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100

UWHC,

Policies,Administrative,UWHC,Department Specific,Facilities & Engineering Services

Infection Control Policy (F&E.03.10.03)

Infection Control Policy (F&E.03.10.03) - Policies, Administrative, UWHC, Department Specific, Facilities & Engineering Services

F&E.03.10.03




PE.03
I PUR

II PO

IV PR

FACILIT
.10.03 Infectio
RPOSE:
To establ
staff whe
Clinics (U

OLICY:
A. Fa
po
ph
ar

B. Fa
inf
eq
tra
pr
Se
em

C. Al
sti
Em

D. Al
of
an

E. Eq
(st
pe
ROCEDURE

A. Op
1.
TIES & EN
P

on Control Poli
ish departm
en in contac
UWHC) facilit
acilities &
olicies that
hysical envir
re provided w
acilities & E
fectious pati
quipment wh
ansport. Em
revent transm
ervices pers
mployee orie
l Facilities
icks during
mployee Hea
l Facilities &
contact wit
nd, if necess
quipment w
terilizers, HE
er manufactu
E:
perations wi
Proced

1a.

1b.
NGINEER
POLICY &
Effective Da
July 2015
Original
Revision X
icy
mental proced
ct with poten
ties.
Engineering
help ensur
ronment and
with the prop
Engineering
ient waste th
hich has not
mployees sh
mission to th
sonnel will b
entation and
& Engineer
the perform
alth as soon
& Engineerin
th tuberculo
sary treatme
hich functio
EPA filter sy
urer’s recom
th infection c
dures having
Maintenanc
air is delive
Maintenanc
agents are
minimizes
RING SER
& PROCE
ate: X Ad
Co
Page
of
dures for the
ntially infect
Services
re infections
d that those
per environm
Services pe
hrough need
been prope
hould routin
hemselves a
be made aw
in-service tr
ring Service
mance of th
n as possible
ng Services
osis will rec
nt.
ons to prote
ystems, etc.)
mmendations
control impli
g impact on
ce of filterin
ered to areas
ce of exhau
e diluted a
risk to the e
RVICES D
EDURE
dministrative
omputer Room
e 1
5
Title:
e protection
tious materi
supports U
s are not
patients req
ment.
ersonnel ma
dle sticks, pl
erly disinfect
ely take ne
and others.
ware of the
raining sess
es employe
heir work w
e.
employees
ceive routine
ect the envi
) will receive
s.
ications
infection con
ng equipmen
s requiring v
ust systems
nd dispose
nvironment,
DEPARTM
Manual
m Manual
Infection C
of patients,
ials in UW
UWHC Infec
transmitted
quiring spec
ay come in
lumbing rep
ted, and infe
ecessary pr
Facilities &
ese hazards
sions.
ees who rec
will report th
s who have
e tuberculos
ironment of
e preventive
ntrol
nt to insure
ventilation.
to insure th
ed of in a
patients, an
MENT
Policy
PE.03.10.
Control Poli
, visitors, an
Hospital an
ction Contro
through th
cial protectio
contact wit
airs, repair o
ectious wast
recautions t
& Engineerin
s during new
ceive needl
e incident t
been notifie
sis screenin
the patient
maintenanc
e clean, fres
hat infectiou
manner tha
nd staff.
03
cy
nd
nd
ol
he
on
th
of
te
to
ng
w
le
to
ed
ng
ts
ce
sh
us
at




PE.03





FACILIT
.10.03 Infectio
2.





TIES & EN
P

on Control Poli

1c.

1d.

1e.

1f.

1g.

1h.
Proced
Engine
2a.
2b.
2c.
2d.
2e.
NGINEER
POLICY &
Effective Da
July 2015
Original
Revision X
icy
Maintenanc
automated
Maintenanc
equipment
Maintenanc
controls.
Transporta
bagging o
procedures
Building a
(operating
Maintenanc
rooms used
dures that p
eering Servic
Building a
isolation pa
Repairs to
disinfected
Services
Owned/Ren
Spills and/o
transport.
Cleaning a
pumps whi
Cleaning a
RING SER
& PROCE
ate: X Ad
Co
Page
of
ce of hot w
cart transpo
ce of the
including et
ce and ope
ation of infe
or collection
s used by inf
and equipm
rooms, cent
ce of exhau
d for care of
potentially po
ces employ
nd equipme
atients.
o equipment
before bei
(UWHC p
nted Equipme
or tears of is
and unclog
ch have pul
nd uncloggi
RVICES D
EDURE
dministrative
omputer Room
e 2
5
Title:
water suppli
ort system c
e steam s
thylene oxide
eration of the
ectious was
n from unit
fectious was
ment mainte
tral processi
ust systems
f patients wit
ose a risk o
yees
ent mainten
t that may
ng sent to
policy 5.29
ent Prior to S
solation was
gging vacuu
led fluids int
ng of sewer
DEPARTM
Manual
m Manual
Infection C
es for dishw
cart washer.
system an
e sterilizers.
e isolation r
ste. (Does
ts and dep
ste disposal
enance in s
ng, etc.)
s that are c
th tuberculos
of infection t
nance in roo
not have b
Facilities &
Disinfection
Serving or Sh
ste bags prio
um piping
to the system
lines.
MENT
Policy
PE.03.10.
Control Poli
washers an

nd sterilizin
.
room air flow
s not includ
partments o
contractor.)
sterile area
connected t
sis.
o Facilities
oms housin
been proper
& Engineerin
n of Hospita
hipping).
or to or durin
and vacuum
m.
03
cy
nd
ng
w
de
or

as
to
&
ng
rly
ng
al
ng
m




PE.03

FACILIT
.10.03 Infectio
B. Sp
1.






TIES & EN
P

on Control Poli
pecial Preca
Gener
1a.
1b.
1c.

1d.
1e.
1f.
NGINEER
POLICY &
Effective Da
July 2015
Original
Revision X
icy
autions for Fa
al
Personal
goggles, et
policy 13.1
After perfo
in section
employees
policy 13.0
Air filters
recommen
Required
sterile area
Routine wo
Anytime
Engineerin
responsible
hoods, ma
sterile room
If a sterilize
the sterilize
the suspec
insure that
sterilizer.
test device
abnormalit
normal, att
contact th
schedule re
Equipment
blood and
by Central
procedure
Blood and
RING SER
& PROCE
ate: X Ad
Co
Page
of
acilities & En
Protective
tc. are availa
0 Cleaning o
orming a ma
IV above,
s should wa
8 Hand Hyg
s will be
dations.
building or
as changes
ork will be d
maintenanc
g Services
e for the are
asks, and bo
ms.
er test show
er will be che
ct run. A che
t the equipm
A check wil
e was used w
ies, a test c
tempt to cor
he manufac
epairs.
t which req
body fluids
Services p
described
Body Fluids
RVICES D
EDURE
dministrative
omputer Room
e 3
5
Title:
ngineering S
Equipment
able in the a
of Blood and
aintenance p
Facilities &
ash hands
giene.
e changed
r equipment
the status
done while
ce work i
personnel w
ea as soon
ooties are re
ws a positive
ecked for ab
eck will be m
ment was p
ll be made t
with the ster
cycle will be
rect. If corr
cturer's serv
quires main
that have n
personnel, w
in UWHC p
s before atte
DEPARTM
Manual
m Manual
Infection C
Services Per
(PPE) glo
areas specif
d Body Fluid
procedure w
& Engineer
as describe
d per m
t maintenan
of the area
in the room
s done,
will notify th
as possible
equired whe
spore strip,
bnormalities
made with th
properly loa
to insure tha
ilizer. If the
e run. If tes
rections can
vice repres
ntenance a
not or canno
will be clean
policy 13.10
mpting repa
MENT
Policy
PE.03.10.
Control Poli
rsonnel
oves, masks
fied in UWH
ds.
which is liste
ring Service
ed in UWH
manufacturer
nce work
a to unsterile
m is unsterile
Facilities
he superviso
. Scrub suits
en working i
the graph fo
at the time o
he operator t
aded into th
at the correc
graph show
st cycle is no
not be made
entative an
and contain
ot be cleane
ned using th
0 Cleaning o
airs.
03
cy
s,
C
ed
es
C
r’s
in
e.
e.
&
or
s,
in
or
of
to
he
ct
ws
ot
e,
nd
ns
ed
he
of




PE.03








FACILIT
.10.03 Infectio

2.






TIES & EN
P

on Control Poli
1g.
1h.
Plumb
2a.

2b.
2c.
NGINEER
POLICY &
Effective Da
July 2015
Original
Revision X
icy
Preventive
related equ
paragraph
Maintenanc
tuberculosi
minutes aft
from the ro
ing precauti
All mainten
systems w
required.
hands. Reu
the exam
completed,
disposed o
the plastic
Sewer cart
Tools will b
Put on disp
Spray EPA
and clean w
Remove an
Spray EP
Disinfectan
or Central S
Rinse tools
RING SER
& PROCE
ate: X Ad
Co
Page
of
maintenan
uipment will
C of this po
ce on exha
is treatment
ter all tuberc
ooms prior to
ons (Plumbe
nance work
will be perfor
Disposable
usable heav
gloves if ne
, the plast
of. The oute
gloves if the
ts contain se
be cleaned u
posable glov
A registered
with paper to
nd discard d
PA register
nt may be ob
Services.
s with water.
RVICES D
EDURE
dministrative
omputer Room
e 4
5
Title:
nce that a
l be accom
licy.
aust system
t areas will
culosis patie
o disassemb
ers and Main
performed
rmed with gl
exam glove
vy work type
ecessary. A
ic gloves t
er gloves sho
ey cannot be
ewer machin
using the foll
ves.
hospital disi
owel or clea
disposable g
red hospita
btained from
.
DEPARTM
Manual
m Manual
Infection C
affects infec
plished as
ms that exha
be allowed
ents have b
bling the syst
ntenance Me
in sewer lin
loves. Two
es will be w
e gloves will
After the wo
that are so
ould be disp
e cleaned.
nes and tools
lowing proce
nfectant sol
n rag.
loves.
al disinfecta
m Environme
MENT
Policy
PE.03.10.
Control Poli
ction contro
scheduled
aust air from
to run for 6
een remove
tem.
echanics)
es or suctio
o pairs will b
worn over th
be worn ove
ork has bee
oiled will b
posed of wit
s.
edure:
ution on too
ant solution
ental Service
03
cy
ol
in
m
60
ed
on
be
he
er
en
be
th
ls
n.
es




PE.03

V. CO
FACILIT
.10.03 Infectio
3.


OORDINATI
TIES & EN
P

on Control Poli
Spill C
3a.
ON:
NGINEER
POLICY &
Effective Da
July 2015
Original
Revision X
icy
Clean Up:
On Premis
On premis
premises.
immediatel
up supplies
cleaned up
and Body F
Continual
UWHC Lif
Infection C


Wayne
Directo
RING SER
& PROCE
ate: X Ad
Co
Page
of
es Spills:
ses spills ar
On premi
ly when the
s are availab
p using UW
Fluids.
Readiness C
fe Safety Dir
Control

e Abbott
or, Facilities
RVICES D
EDURE
dministrative
omputer Room
e 5
5
Title:
re those tha
ises spills
ey are disco
ble at each f
WHC policy 1
Committee
rector
& Engineeri
DEPARTM
Manual
m Manual
Infection C
at occur on
must be
overed. Nec
facility. The
13.10 Clean

ng Services
MENT
Policy
PE.03.10.
Control Poli
the hospita
cleaned u
cessary clea
spill must b
ning of Bloo

03
cy
al
up
an
be
od