Main

SMOKING *

Effective Date: 
Sat, 11/01/2003
Reviewed: 
Thu, 05/17/2018
Policy: 

UC is 100% smoke and tobacco free and the Student Health Center is a non-smoking facility.

Smoking is not allowed within twenty-five feet of doors, windows and air intakes.

The Student Health Center grounds have designated no smoking signage as appropriate.

TAMPER-RESISTANT PRESCRIPTION PADS *

Effective Date: 
Sun, 08/01/2004
Reviewed: 
Fri, 05/04/2018
Revised: 
Fri, 05/04/2018
Policy: 

As of January 1, 2005, all prescribing practitioners will use tamper-resistant prescription forms for all controlled substance prescriptions. This includes C-II through C-V medications. Legend medications (non-controlled prescription medications) may still be written on ordinary prescription forms or via the EMR and printers.

Tamper-resistant prescriptions have the following elements: void protection to prevent duplication or chemical washing to alter prescriptions; watermark on the backside of the prescription with the text “California Security Prescription”; thermo-chromic ink that changes color when exposed to heat; a description of the security features printed on each prescription form; check off boxes; and the pre-printed name, category of licensure, license number, and federal controlled substance registration number of the prescribing practitioner.

Pre-signed and post-dated prescriptions are prohibited.

 

Procedure: 

The pharmacy will order and provide security of prescription pads by storing all tamper-resistant prescription forms. These forms must be acquired from approved California State Board of Pharmacy “security printers”. The forms are sequentially numbered and will be signed out to specific prescribing practitioners from the pharmacy.

Prescribing practitioners must complete the prescription otherwise the prescription is void. The requirements include,

  • Patient name
  • Patient address (unless readily available)
  • Drug name
  • Drug quantity and drug quantity check off box
  • Drug strength
  • Drug form (if necessary)
  • Directions for use
  • Number of prescriptions on form
  • Refills (check “0” or other amount or fill in blank with number not PRN)*
  • Prescriber signature and date issued – done only by the prescriber
  • Prescriber check off box and supervising physician if a physician assistant prescribes
  • “Do Not Substitute” (DNS, DAW, Dispense as Written) check box and initial if brand required

Tamper-resistant prescription forms may not be faxed. Copied and faxed tamper-resistant prescription forms will result in a prescription that reads “VOID”. Phone and fax orders for C-III through C-V will still be permitted and must be on an ordinary prescription form.

NOTE: Prescribing practitioners not listed on our tamper-resistant prescription form or who do not have their own tamper-resistant prescription forms will be unable to prescribe C-II’s and will have to phone or fax an ordinary prescription to the patients’ pharmacies (including UCSC Pharmacy) for C-III through C-V medications.

* Refills for controlled substances – a maximum of 5 refills or a maximum of a 120 day supply (usually only the original amount plus 3 refills)

 

Key Points: 
  • Tamper-resistant prescription forms must be used for all controlled substances otherwise the prescription can be phoned to a pharmacy or faxed on ordinary prescription forms
  • The tamper-resistant prescription forms must be complete otherwise they are void
  • Prescription pads are securely stored and dispensed to individual prescribers by pharmacy staff
  •  

 

 

 

URGENTLY REQUIRED ANCILLARY SERVICES *

Effective Date: 
Sun, 05/01/2005
Reviewed: 
Mon, 03/19/2018
Revised: 
Mon, 03/19/2018
Policy: 

The Ancillary Services provided in the UCSC Student Health Services include; Pharmacy, Laboratory, Radiology, Optometry and Nutrition. The services are available to all UCSC students and may be requested by in-house clinicians in the same day clinic or by medical appointment or by outside clinicians. Mechanisms are in place for urgent provision of these services.

There are dental services on campus and the direct contact available if needed.

Procedure: 

Clinicians and nursing staff may require urgent access to the following ancillary services:

Pharmacy

  • Summon pharmacy staff in person, by phone or by overhead page
  • If the patient has been to the pharmacy before, provide a printed or electronic prescription and add the necessary information delineating the need in the comments at the bottom
  • The pharmacy staff will work on that task next and will supply the medication wherever listed on the request or as arranged

Laboratory

  • Order a Stat test.
  • Call the lab to come upstairs for a Stat Draw or let lab know that the patient is coming down for a Stat Draw.  If so, ask the patient to knock on the door.
  • If an in-house test, the laboratory staff will run testing immediately and contact the clinician directly with results.

 

  • Outside physicians who want to be called Stat with results need to write that in the orders the student brings with them.  The student should still sign in on the iPad. 
  • All truly needed "Urgent Ancillary Services" would have to go through Clinic Providers.

Radiology

  • Clinician orders exam and documents it as stat or urgent
  • The radiologic technologist (RT) will prioritize the patient to obtain images as quickly as possible
  • The RT will communicate the order's stat status to the remote radiology office and monitor receipt of the incoming results

Nutrition

  • There is limited dietitian staffing, however, if necessary and while present, the clinician can directly contact the dietitian for immediate consultation

Optometry

  • See Optometry Policy on Consultations

Dental

  • Call (650) 400-4258 for an urgently needed dental consultation

WEB SITE

Effective Date: 
Sat, 06/01/2002
Reviewed: 
Mon, 08/22/2011
Revised: 
Fri, 08/26/2011
Policy: 

Student Health Services maintains a departmental web site with the purpose of providing accurate and timely information and resources to students, parents and staff relating to Student Health Services programs, administrative requirements, and public health and safety role.

Procedure: 

PURPOSE AND USE: The Student Health Services website contains general and specific information on services, requirements, and resources in a wide range of areas including but not limited to Medical Services, Counseling Services, Public Health and Safety, Insurance and Billing Requirements and  Services, Health Promotion, On-line Services, Special Announcements and Alerts, Forms, Location and Hours of Operation, and Contact Information.

Key Points: 
  • Student Health Services maintains a departmental web site with the purpose of providing accurate and timely information and resources to students, parents and staff
  • The website is maintained in compliance with UC Santa Cruz Web Policies and Standards

WORKPLACE VIOLENCE *

Effective Date: 
Sun, 01/01/2006
Reviewed: 
Tue, 03/13/2018
Revised: 
Fri, 08/26/2011
Policy: 

The UCSC Student Health Center complies with the University policy of zero tolerance for workplace violence.

See: http://shr.ucsc.edu/topics/violence-in-workplace/policy-procedures.htm The University of California, Santa Cruz is committed to providing a workplace that is as free as possible from intimidation, threats of violence and acts of violence. Any supervisor, manager, or other person in authority who receives a report of a suspected violation of this policy shall investigate the suspected violation and shall consult with the Behavior Risk Assessment Team as appropriate. The results of the investigation shall be reported by the investigating authority to his/her next-in-line supervisor. Any UCSC employee found to be in violation of this policy shall be subject to disciplinary action up to and including dismissal, pursuant to applicable Personnel Policies or Collective Bargaining Agreement, and, if appropriate, shall be prosecuted to the full extent of the law. No employee shall be retaliated against in his/her employment for reporting intimidation, threats or acts of violence. Workplace violence incidents will differ greatly and each situation will dictate a different response. The particular circumstances of a given situation will suggest which of, and in which order, the following should occur: Report to the Police by dialing 9-1-1 at the safest opportunity Alert others o signals, overhead page “Dr. Slug + location” for a show of force, activate panic alarm/s Activate prearranged safety and security plan Secure surroundings, lock doors If appropriate, evacuate employees/leave the area" target="_blank">http://The UCSC Student Health Center complies with the University policy of zero tolerance for workplace violence. See http://shr.ucsc.edu/topics/violence-in-workplace/policy-procedures.htm The University of California, Santa Cruz is committed to providing a workplace that is as free as possible from intimidation, threats of violence and acts of violence. Any supervisor, manager, or other person in authority who receives a report of a suspected violation of this policy shall investigate the suspected violation and shall consult with the Behavior Risk Assessment Team as appropriate. The results of the investigation shall be reported by the investigating authority to his/her next-in-line supervisor. Any UCSC employee found to be in violation of this policy shall be subject to disciplinary action up to and including dismissal, pursuant to applicable Personnel Policies or Collective Bargaining Agreement, and, if appropriate, shall be prosecuted to the full extent of the law. No employee shall be retaliated against in his/her employment for reporting intimidation, threats or acts of violence. Workplace violence incidents will differ greatly and each situation will dictate a different response. The particular circumstances of a given situation will suggest which of, and in which order, the following should occur: Report to the Police by dialing 9-1-1 at the safest opportunity Alert others o signals, overhead page “Dr. Slug + location” for a show of force, activate panic alarm/s Activate prearranged safety and security plan Secure surroundings, lock doors If appropriate, evacuate employees/leave the area

The University of California, Santa Cruz is committed to providing a workplace that is as free as possible from intimidation, threats of violence and acts of violence.

Any supervisor, manager, or other person in authority who receives a report of a suspected violation of this policy shall investigate the suspected violation and shall consult with the Behavior Risk Assessment Team as appropriate. The results of the investigation shall be reported by the investigating authority to his/her next-in-line supervisor.

Any UCSC employee found to be in violation of this policy shall be subject to disciplinary action up to and including dismissal, pursuant to applicable Personnel Policies or Collective Bargaining Agreement, and, if appropriate, shall be prosecuted to the full extent of the law.

No employee shall be retaliated against in his/her employment for reporting intimidation, threats or acts of violence.

Procedure: 

Workplace violence incidents will differ greatly and each situation will dictate a different response. The particular circumstances of a given situation will suggest which of, and in which order, the following should occur:

  • Report to the Police by dialing 9-1-1 at the safest opportunity
  • Alert others
    • signals, overhead page “Dr. Slug + location” for a show of force in which managers respond, activate panic alarm/s.
  • Activate prearranged safety and security plan
  • Secure surroundings, lock doors
  • If appropriate, evacuate employees/leave the area

Quick Reference Sheet

Warning Signs

SAFETY ASPECTS OF THE IMAGING SERVICES *

Effective Date: 
Tue, 06/01/2004
Reviewed: 
Fri, 05/11/2018
Revised: 
Fri, 05/11/2018
Policy: 

To comply with the California Radiation Control Regulations, California Administrative Code Title 17, Health, the University of California, Santa Cruz, Environmental Health and Safety Department and the SHS developed policies that address the safety aspects of the SHS Imaging Services.

The SHS X-Ray Department is a State Licensed Facility. The goal of radiographic services rendered here is to achieve the maximum diagnostic information and image quality, while minimizing exposure to the patient, the operator, and all others.

Procedure: 

PRECAUTIONS AGAINST ALL ELECTRICAL AND RADIATION HAZARDS

Precautions against electrical and radiation hazards are posted on the X-ray department walls and are clearly visible as required by the law. Note: specific signage for pregnancy.

MONITORING OF RADIOGRAPHER'S EXPOSURE WITH DOSIMETRY BADGES

Radiographers working in the X-Ray exam room must wear a dosimetry badge at all times. The badges are collected by a designated member to the UCSC Environmental Health and Safety (EH&S) Department on a quarterly basis. EH&S submits the badges for processing and electronically maintains the resulting employee exposure records. In the event that a badge registers exposure, EH&S contacts the SHC X-Ray Department with the pertinent information.

REDUCTION OF THE PATIENT'S DOSE TO X-RAY IRRADIATION BY SHIELDING

The SHC Radiology Department adheres to the ALARA principle, as introduced by the International Council of Radiation Protection. The goal, keeping radiation dose as low as reasonably achievable, is attained by following these general guidelines:

  1. Radiation exposure must have a specific benefit
  2. All exposure should be kept as low as reasonable achievable
  3. Dose to individuals shall not exceed limits for appropriate circumstances

Whenever possible, gonads are covered with appropriate lead shielding during radiographic exposures. Because it is not always possible to position lead shields in exact locations, the decision concerning the applicability of shielding for an individual patient is dependent upon consideration of the patient’s unique physical characteristics and the diagnostic requirements of the exam.
In order to reduce patient and operator exposure and still obtain a satisfactory radiographic image these conditions must be fulfilled:

  1. X-ray technologist collimates the primary X-ray beam to the area of clinical interest only.
  2. X-ray technologist uses the lowest milli-amperage and highest peak kilo-voltage technique possible.
  3. X-ray technologist keeps the patient - image plate distance to minimum.
  4. X-ray technologist utilizes lead aprons, barriers and shielding.

RELEASING STUDENT HEALTH SERVICE X-RAY IMAGES *

Effective Date: 
Tue, 06/01/2004
Reviewed: 
Tue, 04/17/2018
Revised: 
Wed, 05/13/2015
Policy: 

Digital and film radiographic images may be released to the patient or to an outside provider per the following procedure.

Procedure: 

Releasing the SHS X-ray images:

When releasing any images, form HC 108 “Authorization for Release of Health Information” must be completed.

Medical Records X-ray Retrieval and Release Process

If the images are digital, Medical Records submits the record request to the RT for CD burning.

If the requested images were acquired prior to the installation of digital X-ray equipment, the request has to be processed through the Medical Records Department. Film images are kept in a secure loacation off-site and access arrangements must be made.

 

CASH REGISTER OPERATIONS AND CASH HANDLING PROCEDURES FOR SHC PHARMACY *

Effective Date: 
Wed, 09/01/2010
Reviewed: 
Wed, 02/21/2018
Revised: 
Wed, 11/08/2017
Policy: 

The University of California, Santa Cruz, Student Health Center follows all the legal and UC requirements for cash handling.

Procedure: 
Opening the register:
1. The SHS Operations staff gives the cash drawer to the pharmacy staff upon opening
2. The money is counted by 2 staff members for verification of a starting balance of $100
3. The staff counting & verifying the money complete the “Opening Cash Reconciliation” form HC 615 and place it in the cash drawer
4. Enter the Propharm POS system, click “Open Register”.
5. Hit enter or select the blue “Select Drawer” button
6. Double click on the “Drawer”
7. Enter the cash opening balance of $100
8. Enter your initials
9. Hit “Enter” or “Finish”
10. Check journal tape supply to be sure it will last the whole day
11. Open register, remove the key, place cash drawer in the register. The key is kept in the Rx drawer at all times
12. Remove the auto-settle batch total report print up from the FD130 DUO terminal for previous day.  If no printed report is present then manually settle the credit card terminal by following the instructions below:
a. Press Credit
b. Press Close
c. Press Yes 
13. The settlement report print up should go to the appropriate person for reconciliation
 
Opening Other Register – only AIS transactions at this register
1. On the sign out computer without the cash drawer, open the “Virtual Drawer”
2. On the POS, click “Open Register”
3. The open window will display “Click Finish to complete the opening of your register
4. Click “Finish”
5. This allows you to add items to the patient AIS account
6. Only select AIS (even though cash and check are options)
 
PnC Transactions During the Day:
1. For patients who need to pay on the day of service, Billing staff will ascertain the appropriate fees and escort the patient to the pharmacy for payment, under “PnC ___”. Billing and Insurance Staff will complete the following:
a. Before having any payment accepted from students, check that the charge has not yet been transferred to their student account. To check this, open the ticket through Open Billing, double click on the proper ticket and look for the “green & red transfer flags”. If they are not present, it is acceptable for student to pay at SHC. If charges have been posted to AIS, the student must go to the UCSC Cashier’s Office at the Hahn Student Services and apply payment there.
 
2. If acceptable to collect payment, verify the patient's identity by Student ID number, and patient birthdate, post the amount of transaction into the register, in the POS under the appropriate PnC Transaction (Lab, AIT, Clinic, X-ray, Optometry or Condom Co-op). Type the amount with decimals i.e. $4.00 = 4.00
3. Select the method of payment, i.e. cash, check or credit/debit card (VISA/MasterCard/Discover).
4. For cash transactions, enter the amount tendered, take the cash and return any change if required, put the money in the drawer, then close the drawer.
5. For check transactions, enter the check number into the POS and endorse the check through the receipt printer, face down.  After endorsement put the check in the drawer, then close the drawer (when mechanism not working, stamp the back of the check with the BofA stamp). 
6. For credit card transactions, have the patient insert the card (if it has a chip - may enter the PIN vs signing the transaction) or swipe the card, and have the patient sign the credit card transaction merchant copy and put it in the drawer, then close the drawer.  A customer copy receipt is then printed for the patient.  Alternatively, patients can pay electronically with ApplePay.
7. For patients paying on date of service or for patients paying for prior fees that have not been transferred to the AIS account, Billing staff needs to have documentation of the transaction, therefore, print a duplicate receipt and write in the SID number, Rx number if applicable and if check, the check number, and send to Billing
8. Then gently tear off the paper receipt, and then close the drawer.
9. Staff gives cash register receipt and the itemized statement or invoice to the patient.
 
Pharmacy Transactions During the Day
1. Using the POS system, verify the patient's identity by Student ID number, and patient birthdate, select the appropriate transaction/s – Rx or item look-up. Alternatively, these items may be scanned if the cursor is in the correct location. “F” keys may also be used (F2).
2. Verify that the prescription / product matches the receipt / paperwork.
3. Complete the transaction and apply the appropriate payment type (cash, check, credit/debit or AIS Account) NOTE: patients may NOT use more than one payment type when purchasing multiple items (i.e. cash and account) since the tax documentation may be skewed.
4. “Select All”.
5. Assign payment to a specific patient in the database if the transaction is going on the AIS Account.  Set patient for transaction under "More" tab.
6. “Complete Transaction”
7. For cash transactions, enter the amount tendered, take the cash and return any change if required, put the money in the drawer, then close the drawer
8. For check transactions, enter the check number into the POS and endorse the check through the receipt printer, face down.  The cashier initials the endorsement to provide operator identification.  After endorsement put the check in the drawer, then close the drawer.
9.  For credit card transactions, have the patient sign the credit card transaction merchant copy, unless the patient uses a "chip" card with a PIN, and then complete the Propharm process, and put it in the drawer, then close the drawer.  A customer copy receipt  is s then printed for the patient.  Alternatively, patients can pay electronically with ApplePay.
10. For AIS transactions, close the drawer
11. Perform a "soft closing": Print POS transaction log and match credit card receipts with the transactions.  Note: this should be done at noon in the summer and at 1pm during the school year
 
Making change during the day:

1. Whenever cash is picked up from the Pharmacy till in order to request change, a Change Request form is completed, documenting the change requested. This form is signed by both cashier and change provider and left in the cash box or till.

Closing the Register:
1. Register closes after 4:30pm. Students presenting to pay after this time are asked to return the following business day before 4:30pm, or put the amount onto the AIS account.
2. Using the POS, click “Close Register/Reconcile Payments
3. There are two ways to reconcile payments
Automatic Reconciliation- select payment type for Checks and click the "Auto Reconcile For This Type Only" button.  The top of the screen should read "non-matched payments left" once complete.  This means that all payments have been reconciled.  
4. Print Closing Report (Payment Totals). This will display the total amount for each transaction type.
5. Click the "Print Report for All Types" button
6. This will show credit card transactions (VISA/MC).
7. Print the Net Totals Report from the FD130 DUO terminal by following the instructions below
a. Press Credit
b. Press More
c. Press Print Reports
d. Press Net Totals
e. Press Clear (Red X) to exit
8. Verify that the credit card 'Net Totals Report' matches the POS 'Report for VISA/MC Types' 
9. Include the 'Net Totals Report' in the deposit envelope
If a discrepancy is noted, the cashier will then be able to investigate and correct any transactions if the tendered method of payment was incorrectly recorded in the POS, i.e. cash recorded in POS, but really credit card was accepted for payment and vice versa.  
10. Click "OK" to place the register batch into closing mode for the drawer cash.
11. In step 1, enter the amount that will be left in the drawer. You may use the Counting Helper button to enter the individual values of coins and currency to give a total.
12. Click “Print Report” for a report of the drawer’s currency breakdown
13. In step 2, count the cash that will be deposited. Again the Counting Helper may be used to enter individual values of coins and currency to give a total. Print
14. Step 4, shows any variance between register records and drawer counting
15. Step 5, Enter your name or initials as the person responsible for the count
16. Step 6, AT END OF DAY, “Do POS Close (Final Permanent Operation). Clicking this button will permanently close the drawer/batch. No adjustments can be made after closing
17. Click OK to place the register batch into “POS Closed” mode and click “Close”
18. The money is counted by 2 staff members for verification of an
ending balance of $100 + any daily receipts. Daily receipt amounts must match total on “POS Closing Report”
19. Print all the reports listed at the close (Tax, Void, POS Closing Report etc.)
20. The staff counting & verifying the money complete the “Closing Cash Reconciliation” form HC 615. NOTE: enter the cash drawer Batch Number on the “Z Tape” blank
21. Leave $100 in change inside the drawer for next day.
22. If there is any variance, document the variance  on the variance report to be sent to the manager, and sign on the POS Closing Report 
23. In a deposit envelope place:
a. All other cash & checks
b. Completed blue Opening/Closing Cash Reconciliation HC615 form
c. POS Counting Helper (if used)
d. POS Closing Report NOTE: final report should have actual date opened and date closed
e. Variance form, signed by the supervisor, if there is a variance
23. Also print the activity report for documentation of revenues for PnC transactions
 - may be printed by the pharmacist
24. On the outside of the envelope write the date, amount of deposit and staff initials and place it with the cash drawer
25. The SHS Operations staff collects the cash drawer plus deposit envelope at the end of each day

                                      

a. Manual Reconciliation – select appropriate payment type, i.e. Checks, enter the amount and hit “Enter”
b. Automatic Reconciliation – select payment type and click the “Auto Reconcile For This Type Only” button. The top of the screen should read “ non-matched payments left” once complete. This means that all payments have been reconciled
4. Print Closing Report (Payment Totals). This will display the total amount for each transaction type
5. Click the “Print Report for All Types” button
6. Print the Net Totals Report from the FD130 DUO terminal by following the instructions below:
a.Press Credit
b.Press More
c.Press Print Reports
d.Press Net Totals
e.Press Clear (Red X) to exit
7. Verify that the credit card 'Net Totals Report' matches the POS 'Closing Report' totals for credit card transactions
8. Include the 'Net Totals Report' in the deposit envelope
If  a discrepancy is noted, the cashier will then be able to investigate and correct any transactions if the tendered method of payment was incorrectly recorded in the POS, i.e. cash recorded in POS, but really credit card was accepted for payment and vice versa
9. Click the "Next" button
10. Click “OK” to place the register batch into closing mode for the drawer cash
 
 
Closing Other Register – only AIS transactions at this register
1. In the POS system, click “Close Register/Reconcile Payments
2. Complete the automatic reconciliation
3. Press the “Print Closing Report”
4. Click the “Print Report for All Types” button
5. Click “OK” to place the batch into closing mode
6. Click “Do POS Close” and “Next”
7. Enter your initials and click :Close:
8. Click “Closing Report” and click “Close”
9. Print report for actual close with “date opened” and “date closed”
10. Finally, print “POS Transaction Report” for the day, which should include every transaction and includes all drawers
 
Returns

1. Returns are only authorized by the pharmacist on duty
2. Justification must be documented regarding the return
3. In the POS system, select “Return Item”
4. Select the patient, if necessary, the payment method and credit the patient in AIS or with cash (as was paid initially)
5. Note: This should be extremely infrequent

6. Inform Billing staff - fill out a "blue sheet"

 
Taxes
A tax report is sent to FAST (Lynne Boccignione) at the end of each quarter, for the prior months' taxes, using the POS Sales Tax Report
 
SAFE LINE OF CONTACT:
1.Operations staff 9-5407 or 9-1468
2. Assistant to the Directors 9-2869
3. IT / Business Services Coordinator 9-5623
4. Business Services Analyst 9-4233
Please follow the line of contact in order of sequence.
 
BACKUP FOR CASH COUNTING:
1. Pharmacy tech and cashier
2. Pharmacist
3. Student Pharmacy technician
4. Pharmacy Manager

 

Key Points: 
  • Staff follows all UC and legal requirements
  • Staff follows all the POS processes as listed in the procedure
  • A single transaction cannot have more than one form of payment.  There would need to be separate transactions
  • Credit card numbers are never stored
  • Video, photo or copying equipment must be separate from credit card processing 
  • Print reports for full deposit information

HAZARDOUS WASTE MANAGEMENT *

Effective Date: 
Mon, 04/01/2002
Reviewed: 
Thu, 04/19/2018
Revised: 
Thu, 04/19/2018
Policy: 

 

1. PLEASE SEE UCSC SHS P&P MANUAL FOR “COLLECTION, STORAGE, AND DISPOSAL" policy.
2. The Hazardous Waste Management Policy includes guidelines for the proper handling of contaminated trash, sharps, and lab specimens in the clinic area and the disposal of other hazardous waste.
3. All personnel use proper practices in the handling and disposition of infectious waste to effectively control the spread of infection.
4. Infectious waste includes, but is not limited to, the following:
a. Syringes, needles, and I.V. sets
b. Surgical blades
c. Dressings from draining wounds
d. Any material which comes in contact with a draining wound
e. Human tissue/specimen not sent for pathological evaluation
f. Blood elements, excreta, and secretions
g. Disposable equipment/supplies used for the care of the patient
h. Any other material presenting a threat of infection
 
Staff are trained on proper identification, management, handling, transport, and disposal of all hazardous materials and wastes.
Procedure: 
A. HAZARDOUS TRASH
1. Hazardous waste trash receptacles are labeled as such and lined with red bags. Only trash that is saturated with blood is considered hazardous waste for the purpose of utilizing this disposal system.
2. Nursing personnel is responsible (not custodial staff) for the emptying of biohazardous wastes - to be disposed of daily if there are any contents.
3. Staff member wears gloves and other items of PPE (i.e., lab coat or gown) while handling biohazardous waste.
4. The red bag is removed from the can and closed securely.
5. The red bag is transported to the laboratory and put in the biohazardous waste cans for pickup.
6. A fresh bag is readied in the hazardous waste can for subsequent use.
B. BODY FLUIDS AND OTHER LABORATORY SPECIMENS
1. All employees handling bodily fluids or lab specimens wear personal protective equipment (PPE) as indicated by the anticipated risk of performing the task. Gloves, gowns, masks, leg coverings and booties or full suit etc. are readily available in convenient locations for the handling of specimens.
2. Clinical or utility areas where lab specimens are processed (POC testing only) are clearly designated regarding clean or dirty for the purposes of defining where various tasks are performed.
3. Hand hygiene is performed at a station separate from the dirty utility sink area.
4. All specimens are sent to the lab in transport trays for processing and/or disposal.
5. Transport trays are cleaned by laboratory staff after each use.
C. SHARPS CONTAINERS
1. Puncture-proof sharps containers are located throughout the patient care areas, secured in a manner to prevent tampering.
2. These specialty collection units are for the proper disposal of needles, syringes, scalpels, and any other sharps items that fit easily into the puncture-proof sharps collection boxes.
3. The sharps containers are removed when filled to the "fill line" by the nursing personnel and are replaced with new containers.
4. The full sharps containers are stored with the hazardous waste bags in the designated, closed container located near the lab.

D. PHARMACEUTICAL WASTE CONTAINERS

1. Pharmaceutical waste must be incinerated. The SHC uses a third party reverse distributor for returning unused and expired medications as much as possible.

2. In the SHC, all partially used non-hazardous, pharmaceutical waste must be collected and stored in an alternate, approved sharps container, labeled "incineration only". The pharmaceutical sharps container is segregated and placed in areas in the SHC where pharmaceuticals are prepared and used for patient administration.

3. Only partially used vials, syringes and ampules of pharmaceutical waste need to be deposited in the pharmaceutical waste container. Empty vials, glass or otherwise, and without PHI, may be thrown into regular trash. Empty is commonly accepted as less than 3% of original total volume and there are no pourable contents. Broken glass vials and ampules need to be placed in a regular sharps container. Non-pharmaceuticals, including sodium bicarbonate, sodium chloride and water for injection may also be thrown into regular trash. Examples of pharmaceuticals to be placed into the pharmaceutical waste containers include the following: lidocaine and other injectable anesthetics, injectable ketorolac, injectable sumatriptan, injectable steroids, injectable ondansetron, injectable promethazine and ceftriaxone.  It also includes epinephrine.

4. A full pharmaceutical waste container may be stored for up to 90 days and a partially full container must be disposed of annually. The containers have a sticker that must be dated when the container is operational. These full pharmaceutical waste containers will be collected and stored separately from the biohazardous waste, and our biohazardous waste hauler will collect, document via manifest, and haul, both types of sharps containers plus biohazards.

5. Patients and visitors can dispose of pharmaceutical waste in the "waste" bin at the Pharmacy. Vitamins, minerals, fiber supplements, etc., can be disposed of in the regular trash.

E. Other Hazardous Waste

All other hazardous waste that must be collected is done via the Environmental Health and Safety (EH&S) department using their On Line Waste Tag system - WASTe (includes Trichloroacetic Acid, thimerosal and reagents etc.). 

APPROVED CLEANING AGENTS *

Effective Date: 
Wed, 09/08/2010
Reviewed: 
Mon, 04/16/2018
Revised: 
Mon, 04/16/2018
Policy: 

The SHC uses only approved decontamination/disinfecting agents for general cleaning, processing of instruments, hand hygiene, skin preparation for procedures, etc.  All such agents are approved as indicated by the Infection Control Committee.  Information regarding all approved products can be found in the departmental SDS / Hazard Binders and on the Products Use Charts located in the Utility Rooms. 

Key Points: 
DEFINITIONS
Decontamination: The process of removing rather than destroying microorganisms.
Disinfecting: An intermediate measure between physical decontamination and sterilization.
Sterilizing: The destruction of all forms of microbial life.
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