INFECTION INFECTION CONTROL CONTROL PROGRAMPROGRAM

PURPOSEPURPOSE To establish a program for the To establish a program for the

development, identification, development, identification, implementation and review of all implementation and review of all Infection Control Policies and Infection Control Policies and Procedures. Procedures.

The Stone Center will maintain and The Stone Center will maintain and enforce the Infection Control Program enforce the Infection Control Program to minimize the exposure of patients, to minimize the exposure of patients, staff, physicians and visitors to health staff, physicians and visitors to health care associated infections; and to care associated infections; and to ensure patient safety as well as a safe ensure patient safety as well as a safe environment for patients, staff, environment for patients, staff, physicians and visitors.physicians and visitors.

RESPONSIBILITYRESPONSIBILITYThe Director of Clinical Operations is The Director of Clinical Operations is responsible for the Infection Control Program responsible for the Infection Control Program

The Infection Control Consultant will assist The Infection Control Consultant will assist with the development and implementation of with the development and implementation of infection control policies and proceduresinfection control policies and procedures

The Medical Director and staff will participate The Medical Director and staff will participate in Infection Control activities. in Infection Control activities.

Infection Control Committee Meetings will be Infection Control Committee Meetings will be held quarterly. All infection control activities held quarterly. All infection control activities are reported at regularly scheduled Quality are reported at regularly scheduled Quality Assurance Meetings, Board Meetings, and Assurance Meetings, Board Meetings, and Staff Meetings.Staff Meetings.

GOALSGOALS Education of our staff and patients about Education of our staff and patients about

the prevention and identification of the prevention and identification of infectious diseasesinfectious diseases

Prevention of exposure to infectious Prevention of exposure to infectious diseases and health care associated diseases and health care associated infections to staff, patients, physicians infections to staff, patients, physicians and visitors and visitors

Monitor for occurrence of infections and Monitor for occurrence of infections and implement appropriate control measuresimplement appropriate control measures

Identify and correct problems related to Identify and correct problems related to the Infection Control Programthe Infection Control Program

STRATEGIESSTRATEGIES Identify any potentially infectious Identify any potentially infectious

exposure or infectious patient exposure or infectious patient On the day of treatment antibiotic On the day of treatment antibiotic

therapy will be delivered to patients as therapy will be delivered to patients as ordered ordered

Patients suspected of or diagnosed Patients suspected of or diagnosed with contagious infections at the time with contagious infections at the time of the pre-procedure call will not be of the pre-procedure call will not be treated at The Center treated at The Center

Any patient with a drug resistant Any patient with a drug resistant bacterial infection (MRSA, VRE ) will bacterial infection (MRSA, VRE ) will need 3 negative cultures before need 3 negative cultures before scheduled procedure can be performed scheduled procedure can be performed

STRATEGIESSTRATEGIES Any patient identified to have an Any patient identified to have an

infection will be evaluated and the infection will be evaluated and the patient will be referred to the patient will be referred to the appropriate physician/facility for follow-appropriate physician/facility for follow-up.up.

Patients found to have any infectious Patients found to have any infectious diseases upon admission to The Stone diseases upon admission to The Stone Center will be isolated. The Infection Center will be isolated. The Infection Control Consultant will be notified to Control Consultant will be notified to assist with patient transfer and follow-assist with patient transfer and follow-up for employees. The NJDOHSS will be up for employees. The NJDOHSS will be notified if indicatednotified if indicated..

SURVEILLANCESURVEILLANCE MD’s will notify the Center of any MD’s will notify the Center of any

identified infection in a patient after identified infection in a patient after discharge post procedure.discharge post procedure.

MD’s must complete a Post Procedure MD’s must complete a Post Procedure Patient Infection Surveillance Form on Patient Infection Surveillance Form on his/her patient his/her patient

MD’s must report any MD’s must report any communicable/infectious disease that communicable/infectious disease that he/she may have to the Director of he/she may have to the Director of Clinical OperationsClinical Operations

Communicable/Public Health concerns Communicable/Public Health concerns will be reported to the NJDOHSS.will be reported to the NJDOHSS.

Post Procedure Phone CallsPost Procedure Phone Calls Proper Hand Washing TechniqueProper Hand Washing Technique

PREVENTIONPREVENTION Reduce risk of health care associated Reduce risk of health care associated

infection by providing guidelines on infection by providing guidelines on hand washing and standard precautionshand washing and standard precautions

Review the Infection Control survey Review the Infection Control survey results with the staffresults with the staff

Screening of patients pre-procedureScreening of patients pre-procedure Delivery of antibiotics to patient as Delivery of antibiotics to patient as

orderedordered Contagions/communicable diseases are Contagions/communicable diseases are

not treated not treated Staff and patient education Staff and patient education

EVALUATIONEVALUATION Any areas that are identified as potential Any areas that are identified as potential

risks for infection or potential risks for risks for infection or potential risks for infection, will be evaluated and revised as infection, will be evaluated and revised as warranted by the QA Committee annually. warranted by the QA Committee annually. All aspects of the program will be All aspects of the program will be considered in the evaluation process.considered in the evaluation process.

Data from the Infection Control Survey, QA Data from the Infection Control Survey, QA Audit Form, Occurrence Screen and Post Audit Form, Occurrence Screen and Post Procedure Infection Surveillance Form are Procedure Infection Surveillance Form are compiled and reported at Staff Meetings, compiled and reported at Staff Meetings, and to the QA Committee and the Board at and to the QA Committee and the Board at regularly scheduled meetings. The Director regularly scheduled meetings. The Director of Clinical Operations will follow-up on any of Clinical Operations will follow-up on any recommendations recommendations