N.J. Admin. Code § 8:43G-14.1

Current through Register Vol. 56, No. 9, May 6, 2024

Section 8:43G-14.1 - Infection control program structural organization

(a) A hospital epidemiologist shall direct and oversee the hospital Infection Control Program. A hospital epidemiologist is defined as a physician who is board certified in a medical specialty, preferably Infectious Diseases, and has training (such as a Centers for Disease Control and Prevention Course, or Society for Healthcare Epidemiology of America, (SHEA) course, or a Master's Degree in Public Health) or at least five years experience in hospital epidemiology. The hospital epidemiologist may be a consultant.

(b) A hospital Infection Control Program shall be multi-disciplinary and include a hospital epidemiologist, infection control professional(s), a clinical microbiologist, and a pharmacist. In addition, the program shall have an on-going surveillance system to monitor nosocomial infections, antimicrobial resistance, antimicrobial use, and outbreaks of infectious diseases.

(c) There shall be a hospital infection control committee that includes representatives from at least: infection control, medical staff, nursing service, dietary, administration, clinical microbiology, respiratory care services, surgical services, central services, environmental services, pharmacy, and the employee health service. The chairman of the committee shall be the hospital epidemiologist. The committee shall participate in the hospital's overall quality improvement program and shall receive formal advice from all other services upon its request.

(d) The infection control program shall oversee, but not be limited to, the following activities:

1. Formulating a system for surveillance, prevention, and control of non-socomial infections.

i. Surveillance of nosocomial infections shall be performed. The surveillance process shall include at least the following elements:

(1) Identification and description of the problem or event to be studied;

(2) Definition of the population at risk;

(3) Selection of appropriate methods of measurements, including statistical tools and risk stratification;

(4) Identification and description of data sources and data collection personnel and methods;

(5) Definitions of numerators and denominators;

(6) Preparation and distribution of reports to appropriate groups; and

(7) Selection of specific events to be monitored and guided by validated, available benchmarks and appropriately adjusted for patient risks so that meaningful comparisons can be made.

ii. Rates are calculated from the above surveillance monitoring for internal quality improvement activities.

iii. Prevention and control activities shall be based on Centers for Disease Control and Prevention published guidelines and Hospital Infection Control Practices Advisory Committee (that is, HICPAC) recommendations. An exception to the adoption of the following guidelines shall be allowed providing that there is a sound infection-control rationale based upon scientific research or epidemiologic data. The following published guidelines and recommendations are incorporated herein by reference, as amended and supplemented:

(1) Gould CV, Unscheid CA, Agarwal RK, et al., and the Healthcare Infection Control Practices Advisory Committee. "Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009)." Last update: February 15, 2017; 1-61. This publication is available at http://www.cdc.gov/infectioncontrol/guidelines/cauti/.

(2) O'Grady NP, Alexander M, Dellinger EP, et al., and the Healthcare Infection Control Practices Advisory Committee; Centers for Disease Control and Prevention. "Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011." Last update: February 15, 2017; 1-83. This publication is available at www.cdc.gov/infectioncontrol/guidelines/bsi.

(3) Berrios-Torres SI, Umscheid CA, Bratzler DW, et al., for the Healthcare Infection Control Practices Advisory Committee; Centers for Disease Control and Prevention. "Guideline for the Prevention of Surgical Site Infection, 2017." JAMA Surg. 2017; 152(8); 784-791. doi:10.1001/jamasurg.2017.0904;

(4) Tablan OC, Anderson LJ, Besser R, et al., for the Healthcare Infection Control Practices Advisory Committee; Centers for Disease Control and Prevention. "Guidelines for Preventing Health-Care--Associated Pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee." MMWR. 2004; 53-(RR-3); 1-40. This publication is available at http://www.cdc.gov/mmwr/PDF/rr/rr5303.pdf and at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm;

(5) Centers for Disease Control and Prevention; Healthcare Infection Control Practices Advisory Committee. "Guidelines for Environmental Infection Control in Health-Care Facilities." MMWR. 2003; 52(RR-10); 1-42. Last update: February 15, 2017; 1-240. This publication is available from www.cdc.gov/infectioncontrol/guidelines/environmental/;

(6) Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee. "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" Last update: February 15, 2017; 1-161. This publication is available at: http://www.cdc.gov/infectioncontrol/guidelines/index.html;

(7) Boylard EA, Tablan OC, Williams WW, et al., and the Hospital Infection Control Practices Advisory Committee. "Guideline for Infection Control in Health Care Personnel, 1998." Published simultaneously in AJIC: American Journal of Infection Control (1998; 26: 289-354) and Infection Control and Hospital Epidemiology (1998; 19: 407-63);

(8) Siegal JD, Rhinehart E, Jackson M, et al., and the Healthcare Infection Control Practices Advisory Committee. "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings." Last update: February 15, 2017; 1-209. This publication is available at: http://www.cdc.gov/infectioncontrol/guidelines/index.html;

(9) Jensen, PA, Lambert, LA, Iademarco, MF, et al., and Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention. "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health- Care Settings, 2005." MMWR. 2005; 54(RR-17); 1-141. This publication is available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm; and

(10) Siegal, JD, Rhinehart, E, Jackson, M, et al., and the Healthcare Infection Control Practices Advisory Committee. "Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006." Last update: February 15, 2017; 1-74. This publication is available at: http://www.cdc.gov/mrsa/pdf/mdroGuideline2006.pdf.

2. Developing and implementing a system of infection control and isolation procedures, including Universal (OSHA)/Standard (CDC) Precautions, using at least criteria which meet or exceed the criteria established by 29 CFR 1910.1030, OSHA's Blood Borne Pathogens regulation incorporated herein by reference. as amended and supplemented if in effect;

3. Reviewing and approving written policies and procedures for decontamination, disinfection, sterilization, and handling of regulated medical waste and all other solid waste. (See N.J.A.C. 8:43G-13, Housekeeping, Laundry, and Sanitation);

4. Reviewing, every three years or more frequently as necessary, the hospital's policies and procedures related to infection control such as: isolation, aseptic technique, employee health, and staff training. Review on at least an annual basis antimicrobial susceptibility and trends, the prevention of infection, and general improvement of patient care;

5. Identifying and reporting communicable diseases throughout the hospital, with the cooperation of the clinical laboratory, medical records, and the medical staff, as specified in N.J.A.C. 8:57-1, "Reportable Communicable Diseases"; and

6. Identifying and reporting of HIV/AIDS as specified in N.J.A.C. 8:57-2, "Reporting of Acquired Immunodeficiency Syndrome and Infection with Human Immunodeficiency Virus."

(e) The infection control program, with the cooperation of the infection control committee, shall share information, including problems, data, and relevant recommendations, with at least the quality improvement program, nursing service, administration, and the medical staff, and shall ensure that corrective actions are taken.

(f) The infection control committee shall meet at least six times per year with at least one meeting per quarter.

(g) The hospital epidemiologist and the infection control professional shall participate in the development of and shall approve all hospital policies and procedures related to infection control.

N.J. Admin. Code § 8:43G-14.1

Amended by 50 N.J.R. 552(b), effective 1/16/2018