Maintaining an Infection-Free Environment

Responsibility Statement
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 
              Medical Director.
           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 
          utility rooms
    1.  STANDARD-Blood-and-Body-Fluid 
        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.
    1. Disposable patient care supplies are not reused.
    2. Decontamination: 
       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
    3.  Storage:
        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 

    4.  Outdates: 
        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.
    1.  Responsibility 
        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 
           be used. 
           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 
          cleaning supplies. 
       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.   
    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 
       Control policies 
    2. Infection Control in-service education is provided to 
       new employees and annually.
Approved By Governing Board    
Control #107.7