STANDARD 22: Infection Prevention and Control

22.1 General

1. The healthcare organization shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There shall be an active program for the prevention, control, and investigation of infections and communicable diseases.

22.2 Organization and Policies

1. The healthcare organizations shall appoint an infection control officers qualified through education, training, experience, and certification. Their credentials shall include completion of a basic surveillance course in infection prevention and control.

2. The infection control officer(s) shall develop and implement an infection control plan consistent with the needs of the healthcare facility.

3. This plan shall be based on a risk assessment defining the most likely threats to the healthcare organization scope of services. It shall describe the necessary associated prevention, mitigation, and required responses to disease, bioterrorism, and natural disasters.

4. Clinical indicators to monitor and measure the success of this plan shall be established and reviewed at least annually. Necessary changes shall be made when indicted by this review.

5. As an output of the above requirements, infection control policies shall be created and integrated throughout the healthcare organization and off-site locations.

6. The infection control service shall ensure that:

a) healthcare organization committees and departments interface with the infection control program;

b) training programs for identifying, reporting, investigating, and controlling infections and communicable diseases of patients, staff, and other personnel are developed, activated, monitored, measured, and reviewed as part of the annual review.

7. The following areas of surveillance shall be included at a minimum (see also 4.1.3.–4.1.5):

a) mitigation of risks associated with hospital acquired patient infections as well those present upon admission;

b) surveillance of invasive procedure related infections including but not limited to surgery, endoscopy, radiology, etc.;

c) policies for the early identification of patients who require isolation in accordance with CDC, ECDC and WHO guidelines;

d) mitigation of risks contributing to healthcare-associated infections;

e) cooperation and compliance with necessary data input with local health and emergency preparedness authorities to address communicable disease threats, bioterrorism, and outbreaks;

f) cooperative oversight with the sterilization and decontamination service on process, storage, and transport of reusable medical equipment.

8. The infection control officer(s) shall be responsible for staff healthcare to include but not limited the following:

a) hand washing methods and compliance;

b) immunization status for designated infectious diseases, as needed;

c) screening for staff infection;

d) policies to address restriction of patient care and/or other duties of infected healthcare organization staff or volunteers;

e) staff and volunteer orientation/ongoing training to prevent transmission of infections diseases;

f) measures to evaluate, treat, and mitigate illness in staff and volunteers exposed to:

i. persons with infections disease;

ii. injury within the healthcare organization including biohazard exposure (sharps and needles injuries or chemical injuries);

iii. proper disposal of biohazard (see 28.5);

g) policies for use of personal protective equipment including gowns, gloves, masks and eye protection devices.

9. The infection control process shall develop and implement policies and procedures, based on international accepted guidelines that address the following:

a) ventilation and water quality control, including measures taken to maintain a safe environment during internal or external construction/renovation;

b) maintaining safe air handling systems in areas of special ventilation, such as operating rooms, intensive care units, and airborne infection isolation rooms;

c) techniques for food handling and sanitation;

d) techniques for cleaning and disinfecting environmental surfaces, carpeting and furniture;

e) textiles reprocessing, storage and distribution;

f) disposal of regulated and non-regulated waste;

g) pest control;

h) use of antibiotics.

NOTE 1 Education on the principles and practices for preventing transmission of infectious agents within the healthcare organization should be provided to anyone who has an opportunity for contact with patients or medical equipment, e.g., nursing and physicians; therapists and technicians, such as those involved in respiratory, physical, and occupational therapy and radiology and cardiology services; phlebotomists; housekeeping and maintenance staff; volunteers; all students and trainees in healthcare professions.