1. Essential Components of Your Infection Prevention and Control Manual Ruth Carrico PhD RN FSHEA CIC Associate Professor Division of Infectious Diseases University of Louisville

2. Objectives Review critical elements of the infection prevention and control policy manual Identify strategies to engage departments and facility personnel in the policy generation and adherence process

3. Why Have a Policy Manual? Outline the expectations Clarify authority and responsibilities Enable adherence with best practices Protect the patient Protect the healthcare worker Protect the facility

4. Your Responsibility Clear policies and procedures Test to ensure utility and feasibility Review at least annually and whenever situations change that impact the existing documents Make them available Make sure personnel are aware of their responsibilities Monitor effectiveness Make sure there is alignment with facility philosophies Department specific policies and procedures

5. Policy/Procedure Domains A.The Infection Prevention and Control Program B.Surveillance and Reporting C.Relevant Plans D.Isolation E.Patient Care Practices F.Performance Improvement G.Sterilization and Disinfection H.Environment of Care I.Emerging Infections J.Laboratory Support K.Employee/Occupational Health

6. Policy/Procedure Domains A.The Infection Prevention and Control Program – Infection Prevention and Control Risk Assessment – Infection Prevention and Control Plan – Infection Prevention and Control Annual Report – Infection Prevention and Control Authority Statement – Infection Prevention and Control Committee – Infection Prevention and Control Department Personnel Job Description(s) – Disclosure of HAI Events – New Employee Orientation

7. Policy/Procedure Domains B.Surveillance and Reporting – Surveillance Plan – Criteria for Determining Presence and Classification of Infection – HAI Reporting (NHSN) – Public Health Reporting – Outbreak – Notifiable Diseases – HIV/AIDS Reporting – Outbreak Response Plan – Sentinel Event Policy – Department Quality Monitoring

8. Policy/Procedure Domains C.Relevant Plans – Respiratory Protection Plan – Tuberculosis Control Plan – Exposure Control Plan

9. Policy/Procedure Domains D.Isolation – Isolation Precautions Standard Precautions Airborne Precaution Droplet Precautions Contact Precautions Special Precautions – Personal Protective Equipment Gloves Gowns Eye Protection/Face Shields Masks Respirators

10. Policy/Procedure Domains E.Patient Care Practices – Aseptic Technique – Hand Hygiene Policy – Hand Hygiene Monitoring Tool – Visitation Policies – Visitation Policy: Animals – Creutzfeldt-Jakob Disease – Invasive Surgical Procedures Performed at the Bedside

11. Policy/Procedure Domains F. Performance Improvement – Communication of HAI Rates – Product Standards – Infection Prevention and Control Liaison Program

12. Policy/Procedure Domains G. Sterilization and Disinfection – Cleaning and Disinfection – Cleaning and Disinfection Monitoring – Sterilization Steam Chemical Ethylene Oxide – Sterilization/Biological Monitoring – Recall of Sterilized Items – Sterilization Errors – Reprocessing of Single Use Devices – Reprocessing of Reusable Supplies and Equipment

13. Policy/Procedure Domains H. Environment of Care – Infection Control Monitoring Tool for EoC – Construction and Renovation Policy – Infection Prevention and Control Risk Assessment – Environment of Care Monitoring – Waterborne Disease Monitoring Environmental Hygiene – Traffic Control – Use of Facility Provided Scrubs – Waste Monitoring – Laundry and Textiles – Laundering of Employee Personal Attire – Sharps Management – Integrated Pest Management (Bedbugs, Lice, etc.)

14. Policy/Procedure Domains I. Emerging Infections – Emergency Response to Emerging Infections – Emergency Response to Disaster

15. Policy/Procedure Domains J. Laboratory Support – Specimen Collection – Notification of Laboratory Reports – Environmental Culturing – Postmortem Examination – Positive Blood Cultures in Emergency Department Patients

16. Policy/Procedure Domains K.Employee/Occupational Health – Healthcare Personnel Illness Monitoring – Healthcare Personnel Work Restrictions – Occupational Exposure – Immunization – Tuberculosis Testing

17. Alignment with CMS and TJC Review CMS regulations and TJC standards to ensure that you have necessary policies Whatever you put in policy will determine your accountability Discoverability Patient Safety Organization (Kentucky Institute for Patient Safety and Quality)