Infection Control SOP Template

1.Purpose

To prevent the spread of infectious disease between patients and staff by applying the correct precautions, personal protective equipment and cleaning at every stage of care.

2.Scope

Applies to all clinical areas where patients may require standard, contact, droplet or airborne precautions. Sterile processing and surgical asepsis are covered by separate SOPs.

Definitions

Standard precautions

Baseline infection prevention practices used for every patient regardless of diagnosis, including hand hygiene and PPE based on anticipated exposure.

Transmission-based precautions

Additional precautions, such as contact, droplet or airborne, added for patients known or suspected to have a specific infectious organism.

Donning and doffing

Putting on and taking off personal protective equipment in a sequence that avoids self-contamination.

Exposure

Contact with blood, body fluids or an infectious organism that may require follow-up evaluation.

3.Responsibilities

Clinical Staff Member

Applies the correct precautions, dons and doffs PPE correctly, and reports possible exposures immediately.

Charge Nurse

Confirms precaution signage, assigns isolation rooms and verifies PPE supply on the unit.

Infection Prevention Coordinator

Determines precaution type, investigates exposures and clusters, and updates precaution orders.

Environmental Services Technician

Cleans and disinfects isolation rooms and restocks PPE stations outside precaution rooms.

RACI matrix

R = Responsible, A = Accountable, C = Consulted, I = Informed

4.Materials and PPE

Materials, tools and systems

• →Precaution signage (contact, droplet, airborne)
• →PPE cart outside each isolation room (gowns, gloves, masks, eye protection)
• →N95 or higher respirator with fit-test records
• →Alcohol-based hand rub at room entry and exit
• →EHR precaution order and isolation log
• →Exposure incident report form

Personal protective equipment

• →Disposable gown
• →Gloves
• →Surgical mask or fit-tested respirator
• →Eye or face protection

5.Procedure

1. 5.1

   Identify the required precaution type

   Infection Prevention Coordinator

   Review the patient's diagnosis, symptoms and lab results to determine whether standard precautions are sufficient or contact, droplet or airborne precautions are needed, and enter the order in the EHR.

2. 5.2

   Post signage and prepare the room

   Charge Nurse

   Post the correct precaution sign on the door, stock the PPE cart outside the room, and assign a single room or cohort area if required by the precaution type.

   Checkpoint: Signage matches the active precaution order in the EHR.

3. 5.3

   Perform hand hygiene before donning

   Clinical Staff Member

   Clean your hands with alcohol-based rub or soap and water immediately before putting on any PPE.

4. 5.4

   Don PPE in sequence

   Clinical Staff Member

   Put on the gown first, then the mask or respirator, then eye protection, then gloves last, pulling gloves over the gown cuffs.

   Checkpoint: All PPE is fully in place and fitted correctly before entering the room.

5. 5.5

   Provide care within the room

   Clinical Staff Member

   Limit the number of items brought into the room, keep supplies dedicated to that patient where possible, and avoid touching your face or adjusting PPE with contaminated gloves.

6. 5.6

   Doff PPE in sequence

   Clinical Staff Member

   Remove gloves first, then perform hand hygiene, remove the gown by rolling it inward, perform hand hygiene again, then remove eye protection and the mask or respirator last, touching only the clean parts.

   Warning: Removing PPE out of sequence, or touching the outside of a contaminated item, can spread the organism to your skin or clothing.

7. 5.7

   Perform hand hygiene after doffing

   Clinical Staff Member

   Clean your hands immediately after removing the last piece of PPE and again after leaving the room.

8. 5.8

   Dispose of used PPE

   Clinical Staff Member

   Place used PPE in the designated waste container inside the room, and use a biohazard bag if required by facility policy for the precaution type.

9. 5.9

   Clean and disinfect the room

   Environmental Services Technician

   Clean and disinfect high-touch surfaces and equipment using a product effective against the identified organism, following the manufacturer's contact time.

10. 5.10

    Restock the PPE station

    Environmental Services Technician

    Check the PPE cart outside the room during rounds and restock any item that is low or missing before the next shift begins.

    Checkpoint: PPE cart is fully stocked at every shift change.

11. 5.11

    Report a possible exposure

    Clinical Staff Member

    If skin, eyes or mucous membranes contact blood or body fluid, or PPE fails during care, stop the task, complete the exposure incident report, and notify the supervisor immediately for follow-up.

    Warning: Do not delay exposure reporting; some follow-up treatments are time-sensitive.

12. 5.12

    Investigate and discontinue precautions

    Infection Prevention Coordinator

    Review exposure reports and any cluster of cases, and discontinue a precaution order only when clinical criteria for discontinuation are met and documented.

6.Quality checks

• →PPE donning and doffing sequence is observed correctly during audits.
• →Precaution signage matches the active EHR order on every isolation room.
• →Isolation rooms pass post-discharge terminal cleaning inspection.
• →All exposure reports are followed up within the facility's required timeframe.

7.Records

• →Precaution orders and discontinuation notes in the EHR
• →PPE competency and respirator fit-test records
• →Exposure incident reports
• →Isolation room cleaning logs

8.KPIs

• →Healthcare-associated infection rate
• →PPE donning and doffing audit pass rate
• →Time from exposure to incident report filed
• →Isolation room turnaround time

9.Common mistakes

• →Removing gloves and gown together without hand hygiene in between.
• →Leaving precaution signage up after the order has been discontinued.
• →Reusing single-use PPE items between patients to save supplies.
• →Delaying exposure reporting until the end of the shift.

10.Revision history