OAR 333-505-0070: Infection Control and Prevention

(1) A hospital shall establish and maintain an active facility-wide program for the control and prevention of infection. This program shall, at a minimum, include the following: (a) Identification of existing or potential infections in patients, employees, medical staff, and health care practitioners with hospital privileges; (b) Control of factors affecting the transmission of infections and communicable diseases; (c) Provision for orienting and educating all medical staff, health care practitioners with hospital privileges and employees on the cause, transmission and prevention of infections; and (d) Collection, analysis and use of data relating to infections in the hospital. (2) A hospital shall be responsible for the development, implementation and periodic review of policies under section (1) of this rule. (3) In the hospital, the infection control program shall be managed by a qualified individual and overseen by a multidisciplinary committee with responsibility for investigating, controlling and preventing infections in the facility. The composition of the committee may vary but shall include at least representation from major departments and services and shall provide for consultation both from other departments and services and to them. (4) A hospital shall comply with all rules of the Oregon Health Authority (Authority) for the control of communicable diseases. (a) Each hospital shall formally assess the risk of tuberculosis (TB) transmission among staff, residents and patients in accordance with OAR 333-019-0041. (b) A hospital shall require documentation of baseline TB screening conducted in accordance with CDC guidelines, within six weeks of the date of hire, date of executed contract or date of being granted hospital credentials. (c) If a hospital learns that a person or a patient at the hospital has TB disease or suspected TB, the hospital shall: (A) Notify the local public health authority in accordance with OAR chapter 333, division 18; (B) Provide the Authority or local public health authority with any information necessary for it to conduct its investigation; and (C) Cooperate with any public health investigation conducted by the Authority or the local public health authority. (d) A hospital shall notify the local public health authority of its intent to discharge a patient known to have probable or confirmed TB disease. (5) A hospital shall have a system of isolation that prevents the transmission of infections in hospitals. (a) A system of isolation shall: (A) Follow the principles of epidemiology and disease transmission; (B) Include precautions to interrupt the spread of infection by all routes that are likely to be encountered in the hospital; and (C) Be reviewed and approved by a committee responsible for the oversight of the infection control program. (b) Guidelines for isolation precautions are published periodically by the Hospital Infection Control Practices Advisory Committee (HICPAC) and may be used by a hospital as a reference in order to maintain up-to-date isolation practices. (6) The hospital multidisciplinary committee shall oversee all aspects of the infection control program, and will ensure that the system of isolation implemented addresses the following fundamentals of infection control: (a) Handwashing and gloving; (b) Patient placement; (c) Transport of infected patients; (d) Protective apparel; (e) Patient care equipment and articles; (f) Linen and laundry; (g) Dishes, glasses, cups, and eating utensils; and (h) Routine and terminal cleaning. (7) A hospital shall have policies and procedures related to cleaning, disinfection, sterilization, and disposal of patient care items. (a) All instruments or equipment used in patient care should be disinfected or sterilized based on whether the item is critical, semi-critical, or non-critical. (A) Critical items are those patient care items which enter the vascular system. These items must be sterile and should be sterilized by a Federal Drug Administration (FDA) approved method or purchased sterile for use. (B) Semi-critical items are those patient care items which come into contact with mucous membranes or nonintact skin. These items must be free of all organisms except spores. Semi-critical items require high level disinfection using wet pasteurization or chemical sterilants which are FDA-approved. (C) Non-critical items are those items that come into contact only with intact skin. Low level disinfectants may be used which have been approved by the Environmental Protection Agency (EPA) as hospital disinfectants. (b) All patient care items shall be disposed of properly at discharge or processed according to the categorization of the items: critical, semi-critical, or non-critical. Single patient use equipment must be disposed of or sent home with the patient at discharge.