Infection Prevention and Control (IPC)

An Operator shall establish, implement and maintain documented IPC policies and procedures which must address but are not limited to the following:

  1. performance of a point of care risk assessment to evaluate the risk factors related to the interaction between a Client and the Client’s environment, which must include the Client’s immunization and screening status, to determine their potential for exposure to infectious agents and identify risks for transmission;
  2. hand hygiene programs for Staff, Clients, volunteers and visitors;
  3. source control to contain infectious agents from an infectious source including signage, separate entrances, partitions, early recognition, diagnosis, treatment and respiratory hygiene;
  4. aseptic technique;
  5. immunizations and screening requirements for Staff;
  6. use of personal protective equipment by Staff;
  7. sharps safety program;
  8. management of the Client care environment, including but not limited to the following:
    1. cleaning of the Client care environment
    2. cleaning and disinfection of Non-Critical Medical Devices; and
    3. handling of waste and linen;
  9. guidelines for the implementation of additional precautions;
  10. outbreak prevention, identification, management and control for Staff, Clients, volunteers and visitors;
  11. target surveillance and reporting of notifiable diseases in accordance with the Notifiable Disease Management Guidelines;
  12. IPC management of Operator-owned, Client-owned, and pet-therapy pets and animals;
  13. the cleaning, disinfection, and sterilization of single use medical devices, intended for use with a single Client; and
  14. the cleaning, disinfection and sterilization of Reusable Medical Devices.

Notes

  • Reviews for compliance with Alberta Health's infection prevention and control standards will also be performed in applicable settings. The examples of evidence for compliance with such standards as provided in this Information Guide are for information only. Operators must refer directly to Alberta Health's infection prevention and control standards when determining how to comply with those standards, which are available on-line at: https://www.alberta.ca/disease-prevention-surveillance.aspx

  • For additional information on Alberta Health's infection prevention and control standards,
    please contact: infectionpreventioncontrol@albertahealthservices.ca

Programs

  • Hand Hygiene Program

    A hand hygiene program may contain, but is not limited to the following components:
    • assessment of Staff readiness and cultural influences related to hand hygiene;
    • policies and procedures;
    • education;
    • Client engagement; and
    • process for monitoring, evaluating and improving compliance to hand hygiene.
    • (Provincial Infectious Diseases Advisory Committee, 2014)
       
  • Sharps Program

    A sharps program may contain, but is not limited to the following components:
    • assessment of the current setting (review of safety devices used, i.e. safety engineered needles), access to sharps containers, Staff readiness and cultural influences;
    • education;
    • process for selecting and evaluating devices;
    • process for reporting and analyzing injuries related to sharps;
    • process for monitoring, evaluating and improving outcomes of the sharps program (i.e. reduction in needle stick injuries).
    • (Centers for Disease Control and Prevention, 2008)

Evidence of compliance can be found within the Alberta Health CCHSS Information Guide

  • Documentation:
     
    • Policies and procedures related to IPC, as listed in Standard 11.1
    • Hand hygiene audits results
    • Client immunization and screening records
    • Staff immunization records
    • Surveillance and reporting of notifiable diseases
    • Current outbreak identification and management process
    • Process for management of Clients with antibiotic resistant organisms (ARO)
    • Current pet health records and pet related cleaning schedules
    • Cleaning and disinfection schedules
  • Auditor conversations with Staff regarding:
     
    • Point of care risk assessments
    • Process for management of Clients with Antibiotic Resistant Organisms (ARO)
    • Communicable disease outbreak identification process
    • Use and management of single use medical devices as per Alberta Health's Standards for Single Use Medical Devices
    • Cleaning, disinfection and sterilization of Reusable Medical Devices as per Alberta Health's Standards for Cleaning, Disinfection and Sterilization of Reusable Medical Devices for Health Care Facilities and Settings
  • Auditor observation of:
     
    • Hand hygiene programs
      • Hand washing station and/or alcohol based hand rub is easily accessible
    • Sharps programs
      • Access to sharps containers
    • Use and management of single use medical devices as per Alberta Health's Standards for Single Use Medical Devices
    • Handling of waste and laundry

Evidence of compliance can be found within the Alberta Health CCHSS Information Guide

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