SILETZ COMMUNITY HEALTH CLINIC (2025)

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SILETZ COMMUNITY HEALTH CLINIC

POLICY

INFECTION CONTROL

TABLE OF CONTENTS

Page

Infection Control Policy

II.

Infection Control (IC) Committee

III.

Infection Control Officer

IV.

Infection Control Quality Improvement

Infection Control Surveillance

VI.

Employee Infection Control Orientation

VII.

Hepatitis B Vaccination

VIII.

Handwashing and Hand Protection

IX.

Proper Attire

Respiratory Hygiene and Cough Etiquette

XI.

Standard Precautions

XII.

Transmission Based Precautions

XIII.

Safe Injection Practices/Sharps Injury Prevention

XIV.

Blood/Body Fluid Spills

XV.

Environmental Cleaning

XVI.

Medical Equipment and Supplies

XVII.

Point of Care Device Safe Handling and Disinfection

XVIII.

Infectious Diseases

XIX.

Employee Health and Occupational Exposure Risk Mitigation

XX.

N95 Respirator Fit Testing

XXI.

Hazard Communication Standard

XXII.

Medical Instrument Sterilization

XXIII.

Management of a Positive Biological Indicator in a Steam Sterilizer

XXIV.

Isolation and/or Transfer of Patient

XXV.

Influx of Patients

XXVI.

Post-Exposure Evaluation and Follow-Up Procedure to Communicable

Page

Disease

XXVII.

Outbreak Identification and Management Policy

XXVIII.

TB Exposure Control Plan

XXIX.

TB Containment in the Clinic Setting

XXX.

Eye and Face Wash Stations

XXXI.

Corrugated Cardboard

XXXII.

Sink Cabinets

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Part 14

Infection Control Program

INFECTION CONTROL POLICY

It is the policy of the Siletz Community Health Clinic (SCHC) to adopt the Center for Disease

Control’s Infection Control Guidelines for hand hygiene and safe injection practice and

precautions, to minimize communicable disease exposure to patients and staff; to ensure the

SCHC Infection Control policy meets or exceeds the CDC Guide to Infection Prevention for

Outpatient Settings: Minimum Expectations for Safe Care (version 2.3 – September 2016); and

to use other nationally recognized guidelines, such as World Health Organization and APIC, for

best practices. The Infection Control policy will be reviewed annually by the Infection Control

Committee and updated as needed. See Part 18 for policies and procedures related to COVID19.

II.

INFECTION CONTROL (IC) COMMITTEE

The Safety/Infection Control Committee will serve as the IC Committee. A medical staff member

will be included in the IC Committee and will serve as the Infection Control Officer. Each clinic

and department will be represented on the IC Committee. IC Committee meetings will be open

to all staff to discuss infection control concerns within the facility. All changes to infection

control policy will be brought before the IC Committee for review and discussion before a policy

is changed. The Safety/Infection Control Committee will monitor the effectiveness of the

Infection Control Program outlined in the following policy and procedures.

III.

INFECTION CONTROL OFFICER

Responsibilities include:

Keep apprised of CDC, APIC, WHO, ADS, and OSHA infection control standards and

requirements.

Provide technical assistance to the Safety/Infection Control Committee and staff in

providing a safe workplace.

Maintain documentation of all reported exposures and assure that OSHA guidelines are

followed.

Maintain employee training and health records.

Prepare and conduct orientation and annual infection control in-services.

Provide direct intervention to prevent infection, as needed.

Conduct an Infection Control Risk Assessment on an annual basis that is reviewed by

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Safety/Infection Control Committee and presented to the Governing Board.

Perform facility TB risk assessment on an annual basis that is reviewed by

Safety/Infection Control Committee.

Provide training to new staff within 30 days of hire and all staff on an annual basis.

Training topics include: hand hygiene, bloodborne pathogens, sharps safety, Standard

Precautions, Contact Precautions, and Airborne Precautions.

IV.

INFECTION CONTROL QUALITY IMPROVEMENT

The Infection Control Officer and Safety/Infection Control Committee will evaluate the

Infection Control Program on a continuing basis in order to identify areas needing

improvement.

Environmental rounds and the infection control risk assessment will be used as tools to

identify areas in need of quality improvement.

Areas identified as needing improvement will be evaluated by the Infection Control

Officer and/or the Safety/Infection Control Committee as possible quality improvement

projects.

Quality improvement projects will be documented and progress reports given to the

Quality Improvement Coordinator on a regular basis.

INFECTION CONTROL SURVEILLANCE

Surveillance, as part of an infection prevention and control program in health care

facilities, contributes to meeting the program’s overall goals, namely:

Protect the patient.

Protect the health care worker, visitors, and others in the health care

environment.

Accomplish the previous two goals in a timely, efficient and cost-effective

manner whenever possible.

Infection Control Surveillance Program

The IC Committee, in conjunction with risk management and clinic leadership,

will determine the measures that will be included in the infection control

surveillance matrix. The IC Committee will also determine the method by which

surveillance of each measure will be conducted.

The IC Committee will meet monthly in order to analyze surveillance data. This

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

data will then be disseminated to directors and supervisors to share with all

staff.

Infection control quality improvement initiatives will, in part, be determined by

surveillance data.

The IC Committee will meet on an annual basis to re-evaluate surveillance

measures and make changes to those measures as determined by the

committee.

Surveillance data will be documented on a standard form and will be stored on

the shared clinic hard drive in the IC Committee folder for staff to view at any

time.

Surveillances

Safe Injection Practices Observed

Environmental Cleaning

Equipment and exam room cleaning

ii.

Hand hygiene compliance rate

iii.

Employee influenza vaccination rate

iv.

Employee hepatitis B immunization compliance rate

Employee blood and body fluid exposures

References

Lee, Terrie B., RN, MS, MPH, CIC; Montgomery, Ona G., RN, MSHA, CIC; Marx, James, RN, MS,

CIC; Olmsted, Russell N., MPH, CIC; and Scheckler, William E., MD. “Recommended practices

for surveillance: Association for Professionals in Infection Control and Epidemiology (APIC),

Inc.” American Journal of Infection Control, 2007; 35: 427-440.

VI.

EMPLOYEE INFECTION CONTROL ORIENTATION

New employees will receive orientation regarding the Infection Control policy within the

first 30 days of employment.

Tuberculosis Screening

Initial Tuberculosis screening by intradermal PPD injection or a blood test known as the

Interferon Gamma Release Assay (IGRA). If an employee has not had a documented

negative test result in the prior year, and chooses the intradermal PPD injection, Two3

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Step Testing will be done. Employees who have had a prior positive PPD will be

evaluated to determine the need for annual chest x-rays or a Blood Assay for

Mycobacterium Tuberculosis (BAMT).

Employee Vaccination

Employees of healthcare facilities are at risk for exposure to and possible

transmission of vaccine-preventable diseases because of their contact with

patients or infective material from patients. Employers and employees have a

shared responsibility to prevent occupationally acquired infections and avoid

causing harm to patients by taking reasonable precautions to prevent

transmission of vaccine preventable diseases.

Disease for which vaccination is recommended:

Hepatitis B

Influenza

MMR

Varicella (chickenpox)

Tdap (Tetanus, Diphtheria, Pertussis) or Td

COVID-19

VII.

HEPATITIS B VACCINATION

Infection Control Officer will provide training to employees about hepatitis B

vaccinations, addressing safety, benefits, efficacy, methods of administration, and

availability.

The hepatitis B vaccination series is available at no cost after initial employee training

and within 10 days of initial assignment to all employees identified in the exposure

determination section of this plan. Vaccination is encouraged unless:

Documentation exists that the employee has previously received the series;

Antibody testing reveals that the employee is immune; or

Medical evaluation shows that vaccination is contraindicated.

If an employee declines the vaccination, the employee must sign a declination form.

Employees who decline may request and obtain the vaccination at a later date at no

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

cost. A blank copy of the documentation of refusal of the vaccination is kept at in the

following location:

J:\Reports_Forms_Minutes\Forms-Schedules\Medical-Nursing\Hep B Vaccine Acceptance

or Declination Form

Vaccination will be provided by the nursing department.

VIII. HANDWASHING AND HAND PROTECTION

Indications for Hand Washing

In the United States, patients get nearly 2 million infections each year. Some

infections can be life-threatening and hard to treat. Hand hygiene is one of the

most important ways to prevent the spread of infections. Healthcare providers

should practice hand hygiene at key points in time to disrupt the transmission of

microorganisms to patients. Hand hygiene is also discussed in Part 18, Section

18G Hand Hygiene related to COVID-19 pandemic.

Indications for hand hygiene using soap and water, following soaps

manufacture’s guidelines for use. When hands are visibly dirty or contaminated

with proteinaceous material or are visibly soiled with blood or other body fluids,

wash hands with soap and water.

Before and after eating

Before and after using a restroom

Before and after providing care to a patient with a diarrheal episode or

with known or suspected C. difficile or Bacillus anthracis infection.

Indications for Hand Hygiene Using a Hand Washing Agent or Alcohol-based

Hand Rub. A hand washing agent or alcohol-based hand rub, performed for at

least 30 seconds (or per manufacture standards), may be used for routinely

decontaminating hands in the following clinical situations:

Before having direct contact with patients

Before gloving

After contact with a patient’s intact skin (e.g., when taking a pulse or

blood pressure, or lifting a patient)

After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings, even if hands are not visibly soiled

Before invasive procedures, such as venipunctures or skin punctures

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

When moving from a contaminated body site to a clean body site during

patient care

After contact with inanimate objects (including medical equipment) in the

immediate vicinity of the patient

After removing gloves

Before accessing clean or sterile supplies and before stocking supplies

After trash or infectious waste removal

All hand hygiene products are utilized in accordance with manufacturer’s

instructions for use.

Procedure

Hand washing with soap and water

Remove jewelry and wristwatches.

Turn on warm sink water.

Wet hands and forearms with running water.

Apply enough hand washing agent to cover all hand surfaces.

Vigorously rub hands together for at least 20 seconds, covering all

surfaces of hands and fingers, interlace fingers paying attention to the

space between knuckles, rub fingernails into palms paying attention to

under the nails, clean thumbs independently, and clean at least 2 inches

of wrist.

Rinse hands thoroughly with water and with hands angled down in the

sink, avoid splashing.

Pat hands with a disposable towel until they are thoroughly dry.

Use disposable towel to turn off the water faucet.

Discard the disposable towel into the appropriate container.

Alcohol based hand rub

Apply recommended amount of product to palm of one hand.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Rub hands together, covering all surfaces of hands and fingers and under

the nails.

Continue to rub until hands are dry; do not rinse.

Repeated use of alcohol hand rubs may result in a sticky residue on the

hands; wash with soap and water periodically to remove the hand rub

residue.

Fingernail Hygiene

Artificial fingernails, wraps, overlays, extenders, or nail jewelry may not be worn

if duties include direct contact with patients.

Natural nail tips shall be less than one-quarter inch long.

Nails must be well manicured.

Liquid Soap Containers

Disposable containers are to be used; and are replaced by housekeeping, or

appropriate staff when empty.

Containers are replaced when expired.

Soap containers are never refilled or “topped-off”.

Soap and Water vs. Alcohol-based Hand Rub

Soap and water should be used when hands are visibly soiled (e.g. blood, body fluids)

and is also preferred after caring for a patient with known or suspected C. difficile or

norovirus during an outbreak. However, in the absence of the above situations alcoholbased hand rub is preferred over soap and water in the majority of clinical situations.

Glossary of Commonly Used Hand Hygiene Terms

Alcohol-based hand rub: An alcohol-containing preparation designed for

application to the hands for reducing the number of viable microorganisms on

the hands; in the United States, such preparations usually contain 60%–95%

ethanol or isopropanol.

Antimicrobial soap: Soap (i.e., detergent) containing an antiseptic agent.

Antiseptic agent: Antimicrobial substances that are applied to the skin to reduce

the number of microbial flora (e.g., alcohols, chlorhexidine, chlorine,

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

hexachlorophene, iodine,

compounds, and triclosan).

chloroxylenol

(PCMX),

quaternary

ammonium

Antiseptic hand rub: Applying an antiseptic hand rub product to all surfaces of

the hands to reduce the number of microorganisms present.

Antiseptic hand wash: Washing hands with water and soap or other detergents

containing an antiseptic agent.

Cumulative effect: A progressive decrease in the numbers of microorganisms

recovered after repeated applications of a test material.

Decontaminate hands: To reduce bacterial counts on hands by performing

antiseptic hand rub or antiseptic handwash.

Detergent: Detergents (i.e., surfactants) are compounds that possess a cleaning

action. They are composed of both hydrophilic and lipophilic parts and can be

divided into four groups: anionic, cationic, amphoteric, and nonionic detergents.

Although products used for handwashing or antiseptic handwash in healthcare

settings represent various types of detergents, the term “soap” is used to refer

to such detergents in this policy and procedure.

Hand antisepsis: Refers to either antiseptic handwash or antiseptic hand rub.

10.

Hand hygiene: A general term that applies to either handwashing, antiseptic

handwash, antiseptic hand rub, or surgical hand antisepsis.

11.

Hand washing: Washing hands with plain (i.e., non-antimicrobial) soap and

water.

12.

Persistent activity: Persistent activity is defined as the prolonged or extended

antimicrobial activity that prevents or inhibits the proliferation or survival of

microorganisms after application of the product. This activity may be

demonstrated by sampling a site several minutes or hours after application and

demonstrating bacterial antimicrobial effectiveness when compared with a

baseline level. This property also has been referred to as “residual activity.” Both

substantive and non-substantive active ingredients can show a persistent effect if

they substantially lower the number of bacteria during the wash period.

13.

Plain soap: Plain soap refers to detergents that do not contain antimicrobial

agents or contain low concentrations of antimicrobial agents that are effective

solely as preservatives.

14.

Substantivity: Substantivity is an attribute of certain active ingredients that

adhere to the stratum corneum (i.e., remain on the skin after rinsing or drying)

to provide an inhibitory effect on the growth of bacteria remaining on the skin.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

15.

Surgical hand antisepsis: Antiseptic handwash or antiseptic hand rub performed

preoperatively by surgical personnel to eliminate transient and reduce resident

hand flora; antiseptic detergent preparations often have persistent antimicrobial

activity.

16.

Visibly soiled hands: Hands showing visible dirt or visibly contaminated with

proteinaceous material, blood, or other body fluids (e.g., fecal material or urine).

17.

Waterless antiseptic agent: An antiseptic agent that does not require use of

exogenous water; after applying such an agent, the hands are rubbed together

until the agent has dried.

References

Boyce, J. M., & Pittet, D. (2002). Guideline for Hand Hygiene in Health-Care Settings:

Recommendations of the Healthcare Infection Control Practices Advisory Committee and the

HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report,

51(RR16), 1-44. Centers for Disease Control and Prevention, Guidelines for Hand Hygiene in

Healthcare Settings. http://www.cdc.gov/handhygiene/ World Health Organization. (2009).

WHO Guidelines on Hand Hygiene in Health Care.

IX.

PROPER ATTIRE

Clean clothes and/or uniforms shall be worn each day. As stated in the Personnel Manual,

employees are expected to present a professional appearance.

Staff providing direct patient care are to wear scrubs, unless otherwise privileged (i.e.

providers).

All staff that use, handle, or have ongoing exposure to sharps must wear closed toed

shoes.

RESPIRATORY HYGIENE AND COUGH ETIQUETTE

To prevent the transmission of all respiratory infections in healthcare settings, including

influenza, the following infection control measures should be implemented at the first

point of contact with a potentially infected person and is one component of Standard

Precautions.

Visual Alerts

Visual alerts (in appropriate languages) should be posted at the entrance of the clinic

instructing patients and persons who accompany them (e.g., family, friends) to inform

healthcare personnel of symptoms of a respiratory infection when they first register for

care and to practice Respiratory Hygiene and Cough Etiquette.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Respiratory Hygiene and Cough Etiquette

Cover your mouth and nose with the crook of your elbow, or a tissue

when coughing or sneezing.

Use the nearest waste receptacle to dispose of the tissue after use.

Perform hand hygiene (e.g., hand washing with soap and water or using

an alcohol-based hand rub) after having contact with respiratory

secretions and contaminated objects or materials.

Availability of Materials

The following measures to contain respiratory secretions are recommended for

all individuals with signs and symptoms of a respiratory infection.

SCHC should ensure the availability of materials in waiting rooms, so that

patients and visitors can adhere to these measures:

Tissues and no-touch receptacles for used tissue disposal.

Alcohol-based hand rub and/or hand washing supplies (soap and water,

clean towels).

Masking or Separation of Persons with Respiratory Symptoms during Periods of

Increased Community Respiratory Virus Activity (e.g., Influenza Season). (See Part 18,

Section 18A Face Mask, Face Covering, Face Shield for staff, patients, and visitors

related to COVID-19 pandemic.)

During periods of increased respiratory infection activity in the community (e.g.,

when there is increased absenteeism in schools and work settings and increased

medical office visits by persons complaining of respiratory illness), SCHC shall

offer masks to persons who are coughing.

Procedure masks (i.e., with ear loops) or surgical masks (i.e., with ties)

may be used to contain respiratory secretions (respirators such as N-95

or above are not necessary for this purpose).

When space and chair availability permit, SCHC shall encourage coughing

persons to sit at least six feet away from others in common waiting

areas. (See Part 18, Section 18H Occupational Health for social distancing

related to COVID-19 pandemic.)

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Droplet Precautions (See Transmission Based Precautions)

Medical staff shall observe Droplet Precautions (i.e., wearing a surgical or

procedure mask for close contact), in addition to Standard Precautions, when

examining a patient with symptoms of a respiratory infection, particularly if fever

is present.

These precautions should be maintained until it is determined that the cause of

symptoms is not an infectious agent that requires Droplet Precautions.

References

Bennett, G. & Kassai, M. (2011). Infection Prevention Manual for Ambulatory Surgery Centers.

ICP Associates: Rome, Georgia. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & the

Healthcare Infection Control Practices Advisory Committee. (2007). 2007 Guideline for Isolation

Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Atlanta,

Georgia: Centers for Disease Control and Prevention. Respiratory Hygiene/Cough Etiquette in

Healthcare Settings http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

XI.

STANDARD PRECAUTIONS

Definitions

Doffing: To take off

Donning: To put on

HCW: Health Care Worker

OPIM: Other potentially infectious materials

Standard Precautions:

Practices to reduce healthcare associated infections.

Used with all patients regardless of diagnosis or isolation status.

Applies to interactions with blood, all body fluids, secretions, and

excretions except sweat, regardless of whether they contain visible blood,

non-intact skin, or mucous membranes.

Are sufficient to interrupt the spread of most infectious agents and

include:

Hand hygiene

ii.

Personal Protective Equipment (PPE): Use of PPE (e.g., gloves,

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

gowns, facemasks, shoe covers), depending on the anticipated

exposure

iii.

Respiratory hygiene and cough etiquette

iv.

Safe injection practices

Sharps precautions

vi.

Safe handling of potentially contaminated equipment or surfaces

in the patient environment

vii.

General infection control practices

Standard Precautions

Standard Precautions apply to all patients and all situations, regardless of diagnosis or

presumed infection status. Because all patients can serve as reservoirs for infectious

agents, adhering to Standard Precautions during the care of all patients is essential to

interrupting the transmission of microorganisms. Standard Precautions represent the

minimum infection prevention measures that apply to all patient care, regardless of

suspected or confirmed infection status of the patient, in any setting where healthcare is

delivered. These evidence-based practices are designed to protect healthcare personnel

and prevent the spread of infections among patients.

Hand Hygiene (See Handwashing and Hand Protection and/or Part 18, Section 18G

Hand Hygiene related to COVID-19 pandemic)

Hand hygiene procedures include the use of alcohol-based hand rubs (containing 6095% alcohol) and handwashing with soap and water. Alcohol-based hand rub is the

preferred method for decontaminating hands, except when hands are visibly soiled

(e.g., dirt, blood, body fluids), or after caring for patients with known or suspected

infectious diarrhea (e.g., Clostridium difficile, norovirus), in which case soap and water

should be used.

Personal Protective Equipment (PPE) (See Part 18, Section 18B COVID-19 Personal

Protective Equipment (PPE))

PPE is provided free of charge to all employees. OSHA’s Bloodborne Pathogens

Standard (29 CFR 1910.1030) requires employers to protect workers who are

occupationally or can reasonably be anticipated to come into contact with blood

and other potentially infectious materials (OPIM). Each employee is responsible

for knowing where the equipment is kept in their department. The type of PPE

used should be appropriate for the procedure being performed and the type of

exposure anticipated.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Gloves

Gloves should be worn whenever contact with blood, blood products, body

fluids, excretions, secretions, mucous membranes, or non-intact skin is

anticipated. Gloves should also be worn when touching dressings or drainage

tubes or when performing venipuncture or invasive procedures.

Changing Gloves

Between each patient contact

ii.

Between tasks and procedures on the same patient after contact

with material that may be contaminated

iii.

When holes or tears are noted or when the glove’s ability to

function as a barrier is compromised

Removing Gloves

After each use

ii.

Before touching non-contaminated items and environmental

surfaces

iii.

Before going to another patient

Reusing Gloves

Single use gloves are not to be reused

ii.

Utility gloves may be decontaminated for re-use with an approved

EPA-registered disinfectant if the integrity of the glove is not

compromised

iii.

An approved hospital disinfectant is suitable for decontaminating

utility gloves

iv.

Utility gloves must be discarded if they are cracked, peeling, torn,

punctured, or exhibit any signs of deterioration

Selecting Gloves

Gloves should be chosen to fit hand size

ii.

Gloves should provide flexibility and tactile sensitivity needed

during the procedure

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

iii.

The following should be considered when selecting gloves:

Need to follow the Sterile Procedure (sterile versus nonsterile)

Potential for exposure to blood and body fluids during the

procedure both in terms of the amount and the length of

time exposed

Exposure to other substances that break down glove

material, such as disinfectants and solvents

The amount of stress placed on the glove during the

procedure

Protective Face and Eyewear

Masks, goggles, or face shields must be worn to provide protection of the

mucous membranes of the eyes, nose, and mouth during procedures and

patient care activities that are likely to generate droplets or splashing of

blood, body fluids, secretions, or excretions.

Prescription glasses alone do not provide protection from splatter and

splashes. Removable side shields are needed to adequately protect

healthcare workers from blood and body fluid exposures when they wear

prescription glasses.

Selecting Masks

Check the mask box for the mask’s filtering efficiency.

ii.

Make sure the mask will filter to the level of protection that is

needed. For example, if the mask is intended to protect a HCW

from TB, a NIOSH-approved respirator must be selected. See

Respiratory Protection Program in this policy.

iii.

Do not use adult masks on small children and infants.

Wearing Masks

Adjust the mask so it fits snugly against the face, is secured along

the sides of the face, and molded over the bridge of the nose; air

should not enter around the mask edges.

ii.

Keep beards groomed so the mask fits as closely to the face as

possible.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

iii.

Change the mask between patients.

iv.

Change the mask if it gets wet.

Remove the mask as soon as treatment is over.

vi.

Do not leave the mask dangling around your neck.

Gowns, Lab Coats, and Protective Apparel

Gowns are worn to prevent contamination of clothing and to protect the

skin from blood and body fluid exposures. Gowns and other appropriate

protective apparel must be worn when there is potential that an exposure

(splashing with blood or body fluids) will occur. Various types of gowns

and protective apparel are worn to provide barrier protection and reduce

opportunities for transmission of microorganisms. Uniforms and scrubs do

not provide adequate protection from blood and body fluid exposure. If

attire becomes contaminated with blood or body fluids it must be cleaned

by an approved laundry process prior to next use.

Selecting gowns and protective apparel

Protective garments should fit the HCW.

ii.

Choose garments that prevent blood or other potentially infectious

materials from passing through or reaching the HCW’s clothes or

body.

iii.

Select protective garments that are appropriate for the activity

and amount of fluid likely to be encountered.

iv.

Do not wear the same gown for the care of more than one

patient. Dental department to follow manufacture guidelines, and

their procedures for gowns.

Remove gown and perform hand hygiene before leaving the

patient’s environment (e.g., exam room, or designated doffing

area). Dental department to follow manufacture guidelines, and

their procedures for gowns.

If the uniforms or scrubs become soiled with blood or body fluids:

Glove and remove clothing immediately; handle clothing as little

as possible.

ii.

Do not rinse clothing.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

iii.

Wash contaminated skin with soap and water prior to changing

into replacement scrubs.

Respiratory Hygiene and Cough Etiquette (See Respiratory Hygiene and Cough Etiquette

in this policy)

Safe Injection Practices (See Safe Injection Practices in this policy)

Sharps Precautions

Staff who use sharps and safety equipment will be oriented to safe practices to

prevent injury to patients and themselves during orientation and annually or as

needed.

Safer sharps devices will be used whenever commercially available as a

substitute for a non-safety engineered device.

The safety device should be engaged before the device is placed into the sharps

container.

Used needles will not be recapped, purposely bent or broken by hand, removed

from disposable syringes, or otherwise manipulated by hand. Dental to follow

their procedures for needle safety.

Used sharps should be placed directly into an appropriate sharps container that

is impervious, rigid, leak-proof, and puncture-resistant to eliminate the hazard of

physical injury.

The sharps containers will be appropriately marked with the bio-hazard symbol.

Sharps containers will be placed in appropriate patient care areas, (ex. exam

rooms, dental, laboratory drawing station) which are locked and secure from

tampering.

Containers should be emptied when they are three-fourths full or are level with

the containers line marked “full”.

Accidental Needle Stick “Sharps” Exposure

If an accidental needle stick “sharps” exposure occurs, the employee should

immediately clean the area with soap and water, notify his or her supervisor,

seek medical attention as needed, and follow up with the employee health nurse

to complete exposure packet.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Safe Handling of Patient-Care Equipment and Articles

Patient care equipment and articles that have become soiled or contaminated

with infective material should be handled by employees wearing appropriate

PPE.

The handling of patient care equipment and articles depends upon the type of

item being handled.

Any disposable item that has become soiled or contaminated with

infectious material should be disposed of in the appropriate biohazard

container.

Reusable patient care equipment and articles that have been grossly

soiled or contaminated with infectious material should be covered,

handled, and decontaminated or sterilized according to the transmissionbased isolation precautions, cleaning/disinfection, and sterilization

policies.

General Infection Control Practices

Ventilation Devices

Resuscitation equipment mouthpieces or other ventilation devices are available in

the procedure room on the code cart as alternatives for mouth to mouth

resuscitation.

Linen and Laundry

Linen that is soiled or contaminated with infective material should be

handled by employees wearing appropriate PPE.

Soiled or contaminated linen should be placed directly into the

impervious linen bags that line the linen hampers.

ii.

Soiled linen should be handled as little as possible to prevent

gross contamination of the environment and exposure of

personnel handling the linen to organisms within the linen.

Soiled laundry and linen should be picked up by an authorized laundry

service.

Routine and Terminal Cleaning

Routine and thorough cleaning, and adequate disinfection of rooms and shared

patient equipment, will be accomplished according to the cleaning, disinfection,

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

sterilization, and environmental cleaning sections of this policy. Special attention

should be given to items that have been in direct contact with the patient or in

contact with the patient’s body fluids.

Regulated Medical Waste

All medical waste should be handled by employees wearing appropriate

PPE based on potential exposure risks.

Waste should be bagged in impervious bags or containers.

ii.

Regulated medical waste shall be placed in an appropriately

labeled or color coded bag according to state and local

regulations.

iii.

An authorized waste disposal service should pick up biohazardous

waste on a weekly basis.

Lab Specimens

At the time of collection, all specimens must be placed in a labeled

container which prevents leakage during collection, handling, processing,

storage, transport, or shipping.

All specimens must be contained in a plastic biohazard lab specimen bag

before leaving the collection area.

Some specimens may require special handling procedures. Contact your

state and/or local health department or CDC to determine the proper

category for shipment of specimens based on clinical history and risk

assessment to obtain detailed shipping guidance and shipping

documents.

Blood Spills

Gloves should be worn during cleaning and decontamination.

Spills of blood or other body fluids should be removed and the area

decontaminated using an OSHA approved blood spill kit.

OSHA approved blood spill kits are located on all three floors of

SCHC in labeled cupboards.

ii.

The manufacturer’s directions should be followed for use of the

product in cleaning and decontaminating spills.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

iii.

The disinfectant should be EPA registered and have kill data

against Hepatitis B, HIV, Noroviruses, non-enveloped viruses, and

tuberculosis.

Food and Drink

In patient access areas (ie. Nurse/MA stations, etc.), staff can designate

specific locations where drinks with lids are allowed.

The pre-approved locations must be separate from areas where

lab specimens or contaminated equipment are handled.

ii.

Eating from utensils or drinking from open containers or coffee

cups are prohibited at laboratory workstations or in areas where

patient care occurs.

References

United States Department of Labor, Occupational Safety and Health Administration.

Occupational Safety and Health Standards, Toxic and Hazardous Substances, Bloodborne

Pathogens. 29 CFR, 1910.1030. Basic Infection Control and Prevention Plan for Outpatient

Oncology

Settings

http://www.cdc.gov/HAI/settings/outpatient/basic-infection-controlprevention-plan-2011/fundamental-of-infection-prevention.html Siegel, J. D., Rhinehart, E.,

Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee.

(2007). 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents

in Healthcare Settings. Atlanta, Georgia: Centers for Disease Control and Prevention. Guide to

Infection Prevention in Outpatient Settings http://www.cdc.gov/HAI/settings/outpatient

/outpatient-care-gl-standard-precautions.html

XII.

TRANSMISSION BASED PRECAUTIONS (See Part 18 for additional COVID-19

related precautions)

To reduce the risk of transmission of microorganisms from both recognized and

unrecognized sources of infection.

Contact Precautions

Contact precautions apply to patients with any of the following conditions or

diseases:

The presence of stool incontinence (may include patients with norovirus,

rotavirus, Ebola (EBV), or Clostridium difficile), draining wounds,

uncontrolled secretions, pressure ulcers, or presence of ostomy tubes

and/or bags draining body fluid.

Precautions also apply to any patient with the presence of a generalized

rash or exanthemas.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Prioritize placement of patients in an exam room if they have stool incontinence,

draining wounds and/or skin lesions that cannot be covered.

Perform hand hygiene before touching patient and prior to wearing gloves.

Use PPE that is appropriate for the type of exposure anticipated. Gown and

gloves are minimum.

Perform hand hygiene after removal of PPE. Use soap and water when hands

are visibly soiled (e.g., blood, body fluids), or after caring for patients with

known or suspected infectious diarrhea (e.g., Clostridium difficile, norovirus).

Clean and disinfect the exam room accordingly.

Instruct patients with known or suspected infectious diarrhea to use a separate

bathroom, if available; clean and disinfect the bathroom before it can be used

again.

Droplet Precautions

Droplet precautions apply to patients known or suspected to be infected with a

pathogen that can be transmitted by droplet route. These include, but are not

limited to:

Respiratory viruses (e.g., influenza, parainfluenza virus, adenovirus,

respiratory syncytial virus, human metapneumovirus, SARS-COV-2

(COVID-19))

Bordetella pertussis

Neisseria meningitides and Group A streptococcus (for first 24 hours of

therapy)

The patient should be provided a facemask and placed in a separate area as far

from other patients as possible while awaiting care.

PPE Use

Wear a facemask, such as a procedure or surgical mask, for close contact

with the patient; the facemask should be donned prior to entering the

exam room.

If substantial spraying of respiratory fluids is anticipated, gloves and

gown as well as goggles (or face shield in place of goggles) should be

worn.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Perform hand hygiene before and after touching the patient and after contact

with respiratory secretions and contaminated objects or materials. Use soap and

water when hands are visibly soiled (e.g., blood, body fluids)

Instruct patient to wear a facemask when exiting the exam room, avoid coming

into close contact with other patients, and practice respiratory hygiene and

cough etiquette.

Clean and disinfect the exam room accordingly following the cleaning,

disinfection, and sterilization sections of this policy.

Airborne Precautions (See Part 18, Section 18F Testing for COVID-19 Virus)

Airborne precautions apply to patients known or suspected to be infected with a

pathogen that can be transmitted by an airborne route. These include, but are

not limited to:

Tuberculosis

Measles

Chickenpox (until lesions are crusted over)

Localized (in immunocompromised patient) or disseminated herpes zoster

(until lesions are crusted over)

COVID-19 when performing aerosol generating procedure

Have patient enter through the ambulance entrance to the facility, if available, to

avoid the reception and registration area.

Provide a facemask (e.g., procedure or surgical mask) to the patient and place

the patient immediately in the negative pressure exam room, (Procedure Room

150), with the door closed and turn on the negative air flow switch located on

the wall between the two room doors. When available, turn on negative

pressure before bringing patient to room. If negative pressure room is not

available, use exam room farthest away from other patients, keeping door closed

as much as possible. Use portable HEPA filter air purifier in exam rooms when

negative pressure is not available.

Instruct the patient to keep the facemask on while in the building and to change

the mask if it becomes wet.

Initiate protocol to transfer patient to a healthcare facility that has the

recommended infection control capacity to properly manage the patient if

indicated. See the Isolation Management of Patients with Transmissible Disease

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

section of this policy.

PPE Use

Wear a fit-tested N-95 or higher level disposable respirator when caring

for the patient. The respirator should be donned prior to room entry and

removed after exiting room. See the N95 Respirator Fit Testing section of

this policy.

If substantial spraying of respiratory fluids is anticipated, gloves and

gown as well as goggles or face shield should be worn. See the

Respiratory Protection Program section of this policy.

Perform hand hygiene before and after touching the patient and after contact

with respiratory secretions or body fluids and contaminated objects or materials.

Use soap and water when hands are visibly soiled (e.g., blood, body fluids).

Instruct patient to wear a facemask when exiting the exam room, avoid coming

into close contact with other patients, and practice respiratory hygiene and

cough etiquette.

When the patient leaves, the exam room should remain vacant for one

hour with a portable HEPA filter air purifier negative pressure on before

anyone enters. This increases to two hours when a patient with

suspected or confirmed COVID-19 has been in an exam room that is not

an airborne isolation room. After the appropriate time has passed the

exam room is to be terminally cleaned by staff wearing appropriate PPE

prior to next use.

If the patient was in the airborne isolation room (procedure room 150)

then 30 minutes should elapse prior to staff wearing appropriate PPE

entering the room to clean and disinfect.

If staff must enter the room during the wait time, they are required to

use respiratory protection. See the Respiratory Protection Program

section of this policy.

Ventilation of airborne isolation room should be maintained for 30

minutes after prior patient departure before occupying with a subsequent

patient.

References

United States Department of Labor, Occupational Safety and Health Administration.

Occupational Safety and Health Standards, Toxic and Hazardous Substances, Bloodborne

Pathogens. 29 CFR, 1910.1030.

Healthcare Associated Infections, Transmission Based

Precautions http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

2011/transmission-based-precautions.html Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello,

L., & the Healthcare Infection Control Practices Advisory Committee. (2007). 2007 Guideline for

Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

Atlanta, Georgia: Centers for Disease Control and Prevention. Guide to Infection Prevention in

Outpatient Settings http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-gl-standaredprecautions.html

XIII. SAFE INJECTION PRACTICES / SHARPS INJURY PREVENTION

Staff are to be trained and demonstrate proper sharps safety practices prior to the use of any

sharps device. Safety devices, such as hooded needles and retractable scalpel blades, etc., are

to be used when available.

Siletz Community Health Clinic follows the CDC “One and Only” campaign for safe injection

practices.

A Single Needle and Single Syringe Are Used For a Single Patient

It shall be the policy for licensed staff to give immunizations in accordance with

current standing orders and recommendations set forth by the World Health

Organization (WHO) best practices for injections.

Perform hand hygiene prior to accessing medications and solutions and

immediately before drawing up or administering the medication.

Check expiration dates prior to administration.

Use aseptic technique to avoid contamination of sterile injection equipment; the

stopper on vials shall be scrubbed with alcohol (or other products if appropriate)

prior to each entry.

Medication vials are always entered into with a new needle and new syringe

regardless of whether that medication vial is dedicated for that patient only and

is being used for the same procedure.

Needles, cannula, and syringes are sterile, single-use items; they will not be

reused for another patient or to access a medication or solution that might be

used for a subsequent patient.

The Dental Clinic uses sterile aspirating syringes that are sterilized between

patients.

Do not administer medications from a syringe to multiple patients, even if the

needle or cannula on the syringe is changed.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Sharps will be disposed of in a puncture-resistant sharps container. Sharps

containers to be placed in appropriate care areas, secured from tampering, and

replaced when the fill line is reached. Lock lid before handling sharps containers,

use gloves. Store full sharps containers in appropriate dirty utility area. Disposal

of filled sharps containers performed by appropriate contracted service.

Use of Single-Dose or Single Patient Use Vials for Medications

Do not administer medications from single-dose vials or ampules to multiple

patients or combine leftover contents for later use.

Discard vials or solutions labeled with "single patient use" or "single use" or

"preservative free" after use on single patient.

Manufactured pre-filled syringes that may have enough medication for more than

one patient must still only be used for one patient and discarded at the end of

the procedure.

Use of Multi-Dose Injectable Vials

Multi-dose injectable vials are only used for one patient, whenever possible.

If multi-dose vials must be used, both the needle or cannula and syringe used to

access the multi-dose vial must be sterile.

Multi-dose containers (e.g., vials, eye drops) are formulated for removal of

portions on multiple occasions because they contain antimicrobial preservatives.

The beyond-use date after initially entering or opening (e.g., needle-punctured)

multi-dose containers is 28 days, unless a shorter timeframe is otherwise

specified by the manufacturer.

Do not keep multi-dose vials in the immediate patient treatment area; store in

accordance with the manufacturer's recommendations and discard if sterility is

compromised or questionable.

Medicine Preparation

Draw up medication, using aseptic technique, just prior to the procedure.

Do not draw up for multiple patients.

Pre-drawn medications must be labeled properly with the time of the draw,

initials of the person drawing up the medication, name of the medication,

strength of medication, and expiration date if the manufacturer has not printed it

on the vial. Sharps should be disposed of in a puncture-resistant sharps

container.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Never store or carry medications in personal clothing or pockets.

Eye Ointments and Eye Drops

Use eye ointments and eye drops in single-dose or smaller sized containers

whenever possible.

Use only single unit sterile fluorescein strips.

If using multi-dose eye drops the bottle tip should not come into direct contact

with the patient's tears or conjunctiva; if the tip does touch the patient, the

bottle must be discarded.

Pharmaceutical dispenser tips should never touch tears or tissues. If they do,

discard.

Discard the bottle when used on patient with an infectious eye process.

Store all eye ointments and eye drops in accordance with the manufacturer's

recommendations and discard if sterility is compromised or questionable.

References

American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic

Registered Nurses. Recommended Practices for Cleaning and Sterilizing Intraocular Surgical

Instruments. February 16, 2007. Dolan, S.A., Felizardo, G., Barnes, S., Cox, T.R., Patrick, M.,

Ward, K.S., & Arias, K.M. (2010). APIC Position Paper: Safe Injection, Infusion, and Medication

Vial Practices in Healthcare. American Journal of Infection Control, 38(3), 167-72. Siegel, J.D.,

Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory.

(2007). 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents

in Healthcare Settings. Atlanta, Georgia: Centers for Disease Control & Prevention. One Needle,

One Syringe, Only One Time. Centers for Disease Control & Prevention, Safe Injection Practices

Coalition.

WHO

best

practices

for

injections

and

procedures

http://whqlibdoc.who.int/publications/2010/9789241599252_eng.pdf?ua=1

XIV.

BLOOD/BODY FLUID SPILLS

All spills of blood or other body fluids will be cleaned in the following manner:

Blood spills will be cleaned using an OSHA approved blood spill kit. Manufacturer’s

recommendations for cleaning and decontaminating the spill will be followed. Spill kits

can be found in the following areas.

Ground Floor: Maintenance office and Behavioral Health

First Floor: Laboratory, in Procedure Room 150 and in Pod B.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Second Floor- Dental Clinic

If a blood spill kit is used, the disinfectant should be EPA registered and have kill data

against Hepatitis B and HIV or should be tuberculocidal. Blood spill kits have expiration

dates that must be monitored.

If a blood spill kit is not available, as an alternative, a fresh 1:10 dilution of bleach may

be used.

Gloves and other appropriate personal protective equipment (PPE) will be worn. PPE

should be selected based on the specific situation.

Post-appropriate signage to alert other staff of the wet area.

XV.

ENVIRONMENTAL CLEANING (See Part 18, Section 18E Cleaning, Decontamination,

High-Level Disinfection and Sterilization for COVID-19 specific instructions)

General Principles

Personal protective equipment (PPE) must be worn according to the OSHA

Bloodborne Pathogen Standard when disposing of waste that could result in

exposure to bloodborne or other potentially infectious microorganisms and

hazardous material. Attention to frequently touched surfaces (e.g., light

switches, door handles) is essential.

EPA registered disinfectants or facility approved cleaning agents shall be used as

directed following manufacturer recommendations. Cleaning agents are only

effective when they remain wet for the appropriate contact time. Refer to the

cleaning agent label for organism kill times.

Thorough scrubbing with mechanical friction (back and forth motion) will be

used for all environmental surfaces.

Mop heads, cleaning cloths, and cleaning solutions will be changed frequently.

HEPA-filtered vacuums shall be used in patient care areas. Carpeting will be

vacuumed regularly, cleaned promptly if spills occur, and shampooed regularly or

when indicated by appearance or after contaminated with body fluids.

In patient care areas, cleaning of non-carpeted floors and other horizontal

surfaces will be done daily and more frequently if spillage or visible soiling occurs

using an Environmental Protection Agency (EPA)-registered disinfectant or

facility-approved cleaning agent.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Cleaning of Patient Exam Rooms

Patient exam rooms should be terminally cleaned at the beginning of the day,

using a facility-approved, EPA-registered disinfectant or wipe and visually

inspected for cleanliness before the first patient of the day is brought into the

room. All surfaces and any devices are to be cleaned.

Cleaning of the patient exam room between patients must be done with a

facility-approved, EPA-registered disinfectant or wipes. Any surface, or device,

that was touched by either the patient or staff is to be cleaned.

Clean hands and put on gloves.

Collect and remove all soiled linen and place in the designated laundry

hamper.

Collect and remove trash. All waste will be disposed of in the proper

biohazard container. Remove gloves and wash hands.

Clean hands and put on gloves. Use facility approved disinfectant or

wipes to clean and disinfect surfaces that have come in contact with a

patient, staff, or body fluids, including blood pressure cuffs.

Clean and disinfect horizontal surfaces, exam tables, counters, prep

tables, chairs, etc. When cleaning is complete, remove gloves and wash

hands.

Call maintenance to damp mop floor only if visibly soiled; allow to air dry.

Laboratory Responsibilities

The phlebotomy room should be terminally cleaned at the beginning of the day,

using a facility-approved, EPA-registered disinfectant or wipe and visually

inspected for cleanliness before the patient is brought into the area for a blood

draw.

Cleaning of the phlebotomy chair between patients must be done with a facilityapproved, EPA-registered disinfectant or wipes. Any surfaces or devices that the

staff, or patient, touched are to be cleaned.

Dental Responsibilities

Dental exam areas and chairs should be terminally cleaned at the beginning of

the day, using a facility-approved, EPA-registered disinfectant or wipe and

visually inspected for cleanliness before the patient is brought into the exam

area.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Cleaning of the dental exam area and chairs between patients must be done

with a facility-approved, EPA-registered disinfectant or wipes.

Clean hands and put on gloves. Use facility-approved disinfectant wipes

to clean and disinfect surfaces that have come in contact with a patient,

staff, or body fluids.

Clean and disinfect horizontal surfaces, counters, prep tables, chairs, etc.

When cleaning is complete, remove gloves and wash hands.

Call maintenance to damp mop floor only if visibly soiled; allow to air dry.

Cleaning of Optometry Exam Areas

Optometry exam areas should be terminally cleaned at the beginning of the day,

using a facility-approved, EPA-registered disinfectant or wipe and visually

inspected for cleanliness before the patient is brought into the exam area.

Cleaning of the optometry exam area between patients must be done with a

facility-approved, EPA-registered disinfectant or wipes. All surfaces and devices

that were touched by either the staff, or patient, are to be cleaned.

Cleaning of Nursing Stations and Staff Lounges

All nursing stations and staff lounges will be cleaned on a daily basis and as needed if

they become soiled using a facility approved EPA-registered cleaning agent.

Maintenance Responsibilities

All high touch surfaces will be cleaned twice daily at a minimum.

All bathrooms will be cleaned by maintenance staff on a daily basis and as

needed if they become soiled using a facility- approved, EPA-registered cleaning

agent.

Non patient care areas, waiting rooms, and other clinic areas not listed above

will be cleaned on a twice daily basis and as needed if they become soiled using

a facility-approved, EPA-registered cleaning agent.

Walls, ceiling, and ceiling vents will be cleaned every six months or more often if

needed.

Light fixtures will be checked weekly for bugs.

Maintenance is responsible for emptying all waste containers daily or more often

as needed.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

XVI.

MEDICAL EQUIPMENT AND SUPPLIES

Soiled supplies and equipment may not be stored near clean supplies and equipment.

Sterile and non-sterile supplies will be stored in separate areas or on separate shelves.

All sterile supplies and equipment will be checked for sterility prior to use by examining

the expiration date and the condition of the packaging. Supplies will be dated and

rotated in a timely manner.

SCHC follows all manufacturer’s guidelines and instructions for use regarding

maintenance and cleaning of reusable medical equipment.

Product recalls are forwarded to the Nursing Supervisor or designee via mail or email

through a supplier. Those lot numbers are verified by the Nursing Supervisor or

designee with the current stock and removed if found on hand and returned to supplier.

A list of patients who may have received products in question are contacted by phone or

mail to recover the product. Product recall notices are kept by the Nursing Supervisor.

XVII. POINT OF CARE DEVICE SAFE HANDLING AND DISINFECTION

Use of Point of Care Devices (including glucometers and INR ratio testing devices)

Laboratory and nursing staff will be properly trained and educated on the use of

point of care testing devices. Competency will be documented before these

devices are used on patients. Annual competency will be demonstrated. Training

checklists will be on file in the Nursing Supervisor’s office.

Perform hand hygiene prior to performing fingersticks on patients.

Always wear gloves during fingerstick glucose monitoring and during any other

procedure that involves potential exposure to blood or body fluids.

A disposable, single-use, auto-disabling lancet is the only type of device that

should be used when performing fingersticks. When performing a finger

puncture, direct the blood away from the face. Squeezing a puncture site to

obtain an adequate amount of blood can cause a blood splash onto the face or

mucous membranes.

Dispose of the used lancet in an approved sharps container.

Never reuse lancets.

Do not recap, bend, or break used lancets because these practices are potential

causes of needle stick injury.

Change gloves between patient contacts; change gloves that have touched

potentially blood-contaminated objects or fingerstick wounds before touching

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

clean surfaces.

Remove and discard gloves in appropriate receptacles after every procedure that

involves potential exposure to blood or body fluids, including fingerstick blood

sampling.

10.

Perform hand hygiene immediately after removal of gloves and before touching

other medical supplies intended for use on other patients.

11.

Wash hands immediately with soap and water if they become contaminated with

blood or body fluids.

Disinfection After Using Point of Care Testing Devices

The SCHC uses point of care testing devices (such as glucose meters and INR

ratio testing devices) that are designed for use on multiple patients, as indicated

by the manufacturer’s indications and instructions. Refer to the manufacturer

instructions regarding how the device should be cleaned and disinfected.

Special precautions apply for testing devices used on multiple patients and that

require the lanced finger to be brought to the surface of the device. Continue to

wear gloves while cleaning the device thoroughly after each use and disinfecting

it according to manufacturer’s recommendations with an EPA-approved

disinfectant or wipe.

Immediately and thoroughly clean any countertops and surfaces that have

become contaminated with blood or body fluids and disinfect with an EPAapproved, germicidal solution.

Accidental Needle Sticks

Report and manage accidental needle sticks and mucous membrane exposure following

the Employee Exposure to a Bloodborne Pathogen instructions.

References

ASC Quality Collaboration; Centers for Disease Control and Prevention. Infection Prevention

during Blood Glucose Monitoring and Insulin Administration. Atlanta, Georgia.

XVIII. INFECTIOUS DISEASES

It is the policy of the Siletz Community Health Clinic that all persons entering into

patient care areas be properly screened for communicable disease. To limit the

possibility of cross-infection, only patients seeking care, and those required to attend

with patients (ie, family, guardians, etc.) or otherwise authorized persons, are allowed

to enter patient care areas.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

If a patient is diagnosed or suspected of having a communicable disease of extreme

health significance, the Medical Director, Nursing Supervisor and the nursing staff will be

notified immediately to coordinate terminal cleaning and disinfection of the

contaminated area. Nursing Supervisor and nursing staff will notify the Patient Care

Coordinators to ensure future scheduling considerations.

Some infectious diseases are required by law to be reported to the local health

department.

The registered nurses shall report all cases or suspected cases of the diseases,

infections, microorganisms, and conditions specified below. Reports should be

made to the patient’s local health department.

Reports on out-of-state residents can be made to the provider’s local health

department or (preferably) directly to the Oregon Health Authority’s (OHA)

Public Health Division (phone 971-673-1222; fax 971-673-1100). The timing of

healthcare provider reports is specified to reflect the severity of the illness or

condition and the potential value of rapid intervention by public health agencies.

When local public health authorities cannot be reached within the specified time

limits, reports shall be made directly to OHA, which shall maintain an aroundthe-clock public health consultation service.

Report immediately, day or night:

Bacillus anthracis (anthrax)

Clostridium botulinum (botulism)

Corynebacterium diphtheriae (diphtheria)

Severe Acute Respiratory Syndrome (SARS) and infection by SARScoronavirus

Yersinia pestis (plague)

Intoxication caused by marine microorganisms or their byproducts (for

example, paralytic shellfish poisoning, domoic acid intoxication, ciguatera,

scombroid); any known or suspected common-source outbreaks

Any uncommon illness of potential public health significance

Ebola Virus Disease (EBV)

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Report within 24 hours (including weekends and holidays):

Haemophilus influenzae (any invasive disease; for laboratories, any

isolation or identification from a normally sterile site)

Measles (rubeola)

Neisseria meningitidis (any invasive disease; for laboratories, any

isolation or identification from a normally sterile site)

Pesticide poisoning

Poliomyelitis

Rabies (human or animal)

Rubella

Vibrio (all species)

SARS-COV-2 (COVID-19)

Report within one local public health authority working day:

Bordetella pertussis (pertussis)

Borrelia (relapsing fever, Lyme disease)

Brucella (brucellosis)

Campylobacter (campylobacteriosis)

Chlamydophila (Chlamydia) psittaci (psittacosis)

Chlamydia trachomatis (chlamydiosis, lymphogranuloma venereum)

Clostridium tetani (tetanus)

Coxiella burnetii (Q fever)

Creutzfeldt-Jakob

encephalopathies

Cryptosporidium (cryptosporidiosis)

Cyclospora cayetanensis (cyclosporidiosis)

disease

and

other

transmissible

spongiform

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Escherichia coli (Shiga-toxigenic, including E. coli O157 and other

serogroups)

Francisella tularensis (tularemia)

Giardia (giardiasis)

Haemophilus ducreyi (chancroid)

Hantavirus

Hepatitis A

Hepatitis B (acute or chronic infection)

Hepatitis C

Hepatitis D (delta)

HIV infection (does not apply to anonymous testing) and AIDS

Legionella (legionellosis)

Leptospira (leptospirosis)

Listeria monocytogenes (listeriosis)

Mumps

Mycobacterium tuberculosis and M. bovis (tuberculosis)

aa.

Neisseria gonorrhoeae (gonococcal infections)

bb.

Pelvic inflammatory disease (acute, non-gonococcal)

cc.

Plasmodium (malaria)

dd.

Rickettsia (all species: Rocky Mountain spotted fever, typhus, others)

ee.

Salmonella (salmonellosis, including typhoid)

ff.

Shigella (shigellosis)

gg.

Taenia solium (including cysticercosis and other undifferentiated Taenia

infections)

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

hh.

Treponema pallidum (syphilis)

ii.

Trichinella (trichinosis)

jj.

Yersinia (other than pestis)

kk.

Any infection that is typically arthropod vector-borne (e.g., Western

equine encephalitis, Eastern equine encephalitis, St. Louis encephalitis,

dengue, West Nile fever, yellow fever, California encephalitis, ehrlichiosis,

babesiosis, Kyasanur Forest disease, Colorado tick fever, etc.)

ll.

Human bites by any other mammal

mm.

CD4 cell count <200/ml (mm3) or CD4 proportion of total lymphocytes

<14%

nn.

Hemolytic uremic syndrome

Report within 7 days:

Suspected lead poisoning (for laboratories, this includes all blood lead tests

performed on persons with suspected lead poisoning). SCHC submits all blood

lead screening tests to Oregon Health Authority regardless of results. See Part 7

Nursing Procedures, Lead Screening.

References

Oregon Department of Human Services, Office of Disease Prevention and Epidemiology. (2010).

Oregon Public Health Division Reporting for Clinicians (poster). DHS 8577; Oregon Health

Authority, Public Health Division. Communicable Disease Reporting Phone Numbers by County;

Centers for Medicare and Medicaid Services (CMS), Point of Care Devices and Infections in

Nursing Homes http://www.cms.gov/site-search/search-results.html?q=point%20of%20care%

20 testing Rutala, W.A., Weber, D.J., and the Healthcare Infection Control Practices Advisory

Committee. (2008). Guideline for Disinfection and Sterilization in Healthcare Facilities. Atlanta,

Georgia: Centers for Disease Control & Prevention; American Association of Diabetes Educators.

Position Statement: Educating Providers and Persons with Diabetes to Prevent the Transmission

of Bloodborne Infections and Avoid Injuries from Sharps. Chicago, Illinois.

XIX.

EMPLOYEE HEALTH AND OCCUPATIONAL EXPOSURE RISK MITIGATION (See

Part 18, Section 18H Occupational Health related to COVID-19 pandemic)

Employee Health

Employee, for the purposes of this policy is defined as: “Anyone whose

employment is primarily based at the Siletz Community Health Clinic.”

Employees of the SCHC who work outside of the Siletz area are not included in

the scope of this policy.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Employees who are ill with an acute infection (including respiratory,

gastrointestinal, and skin) may require evaluation by a health care provider, at

their supervisor’s discretion, for clearance to remain on duty or to return to

work. Symptoms that may indicate an acute infection include fever (>100.4),

chills, diarrhea, vomiting, persistent cough, or draining skin lesions.

Occupational Exposure Risk Mitigation

SCHC is committed to providing a safe and healthful work environment for the

entire staff. In pursuit of this goal, the following exposure control plan (ECP) is

provided to eliminate or minimize occupational exposure to bloodborne

pathogens in accordance with OSHA standard 29 CFR 1910.1030, “Occupational

Exposure to Bloodborne Pathogens.”

The ECP is a key document to assist in implementing and ensuring compliance

with the standard, thereby protecting the employees. The ECP includes:

Determination of employee exposure

Implementation of various methods of exposure control, including:

standard precautions, transmission based precaution, engineering and

work practice controls, personal protective equipment, and housekeeping.

All of these are addressed in the Exposure Control Plan section of this

policy.

Hepatitis B vaccination- addressed earlier in this document

Post-exposure evaluation and follow-up

Communication of hazards to employees and training

Recordkeeping

Procedures for evaluating circumstances surrounding exposure incidents

Program Administration

The Safety/Infection Control Committee is responsible for implementation of the

ECP. The Infection Control Officer will maintain, review, and update the ICP/ECP

at least annually, and whenever necessary to include new or modified tasks and

procedures. Contact phone number: Infection Control Officer at 541-444-9610 or

X1610.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Employees who are determined to have occupational exposure to blood or other

potentially infectious materials (OPIM) must comply with the procedures and

work practices outlined in this policy.

Nursing, dental, and maintenance supervisors will provide and maintain all

necessary personal protective equipment (PPE), engineering controls (e.g.,

sharps containers), labels, and red bags as required by the standard. The

supervisors will ensure that adequate supplies of the aforementioned equipment

are available in the appropriate sizes. Contact phone number: 541-444-1030 and

ask for department you are trying to reach.

Infection Control Officer will be responsible for ensuring that all medical actions

required by the standard are performed and that appropriate employee health

and OSHA records are maintained. Contact phone number: Infection Control

Officer at 541-444-9610 or x1610.

QI Coordinator will be responsible for training, documentation of training, and

making the written ECP available to employees, OSHA, and NIOSH

representatives. Contact phone number: QI Coordinator at 541-444-9633 or x

1663.

Employee Exposure Determination

The following is a list of job titles for employees who have potential occupational

exposure:

Job Title

Clinicians

Registered Nurse

Medical Assistant

Dental Hygienist

Dental Assistant

Laboratory Staff

Maintenance

Department/Location

Medical, Dental, Optometry

Medical

Dental

Lab

Maintenance

The following is a list of job classifications for some employees who have

occupational exposure. Included is a list of tasks and procedures, or groups of

closely related tasks and procedures, in which occupational exposure may occur:

Job Title

A&D Counselor

Behavioral Health Program Administrator

Data Coordinator

Peer Recovery Mentor

Prevention Coordinator

TLC Aide

Department/Location

Behavioral Health

Task/Procedure

Collecting UA’s

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

TLC Coordinator

Youth Development Program Coordinator

Behavioral Health

Collecting UA’s

NOTE: Part-time, temporary, contract and per diem employees are covered by the

bloodborne pathogens standard.

Post-Exposure Evaluation and Follow-Up

All employees who have an occupational exposure to blood or body fluids are

to immediately clean the area with soap and water, then seek medical

evaluation, and document the exposure accordingly with the employee health

nurse. It is the responsibility of the supervisor of the employee to immediately

relieve the employee from their current assignment to allow for prompt postexposure assessment and treatment.

Definitions

Blood or Body Exposure: For transmission of blood borne pathogens

(Human Immunodeficiency Virus (HIV), Hepatitis BVirus (HBV), Hepatitis

C Virus (HCV)) to occur, an exposure must include one or more of the

given factors. If one or more are not present, there is no risk of

transmission and further evaluation is not required.

Infectious body fluid: Blood, semen, vaginal fluids, amniotic fluids,

breast milk, cerebrospinal fluid, pericardial fluid, peritoneal fluid,

pleural fluid, and synovial flood can transmit HIV, HBV, and HCV.

Note that saliva, vomitus, urine, feces, sweat, tears, and

respiratory secretions do not transmit bloodborne pathogens

(unless visibly bloody).

ii.

A portal of entry (percutaneous, mucous membrane, cutaneous)

Occupational Exposure: Reasonably anticipated skin, eye, mucous

membrane, or parenteral contact with blood or other potentially

infectious material that may result from the performance of an

employee’s duties.

PEP Exposure Protocol: A guide to assist with early intervention and

urgent decision-making for occupational exposures to HIV and Hepatitis B

and C.

Post-Exposure Prophylaxis (PEP): Any preventive medical treatment

started immediately after exposure to a pathogen (such as a diseasecausing virus), in order to prevent infection by the pathogen and the

development of disease.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Prevention

Avoiding occupational blood exposures is the primary way to prevent

transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), and human

immunodeficiency virus (HIV) in health-care settings, followed by vaccination of

hepatitis B virus (Centers for Disease Control and Prevention [CDC], 2001)

Standard Precautions

Wash hands frequently and thoroughly before and after patient care

Use appropriate Personal Protective Equipment (PPE) -- gloves, gowns,

boots, shoe covers, eyewear, and masks

Gloves must be worn when any kind of venous or arterial access is being

performed

Use sharps with caution:

Plan ahead – use sharps in a safe environment with a sharps

container nearby

ii.

Dispose of used sharps in puncture proof receptacles immediately

after use

iii.

Do not recap needles

Use safety devices if available

Risk of Exposure

The risk of exposure to blood and bloodborne pathogens is slightly greater for

healthcare employees than for people who do not work around blood.

An exposure to infected blood, tissue, or other potentially infectious body fluids

can occur by:

Percutaneous injury (e.g. a needle stick or cut with a sharp object)

Contact with mucous membrane or non-intact skin (e.g. skin that is

chapped, abraded, or affected by dermatitis)

After percutaneous injury, the risk of infection varies for specific bloodborne

pathogens:

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

The risk of infection appears to be higher with:

Exposure to a larger quantity of blood or other infectious fluid

Prolonged or extensive exposure of non-intact skin or mucous

membrane to blood or other infectious fluid or concentrated virus in a

laboratory setting

Exposure to the blood of a patient in an advanced disease stage or with

a high viral load

A deep percutaneous injury

An injury with a hollow-bore, blood-filled needle

PEP Exposure Protocol

Step 1: Treat Exposure Site

Use soap and water to wash areas exposed to potentially infectious fluids

as soon as possible after exposure

Flush exposed mucous membranes with water

Flush exposed eyes with water or saline solution

Do not apply caustic agents, or inject antiseptics or disinfectants into the

wound

Step 2: Report and Document

Report occupational exposures immediately; circumstances of the exposure and

post exposure prophylaxis (PEP) management should be recorded in the

exposed employee’s confidential medical record. Include the following:

Date and time of exposure

Details of the incident:

Where and how the exposure occurred

ii.

Exposure site(s) on the employee’s body

iii.

If related to sharp device, the type and brand of device

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Details of the exposure:

Type and amount of fluid or material

ii.

Severity of exposure

Details about the exposure source:

Whether the source material contained HIV, HBV or HCV

ii.

If the source patient is HIV-infected, determine stage of disease,

CD4 cell count, HIV viral load, history of antiretroviral therapy, and

antiretroviral resistance information.

Details about the exposed employee:

Hepatitis B vaccination and vaccine-response status

Step 3: Evaluate the Exposure

The exposure should be evaluated for potential to transmit HBV, HCV, or

HIV based on the type of body substance involved, the route, and

severity of exposure.

Significant exposures to any of the following may pose a risk for

bloodborne pathogen transmission and require further evaluation:

Blood

ii.

Semen

iii.

Vaginal secretions

iv.

Breast milk

Cerebrospinal fluid

vi.

Synovial fluid

vii.

Pleural fluid

viii.

Peritoneal fluid

ix.

Pericardial fluid

Amniotic fluid

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Body fluids that do not pose a risk of bloodborne pathogen transmission

unless visibly contaminated with blood include:

Urine

ii.

Saliva

iii.

Vomitus

iv.

Respiratory secretions

Feces

vi.

Tears

vii.

Sweat

Factors to consider in assessing the need for follow-up:

ii.

Type of exposure

Percutaneous injury

Mucous membrane exposure

Non-intact skin exposure

Bites resulting in blood exposure to either person involved

Type and amount of fluid/tissue

Blood

Fluids containing blood

Potentially infectious fluid or tissue

Direct contact with concentrated virus

Infection status of source patient

If positive for HBsAg, consider testing for presence of HBeAg

ii.

If positive for HCV antibody, consider measuring HCV viral load

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

iii.

If positive for HIV antibody, consider obtaining HIV viral load,

resistance testing, and evaluating clinical status of patient

iv.

Susceptibility of exposed employee

Hepatitis B vaccine and vaccine response status

HBV, HCV, and HIV status—baseline testing for HBsAb,

anti-HCV, and HIV antibody should be completed as early

as possible (preferably within 72 hours)

Step 4: Evaluate the Exposure Source

When source patient is known

ii.

Test patient for HBsAg, HCV antibody, and HIV antibody

HIV viral load assessments for routine screening of source

patients are not recommended

Use a rapid HIV-antibody test

If the source person is not infected with a bloodborne

pathogen, baseline testing or further follow-up of

employee is not necessary

Follow state regulations related to informed consent and

confidentiality

For patients who cannot be tested, consider medical diagnoses,

clinical symptoms, and history of risk behaviors

When source patient is not known

Evaluate the likelihood of high risk exposure

Consider the likelihood of bloodborne pathogen infection among

patients in the exposure setting, e.g. what is the community

infection rate? Does the clinic for a large number of HIV-, HBVor HCV-infected or at-risk patients?

ii.

Do not test discarded needles for bloodborne pathogens; the

reliability of these findings is not known

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Step 5: PEP Management

After performing steps above, provider will call the Clinicians’ Post

Exposure Prophylaxis Hotline (PEP line) at 1-888-448-4911 or go to the

following link for access to current up to date standards on post

exposure management.

https://nccc.ucsf.edu/clinical-resources/pep-resources/pep-quick-guide/

Provider will discuss recommended treatment options with employee.

Step 6: Follow-up

Hepatitis-exposed employee

HBV exposure follow-up testing and counseling:

Test for anti-HBs 1-2 months after last dose of vaccine;

Anti-HBs cannot be ascertained if HBIG is given within 6-8

weeks

Advise exposed employee to refrain from donating blood,

plasma, organs, tissue, or semen and use risk reduction

methods including latex barriers during sex, not sharing

injection equipment, and abstaining from risk behaviors

Offer mental health counseling as needed

HCV exposure follow-up testing and counseling

Repeat test for anti-HCV and ALT at least 4-6 months post

exposure; confirm repeatedly positive anti-HCV EIA results with

supplemental tests

ii.

Test for HCV RNA at 4-6 weeks for earlier diagnosis. (Caution

must be used due to occurrence of false positive results)

iii.

During follow-up period, refrain from donating blood, plasma,

organs, tissue, or semen

iv.

Guidelines do not recommend changes in sexual activity,

pregnancy, breastfeeding, or professional activities

Offer mental health counseling as needed

vi.

HIV-exposed employee

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

HIV exposure follow-up testing

Repeat HIV-antibody testing at 6 weeks, 3 months, and 6 months

post exposure, or as recommended from Clinicians’ Post

Exposure Prophylaxis Hotline

ii.

If illness compatible with acute retroviral syndrome occurs,

perform HIV viral load

iii.

Extended follow-up (12 months) is recommended for employees

who become infected with HCV following an exposure to a source

co-infected with HIV and HCV

iv.

If PEP is given, employee should be monitored for drug toxicity.

CBC, creatinine, and liver enzyme tests (AST, ALT, alkaline

phosphatase, total bilirubin) should be repeated at 2 weeks.

For those receiving a protease inhibitor, monitor for

hyperglycemia

If receiving indinavir(IDV) ortenofovir(TDF), tests should

include urinalysis

Counseling after HIV exposure

Advise exposed employee to refrain from donating blood,

plasma, organs, tissue, or semen; to avoid breastfeeding;

to use methods to prevent pregnancy; and to use risk

reduction methods including latex barriers during sex, not

sharing injection equipment, and abstaining from risk

behaviors.

Offer mental health counseling as needed.

Counsel employee about the signs and symptoms of acute

retroviral syndrome (flu-like syndrome), and the need to

come in for additional testing at the onset of symptoms.

If PEP is given, advise regarding the importance of

adherence and potential side effects and how to minimize

these. Inform regarding any possible drug interactions or

toxicities and the importance of monitoring for these.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Employee Training

All employees who have occupational exposure to bloodborne pathogens receive

initial and annual training conducted by the Infection Control Officer or delegate.

All employees who have occupational exposure to bloodborne pathogens receive

training on the epidemiology, symptoms, and transmission of bloodborne

pathogen diseases. The training program covers, at a minimum, the following

elements:

OSHA bloodborne pathogen standard (copy distributed)

Infection Control Policy and Exposure Control Plan (copy distributed

during clinic orientation)

Methods to recognize tasks and other activities that may involve

exposure to blood and OPIM, including what constitutes an exposure

incident

Use and limitations of engineering controls, work practices, and PPE

Types, uses, location, removal, handling, decontamination, and disposal

of PPE

Basis for PPE selection

Hepatitis B vaccine, including information on its efficacy, safety, method

of administration, the benefits of being vaccinated, and that the vaccine

will be offered free of charge

Appropriate actions to take and persons to contact in an emergency

involving blood or OPIM

Procedure to follow if an exposure incident occurs, including the method

of reporting the incident and the medical follow-up that will be made

available

Post-exposure evaluation and follow-up that the employer is required to

provide for the employee following an exposure incident

Signs and labels and/or color coding required by the standard and used

at this facility

an opportunity for interactive questions and answers with the person

conducting the training session

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Training materials are available in the quality improvement office.

Recordkeeping

Training Records

Training records are completed for each employee upon completion of

training. These documents will be kept for at least three years by the QI

Coordinator.

The training records include:

The dates of the training sessions

ii.

The contents or a summary of the training sessions

iii.

The names and qualifications of persons conducting the training

iv.

The names and job titles of all persons attending the training

sessions

Employee training records are provided upon request to the employee or

the employee’s authorized representative within 15 working days. Such

requests should be addressed to QI Coordinator.

Medical Records

Medical records are maintained for each employee with occupational

exposure in accordance with 29 CFR 1910.1020, “Access to Employee

Exposure and Medical Records.”

Infection Control Officer or delegate is responsible for maintenance of the

required medical records. These confidential records are kept in the

employee health file cabinet in the Infection Control Officer’s office for

the duration of employment. Records for previous employees are sent to

Human Resources to be kept in the permanent file plus 30 years.

Employee medical records are provided upon request of the employee or

to anyone having written consent of the employee within 15 working

days. Such requests should be sent to Human Resources.

OSHA Recordkeeping

An exposure incident is evaluated to determine if the case meets OSHA’s

recordkeeping requirements (29 CFR 1904). This determination and the

recording activities are done by Infection Control Officer.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Sharps Injury Log

In addition to the 1904 Recordkeeping Requirements, all percutaneous

injuries from contaminated sharps are also recorded in a Sharps Injury

Log. All incidences must include at least:

Date of the injury

ii.

Type and brand of the device involved (syringe, suture needle)

iii.

Department or work area where the incident occurred

iv.

Explanation of how the incident occurred.

This log is reviewed as part of the annual program evaluation and

maintained for at least five years following the end of the calendar year

covered. If a copy is requested by anyone, it must have any personal

identifiers removed from the report.

Respiratory Protection Program

All employees who are expected to wear respiratory protection must comply with

the Occupational Safety and Health Administration (OSHA) Respiratory Protection

Standard, 29 CFR 1910.134 and the most current CDC guidelines.

Program Scope and Application

The Respiratory Protection Program applies to all employees who could

potentially be exposed to airborne contaminants with harmful particles including

dusts, fumes, mists, and microbial agents in the form of droplet nuclei such as,

but not limited to, tuberculosis bacteria, influenza, Ebola Virus Disease (EVD),

Severe Acute Respiratory Syndrome (SARS), measles, and smallpox. Depending

on job responsibilities, N95 respirators are considered personal protective

equipment and will be worn during tasks such as entering isolation rooms and

other activities involving close contact with potentially infected persons.

Program Elements

The Respiratory Protection Program will cover the following basic elements:

Program administration

Program scope and application

Identifying work hazards

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Selecting respirators for use in the workplace

Medical evaluations of employees required to use respirators

Fit testing for respirators

Respirator training

Proper respirator use

Cleaning and disinfecting

Inspection, maintenance and care

Documentation and record-keeping

Regular evaluation of the effectiveness of the program

Program Administration

The Infection Control Officer will assume responsibility for supervising the

program administration. The Infection Control Officer or delegate will monitor

the ongoing and changing respiratory protection needs of the facility while

ensuring consistent coordination and direction of the respiratory program

including:

Identifying work areas, processes, or tasks that require respiratory

protection

Ensuring that employees receive appropriate training, medical evaluation,

and fit testing

Arranging and conducting training and fit testing

Selecting and ensuring the availability of appropriate respirator supplies

Monitoring respirator use to ensure that respirators are used in

accordance with certification

Ensuring proper storage and maintenance of respiratory protection

equipment

Conducting evaluations of the Respiratory Protection Program as

necessary and updating the written policy as needed to comply with

OSHA and applicable state and federal regulations

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Evaluating any feedback information or surveys

Maintaining records required by Standard 29 CFR 1910.134

Supervisor Duties

The supervisors of employees expected to use respirators must be

knowledgeable about the program requirements and must also ensure that the

program is understood and followed by employees under their charge. The

Supervisors duties include:

Knowing the hazards and types of respirators used in the area in which

they work

Ensuring the respirator program and worksite procedures are followed

Enforcing and encouraging staff to use appropriate respirators

Ensuring employees receive training and medical evaluations

Coordinating annual retraining and fit testing

Notifying the Infection Control Officer of any problems with respirator use

or changes in work processes that would impact airborne contaminant

levels

Ensuring proper storage and maintenance of all respirators

Employee Responsibilities

Participate in all trainings

Wear respirator when indicated

Maintain equipment

Report malfunctions or concerns to supervisor or Infection Control Officer

Respirator Selection

The Infection Control Officer or delegate will make respirators available to

each employee who is assigned a job that requires respiratory protection

once the medical evaluation, training, and fit testing are completed.

Various sizes of respirators will be stored at appropriate stations.

All respirators selected must be certified by the National Institute for

Occupational Safety and Health (NIOSH) and must be used in accordance

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

with the terms of the certification which appears on the NIOSH

certification label.

N95 Particulate Respirator masks are provided to persons with assigned

tasks that require respiratory protection. N95 Particulate Respirators are

air-purifying respirators certified to have filter efficiency levels of 95% or

greater against particulate aerosols free of oil and greater than 0.3

microns in size.

Medical Evaluation

Employees assigned to tasks that require the use of a respirator must be

physically able to perform the work while using a respirator. The medical

evaluation is designed to identify medical conditions that place employees

who use respirators at risk of serious medical consequences.

All employees requiring respiratory protection will complete the most up

to date OSHA Respiratory Medical Evaluation Questionnaire, Sec.

1910.134 at the time of hire and as warranted by changes in job or

health condition.

Upon completion of the questionnaire the Medical Director will

review the document to determine individual medical clearance.

ii.

Once medical clearance has been granted the employee will be

scheduled for fit testing and basic respirator training.

After review of the OSHA Respiratory Medical Evaluation Questionnaire by

the Medical Director, employees found to have issues that might make

wearing a N95 respirator difficult or cause exacerbation of current

medical conditions must be medically evaluated by a physician or other

licensed healthcare professional and found eligible to wear the respirator

selected for their use prior to fit testing and first-time use of the

respirator in the workplace.

Employees refusing a medical evaluation will not be allowed to

work in conditions requiring respirator use.

Re-evaluation will be conducted if:

Employee reports physical symptoms that are related to the ability

to use a respirator including wheezing, shortness of breath, chest

pain, etc.

ii.

Employee is having a medical problem during respirator use

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

iii.

The Medical Director determines an employee needs to be reevaluated

iv.

A change occurs in the workplace conditions that may result in an

increase physiological burden on the employees

Employee facial

significantly

size,

shape,

and

structure

has

changed

All examinations and questionnaires are to remain confidential between

the employee and health care provider. A hard copy will be kept in the

employee health file.

Fit Testing

The primary purpose of fit testing is to identify the specific make, model,

style, and size of respirator best suited for each employee.

Fit tests are conducted to determine that the respirator fits the user

adequately and that a good seal can be obtained. Respirators that do not

seal do not offer adequate protection.

Fit testing also reinforces respirator training by having wearers review the

proper method of donning and wearing the respirator.

Fit testing will occur upon hire and at least annually thereafter for

employee’s assigned tasks that require respiratory protection.

Fit tests will be conducted:

Prior to being allowed to wear any respirator

ii.

If the clinic changes respirator product

iii.

If an employee changes weight by 10% or more

iv.

If an employee has changes in facial hair or scarring

As OSHA standards require

See the N95 Respirator Fit Testing section of this policy, which outlines

the policy and procedure used to perform the OSHA-accepted Qualitative

Fit Testing including donning instructions, sensitivity test, fit test, and

required documentation.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

10.

Respiratory Training

11.

During initial fit testing and annually thereafter, employees will receive

training on:

OSHA Respiratory Protection Standard (29 CFR 1910.134)

ii.

When and why respirators are necessary including identification of

hazards, potential exposures to these hazards, and health effects

of hazards

iii.

Proper selection of respirators

iv.

Procedure for inspecting the respirator, donning and removing it,

checking the fit and seal, how to wear the mask, and

troubleshooting

Consequences of improper fit, usage, and maintenance

vi.

Limitations and capabilities of respirators

vii.

How to use the respirator in emergency situations

viii.

Proper procedure for maintenance and storage

ix.

Recognition of medical signs and symptoms that limit or prevent

the usage of respirators

Circumstances which would require retraining include changes in the type

of respirator used or if the employee has not retained the requisite

understanding or skill to use the respirator properly.

Proper Respirator Use

Employees must use their respirators under conditions specified by the

Respiratory Protection Program and in accordance with the training

received during fit testing and annually thereafter.

The respirator must not be used in a manner for which it is not certified

by NIOSH or by its manufacturer.

All employees shall conduct positive and negative pressure user seal

checks each time they wear a respirator before entering an area of

concern.

All employees shall leave a potentially contaminated work area

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

immediately to change or remove their (N95-Disposable) respirator if the

respirator is impeding their ability to work. Only remove the respirator

when you are no longer exposed to the potential airborne hazard. This

includes, but is not limited to, the respirator becoming damaged, soiled, or

you experience problems with using the respirator (breathing becomes

difficult, dizziness, irritation).

12.

N95 respirators only filter out particulate contaminants and do not protect

you from chemical vapors, gasses, asbestos, and high-risk aerosolgenerating procedures.

Only use the respirator model, size, and manufacturer for which you have

been fit-tested.

Do not use N95 respirators with beards or other facial hair that interferes

with the direct contact between your face and the sealing surface of the

respirator.

Cleaning and Storage and Inspection of Respirators

Cleaning

N95 Particulate Respiratory masks are disposable and should be

discarded at the end of the work day or if they become dirty, damaged,

or difficult to breathe through. If used for patient care a N95 respirator

must be discarded at the end of that encounter, and a new N95

respirator is to be used for each new encounter. Discard respirator as

contaminated waste.

Storage

Respirators will be stored in designated locations throughout the

clinic, (ie clean linen room, medical Pods A and B, etc) so that

they are protected against damage, contamination, dust, sunlight,

extreme temperatures, excessive moisture, and damaging

chemicals.

ii.

Each respirator should be positioned in the box that it came in so

that it retains its natural configuration.

Inspection

All respirators must be inspected before each use. Respirators that fail to

pass inspection or are otherwise found to be defective must be discarded.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

13.

Documentation and Recordkeeping

14.

The Infection Control Officer must maintain a copy of the OSHA

Respiratory Medical Evaluation Questionnaire in the employee health file ,

and the Fit Test Record that includes:

Name of the person tested

ii.

Type of fit test performed

iii.

Make, model, and size of the respirator fitted

iv.

Date of fit test

Pass or fail results

Fit test records must be maintained to determine whether annual fit

testing has been completed and to assure employees are issued the

correct replacement respirators. The completed medical forms,

documented medical recommendations, and fit test records are

confidential and will be maintained for the duration of the employment of

the individual plus thirty years as required under Standard 29 CFR

1910.134.

Program Evaluation

The Infection Control Officer will conduct evaluations of the Respiratory

Protection Program as necessary to ensure that the provisions of the current

written respirator program are being properly implemented for all employees

required to use respirators. Evaluations must be conducted to ensure the

continued effectiveness of the training program and to determine if the

respirator is being worn accurately under the correct conditions.

References

Product Insert, Kimberly Clark Professional Qualitative Fit Test Kit, www.kcprofessional.com.

Product Insert, MOLDEX N95 Particulate Respirator and Surgical Mask, Moldex-Metric, Inc.

10111 W. Jefferson Blvd, Culver City, CA 90232; NIOSH Respiratory Protection Program

(http://www.cdc.gov/niosh/topics/respirators/); U.S. Department of Labor, Occupational Safety

and Health Administration. Standard 29 CFR 1910.134, Respiratory Protection Standard.

Directive Number: CPL 2-2.54A; US Department of Health and Human Services, 1999, OSHA

Technical Manual: Respiratory Protection 29 CFR 1910.134; (http://www.osha.gov/SLTC/etools/

respiratory/ osha files/otherdocs.html); Yakima Indian Health Service Policy and Procedure,

Respiratory Protection Program, Jackie Follansbee RN-BSN MBA, Infection Prevention Officer

YSU

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

XX.

N95 RESPIRATOR FIT TESTING

The Occupational and Safety Health Administration (OSHA) requires that wearers be fit

tested with respirator masks before use according to the Respiratory Protection

Standard, 29CFR1910.134. Depending on job description, N95 Particulate Respirators

are considered personal protective equipment and will be worn during tasks such as

entering isolation rooms and other activities involving close contact with potentially

infected persons. A medical evaluation is required before fit testing health care workers

with the respirator mask and employee will follow the policies and procedure.

Background

The N95 Particulate Respirator and Surgical Mask used at SCHC have been

tested and certified by NIOSH to have filter efficiency level of 95% or greater

against particulate aerosols free of oil. It is fluid resistant and meets CDC

guidelines for TB exposure control. As a respirator, it is intended to minimize

wearer exposure to airborne particles in a size range of 0.1 to >10.0 microns. It

also provides >99% Bacterial Filtration Efficiency (BFE) against wearergenerated microorganisms.

This respirator does not supply oxygen and must not be used in atmospheres

containing less than 19.5% oxygen

Donning Instructions for the N95 Particulate Respirator and Surgical Mask

Cup the respirator in your hand with the molded nose contour nosepiece (narrow

end) at fingertips, allowing the headbands to hang freely below hands.

Position the respirator under your chin with the nosepiece (narrow end) up.

(Nose cushion must not be creased inside respirator).

Pull the top strap over your head so it rests high on the back of head.

Pull the shorter bottom strap over your head and position it around neck below

ears. Do not wear with only one strap because it may affect the fit.

Adjust respirator for comfortable fit. Using two hands mold the nosepiece to the

shape of your nose by pushing inward while moving fingertips down both sides

of the nosepiece. Continue to adjust the respirator and secure the edges until

you feel you have achieved a good facial fit. (Note: Pinching the nosepiece using

one hand may result in less effective respirator performance).

Directions for User Seal Checking (Face Fit)

User Seal Checking is intended to help the wearer verify that he or she has

properly donned the respirator. The respirator should be checked before each

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

use. User seal checking is not a substitute for fit testing. To check fit:

The wearer should place both hands completely over the respirator;

inhale and exhale sharply several times. The respirator should collapse

slightly when inhaling and bulge out slightly upon exhaling. A negative

pressure should be felt inside the respirator. The wearer should not feel

any air leaking between his or her face and the respirator.

If air leaks around your nose, adjust the nosepiece. If air leaks at

respirator edges, adjust the straps back along the sides of your head and

recheck.

Repeat until sealed properly, otherwise see your supervisor. Entry into a

contaminated area with an improper fit may result in sickness or death.

If the wearer is having a problem successfully “User Seal Checking” the

respirator, he or she should try the following:

Use a mirror while adjusting the respirator

Ask someone to look for hair or earrings that might be caught in the seal

Make sure the headbands are positioned properly

To remove mask, cup the respirator in your hand to maintain position on face.

Pull bottom strap over the head, then pull top strap over the head.

Qualitative Fit Testing of the N95 Particulate Respirator and Surgical Mask

The 3M FT-10 Qualitative Fit Test Apparatus (saccharin-based and BITREX) is

being used to test N95 Particulate Respirators. The kit meets the performance

criteria for fit testing respirators under the current OSHA Standard for

Respiratory Protection 29 CFR 1910.134. Qualitative Fit Testing consists of two

parts: A Threshold/Sensitivity Test and a Fit Test.

Manufacture instructions for use will be followed and used as step by step

instructions by the Infection Control Officer or delegate when performing

Qualitative Fit Testing of N95 Particulate Respirator and Surgical Masks.

References

Product Insert, Kimberly Clark Professional Qualitative Fit Test Kit, www.kcprofessional.com.

Product Insert, MOLDEX N95 Particulate Respirator and Surgical Mask, Moldex-Metric, Inc.

10111 W. Jefferson Blvd, Culver City, CA 90232. Occupational Safety and Health Administration

(OSHA) Standard for Respiratory Protection: 29 CFR 1910.134. https://www.osha.gov/ National

Institute for Occupational Safety and Health (NIOSH) Standard for Respiratory Protection:

NIOSH 42 CFR 84, www.cdc.gov/niosh Yakama Indian Health Service Policy and Procedure,

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Respiratory Protection Program, Jackie Follansbee RN-BSN MBA, Infection Prevention Officer

YSU

XXI.

HAZARD COMMUNICATION STANDARD

Policy

To ensure that information about the dangers of all hazardous chemicals used by

SCHC are known by all affected employees, the following hazardous information

program has been established. Under this program, the employees will be

informed of the contents of the OSHA Hazard Communications standard, the

hazardous properties of chemicals with which they work, safe handling

procedures, and measures to take to protect themselves from these chemicals.

This program applies to all work operations where an employee may be exposed

to hazardous chemicals under normal working conditions or during an

emergency situation. All work units will participate in the Hazard Communication

Program. Copies of the Hazard Communication Program are available in the

Human Resources Department for review by any interested employee.

Human Resources Manager is the program coordinator, with overall responsibility

for the program, including reviewing and updating this plan as necessary.

Container Labeling

Receiving staff will verify that all containers received for use include the

following:

Label that describes the contents

Appropriate hazard warning

Manufacturer’s name and address

The maintenance staff in each section will ensure that all secondary containers

are labeled with either an extra copy of the original manufacturer’s label or with

labels marked with the identity and the appropriate hazard warning. For help

with labeling, see lead maintenance staff.

Safety Data Sheets (SDSs)

The Infection Control Officer is responsible for establishing and monitoring the

SDS program to include:

Ensuring that procedures are developed to obtain the necessary SDSs.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Reviewing incoming SDSs for new or significant health and safety

information.

Communicating new information to affected employees

When an SDS is not received at the time of initial shipment search for the SDS

online.

Copies of SDSs for all hazardous chemicals to which employees are exposed or

are potentially exposed will be kept in departments which the chemical is used,

and a digital master copy to be maintained by the Infection Control Officer.

SDSs will be readily available to all employees during each work shift. If an SDS

is not available, contact the Infection Control Officer.

SDSs will be readily available to employees in each work area using the following

format: SDS books – paper copies, or contact Infection Control Officer for digital

copy.

When revised SDSs are received, the following procedures will be followed to

replace old SDSs: remove old SDS and replace with current SDS. Staff in each

area that are responsible for receiving and unpacking inventory are responsible

for updating SDS book in their respective area. Infection Control Officer to be

informed of any new or updated SDS so digital copy may be maintained and

updated.

Employee Training and Information

Human Resources is responsible for the Hazard Communication Program and will

ensure that all program elements are carried out.

Everyone who works with or is potentially exposed to hazardous chemicals will

receive initial training on the hazard communication standard and this plan

before starting work. Each new employee will attend a health and safety

orientation that includes the following information and training:

An overview of the OSHA hazard communication standard

The hazardous chemicals present at his or her work area

The physical and health risks of the hazardous chemicals

Symptoms of overexposure

How to determine the presence or release of hazardous chemicals in the

work area

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

How to reduce or prevent exposure to hazardous chemicals through use

of control procedures, work practices, and personal protective equipment

Steps the employer has taken to reduce or prevent exposure to

hazardous chemicals

Procedures to follow if employees are overexposed to hazardous

chemicals

How to read labels and SDSs to obtain hazard information

Location of the SDS file and written Hazard Communication program

Prior to introducing a new chemical hazard into any section of this company,

each employee in that section will be given information and training as outlined

above for the new chemical hazard. The training format will be as follows: inservice for all staff using new chemical prior to use.

Information for Contractors

It is the responsibility of the Lead Maintenance Worker to provide contractors

with information about hazardous chemicals their employees may be exposed to

on a job site and suggested precautions for employees. It is the responsibility of

the Lead Maintenance Worker to obtain information about hazardous chemicals

used by other contract employers to which employees of the clinic may be

exposed.

Contractors will be provided with SDSs for hazardous chemicals generated by

this company’s operations in the following manner: Notified of location of SDS

book.

List of Hazard Chemicals

A list of all known hazardous chemicals used by the employees is kept in the

form of SDS books kept in locations hazardous chemicals are used.

When new chemicals are received, the SDS book is updated (including date the

chemicals were introduced) within 30 days.

XXII. MEDICAL INSTRUMENT STERILIZATION

Purpose

The purpose of this policy is to provide current recommendations from the Centers for Disease

Control and Prevention (CDC) regarding cleaning, disinfecting, and sterilization of patient care

equipment, instruments, and the patient care environment. It provides reference to websites

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

where the most up-to-date information should be available.

Policy

It is the policy of the Siletz Community Health Clinic (SCHC) that all reusable instruments,

equipment, and environmental surfaces will be decontaminated, disinfected, and sterilized prior

to use on patients.

Definitions

Biological Indicator: A sterilization process monitoring device consisting of

standardized, viable population of micro-organisms (usually bacterial spores)

known to be resistant to the mode of sterilization being monitored. Biological

indicators are intended to demonstrate whether the conditions were adequate

to achieve sterilization.

Chemical Indicator: A system that reveals change in one or more predefined

process variables based on a chemical or physical change resulting from

exposure to a process.

Cleaning: The removal of all soil from surfaces. This can be accomplished by

using water with detergents. Thorough cleaning is necessary before proceeding

to high-level disinfection and sterilization. This includes pre-cleaning,

manual/ultrasonic, washer/sterilizers, decontaminators, or point of use

cleaning/disinfection processes.

Disinfection: A process that kills or destroys many or all disease-producing

microorganisms on the inanimate object. It usually does not kill spores.

High Level Disinfection: A process that destroys all vegetative microorganisms,

tubercle bacilli, fungi, non-lipid and small viruses and medium-sized viruses with

the exception of high numbers of bacterial spores through a chemical process.

MDRO: Multi-Drug Resistant Organism.

Sterilization: The complete elimination and destruction of all forms of

microbial life by physical or chemical procedures.

Introduction

The infection Control Officer is responsible for the overview of the sterilization program.

Department supervisors are responsible for the assignment of appropriately trained staff

to perform sterilization duties.

Determine the appropriate category for the article to be cleaned and disinfected and the

level of disinfection that is indicated

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

CLASS I – CRITICAL

Sterility is the standard for any instrument which can be introduced into the

bloodstream or through the patient's skin or into other normally sterile areas.

CLASS II - SEMI-CRITICAL

Items requiring high-level disinfection include instruments which come into

contact with intact mucous membranes but do not penetrate body surfaces.

CLASS III - NON-CRITICAL

Items which do not touch patients or touches only intact skin and rarely, if ever,

transmits infection. These items include countertops, crutches, blood pressure

cuffs, stethoscopes, and chin and forehead rests. Routine cleaning with soap and

water is sufficient. Alcohol or a facility approved disinfectant will be used to clean

the surface of these items between patients if they are not visibly soiled.

SINGLE-USE (SUDS)

SUDS are labeled by the manufacturer for a single use and do not have

reprocessing instructions. They may not be reprocessed for reuse except by

entities which have complied with FDA regulatory requirements and have

received FDA clearance to reprocess specific SUDs.

Disinfection

Destruction of pathogenic and other kinds of microorganisms by physical or

chemical means. Disinfection is less lethal than sterilization, because it destroys

most recognized pathogenic microorganisms, but not necessarily all microbial

forms, such as bacterial spores. Disinfection does not ensure the margin of

safety associated with sterilization processes.

The Environmental Protection Agency (EPA) classifies sterilization products

sporicidal as sterilizing agents. Defined levels of disinfection are based upon (1)

the biocidal activity of an agent against bacterial spores, tubercle bacilli,

vegetative bacteria, and viruses and (2) the contact time of the solution.

Sterilization. The use of a physical or chemical procedure to destroy all

microorganisms including large numbers of resistant bacterial spores.

High-Level Disinfectants (Sterilizing Agents). A disinfection process that

inactivates vegetative bacteria, mycobacteria, fungi, and viruses but not

necessarily high numbers of bacterial spores. The FDA further defines a

high-level disinfectant as a sterilant used under the same contact

conditions except for a shorter contact time.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Intermediate-Level Disinfectants. A liquid chemical germicide registered

by the EPA as hospital disinfectant and with a label claim of potency as a

tuberculocidal.

Low-Level Disinfectants. A liquid chemical germicide registered by the

EPA as a hospital disinfectant. OSHA requires low-level disinfectants also

to have a label claim for potency against HIV and HBV if used for

disinfecting clinical contact surfaces.

Sanitization. A process which removes gross debris and reduces the

number of microorganisms on nonliving material.

Personal Protective Equipment (PPE)

Use PPE when cleaning an item for protection against exposure to the chemicals

as directed by the Safety Data Sheets (SDS).

Traffic between the decontamination, preparation, and assembly areas should be

minimized and employees should wash their hands upon leaving the area. See

the Standard Precautions section of this policy.

Cleaning

The manufacturer’s specifications for the quality of water used for cleaning

should be followed (i.e., sterile, distilled, de-ionized).

Safely transport contaminated items to the sterilization room.

Following manufacturer’s directions, immediately immerse contaminated items in

an enzymatic disinfectant, or place immediately in an ultra-sonic cleaner, or

washer/sterilizer.

Cleaning solutions and detergents should be used and discarded appropriately

according to the manufacturer’s directions.

Cleaning solutions and detergents should be compatible with the instruments

and equipment for which they are used.

Appropriate sharps which are contaminated with blood or other potentially

infectious materials should be placed in drainage type baskets prior to

submerging in cleaning solutions. Sharps should not be stored or processed in a

manner which requires employees to reach by hand into the container where

these sharps have been placed.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Sterilization

Select the appropriate method of sterilization according to the instrument or

equipment manufacturer’s instructions. The sterilization process, including critical

parameters (time, pressure, temperature) and chemical indicators, must be

identified and followed accordingly. Refer to Operator’s Manual.

Assure adequate drying time for instruments and equipment prior to packaging

for sterilization.

Follow manufacturer’s recommendations for the following items:

Lubricants

Type of wrap or container that may be used

Shelf life and storage recommendations

Wrapping of delicate instruments and sharp points

Monitoring

Mechanical (physical), chemical, and biological monitors must be used to assure

that the sterilization process has been effective. In the event of a failed biological

monitor, follow the Management of Positive Biological Indicator in a Steam

Sterilizer section of this policy.

Monitors include time, temperature, pressure gauges, and displays. At the end of

each cycle, the operator will examine the monitors to verify that all cycle

parameters have been met.

Check steam integrators for adequacy of sterilization process.

Biological indicators are performed at least weekly, or more often, when using

autoclaves. Chemical indicators are placed in every package; Dental department

may follow their procedure guidelines and packaging manufactures standards.

Loading of Sterilizer

Arrange on rack or carriage so as to present least possible resistance to the

passage of steam.

Do not overload sterilizer; items should never touch sterilizer chamber walls.

When possible, sterilize like materials together.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Basins and trays must be set on edge or upside down so air will flow out freely

as steam flows in.

Removing Load from Sterilizer

Load should be dry and cool when removed.

If packs are wet when removed, they must be re-sterilized.

Check the chemical and process biological monitor to ensure proper temperature

and exposure time has been met.

Documentation

Package identification should include which sterilizer was used (if more than one

sterilizer is in use), which load of the day (if more than one load is completed) date of

sterilization, and initials of processor. Expiration date is set per manufacture standards;

medical defaults to one year expiration. In addition, generalized contents should be

labeled on wrapped packaging.

Documentation binders specific to sterilization process are to be maintained. (ie, loads

ran, BI results, equipment scheduled maintenance and cleaning, and individual

equipment manuals.

Supply and Equipment Management

Integrity of clean and sterile equipment and supplies shall be assessed prior to

use.

Packaging will be considered non-sterile (compromised) when the following

events occur and will not be used:

Holes or tears

Broken or no seal

Dropped

Moisture

Unsealed dust cover

Broken tape

Lids improperly applied

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Store items in a manner that prevents crushing or binding together

Place lighter items on heavier ones

Store items in closed cabinets; if this is not possible, store items on wire shelves

in a restricted storage area with the bottom shelf being solid

Store materials at least 18” below the ceiling and sprinkler head

Do not store sterile items under plumbing values and traps

Cleaning Non-Critical Patient Care Items

All non-disposable patient care equipment shall be cleaned the same regardless

of the patient’s infection status

In the exam rooms of patients with MDROs, the amount of non-disposable

equipment taken into the room shall be limited as much as feasible.

Safe Handling of Medical Devices

Medical devices that need to be sent to an external vendor for reprocessing,

inspection, or repair must first be decontaminated to ensure the safety of all who

come into contact with the device. Documentation of pre-cleaning to return the

device to a non-infectious state is required prior to transport and handling or

packaging of the device.

Follow the manufacturer’s recommendations for disinfection, as different devices

will have separate pre-cleaning requirements. A log should be kept to track the

vendor, type of disinfection, and date of return to service of the device.

Proper Storage of Sterile Items

Sterile items and disposable (single-use) items should be stored in an enclosed

storage area (e.g., cabinet or drawer). Dental and medical supplies and

instruments should not be stored under sinks, on windowsills, or adjacent to air

vents. Conditions in these areas can compromise the sterility of the packages

and instruments

Clean and sterile materials should be stored at a height of 8 to 10 inches high

from the floor and 18 inches under the ceiling

Shelf Life of Sterilized Instruments

Sterilized instruments should be stored in a manner that preserves the integrity

of the packaging material. Storage practices can be either date or event related.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Date every sterilized package with date sterilized and follow manufactures

standards for expiration dates.Use shelf-life practices (first in, first out). This

approach recognizes that the product should remain sterile until some event

causes the item to become contaminated (e.g., a package becomes torn or wet)

or the package expires, as determined by the manufactures standards. The

medical department shall observe a one year from sterilization date expiration

standard.

The quality of the packaging material, the conditions under which items are

stored and transported, and the amount that they are handled all affect the

chances that the package and its contents will remain sterile.

All packages containing sterile items should be inspected before use to verify

barrier integrity and dryness. Any package that is wet, torn, dropped on the

floor, or damaged in any way should not be used. The instruments should be recleaned, packaged in new wrap, and sterilized again.

Sterile packages should not be handled unnecessarily so that contamination can

be avoided.

References

Appendix C: Methods for Sterilizing and Disinfecting Patient-Care Items and Environmental

Surfaces (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a4.htm); Association for the

Advancement of Medical Instrumentation. (2010). ANSI/AAMI ST79 Comprehensive Guide to

Steam Sterilization and Sterility Assurance in Health Care Facilities. Washington, D.C. Block, S.S.

“Chemical and Physical Sterilization,” Disinfection, Sterilization and Preservation, 3rd edition,

Lea & Febinger, Philadelphia, 1983; OSHA Quick Facts- Laboratory Safety Autoclaves/Sterilizers

https://www.osha.gov/Publications/laboratory/OSHAquickfacts-lab-safety-autoclavessterilizers.pdf OSHA’s Personal Protective Equipment standard (29 CFR 1910.132); Rutala W.A.,

Weber D.J., and the Hospital Infection Control Practices Advisory Committee. (2008). Guideline

for Disinfection and Sterilization in Healthcare Facilities, 2008. Centers for Disease Control and

Prevention: Atlanta, Georgia; Rutala W.A., and Weber D.J., “Disinfection and Sterilization in

Healthcare Facilities: What Clinicians Need to Know”, Clinical Infectious Diseases

(2004);39:702-9; Owner’s Manual, M11 Autoclave and Biosonic UC125 ultrasonic Cleaning

System Guidelines for Infection Control in Dental Health-Care settings, 2003, MMWR, December

19, 2003:52 (RR-17)

XXIII. MANAGEMENT OF A POSITIVE BIOLOGICAL INDICATOR IN A STEAM STERILIZER

Purpose

To monitor the adequacy of sterilization of all reusable instruments and equipment and

to ensure the proper corrective action is taken when a “Positive Biological Indicator”

occurs.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Definitions

Biological Indicator (BI): A sterilization process monitoring device consisting of

standardized, viable population of microorganisms (usually bacterial spores)

known to be resistant to the mode of sterilization being monitored. Biological

indicators are intended to demonstrate whether the conditions were adequate

to achieve sterilization.

Positive Biological Indicator: Failure of a load to be properly sterilized as

indicated by the lack of a color change in the “Accept” window of the chemical

integrator

Biological Indicators

Biological indicators (BI) provide direct evidence that the sterilization process

conditions are able to kill spores.

A negative BI result indicates conditions were adequate to achieve sterilization.

A positive BI result indicates a failure of the sterilization process.

Procedure

When Biological Indicators are Positive

Take the sterilizer out of service.

Notify Nursing Supervisor and Infection Control Officer.

Repeat biological indicator test in three consecutive sterilizer cycles. If

additional spore tests remain positive, the items should be considered

non-sterile, and supplies processed since the last acceptable (negative)

biological indicator must be recalled. The items from the suspect loads

will be recalled and reprocessed.

Check to ensure the sterilizer was used correctly (i.e., verify correct time

and temperature setting, refer to department procedure manual). If not,

repeat using appropriate settings and recall and reprocess all

inadequately processed items.

Check with maintenance for irregularities (e.g., electrical) or changes in

the clinic steam supply (i.e., from standard ≥ 97% steam, < 3%

moisture). Any abnormalities should be reported.

Check to ensure the biological indicator was used and interpreted

appropriately. If not, repeat using appropriate settings.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

If all three repeat biological indicators from three consecutive sterilizer

cycles are negative, put the sterilizer back in service.

If one or more repeat biological indicators from the three consecutive

sterilizer cycles are positive, do the following:

Request an inspection of the equipment by the Biomed Field

Technician

ii.

Discuss the abnormalities with the sterilizer manufacturer

iii.

Repeat the biological indicator using a different manufacturer's

indicator

REFERENCES

Bennett, G. & Kassai, M. (2011). Infection Prevention Manual for Ambulatory Surgery Centers.

Rome, Georgia: ICP Associates.

Rutala, W.A., Weber, D. J., and the Healthcare Infection Control Practices Advisory Committee.

(2008). Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta

Georgia: Centers for Disease Control and Prevention.

XXIV. ISOLATION AND/OR TRANSFER OF PATIENT (See Part 18, Section 18F Testing for

COVID-19 Virus)

Policy

It is the policy of the Siletz Community Health Clinic (SCHC) to evaluate individuals known or

suspected of having a communicable disease which can be transmitted to other patients or

staff; to have in place procedures to minimize the exposure to other patients and staff; and to

implement preventive strategies to minimize the risk of transmission of infections when

potential transmissible illnesses spread by contact, droplet, or airborne routes are suspected

following CDC Guidelines for Isolation Precautions.

Definitions

Airborne Precautions: Apply to patients known or suspected to be infected

with a pathogen that can be transmitted by airborne route

Contact Precautions: Apply to patients with the presence of stool incontinence,

draining wounds, uncontrolled secretions, pressure ulcers, or presence of ostomy

tubes and/or bags draining body fluids

Droplet Precautions: Apply to patients known or suspected to be infected with a

pathogen that can be transmitted by coughs or sneezes causing droplets

MDRO = Multi-Drug Resistant Organism

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

MRSA = Methicillin Resistant Staph aureus

Assignment of Responsibility

It is the responsibility of the Medical Director and the Infection Control Officer to

ascertain that resources and staff are available to implement Isolation and/or

Transfer Plan (I&T Plan).

It is the responsibility of the Infection Control Officer, or designee, to implement

the I&T Plan and to educate staff.

It is the responsibility of each staff member to understand the information in the

I&T Plan and to follow the outlined procedures.

Isolation Management of Patients with Transmissable Disease

Patient Scheduling and Triage

Reception room staff should be alert to patients presenting with symptoms

of active infection such as fever, generalized rash, respiratory symptoms,

draining wounds, skin lesions, lice, or new onset of diarrheal illness.

Patients will be asked if they have a history of Methicillin Resistant Staph

Aureus (MRSA) or another type of Multi-drug Resistant Organism (MDRO)

Patients who report to the Dental Clinic with a contagious disease (i.e.,

Group A Strep, etc.,) in conjunction with their dental problem, will receive

only emergency dental care. The Dentist will take the necessary steps to

protect himself or herself, the dental staff, and other patients when

treating these patients.

Reception staff should notify the clinical staff of their observations of

active infections to enable rapid placement into designated Procedure

Room 150 for isolation until the physician or clinical staff can further

evaluate the situation. Persons not involved in direct patient care are not

allowed to enter designated isolation locations. Family, or other

appropriate accompanying individuals may stay with patient if approved

by attending provider, and provided appropriate PPE. Any persons

entering isolation locations must wear appropriate PPE Multiple patients

with potential transmissible illnesses spread by airborne, contact, or

droplet routes will be segregated, at least six feet away in the waiting

area, or placed in another exam room if available.

Patients suspected of having any of the following diseases will be

given a mask, instructed to perform hand hygiene using an

alcohol based hand rub, and placed in Procedure Room 150 for

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

isolation with the door closed until transfer for additional

treatment at a receiving facility or discharge to home can be

done:

Ebola Virus Disease (EBV): Contact and Droplet

Precautions. Refer to the CDC website for the most current

guidance and recommendations.

http://www.cdc.gov/vhf/ebolahcp/ index.html

Tuberculosis: Airborne Precautions. Wait an hour after the

patient has left the room before reusing the room.

Chickenpox: Airborne and Contact Precautions. Use

Contact Precautions if contact with active lesions is

anticipated or to handle used linens.

Measles: Airborne Precautions. Do not place another

patient in the room for two hours after the patient has left

the area.

Mumps: Droplet Precautions

Rubella: Droplet Precautions

Bacterial meningitis: Droplet Precautions

Sars-COV-2 (COVID-19): Contact, Droplet, and Airborne

Precautions. Refer to the CDC website for the most current

guidance and recommendations.

https://www.cdc.gov/coronavirus/2019CoV/hcp/index.html

ii.

Refer to the CDC’s Guideline for Isolation Precautions: 2007

Guideline for Isolation Precautions: Preventing Transmission of

Infectious Agents in Healthcare Settings for further information on

isolation category requirements.

http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

Staff will notify any receiving facility of the potential infectious disease so

that appropriate precautions may be implemented.

Staff will implement appropriate barriers specific to the situation prior to

transport (e.g., mask on patient, wound covered) and advise the persons

doing the transport of these precautions.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Staff shall follow the Respiratory Hygiene and Cough Etiquette section of

this policy as recommended by the CDC.

Supplies for respiratory hygiene (tissues, hand sanitizers, masks) shall be

kept on a stand located near the reception desks and will be available for

patient use as recommended by the CDC.

All patients will have any open wounds covered with an impermeable

dressing that is clean and dry.

Providers shall be notified of positive laboratory results or concerns regarding

appropriate treatment. Referring or receiving facilities should be notified of

positive patient laboratory results.

Management of Patients with MRSA or Other MDROs

MRSA is usually spread by direct contact with an infected wound or from

contaminated hands, usually those of healthcare providers. Also, people who

carry MRSA but do not have signs of infection can spread the bacteria to others

and potentially cause an infection.

Patients identified as having active or recent infections with MRSA or other

MDROs will have such noted in the patient’s electronic medical record.

Use Standard Precautions at all times for patients known to be infected or

colonized with MRSA or target MDROs, making sure that gloves and gowns are

used for contact with uncontrolled secretions, pressure ulcers, draining wounds,

stool incontinence, and ostomy tubes and bags

If possible, the care provider should consider a private room or spatial

separation of patients with potentially active MRSA or MDROs.

Shared patient care equipment and surfaces (e.g., exam tables, BP cuffs, and

oximeters) should be cleaned and disinfected with an EPA and facility approved

agent before reuse.

A hypochlorite-based germicidal agent should be used to disinfect items used by

incontinent patients with known or suspected C. difficile infections.

Before use, care should be taken to assure disinfected equipment is compatible

with the bleach solution.

Patients and families of patients with MRSA and MDROs shall be provided with

written educational materials to inform them about the MDRO and control

measures

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

References

Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L. & the Healthcare Infection Control

Practices Advisory Committee. (2006). Management of Multidrug-Resistant Organisms in

Healthcare Settings, 2006. Atlanta, Georgia: Centers for Disease Control and Prevention;

Washington, D.C.: U.S. Department of Health & Human Services. Siegel, J. D., Rhinehart, E.,

Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee.

(2007). 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents

in Healthcare Settings. Atlanta, Georgia: Centers for Disease Control and Prevention.

http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

General

Information

About

MRSA

Healthcare

Settings,

http://www.cdc.gov/mrsa/healthcare/index.html

Muto, C. A., Jernigan, J. A., Ostrowsky, B. E., Richet, H. M., Jarvis, W. R., Boyce, J. M., Farr, B.

M. (2003). SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant

Strains of Staphylococcus aureus and Enterococcus. Infection Prevention & Hospital

Epidemiology, 24, 362–386. Guide to Infection Prevention in Outpatient Settings

http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-gl-standared-precautions.html

Ebola Virus Disease (EVD), http://www.cdc.gov/vhf/ebola/hcp/index.html

XXV. INFLUX OF PATIENTS (See Part 18 COVID-19 for various pandemic related policies

and procedures)

Policy

It is the policy of the Siletz Community Health Clinic (SCHC) that in an emergent

outbreak situation the clinic will appropriately triage patients to an alternate level of care

in the community when the need is greater than what the ambulatory clinic can provide.

SCHC will receive patients in accordance with any outlined instructions per the Centers

for Disease Control (CDC).

Identification of patients

Features that should alert the staff to the possibility of an influx of patients and

potential outbreak include:

A rapid increase in disease incidence in a normally healthy population.

An unusual increase in the number of people seeking care, especially with fever,

respiratory, or GI complaints.

Lower attack rates among people who have been indoors compared to those

being outdoors.

Cluster of patients arriving from a single location.

Large numbers of rapidly fatal cases.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Any patient presenting with a disease that is relatively uncommon and has

bioterrorism potential. (ie. anthrax, plague)

Procedure

When a staff member feels as though there is an influx of infectious patients

based on the criteria list above they should bring this information to the

Infection Control Officer and clinic leadership immediately.

To the extent possible, management of the influx of infectious patients will be

conducted in accordance with the organization’s emergency operations plan.

Clinic leadership will establish initial and ongoing contact with Lincoln County

Public Health and IHS resources as appropriate to determine the specific nature

and extent of the infectious issue:

Community hospitals, clinics, and urgent care centers for Lincoln County

Health Department (Lincoln County 541-265-4112 )

Emergency management systems for Lincoln County (541-265-4199)

Center for Disease Control and Prevention (CDC) www.cdc.gov/nors

Portland Area IHS epidemiologist (503) 416-3298

Based on information and recommendations from these agencies, the scope and

depth of the planned response will be determined and appropriate measures will

be implemented including:

Designation of a location where infectious patients will be received and

treated (on-site or off-site).

Relocation of non-infectious patients from areas anticipated to receive

incoming infectious patients. An area should be cleared of non-infectious

patients and designated as the admission unit for the patients presenting

to the clinic.

Designation of providers and staff to see and treat infectious patients.

A determination of supplies and equipment needed.

Elective procedures or screenings may be cancelled

Consideration should be given to the impact of the infectious processes in

the community where the patient will be discharged to determine if

additional precautions are warranted.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

The need to maintain appropriate infection control precautions will be

paramount during this type of emergency. Staff should be informed of

the following by clinic leadership before assuming care during the

emergency:

The specific nature of the infectious process

ii.

The mode of transmission

iii.

What precautions need to be implemented to prevent cross

contamination

iv.

PPE required when in contact with infectious patients

The procedure for use and disposal of appropriate protective

equipment

All waterborne, foodborne, and enteric disease outbreaks need to be reported to

the CDC @ www.cdc.gov/nors

Daily and weekly briefings shall be conducted by leadership as appropriate until

the situation is resolved.

Planning for influx of patients with potential infectious epidemic is monitored by:

Rapid response notification data received by CDC. This information will be

obtained from the Portland area IHS epidemiologist.

Review urgent visits including symptoms and diagnosis.

Review of microbiology results.

XXVI.POST-EXPOSURE EVALUATION AND FOLLOW-UP PROCEDURE TO COMMUNICABLE DISEASE

Employee Exposure to Meningitis

High-risk continual contact with a patient’s respiratory secretions when the

patient was potentially infectious.

Occurs when staff do not wear a mask while caring for a patient with

meningococcal disease and has direct exposure to a patient’s respiratory

secretions. The infectious period starts seven days before onset of the patient’s

signs and symptoms, and ends 24 hours after the onset of effective

antimicrobial therapy.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Procedure for Meningococcal Exposure

If an employee has a possible meningococcal exposure, the employee will

contact the supervisor for referral to appropriate evaluation and

counseling.

Post-exposure prophylaxis should be received within 24 hours of exposure

to the diagnosed of suspected case.

High-risk

includes:

contact

which

requires

post-exposure

chemoprophylaxis

Unprotected mouth-to-mouth resuscitation

ii.

Unprotected suctioning or intubation

iii.

Unprotected close inspection of the oropharynx, including

obtaining nasopharyngeal or throat swab specimens

iv.

Close, face-to-face contact with patient for more than four hours

total

Employee Exposure to Pertussis (Whooping Cough)

Direct contact with respiratory secretions from an infectious patient with

pertussis, face-to face exposure within three feet of a symptomatic patient, or

sharing a confined space (within six feet) with an infectious patient for more

than one hour while unmasked

Pertussis is highly contagious; the most infectious period begins two weeks prior

to cough onset, and ends approximately two weeks after cough onset, or after

five days of appropriate antimicrobial therapy

Procedure for Pertussis Exposure

Employees who believe they have been exposed to pertussis will contact

their supervisor for referral to appropriate evaluation and counseling.

Laboratory testing or post-exposure chemoprophylaxis may be

recommended if a high-risk exposure has occurred within 42 days (two

maximum incubation periods).

Employee Exposure to Scabies

Defined as prolonged direct contact with infested skin. Transfer from garments

and linens occur only if these have been contaminated by an infested patient

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

immediately beforehand.

Scabies can be transmitted as long as the patient remains infested and

untreated.

Employees who may have been exposed to scabies will contact their supervisor

for referral to appropriate evaluation and counseling. Transmission usually

requires prolonged, close, personal contact with the infested patient. Only in

unusual circumstances will prophylactic treatment be recommended.

Procedure for Scabies Exposure

Employees with possible exposure to scabies must be watchful for

symptoms and report to their supervisor if symptoms occur.

The incubation period in people without previous exposure usually is four

to six weeks.

People with a previous history of infestation are sensitized and develop

symptoms one to four days after re-exposure.

Employee Exposure to Varicella (Chickenpox)

Defined as face-to-face contact with a patient who has chickenpox during the

infectious period, unprotected contact with articles freshly soiled by mucous

membrane secretions from a patient with chickenpox or shingles (zoster), or

unprotected contact with open vesicles of a patient with chickenpox or shingles.

Patients with chickenpox are most contagious from two days before to shortly

after the onset of rash. The infectious period persists until crusting of all lesions.

Employees who have followed isolation requirements for the patient with

chickenpox or zoster are considered protected and do not require follow up.

Employees who have a clinical history of chickenpox or laboratory evidence of

immunity to varicella are considered protected and do not require follow up.

Procedure for Varicella Exposure

If an employee has a possible exposure to varicella and is unsure of his

or her disease history, the employee will contact the supervisor for

evaluation on the same or next business day to determine if an exposure

has occurred and if laboratory evaluation is indicated.

If an employee has no evidence of immunity, the employee will be

provided with counseling regarding the potential for disease and possible

work restriction.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Susceptible employees will be vaccinated within three days of exposure.

Varicella-zoster immune globulin (VZIG) will be considered if employee is

immunocompromised.

Procedure for COVID-19 Exposure

If an employee experiences COVID-like symptoms while at work, they will

be directed to isolate from staff/patients, be tested, then supervisor to

determine if employee is to be sent home pending results and nature of

symptoms.

Exposures to COVID-19 positive patients will be addressed using current

OHA and CDC recommendations for healthcare workers exposed to

COVID-19.

See Part 18, Section 18H Occupational Health for further information.

Procedure for Employee Exposure to Other Communicable Diseases

If an employee is exposed to a communicable disease in the workplace, the

employee is responsible to notify the supervisor and to document the exposure

on an incident report form.

Consultation regarding exposure management and recommendations regarding

possible work restriction is available from the local health department.

References

Bolyard, E.A., Tablan, O.C., Williams, W.W., Pearson, M.L., Shapiro, C.N., Deitchman, S.D. &

the Hospital Infection Control Practices Advisory Committee. (1998). Guidelines for Infection

Control in Health Care Personnel, 1998. American Journal of Infection Control, 26, 289-354;

Centers for Disease Control & Prevention. (1997). Immunization of Health Care Workers:

Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the

Hospital Infection Control Practices Advisory Committee (HICPAC). Morbidity and Mortality

Weekly Report, 46(RR-18), 1-42; Centers for Disease Control & Prevention. (2005). Guidelines

for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.

Morbidity and Mortality Weekly Report, 54(RR-17); Oregon Patient Safety Commission Infection

Prevention and Control Toolkit. oregonpatientsafety.org; Panlilio, A.L., Cardo, D.M., Grohskopf,

L.A., Heneine, W., & Ross, C.S. (2005). Updated U.S. Public Health Service Guidelines for the

Management of Occupational Exposures to HIV and Recommendations for Postexposure

Prophylaxis. Morbidity and Mortality Weekly Report, 54(RR09), 1-17.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

XXVII. OUTBREAK IDENTIFICATION AND MANAGEMENT POLICY

Purpose

To standardize the action steps needed if an outbreak of healthcare-associated infections

(HAIs) or adverse events occur or when an unusual microbe or adverse event is recognized.

The goal of any outbreak investigation is to identify probable contributing factors and to stop or

reduce the risk for future occurrences following the most recent APIC Guidelines.

http://www.apic.org/

Procedure

Healthcare-Associated Outbreaks

Healthcare-associated outbreaks are often multifactorial and may be

associated with:

Lapses in infection prevention or clinical practices

ii.

Contaminated or defective products or devices

iii.

Colonized or infected healthcare personnel

iv.

Patients or visitors who have, or are harboring an infectious

disease

Recognition of a Suspected Outbreak and Notification

Any employee who becomes aware of a possible outbreak or cluster of

infections should immediately report this to the supervisor and the

Infection Control Officer.

The Medical Director and Nursing Supervisor should also be notified.

An outbreak investigation team and team leader should be identified.

Initial Investigation

Outbreaks generally do not unfold in a linear or orderly manner. Thus, not all of

the actions described below will be applicable to all situations and many of the

steps may occur simultaneously. Each outbreak shall be handled on a case by

case basis. It is recommended that the infection control officer do the following:

Confirm the presence of an outbreak, which might include laboratory

confirmation.

SILETZ COMMUNITY HEALTH CLINIC

Program

Infection Control

Policy

Infection Control Program

Date Approved

12/21/18

Date Revised

12/17/21; 08/06/22; 02/01/25

Alert key partners about the investigation, which might include the

notification of appropriate state and local entities.

Determine if immediate control measures are needed and implement

accordingly.

Establish a preliminary working case definition using a PDSA report. This

may be refined during the investigation.

Review charts, laboratory results, and information obtained from medical

providers and involved patients or families.

Survey for additional cases linked to the outbreak and for the onset of

new cases.

Gather data

Provide patient name and medical record number

ii.

Room number patient was in

iii.

Date and time of appointment

iv.

Date of infection onset

Site culture results

vi.

Identify physicians, nurses, and other staff who had contact with

the patient

vii.

Provide any other pertinent information

Observe and review potentially implicated patient care activities, such as

hand hygiene, standard precautions, etc.

Consider whether environmental sampling or additional facility testing

(e.g., disinfection) should be performed.

The presumptive hypotheses for the mode of transmission of the

organism and other circumstances will be developed by the team.

Procedures for testing the hypotheses will be outlined.

If necessary, refine the case definition, continue case finding and

surveillance, and refine control and prevention measures to prevent

further or

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