Purpose
|
The Department of Healthcare Epidemiology will be a self governing body. The department will be supported administratively by the medical executive committee and an Executive Director.
|
Audience
|
All Employees of UTMB hospitals and clinics, contract workers, volunteers, and students
|
Policy Program
|
There shall be an effective infection control program within the hospital and UTMB Clinics to identify, control and prevent infections which are potential hazards to all persons having contact with the hospital and clinics.
|
Responsibi-lities
|
Department of Healthcare Epidemiology responsibilities:
• Monitor nosocomial infection rates and communicate trends to appropriate departments.
• Develop protocols designed to protect patients and employees from communicable diseases.
• Organize and direct epidemiologic studies to determine the efficacy of established/proposed infection control techniques.
• Investigate and develop control strategies for any infection outbreak (epidemic).
• Develop infection control policies and procedures in conjunction with other departments for use throughout the hospital for services and for specific areas.
• Review and comment on departmental policies and procedures which have infection control ramifications.
|
Authority Statement
|
• The authority of the Department of Healthcare Epidemiology will be as follows:
• The Hospital Epidemiologist or his designee may initiate and conduct any studies or institute any control measures when there is sufficient evidence of a danger to patients or personnel.
• Environmental, patient or personnel cultures may be carried out as needed by the Hospital Epidemiologist or his designee.
|
|
|
• All hospital information or data pertaining to unusual or clustered nosocomial infections will be made available upon request to the Department of Healthcare Epidemiology.
|
|
|
• All hospital information or data pertaining to antimicrobial usage or bacterial resistance trends will be made available, upon request, to the Department of Healthcare Epidemiology.
|
References
|
1. Comprehensive Accreditation Manual for Hospitals, 2002 Edition; Joint Commission on Accreditation of Healthcare Organizations.
|
