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) Available Upon Request		Next Review

-A-

 

Anesthesiology

6/2028

-B-

 

Bone Marrow Transplant

 2/2028

Burn Center

12/2028

-C-

 

Cardiac Catheterization Laboratories (06/2024)

Cardiac Catheterization Laboratories

Carolina Antimicrobial Stewardship Program Policy

 12/2027

Chlorhexidine Gluconate (CHG) Treatments and Skin Antisepsis1/2028

Cleaning and Disinfection of Non-Critical Items

 8/2028

Clinical Engineering 9/2026

CPD and Other Surgical Svcs Support Areas

3/2027

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

3/2027
Custody of Internal Body Tissue, Organs, or Body Parts 4/2027

Cystoscopy Suite

 6/2027

-D-

 

Dentistry

 3/2027

Dialysis Unit
5/2029
Diversional Supplies

-E-

 

Electrophysiology Lab (1/2024)

Electrophys Lab-1

Emergency Department (8/2025)

 

Endoscope

 

 10/2029

Environmental Services (9/2025)

Exposure Control Plan for Bloodborne Pathogens

-G-

 

Gastrointestinal Procedures

 

GI Motility Studies

 

Guidelines for Disposal of Regulated Medical Waste

Guidelines for Infection Control in Nutrition and Food Services

 

-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)

-I-

 

Infection Prevention Guidelines for Imaging Services

 

Infection Control Guidelines Adult and Peds

Infection Prevention Guidelines for the Advanced Care – Home Program

Infection Prevention Guidelines for Continuing Care

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

 

Infection Prevention Guidelines for Perioperative Services

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

Infection Prevention Guidelines for Safe Patient Care

IPG Safe Patient Care – Att 1

Infection Prevention Invasive Imaging IPG Safe Patient Care – Att 1
Infection Prevention Plan FY 2026UNC Facility Risk Assessment FY26 – Att 1
Hospital Quality Assessment Performance Improvement (QAPI) Plan FY26 – Att 2

Infection Prevention 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

-L-

 

Laundry and Linen Service (06/2027)

 

-M-

 

-N-

 

-O-

 

Occupational Health Service (04/2025)

OHS

-P-

 

Patient Equipment
Patient Exposure to Potentially Infectious Body Fluids and Human Milk
Patients with Cystic Fibrosis
Pediatric Play Facilities and Child Life 

Pharmacy

 

Plant Engineering and Maintenance

Prevention of Intravascular Catheter-Related Infections

Psychiatric Units

-R-

 

Regulated Medical Waste


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

Service Animals (01/2025)

 

Sterilization of Reusable Patient-Care Items

Special Pathogen Unit SPU Activation (07/2027)
SPARC SOP PPE Donning for Special Pathogens 07/2027
SPARC SOP Dialysis Special Pathogens Patient 07/2027
SPARC SOP Handling Liquid Waste 08/2025
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 08/2025
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