Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 251 - UNIVERSITY OF ILLINOIS HOSPITAL INFECTION CONTROL CODE › Section 251.300 - Infection Control

Current through Register Vol. 48, No. 28, July 12, 2024
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.