Policies and Procedures

Infection prevention and control policies

The Department of Infection Prevention and Control is responsible for a number of clinical policies at OHSU. We've included links here to some of the most frequently used policies, but you can always search for a policy in the OHSU Policy Manager System(OHSU login required).

Hand hygiene and standard precautions

Often times a patient may be colonized with a harmful organism that you, as a healthcare worker or clinician, may not know about. Or a patient may have an infectious process that has not yet been diagnosed. This is why all OHSU staff must practice excellent hand hygiene and standard precautions on all patients to prevent the spread of something harmful we may or may not know about. 

  • Hand hygiene Good hand hygiene is best defense against disease transmission. For more information on hand hygiene at OHSU, visit our hand hygiene page .
  • Standard precautions All OHSU employees, students and staff must follow standard precautions at all times. Remember, standard precautions does not mean "do nothing".

Isolation precautions

Knowing how and why OHSU places patients in isolation precautions is important in understanding how we can prevent the transmission of harmful organisms and infectious disease. The following policies and procedures shed light on isolation precautions: 

  • Isolatable infections and conditions Knowing what diseases and conditions require isolation precautions is an important step in preventing the spread of infections. This Isolation Grid will tell you if your patient requires isolation precautions.
  • Isolation policy Understanding OHSU's isolation policy goes beyond simply know which diseases require certain isolation precautions.
  • Transmission-based isolation precautions Why does one patient require Contact precautions, while another requires Droplet precautions? This policy explains the differences in the different isolation precautions and when it is appropriate to use each one.
  • Discontinuing isolation As important as it is to ensure patients are appropriately placed on isolation precautions, OHSU also recognizes how important it is to be able to discontinue isolation when it is no longer necessary. This de-isolation grid offers guidance on how to bring your patients out of isolation precautions.

MRSA de-isolation policy

OHSU has refined the criteria to discontinue isolation for patients previously identified as being MRSA positive.  Visit our MRSA page for detailed information and education about this policy and keeping our patients safe from MRSA. 

Special air flow rooms

Some types of isolation precautions require rooms with special air flow, either positive or negative. The following document lists rooms throughout OHSU that have special air flow capability:

OHSU special airflow rooms

HVAC shutdown guidelines for isolation patients

Ill provider and employee health policies

The worlds of infection prevention and control and employee health overlap often. If our healthcare workers are sick, our patients are at greater risk. Refer to the ill provider policy to find out about work restrictions for sick employees.

To find out more about employee health and what to do in case of occupational exposures, check the occupational health policy.