Statewide Program for Infection Control & Epidemiology

Education to prevent and control healthcare associated infections across the healthcare spectrum

UNC Healthcare Infection Control Policies

Please note: These policies and accompanying attachments have been adopted by UNC Health Care for its use in infection control. They are provided to you as information only.

Note: The date following the policy title is the date that the policy is scheduled to be reviewed.

Policy (in alphabetical order)Policy Attachment(s) (if applicable)

-A-

 

Air and Ground Transport IC0001 (12/2022)

 

Ambulatory Care Clinical Services  (1/2023)

Amb Care-2

Anesthesiology (09/2025)

 

Animal Assisted Activities (8/2023)

 

-B-

 

Bone Marrow Transplant Unit IC0005 (3/2025)

 

Burn Center (5/2026)

-C-

 

Cardiac Catheterization Laboratories (06/2024)

Cardiac Catheterization Laboratories

Carolina Antimicrobial Stewardship Program Policy (1/2025)

 

Cleaning and Disinfection of Non-Critical Items (2/2027)

 

Clinical Engineering (9/2026)

Clinical Neurophysiology Laboratory (04/2022)

 

COVID-19 Control Plan (2/2027)

 

CPD and Other Surgical Svcs Support Areas (03/2027)

CPD-1

CPD-2

Creutzfeldt-Jakob Disease (CJD) (03/2027)

CJD-1

Custody of Internal Body Tissue, Organs, or Body Parts (04/2027)Att 1 UNC Hospitals Labor and Delivery Instructions for Releasing the Placenta
Att 2 Acknowledgement and Authorization for Release of Placenta Form

Cystoscopy Suite (06/2027)

 

-D-

 

Dentistry (03/2027)

 

Dialysis Unit (02/2027)

Diversional Supplies (12/2026)

Dialysis

-E-

 

Electrophysiology Lab (1/2024)

Electrophys Lab-1

Emergency Department (8/2025)

 

Endoscope (04/2027) 

 

Environmental Services (12/2026)

Envir Svcs – Att 1

Envir Svcs – Att 2

Exposure Control Plan for Bloodborne Pathogens

(04/2028)		Exp Ctrl Plan BBP – Att 1
Exp Ctrl Plan BBP – Att 2
Exp Ctrl Plan BBP – Att 3
Exp Ctrl Plan BBP – Att 4
Exp Ctrl Plan BBP – Att 5

-G-

 

Gastrointestinal Procedures (10/2024)

 

GI Motility Studies (10/2024)

 

Guidelines for Infection Control in Nutrition and Food Services (03/2027)

 

-H-

 

Hand Hygiene and Use of Antiseptics (11/2025)

Hand Hygiene and Use of Antiseptics

High-Level Disinfection -HLD – Manual Reprocessing of Reusable Semi-Critical Medical Devices (2/2026)

 

High Consequence Pathogens – Preparedness and Response Plan (4/2026)

High Conseq Path – Att 1
High Conseq Path – Att 2
High Conseq Path – Att 3
High Conseq Path – Att 4
High Conseq Path – Att 5
High Conseq Path – Att 6
High Conseq Path – Att 7
High Conseq Path – Att 8
High Conseq Path – Att 9

-I-

 

Imaging Services (09/2025)

 

Infection Control Guidelines Adult and Peds (01/2023)

Infection Prevention Guidelines for Periop Svcs

Infection Prevention Guidelines for the Advanced Care – Home Program (09/2024)

Infection Prevention Guidelines for Continuing Care (07/2026)

Continuing Care – Att 1 – Criteria for HHH and Inpatient Hospice Care Associated Infection 5-2023

Infection Prevention Guidelines for Attire in Semi-Restricted and Restricted Zones (11/2025)

 

Infection Prevention Guidelines for Perioperative Services (3/2026)

Periop Svcs – Att1
Periop Svcs – Att2
UNC Medical Center Staff Workflow (Temp Humidity)

Infection Prevention Guidelines for Safe Patient Care (11/2026)

IPG Safe Patient Care – Att 1

Infection Prevention Invasive Imaging (12/2026)IPG Safe Patient Care – Att 1

Infection Prevention Program (11/2025)

IC Program

Infection Prevention Plan FY 2021 (09/2024)

IC Plan 2021

Infection Prevention Plan FY 2022 (09/2025)

IC Plan 2022

Infection Prevention Plan FY 2023 (10/2026)

IC Plan 2023 – Att 1
IC Plan 2023 – Att 2
IC Plan 2023 – Att 3
Infection Prevention Plan FY 2024 (10/2025)IC Plan 2024 – Att 1
IC Plan 2024 – Att 2
IC Plan 2024 – Att 3

Infection Prevention Response to Intentional Use of a Biothreat Agent (10/2025)

Biothreat-1

Influenza Immunization of Healthcare Personnel (09/2024)

 

Isolation Precautions (03/2028)

Iso Precautions Att-1
Iso Precautions Att-2
Iso Precautions Att-3
Iso Precautions Att-4
Iso Precautions Att-5
Iso Precautions Att-6
Iso Precautions Att-7
Iso Precautions Att-8
Iso Precautions Att-9
Iso Precautions Att-10
Iso Precautions Att-11

-L-

 

Laundry and Linen Service (06/2027)

 

-M-

 

Medical Engineering (07/2022)

 

Medication Management_ Use of Multi-Dose Vials_Pens of Injectable Medications and Vaccines (01/2023)

 

-N-

 

Nutrition and Food Services (03/2024)

Nutrition & Food Svcs

-O-

 

Occupational Health Service (04/2025)

OHS

-P-

 

Patient Equipment (07/2027)

 

Patient Exposure to Potentially Infectious Body Fluids and Human Milk (9/2026)Pat. to Pat. Exp – Att 1 – Worksheet for Human Milk Exposure
PatientExposure – Att 1 – Patient Exposure to Potentially Infectious Body Fluids Other Than Human Milk

Patient to Patient Exposures (09/2024)

 

Patients with Cystic Fibrosis  (11/2026)

Patients with Cystic Fibrosis

Pediatric Play Facilities and Child Life  (10/2026)

Ped Play Facilities – Att 1
Ped Play Facilities – Att 2
Ped Play Facilities – Att 3
Ped Play Facilities – Att 4
Ped Play Facilities – Att 5

Pharmacy (03/2028)

 

Plant Engineering and Maintenance  (5/2025)

Plant Engineering

Prevention of Intravascular Catheter-Related Infections (09/2026)

Psychiatric Units IC0048 (4/2027)

Att 1 Quick Glance Identify Patients Need Contact Prec for MDROs

-R-

 

Regulated Medical Waste (4/2027)


Rehabilitation Center (3/2026)

Rehabilitation Therapies (02/2027)

 

Reporting of Communicable Diseases (06/2025)

Reporting of Communicable Diseases

Research Animals in UNC Health Care Facilities (6/2027)

Respiratory Care Department (9/2026)

 

Reuse of Single-Use Devices (11/2026)

-S-

 

Safety and Infection Control Management Plan for Construction Renovation and Modernization Projects (9/2022)

Attachments-8

Service Animals (01/2025)

 

Sterilization of Reusable Patient-Care Items (04/2026)

Special Pathogen Unit SPU Activation (07/2027)

Sterilization of Reusable Patient Care Items

SPARC SOP PPE Donning for Special Pathogens 07/2027
SPARC SOP Dialysis Special Pathogens Patient 07/2027
SPARC SOP Handling Liquid Waste 07/2027
SPARC SOP Intubating Special Pathogen Patient 07/2027
SPARC SOP Patient Containment Wrap and Transport 07/2027
SPARC SOP PPE Breach Protocol 07/2027
SPARC SOP PPE Doffing for Special Pathogen Patient 07/2027
SPARC SOP Spill Cleanup 07/2027
SPARC SOP Waste Management 07/2027
SPARC SOP Specimen Collection and Transport 07/2027
SPARC SOP Terminal Room Disinfection 07/2027
SPARC SOP Patient Admission Prebrief 07/2027
SPARC SOP Roles and Responsibilities 07/2027
SPARC SOP Isolation of a Special Pathogen Patient in the ED 07/2027

-T-

 

Tuberculosis Control Plan (03/2028)

TB Control Plan – Att 1_ UNC Hosp AFB Lab Procedures

TB Control Plan Att 2_ Summary of Interpretation of Skin Tests
TB Control Plan – Att 3_ Protocol for Early Identification of Patients with Suspected Tuberculosis – Outpatient Care Services
TB Control Plan – Att 4 – ProcedureForInstitutingAirbornePrecautionsWhenThePatientIsHousedInASemi-PrivateRoom

-U-

 

UNC Home Health (5/2020)

UNC Home Health

-V-

 

Vascular Interventional Radiology (12/2023)

 

-W-

 

Women’s Hospital Maternal Units – Recommendations from Infection Prevention (07/2027)

Women’s Hsp Mtrnl Unts – Att 1
Women’s Hsp Mtrnl Unts – Att 2
Women’s Hsp Mtrnl Unts – Att 3
Women’s Hsp Mtrnl Unts – Att 4