involved in patient transfer and discharge arrangements.
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing hand hygiene
    • Following Standard and Transmission-based Precautions per policy M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9, Management of Wastes and Hazardous Materials
    • Prompt reporting of exposure to biohazardous waste
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  The Department of Social Services adheres to housewide Infection Control policies and procedures.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology includes:
  • Volunteer orientation and yearly inservices
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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Transportation/Dispatch

• Patient Care Practices:
  Dispatch provides patient, equipment, and specimen transport.
• Infection Prevention and Control Issues covered by Employee Health Services or the Occupational Medicine Center include:
  • Pre-employment evaluation
    • Annual health screening
    • Annual TB screening
    • Immunizations
    • Testing, treatment, and monitoring post-exposures
    • Fitness-for-duty evaluations following industrial and non-industrial exposures
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Performing hand hygiene
    • Following Standard and Transmission-based Precautions per policy M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9, Management of Wastes and Hazardous Material
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to biohazardous waste
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  The Dispatch department adheres to housewide and department specific Infection Control policies and procedures.
• Educational and Consultative Roles of Infection Control Committee and Clinical Epidemiology includes:
  • New employee orientation and B.L.U.E.
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

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