CLINICDEMO HEALTHCARE
Infection Prevention and Control Guidelines

Document Reference: IPC-2024-001
Effective Date: November 1, 2024
Review Date: November 1, 2025
Approved By: Dr. Patricia Wong, MD - Infection Control Director
Classification: Internal Clinical Use Only

SECTION 1: INTRODUCTION

Purpose: This document establishes standardized infection prevention and control practices for all ClinicDemo Healthcare facilities to protect patients, staff, and visitors from healthcare-associated infections (HAIs).

Scope: These guidelines apply to all clinical and non-clinical staff, contractors, students, and volunteers who provide services or access patient care areas within ClinicDemo Healthcare facilities.

Regulatory Compliance: These guidelines comply with:
• Centers for Disease Control and Prevention (CDC) guidelines
• Occupational Safety and Health Administration (OSHA) standards
• State Department of Health regulations
• The Joint Commission (TJC) infection control standards
• Centers for Medicare & Medicaid Services (CMS) requirements

SECTION 2: HAND HYGIENE PROTOCOL

CRITICAL IMPORTANCE: Hand hygiene is the single most important measure to prevent the transmission of healthcare-associated infections.

2.1 When to Perform Hand Hygiene

Hand hygiene MUST be performed:

BEFORE:
• Touching a patient
• Performing aseptic or clean procedures
• Handling food or medications
• Donning gloves for patient care
• Leaving patient care area

AFTER:
• Touching a patient or patient's immediate environment
• Contact with body fluids, mucous membranes, or broken skin
• Removing gloves or other personal protective equipment (PPE)
• Using the restroom
• Coughing, sneezing, or blowing nose
• Touching potentially contaminated surfaces

2.2 Hand Hygiene Methods

Method 1: Alcohol-Based Hand Rub (ABHR)
Preferred method for routine hand decontamination

Procedure:
1. Apply product to palm of one hand (3-5 mL)
2. Rub hands together covering all surfaces:
   - Palms and backs of hands
   - Between fingers and fingertips
   - Thumbs and wrists
3. Continue rubbing until hands are completely dry (20-30 seconds)
4. Do NOT use paper towels - allow to air dry

Contraindications for ABHR:
• Hands visibly soiled or contaminated with body fluids
• After caring for patients with Clostridioides difficile (C. diff)
• After exposure to bacterial spores
• When handling cytotoxic medications

Method 2: Handwashing with Soap and Water
Required when ABHR contraindicated

Procedure:
1. Wet hands with clean running water (warm or cold)
2. Apply soap and lather well
3. Scrub all surfaces vigorously for at least 20 seconds:
   - Front and back of hands
   - Between fingers
   - Under fingernails (use nail brush if available)
   - Wrists and lower forearms
4. Rinse thoroughly under running water
5. Dry completely with single-use paper towel
6. Use paper towel to turn off faucet
7. Discard paper towel in waste receptacle

2.3 Additional Hand Hygiene Requirements

• Keep fingernails short, clean, and natural (no artificial nails or extenders)
• Remove jewelry except plain wedding bands
• No nail polish or chipped polish in patient care areas
• Cover cuts and abrasions with waterproof bandages
• Hand hygiene compliance monitored and reported quarterly
• Target compliance rate: 95% or higher

SECTION 3: PERSONAL PROTECTIVE EQUIPMENT (PPE)

3.1 PPE Selection Based on Transmission Precautions

Standard Precautions (ALL patients):
• Gloves: When contact with blood, body fluids, mucous membranes anticipated
• Gown: When clothing may become soiled
• Mask and eye protection: When splashes or sprays possible

Contact Precautions (MRSA, VRE, C. diff):
• Gloves upon room entry
• Gown upon room entry if substantial contact anticipated
• Dedicated equipment (stethoscope, BP cuff, thermometer)
• Single patient room preferred

Droplet Precautions (Influenza, Pertussis, Meningitis):
• Surgical mask upon room entry
• Eye protection if within 6 feet
• Single patient room or cohort with same infection
• Patient wears mask during transport

Airborne Precautions (Tuberculosis, Measles, Varicella):
• N95 respirator (fit-tested) required
• Negative pressure room (door closed)
• Limit room entry to essential personnel only
• Patient wears surgical mask during transport

3.2 Proper PPE Donning Sequence

ORDER MATTERS! Follow this sequence:

1. GOWN
   - Fully cover torso from neck to knees
   - Cover arms to end of wrists
   - Fasten at neck and waist

2. MASK or RESPIRATOR
   - Secure ties or elastic bands
   - Fit flexible band to nose bridge
   - Fit snug to face and below chin
   - Perform seal check for N95

3. GOGGLES or FACE SHIELD
   - Place over face and eyes
   - Adjust to fit snugly

4. GLOVES
   - Select appropriate size
   - Extend to cover wrist of gown

3.3 Proper PPE Doffing Sequence

CRITICAL: PPE is contaminated! Remove carefully to avoid self-contamination.

1. GLOVES
   - Grasp outside of glove with opposite gloved hand; peel off
   - Hold removed glove in gloved hand
   - Slide fingers of ungloved hand under remaining glove at wrist
   - Peel second glove over first glove
   - Discard in waste container

2. GOGGLES or FACE SHIELD
   - Handle by headband or earpieces
   - Place in designated receptacle for reprocessing

3. GOWN
   - Unfasten ties
   - Pull away from neck and shoulders
   - Turn contaminated outside inward
   - Fold or roll into bundle
   - Discard in waste container

4. MASK or RESPIRATOR
   - Grasp bottom ties or elastics first, then top ties
   - Remove without touching front
   - Discard in waste container (or place in designated area for decontamination)

5. HAND HYGIENE IMMEDIATELY

SECTION 4: ENVIRONMENTAL CLEANING AND DISINFECTION

4.1 Cleaning Frequency Requirements

Daily:
• All horizontal surfaces in patient rooms
• High-touch surfaces (door handles, light switches, bedrails, call buttons)
• Bathroom fixtures and floors
• Medical equipment between patient uses

Terminal Cleaning (after discharge or transfer):
• Complete room disinfection
• All surfaces, furniture, and equipment
• Curtains replaced
• Mattress and pillow covers disinfected

4.2 Disinfectant Selection

For General Patient Care Areas:
• EPA-registered hospital-grade disinfectant
• Follow manufacturer's contact time (typically 1-10 minutes)
• Clean surface first, then apply disinfectant

For C. difficile or Norovirus:
• Bleach solution (1:10 dilution = 5,000 ppm)
• Contact time: 5 minutes minimum
• Prepare fresh daily

4.3 High-Touch Surface Examples

Must be cleaned/disinfected multiple times per shift:
• Bedrails and bed controls
• Call buttons and phone
• Overbed tables and bedside tables
• IV poles
• Door handles and light switches
• Toilet flush handles and grab bars
• Faucet handles
• Computer keyboards and mice

SECTION 5: INJECTION SAFETY AND MEDICATION PREPARATION

ZERO TOLERANCE POLICY: Any deviation from safe injection practices is a serious safety event requiring immediate reporting.

Safe Injection Practices:

• ONE needle, ONE syringe, ONLY ONE patient
• Never reuse needles or syringes (even on same patient)
• Never use single-dose vials for multiple patients
• Enter medication vials with new needle/syringe only once
• Discard unused portion of single-dose vials immediately
• Maintain sterility of injection equipment and medications
• Use aseptic technique for medication preparation
• Prepare medications in clean area away from contaminated supplies
• Disinfect access diaphragms of multidose vials before entry
• Date multidose vials when opened
• Discard multidose vials per manufacturer guidelines or 28 days after opening

Sharps Safety:

• Never recap needles (use one-handed technique if absolutely necessary)
• Dispose of sharps immediately in puncture-resistant container
• Do not overfill sharps containers (3/4 full maximum)
• Close sharps container before removing from room
• Report all needlestick injuries immediately to Employee Health

SECTION 6: RESPIRATORY HYGIENE AND COUGH ETIQUETTE

For All Staff, Patients, and Visitors:

• Cover mouth and nose with tissue when coughing or sneezing
• Dispose of used tissues in no-touch waste receptacle
• Perform hand hygiene after contact with respiratory secretions
• Maintain spatial separation (>3 feet) from others when possible
• Wear surgical mask if coughing or respiratory symptoms present

Signage Posted at All Entrances:
"Stop! If you have fever, cough, or flu-like symptoms, alert staff immediately and put on a mask."

Patient Screening:
• Screen all patients for respiratory symptoms at triage/check-in
• Provide surgical mask to symptomatic patients
• Place symptomatic patients in exam room immediately (do not wait in waiting room)

SECTION 7: STAFF HEALTH AND IMMUNIZATIONS

7.1 Required Immunizations

All clinical staff must provide documented immunity or vaccination for:

• Measles, Mumps, Rubella (MMR) - 2 doses or immunity titer
• Varicella (Chickenpox) - 2 doses or immunity titer
• Hepatitis B - 3-dose series or documented declination
• Tetanus, Diphtheria, Pertussis (Tdap) - Within last 10 years
• Annual Influenza - Required October-March or approved declination/exemption
• COVID-19 - Primary series (boosters recommended per CDC)

7.2 Work Restrictions for Illness

Report to Employee Health before reporting to work if you have:

• Fever (>100.4°F or 38°C)
• New onset cough or respiratory symptoms
• Vomiting or diarrhea (restrict until 24 hours symptom-free)
• Rash of unknown origin
• Conjunctivitis (pink eye)
• Known exposure to communicable disease
• Draining wounds or skin lesions

Employee Health Contact:
Phone: 555-0900
Email: employeehealth@clinicdemo.com
Hours: Monday-Friday 7:00 AM - 5:00 PM
After-hours: Call Nursing Supervisor at Extension 5100

SECTION 8: EXPOSURE MANAGEMENT

8.1 Bloodborne Pathogen Exposure (Needlestick, Splash)

IMMEDIATE ACTION REQUIRED:

1. Wound Care:
   - Wash with soap and water (DO NOT squeeze or scrub)
   - Flush mucous membranes with water/saline for 15 minutes

2. Report Immediately:
   - Notify supervisor
   - Contact Employee Health (555-0900)
   - Complete incident report within 2 hours

3. Medical Evaluation:
   - Baseline testing of source patient and exposed employee
   - Post-exposure prophylaxis (PEP) if indicated
   - Must start PEP within 2 hours for HIV exposure

4. Follow-up:
   - Testing at 6 weeks, 3 months, 6 months
   - Confidential counseling available

8.2 Tuberculosis (TB) Exposure

If exposed to unsuspected active TB:
• Notify Employee Health immediately
• Baseline TB test (if negative at last screening)
• Repeat TB test 8-10 weeks post-exposure
• Chest X-ray if symptomatic or test converts to positive
• Treated with LTBI (latent TB infection) therapy if indicated

SECTION 9: REPORTING AND SURVEILLANCE

Report the Following to Infection Control:

• Any patient with suspected or confirmed communicable disease
• Clusters of infections (3 or more related cases)
• Unusual resistance patterns in cultures
• Healthcare-associated infections (C. diff, MRSA, CAUTI, CLABSI, SSI)
• Exposure incidents
• Breaches in infection control practices

Infection Control Department Contact:
Phone: 555-0700
Email: infectioncontrol@clinicdemo.com
24/7 On-Call Pager: 555-IC24

ACKNOWLEDGMENT AND COMPLIANCE

All staff must complete annual infection control training and demonstrate competency in these practices.

Non-compliance with infection control policies may result in:
• Immediate correction and re-education
• Performance improvement plan
• Disciplinary action up to and including termination
• Reporting to regulatory agencies if patient harm occurs

Questions or concerns? Contact the Infection Control Department at any time.

END OF DOCUMENT
Document ID: IPC-2024-001
Version: 3.0
Approved: October 15, 2024
Next Review: November 1, 2025
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