LLUH Department Participation in Infection Control

Admitting/Registration

• Patient Care Practices:
  The Admitting/Registration department is responsible for the admission process of the patient 24 hours a day. They handle patient possessions and interview patients in the Admitting/Registration areas and in patient rooms.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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 exposure
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease.
• Departmental Actions:
  The Admitting/Registration department adheres to housewide and department specific Infection Control policies and procedures
• Educational and Consultative Roles of the 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

Back to top

Ancillary

• Patient Care Practices:
  Ancillary services have direct and indirect patient contacts.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan 
    • 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 and Infection Prevention/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the 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

Back to top

Anesthesia

• Patient Care Practices:
  Anesthesia provides the administration of general and regional anesthesia as well as providing monitored anesthesia care for surgical, obstetrical and medical procedures for all ages of patients in all ASA classifications. They are responsible for cleaning, disinfecting, sterilization, wrapping, storage and distribution of anesthesia circuits.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposures Control Plan
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease
• Departmental Actions:
  All housewide Infection Control policies and procedures are adhered to. Any individual departmental policies and procedures are submitted to Clinical Epidemiology and Infection Prevention/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the 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

Back to top

Central Service/Sterile Processing Department

• Patient Care Practices:
  Central Service/Sterile Processing is responsible for cleaning, disinfecting, sterilization, assembly, wrapping, storage, and distribution of medical equipment, instruments and supplies.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease.
• Departmental Actions:
  All housewide Infection Control policies and procedures are adhered to including policies and procedures for cleaning, disinfection, sterilization. Sterilization practices in Central Service/Sterile Processing are monitored and reported to Clinical Epidemiology and Infection Prevention (CEIP) monthly. CEIP works with Central Service/Sterile Processing in follow-up on recalls (V-23, V-24, V-25). Any individual departmental Infection Control policies and procedures are submitted to CEIP/Infection Control Committee (ICC) for approval at every three years.
• Educational and Consultative Roles of the 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

Back to top

Clinical Laboratory

1. Patient Care Practices:
   The Clinical Laboratory performs venipuncture and processes specimens 24 hours a day, 7 days per week. Services include Blood Bank, Chemistry, Hematology, Histocompatibility, Immunology, Microbiology, and Surgical Pathology. The Clinical Laboratory is to support the laboratory aspects of Infection Control (IC). In endemic, cohort, or epidemic situations, additional culturing, subtyping, and/or plasmid typing may be necessary. In addition, the Clinical Laboratory routinely performs the environmental sampling cultures, reprocessing controls, spore tests, dialysis water, and other laboratory tests as requested by Clinical Epidemiology and Infection Prevention (CEIP).
2. Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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
3. Methods used to reduce risk of transmission of infection between and among staff and patients includes:
   • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
     • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
     • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
     • Cleaning and disinfecting of equipment not specified to be processed in Central Service
     • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
     • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease.

• Departmental Actions:
  The Clinical Laboratory adheres to housewide and department specific Infection Control policies and procedures. Individual departmental policies and procedures that include infection control issues are submitted to CEIP/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the 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

Back to top

Clinics

• Patient Care Practices:
  All hospital-based clinics provide services including seeing patients either by appointment or walk-in clinic by Residents and Attending Physicians. Services include Primary Care, Pediatrics, OB/GYN and Heart Institute.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease.
• Departmental Actions:
  The Clinics 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 and Infection Prevention/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the 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

Back to top

Dialysis

• Patient Care Practices:
  Dialysis provides inpatient and outpatient services for all ages requiring dialysis. They also provide ongoing monitoring of dialysis patients and personnel for hepatitis B.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease.
• Departmental Actions:
  All housewide Infection Control policies and procedures are adhered to, as well as specific departmental policies and procedures related to Infection Control. All departmental Infection Control policies and procedures are submitted to Clinical Epidemiology and Infection Prevention/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the 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

Back to top

Dispatch

• Patient Care Practices:
  Dispatch provides patient, equipment, and specimen transport.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • 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 the 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

Back to top

Emergency Department

• Patient Care Practices:
  The Emergency Department provides care for major or minor trauma, Obstetrical emergencies, Pediatric emergencies; Level 1, 22 beds plus ambulatory; Evaluates for hospital admissions; check-in ambulance transported patient for procedures in Medical Center; after hour care for Occupational Health, Clinics, Faculty Medical Offices, General Medical Offices, and Employee Health Services.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease.
• Departmental Actions:
  All housewide Infection Control policies and procedures are adhered to along with Nursing Techniques. The Emergency Department notifies receiving department and uses precautions when transporting patient with a communicable disease.
• Educational and Consultative Roles of the 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

Back to top

Employee Health Services

• Patient Care Practices:
  Employee Health Service is responsible for annual screening programs, immunizations (including Hepatitis B), special screening following exposures, fitness-for-duty evaluations following industrial and non-industrial exposures.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease.
• Departmental Actions:
  Employee Health Services adheres to housewide Infection Control policies and procedures. A quarterly report of employee exposures is reported to Infection Control Committee (ICC), and the Director is a member of ICC.
• Educational and Consultative Roles of the 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

Back to top

Engineering Services

• Patient Care Practices:
  Engineering Services provides consultative service to the Infection Control Committee (ICC) regarding ventilation and plumbing issues, and management of sewage spills with appropriate traffic control.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • 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 Infection Control Committee (ICC)/Clinical Epidemiology and Infection Prevention (CEIP) for approval at least every three years. CEIP and appropriate departments are notified when water is shut off. CEIP is involved whenever a sewage spill may affect patient care areas or access routes. Physical Therapy pool maintenance and control is reported to ICC quarterly. The Director is a consultative member of ICC.
• Educational and Consultative Roles of the 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

Back to top

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 an Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • 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 and Infection Prevention/Infection Control Committee (ICC) for approval at least every three years. Changes in environmental cleaning procedures or solutions are cleared through ICC. A periodic review of environmental disinfectants being used is presented to ICC for continued approval. The Director is a consultative member of ICC.
• Educational and Consultative Roles of the 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

Back to top

GI Lab

• Patient Care Practices:
  The GI Lab provides stomach, colon, and biliary system endoscopic related procedures. They are responsible for cleaning, disinfecting, sterilization, storage, and distribution of GI scopes.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Policies
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • 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. High-level disinfection practices in the GI Lab are monitored and reported to Clinical Epidemiology and Infection Prevention (CEIP) monthly. Any individual departmental Infection Control policies and procedures are submitted to CEIP/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the 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

Back to top

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 related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • 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 including special ventilation. Departmental IC policies and procedures are submitted to Clinical Epidemiology and Infection Prevention/Infection Control Committee (ICC) for approval at least every three years. The Chief Nursing Officer is a member of ICC.
• Educational and Consultative Roles of the 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

Back to top

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 related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • 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. Nutritional Services reports food-borne illness to Clinical Epidemiology and Infection Prevention (CEIP) [T-(520)-0/5], checks and cleans vending machines (G-3 & CH-G-3), and submits departmental IC policies and procedures to CEIP/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the 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

Back to top

Perioperative Services

• Patient Care Practices:
  Perioperative Services provides care through the pre-operative stage, operative time, post anesthesia care and post surgery. Services include Ambulatory Care & Observation, Anesthesiology, Operating Room, Pre-Op Holding, and Outpatient Surgery Center.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan 
    • 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. Departmental IC policies and procedures are submitted to Clinical Epidemiology and Infection Prevention (CEIP)/Infection Control Committee (ICC) for approval at least every three years. Monitors sterilization practices in O.R.'s & reports to CEIP every other week.  
• Educational and Consultative Roles of the 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

Back to top

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 related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • 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. 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. Departmental IC policies and procedures are submitted to Clinical Epidemiology and Infection Prevention/ICC for approval at least every three years. A Director is a member of ICC.
• Educational and Consultative Roles of the 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

Back to top

Radiation Medicine

• Patient Care Practices:
  Radiation Medicine provides radiation treatment through therapeutic procedures.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease.
• Departmental Actions:
  The Radiation Medicine department adheres to housewide and department specific Infection Control policies and procedures.
• Educational and Consultative Roles of the 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

Back to top

Radiology

• Patient Care Practices:
  Radiology provides imaging procedures used for diagnosis, assessment, and interventional treatments. Services include Angio, CT, Cardiovascular, Diagnostic, MRI, Nuclear Medicine, and Ultrasound.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
    • Evaluation of an employee's assignment when there is a risk of the employee transmitting an infectious disease.
• Departmental Actions:
  The Radiology department adheres to housewide and department specific Infection Control policies and procedures.
• Educational and Consultative Roles of the 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

Back to top

Rehabilitation

• Patient Care Practices:
  Rehabilitation provides individual and group therapy for all muscle groups, ADL training and re-training, limb prosthesis, etc. Services include Hand Rehab Center, Occupational Therapy, Orthotics, Physical Therapy, Speech Language Pathology, and Work Rehab Center.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Pathogents Exposure Control Plan
    • 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. Departmental IC policies and procedures are submitted to Clinical Epidemiology and Infection Prevention/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the 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

Back to top

Respiratory Care

• Patient Care Practices:
  Respiratory Care provides patient care associated with ventilators including topical drug therapy, administration of therapeutic gases, humidification, nebulization, intermittent positive pressure breathing, continuous ventilatory assist, cardiopulmonary resuscitation, postural drainage, spirometry, pulmonary function testing, arterial blood gases, and oximetry and transportation of ventilator dependent patients.
• Infection Prevention Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan 
    • 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. Departmental IC policies and procedures are submitted to Clinical Epidemiology and Infection Prevention/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the 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

Back to top

Security

• Patient Care Practices:
  Security responds to emergency situations and traffic control. Handles patient/visitor/ employee lost and found items.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan 
    • 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.
• Educational and Consultative Roles of the 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

Back to top

Social Services

• 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 related to Employee Health/Occupational Health Services 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:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Proper handling of Medical Waste per policy T-9 or CH T-9, Management of Wastes and Hazardous Materials
    • Cleaning and disinfecting of equipment not specified to be processed in Central Service
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan 
    • 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 the 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

Back to top

Volunteer Services

• Patient Care Practices:
  Volunteers provide patient direction, information, and assistance as well as giving departmental support housewide as assigned. They assist with distribution of patient mail, reading materials and other diversional activity items.
• Infection Prevention and Control issues related to Employee Health/Occupational Health Services include:
  • Pre-placement TB screening
    • Annual TB screening
• Methods used to reduce risk of transmission of infection between and among staff and patients includes:
  • Hand hygiene according to policy I-83 or CH I-83, Hand Hygiene Requirements for Employees
    • Following policy M-50 or CH M-50, Standard and Transmission-based Precautions
    • Prompt reporting of exposure to bloodborne pathogens, per the Bloodborne Pathogen Exposure Control Plan
       
• Departmental Actions:
  The Volunteer 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 and Infection Prevention/Infection Control Committee (ICC) for approval at least every three years.
• Educational and Consultative Roles of the Infection Control Committee and Clinical Epidemiology and Infection Prevention include:
  • Volunteer orientation and yearly inservices
    • 10 minute inservice boards, inservices and lectures as needed
    • Consultation with Infection Preventionist as needed

Back to top