ICC Infection Control Committee

FOREWORD

The Mandaluyong City Medical Center Infection Control Committee is an integral part of the hospital with the following objectives: promotion of health through creation and promulgation of policies and programs that will render quality patient care without exposing their patients and themselves to risks of acquiring infectious diseases while inside the hospital; by providing training and education on appropriate use of antibiotics to avoid the emergence and spread of resistant bacteria and cause undue expenses to the patients; by ensuring environmental cleanliness, sterility of specialized hospital units as well as of hospital equipments and instruments; and by way of surveillance, researches and keeping in close coordination with national and international health organizations, we adept ourselves with the knowledge on how to deal with emerging and re-emerging global infections in service of our patients and the nation.

Infection control is a way of life, it is a culture that has to be nurtured and embedded in each and every healthcare worker. Hence the MCMC-HICC is distributing this primer of the most important principles of infection control to guide everybody in this endeavour, because INFECTION CONTROL IS EVERYBODY’S RESPONSIBILITY!

AUTHOR

Chairperson, MCMC-HICC

MISSION STATEMENT

The Mandaluyong City medical Center (MCMC) is devoted to provide the best health-care services possible primarily for the indigent residents of the City of Mandaluyong. This mission is in accordance with and in compliance to the City Mayor Benjamin S. Abalos’ vision that

“NO MAN SHALL BE DENIED ACCESS TO HOSPITALIZATION BY REASON OF POVERTY.”

VISION

We envision MCMC to be a self-reliant, fully-equipped tertiary hospital committed to the service of the constituents of the Mandaluyong City and to the holistic teaching and training of the potential health servants of the community

GOALS

GENERAL GOALS

As the only general acute care public hospital in the City of Mandaluyong, the Center aims to provide the best health-care services available to as many patients at the lowest cost possible.

SPECIFIC GOALS

FOR OUR PATIENTS

We aim to provide total quality, efficient and effective medical care delivery through the Center’s various clinical services whenever, whatever and wherever possible.

FOR OUR MEDICAL STAFF

We aim to provide better facilities, new technologies, modern equipment, expanded services and continuing education through training programs in specific fields of clinical specialties

FOR OUR SUPPORT STAFF

We aim to provide an ideal working environment to enable them to perform their duties efficiently with confidence and dignity, to encourage employees to do their best and to excel.

HOSPITAL INFECTION CONTROL

Our Vision

The HICC envisions maintaining the Mandaluyong City Medical Center as a safe environment for both the healthcare workers, patients and visitors to co-exist in harmony with insignificant or acceptable level of risks for acquiring healthcare related infections.

Our Mission

The mission of the HICC is to promote complete adherence to infection control policies and rational antibiotic use thereby preventing disease transmission, outbreaks and emergence of highly resistant organisms. It is also the mission of the HICC to establish the Mandaluyong City Medical Center as an institution well known for its contribution to the national surveillance and control of Infectious diseases through research-oriented activities and programs.

Goals

• ♣ To reduce the risk of patients acquiring infection in the hospital
• ♣ To identify and provide adequate care to patients within potentially communicable infection
• ♣ To minimize infection rate of employees, visitors and community contacts

Function

General Function

• ♣ To formulate, implement, evaluate and constantly upgrade policies and programs that will detect and prevent the spread, thereby reducing the rates of hospital acquired infection.

Specific Function:

• ♣ To develop policies and procedures for hospital infection control:
• − Standard patients care procedures especially with communicable diseases.
• − Appropriate isolation techniques and precautions.
• − Hospital environmental controls especially in special/patient care areas (i.e. ICU, NICU, Hemodialysis, etc).

• ♣ To carry out a practical system of surveillance of nosocomial infection
• − Definition of the needs to be monitored.
• − Systematic data collection and consolidation.
• − Data analysis and interpretation (prevalence rate of nosocomial infection).
• − Data dissemination.
• − Instituting appropriate control measures.

• ♣ To monitor hospital antimicrobial use and periodically review antimicrobial resistance data for selected organisms in order to provide recommendation regarding antimicrobial usage.
• ♣ To investigate occurrences of potential disease outbreaks in the different wards and hospital units and provide solution and measures to abort and limit the further spread of infections.
• ♣ To conduct continuing education of the hospital staff regarding hospital infection control.
• ♣ Liaison with department heads from Nursing, Central Supply, Housekeeping, Maintenance, Pharmacy, Dietary, Laboratory and Clinical Services to ensure that an appropriate infection control measures are met.
• ♣ Communication with the employee’s health services to ensure adequate immunization of hospital employees and provide care when personnel are exposed to potentially communicable diseases and screening of applicants for employment.
• ♣ Recommend post exposure management for patients and personnel.
• ♣ To spearhead research activities - these will provide evidences for supporting or changing infection control measures and activities.

Activities

• ♣ Surveillance of nosocomial infections
• ♣ Investigation of outbreaks
• ♣ Promotion of rational antibiotic use
• ♣ Infection control information dissemination and education campaign
• ♣ Microbiologic surveillance of infectious diseases
• ♣ Revision, implementation of Infection Control programs
• ♣ Protection and post-exposure management of healthcare workers against infectious diseases

Organization Chart

DUTIES AND RESPONSIBILITIES OF HOSPITAL INFECTION CONTROL COMMITTEE

The HICC Executive Committee (Infection Control Team)

1. • To evaluate existing departmental policies on infection control and revise and/or update them as necessary
2. • To formulate new policies and programs of infection control in accordance to the needs of the new hospital
3. • To formulate and implement emergency policies in cases of disease outbreaks inside the hospital or epidemics and global pandemics
4. • To decide on problems and conflicts on infection control policies brought about by the different departments and units of the hospital
5. • To recommend support to researches conducted by any hospital personnel on infection control to the Hospital Research Committee   
6. • To get the attention and recommend disciplinary actions on units, departments or individuals who caused spread of infectious diseases because of non-adherence to HICC policies. 

The Supervisory Head Committee

1. • To implement the policies of infection control in their respective departments and units
2. • To monitor adherence of their constituents to the infection control policies
3. • To assist the HICC nurse in the surveillance of nosocomial infections
4. • To assist the HICC nurse in the education of the staff with regards to hospital infection control
5. • To report to the HICC nurse any breaks on infection control for appropriate actions (e.g. needle prick incidents)
6. • To report to HICC nurse unusual clustering of cases or isolation of new or highly resistant organisms from patients attended to or admitted in their respective units/departments/wards
7. • To report to the HICC nurse the admission or presence of patients with highly communicable diseases in their respective units/departments/wards
8. • To encourage their constituents to conduct infection control - related researches and subsequently recommend them to the HICC Executive Committee for citations and funding

HICC Chairman/Vice-Chairman

1. • To schedule regular meetings (and emergency meetings as necessary) with the members of the executive and supervisory committee jointly or separately to ensure implementation of HICC policies; discuss updates and revisions in the programs and policies; and to find solutions to problems raised by the different members of the HICC
2. • To supervise the HICC nurse
3. • To oversee the functions of the executive and supervisory committees
4. • To provide solutions and give counsel on infection-control related problems in the hospital
5. • To organize and supervise the activities of the Hospital Infection Control week celebration
6. • To prepare the annual HICC report for presentation and approval of the body every last week of January

1. • To represent the hospital in Infection Control – related conventions and conferences in and out of Mandaluyong City Medical Center. 
2. • To take over the functions of the HICC Chair in cases when the latter is in no position to perform her duties and responsibilities (on leave of absence, attending conferences, in sickness, or in cases when she cannot legally carry out functions of a unit head)
3. • To supervise the collection of data and reporting of the sensitivity pattern of the most common isolates in the hospital and assist the chair in drawing recommendations on appropriate empiric management of infections based on the gathered data
4. • To assist the chair in overseeing the functions of the executive and supervisory committees

HICC Nurse

• • To conduct daily rounds in the ICU complex and different nursing units to evaluate the day to day concerns of the HICC: 
• o Availability of liquid soap and paper towel
• o Availability of surveillance forms on nosocomial infections
• o Proper color coding and placement of waste containers
• o Reminding nurses to wash hands in between handling of patients
• o Reminding nurses to follow the color coding of waste disposal
• o Reminding nurses to report new cases of nosocomial infection in their units
• o Identification of patients with highly communicable diseases and reminding nurses of the appropriate isolation precautions when handling such patients 
• o Monitor adherence to hospital environmental controls especially in special/patient care areas (i.e. ICU, NICU, Hemodialysis, etc).

• • To coordinate with the nurse supervisor – in – charge of training for orientation of new nursing staff and conduction of regular lectures on the principles of infection control and surveillance in the hospital
• • To conduct active surveillance and monitoring of nosocomial infections
• • To prepare monthly report on: admitted patients with highly communicable disease; nosocomial infections; needle prick incidents; break in HICC policies
• • To prepare quarterly report on the sensitivity pattern of the most common isolates in the hospital
• • To inform the HICC Chair or Co-chair of clustering of cases, possible occurrence of epidemic, isolation of new or highly resistant organisms as soon as they are detected
• • To act upon or provide counsel when it comes to problems on sterilization, disinfections of equipments and fixtures and isolation of patients with possible contagious diseases.
• • To document and keep the records of all the activities of the HICC 
• • To represent the hospital in Infection Control – related conventions and conferences in and out of Mandaluyong City Medical Center 

TECHNICAL TRAINING REQUIREMENT

STAFF EDUCATION

Objective

• • To educate all Mandaluyong City Medical Center (MCMC) staff on the Prevention and Control of Infection (PCI) standards. 

Policy Guidelines

• • ALL employees (regular, casual, contractual and affiliates) of MCMC should be oriented on the PCI standards.
• • All new employees, trainees and affiliates should undergo orientation on PCI before their official time commence.
• • All employees should attend to updates and activities of infection control.
• • The Human Resource Development, Medical Training Office, and Nursing Service Office should inform the HICC of the orientation schedules among new employees, trainees and affiliates.
• • All supervisors have the responsibility in cascading PCI to their staff. 
• • The HICC provides continuing education through the regular updates on infection control. 
• • The HICC conducts general staff meeting quarterly to discuss current recommendations and accomplishments.
• • The HICC celebrates Infection Control Week to stretch out infection control education program.

INFECTION CONTROL COMMITTEE GENERAL POLICIES

Isolation

• ♣ Use of appropriate Personal Protective Equipment (PPE) as precautions in order not to be exposed to communicable diseases both for healthcare worker and patients 
• - Standard Precaution on blood and body fluids for unknown cases
• ¬ Hand Hygiene
• ¬ Use of gloves (sterile or non-sterile)
• ¬ Use of mask (N95 or surgical mask)
• ¬ Use of protective eyewear
• ¬ Use of gown (water resistant or linen gown)

• − Transmission-based Precaution after proper diagnosis
• ¬ Use of Isolation rooms for airborne infections and immunocompromised disseminated cases 
• ¬ Use of ward for cohorting of cases
• ¬ Placement of color coded tags on door entrance to have an information on the necessary precaution to apply

(For detailed policies, please refer to Isolation Policies)

Environmental Care and Waste Management

• ♣ To maintain cleanliness and sanitation of the facility cleaning should be done on regular, routine, and terminal basis. 

(For detailed policies, please refer to Housekeeping)

Waste Management

• ♣ All healthcare workers are responsible in segregating wastes generated and place on appropriate waste bins.

(For detailed policies, please refer to Waste Management)

Disinfection and Sterilization

• ♣ All reusable materials and equipment should undergo the process of decontamination, cleaning and disinfection/sterilization.

(For detailed policies – please refer to Disinfection and Sterilization of Reusable Items)

Surveillance of Healthcare Associated Infections

• ♣ Risk devices (ventilator, Foley catheter and central line) associated with healthcare associated infection should be monitored in ICU/ACSU complex, Hemodialysis unit and Neonatal unit.
• ♣ Clean surgical operations should be monitored for surgical site infection.

(For detailed policies, please refer to Nosocomial Surveillance procedures at Mandaluyong City Medical Center)

Protection of HCW

• ♣ All new employees/trainees should comply with the pre-employment requirement on infection control matters.
• ♣ The Human Resource Development should keep the record of ALL employees of their health status.  

(For detailed policies, please refer to Guidelines for Human Resources Development, Infection Control Protocol for MCMC Employees Exposed to Highly Infectious Diseases, and Prevention of Needle Stick and Sharp Injuries)

1. 2. The HICC should have regular quarterly meeting to present accomplishment reports, analysis and recommendations. The Chairman can call for Executive Committee meeting if there are matters that cannot wait for the regular quarterly meeting.

1. 3. All managers and supervisory heads are responsible for monitoring, implementation and evaluation of Infection Control Policies and Guidelines.

DISINFECTION AND STERILIZATION OF REUSABLE ITEMS

Objectives

• ♣ To be able to have a standard procedures and policies regarding disinfection and sterilization.
• ♣ To render safe use of reusable materials and equipment.

Definition of Terms

• • Decontamination - It is the physical or chemical process that renders a potentially contaminated, inanimate object safe for further handling.  Contaminated instruments are soaked in an enzymatic solution for 20 – 30 minutes or depending on the manufacturer’s instructions.
• • Cleaning - It is the removal of all adherent visible soil from the surfaces, crevices, joints, and Lumina of instruments.  It could be done through hand scrubbing, ultrasonic cleaning, and processing with a washer-sterilizer or washer-decontaminator.  Avoid splatter or aerosols generated during scrubbing by keeping brushes under water during scrubbing.
• • Disinfection - It is a process that results in the destruction of infectious agents on inanimate objects but does not necessarily destroy all bacterial spores.  Exposure time and classification of items. (Please refer to Table 1 -  Methods of Fluid Sterilization and Disinfection)
• • Sterilization -  It is a process of complete destruction of any living organism

Policy Guidelines

1. 1. All disinfectant, materials and equipment related to infection control should have an approval of HICC before purchasing. The product should undergo the process of evaluation. (Please Refer to Product Evaluation)
2. 2. All used materials and equipment should undergo decontamination prior to cleaning.
3. 3. All cleaned equipment and instruments are properly sorted according to its use and undergo appropriate disinfection/sterilization process.
4. 4. Decontamination process
• ♣ Use one chemical only, 1% Na hypochlorite is recommended solution for decontamination.  Do not add soap on the solution. Na hypochlorite is unstable once diluted and should be prepared only when there is reusable equipment/material for decontamination. 
• ♣ Place contaminated reusable item in a perforated tray and soak fully under prepared solution for 30 minutes. Items having lumen should be filled and no bubbles are observed.  Agitate the tray once in a while during the soaking period to loosen the debris. Rinse and do manual cleaning. 

1. 5. Manual cleaning

• ♣ Use soap and water only.
• ♣ Wear Personal Protective Equipment (PPE) (i.e. mask, eyewear, gloves, and gown) during cleaning. If brushing is required to remove debris on the instrument, brush it under water so that aerosol will not be formed.
• ♣ Rinse properly and dry before disinfection or sterilization.

1. 6. Disinfection

• ♣ Semi-critical items need high-level disinfection

These are items that come in contact with mucous membranes or non-intact skin.  These medical devices should be free of all microorganisms, although small number of bacterial spores may be present. Semi-critical items should be rinsed with sterile water after high-level disinfection to prevent contamination of microorganism that may be present in tap water.

• ♣ Non-critical items need intermediate low-level disinfection

These are items that come in contact with intact skin but not mucous membranes.  Intact skin acts as effective barrier to most microorganisms and therefore the sterility of items coming in contact with intact skin is not critical.

1. 7. Sterilization processes (No Sterrad Sterilizer- only Cidex available)

• ♣ Heat sterilization

Requirement to achieve successful sterilization

MATERIALS FOR AUTOCLAVING	PARAMETERS	RANGE	DELIVERED
Wrapped instruments, textiles, porous load	1.  Sterilizing temp. 2.  Sterilizing time 3.  Post vacuum time 4.  Postpuls steam 5.  Postpuls air	134 0C 3 – 7 minutes 0 – 90 minutes 0 – 90 minutes 0 – 90 minutes	134 0C 4 minutes 5 minutes 0 minute 0 minute
Heat sensitive material, rubber, plastic, porous load	1.  Sterilizing temp. 2.  Sterilizing time 3.  Post vacuum time 4.  Postpuls steam 5.  Postpuls air	121 0C 16 – 20 minutes 0 – 90 minutes 0 – 90 minutes 0 – 90 minutes	121 0C 16 minutes 5 minutes 0 minute 0 minute
Rapid process for single, open instrument	1.  Sterilizing temp. 2.  Sterilizing time 3.  Post vacuum time	134 0C 3 – 90 minutes 0 – 90 minutes	134 0C 4 minutes 3 minutes
Bowie/Dick	1.  Sterilizing temp. 2.  Sterilizing time 3.  Post vacuum time	134 – 121 0C 0 – 15 minutes 0 – 90 minutes	134 0C 1 minutes 3 minutes
Liquids in open or vented containers	1.  Sterilizing temp. 2.  Sterilizing time	134 – 105 0C 3 – 90 minutes	121 0C 20 minutes
Automatic leak test	1.  Post vacuum time 2.  Stabilizing time 3.  Test time	5 – 90 minutes 10 – 90 minutes 10 minutes	5 minutes 10 minutes 10 minutes

• ♣ STERRAD

Requirement to achieve successful sterilization

• - Materials that can be sterilized by STERRAD^® 50 Sterilizer

Aluminum	Polycarbonate
Brass	Polyethylene
Delrin	Polymethyl methacrrylate (PMMA)
Ethyl vinyl acetate (EVA)	Polypropylene
Glass	Polystyrene
Kraton	Polyurethane
Latex	Polyvinyl Chloride (PVC)
Neoprene	Silicone
Nylon	Stainless still
Monel	Teflon

All medical devices should be processed in accordance with the medical device manufacturer’s recommendation. Always check the medical device manufacturer’s instructions before loading any device into the STERRAD 50 Sterilizer

1. 8. Items Not Recommended:
• ♣ Any item that is not completely dry.
• ♣ Items or materials that absorb liquids
• ♣ Items made of materials that contain cellulose, such as: cotton, paper or cardboard, linens, hack towels, gauze sponges, or any item containing wood pulp.
• ♣ Paper instrument count sheets or date tags.
• ♣ Single-use items for which the manufacturer does not recommend destabilization.
• ♣ Implants for which the manufacturer has not specifically recommended sterilization in the STERRAD^® 50 Sterilizer
• ♣ Instruments and devices that cannot withstand a vacuum and are labeled for gravity steam sterilization methods
• ♣ Items whose design permits the surfaces to collapse onto each other unless some method is used to keep the surfaces separated.
• ♣ Devices with internal parts, such as sealed bearings, that cannot be immersed may present difficulties in cleaning and should not be processed in the STERRAD 5o Sterilizer.  

1. 9. Guidelines for Wrapping and Packaging
• ♣ Use only STERRAD Instrument Tray and STERRAD Accessories in the sterilization chamber. STERRAD trays are specially designed to allow diffusion of hydrogen peroxide and the plasma around all items in the load.
• ♣ Bottoms of trays should only be padded with polypropylene sterilization wrap. Do not use linen materials.
• ♣ Do not use foam pads in instrument trays; they may absorb hydrogen peroxide.
• ♣ Remove all items that may contain cellulose from the trays
• ♣ Use only polypropylene sterilization wrap and Tyvek pouches. Do not use paper pouches or sterilization wraps containing wood pulp or cotton.
• ♣ Place STERRAD Chemical Indicator Strips inside the tray and peel pouches.

1. 10. Monitoring sterilization process

• ♣ Physical monitoring – observe and record the parameters  of sterilizer functioning such as time, temperature, pressure or gas concentration;
• ♣ Chemical monitoring – color or physical-change indicators that detect exposure to sterilizing agents or conditions;
• - Assures that product is not mistaken for that which has been sterilized
• - Ensures proper packing and sterilizer load configurations
• - Ensures the proper functioning of the processing equipment.

• ♣ Biologic monitoring – spore testing, the most important check on sterilizer function.
• - For steam sterilizer, biological indicator (BI) should be placed at the front on the bottom and near the door in a routinely loaded sterilizer;
• - For EO sterilizer, BI should be in the center of the load or see manufacturers’ recommendation.
• - If a sterilizer underwent preventive maintenance or repair, challenge the unit to confirm proper operation.  The unit should be operated until two consecutive runs return negative BI results before the unit is returned fully to service. 

1. 11. Storage

• ♣ The storage area should be adjacent to sterilizing area, preferably in a separate enclosed, limited access and well ventilated area to provide protection against dust, moisture, and temperature and humidity extremes.
• ♣ The area should be free of insect or vermin that seek the warmth of reprocessed packages for habitat.
• ♣ Sterile materials should be stored at least 8 to 10 inches from the floor, at least 18 inches from the ceiling and at least 2 inches from outside walls.
• ♣ Items should be positioned so that packaging is not crushed, bent, compressed or punctured.
• ♣ Avoid placing sterile supplies on the floor or near window sills.
• ♣ All sterilized package within the facility should be labeled with load control number that indicates the sterilizer used, cycle or load number, the date of sterilization, and an expiry date.  Expiry date for woven linen pouch is one (1) week and fifty (50) weeks for polypropylene peel pouches.
• ♣ Stock sterile packages on a first in first out stock piling according to process dates to avoid unnecessary reprocessing. 

1. 12. Distribution of sterile goods

• ♣ Packs transported to operating rooms and other areas within the healthcare facility should be provided with an additional outer dust-protection cover that can be removed before the pack is taken into the clean zone.  This is also applied either to individual packages or to the total cart.  Transport vehicle should be exclusive for use.

1. 13. Maintenance of sterilizer

• ♣ Preventive maintenance of all sterilizing equipment should be every 3 months using the manufacturer’s service manual as reference.
• ♣ Sterilizers should be cleaned daily or as per manufacturer’s recommendation to prevent accumulation of residue that may transfer on the packaging during sterilization process.
• ♣ The time-temperature charting devices and temperature-pressure gauges should be calibrated after any repair and at least every 6 months or at the interval recommended by the sterilizer manufacturer.

1. 14. Environmental Control

• ♣ SINKS - should be decontaminated with sodium hypochlorite every shift after scrubbing with soap and water. 
• - There should be separate sink for washing dirty items.
• - There should be another sink for the clean or previously soaked items.
• ♣ FLOORS - mopping and sweeping of floors should be done before operation and or as necessary. There should be a separate mop and broom for exclusive use in the area.
• ♣ WALLS - clean at once when grossly soiled by scrubbing with soap and water. Once a month scrubbing with soap and water followed by Na hypochlorite disinfectant.

1. 15. Handwashing

(Please refer to Hand Hygiene Guidelines)

Reprocessing of Reusable Items

APPROPRIATE SOLUTIONS FOR USE

Table 1:  Methods of Fluid Sterilization and Disinfection

	Sterilization	Disinfection
	Critical items	High-level	Intermediate Level	Low Level
Object	Procedure	Exposure Time (ET)	Procedure ET 12 – 30 min at ≥200 C)2,3	Procedure ET ≤ 10 min)	Procedure ET ≤ 10 min)
Smooth, hard surface1,4	A B C D F G H	MR MR MR 10 H 6 H 12 m 3 – 8 H	D E F H I6	J5 K M N	K L M N O
Rubber tubing and catheters3,4	A B C D F G H	MR MR MR 10 H 6 H 12 m 3 – 8 H	D E F H I6
Polyethylene tubing and catheters3,4,7	A B C D F G H	MR MR MR 10 H 6 H 12 m 3 – 8 H	D E F H I6
Lensed instruments4	A B C D F G H	MR MR MR 10 H 6 H 12 m 3 – 8 H	D E F H
Thermometers (oral and rectal)8 Hinged instruments4	A B C D F G H	MR MR MR 10 H 6 H 12 m 3 – 8 H	D E F H I6	K8

Legend:

A	Heat sterilization, including steam or hot air (see manufacturer’s recommendations, steam sterilization processing time from 3 – 30 minutes, see Table 10)
B	Ethelyn oxide gas (se manufacturer’s recommendations, generally 1 – 6 hours processing time plus aeration time of 8 – 12 hours at 50 – 600 C)
C	Hydrogen peroxide gas plasma (see manufacturer’s recommendations, processing time between 45 – 72 minutes; endoscopes or medical devices with lumens >40 cm or a diameter <3mm cannot be processed at this time in the United States)
D,	Glutaraldehyde-based formulations (≥2% glutaraldehyde, caution should be excercised with all glutaraldehyde formulations when further in-use dilution is anticipated); glutaraldehyde (0.95%) and 1.64% phenol/phenate.  One glutaraldehyde-based product has a 5 minute exposure time at 350 C.
E	Ortho-phthalaldehyde 0.55%
F	Hydrogen peroxide 7.5% (will corrode copper, zinc, and brass)
G	Peracetic acid, concentration variable but ≥.2% is sporicidal.  Peracetic acid immersion system operates at 50 – 560 C.
H	Hydrogen peroxide (7.35%) and 0.23% peracetic acid; hydrogen peroxide 1% and peracetic acid 0.08% (will corrode metal instruments)
I	Wet pasteurization at 700 C for 30 minutes with detergent cleaning
J	Sodium hypochlorite (5.25 – 6.15% household bleach diluted 1:50 provides >1000 ppm available chlorine; will corrode metal instruments)
K	Ethyl or isopropyl alcohol (70 – 90%)
L	Sodium hypochlorite (5.25 – 6.15% household bleach diluted 1:500 provides >100 ppm available chlorine
M	Phenolic germicidal detergent solution (follow product label for use-dilution)
N	Iodophor germicidal detergent solution (follow product label for use-dilution
O	Quaternary ammonium germicidal detergent solution (follow product label for use-dilution)
MR	Manufacturer’s recommendations
NA	Not applicable
1	See text for discussion of hydrotherapy
2	The longer the exposure to disinfectant, the more likely it is that all microorganisms will be eliminated. Ten-minute exposure is not adequate to disinfect many objects, especially those that are difficult to clean, because they have narrow channels or other areas that can harbor organic material and bacteria. Twenty-minute exposure at 200 C is the minimum time needed to reliably kill M. tuberculosis and nontuberculous mycobacteria with a 2% glutaraldehyde. With some exception of 2% glutaraldehydes, follow the FDA-cleared high-level disinfection claim. Some high-level disinfectants have a reduced exposure time (e.g., ortho-phthalaldehyde at 12 minutes at 200 C), because of their rapid activity against mycobacteria or reduced exposure time due to increased mycobacterial activity at elevated temperature (2.5% glutaraldehyde at 5 minutes at 350 C).
3	Tubing must be completely filled for disinfection and liquid chemical liquid sterilization; care must be taken to avoid entrapment of air bubbles during immersion.
4	Material compatibility should be investigated when appropriate.
5	Used laboratory where cultures or concentrated preparations or microorganisms have spilled. This solution may corrode some surfaces
6	Pasteurization (washer-disinfector) or respiratory therapy or anesthesia equipment is a recognized alternative to high-level disinfection. Some data challenge the efficacy of some pasteurization units
7	Thermostability should be investigated when appropriate.
8	Do not mix rectal and oral thermometers at any stage of handling or processing.

LINEN

Objective

1. ♣ To be able to provide linen and linen items for all users that is clean and safe for use.

Policy Guidelines

1. 1. The Linen and Laundry Section should be visited periodically to ensure the safety of the linen.
2. 2. All transport carts of linen should be clean
3. 3. Management of Clean Linens

• ♣ Sterile should be used to burn patients.
• ♣ Freshly laundered linen (clean linen) is appropriate to all types of patients other than burn cases.
• ♣ Clean linens are kept in a clean stock room of each patient unit.
• ♣ Appropriate linens are brought to the patient room only when needed.
• ♣ Housekeepers are responsible for preparing bed after terminal cleaning of each room, the same if the patient room is occupied and the patient is ambulatory.
• ♣ The nurse-in-charge and the auxiliary are responsible for linen exchange if the patient is critically ill and with contact, droplet, and airborne Precautions.

1. 4. Management of Used Linens

• ♣ Linen hamper for used linen should be available at bedside when changing patient linen.
• ♣ Soiled linen is never shaken or agitated in the air because shaking can disseminate the microorganism they contain.
• ♣ Linen from on patient’s bed is never (even momentarily) placed on another patient’s bed.
• ♣ Soiled linens should be placed directly into a portable linen hamper or tucked into a pillowcase at the end of the bed before it is gathered up in the linen hamper or linen chute.
• ♣ Keep soiled linen away from your uniform.
• ♣ Wash hands promptly after handling patient’s bed linens.

1. 5. Management of Linen Used by Infectious Patients

• ♣ Used linen should be placed in a yellow plastic bag properly tied and identified
• ♣ Decontamination of linen is done at the soiled linen room before sending to outsourced laundry contractor.
• ♣ Linen items (i.e. bed sheet, pillow case, wool blanket, patient gown or pajama) and additional item for suite room patient (i.e. Bath towel, Face Towel, bath Towel) served to patient must be cleaned.

HOUSEKEEPING

Objective

1. ♣ To maintain the cleanliness of the environment thus making it safe to everybody while in the hospital

Policy Guidelines

1. 1. All patient and non-patient care areas of the hospital should be kept clean at all times.
2. 2. All HCW tasked for this policy should wear the appropriate PPE. (Please Refer to Personal Protective Equipment)
3. 3. The Housekeeping Department shall take the lead to maintain the cleanliness of the hospital at all times.
4. 4. The following special care units should undergo terminal cleaning as scheduled:
5. ♣ Operating/Delivery Suites every Sunday of the month
6. ♣ Neonatal Unit every 15^th and end of the month
7. ♣ Hemodialysis Unit every Sunday of the month
8. ♣ Intensive Care Complex every 15^th and end of the month  
9. ♣ Emergency Room Complex every 1^st and 3^rd Sunday of the month
10. ♣ Special Services every 1^st and 3^rd Saturday of the month 

• • All patient rooms should undergo terminal cleaning every after patient discharge.
• • All patient care units should be cleaned regularly. (Please refer to Disinfection and Sterilization of Reusable Items)
• • There should be appropriate cleansers and disinfectant for use on metal, non-metal, plastic, linen and rubber.
• • The odor and user friendliness of cleansers and disinfectants should be considered in addition to chemical appropriateness.
• • ALL mops and bucket should have a defined area for use and should be cleansed and disinfected every end of the shift.
• • The double bucket system of cleaning should be followed.

PRODUCT EVALUATION

Objective

• ♣ To be able to have meticulous assessment of products before purchasing.

Policy Guidelines

1. 1. Organize a product selection and evaluation team
2. 2. Set priorities for product consideration
3. 3. Gather information on use of the conventional device
4. 4. Establish criteria for product selection and identify other issues for consideration and other issues to consider include:

• ♣ Quality control of all products
• ♣ Identification of cost effectiveness of products
• ♣ Impact on waste volume
• ♣ Packaging / expirations / manufacturer
1. 5. Obtain information on available products
2. 6. Obtain samples of devices under consideration
3. 7. Develop a product evaluation survey form and evaluation plan
4. 8. Tabulate and analyze the evaluation results
5. 9. Select and implement the preferred product
6. 10. Perform post-implementation monitoring

WASTE MANAGEMENT

Objective

• ♣ To provide safe, efficient and environment-friendly management of waste generated on all work areas from segregation, collection, handling, transport, storing and treatment until disposal

Definition of Terms

1. 1. Health Care Waste - includes all wastes that is generated or produced as a result of any of the following:

• ♣ Diagnosis, treatment, or immunization of human beings or animals;
• ♣ Research pertaining to the above activities;
• ♣ Production or testing of biologicals; and
• ♣ Waste originating from minor or scattered sources.

1. 2. Categories of Health Care Waste

• ♣ General Waste – comparable to domestic waste, this type of waste does not pose special handling problem or hazard to human health or to the environment. It comes mostly from the administrative and housekeeping functions of health care premises. General wastes are disposed to the city waste disposal system.

• ♣ Infectious Waste – this type of waste is suspected to contain pathogens (bacteria, viruses, parasites, fungi) in sufficient concentration or quantity to cause disease in susceptible host.  This includes:
• - Cultures and stocks of infectious agents from laboratory work;
• - Waste from surgery autopsies on patients with infectious diseases (tissues, materials or equipment that have been in contact with blood and other body fluids);
• - Waste from infected patients in isolation areas (excreta, dressings from infected surgical wounds, clothes heavily soiled with human or other body fluids);
• - Waste that have been in contact with infected patients undergoing hemodialysis (dialysis equipment and used PPEs);
• - Infected animals from laboratories; and 
• - Any other instruments or materials that have been in contact with infected persons or animals.   

• ♣ Pathologic Waste – consists of tissues, organs, body parts, human fetus and animal carcasses, blood and body fluids. Within this category, recognizable human or animal body parts are also called anatomical waste and considered infectious waste, even though it may also include healthy body parts.

• ♣ Sharps – include needles, syringes, scalpels, saws, blades, broken glass, infusion sets, knives, nails and any other items that can cause a cut or punctured wounds.  Whether or not they are infected, such items are usually considered as highly hazardous health care waste.

• ♣ Pharmaceutical Waste – include expired, unused, spilt, and contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer required and need to be disposed of appropriately. This category also includes discarded items used in handling of pharmaceuticals such as bottles or boxes with residues, gloves, mask, connecting tubing and drug vials. (Please to Restricted Antibiotic Policy)

• ♣ Genotoxic Waste – include certain cytotoxic drugs, vomit, urine, or feces from patients treated with cytotoxic drugs, chemicals, and radioactive materials. This type of waste is highly hazardous and may have mutagenic, teratogenic, or carcinogenic properties. Sources of cytotoxic wastes: (Please to Guidelines for Pharmacy Department)
• ♣ Contaminated materials from drug preparation and administration (needles, syringes, gauge, vials, packaging; outdated drugs, excess/leftover solutions, and drugs returned from the wards.

• - Urine, feces, and vomit from patients which may contain potentially hazardous amounts of administered cytotoxic drugs or of their metabolites and which should be considered genotoxic for at least 48 hours and sometimes up to 1 week after drug administration.

• ♣ Chemical Waste – consists of discarded solid, liquid, and gaseous chemicals from cleaning, housekeeping, and disinfecting procedures.  Chemical waste maybe hazardous or non-hazardous. (Please refer to Hazardous Materials Policy)
• ♣ Waste with high content of heavy metals – mercury, cadmium (Refer to Hazardous Materials Policy
• ♣ Pressurized Containers
• ♣ Radioactive Waste (Please refer to Radiation Policy)

1. 3. Composition of Health Care Waste

• ♣ Medical Wards

• - Mostly general waste; a limited amount of infectious waste such as blood-soaked dressings, bandages, and sticking plaster; contaminated gloves, contaminated packaging and disposable medical items; used or unused hypodermic needles and IV sets; and certain body fluids.

• ♣ Operating Rooms And Surgical Wards

• - General waste (including packaging); pathological and anatomical waste, including tissues, organs, products of conception and body parts other potentially infectious wastes (blood soaked gauze and materials, contaminated gloves, tubing, body fluid containers, and sharps).

• ♣ Other Health Care Units

• - Mostly general waste with small percentage of infectious waste (mostly sharps)

• ♣ Laboratories

• - General waste (including packaging and containers), pathological (including some anatomical) wastes, tissue samples, microbiological cultures and stocks, blood and body fluids, contaminated gloves, tubing and containers, sharps, possibly some radioactive materials, a large number of chemicals. Tissue samples are packed with formalin and no longer infectious but must be separated creating a chemical and a pathological waste for proper disposal.

• ♣ Pharmaceutical and chemical stores

• - Mainly general waste, product packaging, small quantities of pharmaceutical and chemical waste (if stocks are properly managed to prevent large quantities from expiring), possibly cytotoxic drugs, if chemotherapy treatment are prepared in the pharmacy.

• ♣ Support units

• - General waste

1. 4. Cleaning And Disinfection Of Ambulance After Transporting Infected Patients

The inanimate environment of the ambulance is unlikely to be a source or reservoir from which patients could acquire ordinary infections (e.g. wound, skin, childhood infections). Provided the following precautions are taken there should be little risk of transferring infection to staff or subsequent occupants.

• ♣ Hands of attendants should be thoroughly washed after the patient has been removed, and before eating, smoking or handling another patient. Disinfection of the hands with 70% alcohol would be useful procedures if washing facilities are not readily available.
• ♣ Beddings (blankets, sheets, pillow covers) should be sealed in a plastic bag and Laundered before re‑use. This is particularly important if the bedding is soiled by blood, excretions or secretions (and should be done even if the patient is not designated as infected).
• ♣ Spillage of blood, pus, excretions, vomit etc. should be promptly removed with Disposable wipes and a phenolic disinfectant. Discarded wipes should be sealed in a plastic bag and sent for incineration.
• ♣ The stretcher should also be wiped over with a phenolic disinfectant. Disposable Gloves should be worn for cleaning, and a plastic apron may be worn to protect clothing. Hands should be washed even if gloves are worn.
• ♣ Respiratory resuscitation equipment should be returned to a hospital Central Sterile Supply Department or Medical Equipment Cleaning Section for processing.

• ♣ Additional procedures for special infections

When an ambulance is used for a specially designated infection it is advisable:

1. ♣ to remove any equipment not considered necessary, e.g. spare stretcher;
2. ♣ to seal equipment locker with adhesive tape (terminal cleaning of inside will not then be necessary);
3. ♣ to seal clean blankets and bedding in a plastic bag and carry in cab and to seal box containing resuscitation equipment, so that if it is contaminated only the outside of the box will require cleaning or disinfection.

Diarrhoea and vomiting of unknown origin or gastro‑intestinal infection

Bedpans, urinals, vomit bowls, etc. should be either washed in a bedpan washer with a steam disinfection cycle or washed in a phenolic disinfectant. Disposable cups should be used. If surfaces are extensively contaminated the ambulance should be taken out of service and all surfaces cleaned with a phenolic disinfectant. Surfaces should be dry before the ambulance is re‑used.

Infectious or serum hepatitis

As above, but disinfect with I% hypochlorite (containing 0. 1% available chlorine).

Tuberculosis

As above, Sputum containers and wipes used for removing secretions from patient should be sealed in a plastic bag and incinerated.

Highly dangerous infections

Lassa fever and other viral haemorrhagic infections and small-pox: special precautions are required.

Immunization

Ambulance staff should be immunized against poliomyelitis, tetanus and tuberculosis (if tuberculin-negative)

1. 5. Health care waste from other sources generally has the following composition:

• ♣ Health care provided by nurses

• - General waste, a limited amount of infectious and some sharps

• ♣ Physicians’ offices/clinics

• - General waste, a limited amount of infectious and some sharps

• ♣ Dental clinics and dentists’ offices

• - General waste, a limited amount of infectious, sharps and waste with high heavy metal content

1. 6. Waste Segregation Guide:

• ♣ Black
• ♣ Green
• ♣ Yellow
• ♣ Sharp Containers
• ♣ Yellow with black band (Please refer to FMS Hazardous Materials Policy)
• ♣ Orange (Please refer to FMS Hazardous Materials Policy)

Policy Guidelines

1. 1. The waste water should undergo treatment (primary, secondary, tertiary, and sludge treatments) prior to disposal to the nearest body of water.
2. 2. Liquid medical wastes are disposed on the designated sinks on every patient floor.
3. 3. The hospital solid wastes should be segregated according to the prescribed color coding of waste bins lining as follows:

• ♣ Black for dry non-infectious waste
• ♣ Green for wet non-infectious waste
• ♣ Yellow for wet and dry waste contaminated with blood and body fluids
• ♣ Yellow with black band for hazardous materials (Please refer to FMS Hazardous Materials Policy)
• ♣ Orange for waste generated from radiation rooms (Please refer to FMS Hazardous Materials Policy)
• ♣ Sharp Containers for items that can cause cuts or puncture wounds (i.e. scalpels, syringes etc.)

1. 4. All patient care areas should be provided with color coded waste bins.
2. 5. Everybody in the hospital is responsible for proper segregation of generated wastes.
3. 6. The housekeeper is responsible for collection and transport of segregated waste on a regular basis. Appropriate PPE should be used.
4. 7. Tong should be used to collect unidentified waste to avoid sharp injuries.
5. 8. Used close thoracostomy tube (CTT) bottles and suction bottles should be decontaminated prior to disposal of contents. (For detailed policies, please refer to Disinfection and Sterilization of Reusable Items)
6. 9. General wastes are disposed to the city waste disposal system.
7. 10. All other wastes are disposed to outsourced contractors.
8. 11. Body parts may not be included in the disposal of pathologic waste.

SEGREGATION OF HEALTHCARE WASTE ACCORDING TO TYPES OF WASTE 

AND SOURCES

WASTE SEGREGATION GUIDE	EXAMPLES OF WASTE
RED (Sharps and Pressurized Containers)	♣ Needles and syringes ♣ Scalpel blades ♣ Glass vials – tuberculin/insulin ♣ Stylet ♣ Capillary  tubes ♣ Ampules ♣ Test tubes ♣ Blood evacuation tubes ♣ Pipette slides/cover slips ♣ Aluminum cover ♣ Blood lancets ♣ Empty aerosol cans ♣ Rusty pins, nails, clips, and screws ♣ Broken glasses
YELLOW (Infectious and Pathological Wastes)	♣ Gauze, cotton bandage, cotton applicators soaked with blood/body fluids from dressing of infected wounds and post operative cases, procedures such as PAP Smear, immunization ♣ Foreign bodies removed from any body parts ♣ Placenta, umbilical cord ♣ Used gloves ♣ Used Foley catheters ♣ Used tubing – IV, nebulizer ♣ Used diapers, sanitary napkins ♣ Used suction tubes ♣ Used NGT ♣ Used test drips ♣ Used urine bags ♣ Used drains – penrose ♣ Used cord clamp ♣ Used plaster ♣ Empty colostomy bag ♣ Used swabs ♣ Heplock ♣ Endotracheal tubes ♣ Used tongue guard ♣ Used oxygen tubing ♣ Used glad wrap ♣ Used mask/face mask ♣ Used thoracic tube ♣ Used hemovac ♣ Used sensor/electrodes ♣ Used bandages ♣ Used rubber sheet ♣ Used rubber tubing
YELLOW (Infectious and Pathological Wastes)	♣ Used CVP tubes ♣ Used t-tubes ♣ Used central lines ♣ Used oxygen catheter ♣ Amputated limbs, toes, fingers, organs, extracted tooth ♣ Tissues from minor/major operation ♣ Specimen containers of blood and body fluids ♣ Used culture media, tissue culture plate ♣ Used beads/plates ♣ Used kit from laboratory analyzer ♣ Used reaction pads, foils ♣ Used plastic wares/disposable ♣ Used Hemoline Diphasique ♣ Used T & B cell separator ♣ Used tissue typing/x-matching trays for discards ♣ Used filters ♣ Used blood product bags and tubing
YELLOW (Chemical and Pharmaceutical Wastes)	♣ Empty bottles of acids, HCl, H2SO4, HNO3, etc ♣ Empty bottles of betadine, iodine, KMNO3 ♣ Empty bottles of laboratory reagents (Formaline, Tolouene, Xylene) ♣ Empty bottles/cans of Kerosene, Acetone, Alcohol, Anesthetic lacquer ♣ Empty bottles of disinfectants ♣ Busted fluorescent bulb ♣ Defective thermometer ♣ Empty cans of glue, epoxy, and floor wax ♣ Expired and adulterated drugs and medicines ♣ Used batteries
BLACK (Non-infectious Dry Wastes)	♣ Paper and paper products - Used papers - Newspapers - Tetra packs, paper cups - Boxes/cartons ♣ Bottles - Glass and plastic ♣ Packaging materials - Styropore - Aluminum - Plastic, candy/food wrapper
GREEN (Non-infectious Wet Wastes)	♣ Kitchen left-over food ♣ Used cooking oil ♣ Fish entrails, scale, and fins ♣ Fruits and vegetables peelings ♣ Rotten fruits and vegetables ♣ Non-infection left over foods
ORANGE (Radioactive/Nuclear Wastes)	♣ 1125 (Iodine 125) ♣ Iodine 131 ♣ H3 – Thymidine ♣ Cesium – 137 ♣ Chromium – 51 ♣ Things contaminated with these radioactive materials - Gloves - Tissue papers - Cotton swabs - Aluminum foil - Gauze - Test tubes - Pipette tips - Repetitive syringes - Technetium 99m - tritium ♣ Used x-ray films, developers, and fixers

WATER SUPPLY FROM HEMODIALYSIS AND OPERATING ROOMS

Objectives

• ♣ To be able to identify those sites from which specimens are to be collected
• ♣ To monitor the sterility of water supply from Reverse Osmosis and Distiller

 

Policy Guidelines

1. 1. Specimens must be collected from the water outlets of Hemodialysis and Operating Rooms. 
2. 2. Specimen (i.e. water) is routinely collected every last Sunday of the month.
3. 3. Specimens must be collected and handled properly and with care.
4. 4. Results should be forwarded to HICC.

Procedures

1. A. Collecting a Specimen

1. 1. Prepares all necessary materials needed: 

• ♣ Sterile OS
• ♣ Clean Gloves
• ♣ Betadine antiseptic
• ♣ Water container
• ♣ Pail for draining water from the faucet
• ♣ Clean Towel
• ♣ Sterile specimen cup

1. 2. Washes hands before the start of the procedure
2. 3. Wears clean gloves
3. 4. Disconnects the hose from the faucet
4. 5. Opens the faucet and lets the water run from the faucet for at least 15 seconds
5. 6. Wipes the faucet with clean sterile OS wet with betadine antiseptic and waits for two minutes to drain 
6. 7. Opens the faucet again for 15 seconds  
7. 8. Repeats this step three (3) times.
8. 9. Collects the specimen 
9. 10. Labels it appropriately 
10. 11. Brings the specimen ASAP to the laboratory

ISOLATION POLICY

Objectives

• ♣ To prevent exposure to infectious communicable diseases among healthcare workers and patients
• ♣ To properly contain the spread of infectious communicable diseases among patients

Definition of Terms

1. 1. Airborne transmission is indirect method of transfer.  Entities transmitted by this method include droplet nuclei 1 – 5μm and remain suspended on air for long periods, spores, and shed microorganisms.  They are Mycobacterium Tuberculosis, chicken pox, and measles.
2. 2. Droplet transmission is a direct transfer of large particle droplet spread of infectious secretions within 3 feet distance through talking, coughing, sneezing or performance of procedures.
3. 3. Contact transmission is a transfer of microorganisms through direct contact (e.g. touching) or contact with contaminated items in the environment.

Policy Guidelines

1. 1. Hand hygiene is a MUST (Please Refer to Hand Hygiene Guidelines)
2. 2. Standard precaution should be applied to all patients during triaging until diagnosed.
3. 3. The personal protective equipment (PPE) to be used is gloves, mask, eye shield, and gown.(Please Refer to Personal Protective Equipment)
4. 4. Transmission-based precaution should be applied to all patients in addition to standard precaution once diagnosed.  The modes of transmission are Droplet, Airborne, and Contact.
5. 5. The Personal Protective Equipment (PPE) for Droplet precaution in addition to standard precaution is the use of mask.
6. 6. The Personal Protective Equipment (PPE) for airborne precaution in addition to standard precaution is the use N95 mask.
7. 7. The Personal Protective (PPE) for Contact precaution in addition to standard precaution is the use gloves and gown.
8. 8. All contaminated items and patient care equipment should undergo the process of decontamination, cleaning and disinfection/sterilization.
9. 9. Place a color coded tag at the door entrance under the doctors’ name on the appropriate isolation practices to apply.
10. 10. Ward is used for cohorting of patients. There should be three (3) feet distance in between patients. Patients with airborne infection should not be admitted in the ward.
11. 11. Always refer to the attached list of diseases, type of precaution, and room placement. This is your guide to carry isolation practices properly. (Please Refer to Guide for Patient Room Replacement for Admission)
12. 12. Use of appropriate Personal Protective Equipment (PPE) as precautions in order not to be exposed to communicable diseases both for healthcare workers and patients. (Please Refer to Table for Appropriate Use of Personal Protective Equipment)
13. 13. Standard Precaution on blood and body fluids for unknown cases
• ♣ Hand hygiene
• ♣ Use of gloves (sterile or non-sterile)
• ♣ Use of mask (N95 or surgical mask)
• ♣ Use of protective eyewear
• ♣ Use of gown (water resistant or linen gown)
14. 14. Transmission-based Precaution after proper diagnosis

• ♣ Airborne precaution
• ♣ Droplet precaution
• ♣ Contact precaution
• ♣ Protective environment

APPROPRIATE USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE)

	Single Room	Mask	Gloves	Gown	Patient Transport
Standard Precautions	+ or -	+ or -	+ or -	+ or -
Droplet	+ or - (but 3 ft. distance bet. beds)	+ (if within 3 ft from the patient)	+ (if soiling is likely)	+ (if  soiling is likely)	+ mask (ordinary surgical mask)
Airborne	+ (door is always closed); negative - pressure	+ (preferably N95 mask)	+ (if  soiling is likely)	+ (if soiling is likely)	+ mask (pref N95)
Contact	-	-	+	+ (if soiling is likely)	+ gown and gloves

PERSONAL PROTECTIVE EQUIPMENT  

Policy Guidelines

1. A. Scrub Suites
1. 1. Hospital-owned scrubs suits are handled by the hospital and personnel-owned scrub suits are maintained by the personnel.
2. 2. Visibly soiled scrub suits should be changed immediately once patient safety is assured.
3. 3. Scrub suit is restricted to Operating Suite only. In cases where personnel must go out, he/she should change to prescribed hospital uniform or street clothes. 
4. 4. The prescribed clothing consist of pants and a shirt

1. B. Mask

Surgical Mask

1. 1. Protects the wearer’s nose and mouth from inadvertent exposures to blood and other body fluids.
2. 2. Surgical team should wear mask while inside the operating suite especially when an operation is ongoing and when sterile materials and equipment are opened already.
3. 3. Mask should be properly fitted covering the mouth and nose of the wearer.
4. 4. Mask can be used until 6 hours of continuous use.
5. 5. Do not rub the outer part of the mask when in use.
6. 6. Do not place extra pads inside the mask while in use.
7. 7. If wearer has respiratory infection, mask can be worn anywhere
8. 8. Dispose mask in a yellow waste bin.
9. 9. Wash hands after removing the mask.

N95

1. 1. N95 should be used if the patient has or suspected of having infectious tuberculosis, measles and chicken pox.
2. 2. Mask should be properly fitted covering the mouth and nose of the wearer.  Do test fit by using cuffed hands over the mask and inhale. Feel the air that passes in between fingers.  Observe for clouding of protective eyewear, if present fit the wire on nose part properly.
3. 3. Do not rub the outer part of the mask when in use.
4. 4. Do not place extra pads inside the mask while in use.
5. 5. Wash hands after removing the mask.

1. C. Protective Eyewear
1. 1. Goggles or glasses with solid shield or chin-length face shields be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose or mouth contamination can be reasonably anticipated.

1. D. Surgical Caps/Hoods
1. 1. Surgical team should surgical caps/hood while inside the operating suite especially when an operation is ongoing and when sterile materials and equipment are opened already.
2. E. Shoe Covers Or Boots
1. 1. Should be worn to protect the surgical team members from exposure to blood and other body fluids during operation. Street shoes covered by shoe cover are not allowed.

1. F. Sterile Gloves

1. 1. Should be put on after donning sterile gowns.
2. 2. Should be worn by all surgical team.
3. 3. Prevent the surgical team members’ hands with patients’ blood and body fluids.
4. 4. Change promptly when gloves are torn or integrity is compromised.
5. 5. Double gloving should be used in patients with highly infectious blood and body fluids.
6. 6. Used for sterile procedures.

1. G. Clean Gloves

1. 1. Always wear gloves (clean, non-sterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items. 
2. 2. Put on clean gloves just before touching mucous membranes and non-intact skin.
3. 3. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
4. 4. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environment.

1. H. Surgical Gowns

1. 1. Sterile gown should be worn by the surgical team members during sterile procedures/operation.
2. 2. Surgical gowns are never worn outside surgical suite premises during procedures/operations.

1. I. Water Resistant Apron/Gown

1. 1. Should be used on top of clean linen gown when splashes are anticipated.
2. 2. Should be placed under a sterile linen gown during sterile procedures/operations and splashes are anticipated.  

HAND HYGIENE

Objectives 

• ♣ To be able to improve hand-hygiene practice
• ♣ To reduce the transmission of pathogenic microorganisms to patients and personnel in health-care settings

Definition of Terms

1. A. Ranking of Evidence for Recommendation

Agreement of CDC & HICPAC system for categorizing recommendations is adapted as follows:

1. 1. Category IA - Strongly recommended for implementation and strongly supported by well designed experimental, clinical, or epidemiological studies.
2. 2. Category IB - Strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and a strong theoretical rationale.
3. 3. Category IC - Required for implementation, as mandated by federal and/or state regulation or standard.
4. 4. Category II - Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale or a consensus by a panel of experts.

Policy Guidelines

1. A. Indications for Handwashing and Hand Antisepsis

1. 1. Wash hands with soap and water when visibly dirty or contaminated with proteinaceous material, or visibly soiled with blood or other body fluids, or if exposure to potential spore-forming organisms is strongly suspected or proven (CATEGORY IB) or after using the restroom (CATEGORY II).
2. 2. Preferably use an alcohol-based hand rub for routine hand antisepsis in all other clinical situations described below if hands are not visibly soiled (CATEGORY IA). Alternatively, wash hands with soap and water (CATEGORY IB).
• ♣ Perform hand hygiene:
• ♣ Before having direct contact with patients (CATEGORY IB)
• ♣ After removing gloves (CATEGORY IB)
• ♣ Before handling and invasive device (regardless whether or not gloves are used) for patient care (CATEGORY IB)
• ♣ After contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings (CATEGORY IA)
• ♣ If moving from a contaminated body site to a clean body site during patient care (CATEGORY IB)
• ♣ After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (CATEGORY IB) 
3. 3. Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol-based formulation before handling medication and preparing food (CATEGORY IB)
4. 4. When alcohol-based hand is already used, do not use antimicrobial soap concomitantly (CATEGORY II)

1. B. Hand-hygiene Technique

1. 1. Apply a palmful of the product and cover all surfaces of the hands. Rub hands until hands are dry (CATEGORY IB).
2. 2. When washing hands with soap and water, wet hands with water and apply the amount of product necessary to cover all surfaces. Vigorously perform rotational hand rubbing on both palms and interlace fingers to cover all surfaces. Rinse hands with water and dry thoroughly with a single use towel. Use running and clean water whenever possible. Use towel to turn off faucet (CATEGORY IB).
3. 3. Make sure hands are dry. Use a method that does not recontaminate hands. Make sure towels are not used multiple times or by multiple people (CATEGORY IB). Avoid using hot water, as repeated exposure to hot water may increase the risk of dermatitis (CATEGORY IB).
4. 4. Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a non-antimicrobial soap and water. When bar soap is used, small bars of soap in racks that facilitate drainage should be used (CATEGORY II).

Illustration:

1. C. Surgical Hand Preparation 

1. 1. If hands are visibly soiled, wash hands with a plain soap before surgical hand preparation (CATEGORY II). Remove debris from underneath fingernails using a nail cleaner, preferably under running water (CATEGORY II).
2. 2. Sinks should be designed to decrease the risk of splashes (CATEGORY II).
3. 3. Remove rings, watches, and bracelets before beginning surgical hand preparation (CATEGORY I). Artificial nails are prohibited (CATEGORY IB).
4. 4. Surgical hand antisepsis should be performed using either an antimicrobial soap or an alcohol-based hand rub, preferably with sustained activity, before donning sterile gloves (CATEGORY IB).
5. 5. If quality of water is not assured in the operating theatre, surgical hand antisepsis using an alcohol-based hand rub is recommended before donning sterile gloves when performing surgical procedures (CATEGORY II). 
6. 6. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, 2 to 5 min. Long scrub times (e.g. 10 min) are not necessary (CATEGORY IB). 
7. 7. When using an alcohol-based surgical hand rub product with sustained activity, follow the manufacturer’s instructions. Apply the product on dry hands only (CATEGORY IB). Do not combine surgical hand scrub and surgical hand rub with alcohol-based products sequentially (CATEGORY II). 
8. 8. When using an alcohol-based product, use sufficient product to keep hands and forearms wet with the hand rub throughout the procedure. (CATEGORY IB). 
9. 9. After application of the alcohol-based product, allow hands and forearms to dry thoroughly before donning sterile gloves (CATEGORY IB).

1. D. Selection and Handling of Hand-Hygiene Agents 

• 1. Provide health-care workers with efficacious hand hygiene products that have low irritancy potential (CATEGORY IB). 
• 2. To maximize acceptance of hand hygiene products by health-care workers, solicit their input regarding the feel, fragrance, and skin tolerance of any products under consideration. In some settings, cost may be a primary factor (CATEGORY IB). 
• 3. When selecting hand hygiene products: 
• ♣ Determine any known interactions between products used to clean hands, skin care products, and the types of gloves used in the institution (CATEGORY II);
• ♣ Solicit information from manufacturers about risk of contamination (pre-marketing and in-use) (CATEGORY IB); 
• ♣ Ensure that dispensers are accessible at the point of care (CATEGORY IB); 
• ♣ Ensure that dispensers function adequately and reliably, and deliver an appropriate volume of the product (CATEGORY II); 
• ♣ Ensure that the dispenser system for alcohol-based formulations is approved for flammable materials (CATEGORY IC); 
• ♣ Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand rubs may have on the effects of antimicrobial soaps being used in the institution (CATEGORY IB).
• 4. Do not add soap to a partially empty soap dispenser. If soap dispensers are reused, follow recommended procedures for cleansing (CATEGORY 1A)

1. E. Skin Care 

1. 1. Include information regarding hand care practices designed to reduce the risk of irritant contact dermatitis and other skin damage in health-care workers education programmed (CATEGORY IB). 
2. 2. Provide alternative hand hygiene products for health-care workers with allergies or adverse reactions to standard products used in the health-care setting (CATEGORY II). 
3. 3. When needed to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or hand washing, provide health-care workers with hand lotions or creams (CATEGORY IA).

1. F. Use of Gloves

1. 1. The use of gloves does not replace the need for hand cleansing by either hand rubbing or hand washing (CATEGORY IB). 
2. 2. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin will occur (CATEGORY IC).
3. 3. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient (CATEGORY IB). 
4. 4. When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to a clean body site within the same patient or to the environment (CATEGORY II). 
5. 5. Avoid reuse of gloves (CATEGORY IB). If gloves are re-used, implement reprocessing methods to ensure glove integrity and microbiological decontamination (CATEGORY II).

1. G. Fingernails of Healthcare Worker

1. 1. Do not wear artificial fingernails or extenders when having direct contact with patients (CATEGORY IA).
2. 2. Keep natural nails short (tips less than 0.5 cm long) (CATEGORY II).

1. H. Healthcare Worker Educational Training and Motivational Programmed

1. 1. The hand hygiene promotion programmes for health-care workers is focused specifically on factors currently found to significantly influence behavior, and not solely on the type of hand hygiene products. The strategy must be multifaceted and multimodal and include education and senior executive support for implementation (CATEGORY IB). 
2. 2. Educate health-care workers about the type of patient-care activities that can result in hand contamination and about the advantages and disadvantages of various methods used to clean hands (CATEGORY II). 
3. 3. Monitor health-care workers’ adherence to recommended hand hygiene practices and provide them with performance feedback (CATEGORY IA). 
4. 4. Encourage partnerships between patients, their families and health-care workers to promote hand hygiene in health care (CATEGORY II).

1. I. Institutional Responsibility and Role of Administrators

1. 1. Provide health-care workers with access to safe continuous water supply at all faucets and access to necessary facilities to perform hand washing (CATEGORY IB). 
2. 2. Provide health-care workers with a readily accessible alcohol-based hand rub at the point of patient care (CATEGORY IA). 
3. 3. Make improved hand hygiene adherence an institutional priority and provide appropriate leadership, administrative support and financial resources (CATEGORY IB). 
4. 4. Assign health-care professionals with dedicated time and training for the institutional infection control activities, including the implementation of a hand hygiene promotional programme (CATEGORY II). 
5. 5. Implement a multidisciplinary, multifaceted and multimodal programme designed to improve adherence of health-care workers to recommend hand hygiene practices (CATEGORY IB). 
6. 6. With regard to hand hygiene, ensure that the water supply within the health-care setting is physically separated from drainage and sewerage, and provide routine system monitoring and management (CATEGORY IB). 
7. 7. Store supplies of alcohol-based hand rubs in cabinets or areas approved for flammable materials

1. J. Performance Indicators

The following performance indicators are recommended for measuring improvements in HCWs' hand-hygiene adherence: 

1. 1. Periodically monitor and record adherence as the number of hand-hygiene episodes performed by personnel/number of hand-hygiene opportunities, by ward or by service. Provide feedback to personnel regarding their performance. 
2. 2. Monitor the volume of alcohol-based hand rub (or detergent used for hand washing or hand antisepsis) used per 1,000 patient-days.
3. 3. Monitor adherence to policies dealing with wearing of artificial nails. 
4. 4. When outbreaks of infection occur, assess the adequacy of health-care worker hand hygiene.

PREVENTION OF BURN WOUND INFECTION

Objective

• ♣ To prevent secondary infections among burned patients.

Policy Guidelines

1. 1. Newly burned patient requiring intensive care should be admitted at Isolation A in ICU.
2. 2. Single room is required when patient is for transfer out of Isolation A. Live flower/plants is not allowed.
3. 3. Personnel taking care of burned patient should wear standard PPE.
4. 4. Prevent contamination of burn patient from hydrotherapy by using shower.
5. 5. Diminish the colonization and growth of microorganisms on the surface of burn wound by applying appropriate topical antimicrobial agent. Consider testing of strain of microorganisms to antimicrobial prior to its use.
6. 6. Appropriate use of systematically administered antimicrobial to reduce the pressure for selection of resistant organisms. Use of antibiotics should be limited when possible, on the results of cultures and antimicrobials susceptibility tests.
7. 7. Early excision and closure of the burn wound
8. 8. Selective decontamination of the digestive tract. 
9. 9. Prevention of cross-contamination from inanimate surfaces and food 

• ♣ Each patient should have individual stethoscope, BP apparatus, box of clean disposable gloves, containers of antimicrobial agents
• ♣ Items or equipment that must be shared must be cleaned and disinfected in between patients
• ♣ Mattress covers should be inspected for any breaks that later may contaminate mattress foam
• ♣ Linen should be sterile
• ♣ Computer keyboards were discovered to be colonized and important source of microorganisms, therefore plastic covers should be provided and clean on a daily basis
• ♣ Burn patients should not be fed with raw fruits and vegetables
• ♣ Avoid contamination of kitchen utensils with raw fruits and vegetables that may later contact uncontaminated foods before they are served to burn patients

RECOMMENDATIONS FOR PLACEMENT OF INTRAVASCULAR CATHETERS IN ADULTS AND CHILDREN

Objectives

• ♣ These recommendations are designed to reduce the infectious complications associated with intravascular catheter use.
• ♣ Recommendations should be considered in the context of the institution’s experience with catheter-related infections, experience with other adverse catheter-related complications (e.g., thrombosis, hemorrhage, and pneumothorax), and availability of personnel skilled in the placement of intravascular devices. 

Policy Guidelines

1. A. The HICC Adopted the CDC/HICPAC Recommendations

1. 1. The CDC/HICPAC system for categorizing recommendations is as follows:

• ♣ Category IA. - Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
• ♣ Category IB - Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies, and a strong theoretical rationale.
• ♣ Category IC - Required by state or federal regulations, rules, or standards.
• ♣ Category II - Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
• ♣ Unresolved issue - Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists.

1. 2. Health-Care Worker Education and Training

• ♣ Educate health-care workers regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter related infections. (Category IA)
• ♣ Assess knowledge of and adherence to guidelines periodically for all persons who insert and manage intravascular catheters. (Category IA)
• ♣ Ensure appropriate nursing staff levels in ICUs to minimize the incidence of CRBSIs.  (Category IB)

1. 3. Surveillance

• ♣ Monitor the catheter sites visually or by palpation through the intact dressing on a regular basis, depending on the clinical situation of individual patients. 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. (Category IB)
• ♣ Encourage patients to report to their health-care provider any changes in their catheter site or any new discomfort.(Category II)
• ♣ Record the operator, date, and time of catheter insertion and removal, and dressing changes on a standardized form. (Category II)
• ♣ Do not routinely culture catheter tips. (Category IA)

1. 4. Hand hygiene

• ♣ Observe proper hand-hygiene procedures either by washing hands with conventional antiseptic containing soap and water or with waterless alcohol-based gels or foams. Observe hand hygiene before and after palpating catheter insertion sites, as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter.  Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained. (Category IA)
• ♣ Use of gloves does not obviate the need for hand hygiene. (Category IA)

1. 5. Aseptic technique during Catheter Insertion and Care

• ♣ Maintain aseptic technique for the insertion and care of intravascular catheters. (Category IA)
• ♣ Wear clean or sterile gloves when inserting an intravascular catheter as required by the Occupational Safety and Health Administration Bloodborne Pathogens Standard. Category IC. 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. Sterile gloves should be worn for the insertion of arterial and central catheters. (Category IA)
• ♣ Wear clean or sterile gloves when changing the dressing on intravascular catheters. (Category IC)

1. 6. Catheter insertion

• ♣ Do not routinely use arterial or venous cut down procedures as a method to insert catheters. (Category IA)

1. 7. Catheter site care

• ♣ Cutaneous antisepsis

• - Disinfect clean skin with an appropriate antiseptic before catheter insertion and during dressing changes. Although a 2% chlorhexidine based preparation is preferred, tincture of iodine, an iodophor, or 70% alcohol can be used. (Category IA)
• - No recommendation can be made for the use of chlorhexidine in infants aged <2 months. (Unresolved issue)
• - Allow the antiseptic to remain on the insertion site and to air dry before catheter insertion. Allow povidone iodine to remain on the skin for at least 2 minutes or longer if it is not yet dry before insertion. (Category IB)
• - Do not apply organic solvents (e.g., acetone and ether) to the skin before insertion of catheters or during dressing changes. (Category IA)

1. 8. Catheter-site dressing regimens

• ♣ Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site. (Category IA)
• ♣ Tunneled CVC sites that are well healed might not require dressings. (Category II)
• ♣ If the patient is diaphoretic, or if the site is bleeding or oozing, a gauze dressing is preferable to a transparent, semi-permeable dressing. (Category II)
• ♣ Replace catheter-site dressing if the dressing becomes damp, loosened, or visibly soiled. (Category IB)

• ♣ Change dressings at least weekly for adult and adolescent patients depending on the circumstances of the individual patient. (Category II)
• ♣ Do not use topical antibiotic ointment or creams on insertion sites (except when using dialysis catheters) because of their potential to promote fungal infections and antimicrobial resistance. (Category IA) 
• ♣ Do not submerge the catheter under water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower. (Category II)

1. 9. Selection and Replacement of Intravascular Catheters

• ♣ Select the catheter, insertion technique, and insertion site with the lowest risk for complications (infectious and noninfectious) for the anticipated type and duration of IV therapy. (Category IA)
• ♣ Promptly remove any intravascular catheter that is no longer essential. (Category IA)
• ♣ Do not routinely replace central venous or arterial catheters solely for the purposes of reducing the incidence of infection. (Category IB)
• ♣ 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. (Category IB)
• ♣ When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and after no longer than 48 hours. (Category II)
• ♣ Use clinical judgment to determine when to replace a catheter that could be a source of infection (e.g., do not routinely replace catheters in patients whose only indication of infection is fever). Do not routinely replace venous catheters in patients who are
• ♣ bacteremic or fungemic if the source of infection is unlikely to be the catheter. (Category II)
• ♣ Replace any short-term CVC if purulence is observed at the insertion site, which indicates infection. (Category IB)
• ♣ Replace all CVCs if the patient is hemodynamically unstable and CRBSI is suspected. (Category II) 
• ♣ Do not use guidewire techniques to replace catheters in patients suspected of having catheter-related infection. (Category IB)

1. 10. Replacement of administration sets*, needleless systems, and parenteral fluids

• ♣ Administration Sets
• - 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.  (Category IA)
• - Replace tubing used to administer blood, blood products, or lipid emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion. (Category IB)
• - If the solution contains only dextrose and amino acids, the administration set does not need to be replaced more frequently than every 72 hours. (Category II)
• - Replace tubing used to administer protocol infusions every 6 or 12 hours, depending on its use, per the manufacturer’s recommendation. (Category IA)

• ♣ Needleless Intravascular Devices

• - Change the needleless components at least as frequently as the administration set. (Category II)
• - Change caps no more frequently than every 72 hours or according to manufacturers’ recommendations. (Category II)
• - Ensure that all components of the system are compatible to minimize leaks and breaks in the system. (Category II)
• - Minimize contamination risk by wiping the access port with an appropriate antiseptic and accessing the port only with sterile devices. (Category IB)

• ♣ Parenteral Fluids
• - Complete the infusion of lipid-containing solutions (e.g., 3-in-1 solutions) within 24 hours of hanging the solution. (Category IB)
• - Complete the infusion of lipid emulsions alone within 12 hours of hanging the emulsion. If volume considerations require more time, the infusion should be completed within 24 hours. (Category IB)
• - Complete infusions of blood or other blood products within 4 hours of hanging the blood. (Category II)
• - No recommendation can be made for the hang time of other parenteral fluids. (Unresolved issue)

1. 11. IV - Injection Ports

• ♣ Clean injection ports with 70% alcohol or an iodophor before accessing the system. (Category IA) 
• ♣ Cap all stopcocks when not in use. (Category IB)

1. 12. Preparation and Quality Control of IV Admixtures

• ♣ Admix all routine parenteral fluids in the pharmacy in a laminar-flow hood using aseptic technique. (Category IB)
• ♣ Do not use any container of parenteral fluid that has visible turbidity, leaks, cracks, or particulate matter or if the manufacturer’s expiration date has passed. (Category IB)
• ♣ Use single-dose vials for parenteral additives or medications when possible. (Category II)
• ♣ Do not combine the leftover content of single-use vials for later use. (Category IA)
• ♣ If multidose vials are used
• - Refrigerate multidose vials after they are opened if recommended by the manufacturer. (Category II)
• - Cleanse the access diaphragm of multidose vials with 70% alcohol before inserting a device into the vial. (Category IA)
• - Use a sterile device to access a multidose vial and avoid touch contamination of the device before penetrating the access diaphragm. (Category IA)
• - Discard multidose vial if sterility is compromised. (Category IA)

1. 13. In-Line Filters

• ♣ Do not use filters routinely for infection-control purposes. (Category IA)

1. 14. IV - Therapy Personnel

• ♣ Designate trained personnel for the insertion and maintenance of intravascular catheters. (Category IA)

1. 15. Prophylactic Antimicrobials

• ♣ Do not administer intranasal or systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or BSI. (Category IA)

1. B. Peripheral Venous Catheters, Including Midline Catheters, in Adult and Pediatric Patients

1. 1. Selection of Peripheral Catheter

• ♣ Select catheters on the basis of the intended purpose and duration of use, known complications (e.g., phlebitis and infiltration), and experience of individual catheter operators. (Category IB)
• ♣ Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasations occur. (Category IA)
• ♣ Use a midline catheter or PICC when the duration of IV therapy will likely exceed 6 days. (Category IB)

1. 2. Selection of Peripheral-Catheter Insertion Site

• ♣ 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. (Category IA)
• ♣ In pediatric patients, the hand, the dorsum of the foot, or the scalp can be used as the catheter insertion site. (Category II)
• ♣ Replacement of catheter
• - Evaluate the catheter insertion site daily, by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use. Gauze and opaque dressings should not be removed if the patient has no clinical signs infection. If the patient has local tenderness or other signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually. (Category II)
• - Remove peripheral venous catheters if the patient develops signs of phlebitis (e.g., warmth, tenderness, erythema, and palpable venous cord), infection, or a malfunctioning catheter. (Category IB)
• - In adults, replace short, peripheral venous catheters at least 72–96 hours to reduce the risk for phlebitis. If sites for venous access are limited and no evidence of phlebitis or infection is present, peripheral venous catheters can be left in place for longer periods, although the patient and the insertion sites should be closely monitored. (Category IB)
• - Do not routinely replace midline catheters to reduce the risk for infection. (Category IB)
• - In pediatric patients, leave peripheral venous catheters in place until IV therapy is completed, unless a complication (e.g., phlebitis and infiltration) occurs. (Category IB)

1. 3. Catheter And Catheter-Site Care

• ♣ Do not routinely apply prophylactic topical antimicrobial or antiseptic ointment or cream to the insertion site of peripheral venous catheters. (Category IA)

1. C. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters, in Adult and Pediatric Patients

1. 1. Surveillance

• ♣ Conduct surveillance in ICUs and other patient populations to determine CRBSI rates, monitor trends in those rates, and assist in identifying lapses in infection control practices. (Category IA)
• ♣ Express ICU data as the number of catheter-associated BSIs per 1,000 catheter-days for both adults and children and stratify by birth weight categories for neonatal ICUs to facilitate comparisons with national data in comparable patient populations and health-care settings. (Category IB)
• ♣ Investigate events leading to unexpected life-threatening or fatal outcomes. This includes any process variation for which a recurrence would likely present an adverse outcome. (Category IC)

1. 2. General Principles

• ♣ Use a CVC with the minimum number of ports or lumens essential for the management of the patient. (Category IB)
• ♣ Use an antimicrobial or antiseptic-impregnated CVC in adults whose catheter is expected to remain in place >5 days if, after implementing a comprehensive strategy to reduce rates of CRBSI, the CRBSI rate remains above the goal set by the individual institution based on benchmark rates and local factors. The comprehensive strategy should include the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a 2% chlorhexidine preparation for skin antisepsis during CVC insertion. (Category IB)
• ♣ No recommendation can be made for the use of impregnated catheters in children. (Unresolved issue)
• ♣ Designate personnel who have been trained and exhibit competency in the insertion of catheters to supervise trainees who perform catheter insertion. (Category IA)
• ♣ Use totally implantable access devices for patients who require long-term, intermittent vascular access. For patients requiring frequent or continuous access, a PICC or tunneled CVC is preferable. (Category II)
• ♣ Use a cuffed CVC for dialysis if the period of temporaryaccess is anticipated to be prolonged (e.g., >3 weeks). (Category IB)
• ♣ Use a fistula or graft instead of a CVC for permanent access for dialysis. (Category IB)
• ♣ Do not use hemodialysis catheters for blood drawing or applications other than hemodialysis except during dialysis or under emergency circumstances. (Category II)
• ♣ Use povidone-iodine antiseptic ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the material of the hemodialysis catheter per manufacturer’s recommendation. (Category II)

1. 3. Selection Of Catheter Insertion Site

• ♣ Weigh the risk and benefits of placing a device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement. (Category IA)
• ♣ Use a subclavian site (rather than a jugular or a femoral site) in adult patients to minimize infection risk for nontunneled CVC placement. (Category IA)
• ♣ No recommendation can be made for a preferred site of insertion to minimize infection risk for a nontunneled CVC. (Unresolved issue)
• ♣ Place catheters used for hemodialysis and pheresis in a jugular or femoral vein rather than a subclavian vein to avoid venous stenosis if catheter access is needed. (Category IA)

1. 4. Maximal Sterile Barrier Precautions During Catheter Insertion

• ♣ Use aseptic technique including the use of a cap, mask, sterile gown, sterile gloves, and a large sterile sheet, for the insertion of CVCs (including PICCS) or guidewire exchange. (Category IA)
• ♣ Use a sterile sleeve to protect pulmonary artery catheters during insertion. (Category IB)

1. 5. Replacement of Catheter

• ♣ Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. (Category IB)
• ♣ Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. (Category II)
• ♣ Guidewire exchange

• - Do not use guidewire exchanges routinely for nontunneled catheters to prevent infection. (Category IB)
• - Use a guidewire exchange to replace a malfunctioning nontunneled catheter if no evidence of infection is present. (Category IB)
• - Use a new set of sterile gloves before handling the new catheter when guidewire exchanges are performed. (Category II)

1. 6. Catheter and Catheter-Site Care

• ♣ General measures
• ♣ Designate one port exclusively for hyperalimentation if a multilumen catheter is used to administer parenteral nutrition. (Category II)
• ♣ Antibiotic lock solutions
• ♣ Do not routinely use antibiotic lock solutions to prevent CRBSI. Use prophylactic antibiotic lock solution only in special circumstances (e.g., in treating a patient with a long-term cuffed or tunneled catheter or port that has a history of multiple CRBSIs despite optimal maximal adherence to aseptic technique). (Category II)
• ♣ Catheter-site dressing regimens

• - Replace the catheter-site dressing when it becomes damp, loosened, or soiled or when inspection of the site is necessary. (Category IA)
• - Replace dressings used on short-term CVC sites every 2 days for gauze dressings and at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter outweighs the benefit of changing the dressing. (Category IB)
• - Replace dressings used on tunneled or implanted CVC sites no more than once per week, until the insertion site has healed. (Category IB)
• - No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled CVCs. (Unresolved issue)

• ♣ No recommendation can be made for the use of chlorhexidine sponge dressings to reduce the incidence of infection. (Unresolved issue)
• ♣ Do not use chlorhexidine sponge dressings in neonates aged <7 days or of gestational age <26 weeks. (Category II)
• ♣ No recommendation can be made for the use of suture less securement devices. (Unresolved issue)
• ♣ Ensure that catheter-site care is compatible with the catheter material. (Category IB)
• ♣ Use a sterile sleeve for all pulmonary artery catheters. (Category IB)

1. D. Additional Recommendations for Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Pediatric Patients

1. 1. Selection Of Pressure Monitoring System

• ♣ Use disposable, rather than reusable, transducer assemblies when possible. (Category IB)

1. 2. Replacement of catheter and pressure monitoring system

• ♣ Do not routinely replace peripheral arterial catheters to prevent catheter-related infections.  (Category II)
• ♣ Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced. (Category IB)

1. 3. Care of pressure monitoring systems

• ♣ General measures

• - Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile. (Category IA)
• - Minimize the number of manipulations of and entries into the pressure monitoring system. Use a closed-flush system (i.e., continuous flush), rather than an open system (i.e., one that requires a syringe and stopcock), to maintain the patency of the pressure monitoring catheters. (Category II)
• - When the pressure monitoring system is accessed through a diaphragm rather than a stopcock, wipe the diaphragm with an appropriate antiseptic before accessing the system. (Category IA)
• - Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit. (Category IA)

• ♣ Sterilization or disinfection of pressure monitoring systems

• - Use disposable transducers. (Category IB)
• - Sterilize reusable transducers according to the manufacturers’ instructions if the use of disposable transducers is not feasible. (Category IA)

1. E. Recommendations for Umbilical Catheters

1. 1. Replacement of catheters

• ♣ Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency, or thrombosis are present. (Category II)
• ♣ Remove and do not replace umbilical venous catheters if any signs of CRBSI or thrombosis are present. (Category II)
• ♣ No recommendation can be made for treating through an umbilical venous catheter suspected of being infected. (Unresolved issue)
• ♣ Replace umbilical venous catheters only if the catheter malfunctions. (Category II)

1. 2. Catheter-Site Care

• ♣ Cleanse the umbilical insertion site with an antiseptic before catheter insertion. Avoid tincture of iodine because of the potential effect on the neonatal thyroid. Other iodine-containing products (e.g., povidone-iodine) can be used. 
  (Category IB)
• ♣ Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential to promote fungal infections and antimicrobial resistance. (Category IA)
• ♣ Add low doses of heparin (0.25–1.0 F/ml) to the fluid infused through umbilical arterial catheters. (Category IB)
• ♣ Remove umbilical catheters as soon as possible when no longer needed or when any sign of vascular insufficiency to the lower extremities is observed. Optimally, umbilical artery catheters should not be left in place >5 days. (Category II)
• ♣ Umbilical venous catheters should be removed as soon as possible when no longer needed but can be used up to 14 days if managed aseptically. (Category II)

PREVENTION CATHETER-ASSOCIATED URINARY TRACT INFECTIONS

Summary of Major Recommendations

1. A. Category I. Strongly Recommended for Adoption*

1. 1. Educate personnel in correct techniques of catheter insertion and care. 
2. 2. Catheterize only when necessary. 
3. 3. Emphasize hand washing. 
4. 4. Insert catheter using aseptic technique and sterile equipment. 
5. 5. Secure catheter properly. 
6. 6. Maintain closed sterile drainage. 
7. 7. Obtain urine samples aseptically. 
8. 8. Maintain unobstructed urine flow. 

1. B. Category II. Moderately Recommended for Adoption

1. 1. Periodically re-educate personnel in catheter care. 
2. 2. Use smallest suitable bore catheter. 
3. 3. Avoid irrigation unless needed to prevent or relieve obstruction. 
4. 4. Refrain from daily meatal care with either of the regimens discussed in text. 
5. 5. Do not change catheters at arbitrary fixed intervals. 

1. C. Category III. Weakly Recommended for Adoption

1. 1. Consider alternative techniques of urinary drainage before using an indwelling urethral catheter. 
2. 2. Replace the collecting system when sterile closed drainage has been violated. 
3. 3. Spatially separate infected and uninfected patients with indwelling catheters. 
4. 4. Avoid routine bacteriologic monitoring. 

Policy Guidelines

1. D. Personnel

1. 1. Only persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic insertion and maintenance of the catheter should handle catheters (CATEGORY I)
2. 2. Hospital personnel and others who take care of catheters should be given periodic in-service training stressing the correct techniques and potential complications of urinary catheterization. (CATEGORY II)

1. B. Catheter Use

1. 1. Urinary catheters should be inserted only when necessary and left in place only for as long as necessary. They should not be used solely for the convenience of patient-care personnel. (CATEGORY I)
2. 2. For selected patients, other methods of urinary drainage such as condom catheter drainage, suprapubic catheterization, and intermittent urethral catheterization can be useful alternatives to indwelling urethral catheterization. (CATEGORY III)

1. C. Handwashing

1. 1. Handwashing should be done immediately before and after any manipulation of the catheter site or apparatus. (CATEGORY I)

1. D. Catheter Insertion

1. 1. Catheters should be inserted using aseptic technique and sterile equipment. (CATEGORY I)
2. 2. Gloves, drape, sponges, an appropriate antiseptic solution for periurethral cleaning, and a single-use packet of lubricant jelly should be used for insertion. (CATEGORY II)
3. 3. As small a catheter as possible, consistent with good drainage, should be used to minimize urethral trauma. (CATEGORY II)
4. 4. Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction. (CATEGORY I)

1. E. Closed Sterile Drainage

1. 1. A sterile, continuously closed drainage system should be maintained. (CATEGORY I)
2. 2. The catheter and drainage tube should not be disconnected unless the catheter must be irrigated (please refer to Irrigation Recommendation). (CATEGORY I)
3. 3. If breaks in aseptic technique, disconnection, or leakage occur, the collecting system should be replaced using aseptic technique after disinfecting the catheter-tubing junction. (CATEGORY III)

1. F. Irrigation

1. 1. Irrigation should be avoided unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery); closed continuous irrigation may be used to prevent obstruction. To relieve obstruction due to clots, mucus, or other causes, an intermittent method of irrigation may be used. Continuous irrigation of the bladder with antimicrobials has not proven to be useful and should not be performed as a routine infection prevention measure. (CATEGORY II)
2. 2. The catheter-tubing junction should be disinfected before disconnection. (CATEGORY II)
3. 3. A large-volume sterile syringe and sterile irrigant should be used and then discarded. The person performing irrigation should use aseptic technique. (CATEGORY I)
4. 4. If the catheter becomes obstructed and can be kept open only by frequent irrigation, the catheter should be changed if it is likely that the catheter itself is contributing to the obstruction (e.g., formation of concretions). (CATEGORY II)

1. G. Specimen Collection

1. 1. If small volumes of fresh urine are needed for examination, the distal end of the catheter, or preferably the sampling port if present, should be cleansed with a disinfectant, and urine then aspirated with a sterile needle and syringe. (CATEGORY I)
2. 2. Larger volumes of urine for special analyses should be obtained aseptically from the drainage bag. (CATEGORY I)

1. H. Urinary Flow

1. 1. Unobstructed flow should be maintained. (Category I) (Occasionally, it is necessary to temporarily obstruct the catheter for specimen collection or other medical purposes.)
2. 2. To achieve free flow of urine (1) the catheter and collecting tube should be kept from kinking; (2) the collecting bag should be emptied regularly using a separate collecting container for each patient (the draining spigot and nonsterile collecting container should never come in contact ); (3) poorly functioning or obstructed catheters should be irrigated (please refer to Irrigation Recommendation) or if necessary, replaced; and (4) collecting bags should always be kept below the level of the bladder. (CATEGORY I)

1. I. Meatal Care

1. 1. Twice daily cleansing with povidone-iodine solution and daily cleansing with soap and water have been shown in 2 recent studies not to reduce catheter-associated urinary tract infection. Thus, at this time, daily meatal care with either of these 2 regimens cannot be endorsed. (CATEGORY II)

1. J. Catheter Change Interval

1. 1. Indwelling catheters should not be changed at arbitrary fixed intervals. (CATEGORY II)

1. K. Spatial Separation of Catheterized Patients

1. 1. To minimize the chances of cross-infection, infected and uninfected patients with indwelling catheters should not share the same room or adjacent beds. (CATEGORY III)

1. L. Bacteriologic Monitoring

1. 1. The value of regular bacteriologic monitoring of catheterized patients as an infection control measure has not been established and is not recommended. (CATEGORY III)

PREVENTION OF HEALTH-CARE-ASSOCIATED BACTERIAL PNEUMONIA

Definition of Terms

Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC)

Categorization of Recommendations

In this document, as in previously published HICPAC guidelines, each recommendation is categorized on the basis of existing scientific evidence, theoretical rationale, applicability, and potential economic impact. In addition, a new category accommodates recommendations that are made on the basis of existing national or state health regulations. The following categorization scheme is applied in this guideline:

1. 1. Category IA - Strongly recommended for implementation and strongly supported by well designed experimental, clinical, or epidemiologic studies.
2. 2. Category IB - Strongly recommended for implementation and supported by some clinical or epidemiologic studies and by strong theoretical rationale.
3. 3. Category IC - Required for implementation, as mandated by federal or state regulation or standard.
4. 4. Category II - Suggested for implementation and supported by suggestive clinical or epidemiologic studies or by strong theoretical rationale.
5. 5. No Recommendation; Unresolved Issue - Practices for which insufficient evidence or no consensus exists about efficacy.

Policy Guidelines

1. A. Staff Education and Involvement in Infection Prevention

1. 1. Educate health-care workers regarding the epidemiology of, and infection control procedures for, preventing health-care-associated bacterial pneumonia to ensure worker competency according to the worker’s level of responsibility in the healthcare setting, and involve the workers in the implementation of interventions to prevent health-care-associated pneumonia by using performance-improvement tools and techniques. (CATEGORY IA)

1. B. Infection and Microbiologic Surveillance

1. 1. Conduct surveillance for bacterial pneumonia in ICU patients who are at high risk for health-care-associated bacterial pneumonia (e.g., patients with mechanically assisted ventilation or selected postoperative patients) to determine trends and help identify outbreaks and other potential infection-control problems. The use of the new NNIS system’s surveillance definition of pneumonia is recommended. Include data on the causative microorganisms and their antimicrobial susceptibility patterns. Express data as rates (e.g., number of infected patients or infections per 100 ICU days or per 1,000 ventilator days) to facilitate intrahospital comparisons and trend determination. Link monitored rates and prevention efforts and feed data back to appropriate health-care personnel. (CATEGORY IB)

1. 2. In the absence of specific clinical, epidemiologic, or infection-control objectives, do not routinely perform surveillance cultures of patients or of equipment or devices used for respiratory therapy, pulmonary-function testing, or delivery of inhalation anesthesia.  (CATEGORY II)

1. C. Prevention of Transmission of Microorganisms

1. 1. Sterilization or Disinfection and Maintenance of Equipment and Devices
• ♣ General Measures

• − Thoroughly clean all equipment and devices to be sterilized or disinfected. (CATEGORY IA)
• − Whenever possible, use steam sterilization (by autoclaving) or high level disinfection by wet heat pasteurization at >158^oF (>70^oC) for 30 minutes for reprocessing semi critical equipment or devices (i.e., items that come into direct or indirect contact with mucous membranes of the lower respiratory tract) that are not sensitive to heat and moisture (please refer to Attachment C). Use low-temperature sterilization methods (as approved by the Office of Device Evaluation, Center for Devices and Radiologic Health, FDA) for equipment or devices that are heat- or moisture-sensitive. After disinfection, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items in the process.  (CATEGORY IA)
• − Preferentially use sterile water for rinsing reusable semi critical respiratory equipment and devices when rinsing is needed after they have been chemically disinfected. If this is not feasible, rinse the device with filtered water (i.e., water that has been through a 0.2: filter) or tap water, and then rinse with isopropyl alcohol and dry with forced air or in a drying cabinet.  (CATEGORY IB)
• − Adhere to provisions in the FDA’s enforcement document for single use devices that are reprocessed by third parties.  (CATEGORY IC)

• ♣ Mechanical ventilators
• − Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators.  (CATEGORY I)

• ♣ Breathing circuits, humidifiers, and HMEs
• − Breathing circuits with humidifiers

• ¬ Do not change routinely on the basis of duration of use the breathing circuit (i.e., ventilator tubing and exhalation valve and the attached humidifier) that is in use on an individual patient. Change the circuit when it is visibly soiled or mechanically malfunctioning. (CATEGORY IA)
• ¬ Breathing-circuit-tubing condensate
• o Periodically drain and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward the patient. (CATEGORY IB)
• o Wear gloves to perform the above procedure or handle the fluid.  (CATEGORY IB)
• o Decontaminate hands with soap and water (if hands are visibly soiled) or with an alcohol-based hand rub, after performing the procedure or handling the fluid. (CATEGORY IA)

• ¬ No Recommendation can be made for placing a filter or trap at the distal end of the expiratory-phase tubing of the breathing circuit to collect condensate.  (UNRESOLVED ISSUE)

• ¬ Humidifier fluids

• o Use sterile (not distilled, nonsterile) water to fill bubbling humidifiers.  (CATEGORY II)
• o No recommendation can be made for the preferential use of a closed, continuous-feed humidification system. (UNRESOLVED ISSUE)

• − Ventilator breathing circuits with HMEs

• ¬ No recommendation can be made for the preferential use of either HMEs or heated humidifiers to prevent pneumonia in patients receiving mechanically assisted ventilation. (UNRESOLVED ISSUE)
• ¬ Changing HMEs

• o Change an HME that is in use on a patient when it malfunctions mechanically or becomes visibly soiled. (CATEGORY II)
• o Do not routinely change more frequently than every 48 hours an HME that is in use on a patient. (CATEGORY II)

• ¬ Do not change routinely (in the absence of gross contamination or malfunction) the breathing circuit attached to an HME while it is in use on a patient. (CATEGORY II)

• ♣ Oxygen humidifiers

• - Follow manufacturers' instructions for use of oxygen humidifiers. (CATEGORIES II and IC)
• - Change the humidifier-tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated. (CATEGORY II)

• ♣ Small-volume medication nebulizers: in-line and hand-held nebulizers

• - Between treatments on the same patient: clean, disinfect; rinse with sterile water (if rinsing is needed), and dry small-volume in-line or hand-held medication nebulizers. (See recommendation III-A-1-c if rinsing with sterile water is not feasible.) (CATEGORY IB)
• - Use only sterile fluid for nebulization, and dispense the fluid into the nebulizer aseptically. (CATEGORY IA)
• - Whenever possible, use aerosolized medications in single-dose vials.  If multidose medication vials are used, follow manufacturers’ instructions for handling, storing, and dispensing the medications. (CATEGORY IB)

• ♣ Mist-tents (?)

• - Between uses on different patients, replace mist tents and their nebulizers, reservoirs, and tubings with those that have been subjected to sterilization or high-level disinfection.(CATEGORY II)
• - No Recommendation can be made about the frequency of routinely changing mist-tent nebulizers, reservoirs, and tubings while in use on one patient. (UNRESOLVED ISSUE)
• - Subject mist-tent nebulizers, reservoirs and tubings that are used on the same patient to daily low-level disinfection (e.g., with 2% acetic acid) or pasteurization followed by air-drying. (CATEGORY II)

• ♣ Other devices used in association with respiratory therapy

1. - Respirometers and ventilator thermometers
2. - Between their uses on different patients, sterilize or subject to high level disinfection portable respirometers, and ventilator thermometers. (CATEGORY IB)
3. - Resuscitation bags
• ¬ Between their uses on different patients, sterilize or subject to high-level disinfection reusable hand-powered resuscitation bags. (CATEGORY IB)
• ¬ No Recommendation can be made about the frequency of changing hydrophobic filters placed on the connection port of resuscitation bags.  (UNRESOLVED ISSUE)

• ♣ Anesthesia machines and breathing systems or patient circuits

• - Do not routinely sterilize or disinfect the internal machinery of anesthesia equipment. (CATEGORY IB)
• - Between uses on different patients, clean reusable components of the breathing system or patient circuit (e.g., tracheal tube or face mask; inspiratory and expiratory breathing tubing; y-piece; reservoir bag; humidifier; and tubing) and then sterilize or subject them to high-level liquid chemical disinfection or pasteurization in accordance with the device manufacturers' instructions for their reprocessing. (CATEGORY IB)
• - No recommendation can be made about the frequency of routinely cleaning and disinfecting unidirectional valves and carbon dioxide absorber chambers.  (UNRESOLVED ISSUE)
• - Follow published guidelines and manufacturers' instructions about in use maintenance, cleaning, and disinfection or sterilization of other components or attachments of the breathing system or patient circuit of anesthesia equipment.  (CATEGORY IB)
• - No recommendation can be made for placing a bacterial filter in the breathing system or patient circuit of anesthesia equipment. (UNRESOLVED ISSUE)

• ♣ Pulmonary-function testing equipment

• - Do not routinely sterilize or disinfect the internal machinery of pulmonary-function testing machines between uses on different patients. (CATEGORY II)
• - Change the mouthpiece of a peak flow meter or the mouthpiece and filter of a spirometer between uses on different patients. (CATEGORY II)

• ♣ Room-air “humidifiers” and faucet aerators

• - Do not use large-volume room-air humidifiers that create aerosols (e.g., by venturi principle, ultrasound, or spinning disk, and thus actually are nebulizers) unless they can be sterilized or subjected to high-level disinfection at least daily and filled only with sterile water.  (CATEGORY II)
• - Faucet aerators
• ¬ No recommendation can be made about the removal of faucet aerators from areas for immunocompetent patients (see also section on Legionnaires Disease, Part II, and Section I-C-1-d).  (UNRESOLVED ISSUE)
• ¬ If Legionella spp. is detected in the water of a transplant unit and until Legionella spp. are no longer detected by culture, remove faucet aerators in the unit (see also section on Legionnaires Disease, Part II, and Section I-C-1-d).  (CATEGORY II)

1. 2. Prevention of Person-to-Person Transmission of Bacteria
• ♣ Standard Precautions
• - Hand hygiene. (Please refer to Hand Hygiene Guidelines)(CATEGORY IA)
• - Gloving
• ¬ Wear gloves for handling respiratory secretions or objects contaminated with respiratory secretions of any patient. (CATEGORY IB)
• ¬ Change gloves and decontaminate hands as described previously between contacts with different patients; after handling respiratory secretions or objects contaminated with secretions from one patient and before contact with another patient, object, or environmental surface; and between contacts with a contaminated body site and the respiratory tract of, or respiratory device on, the same patient. (CATEGORY IA)
• - Gowning
• ¬ When soiling with respiratory secretions from a patient is anticipated, wear a gown and change it after soiling occurs and before providing care to another patient. (CATEGORY IB)

• ♣ Care of Patients with Tracheostomy
• - Perform tracheostomy under aseptic conditions. (CATEGORY II)
• - When changing a tracheostomy tube, wear a gown, use aseptic technique, and replace the tube with one that has undergone sterilization or high-level disinfection. (CATEGORY IB)
• - No recommendation can be made for the daily application of topical antimicrobial agent(s) at the tracheostoma. (UNRESOLVED ISSUE)

• ♣ Suctioning Of Respiratory Tract Secretions.  (See also Section IV-B-1-d.)
• - No recommendation can be made for the preferential use of either the multiuse closed-system suction catheter or the single-use open system suction catheter for prevention of pneumonia. (UNRESOLVED ISSUE)
• - No recommendation can be made about wearing sterile rather than clean gloves when performing endotracheal suctioning. (UNRESOLVED ISSUE)
• - No recommendation can be made about the frequency of routinely changing the in-line suction catheter of a closed-suction system in use on one patient. (UNRESOLVED ISSUE)
• - If the open-system suction is employed, use a sterile single-use catheter.
• - (CATEGORY II)
• - Use only sterile fluid to remove secretions from the suction catheter if the catheter is to be used for re-entry into the patient's lower respiratory tract.  (CATEGORY II)

PREVENTION OF NEEDLES STICK AND SHARP INJURY

Objective

• ♣ To prevent healthcare associated infection and ensuring safety in handling, manipulation, and disposal of sharps.

Policy Guidelines

1. 1. All healthcare workers who handle sharps should be properly oriented on its safe use and disposal.
2. 2. All healthcare workers should handle needles, blades/lancets and other sharp instrument carefully so that accident can be prevented.
3. 3. Use safety engineered sharps and needleless connectors whenever possible.
4. 4. All used needles, blades/lancets and other sharp instrument should be disposed to punctured proof resistant container immediately after use.
5. 5. Punctured proof resistant container should be accessible so that the operator can dispose immediately the sharp and avoid mixing it with other wastes.
6. 6. All healthcare workers should practice safety techniques in handling sharps from use until disposal

• ♣ Do not recap needles. If recapping is necessary use single hand technique or use mechanical device (forceps).
• ♣ Place the sharp on a solid tray and make sound or announcement every time it is passed.
• ♣ Always seek orientation on how to properly manipulate new gadget using sharp (e.g. CBG lancets).
• ♣ Do not bend needle. Do not manipulate the capped needle. If needle should be removed from the syringe, always use forceps.
• ♣ Use forceps in picking sharps debris or any equivalent.
• ♣ Sharps should be pointing away from the operator when manipulated but not facing anybody and be aware of the persons beside you.
• ♣ Do not overfill sharp containers and seal properly if ready for disposal. 

1. 7. Punctured proof resistant container should be available in the following areas at all time.

• ♣ All patient rooms in ICU complex, Surgery Suites, Delivery Suites
• ♣ Individual hemodialysis patient units
• ♣ Medication room/IV trays
• ♣ Laboratory
• ♣ Procedure/treatment room
• ♣ Anywhere that sharps are used

1. 8. All needles/sharp injuries should be reported for evaluation and management. (Please Refer to Guidelines for Human Resources Development)

PREVENTION OF SURGICAL SITE INFECTION

Objectives

• ♣ To provide a clean and safe environment that will prevent the development of any healthcare associated infections to ALL procedures done in the Surgery Suites.

Definition of Terms

1. A. Prevention of Surgical Site Infection

Ranking of evidence for recommendation (Centers for Disease Control and Prevention Guideline for Prevention of Surgical Site Infection)

1. 1. Category IA - Strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiological studies.
2. 2. Category IB - Strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and strong theoretical rationale.
3. 3. Category II - Suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale.
4. 4. No recommendation; unresolved issue - Practices for which insufficient evidence or no consensus regarding efficacy exists. Practices required by federal regulation are denoted with an asterisk (*).

1. II. Policy Guidelines

• A. Attire

1. 1. ALL personnel of the Operating Suites should adhere to prescribed attire.  These are:

• ♣ Scrub suites (Color Coding)
• ♣ Monday – Gray with Dark Gray
• ♣ Tuesday – Apple green
• ♣ Wednesday – Dark green
• ♣ Thursday – Gray with Dark Gray
• ♣ Friday – Light green
• ♣ Saturday – Any of green 
• ♣ Mask 
• ♣ Protective eyewear
• ♣ Surgical caps/hoods
• ♣ Shoe covers or boots
• ♣ Sterile gloves
• ♣ Surgical gowns 

1. B. Preoperative

Preparation of the Patient

1. 1. Whenever possible, identify and treat all infections remote to the surgical site before elective operation and postpone elective operations on patients with remote site infections until the infection has resolved. (CATEGORY IA)
2. 2. Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation. (CATEGORY IA)
3. 3. If hair is removed, remove immediately before the operation, preferably with electric clippers. (CATEGORY IA)
4. 4. Adequately control serum blood glucose levels in all diabetic patients and particularly avoid hyperglycemia perioperatively. (CATEGORY IB)
5. 5. Encourage tobacco cessation. At minimum, instruct patients to abstain for at least 30 days before elective operation from smoking cigarettes, cigars, pipes, or any other form of tobacco consumption (e.g., chewing/dipping). (CATEGORY IB)
6. 6. Do not withhold necessary blood products from surgical patients as a means to prevent SSI. (CATEGORY IB)
7. 7. Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day. (CATEGORY IB)
8. 8. Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation. (CATEGORY IB)
9. 9. Use an appropriate antiseptic agent for skin preparation. (CATEGORY IB)
10. 10. Apply preoperative antiseptic skin preparation in concentric circles moving toward the periphery. The prepared area must be large enough to extend the incision or create new incisions or drain sites, if necessary. (CATEGORY II)
11. 11. Keep preoperative hospital stay as short as possible while allowing for adequate preoperative preparation of the patient. (CATEGORY II)
12. 12. No recommendation to taper or discontinue systemic steroid use (when medically permissible) before elective operation. (UNRESOLVED ISSUE)
13. 13. No recommendation to enhance nutritional support for surgical patients solely as a means to prevent SSI. (UNRESOLVED ISSUE) 
14. 14. No recommendation to preoperatively apply mupirocin to nares to prevent SSI. (UNRESOLVED ISSUE)
15. 15. No recommendation to provide measures that enhance wound space oxygenation to prevent SSI. (UNRESOLVED ISSUE)

Hand/Forearm Antisepsis for Surgical Team Members

1. 1. Keep nails short and do not wear artificial nails. (CATEGORY IB)
2. 2. Perform a preoperative surgical scrub for at least 2 to 5 minutes using an appropriate antiseptic. Scrub the hands and forearms up to the elbows. (CATEGORY IB)
3. 3. After performing the surgical scrub, keep hands up and away from the body (elbows in flexed position) so that water runs from the tips of the fingers toward the elbows. Dry hands with a sterile towel and don a sterile gown and gloves. (CATEGORY IB)
4. 4. Clean underneath each fingernail prior to performing the first surgical scrub of the day. (CATEGORY II)
5. 5. Do not wear hand or arm jewelry. (CATEGORY II)
6. 6. No recommendation on wearing nail polish. (UNRESOLVED ISSUE)

Management of Infected or Colonized Surgical Personnel

1. 1. Educate and encourage surgical personnel who have signs and symptoms of a transmissible infectious illness to report conditions promptly to their supervisory and occupational health service personnel. (CATEGORY IB)
2. 2. Obtain appropriate cultures from, and exclude from duty, surgical personnel who have draining skin lesions until infection has been ruled out or personnel have received adequate therapy and infection has resolved. (CATEGORY IB)
3. 3. Do not routinely exclude surgical personnel who are colonized with organisms such as S. aureus (nose, hands, or other body site) or group A Streptococcus, unless such personnel have been linked epidemiologically to dissemination of the organism in the healthcare setting. (CATEGORY IB)
4. 4. Personnel who have potentially transmissible infectious conditions should seek clearance from HICC before assumption of duty. Clearance would include (a) personnel responsibility in using the health service and reporting illness, (b) work restrictions, and (c) clearance to resume work after an illness that required work restriction. (CATEGORY IB)

Antimicrobial Prophylaxis

1. 1. Administer a prophylactic antimicrobial agent only when indicated, and select it based on its efficacy against the most common pathogens causing SSI for a specific operation and published recommendations. (CATEGORY IA)
2. 2. Administer by the intravenous route the initial dose of prophylactic antimicrobial agent, timed such that a bactericidal concentration of the drug is established in serum and tissues when the incision is made. Maintain therapeutic levels of the agent in serum and tissues throughout the operation and until, at most, a few hours after the incision is closed in the operating room. (CATEGORY IA)
3. 3. Before elective colorectal operations, mechanically prepare the colon by use of enemas and cathartic agents. Administer nonabsorbable oral antimicrobial agents in divided doses on the day before the operation. (CATEGORY IA)
4. 4. For high-risk cesarean section, administer the prophylactic antimicrobial agent immediately after the umbilical cord is clamped. (CATEGORY IA)
5. 5. Do not routinely use vancomycin for antimicrobial prophylaxis. (CATEGORY IB)

1. C. Intraoperative

Ventilation

1. 1. Maintain positive-pressure ventilation in the operating room with respect to the corridors and adjacent areas. (CATEGORY IB)
2. 2. Maintain a minimum of 15 air changes per hour, of which at least 3 should be fresh air.  (CATEGORY IB)
3. 3. Filter all air, recirculated and fresh, through the appropriate filters per the American Institute of Architects’ recommendations. (CATEGORY IB)
4. 4. Introduce all air at the ceiling, and exhaust near the floor. (CATEGORY IB)
5. 5. Do not use UV radiation in the operating room to prevent SSI. (CATEGORY IB)
6. 6. Keep operating room doors closed except as needed for passage of equipment, personnel, and the patient. (CATEGORY IB)
7. 7. Consider performing orthopedic implant operations in operating rooms supplied with ultraclean air. (CATEGORY II)
8. 8. Limit the number of personnel entering the operating room to necessary personnel. (CATEGORY II)

Cleaning and Disinfection of Environmental Surfaces

1. 1. When visible soiling or contamination with blood or other body fluids of surfaces or equipment occurs during an operation, use an EPA-approved hospital disinfectant to clean the affected areas before the next operation. (CATEGORY IB)
2. 2. Do not perform special cleaning or closing of operating rooms after contaminated or dirty operations. (CATEGORY IB)
3. 3. Do not use tacky mats at the entrance to the operating room suite or individual operating rooms for infection control. (CATEGORY IB)
4. 4. Wet vacuum the operating room floor after the last operation of the day or night with an EPA-approved hospital disinfectant. (CATEGORY II)
5. 5. No recommendation on disinfecting environmental surfaces or equipment used in operating rooms between operations in the absence of visible soiling. (UNRESOLVED ISSUE)

Microbiologic Sampling

1. 1. Do not perform routine environmental sampling of the operating room. Perform microbiologic sampling of operating room environmental surfaces or air only as part of an epidemiologic investigation. (CATEGORY IB)

Sterilization of Surgical Instruments

1. 1. Sterilize all surgical instruments according to published guidelines. (CATEGORY IB)
2. 2. Perform flash sterilization only for patient care items that will be used immediately (e.g., to reprocess an inadvertently dropped instrument). Do not use flash sterilization for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time.  (CATEGORY IB)

Surgical Attire and Drapes

1. 1. Wear a surgical mask that fully covers the mouth and nose when entering the operating room if an operation is about to begin or already under way, or if sterile instruments are exposed. Wear the mask throughout the operation. (CATEGORY IB*)
2. 2. Wear a cap or hood to fully cover hair on the head and face when entering the operating room. (Category IB*)
3. 3. Do not wear shoe covers for the prevention of SSI. (Category IB*)
4. 4. Wear sterile gloves if a scrubbed surgical team member. Put on gloves after donning a sterile gown. (Category IB*)
5. 5. Use surgical gowns and drapes that are effective barriers when wet (i.e., materials that resist liquid penetration). (Category IB)
6. 6. Change scrub suits that are visibly soiled, contaminated, and/or penetrated by blood or other potentially infectious materials. (Category IB*)
7. 7. No recommendations on how or where to launder scrub suits, on restricting use of scrub suits to the operating suite, or for covering scrub suits when out of the operating suite. (UNRESOLVED ISSUE)

Practice of Anesthesiology

1. 1. Anesthesia team members must adhere to recommended infection control practices during operations. (CATEGORY IA)

Asepsis and Surgical Technique

1. 1. Adhere to principles of asepsis when placing intravascular devices (e.g., central venous catheters), spinal or epidural anesthesia catheters, or when dispensing and administering intravenous drugs. (CATEGORY IA)
2. 2. Assemble sterile equipment and solutions immediately prior to use. (CATEGORY II)
3. 3. Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue and foreign bodies (i.e., sutures, charred tissues, necrotic debris), and eradicate dead space at the surgical site. (CATEGORY IB)
4. 4. Use delayed primary skin closure or leave an incision open to heal by second intention if the surgeon considers the surgical site to be heavily contaminated (e.g., Class III and Class IV). (CATEGORY IB)
5. 5. If drainage is necessary, use a closed suction drain. Place a drain through a separate incision distant from the operative incision. Remove the drain as soon as possible. (CATEGORY IB)

1. D. Postoperative Incision Care

1. 1. Protect with a sterile dressing for 24 to 48 hours postoperatively an incision that has been closed primarily.  (CATEGORY IB)
2. 2. Wash hands before and after dressing changes and any contact with the surgical site. (CATEGORY IB)
3. 3. When an incision dressing must be changed, use sterile technique. (CATEGORY II)
4. 4. Educate the patient and family regarding proper incision care, symptoms of SSI, and the need to report such symptoms. (CATEGORY II)
5. 5. No recommendation to cover an incision closed primarily beyond 48 hours, or on the appropriate time to shower or bathe with an uncovered incision. (UNRESOLVED ISSUE)

1. E. Surveillance

1. 1. Use CDC definitions of SSI without modification for identifying SSI among surgical inpatients and outpatients. (Please refer to Attachment D)  (CATEGORY IB)
2. 2. For inpatient case-finding (including readmissions), use direct prospective observation, indirect prospective detection, or a combination of both direct and indirect methods for the duration of the patient’s hospitalization.  (CATEGORY IB)
3. 3. When post discharge surveillance is performed for detecting SSI following certain operations (e.g., coronary artery bypass graft), use a method that accommodates available resources and data needs. (CATEGORY II)
4. 4. For outpatient case-finding, use a method that accommodates available resources and data needs.  (CATEGORY IB)
5. 5. Assign the surgical wound classification upon completion of an operation. A surgical team member should make the assignment. (CATEGORY II)
6. 6. For each patient undergoing an operation chosen for surveillance, record those variables shown to be associated with increased SSI risk (e.g., surgical wound class, ASA class, and duration of operation). (CATEGORY IB)
7. 7. Periodically calculate operation-specific SSI rates stratified by variables shown to be associated with increased SSI risk (e.g., NNIS risk index). (CATEGORY IB)
8. 8. Report appropriately stratified, operation-specific SSI rates to surgical team members. The optimum frequency and format for such rate computations will be determined by stratified case-load sizes (denominators) and the objectives of local, continuous quality improvement initiatives.  (CATEGORY IB)
9. 9. No recommendation to make available to the infection control committee coded surgeon-specific data.  (UNRESOLVED ISSUE)

1. F. Watchers and Visitors

1. 1. Visitors are not allowed in the operating theater.  For pediatric patients only one (1) relative is allowed to accompany the patient inside the operating theater until patient is sedated.  The accompanying relative should change clothes to OR attire.
2. 2. Patient relative in post anesthesia recovery unit is allowed if needed.  A clean gown must be worn on top of the street clothes and footwear should be changed to OR slippers.
3. 3. Food, flowers, and other patients’ belongings are not allowed.

1. G. Performance of Procedures

(Please refer to Recommendations for Placement of Intravascular Catheters in Adults and Children, Prevention of Health-Care-Associated Bacterial Pneumonia, and Guidelines for Prevention of Catheter-Associated Urinary Tract Infections)

1. H. Reprocessing of Reusable Materials/Equipment

(Please Refer to Disinfection and Sterilization of Reusable Items Polices and Procedures)

1. I. Isolation Policies

(Please Refer to Isolation Policies and Isolation Precaution)

1. J. Implementation and Monitoring

The OR training Supervisor and Head Nurse who had undergone basic training course in infection control and the HICN shall conduct separate weekly monitoring of adherence to HIC policies by random selection of HCWs’ and procedures the HIC chairperson or a member of the executive committee or IC team will conduct monthly IC lecture on selected cases for audit of incidents of breaks in infection control which will coincide with the unit meeting.  

GUIDELINES OF HUMAN RESOURCE DEVELOPMENT

Objectives

1. ♣ To stress maintenance of sound habits in personal hygiene and individual responsibility in infection control
2. ♣ To monitor and investigate infectious diseases, potentially harmful infectious exposures, and outbreaks of infections among personnel
3. ♣ To provide care to personnel for work related illnesses or exposures
4. ♣ To contain cost and eliminate unnecessary procedures and by preventing infectious disease that results in absenteeism and disability

Policy Guidelines

• 1. All applicants should have their known active serological status on Hepatitis B, history of measles and chicken pox. The hospital is not assuming the responsibility to give vaccine as routine immunization.
• 2. All healthcare workers should have health inventory upon hiring for proper work placement as determined by the HICC. A health inventory should be obtained from personnel who will have patient contact. 
• ♣ For infection control, complete physical and laboratory examinations should not be routinely required for all personnel but should be done when indicated; for example, the need for an examination or laboratory test may be determined from results of the health inventory. 
• ♣ Health assessments of personnel other than placement evaluations should be done depending only on need; for example, as required to evaluate work-related illness or exposures to infectious diseases.  
• ♣ Routine culturing of personnel, such as taking cultures of the nose, throat, or stool, should not be done as part of the placement evaluation or thereafter. 

• 3. All employees (doctors, nurses, paramedical, and non medical), affiliates should undergo orientation on infection control policies and programs.

• ♣ Initial job orientation and ongoing in-service education should include the infection control aspects of personnel health and the proper use of the personnel health service.
• ♣ Specific written policies and procedures for control of infections

• 4. All job-related illnesses and exposures of should be reported to HICC.

• ♣ A record should be maintained on hospital personnel that include information obtained during the placement evaluation, immunization records, results of tests obtained in any screening or control programs, and reports of work-related illnesses or exposures. A readily available mechanism should be established for personnel to obtain advice about illnesses they may acquire from or transmit to patients.
• ♣ Evaluation of job-related illnesses or important exposures and post-exposure prophylaxis, when indicated, should be provided.
• ♣ Written protocols should be established for handling job-related infectious diseases or important exposures. These occurrences should be recorded in the person's record and, when applicable, the appropriate member of the infection control committee and personnel health service should be notified. 

(Please refer to Attachment E and F)

• 5. Post-exposure Prophylaxis (PEP) for Healthcare Workers (HCWs) Exposed to Blood and/or Body Fluids with HIV should be started as soon as possible, preferably within few hours rather than days after exposure.  Duration of PEP is 4 weeks.  Counseling, follow-up and monitoring of HCW for seroconversion and PEP toxicity is essential (Please refer to Table – Summary of Post exposure Prophylaxis For Acute Percutaneous Exposure)

• 6. When prophylactic treatment with drugs, vaccines, or immune globulins is deemed necessary, and is offered, personnel should be informed of alternative means of prophylaxis, the risk (if this is known) of infection if treatment is not accepted, the degree of protection provided by the therapy, and the potential side effects.  
• 7. Personnel who have responsibilities for patient care and have signs and symptoms of a transmissible infectious disease should report promptly to their supervisor for work restrictions.
• 8. All healthcare workers are provided with Influenza A vaccine charge to employee benefit as determined HRD.
• 9. Education program related to prevention and management of HCW exposure to blood and body fluids, infectious diseases, sharp injuries, etc. should be provided. 

INFECTION CONTROL PROTOCOLS FOR MCMC EMPLOYEES EXPOSED TO HIGHLY INFECTIOUS DISEASES

Policy Guidelines

1. 1. Identification of highly contagious diseases (SARS, Meningococcus, varicella, hepatitis, measles, sputum (+) TB, mumps, rabies)

• ♣ Microbiology Laboratory confirms the identity of microbes and informs the patient’s attending physicians and HICC.
• ♣ Exposed health workers:

• - Regular employees go to Industrial Clinic (during office hours) or ER (after office hours, including Saturday, Sunday, and holiday) and fills up Health Care Workers Exposure Report Form. (Please refer to Attachment G)
• - Contractors will go to ER (anytime, including Saturday, Sunday, and holiday) and fills up Health Care Workers Exposure Report Form.

• ♣ Industrial Clinic or ER physician calls up and informs IC Nurse of the exposure and asks for technical advice on management.
• ♣ Industrial Clinic or ER physician implements management and endorses Report to update IC Nurse. 
• ♣ For meningococcemia, Industrial Clinic or ER physician issues prescription for ciprofloxacin (single dose) or rifampicin (two doses). HICC approval is sought first.
• ♣ Health worker goes to Pharmacy and has prescription filled. Pharmacy detects that the prescription for single dose ciprofloxacin or two doses of rifampicin is for meningococcemia and checks for HICC approval before serving prescription. 
• ♣ Health workers follow up at Industrial Clinic for check-up and IC Nurse contacts worker to encourage compliance.

1. 2. Needle stick injuries

• ♣ Exposed health workers: 

• - Regular employees go to Industrial Clinic (during office hours) or ER (after office hours, including Saturday, Sunday, and holiday) and fills up EPINet Form.
• - Contractors will go to ER (anytime, including Saturday, Sunday, and holiday) and fills up EPINet Form.

• ♣ Industrial Clinic or ER physician calls up and informs IC Nurse of the exposure and asks for technical advice on management.
• ♣ Industrial Clinic or ER physician implements management and endorses Report to update IC Nurse.
• ♣ If indicated, Industrial Clinic or ER physician issues prescription for immunoglobulin (for hepatitis). HICC approval is sought first.
• ♣ Health worker goes to Pharmacy and has prescription filled. 
• ♣ Pharmacy detects that the prescription for immunoglobulin is for hepatitis exposure and checks that the prescription has HICC approval before serving prescription. 
• ♣ Health workers follow up at Industrial Clinic for check-up and IC Nurse contacts worker to encourage compliance.

1. 3. Identification of multiple-resistant organisms (such as MDRTB, MRSA)

1. ♣ Microbiology Laboratory confirms the identity of microbes and informs the patient’s attending physicians and HICC.
2. ♣ Exposed Health Workers:

• - Regular employees go to Industrial Clinic (during office hours) or ER (after office hours, including Saturday, Sunday, and holiday) and fills up EPINet Form.
• - Contractors will go to ER (anytime, including Saturday, Sunday, and holiday) and fills up EPINet Form.

1. ♣ Industrial Clinic or ER physician calls up and informs IC Nurse of the exposure and asks for technical advice on management.
2. ♣ Industrial Clinic or ER physician implements management and endorses Report to update IC Nurse. 
3. ♣ Health worker goes to Pharmacy and has prescription filled. Pharmacy detects that the prescription for single dose ciprofloxacin or two doses of rifampicin is for meningococcemia and checks for HICC approval before serving prescription. 
4. ♣ Health workers follow up at Industrial Clinic for check-up and IC Nurse contacts worker to encourage compliance.

1. 4. Post Exposure Prophylaxis

• ♣ When prophylactic treatment with drugs, vaccines, or immune globulins is deemed necessary, and is offered, personnel should be informed of alternative means of prophylaxis, the risk (if this is known) of infection if treatment is not accepted, the degree of protection provided by the therapy, and the potential side effects.  
• ♣ Hepatitis A 

• - Personnel who have had direct fecal-oral exposure to excretions from a patient found to have been incubating hepatitis A should be given immune globulin (IG) (0.02 ml/kg). 
• - Prophylaxis with immune globulin (IG) for all personnel who take care of patients with hepatitis A (other than as suggested in recommendation 5.b.1 above) should not be given. 

• ♣ Hepatitis B 

• - For prophylaxis against hepatitis B after percutaneous (needle-stick) or mucous membrane exposure to blood that might be infective; the recommendations should be followed. (Please refer to Table for Summary of Post exposure Prophylaxis for Acute Percutaneous)

• ♣ Hepatitis Non-A, Non-B 

• - If needle-stick exposures occur involving patients known to have hepatitis non-A, non-B, IG (0.06 ml/kg) should be given. 

• ♣ Meningococcal disease 

• - Antimicrobial prophylaxis against meningococcal disease should be offered immediately to personnel who have had intensive direct contact with an infected patient without using proper precautions. If prophylaxis is deemed necessary, treatment should not await results of antimicrobial sensitivity testing. 

• ♣ Pertussis 

• - Antimicrobial prophylaxis against pertussis should be offered immediately to personnel who have had intensive contact with an infected patient without using proper precautions. 

• ♣ Rabies 

• - Hospital personnel who either have been bitten by a human with rabies or have scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or other potentially infective material from a human with rabies should receive a full course of anti-rabies treatment. 

1. 5. Personnel restriction because of illnesses or special conditions

• ♣ Personnel who have responsibilities for patient care and have signs and symptoms of a transmissible infectious disease should report promptly to their supervisor. 
• ♣ Acute Diarrhea 
• - Personnel with an acute diarrheal illness that is severe, is accompanied by other symptoms (such as fever, abdominal cramps, or bloody stools) or lasts longer than 24 hours should be excluded from direct patient contact pending evaluation. 
• - Whenever appropriate, specific treatment for documented infection with enteric pathogens should be made available to infected personnel. 
• - Personnel with non-typhoidal Salmonella enteric infections should be excluded from the direct care of high-risk patients until stool cultures are Salmonella-free on 2 consecutive specimens collected not less than 24 hours apart. 
• - Personnel infected by enteric pathogens other than Salmonella may return to work after symptoms resolve. These persons should be individually counseled before they return to work about the importance of hand washing. 
• - Follow-up cultures or examinations of stool for pathogens other than Salmonella may be done to determine when the stool is free of the infecting organism. 

• ♣ Herpes Simplex Infections 

• - Personnel with primary or recurrent orofacial herpes simplex infections should not take care of high-risk patients, for example, newborns, patients with burns, or severely immunocompromised patients, until the lesions are healed. 
• - Personnel with herpes simplex infections of the fingers or hands (herpetic whitlow) should not have direct contact with patients until lesions are healed. 

• ♣ Respiratory Infections 

• - Personnel with respiratory infections should not be assigned to the direct care of high-risk patients, for example, neonates, young infants, patients with chronic obstructive lung disease, or immunocompromised patients. 
• - If an influenza epidemic is anticipated, a prevention program should be started for all patient-care personnel and high-risk patients. This program could include use of influenza vaccine and antiviral chemoprophylaxis. 

• ♣ Streptococcal Disease 

• - If group A streptococcal disease is suspected, appropriate cultures should be taken, and the health worker should be excluded from work until she or he has received adequate therapy for 24 hours or until streptococcal infection has been ruled out. (CATEGORY I)
• - Management of Personnel Who Are Linked to Outbreaks Personnel who are linked epidemiologically to an increase in bacterial infections caused by a pathogen associated with a carrier state should be cultured and, if positive, excluded from patient contact until carriage is eradicated or the risk of disease transmission is eliminated. (CATEGORY I)

• ♣ Detection and Control of Tuberculosis 
• - Skin Test
• ¬ During the placement evaluation a tuberculin skin test should be given to all personnel, unless a previously significant reaction (10 mm or more of induration by Mantoux or vesiculation by a multiple puncture test) can be documented. The results should be used as the baseline test in determining treatment and follow-up of these personnel. 
• ¬ The Mantoux technique using 5 TU PPD should be used. 
• ¬ The 2-step test should be used to minimize the likelihood of interpreting a boosted reaction as a true conversion due to recent infection. (Evaluation of the efficacy of the 2-step method in a given area may be necessary.) 
• ¬ If there is a likelihood of a severe reaction to skin testing, an initial test using a 2-step method with 1 TU PPD or a partial dose of 5 TU PPD should be considered. 
• ¬ After the initial skin test, the need for repeat testing should be determined in each hospital by the risk of acquiring new infection; for example, personnel need not have repeat testing if the incidence of tuberculosis in the community and in personnel is very low and personnel have not been exposed to an infective case. 
• ¬ All personnel with significant reactions should be informed about risks of developing disease, risks they may pose to their contacts, and preventive treatment.

• - Skin Tests After BCG Vaccination 
• ¬ Persons who have had prior BCG vaccination should be skin-tested using the Mantoux method, unless a previously significant reaction can be documented.  
• ¬ The results of skin tests in persons who have had prior BCG vaccination should be interpreted and acted on in the same manner as those in personnel who have not been vaccinated with BCG.(Please refer to Preventive Treatment and Work Restrictions) 

• - Chest Roentgenograms 
• ¬ Chest roentgenograms should be taken on those persons with significant tuberculin skin test results a) who have never been evaluated, b) who have had recent conversions, c) who have never received adequate treatment for tuberculosis, or d) who have pulmonary symptoms that may be due to tuberculosis. If the chest film suggests pulmonary TB, these persons should be evaluated to rule out the possibility of current disease. 
• ¬ Routine follow-up roentgenograms should not be taken. 

• - Preventive Treatment and Work Restrictions 
• ¬ Personnel with current pulmonary or laryngeal tuberculosis whose sputum smear shows bacilli should be excluded from work until adequate treatment has begun and the sputum is free of bacilli on 3 consecutive smears obtained on separate days or until sputum cultures show no growth. 
• ¬ Personnel who have current TB at a site other than the lung or larynx should be allowed to continue their usual activities. 
• ¬ Personnel who discontinue medications for current pulmonary or laryngeal disease before the recommended course of therapy has been completed should not be allowed to work. 
• ¬ All personnel with significant skin-test reactions who do not have current tuberculosis and who have not had previous adequate therapy should be advised to receive preventive treatment, unless such therapy is specifically contraindicated. 
• ¬ These personnel, if otherwise healthy and receiving preventive treatment should be allowed to continue usual activities.
• ¬ Personnel who cannot take or do not accept or complete preventive treatment should have their work situations evaluated and may require reassignment. A change in assignment should be considered, if these persons work with high-risk patients. 
• ¬ These persons should be counseled about the risk of developing disease and risks they may pose to their contacts and should be instructed to seek evaluation of any signs or symptoms that may be due to TB. 
• ¬ All persons with a history of TB and all personnel with significant reactions are at risk for developing current disease. These persons should be instructed to report promptly for evaluation if symptoms that may be due to TB develop 
• ¬ Personnel who have completed preventive treatment or adequate therapy for current disease should be exempt from further screening unless symptomatic. 

• - Post exposure Prophylaxis for TB
• ¬ After exposure to an infective case of tuberculosis during which proper precautions were not used, all personnel, except those already known to have significant skin-test reactions, should be skin-tested 10 weeks after the exposure. Personnel whose skin test converts should have a chest roentgenogram taken and, unless specifically contraindicated, are advised to receive preventive treatment, provided current disease has been ruled out. If the chest film suggests pulmonary TB, these persons should be evaluated to rule out current disease.  
• ¬ Unless a skin test was given during the 3 months before exposure, a baseline skin test should be done as soon as possible after the exposure to assist in interpreting the 10-week post exposure skin test. 
• ¬ Personnel already known to have significant reactions should not have a chest roentgenogram taken unless they have pulmonary symptoms that may be due to tuberculosis. 

(Please refer to Post Exposure Prophylaxis for HIV)

• ♣ Personnel Exposed to Varicella or Zoster 

• - After exposure to varicella (chickenpox) or zoster (shingles) personnel not known to be immune to varicella (by history or serology) should be excluded from work beginning on the tenth day after exposure and remain away from work for the maximum incubation period of varicella (21 days). 
• - Personnel who have onset of varicella should be excluded from work at least until all lesions have dried and crusted. 

• ♣ Control of Hepatitis Infections 

• - Personnel who are suspected of being infected with hepatitis A virus (HAV) should not take care of patients until 7 days after the onset of jaundice. 
• - Screening for evidence of prior infection with hepatitis B virus (HBV) in personnel who work in dialysis centers or other high-risk areas should be done only when needed to institute appropriate control measures. 
• - Personnel who are known careers of HBsAg should be counseled about precautions to minimize their risk of infecting others. 
• - Personnel who have no exudative lesions on the hands and who are acutely infected with HBV, are known to be carriers of HBsAg, or have hepatitis non A/non B (NANB) should not be restricted from patient-care responsibilities, unless there is evidence of disease transmission. 
• - Personnel who have no exudative lesions on the hands and who are acutely infected with HBV, are known to be careers of HBsAg, or have hepatitis NANB should wear gloves for procedures that involve trauma to tissues or direct contact with mucous membranes or non-intact skin. 
• - Personnel with exudative lesions on the hands who are HBsAg-positive should either wear gloves for all direct patient contact and when handling equipment that will touch mucous membranes or non-intact skin or abstain from all direct patient care. 
• - Dental personnel should consider routine use of gloves, masks, and protective eyewear when performing dental procedures. 

• ♣ Precautions for AIDS

• - Personnel considered to have any of the clinical features described in the AIDS spectrum should be counseled about precautions to minimize their risk of infecting others (see discussion of AIDS and HBsAg carriers in text). 
• - Personnel considered to have any of the clinical features described in the AIDS spectrum who have no exudative lesions on the hands should wear gloves for procedures that involve trauma to tissues or direct contact with mucous membranes or non-intact skin. 
• - Personnel considered to have any of the clinical features described in the AIDS spectrum and who have exudative lesions on the hands should either wear gloves for all direct patient contact and when handling equipment that will touch mucous membranes or non-intact skin or abstain from all direct patient care. Category II 
• - Dental personnel taking care of patients considered to have any of the clinical features in the AIDS spectrum should consider routine use of gloves, masks, and protective eyewear when performing dental procedures. 

SUMMARY OF POST EXPOSURE PROPHYLAXIS FOR ACUTE PERCUTANEOUS EXPOSURE

Post exposure Prophylaxis for Healthcare Workers (HCWs) Exposed to Blood and/or Body Fluids with Hepatitis B surface antigen (HBsAg)

Immune status of HCW	Source Patient HBsAG (+)	Source Patient  HBsAG (-)	Source not tested or unknown
Unvaccinated	HBIG dose and start HB vaccine 1 series	Start HB vaccine series	Start HB vaccine series
Previously vaccinated
Known responder (anti-HBs>  10 mIU/mL)	No treatment	No treatment
Known non- Responder	HBIG dose and start HB vaccine 1 series	No treatment	If known high risk source, treat as if source were  HBsAg (+)
Antibody response unknown	Check anti-HBs: If >10 mIU/mL, no treatment If < 10mIU/mL, HBIG 1 dose and vaccine booster	No treatment	Check anti-HBs: If >10 mIU/mL, no treatment If < 10mIU/mL, HBIG 1 dose and vaccine booster
HBIG = hepatitis B immunoglobulin; HB = hepatitis B; anti-HBs = anti-hepatitis B surface antigen antibody.  Table adapted from the source.

POST EXPOSURE PROPHYLAXIS FOR HIV

Post-exposure Prophylaxis for Healthcare Workers (HCWs) Exposed to Blood and/or Body Fluids with HIV. PEP should be started as soon as possible, preferably within few hours rather than days after exposure. Duration of PEP is 4 weeks. Counseling, follow-up and monitoring of HCW for seroconversion and PEP toxicity is essential

Exposure	Source Patient HIV (+)	Source Patient Unknown	Considerations
Mucous membrane or skin, integrity compromised	Low titer: source patient asymptomatic and high CD4 count may not need PEP, discuss with HCW
Small (few drops or short duration)	High titer: source patients has advanced AIDS, primary HIV infection, high or increasing viral load or low CD4 count, consider prophylaxis with zidovudine 600 mg/day in two or three divided doses and lamivudine 150mg bid
Large (several drops, major blood splash and/or longer duration, i.e. more than several minutes)	Low titer: source patient asymptomatic and high CD4 count, recommend prophylaxis with zidovudine 600mg/day in two or three divided doses and lamivudine 150mg bid High titer: source patients has advanced AIDS, primary HIV infection, high or increasing viral load or low CD4 count, recommend prophylaxis with zidovudine 600mg/day in two or three divided doses and lamivudine 150mg bid and either indinavir 800mg every 8 hours or nelfinavir 750 mg tid	If there is possible risk for HIV exposure, consider prophylaxis with zidovudine 600mg/day in two or three divided doses and lamivudine 150mg bid and either indinavir 800mg every 8 hours or nelfinavir 750 mg tid
Intact skin	PEP not needed unless there is high exposure to blood, e.g. extensive area of skin exposed or prolonged contact with blood	No treatment
Percutaneous exposure	Low titer: source patient asymptomatic and high CD4 count, recommend prophylaxis with zidovudine 600mg/day in two or three divided doses and lamivudine 150mg bid	If there is possible risk for HIV exposure, consider prophylaxis with zidovudine 600mg/day in two or three divided doses and lamivudine 150mg bid	Combination of factors, e.g. large-bore hollw needle and dep puncture contribute an increased risk for transmission if source is HIV (+)

Exposure	Source Patient HIV (+)	Source Patient Unknown	Considerations
Less severe, e.g. solid needle, superficial scratch	High titer: source patients has advanced AIDS, primary HIV infection, high or increasing viral load or low CD4 count, recommend prophylaxis with zidovudine 600mg/day in two or three divided doses and lamivudine 150mg bid and either indinavir 800mg every 8 hours or nelfinavir 750 mg tid
More severe, e.g. large-bore hollow needle, deep puncture, visible blood on device, or needle used in source patient’s artery or vein	Low titer or high titer: recommend prophylaxis with zidovudine 600mg/day in two or three divided doses and lamivudine 150mg bid and either indinavir 800mg every 8 hours or nelfinavir 750 mg tid
Source: Ling Moi Lin, et al, A Handbook of Infection Control for the Asian Healthcare Worker, 2nd edition

SUMMARY OF IMPORTANT RECOMMENDATIONS AND WORK RESTRICTION FOR PERSONNEL WITH OTHER INFECTIOUS DISEASES

Disease/Problem	Relieve From Direct Patient Contact	Partial Work Restriction	Duration	Category
Conjunctivitis, infectious		Yes	Until discharge ceases	II
Cytomegalovirus infections		No		II
Diarrhea (see 6.c.) Acute stage (diarrhea with other symptoms)		Yes	Until symptoms resolve and infection with Salmonella is ruled out	II
Convalescent stage
Salmonella (non-typhoidal)	No	Personnel should not take care of high-risk patients	Until is free of the infecting organism on two consecutive cultures not less than 24 hours apart	II
Other enteric pathogens	No	(See text & recommendation 6.c)		II
Enteroviral infections	No	Personnel should not take care of infants/newborns	Until symptoms resolve	II
Group A streptococcal disease			Until 24 hours after adequate treatment is started	I
Hepatitis, viral		Yes	Until 7 days after onset of jaundice	III
Hepatitis A				II
Hepatitis B	No	Personnel should wear gloves for procedures that involve trauma to tissue or contact with mucous membranes or non-intact skin	Until antigenemia resolves	II
Acute Chronic antigenemia	No	Same as acute illness	Until antigenemia resolves	II
Hepatitis NANB	No	Same as acute Hepatitis B	Period of infectivity has not been determined
Herpes simplex		(Note:  It is known whether gloves prevent transmission  Personnel should not take care of high risk patients)
Genital	No			II
Hands (herpetic whitlow)	Yes			Lesions until heal	I
Orofacial	No		Lesions until heal	I
Measles
Active	Yes		Until 7 days after the rash appears	I
Post exposure (Susceptible personnel)	Yes		From the 5th through the 21st day after the rash appears	I
Mumps
Active	Yes		Until 9 days after onset of parotitis	I
Post exposure	Yes*		From the 12th day after exposure or until 9 days after onset of parotitis	I

Disease/Problem	Relieve From Direct Patient Contact	Partial Work Restriction	Duration	Category
Pertussis
Active	Yes		From the beginning of the catarrhal stage through the 3rd week after onset of paroxysms or until 7 days	I
Post exposure (Asymptomatic personnel)	No			I
Post exposure (Symptomatic personnel)	Yes		Same as active pertussis	I
Rubella
Active	Yes		Until 5 days after the rash appears	I
Post exposure (Susceptible personnel)	Yes		From the 7th through the 21st day after exposure &/or 5 days after rash appears	II
Scabies	Yes		Until treated	I
Staphylococcus aureus (skin lesions)	Yes		Until lesions have been resolved	II
Upper respiratory infections (high-risk patients)	Yes	Personnel with upper respiratory infections do not take care of high risk patients (See 6.e.)	Until acute symptoms resolved	II
Zoster (Shingle)
Active	No	Appropriate barrier desirable; personnel do not take care of high-risk patients	Until lesions dry and crust	II
Post exposure (Susceptible personnel)	Yes		From the 10th through the 21st day after exposure or if varicella occurs until all lesions dry and crust	I
Varicella (Chickenpox)
Active	Yes		Until lesions dry and crust	I
Post exposure	Yes		From the 10th through the 21st day after exposure or if varicella occurs until all lesions dry and crust	I

* Mumps vaccine may be offered to susceptible personnel. When given after exposure, mumps vaccine may not provide protection. However, if exposure did not result in infection, immunizing exposed personnel should protect against subsequent infection. Neither mumps immune globulin nor immune serum globulin (ISG) is of established value in post exposure prophylaxis. Transmission of mumps among personnel and patients has not been a major problem in hospitals in the United States, probably due to multiple factors, including high levels of natural and vaccine-induced immunity.

DEVELOPMENT OF THE MCMC AVIAN INFLUENZA PANDEMIC PREPAREDNESS GUIDELINES

1. A. Avian Influenza

AI is an infectious disease of birds caused by type A strains of the influenza virus. The disease, which was first identified in Italy more than 100 years ago, occurs worldwide.[27] All birds are thought to be susceptible to infection with AI. Infection in birds causes a wide spectrum of symptoms, ranging from mild illness (low pathogenicity) to a highly contagious and rapidly fatal disease resulting in severe epidemics, which is known as “highly pathogenic AI” (HPAI). This form is characterized by sudden onset, severe illness, and rapid death of affected birds/flocks, with a mortality rate that can approach 100%.

Direct or indirect contact between domestic flocks and wild migratory waterfowl has been implicated as a frequent cause of epidemics in poultry populations. It is generally accepted that migratory waterfowl, most notably wild ducks, are the natural reservoir of AI viruses, which can be transmitted to domestic bird populations and to commercial poultry. 

1. B. Avian-to-Human AI A (H5N1) Transmission

The first human cases of AI A (H5N1) associated with the current outbreak in birds were confirmed in January 2004, after clinical samples taken from two children and one adult admitted to hospital in Hanoi with severe respiratory illness tested positive for this strain.[28]

Since then, additional human cases have occurred in several countries and the clinical spectrum of AI a (H5N1) infection in human ranges from asymptomatic infection to severe disseminated disease.

1. C. World Health Organization (WHO) Recommends

Develop a response plan by pandemic phase. The response plan should indicate the specific response during each phase of a pandemic, and should reflect the detail of the preparedness plan.

1. D. General Rules

1. 1. STAGE 2 – Avian influenza in domestic fowls
1. a. Preparation: stacking of additional PPEs’
• ♣ Stacking of antiviral agents (Oseltamivir)
• ♣ Stacking of additional antimicrobials for pneumonia (according to CPG)
• ♣ Immunization of identified 1^st line HCWs’ 
• ♣ Preparation of contingency plan in cases of absences of clinical and non-clinical personnel
• ♣ Heightened alert/ training of HCWs’
• ♣ Preparation of the appropriate airborne infection isolation room  at the ER (Please Refer to Attachment H)

1. b. Surveillance

• ♣ Start surveillance of all cases presenting with symptoms suggestive of AI at the emergency room
• ♣ Consider the diagnosis of AI:
• - In all patients who present with severe acute febrile respiratory illness (e.g., fever > 38° C, cough, shortness of breath) or other severe unexplained illness (e.g., encephalopathy or diarrhea),[13] particularly in patients with a history of bird exposure, exposure to known or suspected AI-infected patients, or exposure to other severely ill people.
• - Family members who accompany suspected AI-infected patients to the health care facility can be assumed to have been potentially exposed to AI and should also be evaluated for AI infection.

1. 2. STAGE 3 - Avian Influenza  from poultry to humans
1. a. Preparation

• ♣ Preparation of the 14^th floor isolation rooms (i.e., creation of an ante-room). Please Refer to Attachment H)
• ♣ Weekly meeting of the HICC Execom which will act as the AI Task Force
• ♣ Heightened surveillance at the ER 
• ♣ Policy of no direct admissions for cases of fever and respiratory symptoms
• ♣ Weekly audit of the use of antiviral by the pharmacy and therapeutics committee

1. b. Surveillance

• ♣ Start surveillance of all cases presenting with symptoms suggestive of AI at the emergency room
• ♣ Consider the diagnosis of AI:
• - In all patients who present with severe acute febrile respiratory illness (e.g., fever > 38° C, cough, shortness of breath) or other severe unexplained illness (e.g., encephalopathy or diarrhea),[13] particularly in patients with a history of bird exposure, exposure to known or suspected AI-infected patients, or exposure to other severely ill people.
• - Family members who accompany suspected AI-infected patients to the health care facility can be assumed to have been potentially exposed to AI and should also be evaluated for AI infection.

(Please refer to General Rule – Stage No. 2, Surveillance)

1. c. Management of suspected AI Case

• ♣ All stable patients will be isolated at the emergency room and subsequently  transferred to referral hospital (RITM, Lung Center)
• ♣ Unstable patients will be managed at the emergency room for immediate transfer to referral hospital once stabilized
• ♣ Only critically ill patients will be admitted, and shall be confined  at the Isolation ICU-B under the services of  ID and pulmonary consultants
• ♣ No more admissions are allowed once the three cubicles at the Isolation ICU-B are filled up

1. 3. STAGE 4 – Human-to-human transmission of AI
1. a. Preparation

• ♣ Creation of contingency plan in case when the Isolation ICU-B and the 14^th floor isolation rooms are already filled up (additional rooms converted to negative-pressure rooms? Or absorption of non-AI cases?)
• ♣ Training of non-clinical personnel as back-up HCWs’ who will attend to suspected AI patients

1. b. Surveillance

• ♣ Use updated criteria for diagnosis of AI
• ♣ Surveillance to be done even in MATI information and the doctors clinic

1. c. Management of Cases

• ♣ Strict triage at the ER, limitation of visitors to the hospital premises
• ♣ Stable cases will be admitted at the 14^th floor Isolation rooms
• ♣ Unstable/critical cases will be admitted at the Isolation ICU-B
• ♣ All cases should be referred to either an ID or pulmonary consultant
• ♣ No further admissions once all the isolation rooms are already filled up 
• ♣ Release of antiviral drugs only upon ICC approval
• ♣ In cases when there will be overflow of suspected AI cases in RITM and/or Lung Center, the hospital shall coordinate with them to absorb non-AI cases for further management in our institution

1. E. Infection Control Strategies

1. 1. Summary of WHO recommendations:
• ♣ Standard and droplet precautions should be the minimum level of precautions to be used in all health care facilities when providing care for patients with acute respiratory illness, regardless of whether AI infection is suspected. The most critical elements of these precautions include facial protection (eyes, nose, and mouth) and hand hygiene and these precautions should be prioritized. (Please refer to Guidelines for Health Care Facilities – Initiation of AI Infection Control Precautions in Health Care Facilities)
• ♣ Full barrier precautions, which include standard, contact, and airborne precautions (plus eye protection) should be used, when possible, when providing care for suspected or
• ♣ Confirmed AI-infected patients with close patient contact and during aerosol-generating procedures.
• ♣ Because some elements of full barrier precautions (particularly those related to airborne precautions) may not be available in all health care facilities, minimal requirements for caring for AI-infected patients should include standard, contact, and droplet precautions (plus eye protection when within 1 meter of patient and for all aerosol-generating procedures). Additional elements should be prioritized and pursued when resources permit.

• 2. MCMC-HICC Comprehensive Infection Control Policies 

• a. Emergency Room
• ♣ All patients with fever and respiratory symptoms will be given surgical mask and will stay in a separate room to accomplish a checklist for screening of possible avian influenza (AI).
• ♣ In cases when criteria for possible AI were not met the patient can be placed in the general observation area.
• ♣ In cases when the patients satisfies the criteria for possible AI, the patient will be placed in the isolation room (if unoccupied) or inside a cubicle (with a mask on) three feet away from the next bed/cubicle. 
• ♣ Doctors and HCWs’ should wear N95 mask upon entering the isolation room.
• ♣ Doctors and HCWs’ will practice strict hand washing in a designated washing area after attending to the patient (and after removing his N95 mask) before going back to the nurses station.
• ♣ One relative is allowed to stay with the patient inside the isolation room only if patient’s condition necessitates assistance. The relative will be instructed to wear a surgical mask while inside the isolation room.
• ♣ The Isolation room will be disinfected using Lysol solution and Lysol spray in between placement of patients.

• b. Transfer to Referral Hospital:

• ♣ In cases when the patient’s condition is stable, he will be transferred to a referral hospital via ambulance conduction
• ♣ Resident-on-duty will endorse to the physician in the referral hospital the case prior to transfer
• ♣ The ambulance driver and accompanying healthcare worker shall wear N95 masks. If possible the driver should be separated by a glass panel or a plastic cover from the patient.
• ♣ The ambulance interiors will be disinfected using Lysol solution and Lysol spray will be applied before the next use.

• c. In cases of admission (stages 3&4):

• ♣ All patients being worked up as a case of AI will be admitted in the isolation rooms (1414-1419) or ICU Isolation B as necessary.
• ♣ Entry to room will be limited only to the Nurse-in-Charge (NIC), Resident-in-Charge (RIC), and Attending Physician (AP). No members of the housekeeping and Dietary service will enter the room.
• ♣ All HCWs’ will wear N95 mask, goggles, gown and gloves when handling the patient.
• ♣ All HCWs’ will discard his gloves and should have washed his hands inside the washing area in the patient’s room before leaving the room.
• ♣ He shall then remove his goggles, gown and N95 mask (proper technique as in SARS) and put inside a resealable container and wash his hands again in the designated washing area before going to the nurses station.
• ♣ Only one nurse will handle all suspected cases of AI.  

• d. The MCMC Policies on caring for the deceased, handling soiled materials, housekeeping and collection of specimen for transport to referral laboratory will be completely based on the policies published by the WHO (Avian Influenza, including Influenza A (H5N1), in Humans: WHO Interim Infection Control Guideline for Health Care Facilities amended: 9 February 2006)

• 3. Management of exposed HCWs’

• a. WHO Recommendation:

• ♣ Antiviral prophylaxis after AI exposure

Antiviral drugs have demonstrated efficacy in the treatment and prevention of seasonal influenza A.[60, 61] Additional data are needed on the role of antiviral in the treatment and prophylaxis of AI. Older M2 inhibitor antiviral (amantidine and ramantidine) are ineffective against AI A(H5N1) in vitro, [62] but AI A(H5N1) is susceptible in vitro to neuraminidase inhibitors (oseltamivir and zanamivir).[63-65] The optimal dose and duration of treatment for AI with neuraminidase inhibitors are unknown. Of 25 AI A(H5N1) patients who received oseltamivir, 19 died. However, treatment may have been started too late to be effective.[7, 28] The development of antiviral resistance is also a concern and oseltamivir resistance has been detected in AI A(H5N1) isolates from several patients treated with oseltamivir.[66, 67] Even if proven effective for treatment or prophylaxis of AI A(H5N1), neuraminidase inhibitors are expensive and current supplies are limited. Health care facilities should follow the national policy on antiviral prophylaxis of HCWs providing care for AI infected patients.

• ♣ Antiviral prophylaxis for potentially exposed HCWs

Although the efficacy of neuraminidase inhibitors as prophylaxis for AI - (H5N1) is unknown, prophylaxis is suggested for exposed HCWs because of the high mortality of the disease.

When used for potentially exposed HCWs, the HCW should take 75 mg oseltamivir phosphate each day for at least 7 days beginning immediately or as soon as possible after unprotected exposure (< 48 hours) to a AI A(H5N1) infected patient. When used, prophylaxis should continue until 1 week after the last unprotected exposure. 

• b. MCMC Policies of management of exposed HCWs’
• ♣ The MCMC HICC Execom which acts as the AI Task force will decide on who among the HCWs’ have significant exposure needing prophylaxis. 
• ♣ All HCWs’ directly in-charge with taking care of AI cases will be monitored daily and upon development of flu-like symptoms will be evaluated and managed accordingly (Please refer to Attachment I)

1. F. Case Management and Treatment

1. 1. Department of Health (DOH) Guidelines

• a. Decisions on who should stay home and who should be admitted

• ♣ Who should stay at home?

Patients with fever and/or cough or individuals without serious medical conditions may stay at home for symptomatic treatment, take adequate rest, and practice personal hygiene to prevent spread of the disease

• ♣ Who should be admitted to the hospitals?

The following patients with flu-like symptoms should be admitted:

• - Age 6 to 23 months 50 yrs and above
• - With underlying diseases such as chronic cardiovascular disease, chronic lung disease, chronic metabolic diseases, immunossuppressed and those with hemoglobinopathies
• - Residents of nursing homes
• - Health care workers

• b. Management of Influenza pandemic cases:

• ♣ Unless shown otherwise during a pandemic, it is presumed that antiviral agents, if given within the first two days of illness, may be effective in halting the progress of the illness and in the prevention of complications.
• ♣ Osetalmivir may be given to patients with 1st 2 days of illness, if available
• ♣ Antibiotics given IV shall be provided to influenza cases with pneumonia complications
• ♣ IV fluids and IV paraphernalia
• ♣ Ventilator will be used only if indicated and appropriate infection measures shall be carried out.
• ♣ Management of pneumonia shall be based on the PSMID

      

1. 2. Who Advice on Use of Oseltamivir?

Oseltamivir (Tamiflu®) is recommended for use for both treatment and prophylaxis of influenza. The currently recommended doses are:

• a. For treatment of influenza
• ♣ Adults: 75 milligrams (mg) two times a day for five days.
• ♣ Children 1 year of age or older: weight adjusted doses
• - 30mg twice daily for = 15 kg
• - 45mg twice daily for >15 to 23 kg
• - 60mg twice daily for >23 to 40kg
• - 75mg twice daily for >40kg
• ♣ Children up to 1 year of age: not recommended

• b. For prevention of influenza:

• ♣ Adults and teenagers 13 years of age or older: 75 mg once a day for at least seven days.
• ♣ Children from 1 year to 13 years of age:
• - 30mg daily for = 15 kg
• - 45mg daily for >15 to 23 kg
• - 60mg daily for >23 to 40kg
• - 75mg daily for >40kg

In the context of the human cases of avian influenza, WHO has reviewed the limited available information and evidence about the effectiveness and safety of oseltamivir for the treatment of patients with avian influenza and also its use as prophylaxis in health workers and those involved in managing an outbreak.

1. 3. MCMC guidelines on the management of pandemic influenza and use of antiviral (Oseltamivir) will be based on the published guidelines of the WHO, DOH, and specialty societies.
2. 4. All admitted AI cases shall be referred to if not managed by ID and pulmonary specialists.
3. 5. Management of cases involves contact tracing and subsequent referral to DOH for quarantine purposes.

INFECTION CONTROL RECOMMENDATIONS FOR AVIAN INFLUENZA IN HEALTHCARE FACILITIES

Health-Care Facility Infection Control Recommendations for Avian Influenza (AI)

The current avian influenza A (H5N1) epidemic in birds began in south-east Asia in 2003 and has since spread to other parts of the world. Human cases have been reported in several countries since December 2003 and health-care facilities in several countries now face the challenge of providing care for patients infected with avian influenza (AI). It is critical that health-care workers use appropriate infection control precautions when providing care for these patients to minimize the possibility of transmission of infection to themselves, other health-care workers, patients, and visitors.

As of the date of this document, no efficient human-to-human transmission of AI A (H5N1) is known to have occurred, and there is no evidence to suggest airborne transmission from humans to humans. However, enhanced infection control precautions for patients with suspected or confirmed AI infection appear to be warranted because of the uncertainty about the modes of human-to-human AI transmission, the high lethality of human AI A (H5N1) infection to date, and the possibility that the virus could mutate or reassort at any time into a strain capable of efficient human-to-human transmission. 

Policy Guidelines

1. A. Important Advice

1. 1. Use standard and droplet precautions when providing care for patients with acute, febrile, respiratory illness, regardless of whether AI infection is suspected. Facial protection and hand hygiene are the most critical elements of these precautions and should be prioritized.
2. 2. Full barrier precautions (standard, contact, and airborne precautions) should be used, when possible, when working in direct contact with suspected or confirmed AI-infected patients.
3. 3. Because the use of airborne precautions may not be feasible in all health-care facilities, minimal requirements when providing care for AI-infected patients should include standard, contact, and droplet precautions, plus eye protection. Elements of airborne precautions should be prioritized and pursued when resources permit.

• B. Personal Protective Equipment (PPE) and Hand Hygiene Checklist

1. 1. Before entering the AI patient room or area, put on PPE including:
• ♣ Clean, non-sterile long-sleeved gowns.
• ♣ If cloth gowns are used, a plastic apron should also be used if splashing of blood, body fluids, excretions, or secretions is anticipated.
• ♣ Clean, nonsterile, ambidextrous gloves, which cover the cuffs of the gown.
• ♣ Face shield, visor, or goggles.
• ♣ A particulate respirator that is at least as protective as a US NIOSH-certified N95, EU FFP2, or equivalent respirator. If particulate respirators are not available, use surgical or procedure masks.
2. 2. Put on PPE carefully before patient contact to avoid the need for adjustments and to reduce the risk of self-contamination/inoculation. 
3. 3. Remove PPE carefully to avoid self-contamination/inoculation.
4. 4. Perform hand hygiene before and after any patient contact and after contact with contaminated items, whether or not gloves are worn.

• ♣ Perform hand hygiene before putting on PPE, immediately after glove removal, and after taking off all PPE items.
• ♣ Hand hygiene includes either hand washing with soap and water, followed by drying with a clean towel or, preferably, the use of an alcohol-based hand rub.
• ♣ Wash hands with soap and water when they are visibly soiled.

(For more detailed information, please refer to Avian Influenza, including Influenza A (H5N1), in Humans: World Health Organization Interim Infection Control Guideline for Health-care Facilities available at http://www.who.int/csr/disease/avian_influenza/guidelines/infectioncontrol1/en/index.html)

1. C. Health-Care Facility Infection Control Recommendations for Avian Influenza (AI) – Hey Elements at a Glance

(For detailed information, please refer to Epidemic and Pandemic Alert and Response; www.who.int/csr)

• 1. Basic infection control recommendations for all health-care facilities
• ♣ Standard and droplet precautions when caring for patients with acute, febrile, respiratory illness

• 2. Respiratory hygiene/cough etiquette

• ♣ Individuals with respiratory symptoms should cover cough with mask or tissue and perform hand hygiene 

• 3. Early recognition and reporting of AI cases

• ♣ Consider AI in patients with acute, febrile, respiratory illness who have been in an AI-affected region within the 2 weeks prior to symptom onset and who have had exposure to birds or to a human AI case in the region

• 4. Isolation precautions for suspected and confirmed AI cases

• ♣ Place patient in negative pressure room (if available). Full barrier precautions (standard, contact, and airborne) for all persons entering the isolation room 

• 5. Additional measures to reduce nosocomial AI transmission 

• ♣ Limit numbers of health-care workers/family members/visitors exposed to AI patient

• 6. Specimen collection/transport/handling within health-care facilities

• ♣ Use full barrier precautions for specimen collection. Use standard precautions for specimen transport to the laboratory. Health-care facility laboratories should follow best biosafety practices

• 7. Family member/visitor recommendations

• ♣ Family members/visitors should be limited to those essential for patient support and should use full barrier precautions

• 8. Patient transport within health-care facilities

• ♣ AI patient should wear surgical mask. Health-care workers doing transport should wear gowns and gloves

• 9. Pre-hospital care

• ♣ Full barrier precautions for all involved with suspected AI patients

• 10. Waste disposal

• ♣ Treat waste possibly contaminated with AI virus as clinical waste following local regulations

• 11. Dishes/eating utensils

• ♣ Use standard precautions

• 12. Linen and laundry

• ♣ Use standard precautions; avoid shaking linen/laundry

• 13. Environmental cleaning and disinfection

• ♣ AI virus can survive in the environment for variable periods of time (hours to days), and is inactivated by standard hospital disinfectants. Clean and disinfect AI patient room at least once a day; frequently touched surfaces should be cleaned more often

• 14. Patient care equipment

• ♣ Dedicate to AI patient. If not possible, clean and disinfect before reuse

• 15. Duration of AI infection control precautions

• ♣ Adults >12 years: 7 days after resolution of fever
• ♣ Children <12 years: 21 days after symptom onset

• 16. Patient discharge

• ♣ If AI patient is still infectious (i.e. discharged within the period of AI infection control precautions: see box above), instruct family members on appropriate infection control precautions in the home 

• 17. Occupational health recommendations

• ♣ Monitor health of health-care workers exposed to AI patients. Antiviral prophylaxis should follow local policy. Use of seasonal influenza vaccine should be promoted

• 18. Health-care facility administrative controls

• ♣ Health-care worker AI education, training, and risk communication. Adequate staffing and PPE

• 19. Prioritization of PPE when supplies are limited

• ♣ Facial protection (eyes, nose, and mouth) and hand hygiene are priorities

• 20. Health-care facility engineering controls

• ♣ If single rooms for AI patients are not possible, cohort patients in isolation wards keeping at least 1 m between beds. Negative pressure rooms for AI patients, if available 

WORLD HEALTH ORGANIZATION (WHO) CASE DEFINITIONS FOR HUMAN INFECTIONS WITH INFLUENZA A (H5N1) VIRUS

1. A. Background

Prompt and accurate reporting of H5N1 influenza cases to WHO is the cornerstone for monitoring both the global evolution of this disease and the corresponding risk that a pandemic virus might emerge. In collaboration with several partners, WHO has developed standardized case definitions to facilitate:

1. 1. Reporting and classification of human cases of H5N1 infection by national and international health authorities.
2. 2. Standardization of language for communication purposes.
3. 3. Comparability of data across time and geographical areas.

1. B. Application of the H5n1 Case Definitions

1. 1. The case definitions apply to the current phase of pandemic alert (phase 3) and may change as new information about the disease or its epidemiology becomes available.
2. 2. National authorities should formally notify only probable and confirmed H5N1 cases to WHO. The case definitions for persons under investigation and suspected cases have been developed to help national authorities in classifying and tracking cases.
3. 3. The case definitions are not intended to provide complete descriptions of disease in patients but rather to standardize reporting of cases. 
4. 4. In clinical situations requiring decisions concerning treatment, care or triage of persons who may have H5N1 infection, those decisions should be based on clinical judgment and epidemiological reasoning, and not on adherence to the case definitions. While most patients with H5N1 infection have presented with fever and lower respiratory complaints, the clinical spectrum is broad.

1. C. Case Definitions

1. 1. Person under investigation
• ♣ A person whom public health authorities have decided to investigate for possible H5N1 infection.

1. 2. Suspected H5N1 case

• ♣ A person presenting with unexplained acute lower respiratory illness with fever (>38 ºC ) and cough, shortness of breath or difficulty breathing. 
• ♣ One or more of the following exposures in the 7 days prior to symptom onset: 

• - Close contact (within 1 metre) with a person (e.g. caring for, speaking with, or touching) who is a suspected, probable, or confirmed H5N1 case;
• - Exposure (e.g. handling, slaughtering, defeathering, butchering, preparation for consumption) to poultry or wild birds or their remains or to environments contaminated by their faeces in an area where H5N1 infections in animals or humans have been suspected or confirmed in the last month;
• - Consumption of raw or undercooked poultry products in an area where H5N1 infections in animals or humans have been suspected or confirmed in the last month;
• - Close contact with a confirmed H5N1 infected animal other than poultry or wild birds (e.g. cat or pig);
• - Handling samples (animal or human) suspected of containing H5N1 virus in a laboratory or other setting.

1. 3. Probable H5N1 case (notify WHO)

• ♣ Probable definition 1:

• - A person meeting the criteria for a suspected case and
• - One of the following additional criteria: 
• ¬ Infiltrates or evidence of an acute pneumonia on chest radiograph plus evidence of respiratory failure (hypoxemia, severe tachypnea) 
• ¬ Positive laboratory confirmation of an influenza A infection but insufficient laboratory evidence for H5N1 infection. 

• ♣ Probable definition 2:
• - A person dying of an unexplained acute respiratory illness who is considered to be epidemiologically linked by time, place, and exposure to a probable or confirmed H5N1 case.

1. 4. Confirmed H5N1 case (notify WHO)

• ♣ A person meeting the criteria for a suspected or probable case 
• ♣ One of the following positive results conducted in a national, regional or international influenza laboratory whose H5N1 test results are accepted by WHO as confirmatory: 
• - Isolation of an H5N1 virus; 
• - Positive H5 PCR results from tests using two different PCR targets, e.g. primers specific for influenza A and H5 HA;
• - A fourfold or greater rise in neutralization antibody titer for H5N1 based on testing of an acute serum specimen (collected 7 days or less after symptom onset) and a convalescent serum specimen. The convalescent neutralizing antibody titer must also be 1:80 or higher;
• - A microneutralization antibody titer for H5N1 of 1:80 or greater in a single serum specimen collected at day 14 or later after symptom onset and a positive result using a different serological assay, for example, a horse red blood cell haemagglutination inhibition titer of 1:160 or greater or an H5-specific western blot positive result.

CASE DEFINITIONS FOR SURVEILLANCE OF SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

Objective 

• ♣ To describe the epidemiology of SARS and to monitor the magnitude and the spread of this disease, in order to provide advice on prevention and control.

Case Definitions (Revised 1 May 2003)

1. A. Introduction

The surveillance case definitions based on available clinical and epidemiological data are now being supplemented by a number of laboratory tests and will continue to be reviewed as tests currently used in research settings become more widely available as diagnostic tests. Preliminary clinical description of Severe Acute Respiratory Syndrome summarizes what is currently known about the clinical features of SARS. Countries may need to adapt case definitions depending on their own disease situation. Retrospective surveillance is not expected.

Clinicians are advised that patients should not have their case definition category downgraded while awaiting results of laboratory testing or on the bases of negative results. (For detailed information, please refer to Use of Laboratory Methods for SARS Diagnosis at http://www.who.int/csr/sars/labmethods/en/)

1. B. Suspect Case 

1. 1. A person presenting after 1 November 2002¹ with history of: 

• ♣ High fever (>38 °C) and 
• ♣ Cough or breathing difficulty
• ♣ And one or more of the following exposures during the 10 days prior to onset of symptoms:
  -  close contact² with a person who is a suspect or probable case of SARS;
  -  history of travel, to an area with recent local transmission of SARS
  -  residing in an area with recent local transmission of SARS 

• 2. A person with an unexplained acute respiratory illness resulting in death after 1 November 2002,¹but on whom no autopsy has been performed and one or more of the following exposures during to 10 days prior to onset of symptoms: 
• ♣ close contact,² with a person who is a suspect or probable case of SARS; 
• ♣ history of travel to an area with recent local transmission of SARS 
• ♣ residing in an area with recent local transmission of SARS 

1. C. Probable case 

1. 1. A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) on chest X-ray (CXR).
2. 2. A suspect case of SARS that is positive for SARS coronavirus by one or more assays. 

(For detailed information, please refer to Use of Laboratory Methods for SARS Diagnosis at http://www.who.int/csr/sars/labmethods/en/)

1. 3. A suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause.

1. D. Exclusion Criteria

1. 1. A case should be excluded if an alternative diagnosis can fully explain their illness. 

1. E. Reclassification of Cases

As SARS is currently a diagnosis of exclusion, the status of a reported case may change over time. A patient should always be managed as clinically appropriate, regardless of their case status. 

1. 1. A case initially classified as suspect or probable, for which an alternative diagnosis can fully explain the illness, should be discarded after carefully considering the possibility of co-infection.
2. 2. A suspect case that, after investigation, fulfils the probable case definition should be reclassified as "probable".
3. 3. A suspect case with a normal CXR should be treated, as deemed appropriate, and monitored for 7 days. Those cases in which recovery is inadequate should be re-evaluated by CXR.
4. 4. Those suspect cases in whom recovery is adequate but whose illness cannot be fully explained by an alternative diagnosis should remain as "suspect".
5. 5. A suspect case who dies, on whom no autopsy is conducted, should remain classified as "suspect". However, if this case is identified as being part of a chain transmission of SARS, the case should be reclassified as "probable". 
6. 6. If an autopsy is conducted and no pathological evidence of RDS is found, the case should be "discarded".

1. F. Reporting procedures
   

1. 1. All probable SARS cases should be managed in the same way for the purposes of infection control and outbreak containment 
2. 2. At this time, WHO is maintaining surveillance for clinically apparent cases only ie probable and suspect cases of SARS. (Testing of clinically well contacts of probable or suspect SARS cases and community based serological surveys are being conducted as part of epidemiological studies which may ultimately change our understanding of SARS transmission. However, persons who test SARS CoV positive in these studies will not be notified as SARS cases to WHO at this time).
3. 3. Where laboratory tests are not available or not done, probable SARS cases as currently defined above should continue to be reported in the agreed format.
4. 4. Suspect cases with positive laboratory results will be reclassified as probable cases for notification purposes only if the testing laboratories use appropriate quality control procedures.
5. 5. No distinction will be made between probable cases with or without a positive laboratory result and suspect cases with a positive result for the purposes of global surveillance. WHO will negotiate sentinel surveillance of SARS with selected partners to collect detailed epidemiological, laboratory and clinical data.
6. 6. Cases that meet the surveillance case definition for SARS should not be discarded on the basis of negative laboratory tests at this time.

1. G. Rationale For Retaining The Current Surveillance Case Definitions For SARS
   

The reason for retaining the clinical and epidemiological basis for the case definitions is that at present there is no validated, widely and consistently available test for infection with the SARS coronavirus. Antibody tests may not become positive for three or more weeks after the onset of symptoms. We do not yet know if all patients will mount an antibody response. Molecular assays must be performed using appropriate reagents and controls under strictly controlled conditions, and may not be positive in the early stages of illness using currently available reagents. We are not yet able to define the optimal specimen to be tested at any given stage of the illness. This information is accruing as more tests are being performed on patients with known exposures and/or accompanied by good clinical and epidemiological information. We hope that in the near future an accessible and validated diagnostic assay(s) will become available which can be employed with confidence at a defined, early stage of the illness.

Legend:

¹    The surveillance period begins on 1 November 2002 to capture cases of atypical pneumonia in China now recognized as SARS. International transmission of SARS was first reported in March 2003 for cases with onset in February 2003. 

²    Close contact: having cared for, lived with, or had direct contact with respiratory secretions or body fluids of a suspect or probable case of SARS.

HOSPITAL INFECTION CONTROL GUIDANCE FOR SEVERE ACUTE RESPIRATORY SYNDROME (Revised 24 April 2003)

Outpatient/Triage Setting

1. 1. Those presenting to health care facilities who require assessment for SARS should be rapidly diverted by triage nurses to a separate area to minimize transmission to others 
2. 2. Those patients should be given a face mask to wear, preferably one that provides filtration of their expired air. 
3. 3. Staff involved in the triage process should wear a face mask (see below) and eye protection and wash hands before and after contact with any patient, after activities likely to cause contamination and after removing gloves 
4. 4. Wherever possible, patients under investigation for SARS should be separated from the probable cases. 
5. 5. Soiled gloves, stethoscopes and other equipment have the potential to spread infection. 
6. 6. Disinfectants such as fresh bleach solutions, should be widely available at appropriate concentrations. 

Inpatient Setting

Care for probable SARS cases (Please refer to Case Definitions for Surveillance of Severe Acute Respiratory Syndrome (SARS) 

1. 1. Probable SARS cases should be isolated and accommodated as follows in descending order of preference: 

• ♣ negative pressure rooms with the door closed 
• ♣ single rooms with their own bathroom facilities 
• ♣ cohort placement in an area with an independent air supply, exhaust system and bathroom facilities 

1. 2. Turning off air conditioning and opening windows for good ventilation is recommended if an independent air supply is unfeasible. Please ensure that if windows are opened they are away from public places 
2. 3. WHO advises strict adherence to the barrier nursing of patients with SARS, using precautions for airborne, droplet and contact transmission 
3. 4. All staff, including ancillary staff should be trained in the infection control measures required for the care of such a patient 
4. 5. A member of staff must be identified who will have the responsibility of observing the practice of others and provide feedback on infection control 
5. 6. Disposable equipment should be used wherever possible in the treatment and care of patients with SARS and disposed of appropriately. If devices are to be reused, they should be sterilized in accordance with manufacturers’ instructions. Surfaces should be cleaned with broad spectrum disinfectants of proven antiviral activity 
6. 7. Movement of patients outside of the isolation unit should be avoided. If moved the patients should wear a face mask 
7. 8. Visitors, if allowed by the health care facility should be kept to a minimum. They should be issued with personal protective equipment (PPE) and supervised 
8. 9. All non-essential staff (including students) should not be allowed on the unit/ward 
9. 10. Handwashing is crucial: therefore access to clean water is essential
   Hands should be washed before and after contact with any patient, after activities likely to cause contamination and after removing gloves 
10. 11. Alcohol-based skin disinfectants could be used if there is no obvious organic material contamination 
11. 12. Particular attention should be paid to interventions such as the use of nebulisers, chest physiotherapy, bronchoscopy or gastroscopy; any other interventions which may disrupt the respiratory tract or place the healthcare worker in close proximity to the patient and potentially infected secretions. 
12. 13. PPE should be worn by all staff and visitors accessing the isolation unit 
13. 14. The PPE worn in this situation should include: 

• ♣ A face mask providing appropriate respiratory protection 
• ♣ Single pair of gloves 
• ♣ Eye protection 
• ♣ Disposable gown 
• ♣ Apron 
• ♣ Footwear that can be decontaminated 

1. 15. All sharps should be dealt with promptly and safely 
2. 16. Linen from the patients should be prepared on site for the laundry staff. Appropriate PPE should be worn in this preparation and the linen should be put into biohazard bags 
3. 17. The room should be cleaned by staff wearing PPE using a broad spectrum disinfectant of proven antiviral activity 
4. 18. Specific advice concerning air conditioning units will be available soon 
5. 19. Respiratory protection. This should where feasible be provided at *P100/FFP3, or P99/FFP2 filter level (99.97% and 99% efficiency respectively). *N95 filters (95% filter efficiency) also provide high levels of protection and could be worn where no acceptable higher protection alternatives are available for example staff working in triage areas, prior to isolation. Ideally, the masks used should be fit tested using an appropriate "fit test kit" in accordance with the manufacturing instructions. Disposable masks should not be reused. 
6. 20. *N/R/P 95/99/100 or FFP 2/3 or an equivalent national manufacturing standard (NIOSH (N,R,P 95,99,100) or European CE EN149:2001(FFP 2,3) and EN143:2000 (P2) or comparable national/regional standards applicable to the country of manufacture. 

NOSOCOMIAL INFECTION SURVEILLANCE PROCEDURES AT MANDALUYONG CITY MEDICAL CENTER

1. I. Background

Excellence and quality in the provision of care is a core value of Mandaluyong City Medical Center. As such, the Infection Control Program (ICP) of Mandaluyong City Medical Center is an integral component of quality care in the hospital. The aim of the program is to control and prevent hospital infections, thus reducing the hospital stay of patients and costs associated with hospitalization. The infection control program is carried out through education and training of the hospital staff, surveillance of nosocomial infections, and implementation of interventions to reduce these infections.

The Infection Control Committee (ICC) has overall responsibility for the education, training and conduct of activities for the control and prevention of hospital infection.  It recognizes that timely and continuous collection of data on hospital infections is important to establish the extent of the problem, to institute proper interventions to address the problem and to monitor the effectiveness of such interventions to address the problem and to monitor the effectiveness of such interventions. This protocol describes objectives, components, and standard procedures for NIS in Mandaluyong City Medical Center.

1. II. Objectives of the NIS:

The specific objectives of the NIS are:

• ♣ To reduce the risk of hospital infection in Mandaluyong City Medical Center
• ♣ To establish baseline rates of endemic nosocomial infection in high-risk areas
• ♣ To identify outbreaks and disseminate surveillance data to hospital staff on a regular basis
• ♣ To institute prevention and control measures as necessary; and
• ♣ To monitor the effectiveness of such measures through continuous evaluation of data collected.

The ICC thus aims to integrate surveillance activities into an action-oriented feedback loop, a shown below:

Surveillance is “ the ongoing systematic collection, analysis and interpretation of health data essential to the planning, implementation and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know” [CDC, 1988]. At the heart of the NIS is the collection of data on nosocomial infections, defined by the U.S.  CDC National Nosocomial Infections Surveillance (NNIS) [Garner et al., 1988], and adopted by the MCMC ICC, as:

…a localized or systematic condition that results from adverse reaction to the presence of is infectious agent(s) or its toxin(s) and that was not present or incubating at the time of admission to the hospital.

In general, this taken to mean that the infection becomes clinically evident at 48 hours or more after hospital admission.

1. III. Surveillance Methods

Active, prospective surveillance will be the mode of operation of the MCMC NIS, carried out by an infection control professional (ICP). The Hospital Infection Control Committee (HICC) will oversee the activities, which is under Medical Quality Improvement Office headed by Dr. Jose M. Acuin. The current composition of the HICC is as follows:

1. 1. Adviser : ZALDY R. CARPESO, MD
2. 2. Chairman : VICENTE S. QUIMPO, MD
3. 3. Vice-Chairman :  FERNANDO S. SANTOS, MD
4. 4. HICC Nurse :  EVANGELINE L. MENDOZA, RN, MAN

: MERLINA LICO, RN, MAN

Executive Committee:

1. 1. Surgery : GUILLERMO S. AMIGO, JR., MD / ALEXANDER G. UELTA, MD
2. 2. Medicine :
3. 3. OB-Gyne : CATHERINE A. BRINGAS, MD
4. 4. Pediatrics : JULIETA C. CONGE, MD
5. 5. Nursing : TERESITA J. DIMAYACYAC, RN, MAN

The HICC is supported in its function through the supervisory heads of the different hospital areas, namely:

1. 1. NSO – Training : MANUEL A. PACHECO, RN, MAN
2. 2. Intensive Care Unit : JEB BAUTISTA, RN
3. 3. Neonatal Intensive Care Unit : VIRGINITA DE GUZMAN, RN
4. 4. Surgery Suite : VIRGINIA REY, RN
5. 5. Emergency Department : IMELDA DELA TORRE, RN
6. 6. Dialysis : ALLAN MANILA, RN
7. 7. Pharmacy : JINKY ACUBA
8. 8. Housekeeping : JOSEPHINE M. SALES
9. 9. Pulmonary : MARLYN NICOLAS
10. 10. Human Resource Department : HEIDI HERNANDEZ
11. 11. Linen : LUCINA G. BAUTISTA

Targeted surveillance of all areas at high risk for nosocomial infection will be conducted, with the ICPs doing daily rounds, including weekends.  These areas include:

1. 1. Intensive Care Unit (included medical, surgical, neurosurgical care)
2. 2. Pediatric ICU
3. 3. High-risk Nursery Unit

Studies have shown that there are disproportionately more hospital-acquired infections among patients in ICUs compared to non-critical care areas [Donowitz et al., 1982; Hemming et al., 1976; Goldman et al., 1981].

In addition, surgical site infections will be monitored for the following operative procedures:

1. 1. Cardiac surgery procedures: coronary artery bypass graft coronary bypass graft with both chest and leg donor (CBGB) and coronary bypass graft with chest incision only (CBGO) 
2. 2. Neurosurgical procedures: craniotomy (CRAN) and ventricular shunt (VSHN)
3. 3. Cholecystectomy (CHOL)

Evidence fro nosocomial infection is based on a combination of clinical findings and pertinent laboratory results and work-up. A physician’s or surgeon clinical diagnosis of infection, compatible with definitions of specific nosocomial infections for the NIS definitions for 13 major site categories and 48 specific sites) is also accepted and reported.

Standardized protocols from the NNIS will be adopted for the following surveillance   components of the MCMC NIS: (?)

1. 1. Adult and pediatric intensive care unit surveillance component
2. 2. High-risk nursery surveillance component
3. 3. Surgical patient surveillance component
4. 4. Antimicrobial resistance component

Continuous surveillance of the above will be done by the ICPs, with the data aggregated on a monthly basis. Quarterly and annual surveillance reports will be presented at the HICC General Staff Meeting. Demographic data such as age and sex will be collected together with co-morbid conditions. Details of then specific NIS surveillance protocols that have been adopted by the MCMC NIS for the first three components.

For the antimicrobial resistance component, sensitivity results for the different microorganisms isolated in the MCMC Microbiology Laboratory will be reported on a monthly basis for all isolates from the blood, respiratory tract (i.e. Sputum, tracheal, aspirate, bronchial washing), urinary tract, skin, and soft tissues, and other exudates. Using the WHONET software, a monthly antibiogram will be generated. Sensitivity patterns in the hospital will be disseminated on semi-annual basis. The forms used for the different surveillance components are attached (please refer to Attachment J – N).

1. IV. Data Management and Analysis

Surveillance data recorded in the NIS forms are entered by the ICPs on a daily basis into a database system, using the WHONET software. Output tables are generated on a monthly basis and also collated as quarterly reports.  Different nosocomial infection rates and ratios are calculated as follows:

1.  Rates by patient-days and device-days:

Overall patient-day rate =	Number of Infections	x 1000
	Number of patient-days

Catheter-associated UTI rate =	Number of UTI in patient with indwelling urinary catheter	x 1000
	Number of indwelling urinary catheter-days

Central line-associated BSI rate =	Number of BSI in patients with central lines	x 1000
	Number of central-days

Ventilator-associated PNEU rate =	Number of PNEU in patients who were on a ventilator	x 1000
	Number of ventilator-days

Where: 

UTI	=	Urinary Tract Infection
BSI	=	Primary Bloodstream Infection
PNEU	=	Pneumonia

2.  Rate by number of patients at risk:

Overall NI patient rate =	Number of Infections	x 1000
	Number of patient at risk

3. Device utilization ratio:

Central line utilization ratio =	Number of central line-days
	Number of patient-days

Ventilator utilization ratio =	Number of ventilator-days
	Number of patient-days

Urinary catheter utilization ratio =	Number of urinary catheter-days
	Number of patient-days

Overall device utilization ratio =	Number of central line-days + Number of ventilator days + Number of urinary catheter days
	Number of patient-days

4. Average length of stay (ALOS):

ALOS is a proxy for infection risk and is calculated as follows:

ALOS =	d
	c +	a - b
		2

Where:

a	=	Number of Patients in the ICU on the first day of the month
b	=	Number of Patients in the ICU on the first day of the next month
c	=	Number of Patients admitted to the ICU during this month (i.e. sum of the “number of arrivals” column
d	=	Number of Days spent by all patients in the ICU during this month (i.e. total number of patient days which is the sum of the “number of patients’ column”)

1. 5. SSI Measures:

Risk of SSI =	Number of patients with one or more SSIs in a specific category	x 100
	Number of patient undergoing surgery in that category

Ratio of SSI=	Number of SSIs in a specific category	x 100
	Number of operations in that category

Also called the “Procedure-specific rate”, and consider the fact that the same patient can develop more than one SSI related to the same procedure.

Ratio of SSI =	Number of SSIs in a specific category	x 100
	Number of post-operative patient-days of follow-up

This measure takes into account the population at risk and the duration of follow-up (i.e. the number of post-operative patient-days, number of days from the date of operation to the date of discharge).

1. V. Information Dissemination and Feedback

NIS reports will be disseminated in the general Staff Meeting quarterly. However, any significant finding, such as sudden or unusual increase in the number of nosocomial infections will be discussed by the ICC Chair and ICHN with the area supervisor concerned for further assessment and institution of appropriate measures. The results should further discuss by the area supervisor and the ICHN with the hospital staff concerned and recommendations implemented.

During the Infection Control Week held in March of each year, the annual NIS report will also be presented to the hospital staff. Recommendation for improved infection control will lso is discussed at the hospital assembly, followed by staff discussions.

Surveillance Component Protocols (Adopted from the NNIS Surveillance Component Protocols from Emori et al., 1991)
Surveillance Component	Population at Risk	Infection Sites	Denominator Data	Rates/Ratios
Adult and Pediatric ICUs	All patients.  Follow patients for 48 hours after discharge from ICU	All infection sites, with date of onset in the same month	For each ICU, number of: 1. Patients 2. Patient-day 3. Urinary catheter-days 4. Central line-days 5. Ventilator-days 6. Patients present on first day of month and first day of next month	For each ICU: 1. Overall ICU rate per        100 patients and 1000            patient-days 2. Urinary catheter-associated UTI rate per 1000 urinary catheter days 3. Central lien-associated bloodstream infection rate (BSI rate) per 100 ventilator-days 4. Device utilization rates: ♣ Overall ♣ Central line ♣ Ventilator ♣ Urinary catheter
High-risk Nursery	All infants in level III or II/III nursery.  Follow patients for 48 hours after discharge from HRN	All infection with date of onset in same month	Data collected for each of 4 birth weight categories: 1. 1000 g 2. 10001 – 1500 g 3. 1501 – 2500 g 4. 2500 g Number of: 1. Patients 2. Patient-days 3. Central (umbilical) line-days 4. Ventilator-days 5. Infants present on first days of month and first day of next month	Overall HRN rate per 100 patients at risk and 1000 patient-days For each birth-weight category: 1. Overall rate per 100 patients at risk and per 1000 patient-days 2. Central (umbilical) line-associated BSI rate per 1000 central line-days 3. Ventilator-associated pneumonia rate per 1000 ventilator-days Device utilization ratios 1. Overall For each birth weight category: 1. Central (umbilical) line 2. Ventilator

Surveillance Component Protocols (Adopted from the NNIS Surveillance Component Protocols from Emori et al., 1991)
Surveillance Component	Population at Risk	Infection Sites	Denominator Data	Rates/Ratios
Surgical patients	All patients undergoing selected NNIS operative procedures.  Patient followed for infection until their discharge.	All infection or surgical sites (SSIs) only in patients who had their operation during the same month	Risk-specific data on every patient monitored: 1. Operation date 2. NNIS operative procedures category  3. Patient ID No. 4. Age 5. Sex 6. Name of Surgeon 7. Duration of Operation  8. Wound Class 9. General Anesthesia 10. ASA score (ASA – Association of Anesthesiology) 11. Emergency 12. Trauma 13. Multiple Procedures 14. Endoscope approach 15. Discharge date	SSI Rates by: 1. Procedure and risk index 2. Wound class Standardized infection ratios by procedure Rates by procedure and site SSI rates by surgeon, procedure, site

RESTRICTED ANTIBIOTIC PROGRAM (?)

Objectives

1. ♣ To control the emergence of antibiotic resistance
2. ♣ To promote rational use of antibiotics
3. ♣ To provide cost-effective alternatives and quality patient care

Policy Guidelines

• 1. The request form of restricted antibiotic should be accomplished completely and in triplicate.
• 2. Orders of the antibiotics listed below should be approve by Infectious Disease Consultants (ID). If orders are made by ID consultant, the Infection Control Committee (ICC) request form shall bear the ID consultant’s signature.
• 3. ID consultants shall have a uniform approval of 4 days for empiric and 7 days for definitive.
• 4. The signing of phone approval by the ID consultant shall be done at the pharmacy within 24 hours.
• 5. Approved requests shall be released on a daily dose requirement by the pharmacist. If the said antibiotics are purchased outside the hospital it should be documented at the pharmacy through the nurse-in-charge.
• 6. Automatic stop order shall strictly follow the prescribed number of days for both Empiric and Definitive.
• 7. The Information Technology Department (ITD) and the Pharmacy (PHA) shall coordinate in implementing automatic stop orders.
• 8. Nurse-in-charge should forward the approved ICC Requested Antibiotic Form to the pharmacy within his/her shift. (Please Refer Attachment O)
• 9. Emergency cases include the following patient at NICU/ICU/ER having Septic Shock, Sepsis, Meningitis, and Febrile Neutropenia.
• 10. Inform the HICC nurses if there are problems that may cause delay in administration of the ordered antibiotic. 
• 11. The following restricted drugs are:
• ♣ Cefipime
• ♣ Ertapenem
• ♣ Imipenem
• ♣ Linezolid
• ♣ Meropenem
• ♣ Vancomycin
• ♣ Tigecycline

CARDIAC AND VASCULAR CATHETERIZATION UNIT

Objectives 

• ♣ To minimize the risk of acquiring blood-borne diseases for both patients and healthcare workers. 
• ♣ To ensure proper disinfection and sterilization of equipments used in the catheterization unit. 
• ♣ To ensure adequate aseptic technique in patient preparation, carrying out the procedures and rendering post- procedural care to the patients. 
• ♣ To ensure proper isolation techniques of patients with known, or suspected to have infectious disease. 

Policy Guidelines

1. The physical set-up of the unit should be the following: 

• ♣ reception area 
• ♣ pre and post- procedural area (3 beds)  
• ♣ catheterization room 
• ♣ storage room 
• ♣ pantry 
• ♣ changing room 
• ♣ reading/ conference room 
• ♣ technical room 
• ♣ control room 

1. 2. The personnel of the unit should have the following competencies

1. b. Cathlab Head

• ♣ Invasive Cardiologist 

1. c. Nurse Supervisor

• ♣ Undergone cathlab training;
• ♣ Member of Philippine Society of Cardiac Catheterization, Inc. (PSCCI)

1. d. Staff Nurses 

• ♣ Undergone cathlab training 
• ♣ Member of PSCCI 
• ♣ Undergone Advance Cardiac Life Support (ACLS); Basic Life Sup[port (BLS) training 
• ♣ Undergone infection control orientation on catheterization
• ♣ Undergone updated seminars provided by PSCCI 

1. e. Radiologic Technologist (RT)

• ♣ Licensed R.T. 
• ♣ Undergone cathlab training 
• ♣ Member of PSCCI 
• ♣ Undergone infection control orientation on catheterization 
• ♣ Undergone updated seminars provided by PSCCI 

1. f. Nursing aide

• ♣ Undergone cathlab training 
• ♣ Undergone infection control orientation on catheterization 

1. g. Receptionist

• ♣ Computer literate 
• ♣ For training on catheterization operation

1. 3. All invasive procedure should be done aseptically. (Please refer to Infection Control Guidelines for Surgery Suites and Recommendations for Placement of Intravascular Catheters in Adults and Children)
2. 4. In cases where greater wound exposure is necessary (such as pacemaker implantation or brachial cut downs) the full surgical sterile technique should be used. 
3. 5. A vascular sheath should be used to minimize vascular trauma, especially when multiple catheters changes are anticipated. 
4. 6. A generally sterile environment should be maintained during the procedure.
5. 7. Disposal of all materials should also follow local safety and infection control guidelines (Please refer to Waste Management)
6. 8. All cardiac catheterization procedures must be conducted as if there were risks for infection, hence standard precautions should always be practiced. (Please refer to Isolation Policy, Personal Protective Equipment, and Infection Control Guidelines for Linen, and waste Management)
7. 9. All reusable materials and equipment should undergo recycling process.  (Please Refer to Reprocessing of Reusable of Items)
8. 10. Terminal cleaning should be done every after each case. 
9. 11. All blood and body fluids exposure of healthcare workers should be reported. (Please Refer to Guidelines of Human Resource Development)

Implementation and Monitoring 

The head nurse and/or unit supervisors who had undergone basic training course in infection control and the HICN shall conduct separate weekly monitoring of adherence to HIC policies by random selection of HCWs’ and procedures the HIC chairperson or a member of the executive committee or IC team will conduct monthly IC lecture on selected cases for audit of incidents of breaks in infection control which will coincide with the unit meeting. 

EMERGENCY DEPARTMENT

Objectives

• ♣ To be able to triage patients consulting the ER of MCMC early identification and immediate isolation of patients with potential communicable diseases
• ♣ To decide on the patients immediate admission or transfer to another hospital
• ♣ To prevent the potential spread of infections at the ER

Definition of Terms

1. A. Notifiable Diseases – Case Definition

Water and Food Borne Diseases

1. 1. Cholera - Acute watery diarrhea and Vibrio Cholera isolated from stool or rectal swab culture.
2. 2. Hepatitis A - A sign or symptom of viral hepatitis (e.g. Fever, malaise, anorexia, nausea, abdominal pain, jaundice, increases in aminotransferase levels twice the upper limit and Serological evidence of HAV infection (e.g., Positive IgM anti-HAV)
3. 3. Typhoid Fever - Sudden onset of sustained fever of 5 or more days duration and two of the signs and symptoms of; severe headache, anorexia, body malaise, vomiting, constipation or diarrhea and Salmonella typhi isolated from blood or rectal swab.

Animal and Vector Borne Diseases

• 1. Dengue Hemorrhagic Fever - Fever of 3 or more days of duration any hemorrhagic manifestation (e.g. positive tourniquet test, petichiae, platelet count <100,000 mm³) and/or hemoconcentration
• 2. Leptospirosis - Sudden onset of fever and headache, myalgia (especially of calf muscles) and prostration; with any of the following conjuctival suffusion, meningeal irritation, anuria/oligoria/ and or proteinuria, jaundice, hemorrhages (GIT, lung); and History of exposure to infected animals or an environment contaminated with animal urine (e.g. wading in flood water)
• 3. Malaria - Fever and blood smear positive for malaria parasite (plasmodium species)
• 4. Rabies - History of animal bite/scratch or human bite or eating brain of proven rabid animal; hydrophobia; 
• ♣ Any of the following: Foaming of the mouth, convulsions, bladder paralysis, papillary dilatation, difficulty of swallowing

EPI Preventable Diseases

1. 1. Diptheria - Laryngitis or pharyngitis or tonsillitis and hemoconcentration membrane on the tonsils, pharynx or nose
2. 2. Measles - History of fever and generalized maculopapular rash of 3 days or more and at least one of the following: coryza, cough, conjunctivitis.
3. 3. Neonatal tetanus- Any newborn with normal ability to suck and cry during 1^st 2 days of life and who between 3 – 28 days cannot suck normally and become stiff or has convulsion (i.e., jerking of muscles or both).
4. 4. Pertussis - Prolonged cough (lasting at least 2 weeks); any of the following: paroxysms of coughing, inspiratory whoop, post-tussive vomiting (vomiting immediately after coughing); and without apparent cause.

Other Infectious Diseases

• 1. Non-Neonatal tetanus - Patient is more than 28 days old; with history of any of the following: open wound, dental caries, otitis media, surgical procedure; and any of the following: irritability, trismus (lockjaw), muscle   spasms, risus sardonicus, opisthotonus, abdominal rigidity
• 2. Hepatitis B - Any sign or symptom of viral hepatitis (e.g. fever, malaise, anorexia, nausea, abdominal pain, jaundice, increase in aminotransferase levels twice the upper limit and Serological evidence of HBV infection (e.g. Positive IgM anti-  HAV, HBsAg)
• 3. Meningococcal Disease - Sudden onset of fever
• ♣ Any of the following: neck stiffness, altered consciousness, other meningeal signs, patchily or puerperal rash, gram (-) coccid on gram stain of CSV or skin scrapings and without apparent cause

Special Surveillance System

1. 1. Acute Flaccid Paralysis
2. 2. Measles
3. 3. Maternal and Neonatal Tetanus
4. 4. Paralytic Shellfish Poisoning (RED TIDE)
5. 5. Fireworks Related Injury
6. 6. HIV/AIDS
7. 7. Probable Avian Influenza
8. 8. Probable SARS

Policy Guidelines

1. A. Infection Control Policies for Emergency Department

1. 2. Everybody in the ER should practice Hand hygiene including patients. (Please refer to Hand Hygiene Guidelines)
2. 3. All patients at Emergency Room should be properly assessed at the triage area for any infectious disease.
3. 4. All patients suspected to have infectious communicable disease (droplet or airborne) should be given the appropriate PPE and place in the Isolation area.
4. 5. The resident on duty should be informed immediately if the patient is suspected to have infectious communicable disease.
5. 6. The resident on duty should determine the mode of transmission and designate appropriate isolation precaution.
6. 7. The admitting section should be informed of the isolation requirement of the patient if for admission.  
7. 8. All places to be visited by the patient for diagnostic purposes should be informed of the isolation precaution needed including dietary service.
8. 9. All communicable disease cases should be reported to the Hospital Infection Control Nurse at Local 6323.  (Please refer to Attachment Q) 
9. 10. Admission and transport of patients with communicable diseases should follow the isolation precautions applicable for both patients and hospital personnel.  (Please refer to Isolation Policies)
10. 11. ER physician/ER-MROD should prioritize admission/discharge of patients in the isolation room to lessen the duration of patients stay at the ER and to facilitate the availability of Isolation room for the next case.
11. 12. Patients at the isolation area should have a distance of not less than 3 feet and should wear the appropriate mask.  Instruction should be properly given.
12. 13. A checklist for suspected patient with communicable disease should be attached to chart.  (Please refer to Attachment R) 
13. 14. For suspected highly communicable diseases (for admission in 14^th floor) requiring frequent vital signs monitoring, nurse informs relatives of the need for a special nurse on a 24 hour basis.
14. 15. All highly communicable infectious disease for transfer to other healthcare facility should follow transfer policies.
15. 16. All patients with fever and respiratory symptoms will be given surgical mask and will stay in holding area (ER Isolation Room) to accomplish a checklist for screening of possible Avian Influenza (A H1N1).
16. 17. In case when criteria for possible (A H1N1) were not met, the patient can be placed in the general observation area (ER).
17. 18. In cases when patients satisfy the criteria for possible (A H1N1), the patient will be transferred to San Lazaro, Lung Center or RITM.
18. 19. Doctors and Health Workers should wear face mask and gloves upon entering the holding area and while holding the patient.
19. 20. Doctors and Health Care Workers will practice strict hand washing or using disinfectants (alcohol) after attending to the patient (and after removing his facemask) before going back to the nurse station.
20. 21. Only one relative is allowed to stay with the patient inside the isolation/holding area, if patients condition necessities assistance. The relative will be instructed to wear a surgical mask while inside the holding area.
21. 22. The holding area will be disinfecting using LYSOL SPRAY in between placement of patients.
22. 23. Suspected SARS/Avian influenza should have proper coordination to HICC before referral/reporting to RITM, Department of Health (DOH).

Transfer Policies

1. 1. All patients for transfer to other healthcare facility should be properly communicated to the receiving facility. 
2. 2. All Rabies cases will be placed in ER-Isolation and should be transferred to San Lazaro Hospital or RITM.
3. 3. Suspected SARS and Avian flu cases will be referred to RITM or San Lazaro Hospital.
4. 4. All patients with confirmed communicable disease for transfer should be transported via ambulance conduction accompanied by hospital personnel geared with complete PPE as prescribed by the specific isolation precautions.
5. 5. Suspected SARS and Avian flu cases who needed emergency care and will be admitted at Isolation B (ICU) prior to transfer to RITM.
6. 6. In case when the patients’ condition is stable, he will be transferred to a referral hospital via ambulance conduction.
7. 7. Resident-on-duty will accompany and endorse to the physician in the referring hospital the case prior to transfer.
8. 8. The ambulance driver and accompanying health care worker should wear face mask. If possible, the driver should be separated by a glass panel or a plastic cover from the patient.
9. 9. The ambulance interiors will be disinfected using LYSOL SPRAY before next use.
10. 10. All Health Care Workers will discard his/her gloves and should washed his/her hands or disinfect with alcohol before leaving the holding area.
11. 11. He should then remove his face mask inside resealable containers and wash his hands again in the designated washing area before going to the nurse’s station.
12. 12. Only one nurse will handle all suspect cases of (A H1N1) every shift.
13. 13. Policies for the deceased (cadaver) handling soiled materials (to be discussed).
14. 14. ER Physicians should prioritize the communicable disease suspect patient to lessen the duration of stay at the holding area and to facilitate the availability of holding area for the next case.
15. 15. A checklist for suspected patients with communicable disease should be kept on separate folder.
16. 16. All highly communicable infectious diseases for transfer to other health care facility should follow transfer policies.
17. 17. Suspected SARS/Avian Influenza should have proper checklist to HICC before referral / reporting to RITM, DOB.

FACILITY MANAGEMENT

Objective

• ♣ To prevent from acquiring infections while performing the job requested or during preventive maintenance

Introduction

The maintenance/engineering department plans and implements corrective and preventive maintenance, renovation and construction, repair of structures, equipment, and utilities at the Naval Medical Center. The department plans for protection of employees and patients during construction and/or renovation activities. The department provides environmental support for regulated medical waste management and the following infection control procedures:

• ♣ Installs and maintains soap dispensers/sinks throughout the facility to facilitate hand washing.
• ♣ Maintains the air handling systems for control of airborne spread agents.
• ♣ Provides for checks on water and backup equipment for natural disasters, such as; equipment to supply potable water, fluid waste removal, and steam for sterilizers.
• ♣ Provides rodent and pest control at least once a month and treat as necessary. Will keep written documentation of the findings.
• ♣ Provides special exhaust systems for control of noxious fumes and infectious agents.

Employee Health

• ♣ All personnel will be free of communicable diseases before coming in contact with patients.
• ♣ Personnel will follow "Universal/Standard Precautions" in the event of potential exposure to blood and body fluids.
• ♣ In the event of inadvertent exposure to patients with a communicable disease, exposure to contaminated equipment, or an occupational injury (i.e., needle stick or sharps injury), the employee will report this immediately to their supervisor and will be referred to Occupational Health for treatment and follow‑up.

In-service Education

All personnel will participate in in-service education and will be trained in mandatory OSHA blood bone pathogen requirements.

General Policies

• ♣ Equipment can become contaminated with blood, secretions, excretions, and or drainage with potential for employee or patient colonization or infection. Clean and decontaminate equipment with hospital detergent/germicide before and after maintenance or repair.
• ♣ Personnel will wear personal protective equipment (i.e., gloves, goggles, coveralls) when in potentially hazardous areas. Wear protective gloves when handling equipment that could inflict cuts or punctures or when contamination is suspected.
• ♣ Personnel will wear appropriate attire when entering controlled areas (i.e. Operating Room).
• ♣ Limit tools taken into controlled areas, such as the surgical suite. Assure that tools are clean and free of dust before entering area.

Maintenance and Repair of Existing Structures

• ♣ Damaged structural surfaces, such as counter tops, sinks, floors or tiles, will be replaced as soon as possible.
• ♣ Wet ceiling tiles will be replaced as soon as possible. Water leaks on wall board, acoustical ceiling tiles, or insulation, may initiate growth of ubiquitous fungal spores.

Maintenance and Repair of Heating, Ventilation, & HVAC Systems

• ♣ There will be scheduled, routine maintenance of the ventilation system.
• ♣ Critical elements of the system will be monitored, such as: temperature, relative humidity, air changes per hour, air exhaust, and recirculation.
• ♣ Regular cleaning/decontamination of air intakes, exhaust/return vents, ducts, and cooling towers are scheduled.
• ♣ Employees will wear a mask during filter changes.

Maintenance and Repair of Plumbing Supply and Drainage Systems

• ♣ Regular preventive maintenance of the Plumbing, such as: laboratory & sink fixtures, water supply system, drainage pipes, floor drains, and flushing devices will be scheduled.
• ♣ Faucet aerators will be removed or cleaned regularly.
• ♣ Personal protective equipment (PPE), such as masks, goggles, gloves, and coveralls will be provided for personnel working with sewer lines or toilet facilities.
• ♣ Equipment used in patient care areas will be maintained in clean condition. Gross soil will be rinsed from tools and then washed with detergent/disinfectant and stored dry.

Maintenance and Repair of Refrigerators and Freezers

• ♣ Done as needed

Maintenance and Repair of Vacuum Systems

• ♣ Routine maintenance is scheduled on a regular schedule.
• ♣ Exhaust vents are to be at a sufficient distance from air and gas intakes.
• ♣ Hands are to be washed before and after manipulating vacuum controls.
• ♣ When oxygen systems are opened for maintenance or repair, a contract lab is called in to test for solid particulate, purity, hydrocarbon, moisture, halogenated compounds, and carbon monoxide.
• ♣ Gloves and/or protective equipment are to be worn if body secretions or blood exposure is a potential.

Maintenance and Repair of Waste Processing Systems (including Dumpsters Compactors)

• ♣ Waste processing systems are maintained in a way to avoid leakage or reduce it to a manageable level.
• ♣ Personnel will be instructed in the proper operation of equipment.
• ♣ Contaminated waste will not be compacted.
• ♣ Protective attire will be utilized and available for personnel having contact with waste. Attire, such as; heavy gloves, goggles, coveralls, etc.

Maintenance and Repair of Iaminar Flow Systems/Hoods and Biological Hoods

• ♣ Performed by Medical Repair or contracted out to the manufacturer.
• ♣ Provide routine certification of biologic and chemical safety airflow calibrations.
• ♣ Exhaust from chemical hoods will be routed away from intake vents.
• ♣ Flow rates and air exchanges will be monitored and documented
• ♣ Regular preventive maintenance including, but not limited to air intakes, filters, and blowers.

Maintenance and Repair of Icemakers

• ♣ Repairs all defective icemakers promptly.
• ♣ Icemakers are drained and flushed with sodium hypochlorite (bleach 1:10) solution by the air condition shop personnel when cultures are positive.

Provides and Maintains Backup Service for Natural Disasters

• ♣ Will provide an alternate supply of potable water.
• ♣ Will supply non‑potable water for the disposal of liquid wastes.
• ♣ Will coordinate an alternate means of hand washing.
• ♣ Will maintain emergency generators which operate critical systems/equipment

Construction/Renovation Activities in the Facility

• ♣ Will reduce patient and personnel exposure to debris by erecting barriers to contain dust/debris within the construction area. Patients will be removed from the area if possible.
• ♣ Will maintain ventilation system by increasing filter changes or changing filters to a higher efficiency rating.
• ♣ Provide for advance notification of water supply interruptions by scheduling at low activity time periods.
• ♣ Will provide/obtain supply of water for patient care, cleaning, decontaminating, and drinking and food preparation.
• ♣ Will schedule interruptions of heating and air-conditioning during periods of low patient activity.
• ♣ Private contractors will be required to conform to regulations as outlined in this policy.

HEMODIALYSIS UNIT

Objectives

• ♣ To provide comprehensive infection control policy specifically designed for the hemodialysis setting.
• ♣ To prevent transmission of blood borne infection in the hemodialysis unit.
• ♣ To conduct active surveillance for early detection of possible outbreak of blood borne diseases.
• ♣ Routine serologic and immunization of patients and healthcare workers
• ♣ To provide updated training on Infection Control 

Policy Guidelines

1. 1. There should be provision of the following set-up at unit:

• ♣ In-patient – 1 beds 
• ♣ Waiting area (10 chairs for the patient’s relatives/watcher)
• ♣ Water treatment room
• ♣ Storage area for reuse dialyzers
• ♣ Linen cabinet
• ♣ Soiled linen bins
• ♣ Waste bins
• ♣ Storage area for hemodialysis solutions/supplies

1. 2. All Staff should have the following competencies

• ♣ Chairman – Nephrologists
• ♣ Nurse Supervisor 
• - Undergone Hemodialysis Training 
• - Member of RENAP
• - Licensed IV Therapist
• - M.A. Graduate/units
• ♣ Head Nurse
• - Undergone Hemodialysis Training
• - Member of ERNAP
• - Licensed IV Therapist
• - M.A. Graduate / units
• ♣ Staff nurses
• - Licensed IV Therapist
• - Member of Renal Nurses Association of the Philippines
• - Undergone training and orientation on basic and comprehensive hemodialysis operation and procedures
• - Undergone Infection Control Orientation on Hemodialysis
• - Undergone monthly updates on Hemodialysis procedures provided by Nephro fellow 

• ♣ Hemodialysis technicians

• - Undergone training and orientation on basic and comprehensive hemodialysis operation and procedures
• - Undergone updated seminars and workshop provided by RENAP
• - Undergone Infection Control Orientation on Hemodialysis

• ♣ Ward Clerk

• - Computer literate
• - For training on Hemodialysis operation

1. 3. All healthcare workers should wear the appropriate PPE during any patient procedure.
2. 4. Hand hygiene is a must. (Please Refer to Hand Hygiene Guidelines)
3. 5. All healthcare workers should have their serological status known to be anti-HBsAg reactive.
4. 6. All patients known to be HBsAg negative should be vaccinated with Hepatitis B vaccine and anti-HBsAg should be monitored every six months.
5. 7. Strict aseptic technique should be practiced by all operators during the procedure. (Please refer to Recommendations for Placement of Intravascular Catheters in Adults and Children)
6. 8. The environment should be kept safe for patients, visitors and healthcare workers as well. (Please refer to  Housekeeping)
7. 9. All outlets and source of sterile water supply for hemodialysis machine should be tested every last Sunday of the month.
8. 10. Hemodialysis machine should be properly clean and disinfected every after patient use.  Follow the manufacturer’s recommendation for cleaning and disinfection.
9. 11. All reusable patient care equipment should undergo the process of recycling every after each patient. (Please Refer to Disinfection and Sterilization of Reusable Items)
10. 12. All patients should have individual work unit and not sharing any supplies.  In cases where sharing of supplies cannot be prevented, it should be prepared in a centralized area out of the patient unit.
11. 13. If dialyzer is for reuse, follow the manufacturer’s recommendation for reuse.
12. 14. Patients with Hepatitis B should have a dedicated machine and an exclusive nurse during the procedure.
13. 15. All contaminated waste generated in the patient area should be disposed to yellow waste bin and a punctured proof resistant needle dispenser should be available within reach.
14. 16. Used linens should be properly identified before sending to linen section for laundry.
15. 17. Live plants are not allowed in any patient area.
16. 18. All blood and body fluids exposure should be reported. (Please Refer to Guidelines for Human Resource Development)

GUIDELINES FOR INPATIENT SERVICES

Objectives

1. ♣ To reduce risk of acquiring nosocomial infection among admitted patients and healthcare workers in the in the unit
2. ♣ To prevent transmission of communicable diseases in the unit by strict adherence to Isolation Precaution policies while providing adequate patient care
3. ♣ To conduct accurate and active periodic surveillance on healthcare associated infection in the unit
4. ♣ To detect early clustering of cases thereby preventing disease outbreaks

Policy Guidelines

1. 1. All patients should be assigned to appropriate room according to its disease mode of transmission. (Please Refer to Patient Room Replacement)
2. 2. A color coded tag (Isolation Precaution) if there is a special precaution should be placed under the doctors’ name at the door entrance to inform everybody who will enter the room. (Please Refer to Isolation Policies)
3. 3. Handwashing should be done before and after entering the room. (Please Refer to Hand Hygiene Guidelines)
4. 4. Patients with airborne infection or immunocompromised with disseminated infection should be admitted at __________________.
5. 5. Patients seeking accommodation in the ward should be determine to have no airborne infection and comply with the isolation precaution needed. (Please Refer to Isolation Policies)
6. 6. Visitors should comply with the visitors’ policy. (Please Refer to Infection Control Guidelines for Visitors)
7. 7. Personal Protective Equipment should be available. (Please Refer to Personal Protective Equipment)
8. 8. Rooms should be provided with black, green and yellow waste bins. (Please Refer to Waste Management)
9. 9. Terminal cleaning should be done every after patient discharge.

GUIDELINES FOR THE INTENSIVE CARE UNIT COMPLEX

Objectives

• ♣ To reduce risk of acquiring nosocomial infection among admitted patients and healthcare workers in the ICU
• ♣ To identify and isolate patients who have communicable diseases while providing adequate care
• ♣ To conduct accurate and active surveillance on nosocomial infection in the ICU
• ♣ To detect early clustering of cases to prevent disease outbreaks

Policy Guidelines

1. 1. All Healthcare workers and visitors should wash hands before and after entering patients’ rooms.
2. 2. All hand washing facilities are equipped with water, liquid soap, and paper towel.
3. 3. Alcohol-based rub can use as an alternative to hand washing in between patient care activities.
4. 4. Always wear the appropriate PPE during patient care activities.
5. 5. The Infection Control Nurse should monitor patient care activities daily.
6. 6. Live flowers/plants are not allowed in side the unit.
7. 7. Fresh fruits should be washed before bringing in the patient unit.
8. 8. Utilize Isolation A for non-infectious, immunocompromised patients. (Please refer to Guidelines for Isolation A of ICU Complex)
9. 9. Utilize Isolation B for highly infectious patients. (Please refer to Guidelines for Isolation of Isolation B of ICU Complex)
10. 10. Do terminal cleaning for all rooms after patients’ discharges. (Please refer to Guidelines for Terminal Cleaning)
11. 11. Decontaminate all blood and body fluids except urine before disposal to the sewage system. (Please refer Guidelines for Disinfection and Sterilization of Reusable Items)
12. 12. The nurse-on-duty shall handle a maximum of two (2) patients.
13. 13. All doors must be kept closed whether the room is occupied or not. 
14. 14. Cleanliness and sanitation of the area should be maintained. (Please refer to Housekeeping)
15. 15. Wastes are segregated according to the set standard. (Please refer to Waste Management)
16. 16. All healthcare workers should wear neatly the prescribed uniforms. 
17. 17. All invasive procedure should be performed aseptically. (Please refer to Guidelines for Routine Invasive Procedures)
18. 18. Watchers and visitors. (Please Refer to ICU Guidelines)

GUIDELINES FOR ISOLATION A OF ICU COMPLEX

Objective

• ♣ To reduce risk of acquiring nosocomial infection among admitted patients and healthcare workers in the Isolation A

Policy Guidelines

1. 1. Isolation A is intended for patients with immunocompromised condition needing intensive care.
2. 2. Doors should always be kept closed.
3. 3. All healthcare workers should wear the standard personal protective equipment during patient care activities.
4. 4. The patient should wear mask (N95 or surgical mask depending on respiratory condition) all the time.
5. 5. Strict hand washing before and after touching the patient should be observed.
6. 6. Nursing staff assign in the unit is not allowed to enter Isolation B.  More so equipment and supplies should not be shared.
7. 7. The following are priority cases to be admitted in Isolation A:

• ♣ Burns
• ♣ CA and solid tumors
• ♣ Febrile neutropenics
• ♣ 1 post operative patient needs critical care
• ♣ Undergoing chemotherapy

1. 8. Live flowers/plants are not allowed inside the unit.
2. 9. Inform the dietary service if the patient is a burn case, they have special diet preparation.
3. 10. Watchers and visitors (Please Refer to ICU Guidelines)

GUIDELINES FOR ISOLATION B OF INTENSIVE CARE UNIT COMPLEX

Objectives

1. ♣ To prevent the spread of airborne infectious disease while providing adequate care
2. ♣ To maximize the use of negative air pressure rooms

Policy Guidelines

1. 1. All healthcare workers assigned at Isolation B should be able to demonstrate the proper use of PPE.
2. 2. Strict compliance to hand hygiene policies. (Please Refer to Hand Hygiene Guidelines)
3. 3. Nursing staff at Isolation B is exclusive during the shift and not allowed to relieve to other staff at the main ICU complex.
4. 4. Equipment and supplies in Isolation B cannot be shared to the main ICU complex.
5. 5. Adequate supplies of PPE should be maintained.
6. 6. Keep doors always closed.
7. 7. Terminal cleaning should be done for every patient discharge. (Please refer to Housekeeping)
8. 8. Cleanliness and sanitation of the area should be maintained. (Please refer to Housekeeping)
9. 9. There should be a hamper bag and a yellow waste bin available when changing linen and during patient care activities.
10. 10. Wastes are segregated according to the set standard. (Please refer to Waste Management)
11. 11. The Infection Control Nurse should monitor patient care activities daily.
12. 12. Live flowers/plants are not allowed inside the unit.
13. 13. Priority patients that can be admitted are those with airborne infections and/or with immunocompromised disseminated cases.  (See list of cases with proper room utilization)
14. 14. Watchers and visitors (Please Refer to ICU Guidelines)

LABORATORY SERVICES

Objectives

• ♣ To prevent from acquiring healthcare associated infections of both healthcare workers and patients related to use of diagnostic equipment, materials and instruments
• ♣ To prevent from acquiring healthcare associated infections of healthcare workers from chemicals and specimens present in the laboratory 

Definition of Terms

1. 1. Biosafety level 1 practices, safety equipment, and facility design and construction are appropriate for laboratories in which work is done with defined and characterized strains of viable microorganisms not known to consistently cause disease in healthy humans. It represents a basic level of containment that relies on standard microbiological practices with no special primary or secondary barriers recommended other than a sink for hand washing.

1. 2. Biosafety Level 2 practices, equipment, and facility design and construction are applicable to clinical, diagnostic, teaching, and other laboratories in which work is done with the broad spectrum of indigenous moderate-risk agents that are present in the community and associated with human disease of varying severity. With good microbiological techniques, these agents can be used safely in activities conducted on the open bench, provided the potential for producing splashes or aerosols is low. Hepatitis B virus, HIV, the salmonellae, and Toxoplasma spp. are representative of microorganisms assigned to this containment level. Biosafety Level 2 is appropriate when work is done with any human-derived blood, body fluids, tissues, or primary human cell lines where the presence of an infectious agent may be unknown. (Laboratory personnel working with human-derived materials should refer to the OSHA Bloodborne Pathogen Standard (2) for specific required precautions.) 

1. 3. Biosafety Level 3 practices, safety equipment, and facility design and construction are applicable to clinical, diagnostic, teaching, research, or production facilities in which work is done with indigenous or exotic agents with a potential for respiratory transmission, and which may cause serious and potentially lethal infection. Mycobacterium tuberculosis, St. Louis encephalitis virus, and Coxiella burnetii are representative of the microorganisms assigned to this level. Primary hazards to personnel working with these agents relate to autoinoculation, ingestion, and exposure to infectious aerosols. 

1. 4. Biosafety Level 4 practices, safety equipment, and facility design and construction are applicable for work with dangerous and exotic agents that pose a high individual risk of life-threatening disease, which may be transmitted via the aerosol route and for which there is no available vaccine or therapy. Agents with a close or identical antigenic relationship to Biosafety Level 4 agents also should be handled at this level. When sufficient data are obtained, work with these agents may continue at this level or at a lower level. Viruses such as Marburg or Congo-Crimean hemorrhagic fever are manipulated at Biosafety Level 4. 

Policy Guidelines

1. A. Biosafety Level 1

Standard Microbiological Practices 

1. 1. Access to the laboratory is limited or restricted at the discretion of the laboratory director when experiments or work with cultures and specimens are in progress. 
2. 2. Persons wash their hands after they handle viable materials, after removing gloves, and before leaving the laboratory. 
3. 3. Eating, drinking, smoking, handling contact lenses, applying cosmetics, and storing food for human use are not permitted in the work areas.
4. 4. Persons who wear contact lenses in laboratories should also wear goggles or a face shield. Food is stored outside the work area in cabinets or refrigerators designated and used for this purpose only. 
5. 5. Mouth pipetting is prohibited; mechanical pipetting devices are used. 
6. 6. Policies for the safe handling of sharps are instituted. 
7. 7. All procedures are performed carefully to minimize the creation of splashes or aerosols. 
8. 8. Work surfaces are decontaminated at least once a day and after any spill of viable material. 
9. 9. All cultures, stocks, and other regulated wastes are decontaminated before disposal by an approved decontamination method such as autoclaving. Materials to be decontaminated outside of the immediate laboratory are to be placed in a durable, leak proof container and closed for transport from the laboratory. Materials to be decontaminated outside of the immediate laboratory are packaged in accordance with applicable local, state, and federal regulations before removal from the facility. 
10. 10. A biohazard sign can be posted at the entrance to the laboratory whenever infectious agents are present. The sign may include the name of the agent(s) in use and the name and phone number of the investigator. 
11. 11. An insect and rodent control program is in effect. 

Special Practices 

1. 1. There are no special practices for Biosafety Level 1. 

Safety Equipment (Primary Barriers) 

1. 1. Special containment devices or equipment such as biological safety cabinets are generally not required for manipulations of agents assigned to Biosafety Level 1.
2. 2. It is recommended that laboratory coats, gowns, or uniforms be worn to prevent contamination or soiling of street clothes.
3. 3. Gloves should be worn if the skin on the hands is broken or if a rash is present. Alternatives to powdered latex gloves should be available. 
4. 4. Protective eyewear should be worn for conduct of procedures in which splashes of microorganisms or other hazardous materials is anticipated.

Laboratory Facilities (Secondary Barriers) 

1. 1. Laboratories should have doors for access control. 
2. 2. Each laboratory contains a sink for hand washing. 
3. 3. The laboratory is designed so that it can be easily cleaned. Carpets and rugs in laboratories are not appropriate. 
4. 4. Bench tops are impervious to water and are resistant to moderate heat and the organic solvents, acids, alkalis, and chemicals used to decontaminate the work surface and equipment. 
5. 5. Laboratory furniture is capable of supporting anticipated loading and uses. Spaces between benches, cabinets, and equipment are accessible for cleaning. 

1. B. Biosafety Level 2

Standard Microbiological Practices 

1. 1. Access to the laboratory is limited or restricted at the discretion of the laboratory director when experiments are in progress.
2. 2. Persons wash their hands after they handle viable materials, after removing gloves, and before leaving the laboratory.
3. 3. Eating, drinking, smoking, handling contact lenses, and applying cosmetics are not permitted in the work areas. Food is stored outside the work area in cabinets or refrigerators designated for this purpose only.
4. 4. Mouth pipetting is prohibited; mechanical pipetting devices are used.
5. 5. Policies for the safe handling of sharps are instituted.
6. 6. All procedures are performed carefully to minimize the creation of splashes or aerosols.
7. 7. Work surfaces are decontaminated on completion of work or at the end of the day and after any spill or splash of viable material with disinfectants that are effective against the agents of concern. 
8. 8. All cultures, stocks, and other regulated wastes are decontaminated before disposal by an approved decontamination method such as autoclaving. Materials to be decontaminated outside of the immediate laboratory are placed in a durable, leak proof container and closed for transport from the laboratory. Materials to be decontaminated off-site from the facility are packaged in accordance with applicable local, state, and federal regulations, before removal from the facility.
9. 9. An insect and rodent control program is in effect.

Special Practices

1. 1. Access to the laboratory is limited or restricted by the laboratory director when work with infectious agents is in progress. In general, persons who are at increased risk of acquiring infection, or for whom infection may have serious consequences, are not allowed in the laboratory or animal rooms. For example, persons who are immunocompromised or immunosuppressed may be at increased risk of acquiring infections. The laboratory director has the final responsibility for assessing each circumstance and determining who may enter or work in the laboratory or animal room.
2. 2. The laboratory director establishes policies and procedures whereby only persons who have been advised of the potential hazards and meet specific entry requirements (e.g., immunization) may enter the laboratory.
3. 3. A biohazard sign must be posted on the entrance to the laboratory when etiologic agents are in use. Appropriate information to be posted includes the agent(s) in use, the biosafety level, the required immunizations, the investigator's name and telephone number, any personal protective equipment that must be worn in the laboratory, and any procedures required for exiting the laboratory.
4. 4. Laboratory personnel receive appropriate immunizations or tests for the agents handled or potentially present in the laboratory (e.g., hepatitis B vaccine or TB skin testing).
5. 5. When appropriate, considering the agent(s) handled, baseline serum samples for laboratory and other at-risk personnel are collected and stored. Additional serum specimens may be collected periodically, depending on the agents handled or the function of the facility.
6. 6. Biosafety procedures are incorporated into standard operating procedures or in a biosafety manual adopted or prepared specifically for the laboratory by the laboratory director. Personnel are advised of special hazards and are required to read and follow instructions on practices and procedures.
7. 7. The laboratory director ensures that laboratory and support personnel receive appropriate training on the potential hazards associated with the work involved, the necessary precautions to prevent exposures, and the exposure evaluation procedures. Personnel receive annual updates or additional training as necessary for procedural or policy changes.
8. 8. A high degree of precaution must always be taken with any contaminated sharp items, including needles and syringes, slides, pipettes, capillary tubes, and scalpels.

• ♣ Needles and syringes or other sharp instruments should be restricted in the laboratory for use only when there is no alternative, such as parenteral injection, phlebotomy, or aspiration of fluids from laboratory animals and diaphragm bottles. Plastic ware should be substituted for glassware whenever possible.
• ♣ Only needle-locking syringes or disposable syringe-needle units (i.e., needle is integral to the syringe) are used for injection or aspiration of infectious materials. Used disposable needles must not be bent, sheared, broken, recapped, removed from disposable syringes, or otherwise manipulated by hand before disposal; rather, they must be carefully placed in conveniently located puncture-resistant containers used for sharps disposal. Non-disposable sharps must be placed in a hard-walled container for transport to a processing area for decontamination, preferably by autoclaving.
• ♣ Syringes which re-sheathe the needle, needleless systems, and other safety devices are used when appropriate.
• ♣ Broken glassware must not be handled directly by hand, but must be removed by mechanical means such as a brush and dustpan, tongs, or forceps. Containers of contaminated needles, sharp equipment, and broken glass are decontaminated before disposal, according to any local, state, or federal regulations.

1. 9. Cultures, tissues, specimens of body fluids, or potentially infectious wastes are placed in a container with a cover that prevents leakage during collection, handling, processing, storage, transport, or shipping.
2. 10. Laboratory equipment and work surfaces should be decontaminated with an effective disinfectant on a routine basis, after work with infectious materials is finished, and especially after overt spills, splashes, or other contamination by infectious materials. Contaminated equipment must be decontaminated according to any local, state, or federal regulations before it is sent for repair or maintenance or packaged for transport in accordance with applicable local, state, or federal regulations, before removal from the facility.
3. 11. Spills and accidents that result in overt exposures to infectious materials are immediately reported to the laboratory director. Medical evaluation, surveillance, and treatment are provided as appropriate and written records are maintained.
4. 12. Animals not involved in the work being performed are not permitted in the lab.

Safety Equipment (Primary Barriers) 

1. 1. Properly maintained biological safety cabinets, preferably Class II, or other appropriate personal protective equipment or physical containment devices are used whenever:

1. ♣ Procedures with a potential for creating infectious aerosols or splashes are conducted. These may include centrifuging, grinding, blending, vigorous shaking or mixing, sonic disruption, opening containers of infectious materials whose internal pressures may be different from ambient pressures, inoculating animals intranasally, and harvesting infected tissues from animals or embryonate eggs.
2. ♣ High concentrations or large volumes of infectious agents are used. Such materials may be centrifuged in the open laboratory if sealed rotor heads or centrifuge safety cups are used, and if these rotors or safety cups are opened only in a biological safety cabinet.

1. 2. Face protection (goggles, mask, face shield or other splatter guard) is used for anticipated splashes or sprays of infectious or other hazardous materials to the face when the microorganisms must be manipulated outside the BSC.
2. 3. Protective laboratory coats, gowns, smocks, or uniforms designated for lab use are worn while in the laboratory. This protective clothing is removed and left in the laboratory before leaving for non-laboratory areas (e.g., cafeteria, library, administrative offices). All protective clothing is either disposed of in the laboratory or laundered by the institution; it should never be taken home by personnel.
3. 4. Gloves are worn when hands may contact potentially infectious materials, contaminated surfaces or equipment. Wearing two pairs of gloves may be appropriate. Gloves are disposed of when overtly contaminated, and removed when work with infectious materials is completed or when the integrity of the glove is compromised. Disposable gloves are not washed, reused, or used for touching "clean" surfaces (keyboards, telephones, etc.), and they should not be worn outside the lab. Alternatives to powdered latex gloves should be available. Hands are washed following removal of gloves.

Laboratory Facilities (Secondary Barriers)

1. 1. Provide lockable doors for facilities that house restricted agents (as defined in 42 CFR 72.6).
2. 2. Consider locating new laboratories away from public areas.
3. 3. Each laboratory contains a sink for hand washing.
4. 4. The laboratory is designed so that it can be easily cleaned. Carpets and rugs in laboratories are inappropriate.
5. 5. Bench tops are impervious to water and are resistant to moderate heat and the organic solvents, acids, alkalis, and chemicals used to decontaminate the work surfaces and equipment.
6. 6. Laboratory furniture is capable of supporting anticipated loading and uses. Spaces between benches, cabinets, and equipment are accessible for cleaning. Chairs and other furniture used in laboratory work should be covered with a non-fabric material that can be easily decontaminated. 
7. 7. Install biological safety cabinets in such a manner that fluctuations of the room supply and exhaust air do not cause the biological safety cabinets to operate outside their parameters for containment. Locate biological safety cabinets away from doors, from windows that can be opened, from heavily traveled laboratory areas, and from other potentially disruptive equipment so as to maintain the biological safety cabinets' air flow parameters for containment. 
8. 8. An eyewash station is readily available. 
9. 9. Illumination is adequate for all activities, avoiding reflections and glare that could impede vision. 

Standard Microbiological Practices

1. 1. Access to the laboratory is limited or restricted at the discretion of the laboratory director when experiments are in progress.
2. 2. Persons wash their hands after handling infectious materials, after removing gloves, and when they leave the laboratory.
3. 3. Eating, drinking, smoking, handling contact lenses, and applying cosmetics are not permitted in the laboratory. Persons who wear contact lenses in laboratories should also wear goggles or a face shield. Food is stored outside the work area in cabinets or refrigerators designated for this purpose only.
4. 4. Mouth pipetting is prohibited; mechanical pipetting devices are used.
5. 5. Policies for the safe handling of sharps are instituted. 
6. 6. All procedures are performed carefully to minimize the creation of aerosols. 
7. 7. Work surfaces are decontaminated at least once a day and after any spill of viable material. 
8. 8. All cultures, stocks, and other regulated wastes are decontaminated before disposal by an approved decontamination method, such as autoclaving. Materials to be decontaminated outside of the immediate laboratory are placed in a durable, leak proof container and closed for transport from the laboratory. Infectious waste from BSL-3 laboratories should be decontaminated before removal for off-site disposal. 
9. 9. An insect and rodent control program is in effect 

Special Practices 

1. 1. Laboratory doors are kept closed when experiments are in progress. 
2. 2. The laboratory director controls access to the laboratory and restricts access to persons whose presence is required for program or support purposes. Persons who are at increased risk of acquiring infection or for whom infection may have serious consequences are not allowed in the laboratory or animal rooms. For example, persons who are immunocompromised or immunosuppressed may be at risk of acquiring infections. The director has the final responsibility for assessing each circumstance and determining who may enter or work in the laboratory. No minors should be allowed in the laboratory. 
3. 3. The laboratory director establishes policies and procedures whereby only persons who have been advised of the potential biohazard, who meet any specific entry requirements (e.g., immunization), and who comply with all entry and exit procedures, enter the laboratory or animal rooms. 
4. 4. When infectious materials or infected animals are present in the laboratory or containment module, a hazard warning sign, incorporating the universal biohazard symbol, is posted on all laboratory and animal room access doors. The hazard warning sign identifies the agent, lists the name and telephone number of the laboratory director or other responsible person(s), and indicates any special requirements for entering the laboratory, such as the need for immunizations, respirators, or other personal protective measures. 
5. 5. Laboratory personnel receive the appropriate immunizations or tests for the agents handled or potentially present in the laboratory (e.g., hepatitis B vaccine or TB skin testing), and periodic testing as recommended for the agent being handled. 
6. 6. Baseline serum samples are collected as appropriate and stored for all laboratory and other at-risk personnel. Additional serum specimens may be periodically collected, depending on the agents handled or the function of the laboratory. 
7. 7. A biosafety manual specific to the laboratory is prepared or adopted by the laboratory director and biosafety precautions are incorporated into standard operating procedures. Personnel are advised of special hazards and are required to read and follow instructions on practices and procedures. 
8. 8. Laboratory and support personnel receive appropriate training on the potential hazards associated with the work involved, the necessary precautions to prevent exposures, and the exposure evaluation procedures. Personnel receive annual updates or additional training as necessary for procedural changes. 
9. 9. The laboratory director is responsible for ensuring that, before working with organisms at Biosafety Level 3, all personnel demonstrate proficiency in standard microbiological practices and techniques and in the practices and operations specific to the laboratory facility. This might include prior experience in handling human pathogens or cell cultures, or a specific training program provided by the laboratory director or other competent scientist proficient in safe microbiological practices and techniques. 
10. 10. A high degree of precaution must always be taken with any contaminated sharp items, including needles and syringes, slides, pipettes, capillary tubes, and scalpels. 

• ♣ Needles and syringes or other sharp instruments should be restricted in the laboratory for use only when there is no alternative, such as parenteral injection, phlebotomy, or aspiration of fluids from laboratory animals and diaphragm bottles. Plastic ware should be substituted for glassware whenever possible. 
• ♣ Only needle-locking syringes or disposable syringe-needle units (i.e., needle is integral to the syringe) are used for injection or aspiration of infectious materials. Used disposable needles must not be bent, sheared, broken, recapped, removed from disposable syringes, or otherwise manipulated by hand before disposal; rather, they must be carefully placed in conveniently located puncture-resistant containers used for sharps disposal. Non-disposable sharps must be placed in a hard-walled container for transport to a processing area for decontamination, preferably by autoclaving. 
• ♣ Syringes which re-sheathe the needle, needleless systems, and other safe devices are used when appropriate. Broken glassware must not be handled directly by hand, but must be removed by mechanical means such as a brush and dustpan, tongs, or forceps. Containers of contaminated needles, sharp equipment, and broken glass should be decontaminated before disposal, and disposed of according to any local, state, or federal regulations.

1. 11. All open manipulations involving infectious materials are conducted in biological safety cabinets or other physical containment devices within the containment module. No work in open vessels is conducted on the open bench. Clean-up is facilitated by using plastic-backed paper toweling on non-perforated work surfaces within biological safety cabinets. 
2. 12. Laboratory equipment and work surfaces should be decontaminated routinely with an effective disinfectant, after work with infectious materials is finished, and especially after overt spills, splashes, or other contamination with infectious materials. 

• ♣ Spills of infectious materials are decontaminated, contained and cleaned up by appropriate professional staff, or others properly trained and equipped to work with concentrated infectious material. Spill procedures are developed and posted. 
• ♣ Contaminated equipment must be decontaminated before removal from the facility for repair or maintenance or packaging for transport, in accordance with applicable local, state, or federal regulations. 

1. 13. Cultures, tissues, specimens of body fluids, or wastes are placed in a container that prevents leakage during collection, handling, processing, storage, transport, or shipping. 
2. 14. All potentially contaminated waste materials (e.g., gloves, lab coats, etc.) from laboratories are decontaminated before disposal or reuse. 
3. 15. Spills and accidents that result in overt or potential exposures to infectious materials are immediately reported to the laboratory director. Appropriate medical evaluation, surveillance, and treatment are provided and written records are maintained. 
4. 16. Animals and plants not related to the work being conducted are not permitted in the laboratory. 

 

Safety Equipment (Primary Barriers) 

1. 1. Protective laboratory clothing such as solid-front or wrap-around gowns, scrub suits, or coveralls are worn by workers when in the laboratory. Protective clothing is not worn outside the laboratory. Reusable clothing is decontaminated before being laundered. Clothing is changed when overtly contaminated. 
2. 2. Gloves must be worn when handling infectious materials, infected animals, and when handling contaminated equipment. 
3. 3. Frequent changing of gloves accompanied by hand washing is recommended. Disposable gloves are not reused. 
4. 4. All manipulations of infectious materials, necropsy of infected animals, harvesting of tissues or fluids from infected animals or embryonate eggs , etc., are conducted in a Class II or Class III biological safety cabinet 
5. 5. When a procedure or process cannot be conducted within a biological safety cabinet, then appropriate combinations of personal protective equipment (e.g., respirators, face shields) and physical containment devices (e.g., centrifuge safety cups or sealed rotors) are used. 
6. 6. Respiratory and face protection are used when in rooms containing infected animals. 

Laboratory Facilities (Secondary Barriers) 

1. 1. The laboratory is separated from areas that are open to unrestricted traffic flow within the building, and access to the laboratory is restricted. Passage through a series of two self-closing doors is the basic requirement for entry into the laboratory from access corridors. Doors are lockable and a clothes change room may be included in the passageway. 
2. 2. Each laboratory room contains a sink for hand washing. The sink is hands-free or automatically operated and is located near the room exit door. 
3. 3. The interior surfaces of walls, floors, and ceilings of areas where BSL-3 agents are handled are constructed for easy cleaning and decontamination. Seams, if present, must be sealed. Walls, ceilings, and floors should be smooth, impermeable to liquids and resistant to the chemicals and disinfectants normally used in the laboratory. Floors should be monolithic and slip-resistant. Consideration should be given to the use of coved floor coverings. Penetrations in floors, walls, and ceiling surfaces are sealed or capable of being sealed to facilitate decontamination. Openings such as around ducts and the spaces between doors and frames are capable of being sealed to facilitate decontamination. 
4. 4. Bench tops are impervious to water and are resistant to moderate heat and the organic solvents, acids, alkalis, and those chemicals used to decontaminate the work surfaces and equipment. 
5. 5. Laboratory furniture is capable of supporting anticipated loading and uses. Spaces between benches, cabinets, and equipment are accessible for cleaning. Chairs and other furniture used in laboratory work should be covered with a non-fabric material that can be easily decontaminated. 
6. 6. All windows in the laboratory are closed and sealed. 
7. 7. A method for decontaminating all laboratory wastes is available in the facility and utilized, preferably within the laboratory (i.e., autoclave, chemical disinfection, incineration, or other approved decontamination method). Consideration should be given to means of decontaminating equipment. If waste is transported out of the laboratory, it should be properly sealed and not transported in public corridors. 
8. 8. Biological safety cabinets are required and are located away from doors, from room supply louvers, and from heavily-traveled laboratory areas. 
9. 9. A ducted exhaust air ventilation system is provided. This system creates directional airflow which draws air into the laboratory from "clean" areas and toward "contaminated" areas. The exhaust air is not recirculated to any other area of the building. Filtration and other treatments of the exhaust air are not required, but may be considered based on site requirements, and specific agent manipulations and use conditions. The outside exhaust must be dispersed away from occupied areas and air intakes, or the exhaust must be HEPA-filtered. Laboratory personnel must verify that the direction of the airflow (into the laboratory) is proper. It is recommended that a visual monitoring device that indicates and confirms directional inward airflow be provided at the laboratory entry. Consideration should be given to installing an HVAC control system to prevent sustained positive pressurization of the laboratory. Audible alarms should be considered to notify personnel of HVAC system failure. 
10. 10. HEPA-filtered exhaust air from a Class II biological safety cabinet can be recirculated into the laboratory if the cabinet is tested and certified at least annually. When exhaust air from Class II safety cabinets is to be discharged to the outside through the building exhaust air system, the cabinets must be connected in a manner that avoids any interference with the air balance of the cabinets or the building exhaust system (e.g., an air gap between the cabinet exhaust and the exhaust duct). When Class III biological safety cabinets are used they should be directly connected to the exhaust system. If the Class III cabinets are connected to the supply system, it is done in a manner that prevents positive pressurization of the cabinets (Please Refer to Q). 
11. 11. Continuous flow centrifuges or other equipment that may produce aerosols are contained in devices that exhaust air through HEPA filters before discharge into the laboratory. These HEPA systems are tested at least annually. Alternatively, the exhaust from such equipment may be vented to the outside if it is dispersed away from occupied areas and air intakes.
12. 12. Vacuum lines are protected with liquid disinfectant traps and HEPA filters, or their equivalent. Filters must be replaced as needed. An alternative is to use portable vacuum pumps (also properly protected with traps and filters). 
13. 13. An eyewash station is readily available inside the laboratory. 
14. 14. Illumination is adequate for all activities, avoiding reflections and glare that could impede vision. 
15. 15. The Biosafety Level 3 facility design and operational procedures must be documented. The facility must be tested for verification that the design and operational parameters have been met prior to operation. Facilities should be re-verified, at least annually, against these procedures as modified by operational experience. 

Additional environmental protection (e.g., personnel showers, HEPA filtration of exhaust air, containment of other piped services and the provision of effluent decontamination) should be considered if recommended by the agent summary statement, as determined by risk assessment, the site conditions, or other applicable federal, state, or local regulations.

MORTUARY AND POST MORTEM AREA

Objective

• ♣ To provide a clean and safe environment that will prevent transmission of infectious agent to handlers of cadaver during transport and release; in case where autopsy shall be done and for the housekeepers maintaining the area.

Policy Guidelines

1. 1. Only licensed mortician is allowed to assist the pathologist if autopsy shall be done.
2. 2. Licensed mortician and personnel performing post mortem procedures should be oriented to the infection control guidelines of the hospital.
3. 3. All persons involved in handling cadaver must have been immunized with Hepatitis B and BCG.
4. 4. Precautions in handling cadaver should strictly be followed

• ♣ All cadavers are treated potentially infectious therefore Standard Precautions is recommended in alls setting for all people.
• ♣ The cadaver should be placed into a leak-proof body bag.
• ♣ Stretcher to use should be having water resistant cover.
• ♣ In case where autopsy shall be done, the following must be followed:

• - Restricted the number of people present in the room during autopsy.
• - Handwashing is essential before and after the procedure.  The use of antimicrobial soap is recommended.
• - Strict adherence to wear PPEs of all present in the room.

1. 5. The autopsy room should have the following design

• ♣ Negative air pressure room with minimum of 12 ACH;
• ♣ Down draft ventilation under the histology cutting area to facilitate extraction of aerosols
• ♣ Placement of air supply outlets in the ceiling and air exhaust inlets at the floor level to provide downward movement of clean air and avoid inhalation of contaminated air;
• ♣ Use of vacuum devices attached to saws, and faucet water aspirators
• ♣ Do not use high-pressured hose sprays and suction devices to avoid the risk of aerosolization.

1. 6. Other designs to consider are the following:

• ♣ Local shower facilities;
• ♣ Provision for staff to change into protective clothing; 
• ♣ Suitable lighting;
• ♣ Non-porous, seamless work surfaces to aid cleaning (i.e. stainless steel).
• ♣ Floors and walls are designed to be non-slip, impervious, sealed and covered.
• ♣ Floors should have drains connected with appropriate traps and filters to the hospital drainage system.
• ♣ Walls should be painted to withstand frequent cleaning

1. 7. Cleaning and disinfection must be done every after release of cadaver.
2. 8. Healthcare workers exposure to blood and body fluids must be reported. (Please Refer to Infection Control Guidelines for Human Resources Development)

NEONATAL INTENSIVE CARE UNIT

Objectives

• ♣ To prevent healthcare related infections on all babies in the Newborn Services Unit
• - Isolation of patients with proven or suspected infections
• - Isolation of all patients not born in the hospital needing intensive monitoring in the NICU
• - Training of staff members on principles of Infection Control
• - Implementation of infection control policies to include parents and visitors of patients admitted at NICU
• - Implementation of standard precautions to all patients in the unit.

Policy Guidelines

1. 1. The unit should have designated places for separate patient care activities:
• ♣ Discharge Room
• ♣ Level II -Unit-8 bed capacity
• ♣ Hearing Screening Room
• ♣ Equipment Room
• ♣ Working Area
• ♣ Breast feeding Room-6
• ♣ Admitting Area
• ♣ Nurse’s Lounge
• ♣ Soiled Linen Room
2. 2. The staff of the unit should have competencies appropriate for the unit

• ♣ Chairman- Infectious disease pediatrician

1. ♣ Staff Nurses – 10

• - Licensed IV therapist
• - Member of MCNAP
• - Undergone training and orientation on basic and comprehensive NICU operation & procedures
• - Undergone monthly updates on NICU procedures provided by Pedia Residents.

1. ♣ Staff Midwifes - 7

• - Undergone training and orientation on basic and comprehensive NICU operation and procedures
• - Undergone updated seminars internal and external
• - Undergone Infection Control Orientation on NICU

1. 3. All healthcare workers in the unit should comply with the prescribed attire

• ♣ Caps and masks are not routinely worn inside the NICU except during performance of special procedures like umbilical vein catheterization.
• ♣ The NICU staff, residents, and interns are required to wear regulated scrub suits. Standard precautions are practiced when entering the Isolation Room. Gowns used in the Isolation Room should be different from those worn in the other areas.
• ♣ Designated gowns are provided for consultants who make their rounds in the NICU.
• ♣ Nurses and midwives are required to put on smock gowns over their scrub suits when going out of the NICU.
• ♣ Clothing and unscrubbed skin areas of NICU personnel should not be exposed to the infants.

1. 4. Admission criteria should be followed

• ♣ Criteria for admission to NICU Isolation Room:

• - Babies born to mothers with infection or mothers  who present with the following at the time of delivery:
• ¬ Fever
• ¬ Diarrhea
• ¬ Rash
• ¬ UTI
• ¬ varicella
• ¬ TORCHES
• ¬ Hepatitis - babies born to mothers with hepatitis may be placed inside incubators (if available), in the NR area, or in a designated area in the NR, apart from the other babies.
• - Babies staying in the NICU or NICU referral who develop nosocomial infection or babies who are admitted because of community - acquired infection needing NICU care.
• - Babies who are delivered under septic conditions or those who show signs/symptoms of infection will automatically be transferred to the Isolation Room.  The attending pediatrician will be informed by the PROD/NOD of the transfer.
• - Neonates with diarrhea and/or audible cough should be admitted to a private room of choice.
• - The Isolation Room can accommodate 5 babies in bassinets or 2 babies in incubator +2 babies in bassinets.

1. 5. The unit has its own isolation room policies:

• ♣ All equipment and materials used in the isolation room will not be lent out to other units of the NSD or other areas of the hospitals.
• ♣ Specially colored (yellow) gowns and marked slippers will used by the personnel (nurses, doctors, etc) assigned to the unit and will not be brought to the other areas of the nursery.
• ♣ Gowns/ slippers/ equipment to be used per cubicle will not be transferred to other cubicles in the isolation room.
• ♣ If the person assigned to the isolation unit needs to go out, he/she will have to change the yellow gown into the regulated attire prescribed.
• ♣ The nurse assigned to care for the patients in the isolation room will not be allowed to handle babies in other units of the NSD.
• ♣ Soiled diapers and disposable materials used in the care of babies in the isolation unit will be placed in yellow bags prior to disposal.
• ♣ Soiled linen in the area will also be placed in yellow bags prior to disinfection and cleaning.
• ♣ Drugs/medications used in individual cubicles cannot be shared or used on the other isolation cubicles units in the nursery.
• ♣ Daily cleansing and terminal disinfection of each patient cubicle in the isolation room will follow the ICC protocol of the hospital.
• ♣ Parents/guardians of babies admitted to the Isolation Room who want to visit will have to follow the policies on viewing and gowning of the unit.

1. 6. Aseptic technique should be practiced for all invasive procedure and care after.  (Please Refer to Recommendations for Placement of Intravascular Catheters in Adults and Children, Prevention of Healthcare Associated Bacterial Pneumonia, and Hand Hygiene Guidelines)
2. 7. All reusable materials and equipment should undergo the process of decontamination, cleaning and disinfection/sterilization to render it safe on the next use. (Please Refer to Disinfection and Sterilization of Reusable Items)

1. 8. Housekeeping and Care of Linen 

• ♣ Handling and Disinfection of NICU Equipments
• - Concurrent water in bubbling bottles and oxygen tubing is changed every 24 hours. Terminal soaking with (Glutaraldehyde) is followed by rinsing with boiled water, drying, and storage in a clean container.
• - Paper funnels for direct oxygen are not autoclaved and disposed after used.
• - CPAP devices and y-tubing are preferably disposable but could be recycled by soaking in (Glutaraldehyde) Cidex.
• - Terminal cleaning disinfection of equipment is done at the washing area with approved disinfecting solution.
• - Bulb syringe are cleaned, dried and autoclaved.
• - Suction catheters are changed every 2x every shift.
• - 50 cc syringe bottles of Isotonic Solution for suction catheter are replaced 2x every shift.
• - All equipments and materials (with the exception of respirators) used in the Newborn Services Division should not be lent to other units in the hospital.

• ♣ Environmental Control

• - Environmental cleaning and disinfections
• ¬ Nursery floor is vacuumed and never swept. Mopping with Na hypochlorite is done daily.
• ¬ The walls and floors of Isolation Room are scrubbed with Na hypochlorite.
• ¬ Concurrent water in the reservoir of the incubator is replaced everyday with autoclaved water. 
• ¬ Incubator walls/cribs are cleaned with Na hypochlorite once daily.
• ¬ Terminal disinfection is done by thorough scrubbing with soap & water and disinfect with Na hypochlorite. 
• ¬ All parts of the equipment in contact with water are washed with soap and water and then dried until the next admission.

• - Linen

• ¬ Separate room for clean & soiled linens
• ¬ Clean linens should be kept in a closed linen closet or in a covered linen cart that is not located in the patient treatment areas.
• ¬ Soiled linens should be placed in a large container located in an area for soiled linen.
• ¬ Soiled linens from infected patient should be contained in a yellow plastic bag prior to endorsement to the linen section.

1. 9. Personnel Regulations

• ♣ All NICU personnel (nurses. aides, residents and interns) should have complete physical examination and chest X-ray at least once a year. Stool and throat cultures should be done yearly.
• ♣ The nursing staff and other personnel are not allowed to visit patients in other clinical                areas of the hospital while they are on duty.  
• ♣ Children and relatives of personnel are not allowed to stay in the NICU.
• ♣ All personnel should eat at the dining table at the NICU lobby.

1. 10. Monitoring of Implementation 

• ♣ The head nurse and/or unit supervisors who had undergone basic training course in Infection Control and the HICN shall conduct separate weekly monitoring of adherence to HIC policies by random selection of HCWs’ and procedures.
• ♣ The NICU Chairperson who is a member of the Executive Committee or IC team will conduct monthly IC lecture on selected cases for audit of incidents of breaks in Infection Control, which will coincide with the unit meeting.

PHARMACY DEPARTMENT

Objectives

• ♣ To prevent contamination of all products supplied by the pharmacy
• ♣ To maintain the potency of all products supplied by the pharmacy

Policy Guidelines

• 1. Visual Inspection.

All containers of parenteral fluids should be checked for visible turbidity, leaks, cracks and particulate matter and for the manufacturer’s expiration date before admixing and again before distribution. The fluid should not be used if any problem is found.

• 2. All unused or expired drugs should be returned to pharmacy for proper disposal. (Please refer to Waste Management)
• 3. Antibiotic usage programs.

In cooperation with the Infection Control Committee, the Pharmacy and Therapeutic Committee participates in antibiotic usage program.

All high cost broad spectrum and 4th generation antibiotics are place on Restricted Drugs

• ♣ Cefipime
• ♣ Ertapenem
• ♣ Imipenem
• ♣ Linezolid
• ♣ Meropenem
• ♣ Vancomycin
• ♣ Tigecycline

PATIENT WITH AIRBORNE INFECTION IN SURGERY SUITES

Objective

1. ♣ To prevent transmission of airborne infection in Surgery and Delivery Suites

Policy Guidelines

1. 1. The HICC and the concerned operating area, NICU and nursery should be informed prior to the procedure.
2. 2. Schedule patients with airborne infection to be last case for the day if possible.
3. 3. Limit the surgical team to those with past exposure to measles and chickenpox.
4. 4. Use N95 properly in case of PTB and pneumonia in addition to standard PPE.  (For detailed policies, please refer to Personal Protective Equipment)
5. 5. Select a room wherein temperature control can be set to low and keep the door always closed.
6. 6. Patient should stay in the said room for monitoring and should be transferred to isolation room once stable. In case of unavailability of isolation room, patient will remain in the said room until a discharge order is made by attending physician. Terminal cleaning of the room should be follow immediately.
7. 7. In case of delivery, the baby should be managed by the Pediatric Infectious Disease doctors to prevent further contamination.
8. 8. The patient should wear surgical mask if N95 is not tolerated during transport.
9. 9. For hepatitis B reactive patient:

• • Disposable gown should be used by patient and by the doctor who will attend to her delivery (other PPE should be worn properly by all staff on duty)
• • There should be separate set of instruments for the particular case. Proper disinfection of bed, room and delivery table should be done after the procedure. Instruments and suction bottles should be soaked in soap and water with zonrox for 30 minutes to one hour, dry and pack for autoclaving patient’s wastes should be discarded properly.
• • Proper endorsement regarding the patient’s case should be made (patient’s protection of privacy should be observed)

1. 10. Consider all unregistered patients (no regular prenatal check-up / walk-in or no laboratory work-ups for hepatitis, sexually transmitted and other infectious diseases) as suspect carriers of infections and health precautions mentioned above should be applied to them.

PREVENTION AND CONTROL OF SEXUALLY TRANSMITTED INFECTIONS, HEPATITIS B AND HIV/AIDS

Objectives

• ♣ To prevent the spread of sexually transmitted infections (STIs) of clients and among their partners
• ♣ To give counseling and educate clients on prevention and control of sexually transmitted infections
• ♣ To provide privacy thus protecting confidentiality of patients

Policy Guidelines

1. 1. All patients with sexually transmitted infections should be given the appropriate education, counseling and treatment.  (Please refer to Counseling and Risk Reduction Strategies)
2. 2. All blood donors should conform to the conditions of blood donation and agreed to be informed of the result of any blood infections. (Please refer to Blood Donor Record)
3. 3. All clients who will undergo HIV antibody test should be given counseling before signing informed consent.  The test request is “VCT” meaning voluntary counseling and testing.
4. 4. Pre-test counseling should be administered by any healthcare worker (doctors, nurses, medical technologists) who underwent training on counseling before obtaining informed consent. Informed consent form is available at Blood Bank.
5. 5. Specimen together with consent of all in-patients for HIV antibody testing should pass the HICC office for proper coding.  The HICC will send the specimen to the laboratory to maintain confidentiality.
6. 6. A patient who seeks “strict confidentiality” should pay in cash through the HICC for the said test. 
7. 7. All HIV antibody result should be given personally to the client or the representative mentioned on the informed consent.
8. 8. Confirmed HIV antibody test result is reported automatically upon confirmation.
9. 9. Post-test counseling should be provided.  Risk reduction strategies should be discussed to the patient or the authorized representative.  
10. 10. Counseling and testing should be provided with confidentiality.
11. 11. HIV antibody result should be known by the medical team but treated with confidentiality i.e. no marker or posting should be made to patient chart or room about the diagnosis.
12. 12. Patients admitted with STIs/HIV/AIDS need not be isolated except for immunocompromised disseminated cases.  Standard Precautions should be strictly observed. (Please refer to Isolation Policies)
13. 13. List of STIs for education and counseling:

• ♣ Chlamydia

• ♣ Crab lice
• ♣ Gonorrhea
• ♣ Hepatitis B
• ♣ Herpes simplex
• ♣ HIV/AIDS
• ♣ Syphilis
• ♣ Trichomonas
• ♣ Warts

1. 14. Informed consent forms to be used are provided by MCMC Department of Pathology and STD AIDS Cooperative Central Laboratory. 

VISITOR GUIDELINES

Objectives

• ♣ To prevent the spread of infection to watchers/visitors

Visitors Policies and Guidelines

1. 1. No more than two (2) visitors at least are allowed to visit patient (Airborne/Communicable Diseases) precautions instructed at any given time.
2. 2. Visitors are always instructed properly at the precautions required on their visitation by nurse-in-charge / hospital security from the time of entering to our hospital gates and premises.
3. 3. Visitors in extreme of ages (children under 12 years of age) were not advised to visit patient/roaming around hospital premises at all times.
4. 4. Visitors are always instructed on how to disposed their trash at proper color coded trash bins.

Visitors Behavior

1. 1. Visitor should not interfere with or in any way disrupt activities of the hospital staff.
2. 2. Visitor should never sit or lie on patient’s bed or congregate in patient-care areas.
3. 3. Visitor should not place personal belongings on the patient’s bed.
4. 4. Visitor should observe visiting hours at all times.
5. 5. Visitor must always be cooperative to any hospital staff and must implement self-discipline.

Standard Color Coding to protect patients, visitors and healthcare workers (See Visitor Guidelines, Policy No. 3)

The color of the card shall correspond to the color tagged at the door entrance. 

Respiratory Etiquette

INFECTION CONTROL GUIDELINES ON INTERNAL DEMOLITION, CONSTRUCTION, RENOVATIONS, and REPAIRS

Objectives:

1. ♣ To educate construction workers about the importance of control measures
2. ♣ To prepare the site
3. ♣ To notify and issue advisories for staff, patients, and visitors
4. ♣ To move staff and patients and relocating patients as needed
5. ♣ To issue standards of practice and precautions during activities and maintenance 
6. ♣ To monitor for adherence to control measures during construction and providing prompt feedback about lapses in control 
7. ♣ To monitor HVAC performance
8. ♣ To implement daily clean-up, terminal cleaning and removal of debris upon completion
9. ♣ To ensure the integrity of the water system during and after construction.

Policy Guidelines

1. 1. The following construction/repair projects are required to have barrier structures:
2. a. Demolition of walls, wallboard, plaster, ceramic tiles, ceiling tiles, and ceilings
3. b. Removal of flooring and carpeting, windows and doors, and casework
4. c. Working with sinks and plumbing that could result in aerosolization of water in high-risk areas
5. d. Exposure of ceiling spaces for demolition and for installation or rerouting of utility services (e.g., rewiring, electrical conduction installation, HVAC ductwork, and piping)
6. e. Crawling into ceiling spaces for inspection in a manner that may dislodge dust
7. f. Demolition, repair, or construction of elevator shafts
8. g. Repairing water damage
9. 2. Members and functions of a multi-disciplinary coordination team for construction, renovation, repair, and demolition projects
10. a. Members:
1. i. Infection-control personnel, including hospital epidemiologists
2. ii. Laboratory personnel
3. iii. Facility administrators or their designated representatives, facility managers
4. iv. Director of engineering
5. v. Risk-management personnel
6. vi. Directors of specialized programs (e.g., transplantation, oncology and ICU* programs)
7. vii. Employee safety personnel, industrial hygienists, and regulatory affairs personnel
8. viii. Environmental services personnel
9. ix. Information systems personnel
10. x. Construction administrators or their designated representatives
11. xi. Architects, design engineers, project managers, and contractors
11. b. Functions and responsibilities
1. i. Coordinate members’ input in developing a comprehensive project management plan.
2. ii. Conduct a risk assessment of the project to determine potential hazards to susceptible patients.
3. iii. Prevent unnecessary exposures of patients, visitors, and staff to infectious agents.
4. iv. Oversee all infection-control aspects of construction activities.
5. v. Establish site-specific infection-control protocols for specialized areas.
6. vi. Provide education about the infection-control impact of construction to staff and construction workers.
7. vii. Ensure compliance with technical standards, contract provisions, and regulations.
8. viii. Establish a mechanism to address and correct problems quickly.
9. ix. Develop contingency plans for emergency response to power failures, water supply disruptions, and fires.
10. x. Provide a water-damage management plan (including drying protocols) for handling water intrusion from floods, leaks, and condensation.
11. xi. Develop a plan for structural maintenance.
12. 3. Infection-control measures for internal construction and repair projects
12. a. Prepare for the project.
1. i. Use a multi-disciplinary team approach to incorporate infection control into the project.
2. ii. Conduct the risk assessment and a preliminary walk-through with project managers and staff.
13. b. Educate staff and construction workers.
1. i. Educate staff and construction workers about the importance of adhering to infection-control measures during the project.
2. ii. Provide educational materials in the language of the workers.
3. iii. Include language in the construction contract requiring construction workers and subcontractors to participate in infection-control training.
14. c. Issue hazard and warning notices.
1. i. Post signs to identify construction areas and potential hazards.
2. ii. Mark detours requiring pedestrians to avoid the work area.
15. d. Relocate high-risk patients as needed, especially if the construction is in or adjacent to a PE area.
1. i. Identify target patient populations for relocation based on the risk assessment.
2. ii. Arrange for the transfer in advance to avoid delays.
3. iii. At-risk patients should wear protective respiratory equipment (e.g., a high efficiency mask) when outside their PE rooms.
16. e. Establish alternative traffic patterns for staff, patients, visitors, and construction workers.
1. i. Determine appropriate alternate routes from the risk assessment.
2. ii. Designate areas (e.g., hallways, elevators, and entrances/exits) for construction worker use.
3. iii. Do not transport patients on the same elevator with construction materials and debris.
17. f. Erect appropriate barrier containment.
1. i. Use prefabricated plastic units or plastic sheeting for short-term projects that will generate minimal dust.
2. ii. Use durable rigid barriers for ongoing, long-term projects.
18. g. Establish proper ventilation.
1. i. Shut off return air vents in the construction zone, if possible, and seal around grilles.
2. ii. Exhaust air and dust to the outside, if possible.
3. iii. If recirculated air from the construction zone is unavoidable, use a pre-filter and a HEPA filter before the air returns to the HVAC system.
4. iv. When vibration-related work is being done that may dislodge dust in the ventilation system or when modifications are made to ductwork serving occupied spaces, install filters on the supply air grilles temporarily.
5. v. Set pressure differentials so that the contained work area is under negative pressure.
6. vi. Use air flow monitoring devices to verify the direction of the air pattern.
7. vii. Exhaust air and dust to the outside, if possible.
8. viii. Monitor temperature, air changes per hour (ACH), and humidity levels (humidity levels should be <65%).
9. ix. Use portable, industrial grade HEPA filters in the adjacent area and/or the construction zone for additional ACH.
10. x. Keep windows closed, if possible.
19. h. Control solid debris.
1. i. When replacing filters, place the old filter in a bag prior to transport and dispose as a routine solid waste.
2. ii. Clean the construction zone daily or more often as needed.
3. iii. Designate a removal route for small quantities of solid debris.
4. iv. Mist debris and cover disposal carts before transport (i.e., leaving the construction zone).
5. v. Designate an elevator for construction crew use.
6. vi. Use window chutes and negative pressure equipment for removal of larger pieces of debris while maintaining pressure differentials in the construction zone.
7. vii. Schedule debris removal to periods when patient exposures to dust is minimal.
20. i. Control water damage.
1. i. Make provisions for dry storage of building materials.
2. ii. Do not install wet, porous building materials (i.e., sheet rock).
3. iii. Replace water-damaged porous building materials if they cannot be completely dried out within 72 hours.
21. j. Control dust in air and on surfaces.
1. i. Monitor the construction area daily for compliance with the infection-control plan.
2. ii. Protective outer clothing for construction workers should be removed before entering clean areas.
3. iii. Use mats with tacky surfaces within the construction zone at the entry; cover sufficient area so that both feet make contact with the mat while walking through the entry.
4. iv. Construct an anteroom as needed where coveralls can be donned and removed.
5. v. Clean the construction zone and all areas used by construction workers with a wet mop.
6. vi. If the area is carpeted, vacuum daily with a HEPA-filtered–equipped vacuum.
7. vii. Provide temporary essential services (e.g., toilets) and worker conveniences (e.g, vending machines) in the construction zone as appropriate.
8. viii. Damp-wipe tools if removed from the construction zone or left in the area.
9. ix. Ensure that construction barriers remain well sealed; use particle sampling as needed.
10. x. Ensure that the clinical laboratory is free from dust contamination.
22. k. Complete the project.
1. i. Flush the main water system to clear dust-contaminated lines.
2. ii. Terminally clean the construction zone before the construction barriers are removed.
3. iii. Check for visible mold and mildew and eliminate (i.e., decontaminate and remove), if present.
4. iv. Verify appropriate ventilation parameters for the new area as needed.
5. v. Do not accept ventilation deficiencies, especially in special care areas.
6. vi. Clean or replace HVAC filters using proper dust-containment procedures.
7. vii. Remove the barriers and clean the area of any dust generated during this work.
8. viii. Ensure that the designated air balances in the operating rooms (OR) and protective environments (PE) are achieved before occupancy.
9. ix. Commission the space as indicated, especially in the OR and PE, ensuring that the room’s required engineering specifications are met.
10. 4. Strategies to reduce dust and moisture intrusion during external demolition and construction
23. a. Demolition site
1. i. Shroud the site if possible to reduce environmental contamination
24. b. Dust-generating equipment 
1. i. Prior to placing dust-generating equipment, evaluate the location to ensure that dust produced by the equipment will not enter the building through open doorways or windows, or through ventilation air intakes.
25. c. Construction materials storage
1. i. Locate this storage away from the facility and ventilation air intakes.
26. d. Adjacent air intakes
1. i. Seal off affected intakes, if possible, or move if funds permit.
27. e. HVAC system
1. i. Consult with the facility engineer about pressure differentials and air recirculation options; keep facility air pressure positive to outside air.
28. f. Filters 
1. i. Ensure that filters are properly installed; change roughing filters frequently to prevent dust build-up on high-efficiency filters.
29. g. Windows
1. i. Seal and caulk to prevent entry of airborne fungal spores.
30. h. Doors
1. i. Keep closed as much as possible; do not prop open; seal and caulk unused doors (i.e., those that are not designated as emergency exits); use mats with tacky surfaces at outside entrances.
31. i. Water utilities
1. i. Note location relative to construction area to prevent intrusion of dust into water systems*
32. j. Medical gas piping
1. i. Ensure that these lines/pipes are insulated during periods of vibration.
33. k. Rooftops 
1. i. Temporarily close off during active demolition/construction those rooftop areas that are normally open to the public (e.g., rooftop atrium).
34. l. Dust generation
1. i. Provide methods (e.g., misting the area with water) to minimize dust
35. m. Immunocompromised patients
1. i. Use walk-ways protected from demolition/construction sites; avoid outside areas close to these sites; avoid rooftops.
36. n. Pedestrian traffic
1. i. Close off entry ways as needed to minimize dust intrusion.
37. o. Truck traffic
1. i. Reroute if possible, or arrange for frequent street cleaning.
38. p. Education and awareness+
1. i. Encourage reporting of hazardous or unsafe incidents associated with construction.

* Contamination of water pipes during demolition activities has been associated with health-care–associated transmission of Legionella 

+ When health-care facilities have immunosuppressed patients in their census, telephoning the city building department each month to find out if buildings are scheduled for demolition is prudent.

MANDALUYONG CITY MEDICAL CENTER

HOSPITAL INFECTION CONTROL PROGRAM

MANUAL OF OPERATION