| INFECTION CONTROL POLICIES & PROCEDURES - INDEX | ||||||||
| GMH Policy No. | Department/Section | Policy Title | 1=Admin 2=Dept 3=Hosp-wide 4=Rules/Regs 5=Bylaws 6=Others | Effective Date | Last Reviewed (mm/yyyy) | Last Revision (mm/yyyy) | Next Review (mm/yyyy) | Approved (mm/yyyy) |
| 6201-1 | Infection Control | Infection Control Program | 3 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-2 | Infection Control | Infection Control Program Commitment and Statement | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-03 | Infection Control | Infection Control Program | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-04 | Infection Control | Infection Control Orientation and In-service | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-05 | Infection Control | Infection Control Practitioner | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-06 | Infection Control | Infection Control Committee Chairperson | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-07 | Infection Control | Infection Control Committee | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-08 | Infection Control | Infection Control Committee Methods of Surveillance | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-08 | Infection Control | Attachment I: Infection Control Surveillance Log | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-08 | Infection Control | Attachment II: Infection Control Surveillance Report | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-08 | Infection Control | Attachment III: Infection Review Report | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-08 | Infection Control | Attachment IV: Infection Review Report, Additional Information | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-09 | Infection Control | Post-Discharge Follow-Up Surgical Site Infections | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-10 | Infection Control | Infection Control Performance Improvement Plan | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-11 | Infection Control | CDC Guidelines for Determining the Presence and Classification of Healthcare Associated Infections (HAIs) | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-11 | Infection Control | Attachment I: Site Specific Algorithms for Clinically Defined Pneumonia | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-11 | Infection Control | Attachment II: Clinically Defined Pneumonia, Alternate Criteria for Infants and Children | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-11 | Infection Control | Attachment III: Specific Site Algorithms for Common Bacterial Pneumonia with Specific Laboratory Findings | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-11 | Infection Control | Attachment IV: Specific Site Algorithms for Viral, Legionella, Chlamydia, Mycoplasma, and Other Uncommon Bacterial Pneumonias with Specific Laboratory Findings | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-11 | Infection Control | Attachment V: Specific Site Algorithm for Pneumonia in Immunocompromised Patients | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-11 | Infection Control | Attachment VI: Threshold Values for Cultured Specimens Used in Diagnosis of Pneumonia | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-12 | Infection Control | Attachment I: Official Guam Reportable Disease List | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-12 | Infection Control | Attachment II: Morbidity Report Card | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-12 | Infection Control | Attachment III: Notification of Communicable Disease of Infection Triplicate Form | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-12 | Infection Control | Attachment IV: Report of Suspected Infection | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-12 | Infection Control | Attachment V: GMHA Healthcare Associated Infection Post Discharge Form | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-12 | Infection Control | Attachment VI: Surgical Site Infection Worksheet | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-13 | Infection Control | Hand Hygiene Policy | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-14 | Infection Control | Personal Protective Equipment | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-14 | Infection Control | Attachment I: Guidelines for Glove Use and Selection for Healthcare Workers | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-15 | Infection Control | Basic Aseptic Technique | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-16 | Infection Control | Basic Sharps Injury Protection Plan | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-17 | Infection Control | In-Room Needle Disposal Maintenance | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-18 | Infection Control | Updates in Isolation Precautions | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-19 | Infection Control | Rationale for Isolation Precautions | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-20 | Infection Control | Standard Precautions, Respiratory Hygiene, and Cough Etiquette | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-20 | Infection Control | Attachment I: Table of Recommendations for Application of Standard Precautions for the Care of All Patients in All Healthcare Settings | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-21 | Infection Control | Expanded Precautions (Contact Precautions, Droplet Precautions, and Airborne Infection Isolation) | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-21 | Infection Control | Attachment I: Table of Clinical Syndromes or Conditions Warranting Additional Empiric Precautions to Prevent Transmission of Epidemiologically Important Pathogens Pending Confirmation of Diagnosis. | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-21 | Infection Control | Attachment II: Contact Precautions Sign | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-21 | Infection Control | Attachment III: Droplet Precautions Sign | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-21 | Infection Control | Attachment IV: Table of Type and Duration of Precautions for Selected Infections and Conditions | 2 | 04/20/92 | April-05 | April-05 | Sep-01 | |
| 6201-22 | Infection Control | Airborne Infection Isolation Rooms and Instructions for Use | 2 | 04/21/92 | April-05 | April-05 | Sep-01 | |
| 6201-22 | Infection Control | Attachment I; Airborne Infection Isolation Rooms Listing and Instructions for Use | 2 | 04/22/92 | April-05 | April-05 | Sep-01 | |
| 6201-23 | Infection Control | Standards of Care for the Isolated Patient | 2 | 04/23/92 | April-05 | April-05 | Sep-01 | |
| 6201-24 | Infection Control | Guidelines for Prevention of Intravascular Device-Related Infections | 2 | 04/24/92 | April-05 | April-05 | Sep-01 | |
| 6101-24 | Infection Control | Attachment I: Table of Guidelines for the Prevention of Intravascular Device Related Infections | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-25 | Infection Control | Intravascular Pump Set Changes | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-26 | Infection Control | Guidelines for Prevention of Catheter Associated Urinary tract Infections | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-27 | Infection Control | Guidelines for Prevention of Healthcare Associated Pneumonia | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-28 | Infection Control | Routine Maintenance of Ventilator Circuits | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-29 | Infection Control | Major Bloodborne Pathogens (Human Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus) | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-29 | Infection Control | Attachment I: General Information on the Major Bloodborne Pathogens | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-30 | Infection Control | Potentially Infectious Material, OSHA Definition | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-31 | Infection Control | Response to Influx of Infectious Patients | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-32 | Infection Control | Outbreak Investigation | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-33 | Infection Control | Microbiologic Surveillance of the Environment and of Hospital Personnel | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-34 | Infection Control | Exposure Control Plan | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-35 | Infection Control | Exposure to Meningococcal Disease | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-36 | Infection Control | Varicella zoster (Chickenpox) Infection Prevention and Control | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-37 | Infection Control | Varicella zonster (Chickenpox) Exposure | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-38 | Infection Control | Application of Work Restrictions for Personnel Providing Services in the Hospital | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-38 | Infection Control | Attachment I: Table of Suggested Work Restrictions for Healthcare Personnel Infected With or Exposed to Major Infectious Diseases in Healthcare Settings in the Absence of State and Local Regulations. | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-38 | Infection Control | Attachment II: Work Restrictions Application Form | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-39 | Infection Control | Management of Patients with Vancomycin Resistant Enterococcus (VRE) | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-40 | Infection Control | Management of Patients with Methicillin Resistant Staphylococcus Aureus (MRSA) | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-41 | Infection Control | Management of Patients with Norwegian Scabies | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-42 | Infection Control | Tuberculosis Exposure Control Plan | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-43 | Infection Control | Discharge Planning for Patient with Mycobacterium Tuberculosis | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-43 | Infection Control | Attachment I: Tuberculosis Reporting Form | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |
| 6201-43 | Infection Control | Attachment II: Infection Control Standing Order Form for Mycobacterium Tuberculosis Case Discharges | 2 | 04/25/92 | April-05 | April-05 | Sep-01 | |