Forms & Checklists for Infection

1 Forms & Checklists for Infection Prevention, Volume 2 About APICAPIC s mission is to create a safer world through prevention of Infection . The association s more than 15,000 members direct Infection prevention programs that save lives and improve the bottom line for hospitals and other healthcare facilities. APIC advances its mission through patient safety, implementation science, competencies and certification, advocacy, and data & Checklists for Infection Prevention, Volume 2 2017, Association for Professionals in Infection Control and Epidemiology, Inc. (APIC)All rights reserved. Use of this APIC publication does not grant any right of ownership or license to any in the United States of AmericaFirst edition, October 2017 ISBN: 978-1-933013-70-1 All inquiries about this publication or other APIC products and services may be addressed to:APIC1400 Crystal Drive, Suite 900 Arlington, VA 22202 Telephone: 202-789-1890 Fax: 202-789-1899 Email: Association for Professionals in Infection Control and Epidemiology, its affiliates, directors, officers, and/or agents (collectively, APIC ) provides this book solely for the purpose of providing information to APIC members and the general public.

2 The material presented in this book has been prepared in good faith with the goal of providing accurate and authoritative information regarding the subject matter covered. However, APIC makes no representation or warranty of any kind regarding any information, apparatus, product, or process discussed in this book and any linked or referenced materials contained therein, and APIC assumes no liability therefore. WITHOUT LIMITING THE GENERALITY OF THE FOREGOING, THE INFORMATION AND MATERIALS PROVIDED IN THIS BOOK ARE PROVIDED ON AN AS-IS BASIS AND MAY INCLUDE ERRORS, OMISSIONS, OR OTHER IN-ACCURACIES. THE USER ASSUMES THE SOLE RISK OF MAKING USE AND/OR RELYING ON THE INFORMATION AND MATERIALS PROVIDED IN THIS BOOK.

3 APIC MAKES NO REPRESENTATIONS OR WARRANTIES ABOUT THE SUITABILITY, COMPLETENESS, TIMELINESS, RELIABILITY, LEGALITY, UTILITY OR ACCURACY OF THE INFORMATION AND MATERIALS PROVIDED IN THIS BOOK OR ANY PRODUCTS, SERVICES, AND TECHNIQUES DESCRIBED IN THIS BOOK. ALL SUCH INFORMATION AND MATERIALS ARE PROVIDED WITHOUT WARRANTY OF ANY KIND, INCLUDING, WITHOUT LIMITATION, ALL IMPLIED WARRANTIES AND CONDITIONS OF MER-CHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, AND NON-INFRINGEMENT. IN NO EVENT SHALL APIC BE LIABLE FOR ANY INDIRECT, PUNITIVE, INCIDENTAL, SPECIAL, OR CONSEQUEN-TIAL DAMAGES ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE USE OF THIS BOOK OR FOR THE USE OF ANY PRODUCTS, SERVICES, OR TECHNIQUES DESCRIBED IN THIS BOOK, WHETHER BASED IN CON-TRACT, TORT, STRICT LIABILITY, OR of this book required input and expertise from a team of editors, who assembled materials from a range of facilities and other resources including the public domain.

4 The Association for Professionals in Infection Control and Epidemiology acknowledges the valuable contributions from the following EditorSusan Jukins Hudson, RN, BSN, MPH, CIC, LHRMS enior Clinical ConsultantPremier, , NC Associate EditorsGeorge Allen, RN, PhD, FAPIC, CIC, CNORD irector, Infection Prevention and ControlNewYork-Presbyterian Brooklyn Methodist Hospital Brooklyn, NYDebbie Hurst, RN, BSN, CHESP, CICI nfection Prevention & Control ConsultantHandsOn IC Consultative Services LLC Medford, ORReviewersTeri Hulett, RN, BSN, CIC, FAPICI nfection Prevention Consultant Infection Prevention strategies , LLCT hornton, COCynthia A. Kohan, MT(ASCP), MS, CICI nfection Prevention SpecialistProspect Waterbury HospitalWaterbury, CNCarol Vance MSN, RN, PHN, CICM anager of Infection Prevention and Occupational HealthHSHS St.

5 Elizabeth s HospitalBelleville, ILProject ManagementSusan F. SandlerDirector, Practice ResourcesAssociation for Professionals in Infection Control and EpidemiologyJames EbersoleAssistant Editor, Practice ResourcesAssociation for Professionals in Infection Control and EpidemiologyElizabeth GarmanVice President, Communications and Practice ResourcesAssociation for Professionals in Infection Control and EpidemiologyProductionSarah VickersArt Director (cover art)Association for Professionals in Infection Control and EpidemiologyProject Design CompanyText Design and LayoutWashington, DCModern LithoPrintingJefferson City, MODeclarations of Conflicts of InterestOnly individuals who have made declarations of potential conflicts have been listed Allen, RN, PhD, FAPIC, CIC, CNOR is a member of the Association for periOperative Registered Nurses AORN Journal Editorial Board.

6 SECTION 1 | Patient Care Policies1-1 Cleaning and Disinfecting Patient Care Equipment ..71-2 Comparison of Characteristics of Selected Chemicals ..101-3 Chlorhexidine (CHG) Bathing ..111-4 Outbreak Investigation, Influx Infectious Patients ..161-5 List of Multidrug-Resistant Organisms (MDROs) ..241-6 Bed Bug Policy ..251-7 Clostridium difficile Policy ..311-8 Legionella Policy ..341-9 High-level Disinfection Policy ..411-10 Scabies Treatment ..431-11 Tuberculosis Control Plan ..441-12 Post-Exposure Prophylaxis to Prevent Transmission of HIV ..481-13 Section Resources ..52 SECTION 2 | Department Policies2-1 Pharmacy Policy.

7 552-2 Pediatrics and Pediatric Intensive Care Unit (PICU) Policy ..582-3 Radiology Policy ..622-4 Operating Room Policy ..652-5 Classification of Surgical Site Infections ..712-6 Food and Nutrition Services Policy ..742-7 Environmental Services Policy ..802-8 Emergency Department Policy ..842-9 Central Sterile Processing Policy ..872-10 Dental Clinic Policy ..932-11 Environmental Cleaning in Patient Areas Policy ..952-12 Intensified Terminal Room Cleaning EVS Policy ..972-13 Bed Bugs Management ..992-14 Environmental Management of Maggots ..1012-15 Managing Lice Infestation ..1032-16 Section Resources ..105 SECTION 3 | Occupational Health3-1 Respiratory Protection Program.

8 1073-2 Recommended Vaccines for Healthcare Workers ..1103-3 Sample Job Hazard Analysis Form ..1113-4 Disposable Glove Use for PPE ..1123-5 Checklist for Bloodborne Pathogens Training Content ..1133-6 Sharps Needle Disposal Policy ..1143-7 Sharps Injury Log ..1153-8 Employee Training Record ..1163-9 Safety Meeting Record ..1173-10 Section Resources ..118 Table of ContentsSECTION 4 | Construction and Renovation4-1 Infection Control Risk Assessment ..1194-2 Construction & Renovation Policy ..1284-3 Matrix of Precautions for Construction & Renovation ..1324-4 Pre-Project Safety Punch List ..1354-5 End of Project Safety Punch List.

9 1374-6 Caution During Renovation Sign ..1394-7 Section Resources ..140 SECTION 5 | Long-Term Care5-1 Long-Term Care Facility Hand Hygiene Observation Tool ..1415-2 Core Elements of Antibiotic Stewardship in Nursing Homes Checklist ..1435-3 Infographic on Antibiotic Stewardship in Nursing Homes ..1455-4 LTC Facility Environmental Cleaning Checklist ..1465-5 Inter-facility Infection Control Transfer Form 1 ..1485-6 Inter-facility Infection Control Transfer Form 2 ..1505-7 Medical Care Referral Form ..1525-8 Section Resources ..153 APPENDIXR esources ..155 Acronyms ..158 IntroductionForms & Checklists for Infection Prevention, Volume 2 was designed to provide additional resources for the Infection preventionist (IP) from novice to expert, aiming to complete the scope of responsibilities in Infection prevention begun in Forms & Checklists for Infection Prevention,Volume 1.

10 The editors have selected and organized this compilation of Forms , Checklists , policies, and guidelines to create a convenient resource for IPs. These resources are not intended to be all inclusive instead, they provide a variety of samples to aid IPs in creating, improving, and enhancing their Infection prevention and control programs. This second volume of resources is presented in five sections: Patient Care Policies, Department Policies, Occupational Health, Construction and Renovation, and Long-Term Care. Each section provides sample Forms , policies, guidelines, and links to additional resources and background reading in Section Resources pages. The samples may be modified to meet an individual facility s needs for their particular demographic population.