INFECTION CONTROL AND PREVENTION PROGRAM

Effective Date: 
Thu, 01/01/2004
Reviewed: 
Thu, 08/11/2011
Revised: 
Fri, 08/19/2011
Policy: 

The primary purpose of the Infection Control and Prevention Program (ICPP) at the UCSC Student Health Center is to provide a framework for the active and ongoing organization-wide efforts to control, prevent, identify, and report communicable diseases.  The definitive goals of the UCSC Student Health Center’s Infection Prevention and Control Program are as follows:

1.      To identify microorganisms and communicable disease in a timely fashion,

2.      To reduce the risks for transmission of infectious agents among and between patients and health care personnel,

3.      To reduce the risk of infections developing in patients related to the use of devices and procedures required in their care,

4.      To provide the standards and enforcement required to maintain a sanitary environment,

5.      To ensure the reporting of results to the appropriate authorities. 

 

The above goals are achieved through the processes of surveillance, ongoing analysis of data, pro-active prevention, staff education, and quality control.  This Infection Control Policies and Procedures sub-section of the UCSC SHC Manual (located in the Health and Safety Section)  will define the practical methodology and processes needed to produce the desired results and will set the standards of practice and guidelines for achieving these goals.  

The purpose of the UCSC Infection Control Policy and Procedure Manual is three-fold as follows:

1.      To provide a standard of ‘best practice’ as it pertains to the prevention and control of communicable disease and to serve as a reference source for SHC personnel.

2.      To abide by the mandatory standards set forth by government regulatory agencies (i.e. OSHA, CDC, etc.) and to meet the guidelines and expectations of accrediting/certifying agencies within the industry.

3.      To serve as a preparedness guideline for responsive action to a communicable disease outbreak on campus or in the community.

PROGRAM OBJECTIVES

1.      Establish and operate a practical, proactive system for the prevention, identification, reporting, and evaluation of infections in clinic patients and health center personnel.

2.      Initiate appropriate measures to limit unprotected exposure to pathogens throughout the organization and to prevent further spread from identified sources of contagion.

3.      Reduce exposure to pathogens for staff, patients, and visitors through an enhanced hand hygiene program.

4.      Review patient care outcomes as related to the identification, treatment, and control of communicable disease.

5.      Minimize the risk of transmitting infections associated with the use of procedures, medical equipment, and medical devices.

6.      Communicate to all SHC staff employees regarding potential infection prevention and control problems and suggest improvements. 

7.      Serve as a resource for UCSC SHC staff.

8.      In the event of a communicable disease outbreak on campus or in the community the Infection Control and Prevention Program will serve to support the Health Center’s leadership role as a responsive and collaborating partner along with participating UCSC departments, UC administration, and the local authorities in the community.

Procedure: 

The Infection Control and Prevention Program (ICPP) at UCSC SHC, under the governance of the SHC’s Executive Director (See Main SHC P&P Manual/Administration/Governance/ Delegation of Authority), complies with the local, county, state, and federal laws governing ambulatory clinics.  Furthermore, the UCSC Student Health Center ICPP:

1.      Has selected and implemented nationally-recognized infection control guidelines consistent withheld recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).  Adoption of the CDC recommendations is approved first by the Infection Control Committee and then by the Executive Director who is designated as the governing body of the organization. (See description of Executive Director following this section.)

2.      Is an integral part of the organization’s quality improvement program. (See Quality Management Section in this policy.)

3.      Is under the direction of a designated and qualified health care professional who has training and current competence in infection control. (See descriptions of Executive Director and Medical Director following this section.)

4.      The ICPP has established a structured action plan that is implemented in order to:

a.       Prevent, identify, minimize and manage infections and communicable diseases through:

1.       Ongoing monitoring, evaluation, and surveillance of clinic staff compliance to policies, (i.e, Safety Rounds, Autoclave Sterility Testing, and Lab Data Surveillance Plans, etc.).

2.      Surveillance, collation, evaluation of lab data regarding infectious diseases diagnosed in the SHC.

b.      Immediately implement corrective and preventive measures that result in improvements (see Noscomial Infection Response Plan and Communicable Disease Response Plan). 

Definition of Infection Control and Prevention Program Leadership Roles and Responsibilities

Executive Director:   Delegates the responsibility for development and maintenance of Infection Control practices to the Infection Control Committee and, specifically, the Committee Chairperson (designated by the Medical Director).  The Executive Director, as the SHC’s governing body, will oversee all decisions, issues, policies, etc. addressed by the Infection Control Committee. 

Medical Director:  The Medical Director sits on the Infection Control Committee and is responsible for appointing the Committee’s Chairperson.  All medical issues related to Infection Control will be under the authority and tutelage of the Medical Director.  The Medical Director reports directly to the Executive Director. 

Infection Control Committee Chairperson:  The chairperson for the Infection Control Committee is appointed by the Medical Director with the approval of the Executive Director. This chairperson oversees compliance with State and Federal guidelines and assists the Medical and Executive Directors in the development of programs which serve to meet the goals of the Program. 

Infection Control Nurse (ICN):  The ICN is a staff RN designated by the Medical Director as the Infection Control Nurse. The ICN reports directly to the Infection Control Committee Chairperson and/or the Medical Director.  The ICN serves on the Infection Control Committee and reports on identified infection control concerns within the Health Center and/or community.  The ICN is also responsible for the monitoring and evaluation of current practices as they relate to infection control and to bring issues of concern to the ICC.

Infection Control Committee (ICC):  As a regulatory committee with the primary responsibility of Infection Control within the ambulatory care clinic, the Committee:

a.       Identifies possible risk of staff and/or patient exposure to biohazardous materials (i.e. blood, vaginal secretions, urine, etc.). 

b.      Determines the types and methods of infection surveillance including signage, labels, storage areas, containers, etc.

c.       Determines the Infection Control standards for employee.

d.      Has final authority in matters of isolation or infection prevention or control measures where there is felt to be danger to patients, visitors, or personnel.  In situations of extreme urgency, the Medical Director may initiate action after consultation with the Executive Director as appropriate or available (without a meeting or consultation with members of the Committee).

e.       Provides the standards, policies, and enforcement to ensure the consistency of safe practice among SHC staff in regards to Infection Control.

f.       Reviews and makes recommendations on any matter related to Infection Control, such as procedures, products, equipment, construction, and related matters. 

Furthermore, the Committee oversees vaccine recommendations including the recommendation regarding updated childhood vaccines.   The Committee also works with the Student Health Outreach Promotion (SHOP) Coordinator, and other health information providers to coordinate and publicize immunization Clinics and Health Fairs, development of health information materials for distribution to target campus populations or on the website, etc.  

Employee Health Nurse (EHN): The Infection Control Committee Chairperson may act as the Employee Health Nurse or will oversee the designated Employee Health Nurse.  The EHN serves on the IC Committee.  Please see Employee Health Section/Health and Safety/ of UCSC SHC P&P Manual for a full description of the EHN role and responsibilities. 

Infection Control Committee Structure and Meetings     

1.      An Infection Control Committee meeting is convened at the direction of the chairperson at intervals as deemed necessary to conduct the business of the Committee.  There are no less than two (2) meetings per year.

2.      The Committee consists of staff members who agree to an appointment by the Executive Director to serve for a minimum of a one year term.  There is no limitation to the number of terms a member may serve. 

3.      The Committee consists of staff representing laboratory, nursing, medicine, and administration. 

4.      The Committee reviews and/or updates the Infection Control manual annually and makes recommendations for programmatic changes to the Executive Director based on new findings or concerns.

5.      The Committee minutes of these meeting are kept by the committee chairperson or designee and are forwarded to the Health Center’s Administration for review and approval as well as to the Quality Management Committee.

Quality Management of Infection Control Committee (ICC)

1.      At least one member of the Infection Control Committee is a member of the Quality Management Committee and is responsible for reporting the ICC concerns, recommendations, actions, statistics, etc. to the Quality Management Committee.

2.      The Infection Control Committee will report directly to the Executive Director of the Student Health Center via the Medical Director and/or the Committee Chairperson.

3.      The Executive Director or designee is responsible for reporting Infection Control activities, concerns, and recommendations to the Assistant Vice Chancellor for Campus Life

Managing Sentinel/Untoward Events or Unusual Occurrences related to Infection Control

1.      Given the limited nature of services provided at the Health Center, a nosocomial infection would be unexpected and considered an unusual occurrence.

2.      Clinical staff members are required to file an incident report if a patient develops an infection following a minor surgical procedure done at the Student Health Center.  An incident report is also mandatory if it appears evident that a patient may have developed a new illness following an exposure to the pathogen while at the SHC.

3.       The Quality Management Committee is responsible for developing clinical and laboratory supportive documentation in regards to trends in infectious agents as well as advising on testing and treatment issues. 

4.      A member of the Infection Control Committee sits on the Quality Management Committee and is delegated to bring relevant information to the Infection Control Committee regarding incident reports related to nosocomial infections or clusters of unusual infections.  These reports will also include lab data which may reveal trends in wound, urine cultures, etc. 

5.      The occurrence of an unusual event or infection cluster gives cause for the Committee to review and evaluate the Health Center’s procedures and response. Recommendations for changes are given to the appropriate department and reported to the Executive Director.

Surveillance and On-going Analysis of Data Related to  Infectious Disease

The Health Center infection control program includes several systems of surveillance for infectious disease and infectious disease prevention. 

1.  The electronic medical record is reviewed weekly tracking the number of students diagnosed with common, important infectious diseases: gastroenteritis, diarrhea, vomiting and influenza like illness.  Any spike in these numbers triggers a more thorough chart review looking for clusters.   More frequent reports are run in the case of suspected outbreaks or during flu season.  

2.  The Health Center meets regularly with campus environmental health and safety, housing and dining to educate, collaborate, and coordinate prompt campus wide response to suspected cluster cases.  As a result, there are systems in place for campus entities to initiate an investigation of situations that concern them.  Through this network it is possible to begin actions to reduce spread on campus at the same time that we initiate investigation of suspected clusters.  

3.  Internally, regular continuing education of all staff includes the importance of surveillance for infectious disease.  All staff are educated on isolating patients with suspected varicella, offering a mask to patients with cough, and the importance of reporting suspected clusters.  The front office staff are often the first SHC staff to notice a cluster of infectious disease presenting at the SHC.  

4.  An annual antibiogram of drug resistance in urinary tract infections and wound cultures is summarized each year by the SHC lab scientist and posted on line and discussed at clinical meetings.  

5.  Spore counts from the autoclave are monitored weekly to assure medical equipment is appropriately sterilized.