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e I <br />0 <br />t <br />POLICY <br />UNIVERSAL PRECAUTIONS SURVEILLANCE <br />BODY SUBSTANCE ISOLATION (BSI) <br />11 <br />As part of the Tracy -Hos . >,. Infection Control Program, quality assurance <br />activities related to universal Precautions shall be done routinely. <br />OBJECTIVES <br />To ensure compliance the the Universal Precautions policy. <br />To monitor the effectiveness of work practices and the use of protective <br />equipment. <br />PROCESS <br />Surveillance: <br />1. Surveillance of the departments to ensure that required work practices are <br />observed and that protective clothing and equipment are provided and <br />properly used. (The tool for measurement, will be the hospital Universal <br />Precautions - Body Substance Isolation policy. In departments where there <br />are specific departmental policies approved, those policies will be used.) <br />} 2. Investigation of known mucous membrane exposures to body fluids or tissues <br />to establish the conditions surrounding the exposure will be done by the <br />employee heal`h nurse. <br />3. Investigation of known needle punctures will be done -'by the employee health <br />nurse that will include an evaluation of the conditions associated with the <br />puncture. <br />4. Random sampling -may be accomplished by the employee health nurse, safety <br />consultant, and the infection control coordinator. <br />Education: <br />I6 Department directors will periodically review the Universal Precautions <br />policy with all employees. <br />2. Training will be provided yearly during the Infection Control Update. <br />3. Individualized or group training will be done as a result of the <br />surveillance findings. <br />4. Training will be ongoing. <br />Findings: ,: <br />I. The findings of the surveillance activities will be reported to the <br />infection control nurse/committee for the first six months. <br />