INFECTION CONTROL COMMITTEE

6TH ICC. MEETING

DATE: MAY 22, 2020
TIME: 11:50 AM – 3:40 PM
VENUE: BOARD ROOM, ADMINISTRATIVE OFFICE 10TH FLOOR

Attendance:

NAME POSITION/ DEPARTMENT

1) Dr. Rochel Dalay-Edades Acting Head- Infection Control Committee

2) Criscarlson C. Galendez, MAN, RN, USRN, OHN Infection Control Nurse / Infection Control Committee President
3) Aiza M. Alvarez, RN, CNN Hemodialysis Supervisor / Infection Control Committee-NSD Vice President
4) Larizza Ann Ramos, RRT Chief Radiologic Technologist/ Infection Control Committee-Ancillary Vice President
5) Crisanta P. Flores, RMT Chief Medical Technologist/ Infection Control Committee- Ancillary Secretary
6) Ronia Bianca G. De Leon, RMT Asst. Chief Medical Technologist

7) Alex James Escalera, RN Nursing Service Supervisor

I. PRAYER
 Led by Ms. Aiza Alvarez, RN
II. CALL TO ORDER
 The Meeting was called to order at 11:50 AM by Dr. Rochel Dalay-Edades
III. DISCUSSION MATTERS ARISING
1. Reading of the Minutes of the Meeting
 Ms. De Leon of the Laboratory Medicine read the Minutes of the Meeting.
2. Follow up Concerns to Laboratory Medicine
 Dr. Edades follow up status regarding send out of RT-PCR to Singapore Diagnostics
 According to Ms. Flores, the department decided not to go with the Singapore Diagnostic since the
price that they provided to us does not include the Viral Transport Medium.
  One of the suggestion for send out laboratory is the Detoxicare Molecular Diagnostic Laboratory
which offers a lower price compared to Singapore Diagnostic, and since some of our sister companies
like ACE MC- Quezon City and ACE MC- Valenzuela is already sending out their specimens to
Detoxicare.
 Costing and process flow was already approved by Dr. Ribo.
3. Infection Prevention and Control by the Nursing Service Department
 Mr. Escalera read the prepared IPC’s of the Nursing Service Department.
a. Nursing Service General Guidelines
 All staff should strictly adhere in proper wearing of PPE inside the nurse station, handling of
patients, and disposing.
 Room 703 and 9th Large Suite Room are the Designated Room for Donning and Doffing of
PPE.
 The nurses shall apply the five moment of Hand Hygiene by WHO.
 Wall to wall cleaning must be done after the patient is discharged. UV light should be done
after the cleaning.
 All staff nurses are responsible for self-monitoring, if any symptoms occur, inform
immediately the nursing service office for further advice.

b. Specific Guidelines
b.1. 7th floor (Emergency Room Admission / Direct Admission)
CLEAN CASE PATIENT ABNORMAL CHEST X-RAY
OB-Gyne, Medical-Surgical,  Charge nurse on-duty will inform JCON on-duty and
Pedia and Newborn Px supervisor on-duty.
should have:  JCON on duty will Inform AP for medical
 Health Declaration management regarding her patient.
(serves as Clearance  If in case Patient will be tag as Suspected; Supervisor
from Attending will facilitate transfer of Patient to 9th floor;
Physician) or  Supervisor/Charge Nurse will inform 9th Floor Charge
 Clear chest x-ray result; Nurse for the said transfer.
  Accomplished CIF and SARI (if requested) forms will
be prepared by JCON.
 Supervisor on duty will prepare 3 (three) copies; 1
Photocopied CIF form for NSD copy (filed); and 1
original copy for submission to ICC; and for request to
laboratory.

b.2. 9th floor (Emergency Room Admission / Direct Admission)

INFECTIOUS PATIENT SUSPECTED PATIENT/CONFIRMED CASE
 Patient can be OB-Gyne,  Patient can be OB-Gyne, Medical-Surgical, Pedia and
Medical-Surgical, Pedia Newborn; with Abnormal Chest X-ray (ex. Infectious
and Newborn; with Dse.) with the following symptoms:
Abnormal Chest X-ray  Colds, cough, fever, difficulty of breathing and etc.
(ex. Infectious Dse.)
 With Negative result of
COVID Swab (from our
Institution)
b.3. Discharging of Patient
3.1 Discharge of patient depends upon the attending physicians order.
 Those who have no result / those who have (+) result - Patient is coordinated to the RESU
of their respective municipalities.
b.4. Intensive Care Unit (ICU)
 ICU allocated 6 staff nurses in the PUI/COVID area together with 4 nursing assistants. While
4 staff nurses are assigned in the clean area. Rotation is done every 2 weeks to minimize
exposure.
 All staff nurses assigned in the PUI/COVID shall adhere to Standard Precautions:
 Hand hygiene
 Personal protective equipment
 Patient admission
 Aerosol generating procedures
 Visitor access
 Segregation & collection practices
  Cleaning
 Linen
 Patient transfer: intra-hospital transfer
 Documentation:
 Proper handling of remains
 Proposal
 To cover keyboards/ remotes with plastic for easy cleaning and disinfection.
 Use UV light to disinfect Charts / health records and placed it on a sealed plastic prior to
hand over to the Medical Records for safekeeping.
b.5. Neonatal Intensive Care Unit (NICU)
 General Guidelines
 COVID-19 patients (Probable, Suspected, Confirmed), CIF (Case Investigation Form) must be
accomplished immediately upon admission by Pedia JCON on duty.
 All staff should wear outside PPE during rooming in of the newborn patient.
 During transferring, babies are required to cover in basinet using clean wrap (half covered) to
prevent possible transfer of infection.
 There shall be separated nurses for the care of confirmed COVID-19 patients with mild signs
and symptoms. A different set of nurses shall be assigned to provide care for suspect or
probable cases. Three nurses per shift, 1 Nurse for Sick babies, 1 Nurse for well babies and 1
Nurse for COVID-19 patients.
 Mr. Escalera discussed the Guidelines for OPD and viewing of sick and well babies.
 Standard Guidelines
 All gadgets of parents shall be left at nurse’s station.
 No sterilization of feeding bottle from outside.
 All mothers shall be present during discharge of neonate. If mother is not the one to
receive the baby, authorization letter must be provided from the mother with mother/s
valid ID and ID representative.
b.6. Operation and recovery room/ Delivery room
 Mr. Escalera discussed the general guidelines and specific guidelines of the OR/ DR IPC’s
 OB/OB GYNE infectious case
 All suspect, probable and confirmed COVID-19 OB patients must be assessed by OBJCON in
the tent or isolation room in emergency room.
 All infectious OB case must be cohorted, for Cesarean Section (CS), should be placed in
 Endoscopy Room, for Normal Spontaneous Delivery (NSD) should be placed in Optha Room.
 Algorithm and process flow for infectious patients of the hospital must be strictly followed
upon admission.
b.7. Emergency Room Department
 Mr. Escalera discussed the Infection prevention and control preparedness of the emergency
room department in terms of staff, patient, foot traffic, facilities and training.
 Suggestion of the Emergency Room Department
 Swabbing of staff every 2 weeks with or without symptoms until Covid 19 crisis is resolved
 Not to allow staff to render duty until release of negative swab result.
 Wearing of dedicated disposable PPE on top of reusable PPE when attending his/her patient
 Hand hygiene materials must be approved by ICC.
 Suggest that ER staffs must decontaminate before leaving work. Changing into new set of
clothes or taking a shower.
 Aerosol generating procedure i.e: BVM ventilation, nebulization, use of BIPA etc. should be
avoided.
 Wearing of facemask or face shield is required when transporting of patient from one
department to another.
 Alternative route of probable/ suspect Covid 19 patient for transport from one
department to another.
 Installation of several HEPA filters in the ER complex.
 Installation of negative pressure to Covid Transient Isolation room.
 Complete patient support equipment and machines at COVID transient Isolation room
 Adequate supply for approved reusable PPE
 Use of UV light with materials that cannot undergo wet decontamination.
4. ICC Concern to the NSD
 Mr. Galendez suggested to used Biguanid for cleaning of special area.
 Dr. Edades raised a concern regarding the companion waiver form to suspected patients.
 Mr. Escalera suggested to have a special consideration for the companion of suspected patients
(ex.pedia, PWD, etc.).
 According to Dr. Edades, Mr. Escalera should submit a picture for donning and doffing areas per
ward and special area.
 Mr. Escalera raised a concern regarding the existing alcohol and hand wash soap. He suggested that
the Infection Control Committee should be the one to approve the content of the alcohol and hand
 wash soap.
 According to Mr. Escalera, training of all staff for infection prevention and control is highly
recommended since not all staff is fully aware of the proper ways in preventing the spread of
infection. ICC should coordinate with HR to make sure that all staff will attend the trainings.
 Mr. Escalera also suggested to activate the ICC team and assigned specific point person for the
documentation, surveillance, investigation, contact tracing, consolidation, and reporting.
 The management should also give compensation and incentives since this will be another work for
the members of the ICC.
 Mr. Escalera proposed to have a “COVID-19 DAY” a program that will allow the hospital staff to
practice donning and doffing of PPE’s.
 According to Mr. Escalera, all suggested concerns should be consolidated by the ICC team and to be
approved by the management.
 According to Dr. Edades, Mr. Escalera should be the co-chair of the ICC.
 According to Dr. Edades, the ICC will release a memorandum regarding the general guidelines for
the ICC and once approved by the management all concern departments will be called to attend the
meeting for the discussion of the guidelines.
 Dr. Edades instructed Mr. Escalera to revised the suggestion of the Nursing Service Department and
to make the companion waiver form “ASAP”.
 According to Dr. Edades, the ICC and COVID-19 task force will release a memorandum for the
appointment of Ms. Maybelle Cruz and Mr. James Escalera.
 According to Dr. Edades, all ER nurse should wear PPE at all times since all patient in emergency
room should be consider as suspected.
 Ms. Alvarez, raised a concern regarding the CF-2 form for the COVID-19 swabbing.
 According to Ms. Flores, RITM posted a memorandum stating that one of the requirements of
COVID RT-PCR testing is the Phil health CF-2 form and concerns regarding the CF-2 should be
raised to Ms. Febbie, Philhealth supervisor.
 For the next meeting, according to Dr. Edades key persons of each department should be invited.
IV. SCHEDULE OF NEXT MEETING
 All attendees agree to set the meeting on May 28, 2020- Thursday 1:00 pm venue to be announced.

V. ADJOURNMENT
  Meeting was adjourn at 2:46 pm, May 22, 2020

Prepared by: Review by: Approved by: Approved by:

Crisanta P. Flores, RMT Criscarlson C. Galendez, RN, ROCHEL DALAY-EDADES,

MDInfection Control, OIC JANE CLEOFE-PANALIGAN, MD
ICC- Secretary Ancillary Division MAN CoviD-19 Task Force Head
ICC President