Hospital Infection Control: the Basics and Documenting For Legal Purposes

There has been a lot of talk about Ebola and what happened at Texas Health Presbyterian in Dallas recently. Though what happened in Dallas is an extreme case, we all can take a hard look at our own infection control programs. While the rules of infection control can seem very basic, it’s in times where people become too casual in their understanding and deployment of the basics do people then lapse in discharging their duties to patients.

Almost all hospitals have a robust infection control program. Doctors, nurses, and staff should nonetheless be keenly aware of what those practices are so that they can help remain accountable in their duties to patients and their care.

As with many aspects of American life, litigation is a constant specter, especially in healthcare settings where there are many potential claims and plaintiffs. The key with matters like is proper note taking and documentation. Remember that your notes are considered legal documents that can be used as admissible evidence in court proceedings. Having a good paper trail of your efforts for infection control can establish a positive record and aid in any legal defense. What's more, having good statistics and documentation of your efforts will help your performance improvement program.

According to the hospital accreditation agency called Joint Commission on Accreditation of Hospital Organizations (JCAHO), there are certain basic standards that any healthcare agency has to meet. Without going into too much technical detail, and at the most central:


A hospital should be adequately stocked with items like gloves, gowns, face masks, sanitizers, cleaning supplies etc.

If you notice that basic supplies are missing or are empty, or seem to be short supply, such as hand sanitizing wall stations, or gloves , then please ask to have that area restocked as soon as possible


As important has having infection control supplies is, top rate hospitals will have trained their doctors, nurses, and staff on latest practices of infection prevention and control.

At the most basic level, this means that doctors, staff, and anyone who comes into contact with a patient at the hospital will have either washed or sanitized their hands before touching a patient or their loved ones. The healthcare provider should also wash their hands upon leaving the room.

This hand washing rule should expressly be followed when changing dressings, handling open wounds or lesions, getting blood samples, or inserting and changing IV lines.

If you see anyone in a healthcare setting, including doctors and nurses, place hands on a patient in a clinical setting without washing their hands, please say something to them and/or their supervisor. Hand washing is the lynchpin of infection control at a hospital.

To be sure, have the charge nurse document when any lack of hand washing happened in her notes if you feel this rule has been violated. Then also make sure that the violating employee is given remediation training on hand washing and document that too.


One type of situation that is not the most obvious infection control breach, is when a healthcare worker is themselves sick. Doctors and nurses are people too, and they also get the cold or flu. But, they should not be in direct patient contact if they have a possibility to be infectious.

If you find yourself in a situation where a healthcare worker is obviously ill, please don’t be afraid to say something and have the ill healthcare worker reassigned to a non-patient contact area. You will help them from inadvertently causing a patient to fall ill.

Document that the employee was was moved to a different area that does not have any direct patient contact. You may or may not want to document that the employee was sick.


Staff should be deploying proper techniques for sneezing and coughing, which is covering the mouth and nose with a tissue. This greatly reduces the chance that infections they may be carrying from infecting other patients via water droplet transmission.


Staff should all know how to put on, take off, and dispose of gowns and other protective gear in isolation rooms. For instance, hospital staff should know not to enter a hallway with protective gowns or other gear such as gloves after they have been treating a patient. There are many other simple, yet easily overlooked steps to putting on and taking off protective equipment when seeing a highly infectious patient. Please refer to the infection control officer or your policies and procedures manual at your hospital to find out more about what they are.

Making your infection control officer well known and accessible for questions and advisement will help augment staff compliance and knowledge with infection control and good practices.


A hospital room should also be free from medical waste, which includes its disposal on a regular basis. By way of example, needles or scalpels, which are usually in a orange or red 'sharps' container in the room should never be over 2/3 full before it's disposed of.

A good cleaning log can help here.


Any medical equipment that is used on a patient should be sterile. The best way to ensure its sterility is to see it taken out of a new package while using clean technique.

Again, date and time logs when the instruments were cleaned would be very useful.


While this is not nearly an exhaustive list of the rules for infection control, this is the very least providers should be practicing. All hospitals will have a strong infection control program on the books, but it's up to providers to be aware of what the infectious disease program entails, to put it into action, and to remain vigilant in maintaining a high level of surveillance at all times. One lapse can have serious consequences, like in Dallas.

Additionally, having proper documentation of your efforts will aid in your legal defense if a plaintiff decides to bring an action against you related to infection they claim to have received while in your care.



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