Section 251.100  Definitions

 

Act – The University of Illinois Hospital Act [110 ILCS 330].

 

Department – the Department of Public Health

 

Multidrug-Resistant Organisms or MDROs – include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and certain gram-negative bacilli (GNB). (Section 7 of the Act)

 

University – the Board of Trustees of the University of Illinois. (Section 1 of the Act)

 

University of Illinois Hospital or hospital – any hospital, institute, clinic, outpatient department or office owned or leased by the University at which a University health care program is conducted. (Section 1 of the Act)

 

Section 251.200  Incorporated and Referenced Materials

 

a)         Federal Guidelines:

 

1)         Department of Health and Human Services, United States Public Health Service, Centers for Disease Control and Prevention, "2007 Guideline for Isolation Precautions:  Preventing Transmission of Infectious Agents in Healthcare Settings" (June 2007), which may be obtained from National Technical Information Service (NTIS), U.S. Department of Commerce, 5285 Port Royal Road, Springfield, Virginia 22161.

 

2)         Department of Health and Human Services, United States Public Health Service, Centers for Disease Control and Prevention, "Guidelines for Infection Control in Health Care Personnel" (1998), which may be obtained from National Technical Information Service (NTIS), U.S. Department of Commerce, 5285 Port Royal Road, Springfield, Virginia 22161.

 

3)         Department of Health and Human Services, United States Public Health Service, Centers for Disease Control and Prevention, "Guidelines for Hand Hygiene in Health-Care Settings" (October 25, 2002), which may be obtained from the National Technical Information Services (NTIS), U.S. Department of Commerce, 5285 Port Royal Road, Springfield, Virginia  22161.

 

b)         All incorporations by reference of federal guidelines refer to the guidelines on the date specified and do not include any editions or amendments subsequent to the date specified.

 

c)         State of Illinois Statutes:

 

1)         University of Illinois Hospital Act [110 ILCS 330].

 

2)         Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois [20 ILCS 2310].

 

3)         MRSA Screening and Reporting Act [210 ILCS 83].

 

d)         State of Illinois Rules:

 

1)         Department of Public Health, Control of Communicable Diseases Code (77 Ill. Adm. Code 690).

 

2)         Department of Public Health, Control of Sexually Transmissible Diseases Code (77 Ill. Adm. Code 693).

 

3)         Department of Public Health, Control of Tuberculosis Code (77 Ill. Adm. Code 696).

 

Section 251.300  Infection Control

 

a)         The hospital shall designate a person or persons as Infection Prevention and Control Professionals to develop and implement policies governing control of infections and communicable diseases.  The Infection Prevention and Control Professionals shall be qualified through education, training, experience, and/or certification, and the qualifications shall be documented.

 

b)         A multidisciplinary Infection Control Committee, composed at least of members of the medical staff and nursing staff, the Infection Prevention and Control Professionals, and the supervisor of Central Sterile Supply and the hospital administration, shall be responsible for investigations and recommendations for the prevention and control of infections within the hospital.  This Committee shall perform an annual facility-wide infection control risk assessment.  (Section 7 of the Act)

 

c)         Policies and procedures for reporting cases of communicable diseases and for the care of patients with communicable diseases shall be in accordance with the Control of Communicable Diseases Code, the Control of Sexually Transmissible Diseases Code and the Control of Tuberculosis Code.

 

d)         When patients having a communicable disease, or presenting signs and symptoms suggestive of such diagnosis, are admitted, proper precautionary measures shall be taken to avoid cross-infection to hospital personnel, other patients, or the public.

 

e)         The hospital shall provide facilities and equipment for the isolation of known or suspected cases of infectious disease.

 

f)         Policies and procedures for handling infectious cases shall include orders for nursing and non-professional staffs providing for proper isolation technique.

 

g)         All persons who care for patients with or suspected of having a communicable disease, or whose work brings them in contact with materials that are potential conveyors of communicable disease, shall take appropriate safeguards to avoid transmission of the disease agent.

 

h)         The hospital shall develop and implement comprehensive interventions to prevent and control multidrug-resistant organisms (MDROs), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and certain gram-negative bacilli (GNB), that take into consideration guidelines of the Centers for Disease Control and Prevention for the management of MDROs in healthcare settings, including the "2007 Guideline for Isolation Precautions:  Preventing Transmission of Infectious Agents in Healthcare Settings" and "Guidelines for Hand Hygiene in Health-Care Settings".  (Section 7 of the Act)

 

i)          The hospital shall comply with the Centers for Disease Control and Prevention publication "Guidelines for Infection Control in Health Care Personnel".

 

j)          The multidisciplinary Infection Control Committee shall be responsible for developing, implementing, monitoring, and enforcing a hand hygiene program in the hospital.  For the purposes of this Part, "hand hygiene" is a general term that applies to hand washing with plain soap and water; antiseptic hand wash using soap containing antiseptic agents and water; antiseptic hand rub using a waterless antiseptic product, most often alcohol based, rubbed on the surface of the hands; or surgical hand antiseptic.

 

1)         The Committee shall assess the current practices and compliance, assess hand hygiene products that are currently being used, solicit input from clinical staff, and develop a hand hygiene program for all staff.

 

2)         All staff (including contractual and medical) shall be educated in the hand hygiene program during initial orientation and at least annually.  This education shall be documented.

 

3)         The program shall have clear written goals that require quantitative, time-specific improvement targets.

 

4)         The Committee shall develop and implement measurement tools to be used to assure ongoing compliance with the program.

 

5)         The program shall incorporate the requirements for hand hygiene in educational materials presented to all staff on an ongoing basis; engage patients and families in the hand hygiene efforts; monitor compliance of all staff with recommended measurement tools for hand hygiene, including immediate feedback to personnel; and track compliance over time.

 

6)         The results of the monitoring shall be incorporated in the Quality Assurance/Quality Improvement Program.

 

k)         Contaminated material shall be handled and disposed of in a manner designed to prevent the transmission of the infectious agent.

 

l)          Thorough hand hygiene shall be required after touching any contaminated or infected material.

 

m)        The hospital shall establish a systematic plan of checking and recording cases of infection, known or suspected, that develop in the institution; these cases shall be reported to the Infection Control Committee and hospital administration.  The Committee shall be empowered and directed to investigate health care-associated infections to determine the causative organism and its possible sources.  The findings and recommendations of the Infection Control Committee shall be reported to the medical staff and administration for corrective action.

 

n)         Policies and procedures related to this Section and to the following items shall be developed:

 

1)         The admission and isolation of patients with specific and/or suspected infectious diseases and protective isolation of appropriate patients.

 

2)         In-service education programs on the control of infectious diseases.

 

3)         Policies and procedures for isolation techniques appropriate to the working diagnosis of the patient and protective routines for personnel and visitors.

 

4)         The recording and reporting of all infections of clean surgical cases to the Infection Control Committee and procedures for the investigation of those cases.

 

o)         In order to improve the prevention of hospital-associated bloodstream infections due to methicillin-resistant Staphylococcus aureaus (MRSA) and pursuant to Section 2310-312 of the Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois, the hospital shall establish an MRSA control program that requires:

 

1)         Identification of all MRSA-colonized patients in all intensive care units, and other at-risk patients identified by the hospital, through active surveillance testing.

 

2)         Isolation of identified MRSA-colonized or MRSA-infected patients in an appropriate manner.

 

3)         Monitoring and strict enforcement of hand hygiene requirements.

 

4)         Maintenance of records and reporting of cases under Section 10 of the MRSA Screening and Reporting Act. (Section 5 of the MRSA Screening and Reporting Act)