POLICIES AND PROCEDURES MANUAL

INFECTION CONTROL IN ADULT INTENSIVE CARE UNIT

DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 1 of 7
00 REVIEW DUE
IC-01-039 DECEMBER 31, 2020

I. OBJECTIVES

To prevent the spread of potential infections in the ICU.

II. SCOPE
ICU/CCU staff must adhere to the following procedures in order to control infectious
within these critical patients areas.

III. DEFINITION OF TERMS

Intensive Care Unit For purposes of this policy and procedures manual, the
Intensive Care Unit shall
cover the Medical ICU, CCU, and NCCU.
ICU Intensive Care Unit
CCU Coronary Care Unit
NCCU Neurological Intensive Care Unit
ICC Infection Control Committee

IV. POLICIES
1. ICU staff must adhere to the following procedures in order to control infectious
within these critical patient areas.
2. Aseptic technique shall be observed when doing procedures, such as intravenous
therapy, tracheostomy, and urinary catheter care.
3. Disinfection & sterilization shall follow the hospital wide policies recommended by
the Infection Control Committee (ICC). Please refer to Policies & Procedures on
Sterilization and Disinfection.
4. Confirmed or suspected infectious cases and occupational needle stick injuries or
blood and body fluid exposures shall promptly be reported to the Infection Control
Office. Please refer to Policies and procedures on Needle/Sharp Injury and Blood and
Body Fluids.

V. PROCEDURE:
1. Personnel
1.1 All staff should adhere to the hospital Employee Health Program, any
employee having an infectious process or condition shall report to his
immediate supervisor and or to the Chief of Radiologist and to the Employee
Health Physician when needed. Refer to Infection Control Manual Employee
Health Program.

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN ADULT INTENSIVE CARE UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 2 of 7
00 REVIEW DUE
IC-01-039 DECEMBER 31, 2020

1.2 Do not wear artificial fingernails or extenders when having direct contact
with patients.

1.3 Keep natural fingernail tips less than 1/4 inch in length.

2. Standard Precaution

2.1 All blood products, secretion and excretion shall be handled as

potentially hazardous specimens. Appropriate barrier precautions are to be
used in contact with blood and body secretions (Refer to Infection Control
manual, Standard Precaution Policy)

3. Hand hygiene

3.1 Personnel shall closely adhere to the established protocol for Hand
Hygiene (Refer to Infection Control Manual, Hand Hygiene Policy).

4. Isolation

4.1 All employees will follow the Isolation Protocol (Refer to Infection
Control Manual, Isolation Precaution Private Rooms are available for those
ICU patients requiring Airborne, Droplet and Contact precautions. Isolation
waste will be placed into the regular trash unless the patient has a CDC Class
4 disease (which includes but not limited to Rabies, Anthrax, and Brucellosis
Plague and Hemorrhagic fever). Housekeeping will pick up these bags for
proper disposal.

5. Dress

5.1 Personnel shall change into scrub suit or assigned uniform before
reporting for duty in ICU. If scrubs become soiled with blood or secretions,
they are to be changed.

6. Cleaning, Disinfection and Sterilization of Equipment

6.1 Individual patient equipment (i.e. BP cuffs, stethoscope, EKG cable and
leads) shall be cleaned with a disinfectant solution between patients and
whenever visibly soiled.

6.2 Housekeeping personnel clean floors, sinks and commodes daily with a
disinfectant solution. All surfaces, monitors, and EKG equipment shall be
cleaned as needed with a disinfectant solution.

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN ADULT INTENSIVE CARE UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 3 of 7
00 REVIEW DUE
IC-01-039 DECEMBER 31, 2020

6.3 Disinfectants and cleaning agents used in the Unit shall be those
approved by the Infection Control Committee and shall be used
according to manufacturer’s or ICC recommendation. Disinfectants /
cleaning agents used include the following:
6.4 High level disinfectant (e.g. Cidex OPA (Ortho-Phthalaldehye) (No
dilution needed; generally, once used the solution can last for 15 days)
Refer to Policies and Procedures on Sterilization and Disinfection.
6.5 Phenols and Quarternary Ammonium (ex. Lysol) (Recommended dilution
is 6 bottle capfuls into Liters of water; diluted solution should be used
within 24 hours only; contact time is at least 10 minutes Sodium
Hypochlorite (ex. Bleach)
6.6 Alcohols (ex. 70% Isopropyl Alcohol)
6.7 Routine cleaning (surface cleaning, dry sweeping or floor mopping,
collection of garbage and dishes) of the Unit, including patient cubicles,
shall be done at least daily. General cleaning (which includes wall to wall
scrubbing) shall be done at least every 2 weeks, upon patient discharge,
and as needed.
6.8 Cleaning procedures shall follow those stipulated under Cleaning &
Disinfection of Hospital Areas Policies & Procedures.
6.9 Equipment

6.9.1 Laryngoscope Handle and Blade – Please refer

to Policies & Procedures on Sterilization and
Disinfection.

6.9.2 Infusion pumps, cardiac monitors together

with its cables, pulse generator, thermoscan,
ophthalmoscope handle, blood warmers,
pulse oximeter probes, defibrillators and
feeding machine pumps shall be free of dust,
stain and cleaned with a clean cloth with
appropriate disinfectant especially after every
use of patients, allowing for the contact time
to take effect.

6.9.3 Blood pressure cuff, bag valve mask, and face

masks shall be washed, free with any debris
and stain, and disinfected with appropriate
disinfectant, especially after every patient use.

6.9.4 Central line and cut-down set shall be washed

and cleaned with debris before surrendering
Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN ADULT INTENSIVE CARE UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 4 of 7
00 REVIEW DUE
IC-01-039 DECEMBER 31, 2020

to the CSS for proper sterilization.

7. Linen

7.1 Refer to Infection Control Manual, Handling Linen Policy.

8. Sharp Containers

8.1 Sharp container shall be located in each patient’s room. Needle should
not be recapped, bent or broken (Refer to Infection Control Manual
Needle stick and Sharps Injury Prevention.

9. Medical Waste

9.1 Refer to Infection Control Manual, Waste Management Policy.

10. Oxygen, Airway, & Endotrachial Tubes

10.1 Oxygen delivery supplies, oral airways, and endotracheal tubes are
disposable.

10.2 Change bubble through Humidifiers every 24 hours.

11. Respiratory Therapy Equipment

11.1 Refer to Infection Control in RT.

11.1.1 RT equipment shall be cleaned. Humidifier HME and tubing

should be changed every 7 days.

11.1.2 Circuit should be dated and timed.

11.1.3 Change the Circuit when it is visibly soiled or mechanically

malfunctioning.

12. Saline Solution

12.1 Sterile water and saline containers shall be dated and timed. Unused
portions shall be discarded every 24 hours.

13. Procedures

13.1 Invasive procedures and dressing changes shall be performed using

aseptic technique.

14. Suctioning

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN ADULT INTENSIVE CARE UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 5 of 7
00 REVIEW DUE
IC-01-039 DECEMBER 31, 2020

14.1 All suctioning shall be performed with disposable equipment.

14.2 Clean technique using gloves and sterile catheter shall be used during
endotracheal and tracheobronchial suctioning.

14.3 Use different saline containers for tracheal and oral suction.

15. Traffic

15.1 Traffic through the Critical Care Unit is limited. Visitors shall be allowed
one visitor at the time, based upon patient and unit needs. Time of visits will
be 9am-11am, 4pm to 6pm and no visitors allowed at night time to give rest
for the patient.

16. IV Therapy

16.1 Refer to Infection Control Manual, Prevention of Intravascular Catheter

related infection.

17. Surveillance

17.1 Refer to infection control Manual, Healthcare-Associated Infection

Surveillance in OHHC.

18. Work Areas

18.1 Clean and dirty work areas shall be delineated and maintained.

19. Bundles

19.1 See the Attachment of Bundles Care

20. Patients

20.1 Appropriate staff / patient ratios shall be maintained in order to ensure

the implementation of adequate infection control practices.

20.2 Patient assignments shall reflect concern for the prevention of

transmission of infective organisms between infected and susceptible
patients.

VI. REFERENCES

1.APIC text for Infection Control and Epidemiology 2014.

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN ADULT INTENSIVE CARE UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 6 of 7
00 REVIEW DUE
IC-01-039 DECEMBER 31, 2020

VII. SIGN-OFF AND REVISION HISTORY

Owner

INFECTION CONTROL

Initiator

JAN MARVIN M. PALIJO, MSN, RN – CHIEF NURSING OFFICER

Reviewer

GINA M. GARCIA, MD – CHAIRMAN, DEPARTMENT OF MEDICINE

Approvals:

ARGYLL T. ARCIGAL, MD
CHIEF OF CLINICS

CHERRY PINK D. ORDINAL, MD

QMD Head

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

 POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN ADULT INTENSIVE CARE UNIT
DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 7 of 7
00 REVIEW DUE
IC-01-039 DECEMBER 31, 2020

RICO M. RAYOS DEL SOL, MD

Chief Medical Officer

NEIL ANDREW S.J. DE LUMEN, MD

President

Revision History

Revision Effectivity Review Prepared/Revise

Details of Revision
No. Date Due d by

Prepared by: Reviewed by: Conforme: Approved by:

JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT