UTHCPC Procedures - Infection Control Procedures

Infection Control Procedures

Introduction

Date of Last Review 9/5/08
SME: Infection Control Manager

Infection control procedures are accessible on-line to all appropriate staff.

Background

The information in the infection control procedures comes from analysis of current epidemiological and microbiological data.

Approval

Infection control procedures have the concurrence and approval of the:

Infection Control Committee

Medical Staff Executive Committee

Medical Staff

Rules and regulation adherence

The procedures adhere to all rules and regulations concerning control measures for communicable disease as:

Established by the Texas State Board of Health

Recommended by the Centers for Disease Control (CDC)

Determining what to include

The Infection Control Officer and Infection Control Practitioner work together to determine what procedures to include on-line using JCAHO as a minimum standard.

Review

The Infection Control Committee reviews the following policies and procedures annually, or more frequently as needed:

Infection Control on-line

In the department manuals that relate to infection control

In accordance with: JCAHO standards and other outside agencies

Updating the manual

This table describes the process for updating the infection control manual:

Stage	Person Responsible	Description
1	Infection Control Committee	Monitors nationally recognized authoritative sources in the infection control field.
2	Infection Control Committee Chair	Communicates all findings to the designated member of the Performance Improvement Coordinating Council (PICC).
3	PICC	Informs the Infection Control Committee of any findings that pertain to any policies, procedures, or goals of the Infection Control Plan.
4	Infection Control Committee	Uses the information gathered in Stages 1 and 3 to update infection control procedures as necessary.

Additional information

See the following publications for additional information:

Pamphlet titled Information about AIDS for UTHCPC Personnel

Reference: Jennings, J., & Manian, F.A. (Eds.) (1999). APIC Handbook of Infection Control. Canada.

Related Standards

The Joint Commission : Surveillance, Prevention, and Control of Infection

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