Core Components and Essential Activities of Regional Directorates-Based IPC Programs

Core Components and
Essential Activities of
Regional Directorates-Based IPC
Programs
MOH Requirements and Execution Tools
‫المكونات األساسية‬
‫والنشاطات الرئيسية‬
‫ألقسام مكافحة العدوى‬
‫بمديريات المناطق الصحية‬
‫متطلبات وزارة الصحة وأدوات التنفيذ‬
First Edition
2016
‫اإلدارة العامة لمكافحة عدوى المنشآت الصحية‬

‫وزارة الصحة‬
General Directorate of Infection Prevention and Control
This manual outlines the Essential Tools required ‫يحدد هذا الدليل األدوات الرئيسية لبرامج مكافحة العدوى‬
by MOH and involved in defining the direction and ‫هذه المكونات والنشاطات تعتبر‬. ‫في مختلف المستويات‬
operational processes of IPC programs at different
levels. The goal is to build strong programs with ‫إلزامية بهدف تحديد اتجاه البرنامج والعمليات التشغيلية‬
sustained effectiveness and to support ‫ تسعى الوزارة للوصول في النهاية إلى‬.‫الالزمة لذلك‬
standardization of IPC programs essential ‫برامج ذات بنية تحتية مالئمة ونشاطات فعالة ومستديمة‬
activities and formats Kingdom wide when ‫بشكل موحد لألدوات ووسائل التنفيذ في كافة المنشآت‬
applicable. .‫الصحية بالمملكة متى ما أمكن ذلك‬
It also provides guidance and necessary tools on
how these requirements and activities can be ‫ على األدوات والنماذج المساعدة‬،ً‫ أيضا‬،‫يحتوي الدليل‬
carried out. .‫على إتمام هذه النشاطات‬
Core Components and Essential Activities of hospital-Based IPC programs

Practical Guide for Hospitals
First Edition, April 2015

Ministry of Health
IPC Program
Management
Regional Directorate-
Based IPC Programs
Authority Statement
Job Descriptions
‫إعطاء صالحيات‬
Statement of Authority
The Director for the Infection Prevention and ‫مدير مكافحة العدوى في المنطقة محمل المسؤولية ومعطى‬
Control Program of health region has the
responsibility and authority to establish ‫الصاليحيات عإدداد السيااات واخخا اعإررااات واعإررا‬
policies and procedures for the instruction of ‫دلى كافة النشاطات الهادفة للوقاية من العدوى والسيطرة‬
its personnel and for the overall supervision
of infection prevention and control activities . ‫دليها في كافة مستشفيات المنطقة‬
in its facilities.
Approvals:
___________________________
‫ المحافظة‬/‫مدير عام الشئون الصحية بالمنطقة‬
Infection Prevention and Control Director
___________________________
‫المدير العام إلدارة مكافحة عدوى المنشآت الصحية‬
General Director of General Directorate of Infection Prevention and Control
Ministry of Health
JOB DESCRIPTION
Infection Prevention and Control Regional Director (page 1 of 1)
Region:
 Ensures that all MOH strategies, guidelines of GCC Manual for Infection control and nationally
organized recommendations and requirements are implemented to prevent avoidable healthcare
associated infections.
 Plans annual training programs of infection control activities
 Responsible for insuring that all healthcare facilities implement surveillance program with analysis,
interpretation.
 Preparing summary reports of IPC program quarterly based on data collected from all Health care
facilities and send to GDIPC
 Develops and implement IC action plan annually forms to be approved by GDIPC
 Works effectively with supply department to ensure that all products and other necessary infection
control resources are constantly available.
 Sharing in Infection Control Committee of region and prepare the agenda based on emerging
problems during IPC program implementation
 Other duties as assigned.
Reports to: Assistant Director of Public Health

Infection Control
Committee
Regional directorate -
Based IPC Programs
Authority Statement
Agenda
Attendance Grid
ICC Meeting Minutes
Date of Issue: :‫تاريخ اإلصدار‬

The regional Infection Control Committee (ICC),
through its chairperson and members, is vested ‫ من خالل رئيسها‬،‫إن لجنة مكافحة العدوى بالمنطقة‬
with the responsibility and authority to institute ‫ معطاة كافة الصاليحيات الخخا أي إررااات‬،‫وادضائها‬
any appropriate decisions for proper ‫مناابة للتأكد من خطبيق برنامج مكافحة العدوى‬
implementation pf IPC program
Approvals:
__________________________________
‫ المحافظة‬/ ‫إدارة مكافحة العدوى بالمنطقة‬
__________________________________
‫ المحافظة‬/ ‫مديرعام الشئون الصحية بالمنطقة‬
General Director of Health Affairs in the Region/District
Key Requirements of Regional Infection Control Committee:
- ICC coordinates and discusses any issues related to implementation of the infection prevention and
control activities of heath care facilities.
- Sharing experience between committee members to address issues related to the infection
prevention and control and suggested solutions
- Distribution of tasks to team members according to take decisions
- ICC Committee meets quarterly.
- IC committee membership are conformed when applicable from the following members:
 Infection Control Director of the region
 Representative from general directorate of hospitals affairs
 Representative from general directorate of primary health care PHC
 Representative from general directorate of NURSING
 Representative from general directorate of medical supply
 Representative from general directorate of laboratories and blood bank
 Representative from general directorate of dental care
 Representative from general directorate of projects
 Representative from general Department of Maintenance
 CSSDs coordinator of the region
 Representative from quality directorate.
 Infectious disease Consultant
 Other members invited as required
Execution Tools and Documents:
- Infection Prevention and Control Committee Agenda Template

- Infection Prevention and Control Committee Attendance Grid Template
- Infection Prevention and Control Committee Topic Tracker/Scheduler Template
- Ancillary Department Report to Infection Prevention and Control Committee Template
- Risk Assessment Template
Ministry of Health
TEMPLATE FOR ICC-RD:
Agenda (page 1 of 1)
Date:
Intent
Topic Presenter (E.g. approve information Time
only, discussion, etc.)
Review/Approval of Minutes
I.
Announcements
II. Topics:
A.
B.
C.
D.
III. Old Business
IV. New Business
Next Infection Control Committee Meeting

IV.
Date and Time:
Ministry of Health
Attendance Grid (page 1 of 1)
Year:
TOTAL
COMMITTEE MEMBERS Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
ATTENDANCE
CORE MEMBERS
Infection Control Director
Representative from
general directorate o F PHC
Representative from
general directorate of
hospitals
Representative from
general directorate
NURSING
Representative from
general directorate medical
supply
Representative from
general directorate
laboratories and blood
bank
Representative from
dental care
Representative from
general directorate
projects
ID Consultant
Representative from
pharmacy
CSSD coordinator
Other members invited as

required
Other
Ministry of Health
Minutes of Meeting of ICC-RD Committee: (page 1 of 1)
Date Time
Location
Apologies Absent
Name:
Written by
Date:
Responsible
Topics Discussion Next Action Target Date
Person
Core Components and Essential Activities of Regionall-Based IPC programs
Practical Guide for Directorates
First Edition, February 2016

Ministry of Health
Core Components and
Essential Activities of
Hospital-Based IPC
Programs
MOH Requirements and Execution Tools
‫المكونات األساسية‬
‫والنشاطات الرئيسية‬
‫ألقسام مكافحة العدوى‬
‫بالمنشئآت الصحية‬
‫متطلبات وزارة الصحة وأدوات التنفيذ‬
First Edition
2016
‫اإلدارة العامة لمكافحة عدوى المنشآت الصحية‬

‫وزارة الصحة‬
This manual outlines the Essential Tools required ‫يحدد هذا الدليل األدوات الرئيسية لبرامج مكافحة العدوى‬
by MOH and involved in defining the direction and ‫هذه المكونات والنشاطات تعتبر‬. ‫في مختلف المستويات‬
operational processes of IPC programs at different
levels. The goal is to build strong programs with ‫إلزامية بهدف تحديد اتجاه البرنامج والعمليات التشغيلية‬
sustained effectiveness and to support ‫ تسعى الوزارة للوصول في النهاية إلى‬.‫الالزمة لذلك‬
standardization of IPC programs essential ‫برامج ذات بنية تحتية مالئمة ونشاطات فعالة ومستديمة‬
activities and formats Kingdom wide when ‫بشكل موحد لألدوات ووسائل التنفيذ في كافة المنشآت‬
applicable. .‫الصحية بالمملكة متى ما أمكن ذلك‬
It also provides guidance and necessary tools on
how these requirements and activities can be ‫ على األدوات والنماذج المساعدة‬،ً‫ أيضا‬،‫يحتوي الدليل‬
carried out. .‫على إتمام هذه النشاطات‬

First Edition, April 2015

Ministry of Health
MOH Core
Components
Of IPC Programs
IPC Program Management
Authority Statement
Physical and Personnel Resources
Job Descriptions
Annual Performance Appraisals
Infection Control Committee

Goal
Structure
Functions
Clinical Activities
Implementation of Infection Control Monitoring
Implementation of Isolation Precautions
Daily Tracking of Infections
Construction Permit
Outbreak Investigation
Training
Surveillance
IPC Program
Management
Hospital-Based IPC
Programs
Authority Statement
Job Descriptions
Key Requirements:
- Authority for IPC program is delegated by the relevant administrative directors

- IPC program has adequate personnel resources (a full time director and one full time
infection control practitioner to every 100 beds)
- IPC program has adequate physical resources (offices, computers, printers and internet
access)
- IPC program has clear job descriptions for its employees
- IPC program has annual performance evaluations for its employees
- Statement of authority
- Job descriptions (director and infection control practitioner)
- Annual plan
Date of Issue: :‫تاريخ األصدار‬

The Director for the Infection
Prevention and Control Program of the ‫مدير قسم مكافحة العدوى في المستشفى محمل‬
institution has the responsibility and ‫المسؤولية ومعطى الصالحيات إلعداد السياسات‬
authority to establish policies and ‫والتخاذ اإلجراءات واإلشراف على كافة النشاطات‬
procedures for the instruction of its ‫الهادفة للوقاية من العدوى والسيطرة عليها في كافة‬
personnel and for the overall .‫مرافق المستشفى‬
supervision of infection prevention and
control activities in its facilities.
Approvals:
______________________________
‫المدير الطبي‬
Medical Director
______________________________
‫مدير المستشفى‬
Hospital Director
Ministry of Health
JOB DESCRIPTION
Infection Prevention and Control Staff at Health Care Facility
Infection Control Practitioner (page 1 of 1)
Hospital Name: Region:
 Plays a key role as a member of the infection prevention and control team.
 Identifies and implements infection prevention and control strategies according to regulations,
standards and guidelines of MOH and scientific literature related to the IP&C in the areas he
assigned to.
 Collect data of surveillance for nosocomial infections, a systematic and current basis, analyzes
nosocomial infections and prepares reports for the infection control director.
 Reports communicable diseases to the IPC director to be reported to the regional
Directorate/Ministry.
 Enters data into INIIC system or other MOH systems, prepares reports, conducts analytical studies
and summarizes surveillance data to each department.
 Makes recommendations when infections and problems are identified.
 Interacts with departments’ heads, all healthcare workers and support services staff as a
consultant.
 Delivers infection control education and in-services to departments, including orientation for new
employees and evaluates the effectiveness of the education provided.
 Makes daily rounds to clinical areas and weekly rounds to ancillary departments, construction and
renovation sites and conducts weekly environmental rounds, and assures compliance with MOH
and professional standards.
 Reports any deficiency in infection control products to the clinical area directors and infection
control director.
 Assists in providing an infection control resource for all staff and promotes an interest in the
prevention and control of infection.
 Undertakes ward/department audits as part of the infection control audit program.
 Any other duties as assigned.
Reporting:
Dress code:
Female employees: MOH approved attire for female physicians (all conditions are applied)
Male employees: MOH approved attire for male physicians (all conditions are applied) (Thob ‫ ثوب‬is not
allowed)
Ministry of Health
JOB DESCRIPTION:
Infection Prevention and Control Staff at Health Care Facility
Infection Control Director of the Health Care Facility (page 1 of 1)
 Ensures that all MOH strategies, guidelines of GCC Manual for Infection control and nationally
organized recommendations and requirements are implemented to prevent avoidable healthcare
associated infections.
 Plans operational aspects, activities and resources of infection control services and ensures that all
activities and responsibilities for infection control are carried out effectively.
 Responsible for the department's functions related to surveillance, analysis, interpretation and
reporting of healthcare associated infections; educating employees about infection control
prevention
 Develops an infection control risk assessment annually to be approved by Infection Control
Committee
 Develops IC action plan annually to be approved by Infection Control Committee
 Prepares, organizes and manages the Infection Control Committee; prepares statistical reports for
the meeting; reviews, edits and maintains transcribed Infection Control Committee minutes.
 Manages Infection Prevention and Control staff, including day-to-day-supervision, employee
relations and staff development.
 Works effectively with supply department to ensure that all products and other necessary infection
control resources are constantly.
 Responds to any requirements from MOH regarding infection control aspects.
 Responsible for communicating all the IPC related data to the regional IPC directorate
 Other duties as assigned.
Reporting
Regional IPC director
Dress code:
Female employees: MOH approved attire for female physicians (all conditions are applied)
Male employees: MOH approved attire for male physicians (all conditions are applied) (Thob ‫ ثوب‬is not
allowed)
Infection Control
Committee
Hospital-Based IPC
Programs
Authority Statement
Agenda
Attendance Grid
ICC Meeting Minutes
Infection Prevention and Control Committee
Topic Tracker/Scheduler
Risk Assessment
Annual Infection Prevention & Control Plan
:‫تاريخ اإلصدار‬
Date of Issue:
The Hospital Infection Control Committee (ICC), ‫ من خالل‬،‫إن لجنة مكافحة العدوى بالمستشفى‬
through its chairperson and members, is vested ‫ معطاة كافة الصاليحيات الخخا‬،‫رئيسها وادضائها‬
with the responsibility and authority to institute
any appropriate prevention and control measure ‫أي إررااات مناابة للوقاية من العدوى والسيطرة‬
when it is reasonable to presume that an .‫دليها‬
infectious risk to any patient or personnel exists.
Approvals:
__________________________________
‫مدير قسم مكافحة العدوى‬
__________________________________
‫المدير الطبي‬
Medical Director
__________________________________
‫مدير المستشفى‬
Hospital Director
Key Requirements:
- ICC coordinates and supervise the infection prevention and control activities
- ICC Committee meets quarterly or as scheduled.
- IC committee membership should conform when applicable from the following members:
Infection Control Director, Infectious Disease Specialist, Nursing Representative,
Administrative Representative, Engineering/ Maintenance Representative, Dialysis
Representative, Employee Health Service Representative, Home Care Representative
Laboratory Representative, Operating Room Representative, Nutritional Services
Representative, Pharmacy Representative, Respiratory Therapy Representative, Laundry
Representative, Housekeeping Representative, CSSD Representative, Ambulatory Care
Representative and Quality Department Representative
- IC committee ensures reports from the following departments: Construction, Dialysis,
Employee Health Service, Engineering and Maintenance, Home Health Care, Laboratory,
Nutritional Services, Pharmacy, CSSD, Respiratory Care, Environmental Services
- IC committee approves any change in surveillance indicators during the calendar year
- IC committee performs IC annual risk assessment
- IC committee performs annual IC plan
- Infection Prevention and Control Committee Agenda Template

- Infection Prevention and Control Committee Attendance Grid Template
- Infection Prevention and Control Committee Topic Tracker/Scheduler Template
- Risk Assessment Template
- Annual Infection Prevention & Control Plan
Ministry of Health
Template for ICC-HCF:
Agenda (page 1 of 1)
Date:
Intent (e.g. approve, information
Topic Presenter Time
only, discussion, etc.
Review/Approval of Minutes
I.
Announcements
II. Reports:
A. Infection Prevention and Control Department:
Surveillance Reports:
 Resistant Organisms
 Healthcare Associated Infection
statistics
Assessment Results of Departmental
Compliance with Infection Control Practices
MOH Visits Reports
B. Support Departments Reports:
 CSSD
 Employee Health
 Ancillary Departments Construction
 Dialysis
 Engineering
 EVS
 Home Care
 Nutritional Services
 Laboratory
 Pharmacy
C. Public Health Department Report
D. Antibiotic Stewardship Report
III. Policy and Procedure Review
IV. IC Education Provided
IV. Old Business
V. New Business
VII. Adjourn
Next Infection Control Committee Meeting

Date and Time:
Ministry of Health
Attendance Grid (page 1 of 1)

Year:
MONTH TOTAL
COMMITTEE MEMBER
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ATTENDANCE
CORE MEMBERS
Infection Control Director
Infectious Disease Specialist
Nursing Representative
Administrative Representative
Infection Control Practitioners
Engineering/ Maintenance
Dialysis Representative
Employee Health Service
Representative
Home Care Representative
Laboratory Representative
Operating Room
Representative
Nutritional Services
Representative
Pharmacy Representative
Laundry Representative
Housekeeping Representative
CSSD Representative
Ambulatory Care
Representative
Quality Department
Representative
Respiratory Therapy
Representative
Ministry of Health
Topic Tracker/Scheduler (page 1 of 1)

Year:
RESPONSIBLE
GROUP SCHEDULED EVENTS REPORT
TOPIC OR
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
FREQUENCY
PERSON
REPORTS/PLANS
Annual IC Program Plan
and Goals
Annual IC Risk
Assessment
Quarterly Report to
Regional Directorate
SURVEILLANCE
CLABSI
VAP
SSI
CAUTI
Hemodialysis Line
Associated Blood
Stream Infections
Hand Hygiene
Compliance
Occupational Blood
Exposures
MDRO’s
ANCILLARY DEPARTMENT REPORTS

Construction
Dialysis
Employee Health
Service
Engineering and
Maintenance
Home Care
Laboratory
Nutritional Services
Pharmacy
CSSD
Respiratory Care
Ministry of Health
Annual Risk Assessment (page 1 of 2)

Year:
Probability of Occurrence Risk/Impact (Health, Financial, Legal, Regulatory) Current Systems/Preparedness
Prolonged
Life Serious Moderate Minimal
Potential Risks Expected Likely Maybe Rare Never Length of None Poor Fair Good Solid Score
Threatening Loss Clinical Clinical
Stay
4 3 2 1 0 4 3 2 1 0 5 4 3 2 1
Failure of Prevention Activities
Lack of Hand Hygiene Compliance
Lack of Respiratory Hygiene/ Cough
Etiquette
Lack of Supplies for Hand Hygiene
Lack of Patient Influenza Immunization
Isolation Activities
Lack of Standard Precautions
Lack of Airborne Precautions
Lack of Droplet Precautions
Lack of Contact Precautions
Lack of Supplies Necessary for Isolation
Healthcare Acquired Infections
SSI
VAP in ICUs
CLABSI in ICUs
Dialysis-Related Infections
CAUTI
Outbreak
Sentinel Event
Other - HAI
CSSD
Lack of Biological and chemical
indicators
Lack of Staff
Ministry of Health
Annual Risk Assessment (page 2 of 2)

Year:
Probability of Occurrence Risk/Impact (Health, Financial, Legal, Regulatory) Current Systems/Preparedness
Prolonged
Life Serious Moderate Minimal
Potential Risks Expected Likely Maybe Rare Never Length of None Poor Fair Good Solid Score
Threatening Loss Clinical Clinical
Stay
4 3 2 1 0 4 3 2 1 0 5 4 3 2 1
Environment
Contaminated dialysis water system
Infection From Inadequate Sterilization
Poor IC Practices in Laundry
Problems with Cleaning/ Disinfection

Contamination/ Infection From Pharmacy
Environment
Infection Related to Construction/
Renovation
Poor IC Practices with Regards to Waste
Management
Employee Health
Lack of Staff Influenza Immunization
Exposure to Blood borne Pathogens
Exposure to Tuberculosis
Risk of Unknown Level of Communicable
Disease Among Employees
Other
New Program - Mandatory Reporting
Law
New Program
New Procedure
New Procedure
Other
Other
Annual Infection Prevention and Control Plan
The annual Infection prevention and control plan should be developed after selecting and approving the IPC priorities.
The plan has two main parts:
1) Background information about the program
2) The action plan for the year.
Ministry of Health
Annual Infection Prevention and Control Plan (page 1 of 2)
Year:
A. BACKGROUND INFORMATION
1. Demographic information about the Number of beds:
organization Types of services:
Community served:
2. Mission of the IPC program
3. Vision of the IPC program
4. Infrastructure of the IPC program Number of staff and their roles
Training or certification of the IPC committee
Ways in key staff participate in coordinating the
program.
5. Statement about the authority of For example, chairman, IPC physician, IPC nurse, or administrator) to
designated individuals make decisions for such actions as placing a patient in isolation, closing a
unit, or stopping surgery because of construction risks.
6. Scope of services for the IPC team Education

Surveillance activities and outbreak
investigation
Development of policies and procedures
Oversight of maintenance of the environment
and medical equipment, and consultation with
staff throughout the hospital for IPC problems.
7. Integration of the IPC program with
quality improvement and patient
safety
8. Availability and appropriate use of
gloves, masks, soap, and
disinfectants;
9. Surveillance cultures are collected
10. training of staff who clean the
environment
11. How the IPC program uses current
scientific knowledge, accepted
practice guidelines, and applicable
regulations to guide activities and
policy development
Ministry of Health
Annual Infection Prevention and Control Plan (page 2 of 2)

Year:
IPC Measurable
Risk Priority Organizational Goal Method(s) Evaluation Participants
Objective
Clinical Prevention and
Control of Infection
Hospital-Based IPC
Programs
Infection Control Monitoring

Implementation of Isolation Precautions
Daily Tracking of Infections
Construction Permit
Outbreak Investigation
Training
Surveillance
Key Requirements:
- Infection control practitioner monitors infection control practices in the following areas he
or she is assigned to. Observation must be documented in a periodically for the following
areas: Burns, NICU, ER, Dental Setting, ICU, OR, Outpatient Department, Central
Reprocessing Department, Delivery Room, Endoscopy Unit, Laboratory Area, Kitchen,
Mortuary Room, Waste Room, Isolation, Laundry, IPC Office and Pharmacy Compounded
Sterile Preparations (CSPs)

- Infection Prevention and Control Compliance Monitoring Tools (electronic automated forms)
Ministry of Health
Infection Prevention and Control Compliance Monitoring Tools:
Burn Unit: (page 1 of 2)
Location:__________________ Date: ______________________ ICP Name: _______________________________________
Aspect Standard Score
Updated infection control policy and procedures is available in the department.
Policy
Staff aware about the policy and procedures and it is accessible for them.
Healthcare Personnel (HCP) receive job-specific training on infection prevention policies and procedures upon hire
and at least annually.
Hygiene
Hand hygiene supply is available.

Hand
HCP demonstrate appropriate techniques for hand washing and hand rubbing.
Sufficient and appropriate PPE are available and readily accessible to HCP.
PPE
Staff uses personal protective equipment appropriately.
There is a cleaning schedule and is applied
Environmental surfaces are clean and are free from soil.

Housekeeping surfaces (e.g., floors, walls, and sinks) cleaned with MOH approved detergent/ disinfectant using
Environmental Disinfection
double/ or triple bucket technique or scrubbing machines.

Housekeeping equipment is kept clean and dry after use.
There is one spill kit, at a minimum in the department.
Health care personnel demonstrate appropriate technique for management of blood and/or body fluids.
Appropriate PPE, e.g. gloves, masks, gowns and protective eyewear, worn by housekeepers during their routine
activities.
Hydrotherapy equipment is cleaned and disinfected between patients and at the end of the day using a hospital-
approved disinfectant per the manufacturer’s instructions.
Housekeeping practices are monitored stringently to ensure maximum cleaning of common nosocomial
reservoirs, such as mattresses, hydrotherapy equipment, soap dispensers, sinks and floors.
Nurses are responsible for cleaning of all environmental surfaces in patient areas except floors, walls, ceiling and
bathrooms.
All types of waste containers are available in sufficient number and placed in easy access sites and away from
traffic.
Waste Management
Sharp items (e.g., needles, scalpel blades, broken metal instruments, and burs) are placed in an appropriate
sharps container (puncture resistant, color-coded, and leak-proof).
Used needles are not manipulated or recapped and are promptly disposed into sharp containers.
Staff sticks to the approved policies of proper medical waste segregation ( no dangerous medical waste or sharps
are observed outside specified containers)
No overfilling of medical waste bags and sharp boxes.
The patient’s skin are disinfected with an appropriate antiseptic before injection or cannulation
Aseptic Technique
Proper fixation of the peripheral venous cannula and changed routinely every 72 hours as maximum (date of
insertion written)
Preparation & dilution of drugs' vials is only done by ready-made sterile water
Needles and syringes including prefilled syringes, vacutainer holders, and cartridge devices such as insulin pens
are used for only one patient.
Ministry of Health
Single dose medication vials, ampules, suction catheters, urine bags and bottles of intravenous solution are used
for only one patient and brought to patient area when needed only.
If Multi-dose vials must be used , should be dedicated for one patient (as possible as we can) and dated when
they are first opened and discarded after 28 days unless the manufacturer specifies a different date for that
opened vial.
The rubber self-sealed cap on a medication vial is disinfected with alcohol prior to piercing.
IV solution bottles are only accessed through the self-sealed rubber cap.
Multidose medication vials are accessed with a new needle and a new syringe, even when obtaining additional
Aseptic Technique
doses for the same patient.

When crystalloid solutions are being infused, IV tubing including piggyback tubing and stopcocks are replaced
every 72 to 96 hours.
Tubing used to administer blood, blood products, lipid emulsions, or dextrose/amino acid TPN solutions are
replaced within 24 hours of initiating the infusion.
Changing ventilation circuits only when visibly soiled or mechanically malfunctioning.
Only sterile fluids used in nebulizers, humidifiers, or any aerosol generator.
Evacuation of urine bag is done in proper way using appropriate P.P.E.

All items in patient zone used for patient care only and any remaining items after patient discharge are considered
contaminated even in their wrapping.
All used (contaminated) reusable items sent to Central Processing Department (CPD) in proper way without any
interference from the staff.
Laundry
Contaminated linen is collected with minimum agitation in special color-coded and waterproof laundry bags.
Linen carts are covered and not overfilled.

Isolation
Contact isolation precautions are initiated for patients infected or colonized with multidrug-resistant organisms.
Patients with larger burns (>25% total body surface area) are placed in a single room, when applicable, as an
additional precaution.
Clean and dry (temperature and humidity must be controlled)
Away from air vents and well ventilated
Storage shelves are18 inches from the ceiling, 8 to 10 inches from the floor, and 2 inches from the outside wall.
Storage Areas
Storage shelves made from easily cleanable material (not woody or Cardboard)
Sterile and clean items completely separated from personal items &foods and drinks
Rotate supplies on a first-in-first-out basis so as to avoid the use of expired items.
Items not kept in original cardboard boxes

Ministry of Health
Neonate Intensive Care Areas: (page 1 of 2)
Location:__________________ Date: _______________________ ICP Name: _______________________________________
Policy

Hygiene
Hand
PPE

activities.
bathrooms.
The inside and outside surfaces of the incubators should be cleaned daily
Incubators should be disinfected between each baby. The incubator is disinfected after every 7days of
hospitalization (every 5 days for babies less than 1 kilogram).
After use all removable parts must be washed and thoroughly cleaned with detergent. Rinse and dry thoroughly
using disposable paper towels. The incubator should also be cleaned and dried. Then all parts of the incubator
should be disinfected using chlorine (200-500 ppm) or isopropyl alcohol (70%)
Aerate the incubator before re-use.
Adhesive tape is not used to stick baby information's label.
Management
traffic.
Waste
Ministry of Health
Neonate Intensive Care Areas: (page 2 of 2)
Proper fixation of the peripheral venous cannula with written date of insertion.
Preparation & dilution of drugs' vials is only done by ready-made sterile water ampoule.
Needles and syringes including prefilled syringes, vacutainer holders are used for only one patient.
All patient care supplies are brought to patient area when needed with no excess item in the area.
Aseptic Technique
opened vial.
No needles are kept inside the self-sealed rubber cap of IV solution bottle or Multidose vials.
Only sterile fluids used in nebulizers or any aerosol generator, dispensing aerosol fluids aseptically.
Breast milk is collected, labeled appropriately and stored aseptically. Milk is used promptly or stored in a
Infant Feeding
refrigerator for no longer than 24 hours.

If a breast pump is used, pump components are washed in soapy water, rinsed off and sterilized after use.
Ready-made formula is available and labelled by date and time of opening to be used only within 4 hours of
opening.
Storage Area
Sterile and clean items completely separated from personal items &foods and drinks.
Ministry of Health
Emergency Room: (page 1 of 2)
Policy
Hygiene

Hand
PPE

activities.
bathrooms.
traffic.
Waste Management
Aseptic Technique
opened vial.
Ministry of Health
Emergency Room: (page 2 of 2)
Aseptic Technique


Laundry
Available protocol for early detection, management, and transfer of respiratory illness patients.
Signs of respiratory hygiene and cough etiquette at entrances to patients with symptoms of respiratory infection
Tissues and foot operated waste containers for disposal of tissues is available at waiting area.
Hand hygiene supply is available at waiting areas.
Masks are offered to respiratory illness patients upon entry to the facility.
Respiratory Triage
Separate waiting area and pathway for respiratory illness patients.

Ministry of Health
Dental Setting: (page 1 of 3)
Policy
Hygiene
Hand

PPE
There is a cleaning schedule and is applied.
Manufacturer instructions are followed for cleaning and disinfecting products.

Dental care personnel use personal protective equipment, as appropriate, when cleaning and disinfecting
environmental surfaces.
Clinical contact surfaces are cleaned and disinfected using hospital disinfectant with a low- to intermediate-level
activity after each patient.
Surface barriers are used to protect clinical contact surfaces, (e.g., Light handles, switches, dental radiograph
equipment, dental chair-side computers, drawer handles, faucet handles, countertops, pen, telephone handle,
and doorknob) and the barriers are changed between patients.
Housekeeping surfaces (e.g., floors, walls, and sinks) cleaned with a detergent and water or hospital
disinfectant/detergent on a routine basis or when they are visibly dusty or soiled.
bathrooms.
traffic.
Waste Management
Staff sticks to the approved policies of proper medical waste segregation (no dangerous medical waste or sharps
are observed outside specified containers).
traffic.
Extracted teeth that do not contain amalgam are disposed of as regulated medical waste unless returned to the
patient.
Extracted teeth containing amalgam are not being placed in a medical waste container that uses an incinerator for
final disposal.
Ministry of Health
Extracted teeth collected for educational training are cleansed of visible blood and gross debris, maintained in a
hydrated state (stored in sodium hypochlorite diluted 1:10 with tap water) and placed in a well-constructed
container with a secure lid.
If extracted teeth containing amalgam restorations are to be used for educational training, the teeth are
immersed in 10% formalin solution for 2 weeks before sending to the education settings.
Waste Management
A septic microbiology samples should be taken monthly from the dental chair.
- One sample from the water input.
- At least 1 sample from the chair (hand piece, air water current, and spittoon).
- Results should not contain more than 200 CFU/ml.
Sterile saline or sterile water as a coolant/ irrigating is used when performing oral surgical procedures.
Water and air are discharged for a minimum of 20-30 seconds after each patient, from any device connected to
the dental water system that enters the patient's mouth (e.g., hand-pieces, ultrasonic scalers, and air/water
syringes).
Regular maintenance of dental unit.
Dental care personnel wear proper personal protective equipment when exposing radiographs and handling
contaminated film packets.
Reusable autoclavable film-holding and positioning devices used whenever possible.
Heat-resistant devices are cleaned and heat-sterilized between patients.

Supplies for hand hygiene are available and accessible to employees at point of need (sinks plain and
antimicrobial soap and tissues).
Dental lab team members display appropriate hand hygiene techniques according to WHO guidelines.
Personal protective equipment (gloves, masks, gowns, goggles, face masks) are available in a variety of types and
sizes.
Dental Lab
Dental lab personnel use the personal protective equipment properly and in safely manner.
Before they are handled in the laboratory, all dental prostheses and prosthodontics materials (e.g., impressions,
bite registrations, and occlusal rims) are cleaned, disinfected, and rinsed by using disinfectant with at least
intermediate-level activity.
Reusable Heat-resistant items used in the mouth (e.g., metal impression trays and face-bow forks) are cleaned
and heat-sterilized.
No reprocessing of instruments inside the dental laboratory (all the contaminated items are sent to the central
sterilization).
There is a documented cleaning of working surfaces in the lab between the cases.
There is a complete separation between the receiving area and the production area.
The waste containers (sharp and non-sharp) are available in sufficient number and placed in easy access sites and
away from traffic.
Clean and dry (temperature and humidity must be controlled).
Storage Area
Away from air vents and well ventilated.
Storage shelves made from easily cleanable material (not woody or cardboard).
Ministry of Health
Storage
Area
Items not kept in original cardboard boxes.
Clean and dry (temperature and humidity must be controlled).

Ministry of Health
Intensive Care Areas: (page 1 of 2)
Policy
Hygien
Hand
PPE

activities.
bathrooms.
Waste Management
traffic.
The patient’s skin is disinfected with an appropriate antiseptic before injection or cannulation.
Aseptic Technique
opened vial.
Ministry of Health
Intensive Care Areas: (page 2 of 2)
Aseptic Technique
Only sterile fluids used in nebulizers or any aerosol generator, dispensing aerosol fluids aseptically.

Laundry
Storage Area

Ministry of Health
Operating Room: (page 1 of 2)
Policy
Hygiene

Hand
Surgical hand wash units are available.
PPE
The facility has sufficient and appropriate PPE available and readily accessible to HCP.
Staff use personal protective equipment appropriately


activities.
bathrooms.
traffic.
Waste Management
There is clear demarcation between clean, semi sterile and sterile area and movement bet them has restrictions
and precautions.
Floor, walls, ceiling covered with antimicrobial paint that can withstand repeated cleaning and disinfection by
Theater Design
approved disinfectants.
Floors, walls, ceiling should have no cracks, decorative fine parts, and be one piece without connections, minimal
openings and completely sealed openings.
Pressure difference ,temperature , humidity and ACH are continuously monitored and recorded
Operating Room is maintained at positive pressure (5 Pascal) with tolerance ± 5% in respect to corridors (checked
with the utility& maintenance department).
Ministry of Health
Operating Room: (page 2 of 2)
Operating Room is maintained with15 air changes per hour with at least 20% fresh air.
Temperature ranges from 21 to 24 and relative humidity from 30% to 60%

Theater Design
Operating room ventilation system operates all the time and never shut down even in long holidays.
All diffused air into the operating room is filtered through 99.97% HEPA filters (checked with the utility&
maintenance department).
Frequent change of HEPA filters as per manufacture recommendations (checked with the utility& maintenance
department).
Doors are kept closed and only necessary personnel are allowed in the theater.
Clean and sterile supplies stored in semi restricted area and never stored in sterile area.
Single use items never kept on the tables or anesthesia station after use (endotracheal tubes-syringes-suction
catheters-breathing circuits-stylets) and discarded thoroughly.
Aseptic Technique
Minimal items are stored in operating rooms.
Only operating room specified clothes are allowed inside the restricted areas of OR.
Principles of asepsis are adhered to when placing intravascular devices or when administering IV drugs.
Sterile equipment and solutions are assembled immediately prior to use.

Patient with active TB requiring operation are scheduled at the end of the day if possible. OR personnel should
wear N95 masks throughout the procedure and a bacterial filter is placed on the patient’s endotracheal tube.
Reusable items must be collected away as soon as possible after finishing the operation to be reprocessed in CSSD
Storage Area

Ministry of Health
Outpatient Areas: (page 1 of 2)
Policy
Hygiene

Hand
PPE

Environmental disinfection
activities.
bathrooms.
traffic.
Waste Management

traffic.
Aseptic Technique
Ministry of Health
Outpatient Areas: (page 2 of 2)
opened vial.
Aseptic Technique

Signs of respiratory hygiene and cough etiquette at entrances to patients with symptoms of respiratory infection
Tissues and foot operated waste containers for disposal of tissues is available at waiting area.
Hand hygiene supply is available at waiting areas.
Masks are offered to respiratory illness patients upon entry to the facility.
Separate waiting area and pathway for respiratory illness patients.

Respiratory Triage
Storage shelves made from easily cleanable material (not woody or cardboard)

Ministry of Health
Central Reprocessing Department: (page 1 of 2)
Policy
Hygiene

Hand
PPE
Staff is strictly adhered to wearing PPE in decontamination area (utility gloves, face mask, hair cover, goggles,
liquid resistant covering with sleeves and foot protector); PPEs are removed before leaving decontamination area.
There is a cleaning schedule and applied

Available spill kits for management of blood and/or body fluids spills.
Health care personnel demonstrate appropriate technique for management of blood and/or body fluids spills.
activities.
CSSD Technicians/Personnel are responsible for cleaning of all environmental surfaces in patient areas except
floors, walls, ceiling and bathrooms.
traffic.
Waste Management
Job Description of the manager, supervisor, technicians and other staff is available.
Staff
Qualified, trained, immunized staff and able to explain all procedures.
Transport of contaminated items to CSSD is done in a way to prevent spills (using close cart).
Receiving
Area
The carts designed for contaminated items identified with a biohazard label.
The transport carts cleaned and disinfected after each use.

Ministry of Health
Central Reprocessing Department: (page 2 of 2)
The Decontamination Area log Book:
A hygrometer is available to measure Relative humidity (Range of 35% - 60% )
temperature in the range of (18 to 20oC)
negative pressure level in the range of ( -5 Pascal )+or - 2%
Receiving Area
Air change is not less than 10 times/hour

There are records for the receiving items in the log book separate for each ward.
There is evidence for cleaning or disinfection of used items, with log book,
Availability of cleaning devices (brushes with various sizes, etc.)
Using of the enzymatic detergents during the process as per policy and procedures
The ultrasonic chamber water will be changed whenever visibly soiled.
The drying of the items after cleaning is done properly.
The items are checked for proper function and for defects, replace rusty instrument
Inspection magnifying glass lenses are used for items before packing.
Check items for proper cleanliness and return to decontamination area if soiled.
Inspection and
Packing Area
There is a tracking system (manual or computerized) in place and is used properly.

The preparation and packaging Area condition meets
A hygrometer is available to measure Relative humidity (Range of 35% - 60% )
Temperature in the range of (20 to 23oC)
Monitor for measuring positive pressure level in limit of ( + 5 Pascal ), + or -2%
Air change is not less than 10 times/hour (with engineering and AC records )
The wrapped and sterilized items are labeled with sterilization date.
Quality Control
The Record for monitoring of sterilization are kept for one year including:
Automatic Washer test record
Bowie Dick test daily for each steam Sterilizer.
Biological indicators are used daily or minimum once a week for each
Autoclave and every load for Implants Sets.
The sterile storage conditions meet:
A hygrometer is available to measure Relative humidity with limit of 70%
The temperature in the range of (22 - 24 oC)
Monitor for measuring positive pressure level in the range of ( + 5Pascal )-/+2%
Air change is not less than 4 times/hour (with engineering and AC records )
There is a Tracking system (either manual or Computerized) with recall policy & procedures with complete
evidence file.
Sterile Storage
Are the storage Shelves are 20cm from floor, 40cm from ceiling and 5cm from wall.
Shelves and bins are free of dust, Away from sprinklers and air vents.
Items distribution respects the 1st. in 1st out principle
The sterile store shelves are clearly labeled.
The Items arranged properly (Lighter items on top shelves, heavier items on bottom shelves)
The following information is documented for each load sterilizer: type of sterilizer
And cycle, load contents used, lot control number, critical parameters for specific sterilization
Method, operator's name, and results of CI & BI.
Ministry of Health
Delivery Room: (page 1 of 2)
Policy
The facility provides supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-
Hygiene
Hand
based hand rub) and ensures they are readily accessible to HCP in patient care areas
PPE

activities.
bathrooms.
traffic.
Waste Management

traffic.
Aseptic Technique
Ministry of Health
Delivery Room: (page 2 of 2)
opened vial.

Aseptic Technique

Ministry of Health
Endoscopy Unit: (page 1 of 2)
Policy
Hygiene

Hand
PPE
There is a cleaning schedule and applied

Available spill kits for management of blood and/or body fluids spills.
Health care personnel demonstrate appropriate technique for management of blood and/or body fluids spills.
activities.
bathrooms.
traffic.
Waste Management

traffic.
Reprocessing area with negative pressure and good ventilation
Reprocessing Endoscopes
Reprocessing areas should be provided with a separate hand washing station.

and Accessories
Endoscopes wiped down immediately after a procedure
Soiled endoscopes transported to the reprocessing area in a closed container.
Leak testing performed according to manufacturer’s requirements
All detachable components cleaned individually using enzymatic solution.

Ministry of Health
Endoscopy Unit: (page 2 of 2)
Reusable instruments and accessories that break the mucosa are sterilized after use.
Endoscopes and
Reprocessing
Accessories
Single brush use for manual cleaning.
Endoscopes stored uncoiled, hanging vertically in a clean, dry, ventilated storage cabinet with log book.
High level disinfectant should be routinely tested to ensure minimum effective concentration of the active
ingredient.
Workflow should proceed from clean to contaminated areas with adequate separation.
Endoscope Unit
Procedure room should have a separate, dedicated hand- washing sink with hand free controls.
Design
Bronchoscopy for reprocessing should be performed only in a room that meets the ventilation requirements for
an airborne infection isolation room (negative directional air flow, a minimum of 12 air exchanges per hour and
direct exhaust to the outside more than 25 feet from an air intake or discharged through a high efficiency
particulate air filtration system.
Keeping
Records should include patient name, medical record number, the endoscopies, date and time of the clinical
Record
procedure, identification number and type of endoscope and AER, results of inspection and leak test and name of
the person reprocessing the endoscope.
A septic microbiology sample should be taken from the final rinse water in a
Treatment
Weekly : for Aerobic Colony Count

Water
Quarterly: for Environmental Mycobacteria & Pseudomonas Aeruginosa.

Results should not contain more than 100 CFU/ml.
A septic Endotoxin sample should be taken from the final rinse water. The frequency not routinely required (not
contain more than 0.25 EU/ml).
Ministry of Health
Laboratory Areas: (page 1 of 2)
Policy

Hygiene
Hand
PPE
There is a cleaning schedule and is applied.
activities.
bathrooms.
traffic.
Waste Management
Staff sticks to the approved policies of proper medical waste segregation (no dangerous medical waste or sharps
are observed outside specified containers).
Medical waste bags and sharp containers are closed tightly after being filled by3/4 its maximum capacity and
labeled with department and date.
Read culture is destructed in a special autoclave before disposal as regular waste.
Ministry of Health
Laboratory Areas: (page 2 of 2)
Separation of the work areas with no overlapping of items.
Any remaining open vials are thrown after the end of the work.
Working Area
Refrigerators and freezers used to store potentially infectious materials labelled with the universal biohazard
symbol.
Temperature logs for refrigeration are complete and action is taken when temperature is out of parameters.
Laboratory specimens are transported in clean, closed containers.
Restrict access to the laboratory with a sign incorporating the universal biohazard symbol must be posted at the
entrance to the laboratory.
Eating, drinking, smoking, handling contact lenses, and storing food for human consumption must not be
Laboratory Safety
permitted in laboratory areas.

All manipulation of infectious materials that may generate aerosols conducted in a biological safety cabinets.
Biological safety cabinets (class BII) is tested and certified at least annually.
Plastic tubes replaced the glass ones to avoid sharp injuries.
Eye wash station and a shower must be available for immediate action after exposure.
Dedicated room for specimen taking away from the work area.
Specimen Taking
Hand washing supply is available inside the room.

Area
All required PPEs available inside the room.
PPEs are appropriately used during sample taken.

Ministry of Health
Kitchen: (page 1 of 1)
Policy
Hygien
Hand
The facility has sufficient and appropriate PPE available and readily accessible to HCP.
Occupational Health

Stool examination for ova and parasites are done upon hiring and routinely every year thereafter, and results are
documented in personnel files
Personnel with respiratory infections or gastroenteritis are restricted from work.
Kitchen staff is fully compliant with use of head covers and gloves during food preparation & handling.
Kitchen is designed as physically separated areas with separated facilities for different types of food (meat, fish,
vegetables and bakery).
Separate boards are used to cut meat, poultry, and chicken, and vegetables, fruits and are washed immediately
after use.
Surfaces, walls and floors are made of material that is easily cleaned, and declining to prevent stagnation of water.
There is a cleaning schedule and applied.
Fruits and vegetable are washed and disinfected thoroughly.
Food containers are properly labeled and expiry dates noted.
Usage of appropriate equipment that have no hidden places, cracks, scratches and easy to clean.
Food is packed and protected from environment during storage, preparation, display, and transportation.
Refrigerators & deep freezers temperatures are checked daily and documented.
General
Water used are safe for food preparation,(Do not use municipal water)
No refreezing of food products after being defrosted.
Store non-perishable food in clean, dry, properly ventilated areas.
Store food in designated areas. Do not store in housekeeping and dishwashing areas or
Near any sources of potential contamination.
Store food products in a way that avoids cross-contamination between cooked and raw foods and between
washed and non-washed food.
Store food at least 8 to 10 inches above the floor level and away from walls to facilitate cleaning and allow for
pest control measures.
Rotate food stocks to avoid using expired food.
Store food covered and labeled at the proper temperature (freezing storage, less than-
18ºC; refrigeration, 2-7ºC; hot storage, above 60ºC).
Samples of food delivered are kept for 24 hours to be tested in case of occurrence of food poisoning
There is applied effective plan for pest control in the food services department
Temperature controlled vehicle to maintain temperature of food during transportation.
Ministry of Health
Mortuary Room: (page 1 of 1)
Location:__________________ Date: _______________________ ICP Name: _____________________________
Updated infection control policy and procedures is available in morgue.
Policy
All morgue staff receives job-specific training on infection prevention policies and procedures upon hire and at
least annually.
Staff able to identify and apply different types of precautions for different categories of infectious diseases.
Hand Hand hygiene supply is available.

Hygiene All Morgue staff demonstrates appropriate techniques for hand washing and hand rubbing.
All types of PPE are available to morgue staff including mask, goggles, gloves, boots, and water proof full lengths
PPE
aprons.
All equipment, table, and counter surfaces, and transport trolleys must be cleaned after every patient and at the
Environmental disinfection
end of the day.

All tabletops, stretchers, and body boards is made of washable materials
MOH approved disinfectants is used in proper dilution and contact times.

Spills of blood or other potentially infectious material are cleaned and decontaminated with a disinfectant with
low to intermediate-level activity.
activities.
Mortuary technicians are responsible for cleaning of all environmental surfaces in patient areas except floors,
walls, ceiling and bathrooms.
A color-coded or labeled container that prevents leakage (biohazard bag) is used to contain non-sharp medical
waste.
Management
The waste containers are available in sufficient number and placed in easy access sites and away from traffic.
Waste
All morgue staff receive regular evaluation on a yearly basis for checkups and at any other time when necessary (
Occupational such as after exposure to blood and body fluid)
safety
No drinking or eating inside the morgue.
Contaminated linen collected into laundry bags and sent to laundry
Laundry
Temperature of the refrigerator is recorded daily and maintained at 4oC.
Any temperature failure is reported immediately to utilities and maintenance department.
Refrigerator
Different sizes of the body bags are available.
Death log book is available in morgue.
Others
Tag is attached to dead bodies with infectious diseases to identify type of infection control precautions required.
Body parts (including placentas, stillborn, products of miscarriage, etc.) is received in red bag, clearly labeled, and
stored in the refrigerator for temperature storage until burial.
Ministry of Health
Waste Room: (page 1 of 1)
Location:__________________ Date: _______________________ ICP Name: _____________________________
Updated approved guidelines and policies for waste management are available to all workers and they aware
Policy
how to apply.
Medical waste workers attend orientation ICP program before joining the work.
Medical waste workers report needle stick and sharp injuries to occupational health department.
Occupational
Health Post exposure follow up procedures are clear and applicable for exposed medical waste workers.
Waste collection yellow and red bags match the thickness of 80 micron, tear resistant, with bio-hazard logo are
available.
Waste Management
Plastic strips to tie the bags are available.

Yellow color sharp waste container with a lid, one-time close only, bio-hazard logo, different sizes. Are available.
Supply
Hanged at level 1 meter above the ground

Autoclavable bags for microbial cultures’ waste are available in microbiology laboratory are available and used.
Labels indicating the department, date and signature of the department supervisor are available and used.
Yellow Liquid waste containers, biohazard logo, tight lid prevents leakage are available.
All Medical waste workers practicing hand hygiene after handling medical waste.
Cleaning and disinfection of medical waste containers and collection trollies are done with approved
disinfectants.
Practice
Medical waste workers using personal protective equipment properly during handling medical waste (protective
yellow overall / heavy-duty gloves / protective shoes / regular mask / googles)
Collection from departments done at fixed time/s according to time planning without delay with availability of
rapid response when needed. Medical
Medical Waste transfer carts between departments, suitable sizes of stainless steel or plastic, biohazard logo,
with tightly close lid are available and used.
Away from patients’ paths and places of care, other hospital services and labelled by biohazard symbol.
Fit the size of the expected waste production of the facility based on that the maximum duration of waste
storage is 24 hours
Door is closed all the time and only authorized persons allowed to go in.
Never used for storing of other items.
Medical Waste Store
Floors, walls and ceilings are one piece without cracks and coated with materials tolerant to repeated cleaning
and disinfection.
Angles and places of convergence of the ceiling, walls, and the floor are curved for easy cleaning and disinfection.
Have source for clean water and discharge slot for the purposes of cleaning and disinfection
Well-equipped hand hygiene sink is available.
Temperature not exceeding 16 o C.
Negative air pressure in relation to the outside and is fitted with a monitor to measure the pressure difference
on an ongoing basis with the possibility of giving a voice or optical alarm in cases of malfunctioning ventilation
system as well as connectivity to Building Management System (BMS) at the hospital.
Transferred to outside for final treatment daily as a maximum.
There is a schedule for cleaning and is applied.
Ministry of Health
Isolation: (page 1 of 2)
There are approved new policy for isolation rooms procedures describing the proper time and place for starting
Policy
and terminating isolation precautions.
Hand washing sink with hand washing supplies are available (in anteroom or patient room).
Hygiene
Hand
Alcoholic hand rub dispensers are available inside and outside patient room.
Staff demonstrates proper technique of hand wash and hand rubs.
PPE
Proper donning of personal protective equipment including N95 respirator.
Proper doffing of personal protective equipment and proper disposal.
Door closed all the time except for entry or exit of staff or equipment.
Isolation signs are consistent with the patient diagnosis and are posted in Arabic and English, and indicating the
Isolation rules
type of precautions required for staff and visitors.

Visitors restricted and only for few minutes and visitor must pass through permission from nursing station, must
be aware how to use PPE and mode of transmission of the disease.
Assign non-critical patient care equipment (e.g., stethoscope, pressure cuff, etc.) to use only in the isolation room.
Central air condition or separate concealed unit is the source of conditioned fresh air.
Design & Ventilation of the negative pressure room
There is bathroom and Air exhausted from bathroom must be totally exhausted 100% outside through HEPA filter.
There is monitor for continuous monitoring of pressure difference at negative pressure room having audio visual
alarming system.
Records for routine monitoring of pressure gradients and air cycles for negative isolation rooms are available.
Isolation Room is maintained at negative pressure (-5 Pascal or more) with respect to corridors.
Temperature ranges from 21 to 24 and relative humidity from 30% to 60%
Isolation Room is maintained with 6-12 air changes per hour.
Floor, walls, ceiling covered with antimicrobial paint that can withstand repeated cleaning and disinfection by
approved disinfectants.
Floors, walls, ceiling should have no cracks, decorative fine parts, and be one piece without connections, minimal
openings and completely sealed openings.
Air Suction vent is above or beside the head of the patient.

Ministry of Health
Isolation: (page 1 of 2)
There is environmental cleaning schedule and applied.
Environmental Cleaning
Environmental cleaning and disinfection equipment (mops &buckets) dedicated for isolation room only and never
and Disinfection
being used for another area.
Approved disinfectants used with proper dilution and contact time.
Housekeeper well trained about use of PPE and use them properly.
Terminal cleaning done properly between patients.
The waste containers are available in sufficient number and placed in easy access sites and away from traffic.
Management
Waste

Ministry of Health
Laundry: (page 1 of 1)
Policy
Equipment and supply problems are immediately reported to the laundry manger.
Staff receive documented training in infection control
There is definite physical separation between the reception and sorting area, washing machines' area, dryers and
Flow of Work
Laundry and
ironing areas, and storage area of clean linen.

Design of
There is a unidirectional flow of traffic from dirty to clean areas.
Negative pressure is maintained in the receiving area.
The facility provides supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-
Hygiene
Hand
based hand rub) and ensures they are readily accessible in all work areas.
Laundry staff perform Hand hygiene correctly & adheres to hand washing standards.
Required PPE are available (heavy duty gloves, water proof aprons, mask, head cover, and boots. and readily
accessible to workers.
PPE
Laundry staff perform donning & doffing correctly
Laundry workers report needle stick and sharp injuries to occupational health department
Occupati
Health
onal
Post exposure follow up procedures are clear and applicable for exposed workers.
Staff’s with skin lesion is covered by water-proof plasters.
The laundry has a sharps container in the soiled linen area to dispose any sharps found in the linen.
Manage
Supply
Waste
ment
Staff is aware of the correct procedure for disposing of any sharps found in laundry and incidents reporting.
All laundry appliances (washers/dryers, carts) are cleaned daily with detergent germicide solution.
Cleaning
Environ
mental
Supplies for clothing/equipment cleaning are approved by Infection Control Committee.
The supervisor of the laundry has experience, and knowledge in linen management and rest of the staff is able to
explain different steps and main parameters to be followed (steps of washing cycles, PPE to be used, washing
Linen Disinfection
water temperature for thermal disinfection, and conc. of disinfectants to be used for chemical disinfection)
Chemical disinfection is applied by using proper concentration of household bleach.
Thermal disinfection is applied by exposure of textiles to temperature for at least 71ºC for minimum of 25 minutes
is used for hot water cycle.
Washing machines should be validated with documented evidence.
Transport Clean linen is transported separately from soiled linen in carts that have been cleaned and disinfected.
of Linen
Storage of Clean linen is stored and covered in a clean area and separated from potential sources of contamination.
Linen
Ministry of Health
IPC Office: (page 1 of 1)
There is an IC team include IC practitioners depending on the size of the hospital (At least one IC practitioner
doctor, and one IC practitioner nurse for every 100 beds).
There is a specified place for infection control team.
Written infection control policies and procedures is available
There is IC committee that is chaired by the hospital administrator or one his senior medical designees and
IPC Program
includes representatives from medical staff, nursing and IC team director and supportive service to share and
supervise IC activities
The IC committee meets regularly (at least quarterly)
The IC committee meetings are headed by the hospital administrator or one his senior designees
The IC committee meetings are documented correctly (meetings are recorded and include all attendants, review
of previous meetings results, main issues, suggestion, recent recommendations, etc.
The Infection Prevention and Control Department involved and pre-informed officially of all current and future
construction activities at the Healthcare facilities.
There is an effective action plan for health care workers education on IC issues describing what has been achieved
There is an effective system provides education on IC, and orientation to the related hospital's policies to all new
Training
staff upon hiring (documented data)

There is an effective system provides education on IC, and training to the related hospital's policies to all health
care workers especially when new policies and procedures (documented data)
The healthcare facility include occupational health clinic
There are approved written policies and procedures as regard pre-employment examination
(Employment Health Policy OF MOH )
Occupational Health
There are approved written policies and procedures as regard healthcare workers vaccination (Employment
Health Policy of MOH)
There is an effective system for reporting, calculating needle stick & sharp injuries exposure
Dealing with healthcare workers exposed to needle stick & sharp injuries follows the approved policies and
procedures
IC team supervise the application of occupational health policies and procedures (documented data)
Monitoring and documentation of compliance with hand hygiene. HH compliance rate is available for the last
Hand
Hygiene month
Ministry of Health
Policy

Hand
Hygiene HCP demonstrate appropriate techniques for hand washing and hand rubbing.
PPE
Door for the clean area supplied with autoclosure mechanism to be closed all the time
Mixing IV medications must be in the middle of laminar flow hood or safety cabinet and air supplied through high
efficacy filter (HEPA).

Surface of work under the laminar air flow regularly disinfected by any approved disinfectant using non linting
wipes.
Environmental cleaning and disinfection of the clean room with an approved disinfectants.
All supplies and containers used in CSPs preparations must be sterile.
Sharp and medical waste containers available and used in clean room
Used needles are not manipulated or recapped and are promptly disposed into sharps containers.
Key Requirements:
- IPC program ensures in daily manner that all patients with known or suspected infectious
diseases are isolated in accordance with GCC Manual for Infection Control, edition 2013,
pages 45-58: type and duration of precautions needed for selected infections and conditions
and using form IC001.
- IPC program ensures that measures of all types of isolation precautions are implemented.
- IPC program ensures that all necessary supplies are available using form IC001.
- IPC program ensures negative pressure rooms are available and monitored routinely for
infectious patients who require isolation for airborne infections; when negative pressure
rooms are not immediately available, rooms with approved HEPA filtration systems may be
used.
- Form IC001.
Ministry of Health
Unit/Ward Daily Census for Patients on Isolation (page 1 of 1)

Year:
Total
Date Ward Number of patients that should
Number of patients in the Ward Number of patients in Isolation
be isolated, but not
ISOLATION DETAILS
Type of
Identified precautions
Isolation Sign on Door
required Negative
implemented
MRN Pressure Discontinuation of isolation:
Patient Name Diagnosis
Airborne
No. Room (Reason & Date)
Contact
Droplet
Gloves
Gown
Mask
N95
Y/N Monitoring
Infection Control Practitioner Name and Initial:
Form IC 001
Key Requirements:
- IPC program tracks and identifies any signs of infection in all patients daily

- Daily tracking of infections form
Ministry of Health
Daily Tracking of Infections (page 1 of 1)
Year:
Patient Name: Gender: �M �F Reason of Admission:
MRN No.: Date of Birth: ___/___/___ (Y/M/D) Admitting Diagnosis:
Infection Onset __/__/__ (Y/M/D) Ward: Treating Physician:
SITE OF INFECTION RISK FACTORS (tick any that apply)
Urinary
□ Symptomatic Urinary Tract Infection
□ Catheter Related Infection (complete □ Foley Catheter □ Suprapubic Catheter □ Intermittent Catheter
surveillance form for CAUTI)
□ Other Specify:_____________
Respiratory
□ Respiratory Tract - Common Cold/
Pharyngitis
□ Influenza-like illness
□ Pneumonia □ Tracheostomy □ Croup Tent
□ Ventilator
□ Ventilator Associated Pneumonia (complete □ Inhaler Treatments □ Humidifier
surveillance form for VAP)
□ Other Lower Respiratory Tract Infection
(Bronchitis, Tracheobronchitis)
Specify:______________
Gastrointestinal
□ Gastroenteritis □ PEG tube □ NG tube □ OG tube
Bloodstream/IV
□ Septicemia □ Peripheral Line □ Central Line □ Midline
□ Catheter related blood stream infection □ Injections □ Venipuncture
(complete surveillance form for VAP)
Surgical Wound □ Wound Care
□ Drain Tube
□ Surgical Site Infection (complete □ Wound Care Product □ Adhesives
□ Whirlpool
surveillance form for SSI)
Eye, Ear, Nose and Mouth Infection
□ Conjunctivitis
□ Ear Infection □ Redness □ Pus x 24 hours
□ Mouth and Perioral Infection
□ Sinusitis
Skin/Soft Tissue
□ Fungal skin infection
□ Braces □ Wound Care □ Fever or Cold
□ Herpes simplex
□ Immobilizer □ indwelling tube □ assistive device
□ Herpes zoster
□ Medication (e.g.
Other infections (e.g. MDROs) □ Immunocompromised
□ Diabetes Chemotherapy,
□ Other Specify:_______________________ state
Steroids)
Culture Result:____________________ Chest X-Ray:________________ Physician Diagnosis:_____________________
Antibiotic Ordered: ________________ Signs & Symptoms: ________________________________________________
Type of infection:  Infectious  Communicable  Non Communicable
 Hospital Acquired Infection  Community Acquired Infection
Type of precautions required (in addition to Standard Precautions):  Contact  Droplet  Airborne
Name of person completing the form: Date:
Key Requirements:
- Determining the Type of Construction / Renovation According to the GCC Manual for Infection
Control: page
- Ensures that Engineering Department staff are complaint with obtaining the IP&C approval
when the construction activity and risk level indicate that Class III or Class IV control
procedures.
- Ensures that the construction or renovation area is isolated from the occupied areas during
construction and will be negative with respect to surrounding areas.

- Infection Prevention and Control Compliance Monitoring Tools
Ministry of Health
Construction and Renovation Form: (page 1 of 2)
Hospital Name: Project Title:
Location of Construction: Project Start Date:
Project Coordinator: ID#: Estimated Duration:
Contractor Performing Work: Permit Expiration Date:
Supervisor: ID#: Tel Ext.: Mobile #:
Click on type of INFECTION CONTROL RISK Click on Risk
CONSTRUCTION ACTIVITY Activity (see Group (see
Guide 1) GROUP Guide 2)
TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk
TYPE B: Small scale, short duration, Moderate

GROUP 2: Medium Risk
to high levels
TYPE C: Activity generates moderate to high
levels of Dust, requires greater 1 work shift GROUP 3: Medium/High Risk
for completion
TYPE D: Major duration and construction
GROUP 4: Highest Risk
activities Requiring consecutive work shifts
IDENTIFY and CIRCLE CLASSES OF REQUIRED PREVENTIVE MEASURES
INFECTION CONSTRUCTION ACTIVITY
CONTROL RISK TYPE TYPE TYPE
GROUP “A” “B” “C”
Group 1 I I II
Group 2 I I III
Group 3 II III III/IV
Group 4 III II/IV III/IV
CLASSES OF PREVENTIVE MEASURES (click on measures applied):
Class I  Execute work by methods to minimize raising  Minor Demolition for Remodeling
dust from construction operations.  Other ______________________________
 Immediately replace any ceiling tile displaced for
visual inspection.
Class II  Provides active means to prevent air-borne dust  Wet mop and/or vacuum with HEPA filtered
from dispersing into atmosphere. vacuum before leaving work area.
 Water mist work surfaces to control dust while  Place dust mat at entrance and exit of work area.
cutting.  Remove or isolate HVAC system in areas where
 Seal unused doors with duct tape. work is being performed.
 Block off and seal air vents.  Other ______________________________
 Wipe surfaces with disinfectant.
 Contain construction waste before transport in
tightly covered containers.
Ministry of Health
Construction and Renovation Form: (page 2 of 2)
CLASSES OF PREVENTIVE MEASURES (click on measures applied):

Class III  Obtain infection control permit before  Contain construction waste before transport in
construction begins tightly covered containers.
DATE:  Isolate HVAC system in area where work is being  Vacuum work with HEPA filtered vacuums.
_____________ done to prevent contamination of the duct  Wet mop with disinfectant.
INITIAL: system.  Remove barrier materials carefully to minimize
_____________  Complete all critical barriers or implement control spreading of dirt and debris associated with
cube method before construction begins. construction.
 Maintain negative air pressure within work site  Contain construction waste before transporting.
utilizing HEPA equipped air filtration units.  Cover transport receptacles or carts. Tape
 Do not remove barriers from work area until covering.
complete project is thoroughly cleaned by  Remove or isolate HVAC system in areas where
housekeeping. work is being performed
 Other ______________________________
Class IV  Obtain infection control permit before  All personnel entering work site are required to
construction begins. wear shoe covers.
DATE:  Isolate HVAC system in area where work is being  Do not remove barriers from work area until
_____________ done to prevent contamination of duct system. completed project is thoroughly cleaned by the
INITIAL:  Complete all critical barriers or implement control Environmental Service Department.
_____________ cube method before construction begins.  Vacuum work area with HEPA filtered vacuums.
 Maintain negative air pressure within work site  Wet mop with disinfectant.
utilizing HEPA equipped air filtration units.  Remove barrier materials carefully to minimize
 Seal holes, pipes, conduits, and punctures spreading of dirt and debris associated with
appropriately. construction.
 Construct anteroom and require all personnel to  Contain construction waste before transport in
pass through this room so they can be vacuumed tightly covered containers.
using a HEPA vacuum cleaner before leaving  Cover transport receptacles or carts. Tape
work site or they can wear cloth or paper covering.
coveralls that are removed each time they leave  Remove or isolate HVAC system in areas where is
the work site. being done.
 Other ______________________________
Project Description: Estimated Duration:
Inspections :  Daily Weekly Every other day  Twice per week  Other _______
Permit Requested By: Permit Authorized By:

Date: Date:
Ministry of Health
Construction and Renovation Guide 1:- to identify type of construction activity:
(page 1 of 2)
Please indicate the type of work involved:
Type A ( Inspections and Non-invasive activities Includes activities that do not generate dust or require cutting of walls, drilling,
sanding or access to ceilings other than for visual inspection such as:
 Removal of ceiling tiles for visual inspection limited to 2 tiles per 50 square feet
 Minor Electrical work
 Minor plumbing repairs without solder and torches
 Hardware repair of doors and windows
 Sign repair or replacement
 Painting (but not sanding) wall covering
Type B ( Small scale, short duration activities, which will only create minimal dust. Includes, but is not limited to:
 Installation of telephone and computer cabling

 Access to chase spaces
 Small carpentry ASSEMBLY projects
 A maximum of 4 ceiling tile replacements within 50 square feet
 Short duration cutting, drilling, or sanding of very small areas where dust creation is
 small and migration can be controlled
 Minor mechanical repairs; re-lamping; hand-tool operations.
Type C ( Any work which generates a moderate to high level of dust. Any work that requires demolition or removal of any fixed
building components or assemblies, any work with adhesives, paints, solvents, thinners and strong cleaners, any work that takes
more than one shift to complete. Includes, but is not limited to:
 Sanding of walls for painting or dry wall construction, or of any wall covering
 Any drilling of more than a very short duration
 Any use of power cutting or sanding tools in patient occupancy areas
 Removal of any floor coverings, ceiling tiles, or casework covering more than 20% of the total area
 New wall, ceiling, or floor construction
 Any above ceiling duct work, plumbing work or electrical work likely to generate
 moderate amounts of dust
 Major cabling activities
 Any extensive (greater than 35 square feet) use of cleaners, strippers, paints, solvents, sealers, or adhesives
 Any work taking more than 8 hours to complete
Type D ( Any project that requires major demolition and/or major re-construction, extended over several days. Includes, but is not
limited to:
 Any significant water damage of carpeting, ceiling tiles, insulation and dry wall that is more than 48 hours old;
 Major demolition
 Major construction, over several days
 New construction
Ministry of Health
Construction and Renovation Guide 2:- to identify type of risk groups: (page 2 of 2)
Group 1 GROUP 2 GROUP 3 GROUP 4

LOWEST MEDIUM HIGH HIGHEST
1.) Office areas 1) All Med/Surg units 1) Emergency Room 1) Operating Rooms; Sterile
2) Physical Therapy 2) Radiology/MRI Processing
3) Sports Medicine 3) Post-anesthesia Care units 2) Labor and Delivery
4) Admission/Discharge area 4) Labor and Delivery Operating Rooms
5) Outpatient areas 5) Newborn Nurseries 3) Cardiac & EP
6) Pediatrics Catheterization &
7) All other Intensive Care Angiography Areas
Units 4) Oncology
8) Nuclear Medicine 5) Dialysis/Home Training
9) PT – tank areas 6) Renal Services Unit
10) Cafeteria 7) Renal Transplant
11) Echocardiography 8) Cardiology
12) Laboratories 9) Anesthesia and Pump
13) Occupational Lung Center areas
10) Endoscopy/Minor Surgery
11) Pharmacy Admixture
12) Surgical care
13) Central Services
Key Requirements:
- All steps of an outbreak investigation are carried out immediately

- Outbreak is reported to regional health directorate and MOH

- Outbreak Report Form to MOH
- List of Patients Demographic Data
Line
Ministry of Health
Outbreak Report to MOH: (page 1 of 2)
Type of report □ Interim □ Final
Date of report
□ Multi drug resistant organism (MDRO)
□ Gastrointestinal
Type of outbreak
□ Respiratory
□ Others _______________________________________________________________
Health care facility
City
Name and Contacts of Reporter
Name and Contacts of IPC
Department Director
Affected locations
Organism (if known)
Date of onset
(first reported case/specimen)
□ Ongoing (new case occurring)
Status of outbreak □ Contained (existing, but no new case)
□ Resolved (no existing or new cases)
- Total number identified (from clinical specimens and screening):
Description outbreak - Total number of identified infections:
- Total number of identified colonization:
Location Infected Colonized
Distribution
Number of Discharged Patients:

Outcomes Number of Died (attributable) Patients:
Number of Died (not-attributable) Patients:
Number of Ongoing Infections:
□ Contact (direct)
Suspected mode/s of □ Contact (indirect)
transmission □ Droplet
□ Airborne
Suspected Source/s □ A common source □ Multiple sources
Microbiological studies
(if applicable)
To be faxed to: 011-2124255 or to be emailed to info@gdipc.org

Outbreak Criterion: An incident in which two or more people, linked in time/place, experiencing similar symptoms or signs possibly related
to an infectious agent A greater than expected rate of an infectious agent (infection od colonization) compared with the usual background
rate for the place and time where the outbreak has occurred A single case for certain infections ( new pathogen or new multidrug resistant
isolates of known pathogen) or rare diseases such as diphtheria, botulism, rabies, viral hemorrhagic fever or polio
Ministry of Health
Outbreak Report to MOH (page 2 of 2)
Line Listing of Patients’ Demographic Data

Date:
Room Diagnosis
Date of Sample Sample Organism Site of
No. Patient Name No./ MRN Age Sex on Antibiotic Outcome
Admission Type Date Isolated Infection
Bed No. Admission
Key Requirements:
- IPC provides consultation to inpatient and outpatient clinical departments regarding IC
issues, significant event follow-up, risk assessment, prevention and control strategies

- Request of IPC consultation form
Key Requirements:
- IC control training is provided to all new employees.
- IC infection control training is provided to the unit staff on monthly basis on including the
following: Hand Hygiene, Isolation Precautions, Sharps Safety, Tuberculosis (TB) Exposure
Control Plan, Surveillance Outcomes, Dept. Specific Training, Updates on Policy Changes, etc.
- IPC program provides specialized training to its employees including orientation for new ICPs
and provide opportunities for employees to attend MOH IC training courses.

- MOH PowerPoint presentations for new staff (to be provided separately)
- MOH PowerPoint presentation for hand hygiene (to be provided separately)
- MOH PowerPoint presentation for isolation precautions (to be provided separately)
- MOH PowerPoint presentation for Sharps Safety (to be provided separately)
- MOH PowerPoint presentation for Tuberculosis (TB) Exposure (to be provided separately)
Ministry of Health
Annual Infection Control Training Plan
Place of Organizing Frequency of Duration of Date of NO. of target Type of

Progress Title of activity
training hospital activity activity activity audience audience
Key Requirements:
- IPC program conducts ongoing surveillance in the defined population(s) at risk as identified
by local IC Committee including:
 Central Line Associated Bloodstream Infection (CLABSI)
 Dialysis Event (DE)
 Ventilator Associated Pneumonia (VAP)
 Surgical Site Infections (SSI)
 Multi Drug Resistant Organisms (MDROs)
 Prevention Bundles
 Hand Hygiene Compliance
 Occupational Blood Exposure (OBE)
- INICC system is used to report and analyze data
- EPINET system is used to report and analyze OBE data

- Forms to collect data for CLABSI, VAP, CAUTI, SSI, Prevention Bundles, Hand Hygiene, OBE
and MDROs (provided separately)
- INICC system (provided separately)
- EPINET System (provided separately)
First Edition, February 2016

Ministry of Health

Core Components and Essential Activities of Regional Directorates-Based IPC Programs

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Core Components and Essential Activities of Regional Directorates-Based IPC Programs

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Core Components and

‫اإلدارة العامة لمكافحة عدوى المنشآت الصحية‬

Core Components and Essential Activities of hospital-Based IPC programs

General Directorate of Infection Prevention and Control

Reports to: Assistant Director of Public Health

Date of Issue: :‫تاريخ اإلصدار‬

Execution Tools and Documents:

- Infection Prevention and Control Committee Agenda Template

III. Old Business

IV. New Business

Next Infection Control Committee Meeting

Infection Control Director

Other members invited as

General Directorate of Infection Prevention and Control

‫اإلدارة العامة لمكافحة عدوى المنشآت الصحية‬

Core Components and Essential Activities of hospital-Based IPC programs

General Directorate of Infection Prevention and Control

Infection Control Committee

- Authority for IPC program is delegated by the relevant administrative directors

Execution Tools and Documents:

Date of Issue: :‫تاريخ األصدار‬

Hospital Name: Region:

Hospital Name: Region:

Execution Tools and Documents:

- Infection Prevention and Control Committee Agenda Template

IV. IC Education Provided

IV. Old Business

Next Infection Control Committee Meeting

Hospital Name: Region:

Infectious Disease Specialist

Infection Control Practitioners

Hospital Name: Region:

ANCILLARY DEPARTMENT REPORTS

Hospital Name: Region:

Hospital Name: Region:

Contaminated dialysis water system

Infection From Inadequate Sterilization

Poor IC Practices in Laundry

Problems with Cleaning/ Disinfection

Lack of Staff Influenza Immunization

Exposure to Blood borne Pathogens

6. Scope of services for the IPC team Education

Hospital Name: Region:

Infection Control Monitoring

Execution Tools and Documents:

Hand hygiene supply is available.

Staff uses personal protective equipment appropriately.

There is a cleaning schedule and is applied

Environmental surfaces are clean and are free from soil.

double/ or triple bucket technique or scrubbing machines.

There is one spill kit, at a minimum in the department.

doses for the same patient.

Only sterile fluids used in nebulizers, humidifiers, or any aerosol generator.

Evacuation of urine bag is done in proper way using appropriate P.P.E.

Linen carts are covered and not overfilled.

Away from air vents and well ventilated

Rotate supplies on a first-in-first-out basis so as to avoid the use of expired items.

Items not kept in original cardboard boxes

Clean and dry (temperature and humidity must be controlled)

Hand hygiene supply is available.

Staff uses personal protective equipment appropriately.

refrigerator for no longer than 24 hours.

Hand hygiene supply is available.