About Us - Policies and Procedures - Infection, Prevention and Control

As Saskatchewan Health Authority policy directives continue to be developed and approved, they will be communicated to those they apply to and posted on the Authority's employee intranet.

All former regional health authority policies remain in effect until specifically replaced by the Saskatchewan Health Authority policy directives or policies. These include procedures, protocols, guidelines, work standards, standard work, medical directives, etc.

Former Saskatoon Health Region (IP & C) Policies

Infection Prevention and Control policies and procedures are organized according to these categories:

00 - Introduction
10 - Organization
20 - Standard Precautions
30 - Additional Precautions
40 - Specific Prevention & Control Measures
50 - Environmental Control
55 - Outbreak Management
60 - Surveillance
70 - Handouts

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Policy	Name	Effective_Date
Category : 00 - Introduction ‎(6)

Complete Infection Prevention & Control Policy & Procedure Manual	00-000	17-Sep-19

Introduction to Infection Prevention and Control	00-10	01-May-07

IP&C Manual Binder Covers	00-01	17-Sep-19

IP&C Manual Divider Label Template (Avery 11417)	00-02	17-Sep-19

Table of Contents	00-00	06-May-19

Title Page	Title Page	17-Sep-19
Category : 10 - Organization ‎(6)

Abbreviations and Definitions	10-50	01-Oct-06

Infection Prevention & Control Committee	10-20	01-Oct-10

Infection Prevention and Control Committee: Terms of Reference	10-20 Appendix A	01-Oct-12

Infection Prevention and Control Professional	10-30	01-May-07

Infection Prevention and Control Program	10-10	01-Sep-06

Organizational Chart	10-40	24-Aug-16
Category : 20 - Standard Precautions ‎(21)

Dishes	20-70	01-Oct-06

Gloves	20-30	01-Oct-06

Gowns	20-50	01-Oct-06

Hand Hygiene	20-20	01-Oct-14

Health Record Document Contamination	20-140	01-Dec-06

Healthcare Worker Doffing PPE Procedure	20-150 Appendix B	01-Oct-15

Healthcare Worker Donning PPE Procedure	20-150 Appendix A	01-Oct-15

Linen	20-60	01-Oct-06

Masks, Eye Protection and Face Shields	20-40	01-Oct-06

Non-Critical Patient Care Equipment	20-80	01-May-12

Non-critical Patient Care Equipment: Cleaning Guidelines	20-80 Appendix A	01-May-12

Patient Accomodation	20-90	01-Nov-06

Personal Protective Equipment - Donning and Doffing	20-150	01-Oct-15

Point of Care Risk Assessment (POCRA)	20-25	01-Oct-10

Point of Care Risk Assessment Algorithm	20-25 Appendix A	01-Oct-10

Respiratory Hygiene and Cough Etiquette	20-95	01-Feb-08

Routine/Standard Point of Care Risk Assessment	20-25 Appendix B	01-Oct-10

Safe Injection Practices	20-101	01-Nov-08

Specimen Transport	20-130	01-Dec-06

Spills (Blood and Body Fluids)	20-120	01-Nov-07

Standard Precautions	20-10	01-Sep-06
Category : 30 - Additional Precautions ‎(17)

Airborne Precautions	30-20	01-Oct-14

Airborne Precautions: AIIR Details	30-20 Appendix B	01-Jul-17

Airborne Precautions: AIIR Flow Chart	30-20 Appendix A	01-Oct-14

Communicable Disease Reference Table	30-50	01-Oct-14

Communicable Diseases Reference Table: Precautions by Etiology or Clinical Presentation	30-50 Appendix A	28-Apr-16

Contact Precautions	30-10	30-Apr-18

Droplet Precautions	30-30	01-Oct-14

Signage	30-40	01-Dec-10

Signage: Airborne and Contact Precautions	30-40 - Airborne and Contact Precautions	01-Oct-10

Signage: Airborne Precautions	30-40 - Airborne Precautions	01-Oct-10

Signage: Contact Precautions	30-40 - Contact Precautions	01-Oct-08

Signage: Droplet and Contact Precautions	30-40 - Droplet and Contact Precautions	01-Nov-10

Signage: Droplet Precautions	30-40 - Droplet Precautions	01-Nov-10

Signage: Large Stop Sign	30 - 40 - Large Stop Sign	01-Feb-01

Signage: Protect Me	30-40 - Protect Me	01-Dec-10

Signage: Reminder: Wash Your Hands	30-40 - Reminder Wash Your Hands	01-Apr-04

Signage: Small Stop Sign	30-40 - Small Stop Sign	01-Feb-01
Category : 40 - Specific Preventions and Control Measures ‎(53)

CDI: Clostridium difficile Checklist	40-30 Appendix B	01-May-13

CDI: Medical Management of Clostridium difficile	40-30 Appendix A	01-May-13

Chickenpox (Varicella Zoster)	40-20	01-May-07

CJD: CJD Containers	40-40 Appendix C	23-Nov-17

CJD: Contents of the CJD Cupply Bin	40-40 Appendix D	23-Nov-17

CJD: High-risk CJD Client Management	40-40 Appendix A	23-Nov-17

CJD: Management of CJD Specimens Standard Work	40-40 Appendix B	23-Nov-17

Clostridium difficile (CDI)	40-30	01-May-13

Creutzfeld Jakob Disease (CJD)	40-40	23-Nov-17

Cystic Fibrosis	40-45	01-Apr-09

ESBL: Retesting Process to Clear ESBL Positive Status	40-50 Appendix A	30-Apr-18

ESBL: Testing Process for Contact to a Newly Identified ESBL	40-50 Appendix B	30-Apr-18

Extended-spectrum Beta-lactamases (ESBL)	40-50	10-Jun-16

Herpes Zoster (Shingles)	40-140 Table 1	01-Sep-12

Herpes Zoster (Shingles)	40-140	01-Oct-14

Herpes Zoster (Shingles): Dermatomes	40-140 Appendix B	01-Sep-12

Herpes Zoster (Shingles): Point of Care Risk Assessment	40-140 Appendix A	01-Sep-12

ILI: Nasopharyngeal Swab for Influenza Testing	40-70 Appendix A	01-Oct-10

Immune Compromised Clients - Protective Environment	40-60	01-Jul-14

Influenza and ILI - Influenza Management	40-70 Appendix B	01-Oct-14

Influenza and Influenza-Like-Illness (ILI)	40-70	01-Oct-14

Intravascular Infections - Prevention	40-80	01-Mar-13

Lice (Head)	40-90	01-May-15

Lice (Head) - Dealing with Head Lice	40-90 Appendix A	01-May-15

Methicillin-resistant Staphylococcus aureus (MRSA) - Acute Care	40-110	10-Jun-16

Methicillin-resistant Staphylococcus aureus (MRSA) - Community	40-117	16-Jun-16

Methicillin-resistant Staphylococcus aureus (MRSA) - LTC	40-115	10-Jun-16

MRSA - Acute Care: CHG 2% Pre-moistened Disposable Washcloth Protocol	40-110 Appendix E	10-Jun-16

MRSA - Acute Care: MRSA Decolonization Criteria Algorithm	40-110 Appendix C	10-Jun-16

MRSA - Acute Care: MRSA Decolonization Protocol	40-110 Appendix D	10-Jun-16

MRSA - Acute Care: Retesting Process to Clear MRSA Positive Status	40-110 Appendix A	30-Apr-18

MRSA - Acute Care: Testing Process for Contacts to a Newly Identified MRSA	40-110 Appendix B	30-Apr-18

MRSA - Community: MRSA Decolonization Criteria Checklist	40-117 Appendix C	01-Feb-14

MRSA - Community: MRSA Decolonization Protocol	40-117 Appendix D	01-Feb-14

MRSA - Community: Retesting Process to Cleasr MRSA Positive Status	40-117 Appendix A	30-Apr-18

MRSA - Community: Specimen Collection Guide	40-117 Appendix B	30-Apr-18

MRSA - LTC: CHG 2% Pre-moistened Disposable Washcloth Protocol	40-115 Appendix D	10-Jun-16

MRSA - LTC: MRSA Decolonization Criteria Algorithm	40-115 Appendix B	10-Jun-16

MRSA - LTC: MRSA Decolonization Protocol	40-115 Appendix C	10-Jun-16

MRSA - LTC: Retesting Process to Clear MRSA Positive Status	40-115 Appendix A	30-Apr-18

Norovirus	40-118	01-Mar-08

Rubeola (Measles)	40-100	01-May-07

Scabies	40-130	01-Aug-10

Scabies Client Treatment Listing	40-130 Appendix A	01-Jun-13

Surgical Site Infections - Prevention	40-160	01-May-07

Tuberculosis (TB)	40-170	01-May-07

Tuberculosis Management Program	40-175	01-Apr-07

Urinary Tract Infections - Prevention	40-180	01-May-07

Vancomycin-resistant Enterococci (VRE)	40-190	10-Jun-16

Ventilator-Associated Nosocomial Pneumonia - Prevention	40-200	01-May-07

VRE: CHG 2% Pre-moistened Disposable Washcloth Protocol	40-190 Appendix C	10-Jun-16

VRE: Retesting Process to Clear VRE Positive Status	40-190 Appendix A	30-Apr-18

VRE: Testing Process for Contacts to a Newly Identified VRE	40-190 Appendix B	30-Apr-18
Category : 50 - Environmental Control ‎(10)

Resident Pets, Pet Visititation and Pet Therapy Program in LTCF	50-50	01-Sep-10

Antiseptics & Disinfectants	50-10	01-May-07

Computer Equipment - Cleaning and Disinfection	50-25	01-Feb-12

Construction, Renovation and Design of Healthcare Facilities	50-40	01-Oct-09

Construction, Renovation and Design: Infection Control Checks	50-40 Appendix IV	01-Oct-09

Construction, Renovation and Design: Infection Control Inspection Sheet	50-40 Appendix III	01-Oct-09

Construction, Renovation and Design: Infection Control Permit	50-40 Appendix II	01-Oct-09

Construction, Renovation and Design: Infection Control Risk Assessment	50-40 Appendix I	01-Oct-09

Pet Visitation and Pet Therapy Program	50-30	01-Jun-09

Toys and Toy Cleaning	50-20	01-Apr-09
Category : 55 - Outbreak Management ‎(36)

Antibiotic Resistant Organism (ARO) Outbreak - Acute Care	55-30	27-Nov-17

ARO Outbreak: ARO Outbreak - Client, Family and Visitor Handouts	55-30 Appendix H	27-Nov-17

ARO Outbreak: ARO Outbreak Checklist	55-30 Appendix D	30-Apr-18

ARO Outbreak: Cleaning/Disinfecting Commodes Work Standard	55-30 Appendix G	27-Nov-17

ARO Outbreak: Expectations for All Hospital Staff Poster	55-30 Appendix J	27-Nov-17

ARO Outbreak: Large CONFIRMED Outbreak Poster for Entrance	55-30 Appendix N	27-Nov-17

ARO Outbreak: Large SUSPECT Outbreak Poster for Entrance	55-30 Appendix L	27-Nov-17

ARO Outbreak: Multi-unit Staff Protocol for Entering an ARO Outbreak Unit	55-30 Appendix F	30-Apr-18

ARO Outbreak: Outbreak Transfer Communication Tool Template	55-30 Appendix E	27-Nov-17

ARO Outbreak: Phases of the Outbreak Cycle	55-30 Appendix A	27-Nov-17

ARO Outbreak: PPE Audit Template	55-30 Appendix I	27-Nov-17

ARO Outbreak: Small CONFIRMED Outbreak Poster	55-30 Appendix M	27-Nov-17

ARO Outbreak: Small SUSPECT Outbreak Poster	55-30 Appendix K	27-Nov-17

ARO Outbreak: Unit Cleaning Guidelines Checklist Example	55-30 Appendix C	27-Nov-17

ARO Outbreak: Unit Processes During ARO Outbreak Phases	55-30 Appendix B	30-Apr-18

ARO Outbreak: Work Standard for ARO Outbreaks	55-30 Work Standard	30-Apr-18

Gastrointestinal Illness (GI) Outbreak	55-40	01-Oct-12

GI Outbreak: Enhanced Cleaning for Facilities & Engineering and Unit Staff	55-40 Appendix D	01-Dec-11

GI Outbreak: Is this a GI Outbreak Algorithm	55-40 Appendix A	01-Oct-12

GI Outbreak: Patient Line Listing	55-40 Appendix B	01-Dec-11

GI Outbreak: Staff Line Listing	55-40 Appendix C	01-Dec-11

ILI Outbreak: Patient Line Listing	55-60 Appendix A	01-Oct-10

ILI Outbreak: Staff Line Listing	55-60 Appendix B	01-Oct-10

Influenza-like Illness (ILI) Outbreak	55-60	01-Oct-10

Outbreak Management - Acute Care	55-10	01-Feb-14

Outbreak Management - Acute Care: IP&C Outbreak Call List	55-10 Appendix B	01-Feb-14

Outbreak Management - Acute Care: Job Aide Suspect Outbreak	55-10 Appendix A	01-Feb-14

Outbreak Management - Acute Care: Suspect Outbreak Management Work Standard	55-10 Appendix C	09-Jun-14

Outbreak Management - LTC	55-20	01-Nov-06

Scabies Outbreak	55-50	01-Aug-10

Scabies Outbreak: Client Treatment Listing	55-50 Appendix D	01-Jun-13

Scabies Outbreak: Patient/Resident Line Listing	55-50 Appendix B	01-Aug-10

Scabies Outbreak: Protocol for Scabies Investigation	55-50 Appendix A	01-Aug-10

Scabies Outbreak: Staff Line Listing	55-50 Appendix C	01-Aug-10

Visitor Restrictions During Outbreaks	55-70	01-Sep-10

Visitor Restrictions During Outbreaks: Visitors Algorithm	55-70 Appendix A	01-Sep-10
Category : 60 - Surveillance ‎(7)

Screening for Antibiotic Resistant Organisms (AROs) - Medical Directives	60-30	07-Dec-19

Notifiable Diseases	60-20	01-May-07

Screening for AROs - Medical Directives: ARO Admission Screen Medical Directive	60-30 Appendix A	12-Jul-19

Screening for AROs - Medical Directives: ARO ICP Surveillance Orders Medical Directive	60-30 Appendix B	07-Dec-19

Screening for AROs - Medical Directives: ARO Retesting Process to Clear Positive Status	60-30 Appendix D	30-Apr-19

Screening for AROs - Medical Directives: Screening Process for Contacts of AROs	60-30 Appendix E	12-Jul-19

Screening for AROs - Medical Directives: Specimen Collection Guide	60-30 Appendix C	30-Apr-19
Category : 70 - Handouts ‎(23)

Airborne Precautions - Client, Family & Visitor Information	Airborne Precautions	27-Nov-15

Chickenpox Fact Sheet	Chickenpox	01-Jun-07

Client and Family Hand Hygiene	Client and Family Hand Hygiene Brochure	01-Jun-17

Clostridium difficile Fact Sheet	Clostridium difficile	01-Jun-07

Contact Precautions - Client, Family & Visitor Information - For Acute Care	Contact Precautions	27-Nov-15

Contact Precautions - LTC Family and Visitor Information	Contact Precautions - LTC	03-Jun-16

Contacts of an ARO Related to an ARO Outbreak - Client, Family & Visitor Information	Contacts of an ARO Related to an ARO Outbreak	27-Nov-17

Droplet and Contact Precautions - Client, Family & Visitor Information - For Acute Care	Droplet and Contact Precautions	27-Nov-15

Droplet and Contact Precautions - LTC Family and Visitor Information	Droplet and Contact Precautions - LTC	03-Jun-16

Droplet Precautions - Client, Family & Visitor Information	Droplet Precautions	27-Nov-15

ESBL Fact Sheet	ESBL	01-Oct-07

Hand Hygiene Fact Sheet	Hand Hygiene	01-Jun-12

Influenza Fact Sheet	Influenza	01-Sep-09

Lice Fact Sheet	Lice	01-Jun-07

MRSA Fact Sheet	MRSA	01-May-12

Norovirus Fact Sheet	Norovirus	01-Jan-08

Scabies Fact Sheet	Scabies	01-Aug-10

Shingles Fact Sheet	Shingles	01-Oct-07

Teaching Handouts	70-10	27-Nov-17

Visitor Information for Immune Compromised Patients	Immune Compromised Patients	01-Jun-07

Visitor Instructions: During an ARO Outbreak	Visitor Instructions - During an ARO Outbreak	27-Nov-17

VRE Fact Sheet	VRE	01-Jan-09

West Nile Virus Fact Sheet	West Nile Virus	01-Jun-07

Last Modified: Friday, October 25, 2019 |

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