§ 146.1. Principle.
(a) A multidisciplinary committee made up of representatives of the medical staff, the administration, the microbiology laboratory, and the nursing service shall establish effective measures for the control and prevention of infections.
(b) The multidisciplinary committee described in subsection (a) shall do the following:
(1) Develop written standards for hospital sanitation and medical asepsis. Copies of the standards shall be made available to all appropriate personnel. Adequate standards should comply with those described in Infection Control in the Hospital, published by The American Hospital Association, Chicago, Illinois.
(2) Develop isolation procedures.
(3) Develop, evaluate, and revise on a continuing basis the procedures and techniques for meeting established sanitation and asepsis standards.
(4) Develop a practical system to report, evaluate, and keep records of infections which originate in the hospital among patients and personnel to trace the sources of infection, and to identify epidemic situations.
(5) Review periodically the use of antibiotics as they relate to patient care within the hospital.
(6) Provide assistance in the development of the employe health program of the hospital.
(7) Submit a copy of pertinent findings and recommendations to the chief executive officer, the director of nursing service, and other appropriate personnel.
(8) Maintain written minutes of meetings.
Notes of Decisions Adoption of Standards
This regulation only referenced the standard for intravenous catheter sites, and did not require its adoption. The regulation merely states that whatever standards a hospital’s infection committee chooses to adopt should be in line with Infection Control. This regulation did not require the hospital to follow in lock step with the 48-hour rule, so its decision to adopt a 72-hour rule was not necessarily negligent. Therefore, the hospital’s failure to move the patient’s heparin lock after 48-hours did not constitute negligence per se. Edwards v. Brandywine Hospital, 652 A.2d 1382 (Pa. Super. 1995).
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