MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGREVISED ON 20TH NOVEMBER,2010         ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 1 PURPOSE:To establish guideli...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2.4 Blood and Other Potentially Infect...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG  Transmission Based Precautions and I...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG4) Report individuals who do not compl...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG exudative lesions, or is otherwise br...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG substances.• Sterile gowns should be ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGpersonnel who care for a patient with ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG5.9 Examples of Appropriate Use of Per...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 6 HEPATITIS B VACCINATION PROG...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 8 PREVENTION OF TUBERCULOSIS T...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 9 GENERAL GUIDELINES FOR OUTPA...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGAll disposable sharps should be dispos...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGReturn all non-disposable needles and ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG9.7 Procedures Performed in the Clinic...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG    o Any multi-dose vial that does co...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG12.2.3 Intravenous bags    o Chemother...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG12.3.2 General Trash ContainersThe fol...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 13 HOUSEKEEPING & CLEANING OF ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG   •   To wipe excess liquid that may ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG• All clean linen must be kept covered...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGHOSPITAL INFECTION AND ANTIBIOTIC CONT...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGORGANIZATION CHART OF HOSPITAL INFECTI...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG                                   HOS...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. The ICD is the Vice Chairman of HIA...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2. Report on the occurrence and nature...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2. Emergency meetings are arranged for...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Coordinate surveillance activities ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2. Evaluate implementation of infectio...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG3. Assist in the prevention and report...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSurveillance is one of the most import...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGnationwide will be that of CDC definit...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG(bacteremia, UTI, LRI, SSI, etc.) or c...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2. All information should be reported ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGREVISED ON 20TH NOVEMBER,2010         ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGPRIMARY BLOOD STREAM INFECTION (BSI)RE...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGDEFINITION : Laboratory-confirmed bloo...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGIntroductionMulti-resistant organisms ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Moist respiratory equipment, such a...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGDEFINITION: Pneumonia must meet at lea...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSURGICAL SITE INFECTION (SSI)DEFINITIO...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG• A positive culture of a urinary cath...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGInfections that occur more than 48 hou...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Personnel• Only persons who know th...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG preferably the sampling port if prese...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGtaken to reduce the risk of an SSI. On...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGMost bacterial nosocomial pneumonias o...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG       different patients.   •   Clean...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG5. If the patient is diaphoretic, or i...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Use single-dose vials for parentera...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Two or more associated cases occurs...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG8.        Administer outbreak control ...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGOrientation checklist for clinical sta...
MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGThe Ministry of Health aims to create ...
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Hospital changkat melintang.inf control

  1. 1. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGREVISED ON 20TH NOVEMBER,2010 1AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  2. 2. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 1 PURPOSE:To establish guidelines which minimize the potential for transmission of microorganisms to,from, and between patients, and all other persons operating within Hospital Changkat Melintang.SECTION 2 DEFINITIONS:2.1 Persons: All clinical personnel, physicians, students, concession workers, contractors , visitors, and/or any other individuals who receive services from the HCM.2.2 Standard Precautions: Standard and Transmission Based Precautions System is a method to prevent the transmission of infectious agents. It requires the use of protective apparel for all contact with blood and body substances but uses airborne, droplet and contact precautions for patients with diseases known to be transmitted in whole or in part by these routes. Standard Precautions synthesizes the major features of Universal Precautions (Blood and Body Fluid Precautions) - designed to reduce the risk of transmission of bloodborne pathogens and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances). Standard Precautions applies to all patients receiving care, regardless of their diagnosis or presumed infection status. Health care workers should assume that all patients are potentially infectious and use handwashing, protective apparel, and special procedures to prevent exposure to blood and body substances. However, it is important to point out that the use of gloves is intended to supplement and not replace handwashing or other existing infection control measures. The effectiveness of Standard Precautions depends upon vigilant compliance by every health care worker.2.3 Transmission Based Precautions: Transmission Based precautions are designed for patients documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission of these agents. There are three type of Transmission Based Precautions: Airborne, Droplet and Contact. Airborne Precautions are designed to reduce the risk or eliminate the airborne transmission of infectious agent; Droplet Precautions are designed to reduce the risk of droplet transmission of infectious agents and Contact Precautions are designed to reduce the risk of transmission of microorganisms by direct or indirect contact.REVISED ON 20TH NOVEMBER,2010 2AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  3. 3. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2.4 Blood and Other Potentially Infectious Materials: This includes all body substances and fluids which may potentially harbor contagious microorganisms and infectious agents. All secretions and excretions with the exception of sweat are considered potentially infectious for bloodborne pathogens.2.5 Exposure Incident (Bloodborne Pathogen): A specific eye, mouth, or other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious material.2.6 Exposure Control Plan: Refers to Hospital Changkat Melintang’s plan to minimize the potential for exposure to bloodborne pathogens.(follow the KKM guideline on sharp injury)SECTION 3 APPLICATION/SCOPE:This policy applies to all persons who are or may be administratively responsible to HospitalChangkat Melintang. This policy is to be used in conjunction with policies and procedurescontained in the Infection Control Manual. Standard Precautions shall be applied at all times andfor all patients, regardless of diagnosis.SECTION 4 RESPONSIBILITIES:4.1 Hospital Changkat Melintang shall:1) Provide appropriate types and supplies of personal protective equipment (i.e., gloves, goggles, masks, gowns, etc.)2) Provide hypoallergenic gloves, glove liners, or other similar alternatives for those employees who are allergic to the gloves normally provided.3) Assure that employees, all students (e.g. nursing, medical, physician assistant, etc.), and other health care personnel affiliated with the department provide evidence of education and training in the HCM ’s Standard and Transmission Based Precautions and Infection Control policies and procedures that are specific to responsibilities, prior to assuming these responsibilities and annually thereafter.4) Maintain training records for employees, and students affiliated with the department.5) Monitor and document individual compliance with the practice of Standard andREVISED ON 20TH NOVEMBER,2010 3AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  4. 4. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG Transmission Based Precautions and Infection Control policies and procedures at least annually in a fair and equitable manner.6) Include compliance with Standard and Transmission Based Precautions and Infection Control Policies and Procedures as a part of each employees annual performance review.7) Provide appropriate retraining and progressive discipline, if necessary for individuals who fail to comply with department procedures for Standard and Transmission Based Precautions and Infection Control Policies and Procedures.8) Inform visitors that they are not allowed in areas where contagion is likely, unless there is specific need and the visitor receives instruction in Standard/Transmission Based Precautions and Infection Control Policies and Procedures specific to the area/task involved.9) Hospital employees must report the incident to their supervisor and Infection Control Nurse and submit an Incident Reporting of Employee Accident/Injury following all incidents of actual exposure to Blood and body and other potentially infectious materials.(Needle Stick Injury)10) Submit an Incident Report for all instances where an individual’s technique is not consistent with Standard/Transmission Based Precautions and Infection Control Policies and Procedures.4.2 Each Individual Shall:1) Comply with the guidelines of the Occupational Health Service (JKKP). These include but are not limited to: a) completion of pre-employment examination (Hospital) b) provision of proof of immunization & compliance with immunization policies c) not work when they have communicable diseases d) report the presence of Occupational Disease2) Understand and implement the principles of Standard/Transmission Based Precautions and infection control as it applies to their specific job responsibilities.3) Report incidents in which they have had direct contact with blood or other potentially Infectious materials to their supervisor and Infection Control Nurse immediately. The employee should report to the Emergency Department within one hour of the exposure.This exposure includes but is not limited to: Needle/sharps sticks, blood or body fluidssplattered onto mucous membranes or non-intact skin.REVISED ON 20TH NOVEMBER,2010 4AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  5. 5. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG4) Report individuals who do not comply with established policies and procedures regarding Standard/ Transmission Based Precautions and Infection Control.SECTION 5 HANDWASHING AND BARRIER PRECAUTIONS:5.1 Handwashing:Hands should be washed with soap and water for a minimum of 15 seconds, but not limited to thefollowing situations:a) before and after contact with each patientb) before clean/aseptic procedurec) after exposure to body fluid riskd) after contact with patient’s surroundinge) before and after applying or removing gloves5.2 Gloves:Gloves should be worn when touching blood, body fluids, excretions and contaminated items.Put on clean gloves just before touching mucous membranes and non-intact skin. Change glovesbetween tasks and procedures on the same patient; after contact with material that may containhigh concentrations of microorganisms. Remove gloves promptly after use before touching otheritems and environmental surfaces, and before going to another patient; wash hands immediatelyto avoid transfer of microorganisms to other patients and/or environments. Gloves should bediscarded when torn or integrity is compromised. It is important to point out that the use ofgloves is intended to supplement and not replace handwashing. Gloved hands may not bewashed as an alternative tochanging gloves. General-purpose utility gloves, such as household rubber gloves used forhousekeeping and equipment cleaning, may be washed, disinfected, and reused.5.2.1 When to wear glovesGloves are worn to prevent the health care workers hands from becoming contaminated withblood or body substances. Gloves should be worn for:• Procedures involving direct contact with the blood and body substances of any patient.• Procedures where contact with blood and body substances might be expected to occur.• Procedures involving direct or potential contact with the mucous membranes of any patient.• Procedures involving direct or potential contact with the non-intact skin of any patient. Non-intact skin is skin that is cut, chapped, abraded, cracked, afflicted with weeping orREVISED ON 20TH NOVEMBER,2010 5AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  6. 6. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG exudative lesions, or is otherwise broken.• Touching or handling any instruments, equipment, or surfaces that have been, or may have been, in contact with blood or body substances.• In addition, gloves should be worn in providing care to a patient or in managing equipment when the health care worker has cuts, scratches, or other breaks in the skin on his/her hands.Sterile gloves should be used for all sterile procedures and for activities that involve contact withareas of the body that are normally sterile.There should be an adequate supply of clean disposable gloves on the standard precautionstations or in other locations that are convenient to each patients room.Gloves used in patients care should be worn only for contact with the patient. Once used, glovesshould be discarded before leaving the patient’s room.5.3 Gowns/plastic aprons:Gowns, aprons, and other protective apparel are worn to prevent clothing from becoming soiledwith blood and body substances. Selection of the appropriate type of protective apparel is basedon the amount of blood and body substances likely to be encountered and the probability thatclothing may by soiled.Fluid repellent gowns should be worn to protect the skin and prevent gross soiling of clothingduring procedures that are likely to generate splashes or sprays of blood, body fluids, secretionsor excretions. Remove a soiled gown as promptly as possible and wash hands to avoid transfer ofmicroorganisms to other patients or environments. The same gown should never be worn to carefor another patient.5.3.1 Gowns should be worn:• During activities that involve the management of large amounts of blood or body substances that may be difficult to contain properly.• During procedures that may result in the splashing or splattering of blood or body substances.5.3.2 Gowns type:• Large enough to cover the clothing which is likely to be contaminated.• Made of a moisture-resistant material that provides an effective barrier to bodyREVISED ON 20TH NOVEMBER,2010 6AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  7. 7. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG substances.• Sterile gowns should be worn for procedures that require a sterile field.5.3.3 Gowns should be changed and discarded:• When torn• After giving care to an individual patient.• After performing any procedure involving the management of instruments, equipment, or surfaces contaminated by blood or body substances.• Whenever gross soiling occurs.• Discard used gowns in the patient care area or in the other areas in which they were used.5.4 Masks:Masks shall be worn if the patient has a documented or potentially contagious infection, which isspread through the respiratory route. If Pulmonary Tuberculosis is suspected or known a properlyfitted high efficiency mask must be worn (HEPA/N95) after fit testing. This is required perNIOSH recommendations and proposed OSHA Standard. Note: A surgical mask does not protectthe employee from airborne disease.5.4.1 Standard surgical masks are to be used:• When splashing, splattering, or spraying of blood or body fluids is likely to prevent exposure to the mucous membranes of the nose/mouth. Additionally, eye protection is warranted in such situations as well.• When within 3 feet of patient on Droplet Precautions• When working in a sterile field to prevent droplets from contaminating the field.5.5 Respirators:Respirators are masks specifically designed to filter small particles spread by the airborne route.Current OSHA standards require that respirators used as Airborne Precautions forsuspected/confirmed pulmonary tuberculosis minimally filter 95% of 0.3um sized particles. Thislevel of protection can be obtained from either the N95 or N100 disposable respirator. AllREVISED ON 20TH NOVEMBER,2010 7AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  8. 8. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGpersonnel who care for a patient with suspected/confirmed pulmonary TB must wear anN95/N100 respirator upon entering the room of such a patient.5.6 Masks plus Eye Protection or Face Shields:Masks plus eye protection devices (such as goggles or glasses with solid side shields) or chinlength face shields should be worn whenever splashes, spray, splatter, or droplets of blood orother potentially infectious materials may be generated and eye, nose, or mouth contaminationcan be reasonably anticipated.Glasses, goggles, and face shields should be cleaned with an EPA approved disinfectantfollowing contamination with blood or other potentially infectious material. Masks and N95respirators used for Standard precautions should be discarded following each patient contact.5.7 Eye Protection (Goggles)• Protective eyewear is worn to prevent blood and body substances from contaminating the mucous membranes of the eyes. Protective eyewear is available for employee use and will be replaced if lost or damaged.• Protective eyewear should be worn during procedures where blood and body substances may be expected to splash or splatter.• Protective eyewear should be removed and cleaned after each use with soap and water and dried with a paper towel. If visibly soiled, wipe with a 70% alcohol solution.5.8 Face ShieldsFace shields are worn to prevent blood and body substances from contaminating the mucousmembranes of the eyes, nose, and mouth during procedures, which may cause splashing orsplattering. If blood and body substances may be expected to become aerosolized during aprocedure, a mask should also be worn. Face shields should be removed and cleaned after eachuse with soap and water and dried with a paper towel. If visibly soiled, wipe the face shield witha 70% alcohol solution.REVISED ON 20TH NOVEMBER,2010 8AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  9. 9. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG5.9 Examples of Appropriate Use of Personal Protective Equipment:This following table provides examples only and should not be considered comprehensive:Task Handwashing Gloves Gown or Mask Eye plastic apron protectionBleeding, Pressure Routinely Routinely If soiling If If splatteringApplication to likely splattering likelyControl likelyBlood Glucose by Routinely RoutinelyFingerCatheterization, Routinely Routinely If soiling If If splatteringUrinary likely splattering likely likelyCleaning Surfaces Routinely Routinely If soiling If If splatteringContaminated by likely splattering likelyblood likelyand/or body fluidsCPR Routinely RoutinelyDirect Contact with Routinely Routinely Routinely RoutinelyPatient; withfrequent,Forceful coughingSpecimen Collection Routinely RoutinelyEmptying Routinely RoutinelyWastebasketsPelvic exam and PAP Routinely RoutinelysmearIM or SCI Injection Routinely RoutinelyREVISED ON 20TH NOVEMBER,2010 9AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  10. 10. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 6 HEPATITIS B VACCINATION PROGRAM:The Hospital Changkat Melintang administration recognizes that even with adherence to allbloodborne pathogen practices, exposure incidents may occur. A Hepatitis B VaccinationProgram is established in order to minimize the potential consequences of these exposures.All employees whose positions have the potential for contact with bloodborne pathogens or otherinfectious materials are strongly encouraged to receive the Hepatitis B vaccination.1) Hepatitis B vaccinations are provided at no cost to all employees whose positions have the potential for contact with blood, body fluids, or other potentially infectious materials in the performance of duties.2) Hepatitis B vaccinations are available through the Infection Control Nurse during regular working hours for employees.3) The HBV Vaccination Program consists of a series of three inoculations over a six- month period. This series may be modified at the discretion of the Occupational/Employee Health Physician.4) Employees must be tested for antibody to Hepatitis B surface antigen 1 to 2 months after the completion of the series.SECTION 7 POST EXPOSURE EVALUATION AND FOLLOW-UP:Wash area with soap and water. If area exposed is eye or mucous membrane rinse with water.Immediately report exposure to superior.The employee will be sent to the Emergency Department where the appropriateness of postexposure prophylaxis will be considered.The HCM supervisor will complete Incident Reporting Form and JKKP6/WEHU A2 which willbe sent to Infection Control Nurse within 24 hours. Infection Control Nurse will compile theforms and notification to JKN Perak within 4 days.A medical evaluation and follow-up of the exposed employee is conducted in compliance withspecific KKM policies.REVISED ON 20TH NOVEMBER,2010 10AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  11. 11. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 8 PREVENTION OF TUBERCULOSIS TRANSMISSION:Early recognition and treatment is the single most important measure in the control oftransmission of tuberculosis.Patients with HIV or risk of HIV or at high risk of TB should be screened for TB; HIV-infectedpatients with history of positive reaction to PPD of Tuberculin or induration of 5mm or greatershould be regarded as infected and undergo further evaluation. Note that patients with HIVinfection demonstrating reactions of 5mm or greater have been regarded as infected.Patients known or suspected of having active Pulmonary TB should:Receive instruction on methods used to prevent the spread of TB to othersR mask suspected patients and instruct to cover their nose and mouth when coughing, or sneezing or ( applies to all patients) be placed in a isolation cubicle wear an appropriate mask prior to being transported to another areaPersonnel who have contact with patients suspected or known to have TB must wear a properlyfitted appropriate mask (respirator) when entering the exam roomVisitors and family members should be encouraged to remain outside of the patient’s room. Inthe event that the visitor or family member must wait with the patient they must wear anappropriate respirator. The visitor or family member should be instructed regarding the reasonsfor this activity.Whenever a patient with known or suspected active TB is being transported, the patient shouldbe evaluated to determine if it is medically feasible for the patient to wear a high filtration mask(N-95) or a molded surgical mask.The above isolation techniques used for a patient with suspected or confirmed TB shouldcontinue until he or she has clinical improvement, substantially decreased cough, and decreasingnumbers of organisms on three sequential sputum smears. Isolation of a patient with presumptivedrug-resistant organisms should continue until the sputum cultures collected on three consecutivedays are free of tubercle bacilli.REVISED ON 20TH NOVEMBER,2010 11AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  12. 12. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 9 GENERAL GUIDELINES FOR OUTPATIENT DEPARTMENT:9.1 Storage and Consumption of Food and DrinksEating, drinking, application of cosmetics or lip balm, and handling of contact lenses isprohibited in work areas where there is reasonable likelihood of occupational exposure to blood,body fluids, chemicals, radioactive materials, and all other hazardous materials.Food and drink should not be kept in refrigerators, freezers, cabinets, or on shelves orcountertops where blood or other potentially infectious materials are present.9.2 Patients with Communicable DiseasesAll patients who have or may have a disease that is transmitted by the airborne/respiratory routeshould be instructed to wear mask.9.3 Cleaning, Disinfection and SterilizationStretchers and exam/treatment tables should be covered with a clean sheet and/or disposableexam table paper before each patient use. The surface should be wiped down with an EPAapproved tuberculocidal disinfectant at the end of the day and when soiled with blood or bodyfluids.Portable equipment (i.e., IV poles and pumps) should be cleaned with an EPA approvedtuberculocidal disinfectant-detergent in accordance with the manufacturers instructions aftereach patient use.Blood pressure cuffs should be cleaned with an EPA approved tuberculocidal disinfectant-detergent in accordance with manufacturer’s instructions when visibly soiled.Contaminated reusable instruments should be placed in a labeled puncture/leak-proof containerbefore being returned to Central Sterile Supply.All sterile supplies shall be checked weekly for inventory rotation and rips, or moisture damage.Clean supplies should not be stored on the floor, in the soiled utility room, or next to sinks wheresplashing of water or soiling is likely. There should be designated areas for clean and dirtysupplies.9.4 Management of sharpsNeedlesticks occur in situations where needles must be manipulated or dissembled. There aredevices or systems that reduces the need to use needles or decreases the danger of accidentalneedlesticks. These or similar devices should be utilized whenever feasible.REVISED ON 20TH NOVEMBER,2010 12AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  13. 13. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGAll disposable sharps should be disposed of in the designated sharps container. Contaminatedneedles should not be bent, or removed from the syringe by hand. Contaminated needles shouldnot be recapped, unless absolutely necessary for the performance of the procedure. In situationswhere recapping may be necessary, a mechanical device or one-handed technique should beused.9.4.1 Handling SharpsThe potential for transmission of bloodborne pathogens is greatest when needles, scalpels, andother sharp instruments are employed. Precautions should be taken to prevent injuries duringprocedures where needles and sharp instruments are required, when cleaning used instruments,and during disposal of contaminated needles. Gloves and other personal protective clothing willnot prevent penetrating injuries due to accidental needle sticks or cuts from scalpel blades andother sharp instruments. To prevent injury: o Avoid rushing when handling needles and sharps. o Use extreme care when handling contaminated needles and sharp instruments. Obtain assistance when giving injections, starting intravenous lines, and for any other procedure that requires the use of needles and sharp instruments when the patient is uncooperative.Dispose of needles and sharps in the yellow sharps disposal containers located throughout theclinics in all patient care and treatment areas.• It is everyone’s responsibility to check sharps disposal container on a daily basis.• Upon observing a container which is 3/4 full, a designated person in clinic to carefully to close the disposable container, remove the full container, and place container in the designated area for pick up.• At this time, any contamination observable either on the outside or inside of the container holder will be wiped clean, using an approved disinfectant cleaner.• In the event of a sharps disposal container becoming full prior to the next scheduled replacement, call FABER for pick-up.Dispose of all needles and other sharps promptly. It is imperative that these items not be left inpatient care areas, on food trays, or inadvertently deposited in trash containers.Contaminated needles should not be recapped by hand, removed from disposable syringes byhand, or purposefully bent, broken, or otherwise manipulated by hand. In the event recapping isunavoidable, the one-handed scoop technique or a needle-recapping device should be used.REVISED ON 20TH NOVEMBER,2010 13AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  14. 14. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGReturn all non-disposable needles and sharp instruments to the Central Sterile Supply (CSS)Department for decontamination and sterilization.• Place the needles and sharp instruments into a covered, leak-proof, puncture proof container for transportation back to Central Sterile Supply for decontamination and sterilization prior to reuse.• Separate linen, such as towels and drapes, from the reusable needles and sharp instruments.Do not wrap sharp objects and needles in linen or obscure them from the view of CSS personnel.9.5 Lab SpecimensAll specimens should be in a sealed leak-proof container and transported to clinical laboratorieswhile placed in a designated leak-proof plastic bag and closed prior to storage or transportation.Laboratory requisitions should be attached to the outside of the plastic bag or in the designatedpouch on the outside of the bag.9.6 Food, Specimens and Medication RefrigeratorsThere must be separate refrigerators for food, specimens, and medications. Signs are affixed toeach refrigerator designating its purpose. Each refrigerator is used only as designated. Each musthave established cleaning schedules. Signs designating use must be affixed to each refrigerator.There should be a program to monitor temperature and cleanliness, which includes 2x dailytemperature checks, weekly and as-needed cleaning and routine inspection of contents.9.6.1 Utilization/Maintenance on Refrigerators9.6.1.2 Medication RefrigeratorMedication refrigerators are used for the storage of medication requiring refrigeration accordingto manufacturer’s guidelines.9.6.2 Temperature RegulationThe temperature of all refrigerators is checked 2x daily to assure the appropriate temperature ismaintained. The temperature registering on a thermometer inside the refrigerator and the initialsof the individual performing the check are recorded on the temperature log. Logs are maintainedand kept on file for a period of three months.Medication and specimen refrigerators are maintained between 2 -8 º C.When a refrigerator temperature is out of the appropriate range, the charge nurse is notified todetermine the appropriate action to be taken. Any actions taken are documented on thetemperature log.REVISED ON 20TH NOVEMBER,2010 14AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  15. 15. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG9.7 Procedures Performed in the ClinicAll procedures involving blood or other potentially infectious materials should be performed insuch a manner as to minimize splashing, spraying, or generation of droplets.Goggles, gowns, and gloves should be available and easily accessible in all exam rooms.SECTION 10 PATIENT CARE ITEMS – STORAGE10.1 Clean SuppliesClean patient care items should not be stored on the floor, in the soiled utility room, and under ornext to sinks where splashing of water or soiling is likely. There should be designated areas forclean and dirty supplies. All supplies should be stored above floor level using pallets, ifnecessary. No item can be stored within 18 inches from the ceiling.10.2 Sterile itemsSterile packages must be inspected for integrity, rips, or moisture damage prior to use. If theintegrity of the package has been breached, the item is discarded if single use or re-sterilizedbefore use if re-usable.SECTION 11 MEDICATIONS:Multi-dose vials must be labeled with the date they were opened. Stock medications should notbe left in cubicles or treatment rooms. They should be examined for precipitate matter andevidence of discoloration prior to each use.Sterile water and saline for irrigation must be labeled with the date and time it was opened. Thebottles should be discarded at the end of 24 hours.Multi-dose bottles containing solutions such as hydrogen peroxide and povidone iodine will bedated when opened, and discarded in one month.11.1 Expiration Dates for Multi-Dose VialsIn view of sterility and stability of medications in multi-dose vials and the variability of injectiontechnique, preservatives and storage conditions for parenteral products, the following guidelinesare recommended. o Any vial that does not contain a preservative is a single-use vial and shall be used for only a single use.REVISED ON 20TH NOVEMBER,2010 15AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  16. 16. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG o Any multi-dose vial that does contain a preservative shall be inspected prior to each use for particulate matter and discoloration. o All open vials discard after open one month. o Exceptions: • Allergenic extracts, skin test reagents, which are patient specific, can be used until the manufacturers expiration date. • For all immune globulin and vaccine vials follow manufacturers specific guidelines on storage.SECTION 12 REGULATED MEDICAL WASTE :12.1 Regulated WasteRegulated wastes will be handled and disposed in accordance with established CWMS policies.Clinical personnel are responsible for identifying and placing regulated waste in the Biohazardreceptacle.An approved outside vendor by KKM are responsible for removing infectious waste fromthe clinical area. Any item contaminated with blood or other potentially infectious materialswhich would release this substance in a liquid or semi-liquid state if compressed, items that arecaked with dried blood or other potentially infectious materials and are capable of releasing(flaking-off) these material during handling.12.2 Definition of Biomedical Waste12.2.1 Human Pathological WastesPathological waste consists of human tissues; organs; body parts; blood; dialysate; cerebrospinal,synovial, pleural, peritoneal, and pericardial fluids; and their respective containers.12.2.2 Human Blood and Blood Products Waste and Their Containers Including: o Waste human blood and blood products. o Items saturated or dripping with human blood or blood products. o Items caked with dried human blood or blood products. o Items that can release human blood, blood products or body fluids if compressed. o Intravenous (IV) bags.REVISED ON 20TH NOVEMBER,2010 16AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  17. 17. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG12.2.3 Intravenous bags o Chemotherapy Intravenous bags or containers with chemotherapy liquid <3% of container volume must be placed into the red plastic medical waste containers. o IV bags or containers containing human blood and blood products.12.2.4 Sharps WasteThis category includes used hypodermic needles, syringes (with or without the attachedneedles), pasteur pipettes, disposable plastic pipettes, scalpel blades, razor blades, blood vials,test tubes, needles with attached tubing, broken plastic culture dishes, unbroken glass culturedishes, and other types of broken and unbroken glassware that was in contact with infectiousmaterial including microscope slides and coverslips.All intravascular sharps are considered medical waste regardless of the presence of infectiousmaterial and must be discarded in yellow sharps containers.12.2.5 Isolation WastesIsolation wastes are defined as biological wastes and discarded materials contaminated withblood, excretion, exudates, or secretions from humans or animals isolated due to infection.12.2.6 Look-Alike WasteLook-alike waste is not considered medical waste. Look-alike waste is plastic or glass labware,lab matting and gloves that have not been in contact with human materials or other potentiallyinfectious material. Saline IV bags are not regulated medical waste. Place saline bags (no needlesattached) into the general trash containers.12.3 Disposal Procedures12.3.1 Sanitary sewerThe sanitary sewer was designed for the disposal of certain liquid wastes. Use of the sanitarysewer reduces the chance for leaks or spills during transport and reduces disposal costs. o Waste microbiological liquid stocks (Class 1,2 and 3 agents) shall be autoclaved or chemically disinfected and poured down the drain whenever possible. o Human blood and body fluids do not need to be disinfected before being poured down the drain.REVISED ON 20TH NOVEMBER,2010 17AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  18. 18. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG12.3.2 General Trash ContainersThe following items are not regulated medical waste and are discarded into the general trashcontainer: • Office paper, forms, packaging materials. • All soft waste not dripping or soaked with human blood, blood products, or body Fluids • Examples of items not visibly dripping or soaked with human blood, blood products, or body fluids are: o gloves, masks, gowns, o wrappers, foil, paper towels, tissues, cups o casts, cast padding and splints o bandages, dressings, gauze pads, table papers, table drapes o tape, pads, cotton o respiratory suction tubing, ventilator tubing o suction canisters liners and tubing, salem sump (NG) tubes o irrigation sets o foley bags and foley catheters, red rubber catheters o bed pans, emesis bassins,urinals, urinal hats, urinal filters • Any containers, saline containing IV bags and tubing not attached to needles or catheters, with no blood, body fluids, or containing chemotherapy agents. • Urinals, bedpans, emisis basins, etc. (empty and rinsed)12.2.3 Sharps (Needle Disposal) ContainersDiscard all intravascular sharps waste o hypodermic needles, syringes (with/without the attached needles) o All needles such as IV, hypodermic, spinal, sutures needles o Safety pins, spears, scrapers, scissors o Lancets, scalpel blades o Vacutainer holders and needles o Deposit any other type of intravascular sharps waste into this container.REVISED ON 20TH NOVEMBER,2010 18AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  19. 19. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSECTION 13 HOUSEKEEPING & CLEANING OF BLOOD AND BODY FLUID SPILLSRoutine cleaning and cleaning of blood and body fluid spills will be done by the SupportServices or designated personnel in accordance with established policies.13.1 Interim CleaningInterim Cleaning-clinic staff performing interim cleaning services will follow the followingprocedure: o put on gloves o face protection and gown if soiling is likely o saturate disposable cloth with the EPA approved disinfectant o remove gross soilage ( if present) o dispose of cloth, if saturated with blood dispose into regulated waste container o saturate second disposable cloth with disinfectant-detergent and wipe entire area o allow area to dry according to manufacturers recommendations as listed on container13.2 Environmental Considerations for HIV Transmission:The AIDS virus is not stable in the external environment outside the body, and environmentallymediated HIV transmission has never been documented. Studies of the survival of HIV in theenvironment have found that it is rapidly inactivated after drying and following exposuretocommonly used EPA approved tuberculocidal disinfectant. Accordingly, no extraordinaryprocedures are required in existing sterilization, disinfection, housekeeping, laundry, or wastehandling procedures.13.3 Decontamination and Cleaning of Blood and Body Substance Spills on Environmental Surfaces: • All spills of blood and body fluids or any other potentially infectious material should be cleaned from environmental surfaces as soon as possible. • Personnel must wear gloves during this procedure and a gown if the spill might be expected to contaminate clothing. To clean large spills that might splash, a mask and safety glasses/face shields should also be worn.REVISED ON 20TH NOVEMBER,2010 19AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  20. 20. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG • To wipe excess liquid that may accidentally splash, an absorbent cloth or paper towels should be used.NOTE: If glass is involved, do not attempt to clean spill by hand. Tweezers, needle holder oranother instrument should be used to pick up glass prior to cleaningEnvironmental surfaces should be decontaminated with a 1:10 solution of 5.25% sodiumhypochlorite in water .NOTE: These disinfectants are highly caustic unless properly diluted. In addition, disinfectantsolution is intended for use on environmental surfaces only, since it can damage instruments andequipment and skin damage.When there are large spills of cultured or concentrated infectious agents, such as in the clinicallaboratory setting, the contaminated area should first be flooded with a liquid disinfectant thenphysically cleaned and decontaminated with a hospital approved disinfectant. Gloves, gowns,masks, and safety glasses should be worn for cleaning large spills of blood or body fluids.13.4 Decontamination of Patient Clothing and Personal Belongings:Patient clothing and personal belongings that become contaminated by blood or body substancesshould be handled according to the following procedures.13.4.1 ClothingClothing soiled by blood or body substances should be placed in a tightly sealed plastic bag at thepatients bedside and given to the family for home laundering. The family should be instructed towash the clothing by machine, using a laundry detergent. Hot water and chlorine bleach shouldalso be used unless these agents will damage the items. The plastic bag used to contain theclothing during its transport should be placed in a second plastic bag, tightly sealed, anddiscarded in the household trash. Persons involved in the handling of contaminated clothingshould be instructed to wash their hands thoroughly after handling the items.13.4.2 Personal Belongings• Disinfect hard surfaces by wiping the items using a 1:10 solution of 5.25% sodium hypochlorite in water (1 part chlorine bleach to 9 parts water).• Disposable articles, such as magazines, that are contaminated by blood or body substances should be disposed of according to the hospitals regulated and non- regulated waste policy.13.5 Linen HandlingREVISED ON 20TH NOVEMBER,2010 20AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  21. 21. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG• All clean linen must be kept covered at all times before use.• Assigned staff from the clinical area will bag linen in impervious linen bags at the point of generation.• The linen bag will be placed in a covered soiled linen holder.• All used linen is considered contaminated and should remain covered at all times.• Care should be taken to prevent linen bags from being overfilled. The bag must be able to be securely closed prior to removal from the clinic.• Personnel removing linen from the clinic area must wear appropriate personal protective equipment 14. INFECTION PREVENTION PROGRAM OverviewA highly effective strategy in reducing healthcare-associated infections in hospitals is throughthe proper implementation and practice of policies and procedures on infection control byhealthcare providers committed to this vital patient safety effort.Efforts at preventing healthcare associated infections in hospitals remain an ongoing and difficultchallenge in the medical care setting. Practising good infection control measures can significantlyreduce patient morbidity and mortality in hospitals and has been proven to be cost-effective aswell.REVISED ON 20TH NOVEMBER,2010 21AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  22. 22. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGHOSPITAL INFECTION AND ANTIBIOTIC CONTROL COMMITTEERoles of Hospital Infection and Antibiotic Control Committee1. The Hospital Infection and Antibiotic Control Committee (HIACC) of HCM is responsible for developing policies and procedures related to infection control and antibiotic usage in the hospital.2. The HIACC will act as a source of expertise on matters relating to infection and antibiotic usage.3. The HIACC advises the Hospital Director on the technical matters related to Infection Control in the hospital.4. The policies and procedures of the HIACC should be in line with the principles and general policies set out by the National Infection and Antibiotic Control Committee (NIACC).REVISED ON 20TH NOVEMBER,2010 22AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  23. 23. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGORGANIZATION CHART OF HOSPITAL INFECTION AND ANTIBIOTIC CONTROLCOMMITTEEREVISED ON 20TH NOVEMBER,2010 23AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  24. 24. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG HOSPITAL DIRECTOR INFECTION CONTROL DOCTOR INFECTION CONTROL NURSE NURSING KITCHEN PHARMACIST MLT I/C HOSPITAL HSS SUPERVISOR SUPERVISOR SUPERVISOR MANAGERRoles of Infection Control Doctor (ICD)REVISED ON 20TH NOVEMBER,2010 24AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  25. 25. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. The ICD is the Vice Chairman of HIACC and is responsible for the day-to-day management of infection control in the hospital.2. The ICD will be appointed by the hospital director. The ICD should have appropriate training and experience in matters relating to infection and antibiotic control. Infection control should make up a portion of his/her daily activities.3. The ICD will refer to the HIACC for major matters of policy development and for the management of outbreaks in accordance to the major outbreak policy. Roles of Hospital Director1. The Hospital Director act as the chairman of HIACC.2. The chairman should have the training, experience, commitment and seniority needed to provide effective leadership of the HIACC.Membership of the HIACCThe members should include: • Hospital Director • Infection Control Doctor • Infection Control Nurse (Secretary) • Medical Laboratory Technologist in-charge • Pharmacist • Nursing Supervisor • Hospital Supervisor • Kitchen SupervisorAgenda of the meetingsAt each meeting the committee should:1. Report on the incidence and prevalence of ‘alert’ organisms and important infectious diseases.REVISED ON 20TH NOVEMBER,2010 25AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  26. 26. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2. Report on the occurrence and nature of any outbreaks of infection, and on incidents involving microbiological hazards (e.g. needle sharp injuries)3. Report on on-going targeted surveillance of healthcare associated infections.4. Evaluate and report on antibiotic usage and resistance patterns and recommend remedial measures when appropriate.5. Develop and maintain policies for the promotion of good infection control and antibiotic usage guidelines in MOH.6. Review outbreaks of infection and advice managers on how outbreaks might be managed and prevented.7. Assist in the planning and development of services and facilities (construction and demolition activities) in the hospital on issue which are relevant to infection control and antibiotic usage.8. Monitor and advice on specific areas of hygiene and infection control, catering, CSSD, ventilator and water services, occupational health, pharmacy, operating theatres,9. Develop programs for the education of staff and students about infection control practices and policies and appropriate antibiotic prescribing.10. Financial planning and monitoring of budget and expenses of infection control activities.Frequency of meetings1. Meetings must be held at least 4 times a year. (The hospital director or the deputy director should be in attendance).2. Minutes should be kept and verified.3. Minutes should be sent to all members and to those who attended the meeting. In addition, copies should be sent to: o The Dean of the Medical and Allied Health Faculties using the hospital as teaching Facilities. o Heads of Departments and UnitsEmergency meetings and outbreak control1. The Chairman may convene an emergency meeting of the Infection Control Committee at any time and all members or their representative will be notified by telephone.REVISED ON 20TH NOVEMBER,2010 26AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  27. 27. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2. Emergency meetings are arranged for the control of outbreaks of infection and when the infection Control Team requires additional support and notification of the problem in accordance with the major outbreak policy.3. The Chairman will chair all emergency meetings, and is in charge of the technical aspect of outbreak control measures.The Infection Control Nurse (ICN)1. The Infection Control Nurse(s) is a full-time member of the Hospital’s Infection Control Team, which is headed by the Infection Control Doctor.2. The ICN is responsible to the ICD but is professionally accountable to the Director via the appropriate Nursing Supervisor within the nursing hierarchy.3. The primary duties of the nurse are to assist the Infection Control Doctor with the prevention and control of infection in hospital.4. This is achieved through the implementation of infection control policies and procedure, and by educating hospital and non-hospital personnel.5. There is 1 ICN in Hospital Changkat Melintang.Duties and responsibilities of the infection Control NurseClinical1. Liaise closely with the hospital medical microbiologist and clinicians.2. Supervise and advise on isolation technique policies and procedures generally and in specific clinical situations.3. Provide clinical advice and support to nurses, midwives, health visitors and other non-clinical personnel on infection control issues.4. Analyze and provide feedback on microbiology reports to head of department.5. Provide clinical advice and support to other health care professionals, ancillary staff and external agencies concerned with social issues arising from infection control matters.6. Provide guidance and support to the ward link infection control nurses.SurveillanceREVISED ON 20TH NOVEMBER,2010 27AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  28. 28. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Coordinate surveillance activities for the hospital.2. Collect relevant information on behalf of the Infection Control Team including point prevalence studies on healthcare-associated infections, clinical / antibiotic audits, hand hygiene compliance etcCoordination/Organization of Infection Control Activities1. Identify potential infection hazards and suggest appropriate remedial action to relevant personnel.2. Work with the hospital Infection Control Team to identify, investigate and control outbreaks of infection.3. Collaborate with the infection Control Team and clinicians about the routine monitoring of units, such as the isolation area and baby units, particularly vulnerable to infection.Administrative1. Participate in the development and implementation of the infection control policies.2. Monitor compliance with infection control policies, including activities directly associated with audit.3. Preparing timely reports.4. Advise staff on the various aspects of infection control and occupational health safety.EducationThe Infection Control Nurse will:1. Participate in informal and formal teaching programmes for all healthcare workers.2. Advice staff with regards to the microbiologic hazards in occupational health safety.3. Participate and coordinate infection control-related educational campaigns as instructed by the HIACC.Research and Quality Improvement Activities1. Participate with the appropriate clinical staff on research projects that is related to hospital infection.REVISED ON 20TH NOVEMBER,2010 28AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  29. 29. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2. Evaluate implementation of infection control technique.3. Audit infection control activitiesWard Link Nurse (WLN)The WLN is the Ward Sister of each ward with sufficient nursing experience and who arein authority with staff and doctors in the ward. They are to undertake the WLN role alongsidetheir other ward duties.The WLN act as a link between the staff and doctors in the ward and the infection controlteam, and are accountable to the Nursing Supervisor and the infection control team onareas related to infection control.Duties and Responsibilities of WLNSupervision on infection control practices1. Ensure hand hygiene is being practice in ward2. Ensure compliance to aseptic technique.3. Proper cleansing and sterilization according to standard procedures4. Proper storage of sterile instrument and linen5. Proper segregation of waste disposal6. Proper specimen collection and dispatch7. Isolation of patients as required.Surveillance1. Participate in the national point prevalence survey2. Assist in monitoring of alert organism such as MRO/MRSA/ESBLREVISED ON 20TH NOVEMBER,2010 29AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  30. 30. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG3. Assist in the prevention and reporting of sharp injuries among staff4. Collection and reporting of HCAI and outbreaks.5. Audit activitiesEducation1. Immediate reference and advice on matters related to infection control, abiding to infection control guidelines and standard precaution guidelines.2. Disseminate, educate and create awareness on infection control to new health care workers in the wards.ResearchAssist in carrying out research, application on evidence based practices and theconducted of quality improvement activities. SECTION 15 SURVEILLANCE OF HEALTHCARE ASSOCIATED INFECTION15.1 IntroductionREVISED ON 20TH NOVEMBER,2010 30AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  31. 31. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSurveillance is one of the most important components of an effective infection controlprogram. It is defined as the systematic collection, analysis, interpretation, anddissemination of data about the occurrence of HCAIs in a definite patient population.15.2 Purpose of Surveillance1. To established and main a database describing endemic rates of HCAIs. Once endemic rates are known then the occurrence of an epidemic can be detected when infection rates exceed baseline values.2. To identify trends manifested over a finite period, such as shifts in microbial pathogen spectrum, infection rates, etc.3. To provide continuous observation of HCAIs cases for the purpose of prevention and control.4. To obtain useful information for establishing priorities for infection control activities.5. To quantitatively evaluate control measures effectiveness for a definite hospital population.6. To enhance the role and authority of the infection control team in the hospital through participation in ward rounds, consultations and education of healthcare workers.15.3 Main components of Surveillance system1. Definition of HCAIInfections that occur more than hours after admission (It must be taken into account that differentinfections have different incubation periods, so that each occurrence must be evaluatedindividually to determine the relationship between its occurrence and hospitalization).2. Case DefinitionEach case definition must be standardized and consistent. The case definition usedREVISED ON 20TH NOVEMBER,2010 31AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  32. 32. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGnationwide will be that of CDC definitions. (Refer to Appendix A for ‘Definitions ofHCAI’ developed by CDC.)i. Daily review of all positive culture results (Manually / Lab information system / Automated disc reader)ii. Informed by infection control link nurse when diagnosed by clinician.iii. Identified during ward rounds / antibiotic rounds / Infectious disease rounds / ICU rounds.iv. Actively looking for cases in targeted surveillance and follow–up these cases.15.4 Types of Surveillance done in Hospital Changkat Melintang1. National surveillance2. Hospital – wide ( total) surveillance3. Periodic surveillance15.4.1 National SurveillanceType of Surveillance MethodsTargetted organisms Results collected daily and submitted monthly toMRSA/ESBLPoint Prevalence Study 1 day prevalence surveillance, hospital wide. Conducted twice a year on the same day throughout the nationNeedle stick injury Reported yearly during the National Infection and Antibiotic Control Committee meeting.15.4.2 Hospital SurveillancesHospital Changkat Melintang practices targeted surveillance whereby surveillance is based onpathogen and infection site. This approach involves surveillance of infections at the same siteREVISED ON 20TH NOVEMBER,2010 32AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  33. 33. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG(bacteremia, UTI, LRI, SSI, etc.) or caused by the same pathogen, usually one that isepidemiologically significant (MRSA, Vancomycin resistant Enterococcus species).15.4.3 Periodic SurveillanceSurveillance performed at specified intervals (e.g. every three months); each time, the focus is onone specific infection site or on a definite patient population at increased risk of infection.15.5 Data Collection1. Collect essential data from lab forms of all MRO /suspected HCAI /clusters.2. Verify cases from the patient’s BHT and discussion with the doctor in-charge /linknurse /ward sister.3. Exclude non HCAI cases and complete the HCAI form.4. All patients must be followed up and subsequent events must be recorded.5. All data related to the investigations of an outbreak i.e. environment, patients, or staff should be documented.15.6 Tabulation of Data1. Daily (group the suspected and confirmed cases according to type of MRO or infections)2. A SPCC (Statistical Process Control Chart) shall be use to monitor the trend of infections for certain organisms or site of infection. Measuring trend in percentage.3. Reports monthly to JKN , Perak and as required if there is an outbreak or when needed.15.6 Preparation and dissemination of reports1. Compile and prepare summary reports and communicate the information to individuals who can authorize changes that improve treatment outcomes.REVISED ON 20TH NOVEMBER,2010 33AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  34. 34. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG2. All information should be reported to the HIACC Chairman.3. The coordinator shall communicate with the key persons from the clinical services and hospital administration.4. Every outbreak shall be followed by a complete report.SURVEILLANCE FORM (HCAI)REVISED ON 20TH NOVEMBER,2010 34AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  35. 35. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGREVISED ON 20TH NOVEMBER,2010 35AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  36. 36. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGPRIMARY BLOOD STREAM INFECTION (BSI)REVISED ON 20TH NOVEMBER,2010 36AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  37. 37. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGDEFINITION : Laboratory-confirmed bloodstream infection must meet at least one of the following criteria:Criterion 1:Patient has a recognized pathogen cultured from one or more blood cultures and organismcultured from blood is not related to an infection at another site.Criterion 2:Patient has at least one of the following signs or symptoms: fever, chills, or hypotension and atleast one of the following:a. Common skin contaminant (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is cultured from two or more blood cultures drawn on separate occasions.b. Common skin contaminated (e.g., diptheroids, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is cultured from at least one blood culture from a peripheral specimen of a patient with an intravascular line, and the physician institutes appropriate antimicrobial therapy and signs and symptoms and positive laboratory results are not related to an infection at another site.Criterion 3:Patient < or = 1 year of age has at least one of the following signs or symptoms: fever (>38°C),hypothermia (<37°C), apnea or bradcardia and at least on of the following:a. Common skin contaminated (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is cultured from two or more blood cultures drawn on separate occasionsb. Common skin contaminant (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., coagulase-nagetive staphylococci, or micrococci) is cultured from at least one blood culture from a peripheral specimen of a patient with an intravascular line, and physician institutes appropriate antimicrobial therapy and signs and symptoms and positive laboratory results are not related to an infection at another site.MULTIDRUG RESISTANT ORGANISMREVISED ON 20TH NOVEMBER,2010 37AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  38. 38. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGIntroductionMulti-resistant organisms are bacteria that have developed resistance to more than 2 differentgroups of any used antibiotics. Development of multi-drug resistance has been associated withinappropriate and over use of antibioticsResistant organisms of significance in healthcare settings include Pseudomonas aeruginosa,Acinetobacter and Extended-spectrum beta lactamase (ESBL)-producing bacteria which are mostcommonly produced among Escherichia coli (E. coli), Klebsiella and Proteus.Types of MRO • ESBLs • Pseudomonas aeruginosa • AcinetobacterTransmission o The transmission of multi-resistant organisms in hospital and community is by person person spread either directly via staff, patient or visitor unwashed hands that have been contaminated by contact with colonised or infected patient or indirectly from contaminated equipment and surfaces. o ESBLs can also be transmitted via the faecal oral route.Prevention of Colonization And Infection With Multi-Resistant OrganismsAntibiotic policiesExcessive use of broad-spectrum antimicrobials will encourage the emergence of multiply-resistant coliforms and non-fermentatives.Disinfection of equipment and medical instrumentsREVISED ON 20TH NOVEMBER,2010 38AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  39. 39. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Moist respiratory equipment, such as ventilator tubing, nebulizers and humidifiers that come into direct contact with the patient, are easily contaminated with gram-negative organisms and can cause cross-infection.2. It is therefore important that the correct procedures for decontamination are followed and that the equipment is thoroughly dried before use for other patients.3. Heat disinfection should be used wherever possible for equipment used on the ward.4. Disinfection procedures should, where necessary, is checked with the Infection Control Team.5. All creams, gels and liquids used with such equipment must be stored in such a way as to prevent contamination and patient-to-patient spread of Gram-negative organisms. Single-use disposable sachets are preferred.Hand hygiene1. All staff who have contact with patients must be trained in hand washing practices, and use disposable gloves and plastic aprons when hand contamination is likely, for example, when emptying bedpans, changing catheter bags, etc.2. Heavy microbial contamination of hands may not be adequately cleaned by simple washing and, when anticipated, disposable gloves should be used.Ward environment1. All shared communal services such as lavatories, bathrooms, etc. should be cleaned daily and kept dry.2. In general, environment disinfectants are not required; detergent and hot water are adequate.3. Sink traps inevitably harbor organisms, which cannot be removed by disinfectants.4. The taps and sinks should be designed so that ther is minimal splashing from the sink area.NOSOCOMIAL PNEUMONIAREVISED ON 20TH NOVEMBER,2010 39AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  40. 40. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGDEFINITION: Pneumonia must meet at least one of the following criteria:Criterion 1:Patient has rales or dullness to percussion on physical examination of the chest and at least one ofthe following:a. New onset of purulent sputum or change in character of sputumb. Organisms cultured from bloodc. Isolation of an etiologic agent from a specimen obtained by tracheal aspirate, bronchial, brushing, bronchoscopy specimen or biopsy.Criterion 2:Patient has a chest radiographic examination that shows new or progressive infiltrate,consolidation, cavitation or pleural effusion and at least on of the following:a. New onset of purulent sputum or change in character of sputumb. Organisms cultured from bloodc. Isolation of an etiologic agent from a specimen obtained by tracheal aspirate bronchial brushing, bronchoscopy specimens or biopsy.Criterion 3:Patient < or = 1 year of age has at least two of the following signs or symptoms: apnea,tachypnea, bradycardia, wheezing, rhonchi or cough and at least one of the following:a. Increased production of respiratory secretionsb. New onset of purulent sputum or change in character of sputum’c. Organisms cultured from bloodd. Isolation of an etiologic agent from a specimen obtained by tracheal aspirate, bronchial brushing, bronchoscopy specimen or biopsy.COMMENTS:• Expectorated sputum cultured are not useful in the diagnosis of pneumonia but may help identify the etiologic agent and provide useful antimicrobial susceptibility data.• Findings from serial chest x-rays may be more helpful than a single x-ray.REVISED ON 20TH NOVEMBER,2010 40AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  41. 41. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGSURGICAL SITE INFECTION (SSI)DEFINITION: A SSI must meet the following criterion:Infection occurs within 30 days after the operative procedure and patient has at least one of thefollowing:a. Purulent draining from the superficial incision.b. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.c. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat and superficial incision is deliberately opened by surgeon.d. Diagnosis of SSI by the surgeon or attending physician.URINARY TRACT INFECTION (UTI)DEFINITION: A symptomatic urinary tract infection must meet at least one of the following criteria:Criterion 1:Patient has at least one of following signs or symptoms with no other recognized cause: fever(<38°C), urgency, frequency, dysuria, or suprapubic tenderness and patient has a positive urineculture, that is 105 microorganisms per cm3 or urine with no more than two species ofmicroorganisms.Criterion 2:Patient < or = 1 year of age has at least one of the following signs or symptoms with no otherrecognized cause: fever (>38°C) hypothermia (<37°C), apnea, bradycardia, dysuria, lethargy orvomiting and patient has a positive urine culture, that is, 105 microorganisms per cm3 of urinewith no more than two species of microorganisms.COMMENTS:REVISED ON 20TH NOVEMBER,2010 41AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  42. 42. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG• A positive culture of a urinary catheter tip is not an acceptable laboratory test to diagnose a urinary tract infection.• Urine cultures must be obtained using appropriate technique, such as clean catch collection or catheterization.• In infants, a urine culture should be obtained by bladder catheterization or suprapubic aspiration; a positive urine culture from a bag specimen is unreliable and should be confirmed by a specimen aseptically obtained by catheterization or suprapubic aspiration.HEALTHCARE ASSOCIATED INFECTION SURVEILLANCEIntroductionSurveillance is one of the most important components of an effective infection controlprogram. It is defined as the systematic collection, analysis, interpretation, and dissemination ofdata about the occurrence of HCAIs in a definite patient population.Purpose of Surveillance1. To established and main a database describing endemic rates of HCAIs. Once endemic rates are known then the occurrence of an epidemic can be detected when infection rates exceed baseline values.2. To identify trends manifested over a finite period, such as shifts in microbial pathogen spectrum, infection rates, etc.3. To provide continuous observation of HCAIs cases for the purpose of prevention and control.4. To obtain useful information for establishing priorities for infection control activities.5. To quantitatively evaluate control measures effectiveness for a definite hospital population.6. To enhance the role and authority of the infection control team in the hospital through participation in ward rounds, consultations and education of healthcare workers.Definition of HCAIREVISED ON 20TH NOVEMBER,2010 42AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  43. 43. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGInfections that occur more than 48 hours after admission (It must be taken into account thatdifferent infections have different incubation periods, so that each occurrence must be evaluatedindividually to determine the relationship between its occurrence and hospitalization).Case DefinitionEach case definition must be standardized and consistent. The case definition used nationwidewill be that of CDC definitions.i. Daily review of all positive culture results (Manually / Lab information system / Automated disc reader)ii. Informed by infection control link nurse when diagnosed by clinician.iii. Identified during ward rounds / antibiotic rounds / Infectious disease roundsiv. Actively looking for cases in targeted surveillance and follow–up these casesPREVENTION OF HEALTHCARE ASSOCIATED INFECTIONSUrinary Tract InfectionIntroductionUrinary tract infections (UTIs) are common type of HCAIs, accounting for 20% of all infectionsin Malaysian hospitals. About 80% of UTIs occur following instrumentation, primarilycatheterization. The usually benign nature of catheter-associated UTIs and the perception thatthey are easily treated by antibiotics may inhibit aggressive measures for both their preventionand their recognitionIndications for CatheterizationPlacement of an indwelling catheter should be performed only when indicated. It shouldbe removed as soon as possible.The accepted indications for catheterization are:1. For short-term (days) management of incontinence (the inability to control urination) or retention (the inability to pass urine) not helped by other methods.2. To measure urine output over several days in critically ill patients3. . For treatment of bladder outlet obstructionRecommendations To Prevent Catheter-Related UTIREVISED ON 20TH NOVEMBER,2010 43AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  44. 44. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Personnel• Only persons who know the correct technique of aseptic insertion and maintenance of the catheter should handle catheters.2. Catheter Use• Urinary catheters should be inserted only when necessary and left in place only for as long as it is required. They should not be used solely for the convenience of patient-care personnel.3. Hand hygiene• Hand hygiene should be done immediately before and after any manipulation of the catheter site or apparatus.4. Catheter Insertion• Catheters should be inserted using aseptic technique and sterile equipment.• Gloves, drape, sponges, an appropriate antiseptic solution for peri-urethral cleaning, and a single-use packet of lubricant jelly should be used for insertion.• As small a catheter as possible, consistent with good drainage, should be used to minimize urethral trauma.• Indwelling catheters should be properly secured after insertion.5. Closed Sterile Drainage• The catheter collection system should remain closed and not be opened unless absolutely necessary for diagnostic or therapeutic reasons eg irrigation.• If breaks in aseptic technique, disconnection, or leakage occur, the collecting system should be replaced using aseptic technique after disinfecting the cathetertubing junction.6. IrrigationContinuous irrigation should be avoided unless indicated.7. Specimen Collection• If small volumes of fresh urine are needed for examination, the distal end of the catheter, orREVISED ON 20TH NOVEMBER,2010 44AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  45. 45. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG preferably the sampling port if present, should be cleansed with a disinfectant, and urine then aspirated with a sterile needle and syringe.• Larger volumes of urine for special analyses should be obtained aseptically from the drainage bag.8. Urinary Flow • Unobstructed flow should be maintained. • Collecting bags should always be kept below the level of the bladder.9. Meatal Care • Clean the urethral meatal area after each bowel movement or when soiled.10. Catheter Change Interval • To avoid encrustatation, the maximum duration for silicone-coated latex catheter is 14 days.Surgical Site Infection (SSI)IntroductionAn SSI prevention measure can be defined as an action or set of actions intentionallyREVISED ON 20TH NOVEMBER,2010 45AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  46. 46. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGtaken to reduce the risk of an SSI. Only limited surgical procedures are performed in HospitalChangkat Melintang : • Episiotomy and repair of perineal wound • Ritual circumcision • Excision of lumps/bumpsPreparation of the patient: • Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation. • If hair needs to be removed, it is done immediately before operation, preferably using clippers not razor blade. • Adequate control of blood glucose levels in all diabetic patients.Surgical team members: • Keep nails short. • Do not wear hand or arm jewelry. • Perform a preoperative surgical scrub for at least 2 to 5 minutes using an appropriate antiseptic.Nosocomial Respiratory Infection/PneumoniaPneumonia is one of the three most common HCAIs. The risk factors for nosocomial pneumoniaare extremes of age, severe underlying disease, immunosuppression, depressed sensorium,cardiopulmonary disease.REVISED ON 20TH NOVEMBER,2010 46AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  47. 47. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGMost bacterial nosocomial pneumonias occur by aspiration of bacteria colonizing the oropharynxor upper gastrointestinal tract of the patient.Prevention of Person-to-Person Transmission of Bacteria1. Wear gloves when in contact with mucous membranes, handling respiratory secretions or objects contaminated with respiratory secretions. Hand hygiene should be performed after removal of gloves.2. Change gloves and decontaminate hands between contacts with different patients.3. Change gloves between contacts with a contaminated body site and the respiratory tract or respiratory device on the same patient.4. Wear a mask and an apron or gown when anticipate soiling of respiratory secretions from a patient (e.g. intubation, tracheal suctioning) and change it after procedure and before providing care to another patient.5. Use a sterile, single-use catheter, if the open-method suction system is employed.Use only sterile fluid to remove secretions from suction catheter if the catheter is to be used for re-entry into the patient’s lower respiratory tract.Precautions for prevention of aspiration1. Remove devices such as endotracheal, tracheostomy, oro/ nasogastric tubes from patients as soon as they are not indicated.2. Perform orotracheal rather than nasotracheal intubation unless contraindicated.3. Ensure that secretions are cleared from above the endotracheal tube cuff before deflating the cuff in preparation for tube removal or before moving the tube.4. Routinely verify appropriate placement of the feeding tube.Sterilization or disinfection and maintenance of respiratory equipment and devices • Use sterile water to fill bubble-through humidifiers. • Change the oxygen delivery system (tubing, nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated or between uses onREVISED ON 20TH NOVEMBER,2010 47AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  48. 48. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG different patients. • Clean, disinfect, rinse with sterile water and dry nebulizers between treatments on the same patient. Replace nebulizers with those that have undergone sterilization or high- level disinfection between uses on different patients. • Use only sterile fluid for nebulization, and dispense the fluid into the nebulizer aseptically. Use aerosolized medications in single dose vial whenever possible. • Change the mouthpiece of a peak flow meter or the mouthpiece and filter of a spirometer between uses on different patients. • Change entire length of suction-collection tubing and canisters between uses on different patients.Intravascular Catheter-Related InfectionsSurveillance 1. Monitor the catheter sites visually or by palpation through the intact dressing. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI, the dressing should be removed to allow thorough examination of the site 2. Encourage patients to report any changes in their catheter site or any new discomfort. 3. Record the date of catheter insertion and removal, and dressing changes.Hand hygieneObserve proper hand hygiene.Aseptic technique during catheter insertion and care/removal1. Maintain aseptic technique for the insertion and care of intravascular catheters. Wearing clean gloves rather than sterile gloves is acceptable for the insertion of peripheral intravascular catheters if the access site is not touched after the application of skin antiseptics.2. Sterile gloves should be worn for the insertion of arterial and central catheters.3. Change the dressing on intravascular catheters using aseptic technique.4. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site.REVISED ON 20TH NOVEMBER,2010 48AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  49. 49. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG5. If the patient is diaphoretic, or if the site is bleeding or oozing, a gauze dressing is preferable to a transparent, semi-permeable dressing.6. In adults, use an upper- instead of a lower-extremity site for catheter insertion. Replace a catheter inserted in a lower-extremity site to an upper-extremity site as soon as possible. In pediatric patients, the hand, the dorsum of the foot, or the scalp can be used as the catheter insertion site.7. Promptly remove any intravascular catheter that is no longer essential.8. Replace peripheral venous catheters at least every 72—96 hours in adults to prevent phlebitis. Leave peripheral venous catheters in place in children until IV therapy is completed, unless complications (e.g: phlebitis and infiltration) occur.9. Replace any short-term CVC if purulence is observed at the insertion site, which indicates infection.Replacement of administration sets and needleless systemsAdministration sets1. Replace administration sets, including secondary sets and add-on devices, no more frequently than at 72-hour intervals, unless catheter-related infection is suspected or documented.2. Replace tubing used to administer blood or blood products within 24 hours of initiating the infusion.Needleless intravascular devices1. Change the needleless components at least as frequently as the administration set.2. Change caps no more frequently than every 72 hours or according to manufacturers’ recommendations.3. Ensure that all components of the system are compatible to minimize leaks and breaks in the system.4. Minimize contamination risk by wiping the access port with an appropriate antiseptic and accessing the port only with sterile devices.IV-injection portsClean injection ports with 70% alcohol before accessing the system. Cap all stopcocks whennot in use.Preparation and quality control of IV admixturesREVISED ON 20TH NOVEMBER,2010 49AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  50. 50. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Use single-dose vials for parenteral additives or medications when possible.2. Do not combine the leftover content of single-use vials for later use.3. Multidose should be discouraged whenever possible.4. If multidose vials are used; • Refrigerate multidose vials after they are opened if recommended by the manufacturer. • Cleanse the access diaphragm of multidose vials with 70% alcohol before inserting a device into the vial . • Use a sterile device to access a multidose vial and avoid touch contamination of the device before penetrating the access diaphragm. • Discard multidose vial if sterility is compromised.HOSPITAL OUTBREAK MANAGEMENTIntroductionAll health care facilities especially major hospitals would have an on going surveillance activitiesfor healthcare associated infection (HCAI). An upper control limit of the occurrence of theinfection should be identified in order to serve as an alert line for the Infection Control Team(ICT) to investigate for a probable outbreak.DEFINITION OF HEALTHCARE ASSOCIATED INFECTION OUTBREAK (EITHERONE)REVISED ON 20TH NOVEMBER,2010 50AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  51. 51. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG1. Two or more associated cases occurs at the same time within same locality/ Department2. Greater than expected rate of infection compared with the usual background case for the place and time.3. In certain newly emerging disease e.g. Legionnaires infection or anthrax, will only require 1 single case.In HCAI outbreak, clinical findings of reported cases should be reviewed closely. It is importantto directly examine the patients, reviewing of the medical records and have a discussion with thedoctor in-charge. An outbreak maybe judged minor or major after consideration of itscomplexity, number of person affected, pathogenicity of the organism involved, potentialtransmission and any unusual features.Steps in Outbreak Investigation and ManagementNO PROCEDURES RESPONSIBILITIES1. A probable diagnosis of an outbreak arises from laboratory based ICN surveillance or clinical report from a unit/department2. Investigate and gather information on the probable outbreak, both ICN from microbiological data, environmental investigation and patient’s placement and movement. Carry out mapping of cases.3. Suspect a true outbreak if cases appear to be linked in time, space ICCT or persons. Produce a preliminary report and hold the discussion.4. Alert all parties involved of probable outbreak and carry out ICN further investigations such as screening of involved patients, contacts and an environment microbiological samples to identify source, reservoir and mode of transmission.5. Produce report on the outcome of the investigations and ICCT recommendation immediate actions to contain the outbreak and prevent further transmission.6. Discussion at the ICCT level only if it is a minor outbreak. ICD ICCT/HIACC/ will then inform Hospital Director if it is a major outbreak. Hospital Director Declare outbreak. Recommend closure of unit/ward if indicated.7. Check if infection control policies and procedures are breached. ICN THREVISED ON 20 NOVEMBER,2010 51AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  52. 52. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANG8. Administer outbreak control measures according to the known ICCT modes of transmission airborne, droplet or contact) of the organisms and appropriate source control.9. Re-evaluate the outbreak situation and effectiveness of ICCT interventions. Take remedial action if the outbreak is still not contained.10. Announce end of outbreak when no more new cases or the HIACC number of cases has reduced to usual mean control limit. (arbitrarily within 1 month)11. A final report is produced at the end of the outbreak. Recommend ICCT/HIACC on change of infection control policies or procedures if indicated12. Disseminate report to all relevant departments. ICCTINFECTION PREVENTION EDUCATIONORIENTATION AND INSERVICES TRAININGOrientation • All newly hired staffs, concessionaire workers, trainee nurses and contractors will be given briefing by Infection Control Nurse (ICN) on aspects of infection control covering aspects of universal precautions, hand hygiene, isolation practices, management of clinical wastes and usage of PPE.Inservice training • The ICN shall receive adequate training and skills through at least a minimal 2 weeks course (APSIC). • The ICN shall continue to update her knowledge through Continuing Professional Development (CPD) activities. • Regular inservice training is provided by the administration of Hospital Changkat Melintang to all clinical staffs inclusive of doctors, paramedics, drivers, laboratory personnels and radiological staffs.REVISED ON 20TH NOVEMBER,2010 52AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  53. 53. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGOrientation checklist for clinical staff No Items √/- Date given 1. Universal precaution 2. Hand hygiene 3. Isolation practices 4. PPE 5. Clinical waste management 6. Disinfection, decontamination, sterilization 7. Management of needle stick injuryOCCUPATIONAL HEALTH AND SAFETYIntroductionThis document outlines the prevention, reporting and management of sharps injuries, needlestickinjuries and other percutaneous exposures to blood and body fluids which may potentially exposean employee to the risk of blood-borne viruses.Policy StatementREVISED ON 20TH NOVEMBER,2010 53AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA
  54. 54. MANUAL OF POLICIES AND PROCEDURES OF INFECTION CONTROL OF HOSPITALCHANGKAT MELINTANGThe Ministry of Health aims to create awareness, reduce sharps injury and mucosal exposure to areasonably practical level. Should an exposure occur, ensure timely and appropriate managementof the exposure to reduce the risk of blood-borne pathogens to the affected employee.Needlestick and sharps injuries will be managed by the Infection Control Unit. There should be aclear designation of responsibilities in each facilities. All information must be made known to allstaff.Definitions of sharp injurySharps injury can be defined as injury from needle or other sharp device contaminated withblood or a body fluid and penetrates the skin percutaneously mucosal/ cutaneous exposure.Blood borne pathogens are viruses that some people carry in their blood and which maycause severe disease in certain people .The main blood borne viruses of concern are: o Hepatitis B virus (HBV) o Hepatitis C virus (HCV) o Human Immunodeficiency Virus (HIV)Source patient is the person whose blood is present on the item that caused the sharps injury.Responsibilities1. All head of units are responsible for implementing this policy in their respective unit. They must ensure that all employees are aware of this policy and of their responsibilities contained therein.2. Doctor in-charge (other than the affected HCW) will be responsible for:• Obtaining informed consent from the source patient for HBV and HCV blood/ HIV tests. • Taking a 5ml blood sample from the source patient and sending it to the serology laboratory in microbiology for HBV,HCV and HIV. • Ensure immediate first aid has been administered to affected healthcare workers.REVISED ON 20TH NOVEMBER,2010 54AUTHOR : DR LEE OI WAHADAPTED FROM : POLICIES AND PROCEDURES ON INFECTION CONTROL, MOHMALAYSIA

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