Infection Prevention and Control
Physicians and Licensed Independent Practitioners (LIPs) must complete infectious prevention and control education, including Bloodborne Pathogen Safety, during orientation and on an annual basis. Many formats and venues are available to complete annual infection control updates. Contact Nancy Reynolds for more information.
Jose Poblete, M.D.
Chair, Infection Control Committee
Nancy Reynolds, MSN, RN, CIC, FAPIC
Director, Infection Control and Clinical Safety
Infection Prevention Manual
The Infection Prevention manual is available on Summa@Work. The manual contains:
- Exposure Control plans for Bloodborne Pathogen Safety and Tuberculosis
- Standard Precautions used for all patient care
- Transmission-based precautions based on CDC Isolation Guidelines
- System-wide Infection Prevention and Control policies and procedures.
Infection Control Guidelines
Bloodborne Pathogen (BBP) Standard
- Every physician/LIP is responsible for adhering to all elements of the BBP Standard, including the use of Standard Precautions and sharps safety.
- When a blood contaminated exposure occurs from a sharps injury or exposure of mucous membrane or non-intact skin, follow-up is required.
- Every physician is encouraged to report immediately to the Employee Health Department (or, when closed, to the Emergency Department).
- In the rare circumstance that post-exposure prophylaxis would be required, it should be started within two hours.
- Lab testing of the exposed person and the source patient is done through a protocol that meets the requirements of the BBP Standard and regulations.
- TB Screening is required upon appointment, exposure, and as required by the annual Infection Control Risk Assessment.
- TB screening (PPD or Quantiferon) may be completed at a location of convenience, including Employee/Corporate Health.
- The physician/LIP is responsible for documentation and/or health requirements required by the Medical Staff Office and Credentialing Office.
- Persons having an exposed active Herpes Simplex lesion, including herpetic Whitlow, are restricted from working with obstetrical, neonates, and immune-compromised patients.
- Persons with varicella infections are restricted from patient care until lesions are crusted.
- Persons with scabies are restricted from the institution until 24 hours after initiation of appropriate treatment.
- Persons with known HIV/HBV infection are evaluated and counseled regarding possible restrictions to performing high risk patient procedures.
- The Centers for Disease Control and Prevention (CDC) Isolation Guidelines are followed.
- Isolation may be ordered by a physician, LIP, or RN.
- The accepted types of Isolation are:
- C diff Contact
- Standard Precautions apply to every patient.
Infection Prevention and Control – Ohio Reportable Diseases
As required by the Ohio Public Health regulations, Class A Communicable Disease are reported to the local health department by the Summa Microbiology Lab and Infection Control Department Staff. The Health Department will begin its follow-up once they receive a communicable disease report. If the physician has not counseled the patient on test results, he/she may learn of results via the Health Department representative. Physicians are required by Ohio law to report private practice outpatients/office patients with reportable diseases to the appropriate Health Department.
Download the Reportable Infectious Diseases Guide (PDF)