Infection Prevention Manual

EXPOSURE CONTROL PLAN RESPIRATORY PROTECTION PLAN POLICY: It shall be the policy of this agency to adhere to the OSHA standards related to respiratory protection and the CDC guidelines for tuberculosis infection control. PURPOSE: This plan is designed to prescribe practices relating to the management of Mycobacterium Tuberculosis in an effort to minimize the risk of exposure and transmission of this disease to home care staff, patients and others. It shall be available for review by all staff. DEFINITIONS: 1. High Risk a. The agency PPD test conversion rate is significantly greater than previous conversion rates and epidemiological investigation suggests agency acquired transmission of M. Tuberculosis, or b. a cluster of PPD conversions has occurred and epidemiological investigation suggests agency acquired transmission of M. Tuberculosis, or c. possible person-to-person transmission of M. Tuberculosis has been detected. 2. Intermediate Risk a. The agency cares for six or more TB patients per year, b. The PPD test conversion rate is the same as previous conversion rates for the agency, c. no clusters of PPD test conversions have occurred, and d. no person-to-person transmission of M. Tuberculosis has been detected. 3. Low Risk a. The agency cares for less than six TB patients per year, b. The PPD test conversion rate is the same as previous conversion rates for the agency, c. no clusters of PPD test conversions have occurred, and d. no person-to-person transmission of M. Tuberculosis has been detected. 4. Very Low Risk a. The agency does not admit patients with active TB; patients who may have active TB are referred to a collaborative agency, b. The agency provides services to communities of counties where TB cases have been reported during the previous year. 5. Minimal Risk a. The agency does not admit TB patients; patients who may have active TB are referred to a collaborative agency, and b. The agency provides services to communities or counties where no TB cases have been reported during the previous year. PROCEDURES AND RESPONSIBILITIES: 1. The administration of this plan shall be the responsibility of the agency administrator and/or the most appropriate designee. 2. A risk assessment shall be done by the agency periodically and will include: A. A profile of TB in the communities or counties served by the agency including the occurrence of drug resistant TB in the community. B. An evaluation of the data related to TB patients and patients at risk for TB within the agency. . The risk of TB transmission, and the number of patients diagnosed with TB within the agency. . The prevalence of Human Immunodeficiency Virus (HIV) among the agency's patient population. C. The collection and analysis of Mantoux PPD test conversion data within the agency. 3. The risk assessment shall determine the frequency of Mantoux PPD testing among the agency staff. A. Minimal to Low Risk: The Mantoux PPD test shall be done for all agency staff with patient contact annually. B. Intermediate Risk: The Mantoux PPD test shall be done for all agency staff with patient contact every six (6) months. C. High Risk: The Mantoux PPD test shall be done for all agency staff with patient contact every three (3) months.