Maintaining an Infection-Free Environment
It is the responsibility of personnel to adhere to these
Infection Control Policies.
1. Hand washing
a. current CDC guidelines or current
World Health Organization (Soap or an alcohol
based product is
used for routine hand washing.)
b. Anti-microbial soap or other methods determined
to be effective by the current CDC
guidelines is used by
employees before participating in invasive
procedures after contact with blood/body fluids.
2. Employee Health
a. All employees must meet physical health standards
consistent with the requirements of regulatory
b. Hepatitis B vaccine is offered and encouraged for
all employees having routine blood/body fluid
c. Should Blood/body fluid exposure occur:
1. Immediate care
i. Contamination of intact skin: wash skin
with soap and water.
ii. Contamination of non-intact skin or mucous
membranes; needle sticks, or scalpel/glass
cuts: wash skin with soap and water.
iii. Contamination of eyes: rinse eyes well
with normal saline or water at eyewash
2. Report Incident to Clinical Supervisor or
3. Fill out employee incident report. Be sure to
include the name of source patient, if known.
4. Prompt evaluation and possible treatment is
necessary for blood exposures from HIV-
positive or high-risk patients.
3. Food and beverages
a. Are not allowed in patient care areas including
PATIENT CARE PRACTICES
A. All personnel must be knowledgeable about and
adhere to all policies and procedures related to
Standard Blood-and-Body-Fluid Precautions as
delineated in the OSHA Manual.
EQUIPMENT AND SUPPLIES
1. Disposable patient care supplies are not reused.
a. reusable equipment is rinsed of gross soil (by a
person wearing protective attire) cleansed with an
enzymatic cleaner and then high level
decontamination occurs or sterilization
a. All clean and/or sterile patient care supplies
are stored at least 6 inches off the floor; 12
inches from the ceiling and out of the way or
protected from traffic.
b. Supplies are unboxed prior to storage in the
sterile supply area.
c. Sterile items are stored with other sterile
items; unsterile with unsterile.
d. No patient care supplies are on windowsills.
e. All refrigerators have thermometers and are
maintained at the appropriate temperature
a. Stock sterile supplies are rotated and checked
for outdates by the clinical supervisor or
Special order supplies and supplies on emergency
carts are checked at least weekly for outdates by
the clinical supervisor.
a. The staff working within the procedure room,
recovery room, utility room, etc are responsible
for cleaning between procedures, patients, see
policy. A cleaning service is utilized for
terminal cleaning per protocols.
2. Sharps disposal:
a. All needles, lancets, blades and other sharps are
disposed of in point-of-use sharps containers.
Needles should not be recapped before disposal.
If recapping must be done for procedural or
safety reasons, the one-handed technique should
3/4 full sharps containers will be sealed and
disposed of in the regulated waste system. Self retracting needles are encouraged for use for itravenous access
3. Trash/Waste disposal:
a. All solid patient care waste is considered
regulated (infectious) medical waste and is
discarded into red plastic bags.
4. All soiled linens
a. Are placed in laundry bags. If the linens
are extremely wet, the cloth bag is placed in a
plastic bag. Contaminated linens are placed in
appropriate regulated waste bags. Handling of
contaminated lines is performed utilizing personal
protective equipment and handling is kept to a
minimum. For further information please see the
policy: Housekeeping, Regulated Waste and Laundry,
located in this volume.
5. Blood spills
a. Are managed per the policies and procedures
b. A dedicated area away from all sterile supplies
will be used to store necessary equipment and
c. All cleaning products and supplies should be
maintained on shelving, not on the floor. All
products must be labeled; MSDS information must be
d. When refill-able spray bottles are used for
cleaning, the bottle must be labeled in a manner
which resists damage from water and cleaning
supplies. Additionally, labeling will document
the name of the product, concentration, date
prepared, and initials of staff person responsible
for preparation. Such cleaning supplies will be
shelved, not stored on the floor.
DRUG AND STERILE SOLUTIONS
1. For Multi-Dose vials please see the policy on Multi-
dose vials located in this volume.
2. Medications will expire and be discarded in
accordance with the manufacturers' specifications.
3. Proper storage conditions are maintained for all
medications; such conditions are checked on an annual
1. All laboratory specimens are transported to the
laboratory as soon as possible after collection in
appropriate containers. As appropriate, specimens
are refrigerated in a non-food refrigerator.
1. All new employees are oriented to these Infection
2. Infection Control in-service education is provided to
new employees and annually.
Approved By Governing Board