NOSOCOMIAL INFECTION RESPONSE *

Reviewed: 
Fri, 06/11/2021
Revised: 
Fri, 08/26/2011
Policy: 

OBJECTIVE

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

POLICY

All unusual epidemiological trends in pathogen identification will be reviewed and evaluated by the Medical Director of the UCSC Student Health Center or their designee. Pursuit of an epidemiological investigation will be at the Medical Director’s discretion.

Procedure: 
  1. The occurrence of an unusual trend in pathogen identification among SHC patients will be brought to the attention of the Medical Director of the UCSC SHC for review and evaluation.
  2. Clinical staff members are expected to file an incident report if a patient develops an infection following minor surgical procedure done at the SHC or develops a new illness after visiting the SHC that appears to be related to an exposure related to the Center.
  3. The Quality Management Committee, under the direction of the Medical Director, delegates clinical and lab personnel to compose a team for the purpose of performing an infectious disease investigation. A member of the Infection Control Committee will also be appointed to the team. This team will attend to the study, investigation, testing, and reporting regarding the epidemiology of infectious pathogens affecting SHC patients. Other team members may be enlisted by the Medical Director.
  4. The investigative team (above) will submit a report of findings to the Medical Director and to the Quality Control Committee. The goal of the report is to identify clusters of unusual infections, nosocomial infections, or trends in wound and/or urine cultures.
  5. The Quality Management Committee is responsible for the review and evaluation of the SHC’s procedures, policies, and practices. Recommendations for improvement are written and justified in a report to the Medical Director.
  6. The Medical Director initiates and delegates the implementation of the recommendations.