Header:
WISCONSIN ADMINISTRATIVE CODE
DEPARTMENT OF HEALTH SERVICES
CHAPTER DHS 124 HOSPITALS
SUBCHAPTER II -- MANAGEMENT
Date:
08/31/2009
Document:
DHS 124.08 Infection control.
(1) PROGRAM. The hospital 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.
(2) COMMITTEE. (a) Purpose. The governing body or medical staff shall establish an infection control committee to carry out surveillance and investigation of infections in the hospital and to implement measures designed to reduce these infections to the extent possible.
(b) Composition. The infection control committee shall be a hospital or medical staff committee which shall include members from the medical and nursing staffs, the laboratory service and the hospital's administrative staff.
(c) Responsibilities. The infection control committee shall:
1. Establish techniques and systems for discovering and isolating infections occurring in the hospital;
2. Establish written infection control policies and procedures which govern the use of aseptic technique and procedures in all areas of the hospital;
3. Establish a method of control used in relation to the sterilization and disinfection of instruments, medications, and other items requiring sterility and disinfection. There shall be a written policy requiring identification of sterile items and specified time periods in which sterile items shall be reprocessed;
4. Establish policies specifying when individuals with specified infections or contagious conditions, including carriers of infectious organisms, shall be relieved from or reassigned duties. These individuals shall remain relieved or reassigned until there is evidence that the disease or condition no longer poses a significant risk to others; and
5. Annually review infection control policies, procedures, systems and techniques.
(3) EDUCATION. The hospital shall provide training to all appropriate hospital personnel on the epidemiology, etiology, transmission, prevention and elimination of infection, as follows:
(a) Aseptic technique. All appropriate personnel shall be educated in the practice of aseptic techniques such as handwashing and scrubbing practices, personal hygiene, masking, dressing, gloving and other personal protective equipment, techniques, disinfecting and sterilizing techniques and the handling and storage of patient care equipment and supplies.
(b) Orientation and inservice. New employees shall receive appropriate orientation and on-the-job training, and all employees shall participate in a continuing inservice program. This participation shall be documented.
(4) GENERAL INFECTION CONTROL PROVISIONS. (a) Inspection and cleaning. There shall be regular inspection and cleaning of air intake sources, screens and filters, with special attention given to high risk areas of the hospital as determined by the infection control committee.
(b) Sanitary environment. A sanitary environment shall be maintained to avoid sources and transmission of infection.
(c) Disposal of wastes. Proper facilities shall be maintained and techniques used for incineration or sterilization of infectious wastes, and sanitary disposal of all other wastes.
(d) Handwashing facilities. 1. Handwashing facilities shall be provided in patient care areas for the use of hospital personnel.
2. Handwashing facilities in patient care areas used by physicians and hospital staff shall be equipped with special valves that do not require direct hand contact. Provision of wrist-actuated, spade-type handles, or foot pedals shall be considered minimal compliance with this rule.
(e) Sterilizing and disinfecting services. Sterilizing services shall be available at all times.
(f) Soiled linen. 1. Soiled linen may not be sorted in any section of the nursing unit or common hallway.
2. Soiled linen shall be placed immediately in a container available for this purpose and sent to the laundry promptly.
(5) REPORTING DISEASE. Hospitals shall report cases and suspected cases of reportable communicable disease to local public health officers and to the department pursuant to ch. DHS 145.
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