Infection Control Coordinators:

Roles, Resources and Responsibilities

Eve Cuny, MS
University of the Pacific School of Dentistry
&
Kathy Eklund, RDH, MHP
Forsyth Institute
 Today’s Agenda

Infection Control Policy & Program Development and

Evaluation
After attending this session, the participant will be able to:
1. Describe key roles and responsibilities of the infection control
coordinator.
2. Describe education and training indicated for an infection control
coordinator.
3. Identify tools and resources to facilitate program planning,
implementation and evaluation.
Which Comes First?

The program? The program coordinator?

What is an Infection Prevention and Control
Program?

A system of policies, procedures and practices that

when successfully implemented, will minimize the
risk of transmission of pathogenic microorganisms.
The goal is to prevent:
• healthcare-associated infections in
patients
• injuries and illnesses in healthcare
personnel
CDC: The Infection Control Coordinator

An infection-control
coordinator,
knowledgeable or
willing to be trained,
should be assigned
responsibility for
coordinating the
program.
Role of the Infection Control Coordinator

• Review existing policies and standard operating procedures

• Identify gaps and outdated information
• Act as a resource for the rest of the team or organization
• Maintain related permits, licenses and other documents
• Provide training and education related to infection control
• Monitor compliance through observations, checklists and other
methods
Resources

• To be a resource for the team, the coordinator must have access to:
• Publications
• Continuing education
• Workshops and seminars
• Relevant memberships (OSAP, ADAA, ADHA, etc.)
• Time
• Support of top management/administration
• Network with other professionals responsible for infection control
• Often a role within a larger job position, e.g.: Safety director, dental
assistant, office manager, etc.
DEFINITIONS
POLICIES
• Express rules, expectations and requirements
• Explain what to do
• Are realistic and attainable
• Have an active voice (subject-verb-object)
PROCEDURES
• List steps to follow
• Tell “how” to perform a job
• Have an active voice and are imperative
Infection Prevention and Safety Program

Patient
Regulations, & Professional
Guidance, Personnel Standards, Best
Standards Safety Practices

Individual
Provider,
Practice,
Institution
(SOPs,
Ethics)
Policy vs Procedure

POLICY
All staff must complete the XYZ
practice/institution Occupational Health
Questionnaire upon hire.
PROCEDURE
Complete form XYZ-1.
1. Submit form XYZ-1 and
requested documentation to
_____ by_______
STEPS FOR THE DEVELOPMENT OF POLICIES AND
PROCEDURES

1) Assess the Need

2) Determine regulatory requirements and
recommendations
3) Research Best Practice
4) Develop a Written Plan
5) Draft and Edit the Policy and/or Procedure
6) Obtain Approval
7) Engage in Communication and Education
8) Practice Review and Revision
Prompts for Policies

• Regulations
• Guidelines
• Standards
• Institutional Rules
• New issues arise
• Adverse events that are preventable
Key Considerations for Developing Policies

• Finding relevant and credible sources for a policy is only a

first step. To achieve desired outcomes , the policies must
be evaluated and implemented skillfully.
• Consider a policy's relevance, its specificity, its target
population, its readiness for implementation and any
inherent biases.
• Before implementation, build consensus for the policy,
adapt it to meet local practice or organization’s needs, plan
for its evaluation, pilot test it and revise it as needed.
• A critical part of evaluating an infection prevention and
safety policy is examining the evidence that supports it and
the outcomes of its implementation.
Keep Policies Current

• Remain current with all relevant guidelines, regulations

and statutes.
• Join list serves for notifications for new or updated
information .
• Set up a schedule with key websites (e.g.,
www.ohsa.gov/dentistry , www.cdc.gov , www.fda,
etc.)
• Create search strategies on key policy questions and
infection control and safety issues.
• Examples include setting up a MyNCBI account on
PubMEd and inputting the search strategies. Notifications
of new scientific publications will sent from PubMed via
email on your designated notification frequency
WRITING SKILLS
• Say what you mean and mean what you say.
• Be aware of all possible interpretations.
• For example: Chemical Monitoring. Internal Chemical Indicators
will be used inside each instrument cassette.
• Use specific language for Procedures:
• For example: Place the internal chemical indicator inside each
instrument cassette in the middle of the cassette prior to closure
and wrapping for sterilization .
• Consider the Reader/Users
• Don’t assume anything
• For example: Place the Chemical integrator strip in the middle of
the instrument cassette.
• Look at the experience of the user.
WRITING SKILLS

• The Gunning Fog Index defines a difficult word as

any word of three syllables or more.
• Use with words of one or two syllables.
• Aim for a maximum of 15 words per sentence.
• For example: Write, ‘Use form R-31 7b’; do not write,
‘Use the appropriate request form’.
WRITING SKILLS

• Watch out for Weasel Words

• Weasel words are words that sound as if you’re trying to
wiggle out of a commitment.
• For example: CDC Recommends Healthcare Personnel
should receive the influenza vaccine annually. Policy:
Personnel should receive the influenza vaccine annually.
• Words such as should vs must leave room for
interpretation and noncompliance.
• For example: Personnel must receive the influenza vaccine
annually. If personnel refuse they must sign the Influenza
vaccine declination form. All personnel not immunized
must wear a surgical face mask while in the clinical facility
for the duration of influenza season
Discussion
• POLICY EXCERPTS
• Documentation for Sterility Assurance: Maintain a
sterilization log of each sterilization load. Guideline for
Disinfection and Sterilization in Healthcare Facilities,
2008
• AMSI/AAMI ST79 Amendment IV 2013
• Work Restrictions –
• Review the Work Restrictions table to determine when to
refrain from direct patient care. 2007 Guideline for
Isolation Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings
• Report all suspected or confirmed reportable diseases in
patients and personnel to the Clinic Director.
• Reportable diseases as required by state and local
health departments
Developing tools to support policy
implementation
Example: Instrument Processing

Excerpts from a policy on

instrument processing.
All critical and semi critical
instruments must be heat
sterilized between patients
The heat sterilization process
must be validated with the
use of chemical indicators in
each pack, a chemical
integrator challenge pack in
each load and weekly
testing with biological
indicators
An air removal test must be
performed for each sterilizer
at the beginning of each
day, before the first load
(pre-and post-vacuum
autoclaves).
Policies requiring complex procedures
May benefit from standard
operating procedures
(SOP’s) and checklists
Do not include rationale
and references in
SOP’s and checklists
Keep information
process-oriented
Determine requirements
transport
cleaning
prep and pack
sterilization
storage
monitoring
Standard operating procedures

• “A Standard Operating Procedure (SOP) is a set of

written instructions that document a routine or
repetitive activity followed by an organization. The
development and use of SOPs are an integral part
of a successful quality system as it provides
individuals with the information to perform a job
properly and facilitates consistency in the quality
and integrity of a product or end-result”.
• EPA. EPA QA/G-6
Standard operating procedures
Checklists for Repeatable Processes

Remind individuals of critical

steps to complete each
time
Provide verification that the
steps have been
completed
Create a history that can be
reconstructed if there is
an adverse event
Checklist for processes that must be completed in the
same sequence every time
Sterilizer
Date Number
Load Number
1 2 3 4 5 6 7 8 9 10
Turn off
alarm ejc
Check
temp. and
exposure t. ejc
Initial cycle
end time ejc
Move cart
to storage
room ejc
Check the
test & tape
to cart ejc
Checklists for each process group
Immunization and Work Restriction
Policies
Immunization of HCP
CDC. Immunization of health-care personnel: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR 2011;60(No. RR-7).
Common Questions about
Hepatitis B Vaccine Series
Who should receive the HBV vaccine?
• All HCP whose work-, training-,
and volunteer-related activities
involve reasonably anticipated
risk for exposure to blood or
body fluids should be vaccinated
with a complete, ≥3-dose HepB
vaccine series.
• CDC. Immunization of
health-care personnel:
recommendations of the
Advisory Committee on
Immunization Practices
(ACIP). MMWR
2011;60(No. RR-7).
When should HCP receive the HBV vaccine?
OSHA mandates that vaccination be
available for employees within
10 days of initial assignment.

HCP trainees should complete the

series before the potential for
exposure with blood or body
fluids, when possible, as
higher risk has been reported
during professional training
(e.g., residency training).
• CDC. Updated CDC
recommendations for the
management of hepatitis B
virus-infected health-care
providers and students.
MMWR 2012;61(No. RR-3).
Post-Exposure Serologic Assessment
• Because vaccine-induced anti-HBs wanes over time, testing
HCP for anti-HBs years after vaccination might not distinguish
vaccine nonresponders from responders.
• CDC Guidance: Pre-exposure assessment of current or past
anti-HBs results upon hire or matriculation, followed by one
or more additional doses of HepB vaccine for HCP with anti-
HBs <10 mIU/mL, if necessary, helps to ensure that HCP will
be protected if they have an exposure to HBV-containing
blood or body fluids.
• CDC Guidance for Evaluating Health-Care Personnel for
Hepatitis B Virus Protection and for Administering Postexposure
Management Recommendations and Reports December 20,
2013 / 62(rr10);1-19
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm?
s_cid=rr6210a1_w
OSHA and Declination of Vaccination
• OSHA mandates that HCP who refuse HepB vaccination sign a
declination statement
(http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=
10052&p_table=STANDARDS).
• HCP refusing HepB vaccination can obtain vaccination at a later date at
no expense if the HCP is still covered under OSHA's Bloodborne
Pathogens Standard. Health-care institutions should encourage HepB
vaccination among HCP to improve HBV protection and to achieve the
Healthy People 2020 target of 90% vaccination.
• CDC. Healthy people topics and objectives index. Available at
http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx.
Program Evaluation: Immunization of DHCP

• Program Element
• Appropriate immunization of dental health-care personnel (DHCP).
• Develop and implement a program that promotes immunity of
health-care personnel according to current CDC ACIP
recommendations for health-care personnel.
• HBV Vaccine: OSHA Bloodborne Pathogens Standard
Regulate Employer provide Education and Training, access to
HBV vaccine during normal working hours, and pay for the
vaccine. If employee refuses, the OSHA Declination form must
be signed, but employee can change his/her mind.
• Other CDC recommended vaccines.
• Evaluation Activity
• Conduct an annual review of personnel records to ensure up-to-date
immunizations.
• Keep updated immunization records of personnel.
• Refer non-immune personnel to a qualified health-care provider
for evaluation and indicated vaccinations/immunizations.
CDC Resource

• CDC Immunization Recommendations for Healthcare

Personnel:
• Visit this website for general information about
immunizations for healthcare workers:
• http://www.cdc.gov/vaccines/hcp.htm

• Health-Care Personnel (11/25/11)

"Immunization of Healthcare Workers"
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.ht
m?s_cid=rr6007a1_e
Print version [PDF-705KB / 48 pages]
http://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf

• See also: Influenza Vaccination of Health-Care Personnel

The Infection Control Coordinator
Role
Lead in policy development, implementation and monitoring
Policy Examples for Dental Practice Settings -
Forsyth
• All staff (personnel) will complete the Forsyth Institute
Occupational Health Screening Form
(http://intranet2.forsyth.org/intranet/index.cfm).
• Personnel must provide appropriate documentation, including a
copy of a medical immunization record, indicating receipt of the
CDC/ACIP recommended immunizations for healthcare
personnel OR, laboratory evidence of immunity.
• This information will be reviewed by the Forsyth Director
of Occupational Health. and Safety. .
• Referrals to the Occupational Medicine Center at New England
Baptist Hospital for indicated occupational health screenings
and services will be made. The Forsyth Institute Referral for
Medical Evaluation is found on the Forsyth Institute
http://intranet2.forsyth.org/intranet/index.cfm.
•
Accessing Immunizations

• Personnel who do not have immunity to any or all of

the CDC is recommended immunizations for Health
Care Personnel (HCP):
• Forsyth will provide access to and pay for Hepatitis
B immunization and post immunization titer as well
as all immunizations for vaccine preventable
diseases as recommended by CDC Advisory
Council on Immunization Practices (ACIP)
recommendations
http://www.cdc.gov/vaccines/adults/rec-
vac/hcw.htmlhttp://www.cdc.gov/vaccines/hcp.htm#
healthcare
 Give 3-dose series (dose #1 now, #2 in 1 month, #3
Hepatitis B approximately 5 months after #2). Give IM. Obtain anti-HBs
serologic testing 1-2 months after dose #3

Give 1 dose of TIV or LAIV annually. Give TIV intramuscularly or

Influenza
LAIV intranasally. Follow 2014-15 recommendations from CDC

HCP born in 1957 or later without evidence of immunity or prior

vaccination, give 2 doses MMR, 4 weeks apart. Give SC. If born
MMR
before 1957, 1 dose. Two doses for all HCP during mumps
outbreak.

HCP with no serologic proof of immunity, prior vaccination, or

Varicella history of varicella disease, give 2 doses of varicella vaccine, 4
weeks apart. Give SC.
All HCP need Td every 10 years after completing a primary
Tetanus/diph-
series. Give 1 dose of Tdap IM, if direct patient contact,
theria/pertussis
prioritize HCP in contact with pts. <12 mos.
Give 1 dose to microbiologists who are routinely exposed to
Meningococcal
isolates of N. meningitidis.
Refusal

• Personnel who refuse the Hepatitis B immunization

or other CDC recommended immunizations for
healthcare personnel must complete a declination
form located on the Forsyth Intranet
http://intranet2.forsyth.org/intranet/index.cfm in the
Common C drive/Forsyth Safety Program
• Submit the completed form and documents to the
Forsyth Director of Occupational Health and Safety.
Personnel who refuse immunization services at the
time of hire or assignment may reconsider at any
time. Contact the Forsyth Director of Occupational
Health to arrange referrals and services.
Work Restrictions of HCP
Medical Conditions, Work-Related Illness, and
Work Restrictions
• Under certain circumstances, health-care facility
managers might need to exclude DHCP from work or
patient contact to prevent further transmission of
infection (e.g., conjunctivitis, influenza, etc.)
• Managers may exclude DHCP from patient contact to
prevent transmission
• Work restrictions based on mode of transmission
and period of infectivity
• Written policies should define who can exclude
DHCP (e.g., personal physicians) and be clearly
communicated
Medical Conditions, Work-Related Illness and Work
Restrictions

• Exclusion policies should

• 1) be written,
• 2) include a statement of authority that
defines who can exclude DHCP (e.g.,
personal physicians), and
• 3) be clearly communicated through
education and training. Policies should also
encourage DHCP to report illnesses or
exposures without jeopardizing wages,
benefits, or job status.
Medical Conditions, Work-Related Illness and Work Restrictions

Policies should
encourage DHCP to
report illnesses or
exposures without
jeopardizing wages,
benefits, or job status.
Sample Policy - Work Restrictions

• The Forsyth Institute has established referral arrangements

with qualified healthcare professionals for work-related
illnesses and injuries at the New England Baptist Hospital,
Care Group Occupational Health Network to ensure prompt
and appropriate provision of preventive services and post
exposure management and medical follow-up.
• Care Group Occupational Health Network
• 70 Parker Hill Avenue
• 5th Floor
• Boston, MA 02120
• Telephone# 617-754-5620
Program Management- CDC
• Effective program management is a
systematic way to ensure procedures are
• useful
• feasible
• ethical
• accurate
 “Program evaluation provides an
opportunity to identify and change
inappropriate practices, thereby
improving the effectiveness of your
infection control program.”

• Centers for Disease Control (CDC) “Guidelines for Infection Control in

Dental Health-Care Settings – 2003”
Program Evaluation
• Evaluation offers an
opportunity to improve the
effectiveness of both the
infection-control program and
dental-practice protocols.
• Evaluate on a day-to-day basis
and over time.
Continuous Quality Improvement

Proactive

Reactive
Program Evaluation

• If deficiencies or problems in the

implementation of infection-control
procedures are identified, further
evaluation is needed to eliminate
the problems.
• System deficiency?
• Personnel deficiency?
• Resource deficiency?
Program Evaluation
Strategies and Tools
Periodic observational
assessments
Checklists to document
procedures
Routine review of
occupational
exposures and
illnesses
Program Evaluation

Immunizations

PPE
Hand Hygiene
Elements of an Infection Control Program
Evaluation
Biological Monitoring
Dental Water
Quality

Waste Disposal
Program Evaluation

• Evaluate infection control

practices
• Assess adverse outcomes
• Document work-related
illnesses
• Monitor health care-
associated infections
2011 Guide & Checklist Summary
Basic infection prevention recommendations for
outpatient settings
Administrative measures
Education and training of all HCP
Report process and outcome measures
Standard Precautions
Hand hygiene PPE
Injection safety Environmental cleaning
Medical equipment Resp hygiene/cough etiquette
Resources
Disinfection and sterilization
FDA device information
Transmission based precautions
Checklist for Infection Prevention for
Outpatient Settings
OSAP Resource

Best Practices Checklist - COMING SOON

•High visibility, in-practice operational aid
•Lists sequential behaviors for entire life cycle
of patient visit
OSAP Resource for Portable and Mobile Dental
Programs

• Guidance on Infection Control Considerations for Dental Services

in Sites Using Portable Equipment or Mobile Vans :
http://www.osap.org/?page=PortableMobile
 Level II Level III INFECTION CONTROL PRACTICE
Level I
Yes No Comments

X X X Hand Hygiene, Continued

If not, are alcohol-based hand sanitizers available?

Is staff properly trained in the use of alcohol
handrub products?
X X Personal Protective Equipment (PPE) (e.g., gloves,
masks, protective eyewear, protective clothing)

Wear mask if Is there a protocol that outlines what PPE are worn
have for which procedures?
respiratory
infection
Is PPE storage available and close to care?
Are facilities available to disinfect PPE (DHCP
evewear, patient eyewear, heavy duty utility gloves)?

X X As necessary Environmental Surfaces: Clinical Contact Surfaces

(e.g., light handles and countertops)

Is there a list of what surfaces will be cleaned,

disinfected or barrier protected and the process and
products to be used?
If chemical disinfectants are used, is there a protocol
for how they are managed, stored and disposed?

X X Housekeeping Surfaces (e.g., floors, walls)

Is there a list of which housekeeping surfaces will
REFERENCES
• Campbell, N. J. (1998). Writing Effective Policies and
Procedures. New York, NY: AMACOM
• Cryderman, P. (1999). Customized Manuals for Changing
Times. Ottawa, On: Canadian Healthcare Association.
• Page, S. (2004). 7 Steps to Better Written Policies and
Procedures. Westerville, OH: Process Improvement Publishing.
• Page, S. (2004). Achieving 100% Compliance of Policies and
Procedures. Mansfield, OH: BookMasters INC.
• Page, S. (2005). Best Practices in Policies and Procedures.
Mansfield, OH: BookMasters INC.
Infection Prevention and Safety
A Public Trust & Expectation