Doh Infection Prevention & Control Training Manual: Volume II For Health Facility Administrators

DOH INFECTION PREVENTION
& CONTROL TRAINING MANUAL
Volume II for Health Facility Administrators
The UPCM IPC Working Group

University of the Philippines-College of Medicine
in collaboration with the
Department of Health
2020
Copyright © 2020
This project was made possible through the funding from the
Department of Health Philippines.
Suggested citation:
Berba RP (ed) for UPCM IPC Working Group. DOH Infection
Prevention & Control Training Manual Vol II for Health Facility
Administrators 2020.
Manila.
Send correspondence to:
Hospital Infection Control Unit (HICU)

University of the Philippines-Philippine General Hospital
Taft Avenue, Manila
1000 Philippines
Email: pgh.hicu@up.edu.ph
2
IPC HEALS
Project Leader and Editor:
REGINA P. BERBA MD MSc
Chair of the Hospital Infection Control Unit and Associate Professor, Dept of Medicine
Chapter Authors:
CYBELE LARA R. ABAD MD
Clinical Associate Professor, Dept of Medicine, Section of Infectious Diseases
and Chair of Hospital Infection Control and Epidemiology Center, The Medical City
ALEX P. BELLO MD
Assistant Professor Department of Biochemistry De La Salle College of Medicine
De La Salle Health Sciences Institute
JEMELYN U. GARCIA MD
Medical Specialist III, Medical Department
Research Institute for Tropical Medicine
DOMINGA C. GOMEZ RN
Infection Control Nurse, Hospital Infection Control Unit and Nurse VI
MARIA LIZA ANTOINETTE M. GONZALES MD, MSc.

Associate Professor, Department of Pediatrics Section of Infectious & Tropical Diseases
University of the Philippines- Philippine General Hospital
MARIA LOURDES BERNADETH V. MANIPON RN, MSN

Infection Control Nurse
Department of Health-Research Institute for Tropical Medicine
MARIA NICOLETTE M. MARIANO MD

Chair Infection Prevention and Control Office & Faculty, Dept of Internal Medicine, Section of Infectious Disease
De La Salle University Medical Center
CECILIA G. PENA RN, MAN

Deputy Director for Nursing
MELECIA A. VELMONTE MD
Professor Emeritus University of the Philippines-Philippine General Hospital
Chair Infection Control Committee, Manila Doctors Hospital
Reviewers:
NOMAR M. ALVIAR MD MhPEd
Faculty, National Teachers Training Center for the Health Professions
University of the Philippines Manila
ARACELI OCAMPO-BALABAGNO PHD RN

Past Dean and Professor,, College of Nursing, University of the Philippines Manila
FOREWORD AND ACKNOWLEDGMENT
Greetings Friends and Colleagues!
3
IPC HEALS
And warmest greetings to all of you "HEALerS" of Infection
Prevention and Control. We dedicate this training tools to all of you!
Indeed we are very excited to share with you this manual of training
meant for both the "masters" whose programs have been well put in
place in their hospitals as well as the novices still in the developing
stages.
Most of us always feel there are problems in our hospital which do

not seem to have answers to existing published guidelines.
The major aim of this document is to provide healthcare facilities in
the Philippines with up-to-date, practical, relatively concise guidance
in implementing HAI prevention efforts. We share with you the PGH
"HEALS" approach to improve recall and compliance to IPC.
In behalf of the UPCM Study Group, I would like to extend our

sincerest gratitude to the various teams of the Department of Health
who journeyed with us in the development of these materials.
I also thank the editorial and artist project staff. Special thanks to Dr.
Jose Carlo B. Valencia, April Caparas and Dr. Myra Candela whose
input have been essential in the production of these works.
Let us all continue this very challenging yet fascinating, "road-less-

travelled" work we chose and make the path towards improving
safety for our patients in our healthcare institutions the standard for
all.
Salamat at Mabuhay tayong lahat!

Humbly,
Regina Berba MD MSc

Project Leader
TABLE OF CONTENTS
Foreword and Acknowledgements................................................................................ 5
List of Tables........................................................................................................................... 7
List of Figures......................................................................................................................... 7
4
IPC HEALS
Glossary of Terms………………………………………………………………………………... 8
Preface: A NEW TOOL FOR TEACHING IPC TO HEALTHCARE WORKERS...... 15

I. How this Training Manual was Developed ................................................... 15
II. Historical Background........................................................................................... 15
III. Framework for the National Training Program for IPC ....................... 17
IV. The Philippine IPC Training Program .......................................................... 19
V. How to Use this Training Manual.................................................................... 21
VI. The HEALS Approach........................................................................................... 22
Chapter 1 Basic Epidemiology of Healthcare Associated Infections.................... 25
Chapter 2 The Burden of HAI in the Philippines........................................................... 38
Chapter 3 Hand Hygiene.......................................................................................................... 41
Chapter 4 Environmental Care for IPC………................................................................... 52
Chapter 5 Isolation Precautions and Personal Protective Equipment ................ 56
Chapter 6 Battle against Antimicrobial Resistance................................................... 59
Chapter 7 Antimicrobial Stewardship.............................................................................. 62
Chapter 8 Lowering of HAI via Bundles........................................................................... 68
Chapter 9 Infection Control in High Risk Areas: Intensive Care Units............... 73
Chapter 10 Infection Control in High Risk Areas: Operating Rooms................... 77
Chapter 11 Infection Control for Special Infections: Tuberculosis ...................... 79
Chapter 12 Infection Control for Emerging Infections: COVID-19……………….. 87
Chapter 13 Immunization of Healthcare Workers........................................................ 91
Chapter 14 Needlestick Injury Prevention and Management ................................. 94
Chapter 15 Outbreak Investigation. in Healthcare Facilities.................................. 98
Chapter 16 Surveillance ------------------------------------------------------------------101
Chapter 17 Difficult Situations.............................................................................................. 105
LIST OF TABLES
Table 1. Microorganisms frequently causing. ---------------------------------------------- 27
5
IPC HEALS
Table 2. Mode of Transmission of HAI ----------------------------------------------28
Table 3. Step-by-step strategies necessary to set-up a Hand Hygiene Program ----- 48
Table 4. Requirements of a Successful Hand Hygiene Program------------------------- 48
Table 5: Summary of the Bundles of Care --------------------------------------------------- 69
Table 6. Estimates of TB Burden in the Philippines, 2016-------------------------------- 79
Table 7. TB Infection Control Program: Level of Controls-------------------------------80
Table 8. Implementation of TB Control Policy---------------------------------------------81
Table 9. Requirements of TB Isolation Room----------------------------------------------- 84
Table 10, Highly Recommended Vaccinations for Healthcare Workers--------------- 92
Table 11. Examples of Key Performance Indicators for IPC----------------------------- 102
LIST OF FIGURES
Figure 1. Unified Core Components Of The National IPC Program----------------------17
Figure 2. Enabler Framework Of IPC For Every Healthcare Facility --------------------18
Figure 3. The National Framework For IPC To Guide Training---------------------------20
Figure 4. The 3 Elements Required For The HAI To Occur --------------------------------- 26
Figure 5. The Transmission of Infection ----------------------------------------------------29
Figure 6. The Chain of Infection --------------------------------------------------------------29
6
IPC HEALS
Figure 7. Breaking The Chain of Infection----------------------------------------------------30
Figure 8. Snapshot of JCAHO International Standard for Hospital Leadership-------- 36
Figure 9. A patient carrying various organisms on her skin ------------------------------41
Figure 10. Illustration of Movement of Organisms from patient to HCWs’ hands----- 42
Figure 11 Organism surviving in HCWs------------------------------------------------------42
Figure 12. Organisms may grow and multiply in HCWs hands ---------------------------42
Figure 13. The HCW is seen to get the organisms from Patient A onto his hands----- 43
Figure 14. HCW transmitting organisms as he moves from Patient A to Patient B -- 43
Figure 15. The HCW Causes Within-Patient Cross-Transmission-----------------------44
Figure 16. Marked rise in HAI when alcohol supplies ran out --------------------------44
Figure 17. Effect of Hand Hygiene Stock Out on HAI rates-------------------------------45
Figure 18: The Five Moments of Hand Hygiene from the WHO 2009------------------- 46
Figure 19. Interventions for Control of MDROs in Healthcare Settings----------------59
Figure 20. Antimicrobial Stewardship Strategies -------------------------------------------63
Figure 21. Three-dimensional perspective of a TB Isolation Room --------------------- 84
Figure 22. Respiratory Protection for TB Care ---------------------------------------------84
Figure 23. Hierarchy of Control for Needlestick Injury Prevention---------------------95
GLOSSARY OF TERMS AND ACRONYMS

AFB: Acid Fast Bacilli
AIDS: Acquired Immune Deficiency Syndrome
Antimicrobial agent: Any agent that kills or suppresses the growth of

microorganisms.
7
IPC HEALS
AMS: Antimicrobial Stewardship
Antiseptic: A substance that prevents or arrests the growth or action

of microorganisms by inhibiting their activity or by
destroying them. The term is used especially for
preparations applied topically to living tissue.
Asepsis: Prevention of contact with microorganisms.
Aseptic technique Procedures where utmost precautions are put in place to prevent
microorganisms on hands, surfaces and equipment from being
introduced to susceptible sites.
Autoclave: A machine which sterilizes instruments or other objects usually

using steam under pressure.
Bacterial Count: Method of reporting an estimate of the number of bacteria per

sample, usually expressed as number of colony-forming units per
unit volume
Bactericide: A substance with the capacity to kill bacteria.
BHFS: Bureau of Health Facilities and Standards
Bioburden: Amount and types of viable microorganisms contaminating an

item otherwise termed as bioload or microbial load.
Biofilm: Mix of bacteria and other material that is clings to a surface of an

equipment used in humans
Biologic indicator: Used to monitor the sterilization process. This contains a

standardized amount of viable bacterial spores which are known
to be resistant to the sterilization process being monitored.
CAUTI: Catheter-associated Urinary Tract Infection
Ceiling limit: The amount of airborne chemical contaminants which

should not be reached during any part of the workday.
Central Processing department: Unit within a health facility that processes, issues and
controls supplies and equipment, both sterile and non-sterile, for
some or all patient-care areas of the facility.
Chemical indicator: Used to monitor the sterilization process. Designed to have a

characteristic chemical or physical change to specific physical
conditions within the sterilizing chamber. Can detect potential
sterilization failures that results from wrong packaging, incorrect
loading of the sterilizer or malfunctioning of the sterilizer.
Clean Wound: The status of the surgical wound wherein there was no
inflammation seen upon initial skin incision, without a break in
sterile technique, and during which the respiratory, alimentary
or genitourinary tracts are not entered.
8
IPC HEALS
Clean-contaminated Wounds: The status of wound wherein an incision entered the
respiratory, alimentary, or genitourinary tract but under
controlled conditions and no contamination occurred.
Contaminated Wound: The status of wound wherein the incision site had a major break
in sterile technique or gross spillage from the gastrointestinal tract, or acute, non-
purulent inflammation is encountered. Open traumatic wounds that are more than 12–
24 hours old also fall into this category
Colonization The sustained presence of replicating infectious agents on or in

the body without the production of an immune response or
disease
Contact Time: Time a disinfectant is in direct contact with the surface or item to
be disinfected. For surface disinfection, this period from the application to the surface
until complete drying has occurred
Contaminated: State of having actual or potential contact with microorganisms

that could produce disease or infection.
CLABSI: Central Line-associated Blood Stream Infection
Cleaning: Process of removing visible soilage, blood, substances, and all

other debris from surfaces and lumens of instruments, devices
and equipment by a manual or automated process in preparation
for safe handling and further decontamination.
Culture: Growth of microbiologic organisms on a nutrient medium.
Culture Medium: Prepared substance which encourage the growth of

microorganisms.
Decontamination Process of removing, inactivating or destroying pathogens so that

they are no longer capable of transmitting infectious particles
thus making the item safe for handling, use, or disposal.
Detergent: Cleaning agent with a hydrophilic and a lipophilic component.
Disinfectant: A chemical agent used to destroy microorganisms but not kill

bacterial spores from inanimate objects.
Disinfection: Process of eradicating of microorganisms from materials except

bacterial spores
DOH: Department of Health
Endoscope: An instrument used to examine or deliver treatment to hollow

organs of human body
Enzyme cleaner: A solution used before disinfection to facilitate the removal of

organic material
Exposure time: Amount of time when items are exposed to the chemicals at the
specified sterilization parameters.
9
IPC HEALS
Flash sterilization: Process designed to quickly but effectively sterilize patient care
items under steam sterilization
Fomite Any inanimate object capable of carrying infectious organisms

and transferring them from one individual to another
Fungicide: Agent which can destroy fungi including yeasts and spores
from inanimate items
Germicide: Agent which can eradicate pathogenic microorganisms
HAI: Healthcare associated infection
Healthcare associated Infection: Infection acquired in healthcare facilities or

infection which may occur as a complication of a health
intervention. It may manifest after the patient is discharged.
Hand hygiene A general term applying to processes aiming to reduce the

number of microorganisms on hands.
Healthcare facility (HCF) Refers to all possible clinical areas where patients
receive medical care. Includes acute care, inpatient setting,
outpatients, clinic-based and chronic medical care set-ups.
Healthcare worker (HCW) All persons delivering healthcare services who have contact
with patients or with blood or body substances
High-level disinfectant: Agent which can kill all microorganisms including bacterial
spores when used in correct amount and duration.
Host The host is a person who is susceptible to a disease due to a

lack of immunity or physical resistance to overcome invasion by
a pathogenic microorganism. Age, health status and nutritional status and immunity
influence susceptibility
HIV: Human Immunodeficiency Virus
Implantable device: A device placed into the human body with the intention of
remaining there for at least 30 days
Inanimate surface: Nonliving surface like the wall, floor and furniture
Incubator: Equipment used for the growth and cultivation of

microorganisms.
INICC: International Nosocomial Infection Control Consortium
Intermediate-level disinfectant: Agent that destroys all vegetative bacteria, viruses and
fungi but not bacterial spores.
Infection Control Professional (ICP): An infection control practitioner is usually a

licensed physician (MD) or registered nurse (RN) who specializes in the prevention and
control of infectious disease in a hospital setting.
10
IPC HEALS
Infectious agent A microbe which has the ability to cause disease; it may be
bacteria, fungi, virus, protozoa or parasite
IPC: Infection Prevention and Control
Low-level disinfectant: An agent that can destroy all vegetative bacteria except
TB bacilli, some viruses and some fungi, but not spores.
Medical device: An instrument, apparatus, material, or other article used for

diagnosis, treatment, prevention, or monitoring of disease
Microorganisms: Any of bacteria, fungi, viruses and bacterial spores.
Minimum effective concentration (MEC): The minimum concentration of a chemical

needed to achieve the claimed antimicrobial effect.
MRSA: Methicillin resistant Staphylococcus aureus
MDRO: Multidrug resistant organism.
HFDB: Health Facility Development Bureau
One-step disinfection process: Simultaneous cleaning and disinfection of

noncritical surface or item.
Particulate respirator: A personal respiratory protective tightly fitting mask worn for
airborne precautions, which is capable of filtering 0.3μm particles.
Parts per million (ppm): concentrations by volume of trace contaminant gases in the
air
Pasteurization: Process developed by Louis Pasteur of heating milk or other

liquids to 65-77 degrees Celsius for 30 minutes to kill the
pathogenic organisms other than bacterial spores.
Patient-care area The room or area in which patient care takes place
Permissible exposure limit (PEL): the time weighted mean maximum concentration
of an air contaminant a worker can be exposed calculated over 8
hours assuming a 40-hour work week.
PPE Personal protective equipment which is any of the barriers used

alone or in combination to protect mucous membranes, skin, and
clothing from contact with infectious agents and includes masks,
protective eyewear, face shields, gloves and gowns.
Prions: Transmissible pathogenic agents which are extremely resistant

to inactivation by the usual sterilization and disinfection
processes. They are known to cause neurodegenerative diseases
like the Creutzfeldt-Jakob disease.
Procedure: An act of care for a patient where there is a risk of direct

introduction of a pathogen to the patient
11
IPC HEALS
PGH: Philippine General Hospital
PHICS: Philippine Hospital Infection Control Society
PSMID: Philippine Society for Microbiology and Infectious Disease
Reprocessing: Series of methods from cleaning to repackaging designed to

ensure that a medical device meant initially manufactured for
single use only is properly disinfected or sterilized for re-use
Respiratory hygiene and cough etiquette: Recommended action to minimize the

transmission of respiratory pathogens through droplet or
airborne routes
SARS: Severe Acute Respiratory Syndrome
Service Capability: Refers to the level of services, clinical care and management
provided by a Philippine hospital. Last revised explained in AO 2012-0012 Rules and
Regulations Governing the New Classification of Hospitals and Other Health Facilities in
the Philippines. According to functional capacity, general hospitals are categorized as
either Level 1; Level 2; and Level 3
.
Sharp Instruments Used in delivering healthcare that can inflict a penetrating
injury, e.g. needles, lancets
SHEA: Society of Healthcare Epidemiology in America
Single-use devices Medical devices that are labelled by the original

manufacturer as “single use” and are only intended to be
used once.
Spaulding classification: Used during the reprocessing of contaminated medical

devices, this system classifies a medical device as critical,
semi-critical or non-critical. The system guides the level of
germicidal activity required (ie sterilization, high-level or low-
level disinfection).
Spore: Cells consisting of condensed cytoplasm and nucleus surrounded

by an impervious cell wall or coat. Spores of Bacillus and
Clostridium are resistant to disinfection and sterilization
Spore strip: Paper strip impregnated with known spores and used as
biological indicators.
SSI: Surgical Site Infection
Sterilization area: Designated area in the health facility which contains the
equipment to sterilize materials and supplies
Sterilizer: Apparatus used for the sterilization of medical devices,

equipment, or supplies
TWG: Technical Working Group
12
IPC HEALS
UV: Ultraviolet Radiation as adjunct for cleaning
VAP: Ventilator associated Pneumonia
Vegetative bacteria: Bacteria which do not have spores and are easily inactivated by
any type of germicides.
VRE: Vancomycin-resistant enterococcus
WHO: World Health Organization
13
IPC HEALS
Created by:
INFANTE, ONG, ROCIMO, SAN PEDRO
of UPCM Class 2021
14
IPC HEALS
PREFACE
I. HOW THIS MANUAL WILL HELP YOU:

The science of infection prevention and control (IPC) revolves mainly around
preventing healthcare associated infections (HAI) and keeping health care environments
safe and effective. It requires strategic planning based on knowledge of epidemiology of
infections as well as evidence-based practices that need to be understood,
systematically implemented and evaluated for outcomes and limitations.
The Philippines is in a crucial period in the history of hospital Infection Prevention and
Control (IPC). The “National Policy on Infection Control” which was recently signed and
approved on January 2016 (1) as Administrative Order 2016-002 was developed with
the purpose of guiding, standardizing and improving the practice of infection control in
the country across all levels of healthcare facilities, whether private or public, whether
classified as Level 1 facility, level 2, or 3 and whether in rural or urban. Now that the
national policy has been approved, all health facilities must urgently be able to comply
with these set standards and policies, thus will need training and for some, re-training
on basic and advanced infection control.
The University of the Philippines College of Medicine (UPCM), with its historical record
of leadership in initiatives in Infection Control in the country was awarded this project
grant in 2015.
The project team developed these training manuals within a strategic framework
responsive to the stringent requirements of international and local guidelines on
infection control. The educational needs of health care facilities and how these could be
addressed were identified by a series of focused group discussion with various
frontliners in IPC. The manuals were written chapter by chapter by authors all of whom
are current IPC practitioners with wide ranges of expertise, experience, resources and
educational background. Necessarily this training manual has a very large scope which
will include not only knowledge on infection control but also educational tools and
techniques that will motivate and sustain behavioral change towards compliance to
infection control practice.
For most part, guidelines and various other worldwide organizations have the technical
components which summarize recommendations from various studies. Notable are
from the World Health Organization (WHO), Center for Disease Control (CDC) USA, the
Society of Healthcare Epidemiology in America (SHEA), and local guidelines from the
Philippine Society of Microbiology and Infectious Disease (PSMID) and the Philippine
Hospital Infection Control Society (PHICS). What is not present in these landmark
documents is the more difficult step of translating the evidence to everyday health care
facility work. The latter requires immense amount of time and political will to create
change: changing people’s values, practices, attitudes, beliefs and behaviors.
II. HISTORICAL BACKGROUND

IPC in the Philippines may be best described young, evolving and still fragmented. Initial
efforts could probably be traced back to the Philippine General Hospital (PGH) who is
historically recognized as the first hospital to have an institutionalized Infection Control
Committee through a PGH Office Order No. 78-1 issued on January 11, 1978. During the
administration of former Health Secretary Alfredo R. A. Bengzon from 1986 to 1992, the
15
IPC HEALS
Department of Health (DOH) required healthcare facilities to establish Infection Control
Committees (ICC) in hospitals.
In 1992, the Philippine Hospital Infection Control Society (PHICS) was born and became
instrumental in the spread of IPC initiatives in various hospitals in the country. These
efforts were further augmented by the development of the nursing arm: Philippine
Hospital Infection Control Nurses Association (PHICNA) in 1994.
In September 26, 1996, the DOH issued the revised rules and regulation governing
registration and licensing of hospitals, again mandating that each hospital should
establish three vital committees, one of which is the Infection Control Committee (ICC).
Many ICCs existed but did not provide a network for cooperation, information exchange
and reporting on a national scale.
In 2003 when the outbreak of Severe Acute Respiratory Syndrome (SARS) challenged
the capability of all healthcare facilities across the world to manage the threat of
transmission of the coronavirus, the need for a more structured infection control
program at the national, regional and local levels became apparent and urgent. Through
the initiative of the World Health Organization (WHO) and the leadership of the DOH in
collaboration with Philippine Society of Microbiology and Infectious Diseases (PSMID),
PHICS, and PHICNA, SARS preparedness was assessed in DOH hospitals based on
recommended IPC guidelines. Findings revealed deficiencies in knowledge, practice and
policy compliance among local healthcare providers. The study further revealed that
efforts were mostly fragmented and focused towards implementation of IPC in
individual facilities only, lacking the integration of components towards a unified
national IPC program. WHO and DOH recognized the need to strengthen IPC programs
nationwide to enhance preparedness of HCWs to be able to respond to future threats of
outbreaks of highly transmissible infectious diseases. In the 2006 WHO workshop
among ASEAN countries for the evaluation of “Healthcare Facilities for Emergency
Preparedness and Response to Epidemics and Pandemics”, the main obstacles in the
efficient response mechanisms were identified as the following: lack of established IPC
capacities in the healthcare facilities and weakness of infection control national
programs.
In response, the Department of Health through the National Center for Health Facility
Development (NCHFD), together with PHICS and PHICNA and other various experts and
stakeholders, produced the “National Standards in Infection Control for Healthcare
Facilities” (2) which was released in 2009. The national standards provided the
reference for the standardized approach towards a more systematic, evidence-based
and cost-effective implementation of infection control programs among all types of
healthcare settings from large tertiary teaching hospitals down to the barangay health
centers, and across all types of health professionals from all disciplines and specialties,
in both government and private institutions.
The current burden of HAIs in the Philippines can only be partly estimated by limited
studies. In addition to HAIs, the threat of multidrug resistant organisms (MDROs) as
well as the newly emerging infections are urgent reasons why IPC needs to be in place in
our country. Lastly, the Philippines rank several infectious diseases consistently among
the top causes for mortality and morbidity, including tuberculosis, respiratory and
diarrheal infections.
To further realize the vision of a strong national IPC program, the DOH in 2012 created
the Technical Working Group (TWG) on the Development of National Policy in Infection
16
IPC HEALS
Control in Healthcare Facilities. This group, composed of active partners both from the
public and private sectors, was given the task of developing the national policy
statements that shall be adopted nationwide by all health facilities. In the formulation of
this document the TWG considered resource limitation with flexibility to adapt to
current realities in the local healthcare facility setting but at the same time and
consistent with current evidence and international standards. Using the 2009 National
Standards in Infection Control for Healthcare Facilities (2) as the main basis and
complemented by newer evidence, this National Policy has been put together to
establish and sustain a strong, effective, relevant and enduring hospital IPC program and
network in the Philippines. Finally approved in 2016, this period represents a new
opportunity for IPC to be finally embedded into the Philippine healthcare system.
III. FRAMEWORK FOR THE NATIONAL TRAINING PROGRAM FOR

INFECTION PREVENTION AND CONTROL
The emerging challenges in IPC demand a flexible and integrated system. Right now, we
are looking and managing the whole problem of IPC and worsening antimicrobial
resistance by institutions, independently of each other with no firm guidance from any
agency, organization or office. We approach issues, concerns and problems and perform
measures on our own as individuals or hospital committees, and rarely agree to
standardize definitions or procedures. For most part, we depend on data and guidelines
from developed countries whose clinical risks and scenarios are very distant and
different from our experiences in our own clinical settings.
Therefore it is high time we agree to a unified framework, at the least for a basic training
curriculum which will be the very basic level of knowledge, skills, and capacity of all
infection control programs in our country. Figure 1 shows the illustration of the core
components model of IPC (3) by the World Health Organization (WHO) with the
enablers as recommended by the Australian model to address communicable infections.
Evaluation of relationships between institutions and the DOH and other organizations
would show that for most part, IPC programs in our country have the following
limitations:
Fragmentation
● Under the current organization of the DOH, there is no single office that the National
IPC program is assigned to.
● The core components of the IPC as seen in Figure 1 is addressed by various agencies
and organizations without intersecting in objectives, strategies nor evaluations.
● Only very recently through Department Personnel Order No 2016-0711 effective
March 8, 2016, a Technical Working Group for the Health Facility Development
Bureau was created to develop the five-year plan for the Implementation of the
National IPC Program.
17
IPC HEALS
CORE COMPONENTS
Figure 1. Unified Core Components of the National IPC Program
Figure 2. Enabler Framework of IPC for every Healthcare Facility.
Coordination
● There is really no clear control of the content nor quality of IPC services practiced by
the many different IPC committees in the country.
● While there is some semblance of monitoring through the Department of Health
licensing and the Philhealth accreditation, a unified interpretable database of IPC
programs, their capacities, status and outputs within this complex network of
committees and agencies cannot be derived.
● Although many IPC committees most likely prepare their annual reports, there is no
overarching strategy or central point that coordinates, analyses performance, or
promotes evidence-based policies. This makes it very difficult to move together
towards improvement, or identify defined national priorities.
Workforce
● Workforce shortages exist across multiple levels particularly for skilled nurses.
● For most part, inadequacies in IPC can be traced to overburdened healthcare staff.
● Multi-tasking is the best description for the overworked staff of IPC committees
whose work stretch them from tedious surveillance work to training new hires,
addressing occupational concerns such as needlestick injuries to making decisions
on what brand of disinfectant to purchase for the institution.
● IPC personnel to patient ratio is not observed.
● Current education and training arrangements may not prepare many health
professionals for future concerns such as emerging highly communicable infections,
antimicrobial resistance and multidrug resistant organisms.
Nonsupportive infrastructure
● Lack of resources such as basic hand hygiene equipment, personal protective
equipment, isolation rooms for airborne precautions are often lacking.
18
IPC HEALS
● Transmission of infections such as tuberculosis and MDROs is often difficult to
control.
● Common technologies such as electronic medical records and infrastructure such as
ventilation requirements make IPC work hundred-fold more difficult in many health
facilities with limited resources and investments on these necessities. In these
settings, surveillance to drive improvements is virtually impossible.
Performance and accountability

● There is a lack of performance and effectiveness measures to guide individual
institutional programs.
● While we know there is a huge problem on HAIs and a looming problem on AMR, an
estimate of the burden of these is difficult to obtain.
The above system limitations compromise the efficient and effective delivery of
prevention programs, accurate and timely surveillance, and epidemiological
investigations and response to outbreaks. The system limitations make it difficult to
comprehensively address national threats making the Philippines vulnerable to the
potentially disastrous consequences of detecting a national problem once the
opportunity to mount an effective response has passed.
The NATIONAL FRAMEWORK for IPC

A more coordinated, strategic approach emanating from the Department of Health, and
guided by the expertise and technical guidance of a National Council whose composition
is clearly stated in the National Policy is critically important to maintain and improve
IPC in our country. A nationally consistent approach has considerable advantages by
streamlining processes and centralizing some aspects of IPC, allowing a focus on policy
priorities and optimal use of our limited resources.
The national framework can deliver a more integrated response without changing
responsibilities of governments. It involves a commitment from all parties to work
together better in areas of shared responsibility. It also involves a commitment to better
coordinate the public health functions and services of CD control - avoiding duplication,
coordinating planning and implementation and better sharing of information and
innovation.
A national framework provides an opportunity to drive improvements across all

systems without exemption. It also provides a mechanism for engaging not only
government-run health facilities but also private medical centers. It will encourage all
types of health facilities to meet the demands and requirements to measure, reduce the
risk, control and prevent healthcare associated infections and improve outcomes of
hospitalizations and all types of health services.
19
IPC HEALS
Figure 3. The National Framework for IPC to guide training and curriculum
development for IPC during its implementation.
This unified framework was developed upon consultation with various groups and
individuals.
IV. THE PHILIPPINE IPC TRAINING PROGRAM

Aligned with the Mission and Vision statements of the Department of Health, this IPC
Training Program has the following:
A. VISION
Safer healthcare for all health facilities in the Philippines with Infection
Prevention and Control programs meeting global standards
B. MISSION
Our mission is to train and educate health professionals in the promotion of
better healthcare systems which will improve the control and prevention of
healthcare-associated infections and antimicrobial resistance.
C. PROGRAM VALUES
This Infection Prevention and Control (IPC) program seeks to nurture its trainees within
a culture driven by these values:
1. Relevance
2. Passion
3. Timely response
4. Continuous learning
5. Common good
6. Social Accountability
The mission of all Infection Prevention and Control initiatives in the world, whether on
an institutional level (such as the hospital), national (such as the Department of Health)
or global (such as the World Health Organization) levels is to reduce occurrence and
20
IPC HEALS
dissemination of healthcare associated infections as well as promotion of health
care which is safe for patients, health care workers, others in the health care
setting and the environment, and to accomplish these goals in a cost-effective
manner.
D. LEARNING OUTCOMES FOR THIS IPC TRAINING WORKSHOP

Knowledge
● Understand the chain of infection
● Know core and specific strategies to break the chain of infection
● Know the epidemiology of healthcare associated infections in the Philippines
● Define and detect healthcare associated infections
● Master and discuss the core components and principles of infection prevention
and control program
● Understand the occurrence of infections in various clinical settings and how
these can be prevented
● Know current best practices in IPC
Skills
● Recognize, describe and the clinical manifestations of common HAIs
● Perform clinical procedures in aseptic technique following principles of infection
prevention
● Implement an effective IPC program in the hospital
● Work out a cost-efficient outbreak investigation
● Perform surveillance procedures such as surveillance of healthcare associated
infections, and antimicrobial surveillance charts
● Collect, encode and interpret surveillance data
● Utilize evidence-based medicine in making clinical decisions and institutional
policies
● Communicate to colleagues, health staff, patients and families why infection
prevention precautions and strategies are necessary
● Teach and explain preventive health measures among staff and patients
● Lead the health facility in its preparedness and response for new threats of
emerging infections and antimicrobial resistance.
Attitudes
● Develop an awareness and appreciation of the risks of the various patients for
healthcare associated infections and their accompanying morbidity and
mortality outcomes
● Demonstrate love and enthusiasm for lifelong learning
● Acquire deep sense of accountability for the patients served in one's own health
facility
● Acquire an institutional culture of patient safety
● Attain a national culture of patient safety
V. HOW TO USE THIS MANUAL: Volume II for Administrators of

Healthcare Facilities in the Philippines
This Training Manual has been developed to guide administrators (Hospital owners,
Presidents, Chief Executive Officers, Medical Directors, Chief of Clinics and similar high-
ranking officers of health facilities) to know, understand and integrate INFECTION
PREVENTION AND CONTROL into their daily tasks and duties as leaders of their
institutions.
21
IPC HEALS
This Volume II should be used together with Volume I which gives the full detail of the
IPC Manual written primarily for first-line IPC practitioners and all other healthcare
workers.
This Training Manual should also be used in conjunction with the user's institutional
manual procedures on Infection Control.
In addition to what has been discussed in the previous parts, this Training Manual aims
to ensure that all HCWs, students and trainees of health facilities:
1. are aware of the epidemiology of healthcare associated infections (HAI) in the

Philippines;
2. understand the chain of infection;
3. know and understand the core components of Infection Prevention and Control;
4. know the different modes of transmission of infection in healthcare including in
high risk areas and highly communicable infections;
5. are cognizant of standard and transmission based precautions and their role in
the prevention of transmission of infection;
6. have a basic understanding of how healthcare associated infections occur and
how they can be prevented;
7. understand and apply core principles of IPC summarized as "HEALS" which
include such as Hand Hygiene, Environmental Disinfection, Antimicrobial
Stewardship, Lowering of HAIs and Surveillance.
This Training Manual will support initiatives to help prevent spread of infectious
diseases through evidence-based infection control measures in health care settings; and
also prepare these government facilities to prepare for and respond to public health
emergencies of potential international concern.
VI. THE HEALS APPROACH

As a training and learning tool, we have used the "H-E-A-L-S" as an acronym to easy
recall of basic IPC principles. Launched in PGH since August 15, 2013 during the 106th
Celebration of the PGH Foundation Week, it has been successfully used to almost all
training and teaching activities of infection control.
HEALS puts together the 10 "Best Strategies" for IPC as follows:
H for Hand Hygiene. According to all the IPC experts, HH is the simplest approach to
preventing the spread of infections and needs to be incorporated into the culture of all
health organizations.
E for Environmental hygiene. According to distinguished IPC experts, one of the most
common sources of transmission of infection is environmental surfaces. Certain types of
microbial bacteria are capable of surviving on environmental surfaces for months at a
time. When healthcare providers or patients touch environmental surfaces where
bacteria survive, the bacteria can be transmitted to other HCWs and patients and may
cause new infections. Thus, it is very essential that the health facility environments be
kept clean and disinfected.
A for Antimicrobial Stewardship. The misuse and overuse of antimicrobial agents lead
to the development of antimicrobial resistance which can put patients at increased risk
of complications if they contract infections while in the hospital setting. Thus prudent
use of antimicrobials should be part of the efforts of IPC.
22
IPC HEALS
L for Lowering HAIs through the Bundles. Based on recent evidence regarding the
spread of infections and strategies for prevention, the bundle approach for the
prevention of HAIs is vital in the IPC program of each institution.
S for Surveillance and HCW Safety. This part includes many aspects of patient and
HCW safety like screening and cohorting patients, isolation precautions, vaccination of
employees and targeted surveillance. Through surveillance, health facilities can gather
data regarding infection patterns at their own settings. This will help each hospital
measure outcomes, assess processes of care and further promote patient safety.
Teaching and encouraging all healthcare workers as well as patients and their families
to all be part of the HEALerS will help the institution fulfill their mission and vision. An
organization's culture will need to shift from thinking that only the Infection Control
Committee people are accountable for infection prevention. All HCWs, students, and all
other caregivers are accountable, and must be encouraged to comply with all IPC
protocols. IPC programs should be structured, comprehensive and easy for all to comply.
CHAPTER REFERENCES:
1. Department of Health Administrative Order AO 2016-002. National Policy on Infection
Prevention and Control in Health Facilities. www.doh.gov.ph/
2. World Health Organization Core components for infection prevention and control
programmes. Report of the second meeting of the Informal Network on Infection
Prevention and Control in Healthcare. 2009. Available from: http://apps.who.int/
3. Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, Leotsakos A, Donaldson L.

Infection control as a major World Health Organization priority for developing countries.
J Hosp Infec. 2008;68(4):285–92
4. Lipke V, Emerson C, McCarthy C, Briggs-Hagen M, Farley J, Verani AR, Riley PL.

Highlighting the need for more infection control practitioners in low- and middle-income
countries. Public Health Action. 2016;6(3):160–3.
5. Ten Best Strategies in IPC Infection Control & Clinical Quality April 05, 2013
23
IPC HEALS
24
IPC HEALS
CHAPTER 1
BASIC EPIDEMIOLOGY OF HEALTH-CARE ASSOCIATED

INFECTIONS AND INFECTION PREVENTION & CONTROL
Melecia A. Velmonte MD
LEARNING OUTCOMES:
At the end of the chapter, the health facility leader and administrator must
be able to:
1. Explain the concept of health care associated infection (HAI);
2. Describe the process of transmission of infections in the healthcare
environments;
3. Identify the general principles on how these HAIs can be reduced.
4. List how hospital management should support IPC initiatives to reduce HAIs
WHAT ARE HEALTHCARE ASSOCIATED INFECTIONS (HAIs)?

● Infection is the state or condition in which the body or part of the body is
invaded by pathogenic agents (bacteria, viruses, fungi, parasites, and others)
which under favorable condition multiplies and produces adverse effects on the
susceptible host.
Healthcare associated infections (HAIs) are infections that occur in

susceptible patients caused by microbes/ agents acquired within or any
healthcare facility (HCF) during delivery of health services. These infections
are not present on admission, acquired 48 hours after confinement, or
developed after discharge or consultation from any healthcare facility.
● The common sites of HAIs are the urinary tract, respiratory tract,
gastrointestinal tract, skin and soft tissues, bloodstream, surgical sites and
others.
● Healthcare associated infections used to be called “nosocomial infection” which

reflected their original association with hospitalized patients.
● In the current era of managed care, hospital epidemiology has expanded and it
became relevant beyond the acute care hospital and now includes all settings
where healthcare is delivered.
WHY ARE WE CONCERNED WITH HAI?
25
IPC HEALS
● HAIs are significant public health problem because they occur frequently, cause
morbidity and mortality, and results in substantial economic burden to patients,
healthcare workers and the health systems.
● HAIs occur worldwide and affect all countries irrespective of their degree of
development. The prevalence rate of HAI is 3.5% - 12% (average 7.5%) in
developed countries and 5.7% - 19.1% in low and middle countries. The
incidence rate in ICU is 51% in developed countries, 4.4% to 88.9% and 3 times
more for low and middle income countries. Nearly 3 out of 4 HAI in acute care
healthcare facilities are the result of one of the devices.
● Cost of HAI goes beyond the direct patient hospitalization costs and includes
o Patient extended or repeated hospitalization cost
o Income loss
o Disfigurement
o Disability
o Pain and suffering
o Death
o Loss of revenue
o Liability insurance
o Malpractice
o Reputation
WHY DO HAIs OCCUR IN A HEALTHCARE FACILITY (HCF)?

In any healthcare facility, the three elements (Figure 4) required to establish or
complete the chain of infection are present:
● the microbial agent in patient case or reservoir
● the susceptible host
● a means of transmission.
Figure 4. The THREE elements required for the HAI to occur
26
IPC HEALS
1) WHAT ARE THE MICROBIAL AGENTS? WHERE DO THEY COME
FROM IN A HEALTH FACILITY SETTING?
Sources of agents causing HAI
● Infections are usually from outside the body of the patient or from
EXOGENOUS sources
o Hands of healthcare worker is the MOST IMPORTANT SOURCE which
can be reduced
o Instruments/ Endoscopes
o Catheters
o Respiratory equipment
o Transfusion lines
o Intravenous systems
o Linen
o Air
● Infections can also come from the patient’s own microbial flora or called
ENDOGENOUS source
o Oropharynx
o Respiratory
o Gastrointestinal
o Skin
Table 1. Microorganisms frequently causing HAIs

Gram Negative Rods Gram Positive Cocci Others
Escherichia coli Staphylococcus aureus Fungi candida sp

Klebsiella sp. Staphylococcus epidermis Aspergillus sp.
Pseudomonas aeruginosa Enterococci Protozoans
Acinetobacter sp. Mycobacterium tuberculosis
Enterobacter sp. Anaerobes
2) WHO ARE THE SUSCEPTIBLE HOSTS?

All hospitalized patients can have HAIs but those with the following factors listed below
are at increased risk for HAI:
✓ Age – the very young and very old
✓ Immune deficiency states
• Malignancy
• Therapeutic measures
• Immunosuppression with steroids and other drugs
✓ Instrumentation / Diagnostic Procedures
✓ Surgery/ Operations/ Invasive Procedures
✓ Invasive devices
• Catheters and other foreign bodies
• Respiratory equipment
• Chronic underlying disease
• Diabetes
• COPD
• Chronic renal disease (Hemodialysis)
27 IPC HEALS
3) HOW DO THE MICROBIAL AGENTS REACH THE SUSCEPTIBLE HOSTS
AND CAUSE HAI? HOW ARE THEY TRANSMITTED?
Means of transmission of infection
✔ Contact Transmission: actual transfer the microbial agent by physical touching
of surfaces
• Direct-contact
– Direct body surface-to-body surface contact and
– Physical transfer of microorganisms between a susceptible host
and an infected or colonized person
• Indirect-contact
– Contact of a susceptible host with an intermediate object, usually
inanimate, such as contaminated instruments, needles, or
dressings, surfaces or contaminated hands or gloves
✔ Droplet Transmission: Droplets are large particles (larger than 5µm in size)
generated to the air from persons with respiratory and other infections during
coughing, sneezing, and talking or during procedures such as suctioning and
bronchoscopy
• Because droplets are big and heavy, they fall to the ground after a distance
of 3 feet or less; thus, transmission can only occur if there is close contact
between the source and the susceptible hosts
• Transmission may occur if the infectious droplets are deposited on the
susceptible host’s conjunctivae, nasal mucosa, or mouth or inhaled.
✔ Airborne Transmission
● Airborne transfer of small-particle residue (5µm or smaller) of evaporated
droplets containing microorganisms (TB, Measles, Varicella)
● These tiny droplets remain suspended in the air for long time periods
● Dispersed by air currents
● Transmission occurs if the infectious droplets are inhaled by a susceptible
host within the same room or over a longer distance
✔ Vector-borne Transmission
● Mechanical vector-borne transmission
– Agent does not multiply or undergo physiologic change in the vector
(transfusion, intravenous fluid, dengue, leptospirosis)
● Biologic vector-borne transmission
- Agent is modified within the host before being transmitted (malaria,
schistosomiasis)
To summarize the above concepts, the modes of transmission in hospital setting

are listed below:
Table 2. Mode of Transmission of HAI
MODE OF TRANSMISSION PROCESS EXAMPLES OF
INFECTIONS
CONTACT Physical contact with infectious Multidrug resistant organisms,
material most skin infections
DROPLET Inhalation or mucosal exposure Mumps, rubella, pneumonia,
of larger infectious droplets meningococcemia
28 IPC HEALS
AIRBORNE Inhalation of very small Tuberculosis,
infectious droplets measles, chickenpox
VEHICLES Through inanimate materials Infectious diarrheas,
like food, water, Intravenous bacteremias
fluid, medications
The chain of transmission is a very important concept and must become very clear to
healthcare workers. It can be shown through various diagrams such as in Figures 4, 5
and 6. The figures which follow below makes it easy to understand where prevention of
infection may be done to reduce risk for HAI.
Figure 5. The Transmission of Infection showing the Three Components

required for transmission to successfully occur.
On the other hand, the figure below is attractive to use as depicts the non-ending
circle of events creating the concept of a chain of infections.
29 IPC HEALS
Figure 6. The Chain of Infection in an unending cycle unless the factors
leading to infections are controlled or the chain is "broken".
Figure 7. Breaking the chain of infection
30 IPC HEALS
Thus, with Figure 7, it is easier to think of IPC as a structured program put in place to
address the components of the "Chain of Infection" so that the Chain is broken.
PREVENTION AND CONTROL OF HAI are directed to the various links of the chain
(breaking the chain) and include:
1. Elimination or containment of agents
2. Interrupting the transmission of infections
3. Protecting the host against infection and disease
It has been shown that approximately 30% of HAI can be prevented by applying
interventions that have been proven effective and are of low cost.
More recently there has been a paradigm shift on understanding of HAIs.

Whereas in the past HAIs were perceived to be inevitable consequences of
hospitalization, specially prolonged hospitalization, today HAI is considered an
undesirable outcome and always potentially preventable. An effective IPC
program in a healthcare facility can minimize transmission of infectious agents
and development of HAI during delivery of healthcare service.
For full details of Chapter 1, please see DOH IPC MANUAL FOR TRAINING:
MODULE Volume I for HEALTHCARE WORKERS.
WHAT IS THE ROLE OF THE HOSPITAL LEADER and

ADMINISTRATOR IN INFECTION PREVENTION AND CONTROL
(IPC)?
● In all the guidelines written to set up and build a sustainable IPC program,
Leadership Support is the imperative FIRST step.
● Without leadership support and buy-in, IPC efforts in a hospital may quickly go
down the list of priorities.
● Leadership has a direct impact on patient safety and quality of care.
o In most hospitals, programs that receive the visible support and buy-in of
administration are the ones that HCWs take the most seriously; therefore,
these programs are usually the ones that are the most successful.
● Healthcare administrators can actively support an IPC program through the
following actions:
o Allocating the necessary HCW time and resources. Hospital
administration should appropriate financial and resource support for
programs to reduce and prevent the acquisition and spread of infections—
especially health care–associated infections (HAIs). This may involve hiring
more staff or reallocating staff to areas, such as neonatal intensive care units,
in which high staff-to patient ratios help drive down infection rates.
o Allowing access to information. IPC work, in its task to truly analyze and
report infection rates, possible outbreaks, and other critical data points,
needs access to patient records and laboratory databases.
o Providing appropriate IPC equipment like personal protective equipment
(PPE), such as masks, gloves, and gowns; accessible sinks; alcohol-based
hand rub; sharps disposal boxes; and other safety equipment. Leaders
should encourage preference for equipment that can make tasks safer and
easier and can prevent and control infections.
31 IPC HEALS
o Actively supporting a multidisciplinary approach to IPC. This
collaboration may involve attending IPC committee meetings, encouraging
the use of multidisciplinary teams to examine and respond to particular IPC
issues, and allowing time for different disciplines to participate in
multidisciplinary teams.
o Serving as a role model. People imitate what they see. For example, if their
medical directors are practicing good hand hygiene, HCWs throughout the
hospital will be more likely to practice good hand hygiene as well.
Conversely, if leaders skip this critical activity, HCWs will see it is not a
priority and skip it themselves.
o Leadership should also communicate about specific goals and
initiatives and share results of performance improvement projects
related to IPC. HCWs benefit from knowing their roles in preventing the
transmission of infection and are motivated when they see results. When a
particular initiative reduces infection rates, for example, HCWs are more
likely to pay attention to the initiative, and compliance rates may go up.
In general, the hospital administrator/head of hospital has two main responsibilities

in IPC1 and these include:
● Establish an infection control committee (ICC) which will develop and
implement an Infection Prevention and Control program; and
● Provide adequate resources for effective functioning of the infection
control program.
Based on the epidemiology of infections in the healthcare setting, the need for an
infection prevention and control (IPC) program is clearly evident. Risk prevention for
patients and staff is a concern of everyone in the facility and must be supported by the
senior hospital administration.
The IPC program will emanate from the appointed ICC; these broad and very important
duties require members of the ICC to have the necessary knowledge, skills and
leadership abilities. Thus the administrator or head of institution must assure the
organization that the ICC he/she will form will be able efficiently and safely reduce the
risks of infections. He/she will need to choose the leader and members of this
committee. The first step which can pave the way to a successful IPC program is to
carefully put together a strong ICC.
WHAT ARE THE RESPONSIBILITIES OF THE INSTITUTIONAL

HEAD RELATED TO IPC?
As described in the Administrative Order 2016-00022, the head of every healthcare
facility shall be responsible for:
1. Organizing, monitoring and supporting the activities of the IPC Team which
shall implement the day-to-day requirements of IPC standards in the healthcare
facility;
2. Designate one most qualified infection control physician and at least one
infection control nurse as leaders of the IPC team.
3. Ensure that the IPC Team members are qualified, trained and/or certified in an
IPC training course accredited by DOH or other accrediting bodies.
4. Monitor or track records on IPC procedures and reports provided by the IPC
team;
5. Address efficiently and effectively all IPC concerns and the healthcare facility
level.
32 IPC HEALS
WHAT MUST THE HEAD OF HOSPITAL KNOW ABOUT THE IPC PROGRAM?
Details of the Infection Prevention and Control programs are described in other
modules. Enclosed below is are the key information in capsule format for hospital
administrators to understand the IPC Program:
1) WHAT SHOULD THE HOSPITAL ADMINISTRATOR LOOK FOR IN THE

HOSPITAL'S IPC PROGRAM?
In general, the IPC program must:
● Set relevant institutional objectives aligned with the mission, vision and other
objectives of the institution.
● Develop and continually update guidelines for recommended health
care surveillance, infection prevention, and best practices;
● Develop a hospital system to monitor selected infections and assess
● the effectiveness of interventions;
● Monitor, in particular, health-care associated infections (HAI) and to provide
feedback to the professionals concerned.
● Harmonize initial and continuing training program for all the health care
● professionals, trainees and students;
● Facilitate access to equipment, materials and products essential for proper
disinfection, hygiene and safety for all patients and healthcare workers and all
other institutional staff.
2) WHAT SHOULD THE HOSPITAL LEADER and ADMINISTRATOR EXPECT

FROM THE INFECTION CONTROL COMMITTEE?
Each health care facility's ICC needs to:
● Develop an IPC program to ensure the well-being of both patients and staff;
● Develop a work plan at least annually to assess and promote good health care;
● Implement an appropriate hand hygiene, isolation, disinfection and sterilization,
and other related system practices;
● Develop and update infection-related staff (including trainees and students)
training;
● Develop and implement epidemiological surveillance activities for relevant
infections and indicators;
● Create an information campaign related to reducing risk for infections for
patients and families
● Put in place a regular reporting relationship directly to either administration to
promote program visibility and effectiveness.
● In an emergency such as an outbreak, this committee must be able to
meet promptly and address current concerns in a timely fashion.
3) WHAT ARE THE BASIC COMPONENTS OF THE IPC PROGRAM WHICH

WOULD REQUIRE ADMINISTRATIVE SUPPORT FOR POLICY AND
RESOURCES?
The hospital administrator must provide manpower, logistical and budgetary
support and resources to the following components of the IPC program:
● Basic needs for the basic infection control procedures: such as hand hygiene
materials, rooms and protective personal equipment (PPE) for standard and
33 IPC HEALS
transmission-based precautions, equipment and supplies for environmental
disinfection, reprocessing/sterilization of instruments, and other similar needs.
● Hospital-wide programs such as antimicrobial stewardship, waste management,
blood and body fluid exposure, and similar programs;
● Production and dissemination of the IPC manual and its updates;
● Appropriate education and training of infection control and safety management
of health care workers;
● Protection of health care workers, e.g. immunization and provision of PPEs;
● Institutional preparation for emerging infections;
● Surveillance for relevant outcomes such as HAI, antimicrobial resistance (AMR)
and antimicrobial usage (AMU);
● Outbreak investigation; and
● Research
4) WHO SHOULD THE HOSPITAL ADMINISTRATOR APPOINT TO COMPRISE

THE HOSPITAL'S ICC AND IPC TEAM?
a) Infection Control Committee

The hospital's Infection Control Committee is multidisciplinary and include a wide
representation from the following but not limited to these relevant departments:
● Administration; executive offices or hospital management
● Physicians including representatives of all clinical departments
● Nursing
● Other health care workers
● Clinical microbiologist
● Pharmacist
● Central supply staff
● Maintenance personnel
● Housekeeping
● Training services
● Engineering
● Students
b) ICC Chair and Leadership

Leading the ICC is the Chairperson who is appointed by the Hospital Administrator.
Recommendations from various hospital experiences2,3,4,5 include the following
criteria and special tasks of the ICC chairperson as follows:
● The ICC Chair should have direct access to the head of the hospital
administration;
● Best that the ICC Chair is an infection control practitioner or health care worker
trained in the principles and practices of infection control (this could be a
physician, a microbiologist or a registered nurse)
c) IPC Team
On the other hand the IPC Team is the smaller team within the ICC and has the
following responsibilities:
● The infection control team is responsible for the day-to-day activities of the IPC
program.
● The IPC Team must develop and update a hospital's IPC Manual containing all
34 IPC HEALS
instructions and practices for safe patient care and have this approved by the
ICC; the IPC manual must be made readily available for healthcare workers and
updated in a timely fashion.
● The IPC team collects and reviews epidemiological surveillance data and
identify areas for intervention;
● Continuously assesses and promotes improved IPC practice at all levels of the
health facility;
The AO 2016-0002 has the following guides on the staffing of the IPC Team:
● Staffing - There shall be at least one (1) infection control nurse (ICN) and one (1)
infection control doctor (ICD) in every hospital facility. The ratio of at least 1
fulltime ICN for every 100 hospital beds shall be recommended by the DOH to
the Department of Budget and Management, with the number of ICNs increasing
according to capacity, resources, types of cases/services and needs of the
healthcare facility. Outpatient clinics, including those with limited lying-in
facilities, shall designate one IPC officer, preferably, a nurse.
5) WHAT ARE THE OTHER RESOURCE NEEDS THE ICC AND IPC TEAM
WOULD NEED FROM HOSPITAL ADMINISTRATION?
Best practices from the Ontario Provincial Infectious Diseases Advisory Committee
included in its recommendations IPC needs which are similarly relevant to Philippine
healthcare settings.
Administrative Support for IPC Programs:

a) Material Resources
Healthcare settings should provide material resources to support the IPC
program. This should include:
● Sufficient-sized, suitably located office space and equipment, including
furniture and lockable filing cabinets for confidential records in order to
protect the privacy of individual clients/patients/residents
● Communication tools sufficient to support the program (at minimum this
should include telephone, pager, fax and copying services, and basic office
supplies)
● Access to a laptop and data projector for educational presentations.
b) Information Technology Resources

The IPC program requires:
● A computer system that includes a password-protected desktop or laptop
computer and a printer
● A word processing, presentation and spreadsheet software and training
including the ability to generate statistical reports
● An access to the electronic record, preferably through direct linkages to
health information systems
● Resources that enable access or linkages to other health information
systems and programs
● Internet access, including electronic mail.
c) Education Resources and Activities

Maintaining current educational resources is essential for the IPC program in
order to develop policies and guidelines, participate in professional
organizations and serve as an educational resource for IPC and health care
35 IPC HEALS
epidemiology.
The IPC program must have an annual budget allocated to the provision and
maintenance of current educational resources
6) WHAT IS THE LEGAL BASIS FOR THE VITAL ROLE AND

RESPONSIBILITIES OF THE HOSPITAL HEAD IN IPC?
The Administrative Order 2016-002 (Appendix A) contains all the necessary articles to
support the hospital administrator. Under "Funding Mechanism" is the following:
"Healthcare facilities and their administrative arm shall allocate budget for the
implementation of their respective IPC programs. This shall be included in their
respective annual budget. The allocation may be for the following items: payment of
salaries and allowances for infection control personnel and committees, training,
monitoring and travel, hand hygiene supplies, isolation room requirements, and other
requirements for the essential procedures prescribed in the technical guidelines and
enabling mechanisms."
7) WHAT MAY HAPPEN IN THE EVENT SUPPORT FOR IPC FROM HOSPITAL
ADMINISTRATION IS NOT ENOUGH?
The Joint Commissions International cited the three most common causes of a non-
performing IPC program5 and eludes to the point that two of these 3 causes can be
traced back to an unsupportive hospital administration. JCI identifies the following
reasons why IPC programs may not produce desired results:
● Lack of knowledge (staff do not know how to perform the task correctly, or they
do not understand the policy or process or why it is important).
● Inadequate system support, such as lack of equipment or supplies or barriers to
getting or using the equipment or supplies (staff members know how to do the
task, but the equipment or supplies do not support the task or are unavailable
or do not work) or other barriers in the system preventing the desired behavior.
● Lack of motivation or management reinforcement to perform the task correctly
(staff members know how, and equipment or supplies are appropriate, but they
still do the task incorrectly).
Figure 8. Snapshot of JCAHO international standards indicating Hospital

Leadership to provide resources to support IPC program.
KEY MESSAGES FOR CHAPTER:
36 IPC HEALS
CHAPTER REFERENCE:
1. World Health Organization. Practical Guidelines for Infection Control in Health Care
Facilities 2004 SEARO Regional Publication No. 41.
2. Department of Health. Administrative Order 2016-0002 " National Policy on Infection
Prevention and Control in Healthcare Facilities" signed 08 January 2016
3. Joint Commission International. Risk Assessment for Infection Prevention and Control.
2010 USA
4. Ontario Agency For Health Protection and Promotion. Provincial Infectious Diseases
Advisory Committee. Best Practices for Infection Prevention and Control Programs in
Ontario in Health Care Settings 3rd edition. Toronto, ON: Queen’s Printer for Ontario;
May 2012.
5. Rosenthal VD. Epidemiology and control of healthcare-acquired infections in limited-
resource settings (chapter 18). In: Jarvis WR, editor. Bennett & Brachman’s hospital
infections. 6th ed. Philadelphia: Wolters Kluwer. Lippincott & Wilkins; 2014. p. 230–75.
37 IPC HEALS
CHAPTER 2
BURDEN OF HAI IN SOUTHEAST ASIA and the
PHILIPPINES
Regina P. Berba MD MSc
LEARNING OUTCOMES:
At the end of this chapter, the healthcare facility leader and administrator should
be able to:
1) describe the heavy burden of HAI in Southeast Asia and the Philippines;
2) determine how hospital management can support its IPC program.
38 IPC HEALS
CHAPTER SUMMARY:
WHAT MUST HEALTHCARE ADMINISTRATORS KNOW AND DO

TO REDUCE THE BURDEN OF HAI IN HIS/HER FACILITY?
In many countries across the world, the rate of HAIs has emerged as one of the leading
markers of quality of clinical care and patient safety. Infection control underpins 'safe
and sound' clinical practice and requires attention to certain details. While the ultimate
responsibility for the prevention and control of HAI lies with each and every healthcare
practitioner, it is considered equally vital and good hospital management when
administration take the lead role of raising awareness to the problem and making
all individuals, teams, sections, and departments own up responsibility. Lack of
institutional leadership or lack of an existing IPC program to deal with avoidable
infection risks perpetuates the culture of acceptance that HAIs are inevitable
consequences of usual healthcare practices. Since the start of the 21st century, HAIs are
now considered unnecessary adverse events as they are preventable with proper
healthcare worker behavior and compliance with evidence-based infection prevention
procedures and guidelines. There is no more excuse to poor patient safety hospital
procedures and policies.
Thus in many countries, safeguarding patients and healthcare worker staff from the risk
of avoidable HAIs has been made a statutory responsibility of the hospital management.
It has been seen that in the developed countries where resources are not limited and
the setting is ideal for practicing IPC optimally, it is possible to lower the HAI rates only
when infection control is accepted as a core corporate and individual
responsibility by both the management and clinical staff facilitated by an IPC
team under a formal institutional program. The ICT is a source of expert knowledge
and guidance but the responsibility must lie with all the health professionals led by
hospital management. It is also a requirement that the effort to combat HAIs is whole
heartedly backed by the management and made a priority and a core standard to be
achieved.
Additionally, whatever the paying mechanisms are, whether government funds are used
in public hospitals, or Health Maintainance Organizations(HMOs), or the national
insurance (Philhealth) or out of pocket from the patients or his family, HAIs are great
financial burdens to the payors. Thus investments in IPC can lead to institutional
savings.
CHAPTER REFERENCES
1. Moi Lin Ling, Anucha Apisarnthanarak and Gilbert Madriaga. The Burden of Healthcare-Associated Infections
in Southeast Asia: A Systematic Literature Review and Meta-analysis. Clinical Infectious Diseases
2015;60(11):1690–9.
39 IPC HEALS
2. Rosenthal VD. Health care-associated infections in developing countries. The Lancet 15-21 January 2011;
377(9761):186-188.
3. World Health Organization. The Burden of Healthcare-associated Infection Worldwide: A Summary 2010.
4. Rosenthal VD, Bijie H, Maki DG. International Nosocomial Infection Control Consortium (INICC) report, data
summary of 36 countries, for 2004–2009. Am J Infect Control 2012; 40:396–407.
5. Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, Pittet D. Burden of endemic
health-care associated infections in developing countries: systematic review and meta-analysis. Lancet.
2011;377:228–41.
6. World Health Organization. Report on the burden of endemic health-care associated infection worldwide.
2011. Available at: http://apps.who.int/iris/bitstream/10665/80135/1/9789241501507_eng.pdf
7. Vilar-Compte D, Camacho-Ortiz A, Ponce-de-León S Infection Control in Limited Resources Countries:
Challenges and Priorities. Curr Infect Dis Rep. 2017 May;19(5):20. doi: 10.1007/s11908-017-0572-y.
8. Navoa-Ng JA, RBerba, YA Galapia, VD Rosenthal, VD Villanueva, MC Tolentino, GAS Genuino, RJ Consunji and
JBV Mantaring. Device-associated infections rates inadult, pediatric, and neonatal intensive care units of
hospitals in the Philippines: International Nosocomial Infection Control Consortium (INICC) findings. Am J
Infect Control 2011;39:548-54.
9. Navoa-Ng JA, RBerba, YA Galapia, VD Rosenthal, VD Villanueva, MC Tolentino, GAS Genuino, RJ Consunji and
JBV Mantaring. Impact of an International Nosocomial Infection Control Consortium multidimensional
approach on catheter-associated urinary tract infections inadult intensive care units in the
Philippines:International Nosocomial Infection ControlConsortium (INICC) findings. Journal of Infection and
Public Health (2013)6: 389—399.
10. Berba R, M Alejandria, I Reside, J Rosaros, C Ang, JChavez and MMendoza. Incidence, risk factors and outcome
of hospital-acquired pneumonia in critically-ill patients at the Philippine General Hospital. Philippine Journal
of Microbiology and Infectious Diseases. April-June 1999; 28(2) : 29-38.
11. Florentino MM, VRde Jesus. AR Bandola, MR Festin. Risk factors for post-cesarean section surgical site
infections among patients in the Philippine General Hospital: A case control study. Philippine Journal of
Surgical Specialties April-Jun 2009;64(2): 49-54
12. Zanoria BF and RG Kangleon Jr Surgical Wound Infection in a Community Hospital: a Cohort study. Philippine
Journal of Surgical Specialties 2004 Apr-Jun 59(2): 63-68.
13. Cabaluna ND, GB Uy, RM Galicia, SC Cortez, MDS Yray, BS Buckley. A Randomized, Double-blinded Placebo-
controlled Clinical Trial of the Routine Use of Preoperative Antibiotic Prophylaxis in Modified Radical
Mastectomy World Journal of Surgery January 2013, 37(1) Issue 1: 59–66.
14. The Joint Commission. Preventing Central Line–Associated Bloodstream Infections: Useful Tools, An
International Perspective. Nov 20, 2013. Accessed [user please fill in access date].
http://www.jointcommission.org/CLABSIToolkit
15. Salamat S, RBerba. Invasive Device-related Infections in Critically Ill Patients. Philippine Journal of
Microbiology and Infectious Diseases 2004; 34(1): 5-18.
16. Billote-Domingo K, Mendoza MT, Torres T. Catheter-related Urinary Tract Infections: Incidence, Risk Factors
and Microbiologic Profile. Phil J Microbiol Infect Dis. 1999;28(4):133-8
17. Alavaren HF, JA Lim, MAVelmonte, MT Mendoza. Urinary Tract Infection in Patients with Indwelling Catheters.
Phil J Microbiol Infect Dis 1993; 22(2):65-74.
18. Gill CJ1, Mantaring JB, Macleod WB, Mendoza M, Mendoza S, Huskins WC, Goldmann DA, Hamer DH. Impact of
enhanced infection control at 2 neonatal intensive care units in the Philippines. Clin Infect Dis. 2009 Jan
1;48(1):13-21. doi: 10.1086/594120
19. Bontile H. "Performance of DOH-Retained Hospitals in the Philippines" Discussion Paper Series No. 2013-36.
Philippine Institute for Development Studies, July 2013 http://www.pids.gov.ph
40 IPC HEALS
41 IPC HEALS
CHAPTER 3
HAND HYGIENE: H of HEALS
Regina Berba MD MSc
LEARNING OUTCOMES
At the end of this chapter the health facility leader and administrator should be able to
1. State the importance of hand hygiene (HH) as one of the most critical
infection control measures in healthcare;
2. List the Five Moments of Hand Hygiene;
3. Perform the proper steps of Hand Hygiene;
4. Identify how hospital administration can support HH initiatives.
This chapter is written according to the recommendations of the WHO1 in formulating

training programs for hand hygiene.
WHAT IS HAND HYGIENE (HH)?

Hand hygiene refers to the general term referring to any action of hand cleansing. Hand
hygiene is performed to reduce or inhibit the growth of microorganisms by the
application of an antiseptic handrub or by performing an antiseptic handwash.
In the healthcare setting, HAND HYGIENE refers to any action performed by

the HCW to make hands clean before, during and after caring for patients.
HH is considered to be the MOST important pillar of IPC.
o
Created by:
Jesus VILLEZA, Albert YAP, Celina YAP
of UPCM Class 2018
Figure 9. A patient carrying various organisms on her skin as represented

by colored dots.
42 IPC HEALS
● Organisms are present on patient skin or the immediate environment.
● A bedridden patient is shown in Figure 8, 9, 10 (represented by the
orange dots).
● Some environmental surfaces close to the patient are contaminated with
bacteria, presumably shed by the patient.
● As the HCW holds the patient’s hands there is transmission of
microorganisms from the patient’s own flora transfer to HCW’s hands as
seen in Figure 9.
● Figures 10-11 shows survival of the organism on HCW hands.
● Figure 12-13 shows movement of the organisms (orange dots) to other
patients through the HCW hands.
Figure 10. Illustration of organisms ( colored dots) transferred from

patient to HCWs’ hands as the HCW touches the hands of the patient.
Figure 11 Organism surviving in HCWs Figure 12. Organisms may grow and
hands multiply in HCWs hands.
43 IPC HEALS
Figure 13. The HCW is seen to get the organisms from Patient A onto his
hands.
Figure 14. HCW moves from Patient A to Patient B without doing HH. Thus
also transmitting the organisms from Patient A to Patient B. Follow the colored
dots.
44 IPC HEALS
Figure 15. The HCW can also cause within-patient cross-transmission. The
HCW is seen touching the urinary catheter bag (with colored rod-shapes from
urine) first then the same unclean hands now holds the patients hands.
IS THERE EVIDENCE that would LINK HCW HANDS AND HAIs?
There is abundant data on this.

The local data observed at the Philippine General Hospital demonstrated that
HAIs go up whenever the alcohol supply runs out. These are the data shown
below:
Figure 16. Marked rise in HAI when alcohol supplies ran out because of
institutional purchase problems. The blue bars are the low endemic HAI rates.
45 IPC HEALS
Courtesy of PGH HICU Data)
Figure 17. HAI rates seen to increase in ICUs when stocks of hand
sanitizers ran out. Courtesy of PGH HICU data files.
WHAT IS THE CURRENT BEST STRATEGY TO OPTIMIZE HAND HYGIENE?

My Five Moments of Hand Hygiene: the WHO Multimodal Hand Hygiene
Strategy
The 5 MOMENTS OF HAND HYGIENE was formulated to:

1) foster positive outcome evaluation by linking specific hand hygiene actions to
specific infectious outcomes in patients and HCWs (positive outcome beliefs);
2) increase the sense of self-efficacy by giving HCWs clear advice on how to
integrate hand hygiene in the complex task of care (positive control beliefs).
The 5 Moments concept is likely to be more effective by being practical and easy to
remember, compatible with the existing perception of microbiological risk, simple and
straightforward, and specifically tailored to be observable.
The fact that the concept uses the number 5 like the five fingers of the hand gives it a
‘stickiness factor’ the capacity to “stick” in the minds of the target public and influence
its future behavior.
46 IPC HEALS
Figure 18: The Five Moments of Hand Hygiene from the WHO 2009.
WHAT ARE "THE FIVE MOMENTS OF HAND HYGIENE"?

The Five Moments of Hand Hygiene tells us the most important times we need to do
hand hygiene during any patient-healthcare worker encounter. It’s the "bottom line"
when the indication to do Hand Hygiene is absolutely critical, and non-compliance may
lead to increase in the risk of the development of HAI.
Moment 1. Before touching a patient

● Upon entry into the patient's defined zone and before touching the patient,
HH should be performed.
● HH in Moment 1 will mainly prevent colonization of the patient with health
care-associated microorganisms, resulting from the transfer of organisms from
the environment to the patient through unclean hands
● The most common example for Moment 1 is: the potential load of organisms
transferred from touching the door handle upon entering the room of the
patient. HH must be done just before touching the patient.
● The HH agent must be just beside the patient very near the patient's zone, and
not outside the patient's room or the nurses' station because there are
potentially many objects and equipment that can touch the hands of the HCW
before he/she gets to the patient's zone.
47 IPC HEALS
Moment 2. Before a clean/aseptic procedure
● Clean or aseptic procedure carries a risk for HAI if not done properly. These
include procedures like inserting intravenous access line, giving an injection, or
performing wound care.
● If several tasks will be done on a patient when the HCW is inside the patient
zone, HH should still be performed just before the specific aseptic procedure.
This is important because HCWs customarily touch another surface within the
patient zone before contact with a critical site with infectious risk for the patient
or a critical site with combined infectious risk.
● For some tasks on clean sites (lumbar puncture, surgical procedures, tracheal
suctioning, etc.), the use of gloves is standard procedure. In this case, hand
hygiene is required before donning gloves because gloves alone may not
entirely prevent contamination.
Moment 3. After body fluid exposure risk

● After a care task associated with a risk to expose hands to body fluids, e.g. after
accessing a critical site with body fluid exposure risk or a critical site with
combined infectious risk (body fluid site), hand hygiene is required instantly
and must take place before any next hand-to-surface exposure, even within the
same patient zone.
● This Moment 3 HH action has a double objective. First and most importantly, it
reduces the risk of contamination of HCWs with infectious agents that may
occur even without visible soiling. Plus, it reduces the risk of a transmission of
microorganisms from a “colonized” to a “clean” body site within the same
patient.
● Disposable gloves are meant to protect exposure of hands to body fluids.
However, hands are not sufficiently protected by gloves.
● HH is strongly recommended after glove removal.
Moment 4. After touching a patient

● When leaving the patient zone after a care sequence, HH should be performed
this time to minimize the risk of dissemination to the health-care environment
any contamination of the HCWs’ hands with the flora from patient
● HH at Moment 4 also protects the HCWs themselves.
Moment 5. After touching patient surroundings

● The fifth moment for hand hygiene is a variant of Moment 4: it occurs after hand
exposure to any surface in the patient zone but without touching the patient.
This usually refers to objects contaminated by the patient flora that are
extracted from the patient zone to be decontaminated or discarded.
● These may include touching the bedrails, fixing the mechanical ventilator
tubings, assisting the patient with his/her equipment and so on.
HOW DO WE ORGANIZE OUR HEALTH INSTITUTIONS TO IMPLEMENT A

HAND HYGIENE PROGRAM?
Be guided by the core components listed in Table 4 which provides assistance to ICCs
on step-by-step requirements for a successful infection control program. Additionally,
48 IPC HEALS
listed in the Table 5 below are additional implementation strategies which have been
seen to work in different settings including local scenarios seen in the Philippines
Table 3. STEP-BY-STEP STRATEGIES NECESSARY TO SET-UP A HAND HYGIENE

PROGRAM IN A HEALTH FACILITY.
INSTITUTIONAL STRATEGY Specific Actions for the Infection Control Committee
SYSTEM CHANGE Make hand hygiene possible, easy and convenient.
Make alcohol-based handrub available at bedside
Make water and soap always available at the nurses’ station and
other critical areas
Put HH reminders
HAND HYGIENE Serial and repeated educational activities
EDUCATION The more creative the educational style, the better, i.e., use
hospital celebrations as opportunities for dissemination.
Schedule a HH event on May 5 or October (Global Handwashing
Day) of every year.
Look for champions or link nurses to continue the HH education
in the various areas of the health facility.
PROMOTE SKIN CARE FOR Choose HH products according to prescribed as well as users
HCW HANDS feedback.
ROUTINE OBSERVATION Organize a system for identified personnel to do routine HH
AND FEEDBACK observations at various times of the workshifts.
Schedule to give feedback to the different clinical areas to advise
them on the most recent HH compliance rates.
REMINDERS IN THE May be in the form of visual cues (posters or pop-up reminders
WORKPLACE in the institutions computer system), or auditory (repeated
reminders given through the overhead public address system
IMPROVE INSTITUTIONAL Promote active participation at the individual, departmental and
SAFETY CLIMATE institutional levels
Avoid and address patient overcrowding, understaffing and
excessive workload
Institute administrative sanction and/or rewards for HH
Ensure patient empowerment to allow them to remind their
doctors and nurses on HH when caring for them
Table 4. Requirements to set the stage for an Effective HH Program

MULTIMODAL STRATEGY MINIMUM CRITERIA FOR
IMPLEMENTATION
1A. System Change: Alcohol-based Bottles of alcohol-based handrub positioned at
Hand rub must become available the point of care at the wards or given to the
staff
1B. System Change: Access to Safe One sink to at least every 10 beds
Continuous water supply and towels Soap and fresh towels at every sink
2. Training and Education All staff must receive training.
Two periods of observational monitoring
3.. Observations and Feedback
49 IPC HEALS
"How to" and "5 Moments" posters are
4. Reminders in the Workplace displayed in all the wards, patients’ rooms, staff
areas and outpatient departments.
The Chief Executive, Chief Medical Officer and
5. Institutional Safety Climate Chief Nurse all make a visible commitment to
support the institutions' HH program.
Furthermore the same WHO Guidelines include in its recommendations the

following "Institutional Responsibilities"
For health-care administrators (Section 9.1 WHO 2009 HH Guidelines p 162)

1. It is essential that administrators ensure conditions are conducive to the
promotion of a multifaceted, multimodal hand hygiene strategy and an
approach that promotes a patient safety culture by implementation of
points B–I below.
2. Provide HCWs with access to a safe, continuous water supply at all
outlets and access to the necessary facilities to perform handwashing (IB).
3. Provide HCWs with a readily accessible alcohol-based handrub at the
point of patient care (IA)
4. Make improved hand hygiene adherence (compliance) an institutional
priority and provide appropriate leadership, administrative support,
financial resources, and support for hand hygiene and other infection
prevention and control activities (IB).
5. Ensure HCWs have dedicated time for infection control training,
including sessions on hand hygiene (II).
6. Implement a multidisciplinary, multifaceted and multimodal program
designed to improve adherence of HCWs to recommended hand hygiene
practices (IB).
7. With regard to hand hygiene, ensure that the water supply is physically
separated from drainage and sewerage within the health-care setting,
and provide routine system monitoring and management (IB).
8. Provide strong leadership and support for hand hygiene and other
infection prevention and control activities (II).
9. Alcohol-based handrub production and storage must adhere to the
national safety guidelines and local legal requirements (II).
50 IPC HEALS
CHAPTER REFERENCES:
1. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First
Global Patient Safety Challenge Clean Care is Safer Care 2009 Geneva WHO Press.
2. Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care
settings: recommendations of the healthcare infection control practices advisory
committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task
force. MMWR. 2002;51(RR16):1–56.
3. Mehta, Yatin, Abhinav Gupta, Subhash Todi, SN Myatra, D. P. Samaddar, Vijaya
Patil, Pradip Kumar Bhattacharya, and Suresh Ramasubban . Guidelines for prevention
of hospital acquired infections. Indian J Crit Care Med 2014 Mar 18)3): 149-163.
51 IPC HEALS
Created by:
Anton URTULA
of UPCM Class 2021
52 IPC HEALS
CHAPTER 4
ENVIRONMENTAL CARE and DISINFECTION IN

HEALTHCARE FACILITIES: E OF HEALS
Dominga C. Gomez RN
LEARNING OUTCOMES:
At the end of this chapter, the healthcare administrator or the officer-in-charge
should be able to:
1) Characterize factors in the hospital environment which increases risk for
infections to patients and healthcare workers;
2) List the new updated environmental care practices and integrate them to
current hospital practices;
3) Identify effective cleaning and sterilization techniques for reprocessed hospital
equipment and instruments;
4) Name areas of improvement in the immediate hospital environment to prevent
transmission of infections.
A. ENVIRONMENTAL CLEANING AND DISINFECTION
WHY IS ENVIRONMENTAL CARE OF HEALTHCARE FACILITIES VALUABLE IN

INFECTION CONTROL?
• Microorganisms proliferate in the environment wherever dust, air and water are
present.
• They are present in great number in moist organic environments but some can also
persist in dry environment, i.e. gram negative and gram positive bacteria.
• The healthcare environment contains a diverse population but only a few are
significant pathogens for susceptible humans.
• All invasive procedures involve contact between device and patients’ sterile tissue or
mucus membrane. The surfaces in the hospital environment can also be frequently
contaminated by the patients and healthcare workers themselves which can be
sources of cross infection and major risks to susceptible hosts if proper cleaning
disinfection and sterilization is not instituted. Healthcare policies and guidelines are
very essential and should be established for the judicious selection and proper use of
disinfection and sterilization process based on the results of well-designed studies
assessing the effectiveness studies.
• An solid understanding of how infection occurs after exposure, based on the

principles of “Chain of Infection“ and how important it is to appreciate the role of
environment in the development of HAIs (Chapter 1) makes IPC champions more
effective.
• The transfer of microorganisms is mostly through the hands of HCWs.
53 IPC HEALS
• Proper cleaning, disinfection and sterilization is one of the most effective ways of
disrupting the transmission and spread of microorganisms in the healthcare setting.
● The environment can be the reservoir of sources of infections in the

healthcare setting. Thus maintaining the hospital environment "hospital
clean" should be a basic thrust of any IPC program.
● This chapter describes best practices in routine cleaning and
decontamination in healthcare facilities as well as some specific concerns.
● It lists recommendations for the implementation of environmental hygiene
program to keep the environment safe for patients, staff and visitors visiting
a healthcare facility.
● Objective assessment of cleanliness and quality is an essential component of
this program as a method for identifying quality improvement opportunities.
● A training program to relevant health professionals is vital to ensure
consistent adherence to best practices.
HOW SHOULD HOSPITAL ADMINISTRATORS SUPPORT THE IPC PROGRAM

ON ENVIRONMENTAL DISIINFECTION?
Hospital administrators should provide full support of the needs related to

environmental disinfection as this comprises a vital pillar of IPC.
Support must include:
1) MANPOWER RESOURCES
● Assure enough manpower compliment according to the facility needs of
the following departments:
54 IPC HEALS
o Housekeeping
o Laundry
o Central Supply Services
o Dietary
2) MATERIAL RESOURCES
● Assure that mechanisms are in place for continuous supply of
appropriate disinfectants and other cleaning needs; as well as personal
protective equipment (PPE) for the cleaning staff;
● Maintenance and upgrade of equipment for sterilization and disinfection
3) INTERDISCIPLINARY LINKAGES
● Include the ICC in major and minor decisions related to IPC such as
o choice, bidding and purchases of disinfectants and similar
chemicals
o purchases of hospital furniture and equipment that these can be
satisfactorily be maintained and cleaned in a hospital environment;
o construction of new buildings and renovations of existing ones
4) TRAINING NEEDS of above manpower for continuing education at regular
intervals
CHAPTER REFERENCES
1) Centers for Disease Control and prevention Healthcare Infection Control practice Advisory
Committee (HICPAC) Guidelines for Environmental Infection Control in Healthcare
Faciltities updated Feb 15, 2017.
2) Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases
Advisory Committee. Best Practices for Environmental Cleaning for Prevention and
Control of Infections in All Health Care Settings. 2nd Revision. Toronto, ON: Queen’s
Printer for Ontario; 2012.
3) Ling Moi Lin, AApisarnthanarak, LTAThu, VVillanueva, CPandjaitan, MYYusof. APSIC
Guidelines for Environmental Cleaning and Decontamination. Antimicrobial Resistance
and infection Control (2015) 4:58.
4) Rutala WA, Weber DJ, HICPAC, Guideline for Disinfection and Sterilization in Healthcare
Facilities 2008 Available from:
https://www.cdc.gov/infectioncontrol/guidelines/disinfection/
5) Reprocessing medical devices in health care settings: validation methods and labeling
guidance for industry and Food and Drug Administration staff. U.S. Department of Health
and Human Services Food and Drug Administration Center for Devices and Radiological
Health Office of Office of Device Evaluation.
(http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/Guidance
Documents/UCM253010.pdf
6) Quinn MM, PK Henneberger, National Institute for Occupational Safety and Health (NIOSH).
Cleaning and Disinfecting Environmental Surfaces in Healthcare: Toward an Integrated
Framework for Infection and Occupational Illness Prevention. American Journal of
Infection Control 43(2015): 424-34.
7) Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R, Fields B,
McNeil MM, Whitney C, Wong S, Juranek D, Cleveland J. Guidelines for environmental
infection control in health-care facilities. Recommendations from CDC and the Healthcare
Infection Control Practices Advisory Committee (HICPAC). Chicago IL; American Society for
Healthcare Engineering/American Hospital Association; 2004.
8) Department of Health Manual for Healthcare Management 3rd ed. 2012.
9) World Health Organization, Practical Guidelines for Infection Control 2004.
http://www.wpro.who.int/publications/docs/practical_guidelines_infection_control.pdf
55 IPC HEALS
Created by:
DeCastro,Obenieta,Ragasa,
Sucor,Tangkusan,Tuason
of UPCM Class 2018
56 IPC HEALS
CHAPTER 5
ISOLATION PRECAUTIONS and PERSONAL PROTECTIVE

EQUIPMENT
Alex P. Bello MD
LEARNING OUTCOMES:
At the end of the chapter, the healthcare administrator should be able to:
1. List the needs of the hospital for appropriate isolation precaution and use
of personal protective equipment according to the type of infection of the
patient.
2. Identify how the hospital administration can support the above identified IPC
needs
WHAT ARE ISOLATION PRECAUTIONS?
Isolation Precautions
have been defined by the US Centers of Disease Control and the HICPAC as
the systematic processes which comprise the essential factors in achieving
effective interruption in nosocomial transmission of infectious agents.
STANDARD PRECAUTIONS
are precautions used for all clinical situations involving ALL
patients to minimize exposure to blood-borne pathogens from
all patients, not just patients with a diagnosis or suspected
diagnosis of HIV infection.
The term STANDARD PRECAUTIONS superceded the old term
Universal Precautions.
Other Isolation Precautions are transmission -based on
depends on the type of infection present in the patient. These
includes:
AIRBORNE, DROPLET and CONTACT
Personal Protective Equipment or PPE

refers to the various forms of barriers used alone or in combination to
protect the health care workers from contact with infectious agents. The
selection of PPE is based on the nature of the HWC task and/or the likely
mode(s) of transmission.
● The powerful combination of standard precautions and isolation procedures

epitomize vital component of IPC in the control and prevention of healthcare
associated infections.
57 IPC HEALS
CHAPTER REFERENCES:
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices
Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html or
https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf. Last
updated October 2017.
58 IPC HEALS
CREATED BY:
Ria Edeliza IMPERIAL, Krizzia Rae JABONILLO, Michelle Ann LAO
Azalea LAQUI, Dominic Leandro MILLA, Jaime Antonio YU
of UPCM Class 2018
59 IPC HEALS
CHAPTER 6
BATTLE AGAINST ANTIMICROBIAL RESISTANCE:

A of HEALS
Ma. Nicolette M. Mariano MD
LEARNING OUTCOMES
At the end of the chapter the healthcare administrator should be able to:
1. Define what a multidrug resistant organism (MDRO) is;
2. Recognize the burden of antimicrobial resistance (AMR) in the Philippines;
3. Describe trends in Antimicrobial resistance of common organisms causing
infections in the Philippines;
4. Identify what measures could be done to address the problem of AMR.
5. Identify how hospital administration can support the IPC to control and
prevent MDROs in the facility.
WHAT ARE MULTIDRUG RESISTANT ORGANISMS or MDROs?
Multidrug resistant organisms (MDROs). Bacteria resistant to one or

more classes of commonly used antimicrobial agents, such as methicillin
resistant Staphylococcus aureus (MRSA), vancomycin resistant enterococcus
(VRE), multidrug resistant gram negative bacilli (extended spectrum beta
lactamase (ESBL) producing organisms and MDRO Acinetobacter baumannii
and Pseudomonas aeruginosa) and carbapenem resistant enterobacteriaceae
(CRE).
Administrative
Measures
General
Decolonization MDRO Education
Recommen
dations
Environmental Judicious
Measures for Antimicrobial
Use
Routine
Prevent
Infection Control
Surveillance
Precautions
Figure 19. Interventions for Prevention and Control of MDROs in Healthcare
60 IPC HEALS
Settings
WHAT CONTROL INTERVENTIONS ARE RECOMMENDED FOR MDROs?
1. Administrative Measures
2. MDRO Education
3. Judicious Antimicrobial Use
4. Surveillance
5. Infection Control Precautions to Prevent Transmission
6. Environmental Measures
7. Decolonization
CHAPTER REFERENCES:
1. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices
Advisory Committee. Management of multidrug-resistant organisms in healthcare settings,
2006. Available at https://www.cdc.gov/mrsa/pdf/mdroguideline2006.pdf. Accessed 18
September 2017
2. Antimicrobial Resistance Surveillance Reference Laboratory. Antimicrobial Resistance
Surveillance Program 2017 Data Summary Report.
3. Backman C, Taylor G, Sales A, Marck PB. An integrative review of infection prevention and
control programs for multidrug-resistant organisms in acute care hospitals: a socio-
ecological perspective. Am J Infect Control. 2011 Jun;39(5):368-78.
4. Aureden K, Arias K, Burns LA, et al. APIC 2010 Guide to the Elimination of Methicillin-
Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings, 2nd Edition.
Available at http://www.apic.org/Resource_/EliminationGuideForm/631fcd91-8773-4067-
9f85-ab2a5b157eab/File/MRSA-elimination-guide-2010.pdf. Accessed 18 September 2017
5. Calfee DP, Salgado CD, Milstone AM, et al. Strategies to Prevent Methicillin-Resistant
Staphylococcus aureus Transmission and Infection in Acute Care Hospitals: 2014 Update.
Infection Control and Hospital Epidemiology, Vol. 35, No. 7 (July 2014), pp. 772-796
6. Ridenour G, Lampen R, Federspiel J, et al. Selective use of intranasal mupirocin and
chlorhexidine bathing and the incidence of methicillin-resistant Staphylococcus aureus
colonization and infection among intensive care unit patients. Infect Control Hosp Epidemiol
2007; 28:1155-1161
61 IPC HEALS
62 IPC HEALS
CHAPTER 7
ANTIMICROBIAL STEWARDSHIP: A of HEALS

Ma. Liza Antoinette M. Gonzales, M.D., M.Sc.
LEARNING OUTCOMES
At the end of this chapter, the health facility leader or administrator
should be able to:
1) Define antimicrobial stewardship;
2) Identify who are the members of the Antimicrobial Stewardship Team;
3) List the various antimicrobial management strategies under the antimicrobial
stewardship program;
4) Commit to support the institutional Antimicrobial Stewardship Program.
WHAT IS ANTIMICROBIAL STEWARDSHIP (AMS)?

● Antimicrobial stewardship (AMS) refers to coordinated interventions and
strategies designed to improve and measure the appropriate use of
antimicrobials in humans in all healthcare settings.1
● AMS includes not only limiting inappropriate use but also optimizing
antimicrobial selection, dosing, route, and duration of therapy to maximize
clinical cure or prevention of infection while limiting the unintended
consequences, such as the emergence of resistance, adverse drug events, cost. 2
● The primary goal of AMS is to optimize clinical outcomes of patients while
minimizing unintended consequences of antimicrobial use, including toxicity,
the selection of pathogenic organisms, and the emergence of resistance. A
secondary goal of AMS is to reduce health care costs without adversely
impacting quality of care. 1,2
How is National AMS Program being implemented?

Effective 2017, the Department of Health through selected Antimicrobial Stewardship
Training Facilities started to cascade the National Antimicrobial Stewardship Program.
Hospitals are required to attend an AMS training workshop so that the AMS steps
written in this chapter can be fully implemented and monitored.
63 IPC HEALS
CORE STRATEGIES SUPPLEMENTAL
STRATEGIES
64 IPC HEALS
Education/
Guidelines
Dose
optimization
Antimicrobial
Cycling/Switch*
*
Combination
Antimicrobial
therapy **
Formulary
restriction and
Antimicrobial
Preauthorization
Order Forms
Prospective Audit Streamlining

and feedback Parenteral to
/de-escalation
Oral
conversion
Figure 20. Antimicrobial Stewardship AMS Strategies
CHAPTER REFERENCES:
1) Chung G W, Wu JE, Yeo CL, Chan D, Hsu LY. Antimicrobial stewardship A review of prospective
audit and feedback systems and an objective evaluation of outcome. Virulence 2013;4(2):151–157.
2) Dellit TH, Owens RC, McGowan Jr JJP, Gerding DN, Weinstein RA, Burke JP, Huskins WC, Paterson
65 IPC HEALS
DL, Fishman NO, Carpenter CF, Brennan PJ, Billeter M, Hooton TM. Infectious Diseases Society of
America and the Society for Healthcare Epidemiology of America Guidelines for Developing an
Institutional Program to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases 2007;
44:159–77.
3) Shlaes DM, Gerding DN, John JF, et al. Society for Healthcare Epidemiology of America and
Infectious Diseases Society of America joint committee on the prevention of antimicrobial
resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin Infect Dis
1997; 25:584–99.
4) McGowan JE Jr. Economic impact of antimicrobial resistance. Emerg Infect Dis 2001; 7:286–92
5) Cosgrove SE, Carmeli Y. The impact of antimicrobial resistance on health and economic outcomes.
Clin Infect Dis 2003; 36:1433–7.
6) Paterson DL. The role of antimicrobial management programs in optimizing antibiotic prescribing
within hospitals.. Clin Infect Dis 2006; 42(Suppl 2):S90–S95.2–5
7) Fishman N. Society for Healthcare Epidemiology of America; Infectious Diseases Society of
America; Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by
the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of
America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp
Epidemiol 2012; 33:322-7; PMID:22418625; http://dx.doi.org/10.1086/665010.
8) Teng CB, Lee W, Yeo CL, Lee SY, Ng TM, Yeoh SF, et al. Guidelines for antimicrobial stewardship
training and practice. Ann Acad Med Singapore 2012; 41:29-34; PMID:22499478.)
9) Pear SM, Williamson TH, Bettin KM, Gerding DN, Galgiani JN. Decrease in nosocomial Clostridium
difficile-associated diarrhea by restricting clindamycin use. Ann Intern Med 1994; 120:272–7
10) Quale J, Landman D, Aurina G, Atwood E, DiTore V, Patel K. Manipulation of a hospital
antimicrobial formulary to control an outbreak of vancomycin-resistant enterococci. Clin Infect
Dis 1996; 23: 1020–5
11) Bamberger DM, Dahl SL. Impact of voluntary vs. enforced compliance of third-generation
cephalosporin use in a teaching hospital. Arch Intern Med 1992; 152:554–7
12) Hayman JN, Sbravati EC. Controlling cephalosporin and aminoglycoside costs through pharmacy
and therapeutics committee restrictions. Am J Hosp Pharm 1985; 42:1343–7.
13) Woodward RS, Medoff G, Smith MD, Gray JL. Antibiotic cost savings from formulary restrictions
and physician monitoring in a medical school- affiliated hospital. Am J Med 1987; 83:817–23.
14) Coleman RW, Rodondi LC, Kaubisch S, Granzella NB, O’Hanley PD. Cost-effectiveness of
prospective and continuous parenteral antibiotic control: Experience at the Palo Alto Veterans
Affairs Medical Center from 1987 to 1989. Am J Med 1991; 90:439–44.
15) Maswoswe JJ, Okpara AU. Enforcing a policy for restricting antimicrobial drug use. Am J Health
Syst Pharm 1995; 52:1433–5.
16) White AC, Atmar RL, Wilson J, Cate TR, Stager CE, Greenberg SB. Effects of requiring prior
authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes.
17) Martin C, Ofotokun I, Rapp R, et al. Results of an antimicrobial control program at a university
hospital. Am J Health Syst Pharm. 2005;62(7):732-38. 17. Rapp RP, Evans ME, Martin C, Ofotokum
I, Empey KL, Armitstead JA. Drug costs and bacterial susceptibility after implementing a single
fluoroquinolone use policy at a university hospital. Curr Med Res Opin.2004;20(4):469-76
18) Solomon DH, Van Houten L, Glynn RJ. Academic detailing to improve use of broad-spectrum
antibiotics at an academic medical center. Arch Intern Med 2001; 161:1897–902;
19) Fraser GL, Stogsdill P, Dickens JD Jr, Wennberg DE, Smith RP, Prato S. Antibiotic optimization: an
evaluation of patient safety and economic outcomes. Arch Intern Med 1997; 157:1689–94
20) Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic
management program conducted during 7 years. Infect Control Hosp Epidemiol 2003; 24:699–
706
21) LaRocco A Jr. Concurrent antibiotic review programs—a role for infectious diseases specialists at
small community hospitals. Clin Infect Dis 2003; 37:742–3
22) Diazgranados CA. Prospective audit for antimicrobial stewardship in intensive care: Impact on
resistance andclinical outcomes. Am J Infect Control. 2012 Aug;40(6):526-9.
23) Septimus EJ, Owens Jr RC. Need and Potential of Antimicrobial Stewardship in Community
Hospitals. Clinical Infectious Diseases 2011; 53(S1):S8–S14.
24) Bantar C, Sartori B, Vesco E, et al. A hospitalwide intervention program to optimize the quality of
antibiotic use: impact on prescribing practice, antibiotic consumption, cost savings, and bacterial
resistance. Clin Infect Dis 2003; 37:180–6.
25) Belongia EA, Knobloch MJ, Kieke BA, Davis JP, Janette C, Besser RE.Impact of statewide program
to promote appropriate antimicrobial drug use. Emerg Infect Dis 2005; 11:912–20.
26) Girotti MJ, Fodoruk S, Irvine-Meek J, Rotstein OD. Antibiotic handbook and pre-printed
perioperative order forms for surgical antibioticprophylaxis: do they work? Can J Surg 1990;
33:385–8.
66 IPC HEALS
27) Drew RH. Antimicrobial Stewardship Programs: How to Start and Steer a Successful Program J
Manag Care Pharm. 2009;15(2)(Suppl):S18-S23)
28) Toltzis P, Yamashita T, Vilt L, et al. Antibiotic restriction does not alter endemic colonization with
resistant gram-negative rods in a pediatric intensive care unit. Crit Care Med 1998; 26:1893–9.].
29) White AC, Atmar RL, Wilson J, Cate TR, Stager CE, Greenberg SB. Effects of requiring prior
authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes.
30) Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG. A controlled trial of a critical
pathway for treatment of community-acquired pneumonia. JAMA 2000; 283:749–55
31) Price J, Ekleberry A, Grover A, et al. Evaluation of clinical practice guidelines on outcome of
infection in patients in the surgical intensive care unit. Crit Care Med 1999; 27:2118–24
32) Ibrahim EH, Ward S, Sherman G, Schaiff R, Fraser VJ, Kollef MH. Experience with a clinical
guideline for the treatment of ventilatorassociated pneumonia. Crit Care Med 2001; 29:1109–15
33) Chastre J, Wolff M, Fagon J-Y. Comparison of 8 vs. 15 days of antibiotic therapy for ventilator-
associated pneumonia in adults. JAMA 2003; 290:2588–98
34) South M, Starr M. A simple intervention to improve hospital antibiotic prescribing. Med J Aust
2003; 178:207–9.
35) Durbin WA, Lapidas B, Goldmann DA. Improved antibiotic usage following introduction of a novel
prescription system. JAMA 1981; 246:1796–800\
36) Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic
administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;
326:281–6.
37) Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the
national surgical infection prevention project. ClinInfect Dis 2004; 38:1706–15.
38) Echols RM, Kowalsky SF. The use of an antibiotic order form for antibiotic utilization review:
influence on physicians’ prescribing patterns. J Infect Dis 1984; 150:803–7.
39) Briceland LL, Nightingale CH, Quintiliani R, Cooper BW, Smith KS. Antibiotic streamlining from
combination therapy to monotherapy utilizing an interdisciplinary approach. Arch Intern Med
1988; 148: 2019–22.
40) Glowacki RC, Schwartz DN, Itokazu GS,WisniewskiMF, Kieszkowski, P, Weinstein RA. Antibiotic
combinations with redundant antimicrobial spectra: clinical epidemiology and pilot intervention
of computerassisted surveillance. Clin Infect Dis 2003; 37:59–64.
41) Grant EM, Kuti JL, Nicolau DP, Nightingale C, Quintiliani R. Clinical efficacy and
pharmacoeconomics of a continuous-infusion piperacillin- tazobactam program in a large
community teaching hospital. Pharmacotherapy 2002; 22:471–83.
42) Bailey TC, Little JR, Littenberg B, Reichley RM, Dunagan WC. A meta-analysis of extended-interval
dosing versus multiple daily dosing of aminoglycosides. Clin Infect Dis 1997; 24:786–95.
43) Chan R, Hemeryck L, O’Regan M, Clancy L, Feely J. Oral versus intravenous antibiotics for
community acquired lower respiratory tract infection in a general hospital: open, randomized
controlled trial. BMJ 1995; 310:1360–2
44) Opmer BC, Moussaoui E, Speelman P, Prins JM et al. Costs associated with shorter duration of
antibiotic therapy in hospitalized patients with mild-to-moderate severe community-acquired
pneumonia. Journal of Antimicrobial Chemotherapy 2007; 60(5): 1131-1136
45) Ramirez JA, Vargas S, Ritter GW, wt al. Early switch from intravenous to oral antibiotics and early
hospital discharge: a prospective observational study of 200 consecutive patients with
community-acquired pneumonia. Archives of Internal Medicine 1999; 159(20): 2449-54
46) Al-Eidan FA, McElnay JC, Scott MG, Kearney MP, Troughton KEU, Jenkins J. Sequential
antimicrobial therapy: treatment of severe lower respiratory tract infections in children. J
Antimicrob Chemother 1999; 44:709–15.
47) Moody MM, de Jongh CA, Schimpff SC, Tillman GL. Long-term amikacin use: effects on
aminoglycoside susceptibility patterns of gram-negative bacilli. JAMA 1982; 248:1199–202.
48) Betts RF, Valenti WM, Chapman SW, et al. Five-year surveillance of aminoglycoside usage in a
university hospital. Ann Intern Med 1984; 100:219–22.
49) Young EJ, Sewell CM, Koza MA, Clarridge JE. Antibiotic resistance patterns during aminoglycoside
restriction. Am J Med Sci 1985; 290: 223–7.
50) Berk SL, Alvarez S, Ortega G, Verghese A, Holtsclaw-Berk SA. Clinical and microbiologic
consequences of amikacin use during a 42-month period. Arch Intern Med 1986; 146:538–41.
51) Van Landuyt HW, Boelaert J, Glibert B, Gordts B, Verbruggen A-M. Surveillance of aminoglycoside
resistance. Am J Med 1986; 80(Suppl 6B):76–81.
52) Gerding DN, Larson TA, Hughes RA, Weiler M, Shanholtzer C, Peterson LR. Aminoglycoside
resistance and aminoglycoside usage: ten years of experience in one hospital. Antimicrob Agents
Chemother 1991; 35:1284–90.
53) King JW, White MC, Todd JR, Conrad SA. Alterations in the microbial flora and in the incidence of
bacteremia at a university hospital after adoption of amikacin as the sole formulary
67 IPC HEALS
aminoglycoside. Clin Infect Dis 1992; 14:908–15.
54) Gruson D, Hilbert G, Vargas F, et al. Rotation and restricted use of antibiotics in a medical intensive
care unit: impact on the incidence of ventilator-associated pneumonia caused by antibiotic-
resistant gram-negative bacteria. Am J Respir Crit Care Med 2000; 162:837–43.
55) Raymond DP, Pelletier SJ, Crabtree TD, et al. Impact of a rotating empiric antibiotic schedule on
infectious mortality in an intensive care unit. Crit Care Med 2001; 29:1101–8
56) Fridkin SK. Routine cycling of antimicrobial agents as an infection control measure. Clin Infect Dis
2003; 36:1438–44.
57) Harbarth S, Barbino J, Pugin J, Romand JA, Lew D, Pittet D. Inappropriate initial antimicrobial
therapy and its effect on survival in a clinical trial of immunomodulating therapy for severe sepsis.
Am J Med 2003; 115:529–35.
58) American Thoracic Society and Infectious Diseases Society of America. Guidelines for the
management of adults with hospital-acquired, ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med 2005; 171:388–416.
59) Bliziotis IA, Samonis G, Vardakas KZ, Chrysanthopoulou S, Falagas ME. Effect of aminoglycoside
and beta-lactam combination therapy versus b-lactam monotherapy on the emergence of
antimicrobial resistance: a meta-analysis of randomized, controlled trials. Clin Infect Dis 2005;
41:149–58.
60) Drew RH. Antimicrobial Stewardship Programs: How to Start and Steer a Successful Program. J
Manag Care Pharm. 2009;15(2)(Suppl):S18-S23
61) Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve
antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2005;
CD003543; PMID:16235326.
62) Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care.
Cochrane Database Syst Rev. 2005;4:CD003539.
63) Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for
hospital inpatients. Cochrane Database Syst Rev. 2013;4:CD003543.
64) Pope SD, Dellit TH, Owens RC, Hooton TM; Infectious Diseases Society of America; Society for
Healthcare Epidemiology of America. Results of survey on implementation of Infectious Diseases
Society of America and Society for Healthcare Epidemiology of America guidelines for developing
an institutional program to enhance antimicrobial stewardship. Infect Control Hosp Epidemiol
2009; 30:97-8; PMID:19046053; http://dx.doi.org/10.1086/592979.
65) Liew YX, Lee W, Loh JC, Cai Y, Tang SS, Lim CL, et al. Impact of an antimicrobial stewardship
programme on patient safety in Singapore General Hospital. Int J Antimicrob Agents 2012; 40:55-
60; PMID:22591837; http://dx.doi.org/10.1016/j.ijantimicag.2012.03.004.
66) Morris AM, Brener S, Dresser L, Daneman N, Dellit TH, Avdic E, et al. Use of a structured panel
process to define quality metrics for antimicrobial stewardship programs. Infect Control Hosp
Epidemiol 2012; 33:500-6; PMID:22476277; http://dx.doi. org/10.1086/665324.
68 IPC HEALS
Created by:
Hesus Angelo BULURAN, Hannah DE LA CRUZ, Kris Anne ESTOESTA,
Chamson BACUSO, Ana Pholyn BALAHADIA, Ma. Beatrice ESPINOSA
of UPCM Class 2018
69 IPC HEALS
CHAPTER 8
LOWERING OF HAI: L of HEALS

Cybele Lara R. Abad, MD
LEARNING OUTCOMES:
1. Understand what HAIs are and how they develop;
2. Describe the most commonly encountered HAIs;
3. Determine strategies to reduce the risks for HAI.
4. Identify the support the hospital administration should provide to the IPC
committee to lower the HAI in their institutions.
What is a Hospital Acquired Infection?
Any infection acquired during hospitalization which is not present or

incubating at admission, or occurring more than 48 hours after
KEY MESSAGESadmission
FOR CHAPTER:
is usually considered nosocomial.
WHAT SHOULD ADMINISTRATORS KNOW ABOUT HAI and BUNDLES?

Administrators should support all initiatives towards HAI control and management as
follows:
● Support for the needs of the IPC committee to develop and implement policies
related to HAI management including hiring of additional manpower
● Recognize and support need to enhance laboratory capablities
● Prioritize to enhance research methods to better define the occurrence of HAIs,
risk factors, effects of interventions.
What is a HEALTH CARE BUNDLE ?

Table 32: Summary of the Bundles of Care
A “bundle” is a structured way of improving the processes of care and patient
outcomes using a set of practices, generally three to five, that when performed
collectively and reliably, have been shown to improve patient outcomes.
Bundling care processes facilitates implementation by providing a clear, tangible set of

expectations to follow.
70 IPC HEALS
Table 5. Summary of Care Bundles to Prevent HAIs
CLABSI VAP CAUTI SSI

1) Hand hygiene 1) Elevation of the 1) Hand hygiene; 1) Cutaneous
before IV device head of the bed 2) Cutaneous and antisepsis
insertion; to 30-45 degrees; meatal antisepsis 2) Appropriate
2) Maximal barrier 2) Daily sedation 3) Sterile field and antimicrobial
precautions during hold; sterile gloves; dose and
the insertion 3) Deep vein 4) Single attempt at selection;
procedure; thrombosis insertion allowed 3) Prophylactic
3) Cutaneous prophylaxis for each catheter antibiotics within
antisepsis with 4) Gastric ulcer 5) Adequate UC 60 min before
chlorhexidine prophylaxis; balloon inflation; surgery;
gluconate; 5) Oral care 6) Daily review of 4) Glycemic control
4) Optimal catheter the need for a UC 5) Normothermia
insertion site with prompt pre-and post-
selection, with the removal if no operatively
subclavian vein the longer needed
preferred site for
central line catheter
5) Daily review with
immediate removal
when no longer
needed
71 IPC HEALS
CHAPTER REFERENCES:
1. Danchaivijitr S, Tangtrakool T, Chokloikaew S. The Second Thai National Prevalence Study on Nosocomial
Infections 1992. Journal of the Medical Association of Thailand = Chotmaihet thangphaet 1995; 78 Suppl 2:
S67-72.
2. Emmerson AM, Enstone JE, Griffin M, Kelsey MC, Smyth ET. The Second National Prevalence Survey of
infection in hospitals--overview of the results. The Journal of hospital infection 1996; 32(3): 175-90.
3. Gastmeier P, Kampf G, Wischnewski N, et al. Prevalence of nosocomial infections in representative German
hospitals. The Journal of hospital infection 1998; 38(1): 37-49.
4. Gikas A, Pediaditis I, Roumbelaki M, Troulakis G, Romanos J, Tselentis Y. Repeated multi-centre prevalence
surveys of hospital-acquired infection in Greek hospitals. CICNet. Cretan Infection Control Network. The
Journal of hospital infection 1999; 41(1): 11-8.
5. Kim JM, Park ES, Jeong JS, et al. Multicenter surveillance study for nosocomial infections in major hospitals in
Korea. Nosocomial Infection Surveillance Committee of the Korean Society for Nosocomial Infection Control.
American journal of infection control 2000; 28(6): 454-8.
6. Mayon-White RT, Ducel G, Kereselidze T, Tikomirov E. An international survey of the prevalence of hospital-
acquired infection. The Journal of hospital infection 1988; 11 Suppl A: 43-8.
7. Orrett FA, Brooks PJ, Richardson EG. Nosocomial infections in a rural regional hospital in a developing country:
infection rates by site, service, cost, and infection control practices. Infection control and hospital
epidemiology 1998; 19(2): 136-40.
8. Pittet D, Harbarth S, Ruef C, et al. Prevalence and risk factors for nosocomial infections in four university
hospitals in Switzerland. Infection control and hospital epidemiology 1999; 20(1): 37-42.
9. Raymond J, Aujard Y. Nosocomial infections in pediatric patients: a European, multicenter prospective study.
European Study Group. Infection control and hospital epidemiology 2000; 21(4): 260-3.
10. Scheel O, Stormark M. National prevalence survey on hospital infections in Norway. The Journal of hospital
infection 1999; 41(4): 331-5.
11. Valinteliene R, Jurkuvenas V, Jepsen OB. Prevalence of hospital-acquired infection in a Lithuanian hospital. The
Journal of hospital infection 1996; 34(4): 321-9.
12. Vaque J, Rossello J, Arribas JL. Prevalence of nosocomial infections in Spain: EPINE study 1990-1997. EPINE
Working Group. The Journal of hospital infection 1999; 43 Suppl: S105-11.
13. Reed D, Kemmerly SA. Infection control and prevention: a review of hospital-acquired infections and the
economic implications. The Ochsner journal 2009; 9(1): 27-31.
14. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988.
15. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections,
1992: a modification of CDC definitions of surgical wound infections. Infection control and hospital
epidemiology 1992; 13(10): 606-8.
16. McGeer A, Campbell B, Emori TG, et al. Definitions of infection for surveillance in long-term care facilities.
17. O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related
infections. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
2011; 52(9): e162-93.
18. Prevention of hospital-acquired infections: A practical guide 2nd edition. http://www.who.int/emc.
19. NHMRC (2010) Australian Guidelines for the Prevention and Control of Infection in Healthcare.
Commonwealth of Australia.
20. The Philippine clinical practice guideline on the diagnosis and management of urinary tract infections: A quick
reference guide for clinicians. Philippine J Microbiol Infect Dis 2002; 31(1): 27-44.
21. Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. The
Surgical clinics of North America 1980; 60(1): 27-40.
22. Horan TC, Culver DH, Gaynes RP, Jarvis WR, Edwards JR, Reid CR. Nosocomial infections in surgical patients in
the United States, January 1986-June 1992. National Nosocomial Infections Surveillance (NNIS) System.
Infection control and hospital epidemiology 1993; 14(2): 73-80.
23. Bienvenido A, Enrique C, Ludovico J. Nosocomial Infection in a Tertiary Hospital: A Two-Year Surveillance at
Santo Tomas University Hospital. Phil J Microbiol Infect Dis 1990; 19(1): 20-6.
24. Brachman PS, Dan BB, Haley RW, Hooton TM, Garner JS, Allen JR. Nosocomial surgical infections: incidence
and cost. The Surgical clinics of North America 1980; 60(1): 15-25.
25. Fabry J, Meynet R, Joron MT, Sepetjan M, Lambert DC, Guillet R. Cost of nosocomial infections: analysis of 512
digestive surgery patients. World journal of surgery 1982; 6(3): 362-5.
26. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the
1990s: attributable mortality, excess length of hospitalization, and extra costs. Infection control and hospital
epidemiology 1999; 20(11): 725-30.
27. Prabhakar P, Raje D, Castle D, et al. Nosocomial surgical infections: incidence and cost in a developing country.
28. Anderson DJ, Podgorny K, Berrios-Torres SI, et al. Strategies to prevent surgical site infections in acute care
hospitals: 2014 update. Infection control and hospital epidemiology 2014; 35(6): 605-27.
29. Nosocomial infection rates for interhospital comparison: limitations and possible solutions. A Report from the
National Nosocomial Infections Surveillance (NNIS) System. Infection control and hospital epidemiology 1991;
12(10): 609-21.
30. Niederman MS. Guidelines for the management of respiratory infection: why do we need them, how should
72 IPC HEALS
they be developed, and can they be useful? Current opinion in pulmonary medicine 1996; 2(3): 161-5.
31. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care--associated
pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory
Committee. MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations
and reports 2004; 53(Rr-3): 1-36.
32. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-
associated pneumonia. American journal of respiratory and critical care medicine 2005; 171(4): 388-416.
33. Berba R, Alejandria M, Rosaros J, et al. Incidence, Risk Factors and Outcome of Hospital-Acquired Pneumonia
in Critically-Ill Patients at the Philippine General Hospital. Phil J Microbiol Infect Dis 1999;; 28(2): 29-38.
34. Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated
pneumonia: a systematic review. Critical care medicine 2005; 33(10): 2184-93.
35. Crnich CJ, Maki DG. The promise of novel technology for the prevention of intravascular device-related
bloodstream infection. I. Pathogenesis and short-term devices. Clinical infectious diseases : an official
publication of the Infectious Diseases Society of America 2002; 34(9): 1232-42.
36. Klevens RM, Edwards JR, Richards CL, Jr., et al. Estimating health care-associated infections and deaths in U.S.
hospitals, 2002. Public health reports (Washington, DC : 1974) 2007; 122(2): 160-6.
37. Linares J, Sitges-Serra A, Garau J, Perez JL, Martin R. Pathogenesis of catheter sepsis: a prospective study with
quantitative and semiquantitative cultures of catheter hub and segments. Journal of clinical microbiology
1985; 21(3): 357-60.
38. Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term
central venous catheters. Intensive care medicine 2004; 30(1): 62-7.
39. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve
ventilator care processes and reduce ventilator-associated pneumonia. Joint Commission journal on quality
and patient safety 2005; 31(5): 243-8.
40. Halton KA, Cook D, Paterson DL, Safdar N, Graves N. Cost-effectiveness of a central venous catheter care
bundle. PloS one 2010; 5(9).
41. Helder O, van den Hoogen A, de Boer C, van Goudoever J, Verboon-Maciolek M, Kornelisse R. Effectiveness of
non-pharmacological interventions for the prevention of bloodstream infections in infants admitted to a
neonatal intensive care unit: A systematic review. International journal of nursing studies 2013; 50(6): 819-
31.
42. Kim JS, Holtom P, Vigen C. Reduction of catheter-related bloodstream infections through the use of a central
venous line bundle: epidemiologic and economic consequences. American journal of infection control 2011;
39(8): 640-6.
43. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter related bloodstream
infections in Michigan intensive care units: observational study. BMJ (Clinical research ed) 2010; 340: c309.
44. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream
infections in the ICU. The New England journal of medicine 2006; 355(26): 2725-32.
45. Blot K, Bergs J, Vogelaers D, Blot S, Vandijck D. Prevention of central line-associated bloodstream infections
through quality improvement interventions: a systematic review and meta-analysis. Clinical infectious
diseases : an official publication of the Infectious Diseases Society of America 2014; 59(1): 96-105.
46. Evans B. Best-practice protocols: VAP prevention. Nursing management 2005; 36(12): 10, 2, 4 passim.
47. Al-Thaqafy MS, El-Saed A, Arabi YM, Balkhy HH. Association of compliance of ventilator bundle with incidence
of ventilator-associated pneumonia and ventilator utilization among critical patients over 4 years. Annals of
thoracic medicine 2014; 9(4): 221-6.
48. Lawrence P, Fulbrook P. The ventilator care bundle and its impact on ventilator-associated pneumonia: a
review of the evidence. Nursing in critical care 2011; 16(5): 222-34.
49. Lim KP, Kuo SW, Ko WJ, et al. Efficacy of ventilator-associated pneumonia care bundle for prevention of
ventilator-associated pneumonia in the surgical intensive care units of a medical center. Journal of
microbiology, immunology, and infection = Wei mian yu gan ran za zhi 2015; 48(3): 316-21.
50. O'Keefe-McCarthy S, Santiago C, Lau G. Ventilator-associated pneumonia bundled strategies: an evidence-
based practice. Worldviews on evidence-based nursing 2008; 5(4): 193-204.
51. Joint Commission Center for Transforming Healthcare and American College of Surgeons Collaborative.
Reducing Colorectal Infection Rates. Colorectal Surgical Site Infections Project [updated 2013 May 1; cited
2017 Sept]. Available from: http://www.centerfortransforminghealthcare.org/assets/4/6/SSI_storyboard.pdf.
52. Lutfiyya W, Parsons D, Breen J. A colorectal "care bundle" to reduce surgical site infections in colorectal
surgeries: a single-center experience. The Permanente journal 2012; 16(3): 10-6.
53. Tanner J, Padley W, Assadian O, Leaper D, Kiernan M, Edmiston C. Do surgical care bundles reduce the risk of
surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-
analysis of 8,515 patients. Surgery 2015; 158(1): 66-77.
54. Saint S, Olmsted RN, Fakih MG, et al. Translating health care-associated urinary tract infection prevention
research into practice via the bladder bundle. Joint Commission journal on quality and patient safety 2009;
35(9): 449-55.
55. Titsworth WL, Hester J, Correia T, et al. Reduction of catheter-associated urinary tract infections among
patients in a neurological intensive care unit: a single institution's success. Journal of neurosurgery 2012;
116(4): 911-20.
56. Marra AR, Sampaio Camargo TZ, Goncalves P, et al. Preventing catheter-associated urinary tract infection in
the zero-tolerance era. American journal of infection control 2011; 39(10): 817-22.
57. Navoa-Ng JA, Berba R, Rosenthal VD, et al. Impact of an International Nosocomial Infection Control
Consortium multidimensional approach on catheter-associated urinary tract infections in adult intensive care
units in the Philippines: International Nosocomial Infection Control Consortium (INICC) findings. Journal of
infection and public health 2013; 6(5): 389-99.
73 IPC HEALS
74 IPC HEALS
CHAPTER 9
LOWERING THE RISK FOR HAI IN SPECIFIC AREAS:
IPC in INTENSIVE CARE UNITS AND HEMODIALYSIS UNITS
Cecilia G. Peña, RN, MAN
LEARNING OUTCOMES:
At the end the chapter, the health facility leader and administrator should
be able to:
1) Identify the specific conditions present in Intensive Care Units (ICU) and
Hemodialysis (HD) Units which increase risks for infectious complications;
2) Describe the various strategies which have been shown to work in ICU and HD
settings to reduce such risks for HAI.
What makes ICU patients special?
ICU patients require higher level of care and at more risk of developing
HAIs because they carry several risk factors
WHAT IS SPECIAL ABOUT INTENSIVE CARE UNITS IN THE

PRACTICE OF IPC?
● Intensive care units (ICU) carry a high risk for healthcare associated
infections(HAI) contributing to an increase rates in morbidity, mortality, and
healthcare costs. In order to limit the incidence of ICU infections, healthcare
providers should adopt aggressive infection control measures.
● ICU patients' severe illnesses and injuries necessitate much more hands-on care
than in normal wards. That care can include turning, bathing, IV site care,
suctioning and the administration of medication. The fact that there are so many
tasks and so many devices means that there are more opportunities to transmit
pathogens from person to person.
● The implementation of evidence-based infection control practices is essential,
yet challenging for healthcare institutions worldwide. Although acknowledged
that implementation success varies with contextual factors, little is known
regarding the most critical specific conditions within the complex cultural
milieu of varying economic, political, and healthcare systems.
● HAIs are either endogenous or exogenous and must not be evident or incubating
at the time of admission to the acute care setting. Endogenous sources are body
sites, such as the skin, nose, mouth, gastrointestinal (GI) tract, or vagina that
have natural microorganisms. Exogenous sources are those outside body such
as patient care personnel, visitors, medical devices or equipment.
75 IPC HEALS
CHAPTER REFERENCES:
1. Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveillance definition of health
care-associated infection and criteria for specific types of infections in the acute care
setting. Am J Infect Control 36: 309-332.
2. Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, et al. (2007) Estimating
health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep
122: 160-166.
3. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, et al. (2011) Estimating the
proportion of healthcare-associated infections that are reasonably preventable and the
related mortality and costs. Infect Control Hosp Epidemiol 32: 101-114.
4. Parillo JE, Dellinger RP. Chapter 50 (14:825-869): Nosocomial Infection in the Intensive
Care Unit. Critical Care Medicine: Principles of Diagnosis and Management in the Adult,
Fourth Edition. Saunders, an imprint of Elsevier Inc.
5. O'Grady NP, Alexander M, Burns LA, et al., (2011) Guidelines for the prevention of
intravascular catheter-related infections. Clin Infect Dis 52(9):162-193.
6. Fry DE (2008) Surgical site infections and the surgical care improvement project (SCIP):
evolution of national quality measures. Surg Infect (Larchmt) 9: 579-584.
7. Rimawi RH, Kabchi B, Mazer MA, Ashraf MS, Gooch M, Cook PP (2012) Antimicrobial use
in the MICU ? A need for improvement? Poster presented at 2012 IDWeek, Boston, MA,
USA.
8. Kauffman CA, Pappas PG, Patterson TF (2013) Fungal infections associated with
contaminated methylprednisolone injections. N Engl J Med 368: 2495-2500.
9. Blouin AS (2010) Helping to solve healthcare's most critical safety and quality problems.
J Nurs Care Qual 25: 95-99.
10. Chen W, Li S, Li L, Wu X, Zhang W (2013) Effects of daily bathing with chlorhexidine and
acquired infection of methicillin-resistant Staphylococcus aureus and vancomycin-
resistant Enterococcus: a meta-analysis. J Thorac Dis 5: 518-524.
11. Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, et al. (2013) Targeted versus
universal decolonization to prevent ICU infection. N Engl J Med 368: 2255-2265.
76 IPC HEALS
12. Climo MW, Sepkowitz KA, Zuccotti G, Fraser VJ, Warren DK, et al. (2009) The effect of
daily bathing with chlorhexidine on the acquisition of methicillin-resistant
Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated
bloodstream infections: results of a quasi-experimental multicenter trial. Crit Care Med
37: 1858-1865.
13. Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K, et al. (2008) Strategies to
prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 29
Suppl 1: S51-61.
14. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control
Practices Advisory Committee. Guideline for isolation precautions: preventing
transmission of infectious agents in healthcare settings 2007. Atlanta, GA: US
Department of Health and Human Services, CDC; 2007.
15. Haley RW, Culver DH, White JW et al. The efficacy of infection surveillance and control
programs in preventing nosocomial infections in US hospitals. Am. J. Epidemiol. 121,
182–205 (1985).
16. U.S. Renal Data System, USRDS 2009 Annual Data Report: Atlas of Chronic Kidney
Disease and End-Stage Renal Disease in the United States, National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
(2009).
17. Centers for Disease Control and Prevention. Recommendations for preventing
transmission of infections among chronic hemodialysis patients. MMWR Morb. Mortal.
Wkly Rep. 50(RR-5), 1–43 (2001).
18. National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Clinical
practice guidelines for 2006 updates: hemodialysis adequacy, peritoneal dialysis
adequacy, and vascular access. Am. J. Kidney Dis. 48, S1–S322 (2006).
19. O'Grady NP, Alexander M, Dellinger EP et al. Guidelines for the prevention of
intravascular catheter-related infections. MMWR Morb. Mortal. Wkly Rep. 51(RR-10), 1–
29 (2002).
20. Fiore AE, Shay DK, Broder K et al. Prevention and control of seasonal influenza with
vaccines: recommendations of the Advisory Committee on Immunization Practices,
2009. MMWR Morb. Mortal. Wkly Rep. 58(RR-8), 1–52 (2009).
21. Klevens R, Tokars JI, Andrus M. Electronic reporting of infections associated with
hemodialysis. Nephrology News & Issues.2005;(6): 37-43
22. Labriola L, Crott R, Jadoul M. Preventing haemodialysis catheter-related bacteraemia
with an antimicrobial lock solution: a meta-analysis of prospective randomized trials.
Nephrol. Dial. Transplant 23, 1666–1672 (2007).
23. Froio N, Nicastri E, Comandini UV et al. Contamination by hepatitis B and C viruses in
the dialysis setting. Am. J. Kidney Dis. 42, 546–550 (2003).
24. Centers for Disease Control and Prevention. Reduction of central line-associated
bloodstream infections among patients in intensive care units, Pennsylvannia, April
2001–March 2005. MMWR Morb. Mortal. Wkly Rep. 54, 1013–1016 (2005).
25. Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource
use associated with catheter-related bloodstream infection in the surgical intensive care
unit. Arch Surg. 2001;136:229–34. [PubMed]
26. Website:http://www.cdc.gov/dialysis/PDFs/Dialysis-Patient PocketGuide. pdf
77 IPC HEALS
Created by:
78 IPC HEALS
Jose Carlos T. CHANYUNGCO, Paul Johnny C. DIAZ,
Gizzelle Golda LABALAN, Nicole Marella G. TAN
of UPCM Class 2018
CHAPTER 10
LOWERING THE RISK FOR HAI IN SPECIFIC AREAS:
IPC in the OPERATING ROOMS and POST ANESTHESIA
CARE UNITS
Cecilia G. Peña, RN, MAN
LEARNING OUTCOMES:
At the end of the chapter, the Healthcare Administrator should be able to:
1) Identify the factors present in the Operating Rooms (OR)and Post-Anesthesia Care
units (PACU) which lead to higher risk for infectious complications;
2) Describe the various principles and strategies which have been shown to work in
ORs settings to reduce such risks for HAI and maintain patient and healthcare
worker safety;
3) List areas requiring enhanced institutional support for staffing, equipment,
structure and logistics at the Operating Rooms to reduce risk for infections.
KEY MESSAGES FOR THIS CHAPTER:
CHAPTER REFERENCES:
1. Standards and recommendations for Safe Perioperative practice 2011. Third Edition. Association for
Perioperative Practice, Harrogate. Behaviour & Rituals in the Operating Theatre, 2002.
2. WHO Safety Surgical Checklist 2009. National Patient Safety Agency
3. NICE Clinical guidelines www.icid.salisbury.nhs.uk
4. http://www.newcastle-
hospitals.org.uk/downloads/policies/Infection%20Control/InfectionControlTheatres201308.pdf
5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783083/
6. http://www.schn.health.nsw.gov.au/_policies/pdf/2009-8063.pdf
79 IPC HEALS
7. Centers for Disease Control and Prevention. Data and Statistics. Healthcare-associated Infections (HAIs). 2014.
8. Paton L, Jefferson P, Ball DR. The disconnected epidural catheter: a survey of current practice in Scotland.Eur J
Anaesthesiol. Sep 2012;29(9):453-455.
9. Sehulster L, Chinn RY. Guidelines for environmental infection control in health-care facilities.
Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).
MMWR Recomm Rep. Jun 6 2003;52(RR-10):1-42.
10. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing
Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. Dec 2007;35(10 Suppl 2):S65-
164.
11. Weber DJ, Anderson D, Rutala WA. The role of the surface environment in healthcare-associated infections.
Curr Opin Infect Dis. Aug 2013;26(4):338-344.
Created by
80 IPC HEALS
Claudine LUKBAN, Leland LUKBAN,
Emmanuel VELASCO, Jesus VILLEZA, Albert YAP, Celina YAP
of UPCM Class 2018
CHAPTER 11
PREVENTION AND CONTROL OF HIGHLY

COMMUNICABLE INFECTIONS SUCH AS TUBERCULOSIS
TRANSMISSION IN HEALTHCARE FACILITIES
Maria Nicolette M. Mariano MD
LEARNING OUTCOMES
1. Know the factors which increase the risk for the transmission of TB;
2. List the TB Levels of Control for health facilities;
3. Support the components of the institutional TB Infection Control Plan.
WHY IS TB INFECTION CONTROL OF UTMOST IMPORTANCE?

The Philippines ranks ninth among the 22 highest TB-burden countries in the world,
and has one of the highest burdens of multidrug-resistant TB.2 Tuberculosis is also the
sixth leading cause of morbidity and mortality in the country. According to the 2017
Global Tuberculosis Report by WHO, the Philippines has an incidence rate of
554/100,000 in 2016.3
Thus administrators of facilities where TB is cared for must know about
TB Infection Control (TBIC).
Table 6. Estimates of TB Burden in the Philippines, 20163

Rate (per 100,00 population)
Mortality (excludes HIV+TB) 21
Mortality (HIV+TB only) 0.29
Incidence (includes HIV+TB) 554
Incidence (HIV+TB only) 5.9
Incidence (MDRTB) 30
Source: WHO Global Tuberculosis Report 2017
The transmission of M. tuberculosis is transmitted through air and not by surface

contact. The degree of infectiousness of a patient with TB is directly related to the
number of droplet nuclei with tubercle bacilli suspended in the air depending on the
environment. Tuberculosis infection can be transmitted in any setting. People who
work or receive care in healthcare settings are at higher risk to become infected with M.
tuberculosis. Therefore, it is necessary to have a TB infection control plan as part of
general infection control program designed to ensure prompt detection of TB, airborne
81 IPC HEALS
precautions and treatment of persons who have been suspected or confirmed to have
TB disease.5,6
Through the three-level hierarchy of controls, which include administrative control,

environmental control and respiratory protection, TB infection control measures can
decrease the risk of TB transmission even in resource-limited settings. However, more
studies are needed to determine the most efficient interventions. The importance of TB
infection control in resource-limited settings in the era of expanding HIV care and
treatment must also be given attention and addressed.7
WHAT ARE THE COMPONENTS OF A TB INFECTION CONTROL PROGRAM?

All health-care settings need a TB infection-control program designed to ensure prompt
detection, airborne precautions, and treatment of persons who have suspected or
confirmed TB disease.
The program should be based on a three-level hierarchy of controls, including:
1)administrative controls which reduce risk of exposure,
2)environmental controls which prevent and reduce concentration of droplet
nuclei, and
3)respiratory protection controls which further reduce risk of exposure in special
areas and circumstances.4-6
Table 7. TB Infection Control Program: Level of Controls

Administrative Controls
● Assign responsibility for TB Infection Control

● Conduct TB risk assessment
● Develop and institute a written TB infection-control plan
● Ensure the timely availability of recommended laboratory processing, testing and
reporting of results
● Implement effective work practices for the management of patients with suspected
or confirmed TB disease
● Ensure proper cleaning and sterilization or disinfection of potentially contaminated
equipment
● Train and educate healthcare workers
● Test and evaluate healthcare workers for TB infection and disease
● Apply epidemiology-based prevention principles
● Use posters and signs demonstrating and advising respiratory hygiene and cough
etiquette
● Coordinate efforts with the local or state health department
Environmental Controls
● Reduce concentration of infectious droplet nuclei through the following

technologies:
o Ventilation technologies, including
▪ Natural ventilation
▪ Mechanical ventilation
o High efficiency particulate air filtration (HEPA)
o Ultraviolet germicidal irradiation (UVGI)
82 IPC HEALS
Respiratory Protection Controls
● Implement a respiratory-protection program

● Train health-care workers on respiratory protection
● Educate patients on respiratory hygiene and the importance of covering
their cough
● Test HCWs for mask fit and functionality
HOW CAN THE TB INFECTION CONTROL PROGRAM BE

IMPLEMENTED AND WHAT ARE THE OUTCOME MEASURES?
Table 8. Implementation of TB Infection Control Program

TB Infection
Control Implementation4-6 Outcome
Program Measure/Monitoring
83 IPC HEALS
ADMINISTRATIVE Assign someone to head the TB infection Infection Control Plan4
control (IC) program ● One way to assess the impact of
CONTROL implemented IC practices is by
Make an infection control plan. In general, reviewing the medical records of
the IC plan should include: a sample of TB patients seen in
1. Identification of risk areas the facility.
2. Assessment of TB among HCWs
(where feasible) ● The evaluation of outcome
3. Assessment of HIV prevalence in measures can then be used to
the patient population (where identify the areas where
feasible) improvement may be needed.
4. Assessment of HCW training
needs ● Measures that can be examined
5. Area-specific infection control include:
recommendations ✔ Time interval from admission to
6. Time line and budget suspicion of TB
✔ Time interval from suspicion of
Train the Healthcare workers re:
TB to ordering sputum for AFB
1. The basic concepts of TB
smears
transmission and its
pathogenesis ✔ Time interval from ordering to
2. The signs and symptoms of TB the collection of sputum
3. The increased risk of TB disease ✔ Time interval from the
in persons with HIV infection, examination of the smear to the
and other immunosuppressive reporting of results
conditions, who also are infected ✔ Time interval from the return of
with M. tuberculosis laboratory results to the
4. The importance of the IC plan initiation of treatment
and the responsibility that each
HCW has to implement and Unnecessary delays in any of these
maintain IC practices in order to can lead to increased nosocomial
reduce the risk of TB transmission of MTB.
transmission
5. Which settings pose an increased Training of Healthcare Workers9
risk of TB transmission (e.g.,
closed examination rooms) Example from CDC:
6. Specific IC measures and work ● The Self-Study Modules on
practices that reduce the Tuberculosis Slide Sets consist of
likelihood of transmitting M. five presentations:
tuberculosis ✔ Module 1: Transmission and
Pathogenesis
● Early Identification and Diagnosis of Tuberculosis
Suspicion of TB should be high in:
✔ Module 2: Epidemiology of
1. Patients with persistent cough
Tuberculosis
(i.e. more than 3 weeks)
2. Patients with other symptoms ✔ Module 3: Targeted Testing and
compatible with TB (e.g., bloody the Diagnosis of Latent
sputum, night sweats, fever, or Tuberculosis Infection and
weight loss) Tuberculosis Disease
3. Patients in whom the risk of TB is ✔ Module 4: Treatment of Latent
high (e.g., HIV-infected or Tuberculosis Infection and
immunocompromised persons) Tuberculosis Disease
4. Contacts of a person with ✔ Module 5: Infectiousness and
infectious TB Infection Control
84
The laboratory should be proficient at:
1. Methods of sputum specimen IPC
● Each
HEALS
module presentation
contains the following sections:
processing ✔ Overview and Objectives: A
2. The administrative aspects of guide to the information
specimen processing (e.g., participants should learn from
record-keeping, notification) the module.
3. Maintaining quality control of
ENVIRONMENTAL The TB infection control team should Maintenance record
ensure the following:
CONTROL ● A maximized natural ventilation ● Ventilation systems should be
through open windows evaluated regularly to determine
● Provision of mechanical ventilation if they are functioning properly.
(e.g. window fans, exhaust ventilation
systems) in isolation room or wards ● The most simple evaluation
● Provision of AII rooms (from the includes the use of smoke (e.g.
triage/ER department to wards/ICU) smoke tubes) to monitor proper
● Addition of HEPA filters and UVGI to airflow direction.
kill MTB
● Well-functioning environmental ● If window fans are being used to
controls in special or certain high risk produce negative pressure, they
areas (e.g. TB patient isolation should be checked frequently to
areas/rooms, where sputum is ensure air movement is directional
collected, bronchoscopy suites, ICUs, and adequate.
autopsy suites)
Evaluations should be documented in
This requires coordination with the a maintenance record.
healthcare administrator, infection
control committee and engineering UGVI and HEPA
department. ● Manufacturer’s instructions
regarding installation, cleaning,
To maximize benefit, efforts to improve maintenance, and ongoing
ventilation should involve consultation monitoring should be carefully
with an expert in environmental control. consulted. Maintenance and
monitoring should be properly
documented.
RESPIRATORY The TB infection control team should ● Accessibility of N95 masks most
implement the ff: especially in high risk areas for
PROTECTION ● Respiratory-protection program healthcare workers and surgical
CONTROL ▪ provision of N95 masks to masks for patients.
healthcare workers
▪ provision of surgical masks to TB ● Posters seen in the hospital
patients premises regarding respiratory
● Training HCWs on respiratory hygiene and cough etiquette
protection procedures.
▪ incorporated in training of HCW
under administrative control
● Training patients on respiratory
hygiene and cough etiquette
procedures
▪ explain to patients
▪ posters
WHAT ARE THE MINIMUM REQUIREMENTS OF TB ISOLATION ROOMS?
Each TB Isolation room should have the following:
1. Negative Pressure Isolation Rooms system. This will reduce the risk of infection
85 IPC HEALS
via airborne transmission to other persons, visitors and health staff.
The Isolation room pressure is lower than the adjoining rooms or corridor. Pressure
differentials should not be less than 15 Pa between isolation rooms and the adjacent
ambient air. See figure below:
a. The Isolation room pressure is lower than the adjoining anteroom; and the
negative anteroom pressure is lower than the pressure in the corridor
(which is ambient pressure). Pressure differentials should not be less than
15 Pa between isolation rooms and the adjacent areas.
2. An Anteroom should be placed at the entrance of the negative pressure Isolation

Room. Within each anteroom is a sink and faucet with hands-free control, bathroom
and toilet, a self closing door to the corridor and 100% outside air ventilation (i.e.
no return air permitted), with low level exhaust ducts. And cabinets large enough
for Personal Protective Equipments (gowns, gloves, N95 masks).
3. Differential air pressure instrumentation panels are required external to the

isolation and Anteroom in a prominent location. (e.g.: adjacent to the corridor entry
door). It is recommended that the isolation room controls are accessible by staff so
that when required, the negative pressure system can be switched off.
4. Ensure rooms are well sealed. windows, doors, air-intake and exhaust ports.
Monitor air leaks.
5. Air-conditioning systems for negative pressure Isolation Rooms should be
connected to an emergency power supply to maintain air pressurization in the
event of a power failure.
6. Self-closing doors for exit doors.
7. The rooms require labelling as a negative pressure Isolation Rooms.
Table 9. Requirements of TB Isolation Room
REQUIRED COMPONENTS OF ISOLATION ROOMS
Anteroom
Bathroom (with toilet and bath)
Self-closing Door to room
Soap and faucet with hands free operation
Independent air supply
100% intake of fresh air
Low level exhaust 150mm to 300mm above floor level
Pressure monitoring gauge
86 IPC HEALS
Figure 21. Three-dimensional perspective of TB isolation room
Figure 22: Respiratory Protection for TB Care
CHAPTER REFERENCES
1. Centers for Disease Control. Tuberculosis. Basic TB Facts. Availabale at
http://www.cdc.gov/tb/topic/basics/default.htm. Accessed 30 September 2017
87 IPC HEALS
2. Vianzon R, Garfin A, Lagos A and Belen R. The tuberculosis profile of the Philippines, 2003–2011: advancing
DOTS and beyond. Western Pacific Surveillance and Response Journal, 2013, 4(2).
doi:10.5365/wpsar.2012.3.4.022
3. World Health Organization. Global Tuberculosis Report 2017. Available at
http://www.who.int/tb/publications/global_report/en/. Accessed 07 May 2018
4. World Health Organization (WHO). Guidelines for the prevention of tuberculosis in health care facilities in
resource- limited settings. Geneva: WHO, 1999. Available at:
http://www.who.int/tb/publications/who_tb_99_269.pdf. Accessed 30 September 2017
5. Centers for Disease Control. Tuberculosis. Core Curriculum on Tuberculosis. Available at
http://www.cdc.gov/tb/education/corecurr/pdf/chapter7.pdf. Accessed 03 October 2017
6. Jensen PA, Lambert LA, Iademarco MF, Ridzon R, for the Centers for Disease Control and Prevention.
Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005.
MMWR Recomm Rep 2005; 54(RR-17):1–141. Available at: https://www.cdc.gov/Mmwr/PDF/rr/rr5417.pdf.
Accessed 03 October 2017
7. Bock NN, Jensen PA, Miller B, and Nardell E. Tuberculosis Infection Control in Resource-Limited Settings in the
Era of Expanding HIV Care and Treatment. The Journal of Infectious Diseases 2007; 196:S108–13
8. World Health Organization. The Global Plan to Stop TB 2006–2015. Available at
http://www.who.int/tb/features_archive/global_plan_to_stop_tb/en/. Accessed 03 October 2017
9. Centers for Disease Control. Tuberculosis. Self Study Modules on Tuberculosis. Available at
https://www.cdc.gov/tb/publications/slidesets/selfstudy/pdf/ssm-1-5-facilitatator-guide_final5.pdf.
Accessed 03 October 2017
10. International Health Facility Guidelines: Chapter on Isolation Rooms Version 5B 2017
11. Francis J. Curry National Tuberculosis Center, Institutional Consultation Services. Isolation Rooms:
Design, Assessment, and Upgrade 1999.
12. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory
Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
13. CDC Guidelines for the Prevention of Transmission of Mycobacterium tuberculosis in health care facilties
2005.
14. Curry International Tuberculosis Center, 2011: Tuberculosis Infection Control: A Practical Manual for Preventing
TB,
88 IPC HEALS
Created by:
Krizia CO, Karla CRUZADO, Valeria CUYEGKENG
Alexandra LEE, Jabesse MIGUEL, Christine ROBLES
of UPCM Class 2018
89 IPC HEALS
CHAPTER 12
INFECTION CONTROL FOR EMERGING INFECTIONS:

THE COVID-19
LEARNING OUTCOMES:
At the end of this chapter, the health care facility administrator should be able to:
1) Describe the development of the novel coronavirus;
2) Enumerate the infection control measures which should be observed in
health facilities that manage the COVID-19.
3) Identify which processes need urgent support of the administration.
4) Support its Infection Control Committee initiatives for preparedness for
emerging infections.
A new outbreak from the novel coronavirus eventually named COVID-19

presented in Wuhan City, China at the start of 2020. Over a few weeks it has
spread across the world with enormous national and international impact.
Infection Prevention and Control is an extremely important and critical

component of global efforts to contain this infection.
What is the role of hospital leadership in situations like an

infectious outbreak particularly of national and international
importance?
The COVID-19 is a perfect example of how vital it is for hospital

leadership to support its Infection Control Committee in the
preparations to respond appropriately despite the threat of high
communicability. Administrative controls is always at the very top
priority and first requirement to be able to answer to the public
health call to act! Without the “blessing” of administration, it almost
impossible to get anything done. In highly communicable infectious
threats, there is so much resistance, anxiety, fear and other emotions
involved, and the intervention and reassurance from admisitration
through show of support is of utmost importance.
Administrative control means:

● Development and endorsement of hospital policy
90 IPC HEALS
● Approval of proposed strategies by the ICC
● Support in coordinating multispecialty or interdepartmental
cooperation and participation
● Provision of budget and financing of needed space for clinic or
triage area, materials like PPEs, manpower for additional
nursing complement and the likes
● Initiating and providing role-models to instill a culture of
patient safety;
● Assurance that the hospital will care for the HCW staff through
provision of PPEs and post-care monitoring and health
benefits.
References:
1. CDC. 2019 Novel Coronavirus, Wuhan, China: Frequently Asked Questions and Answers. CDC.
Available at https://www.cdc.gov/coronavirus/2019-ncov/faq.html. January 27, 2020.
2. Li Qun, X Guan, Peng Wu, Xiaoye Wang, Lei Zhou, Yeqing Tong, Ruiqi Ren, KSM. Leung, EHY.Lau, JY
Wong, Xuesen Xing, Nijuan Xiang, Yang Wu, Chao Li, Qi Chen, Dan Li, Tian Liu, Jing Zhao, Man Liu,
Wenxiao Tu, Chuding Chen, Lianmei Jin, Rui Yang, Qi Wang, Suhua Zhou, Rui Wang, Hui Liu, Yinbo
Luo, Yuan Liu, Ge Shao, Huan Li, Zhongfa Tao, Yang Yang, Zhiqiang Deng, Boxi Liu, Zhitao Ma,
Yanping Zhang, Guoqing Shi, TTY Lam, JT. Wu, George F. Gao, D.Phil., BJ. Cowling, Bo Yang, GM.
Leung, and Zijian Feng. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–
Infected Pneumonia. N Eng J Med 2020. DOI:10.1056/NEJMoa2001316
3. Kupferschmidt K Study claiming new coronavirus can be transmitted by people without
symptoms was flawed. Science. 2020; (published online Feb 3.) DOI:10.1126/science.abb1524
4. WHO 2019 novel coronavirus Situation Report 8. http://www.who.int/docs/default-
source/coronaviruse/situation-reports/202001278-sitrep-8-ncov-cleared.pdf
5. Department of Health. 2019 novel coronavirus http://www/doh/gov.ph/2019-nCoV.
6. WHO. Novel Coronavirus Situation Report 11. http://www.who.int/docs/default-
source/coronaviruse/situation-reports/202001278-sitrep-11-ncov.pdf
91 IPC HEALS
7. Department of Health Situational Report on the Novel Coronavirus (2019-nCoV) February 3, 2020
Report 007. https://www.doh.gov.ph/sites/default/files/basic-page/2019-nCov-
SituationalReport-02032020.jpg
8. Department of Health Situational Report on the Novel Coronavirus (2019-nCoV) February 5, 2020
nCoV Tracker https://www.doh.gov.ph/sites/default/files/basic-page/2019-nCoV-Tracker-
0205.jpg
9. World Health Organization. Coronavirus disease (COVID-19) Outbreak
https://www.who.int/emergencies/diseases/novel-coronavirus-2019
10. Kupferschmidt K Study claiming new coronavirus can be transmitted by people without
symptoms was flawed. Science. 2020; (published online Feb 3.) DOI:10.1126/science.abb1524
11. PSMID-PIDSP-PHICS Guidelines for the Management and Infection Control of the COVID-19, 2020.
12. WHO/2019-nCoV/IPC/v2020.2. Infection prevention and control during health care when novel
coronavirus (nCoV) infection is suspected. Interim guidance. 25 January 2020.
13. PGH Guidelines on the Screening, Triaging and Management of the 2019 Novel Coronavirus 2020.
UP-Philippine General Hospital.
14. Interim Guideline on the Clinical Management and Prevention of Novel Coronavirus (nCoV)
Infection from the Research Institute for Tropical Medicine (RITM) 2020.
15. Department of Labor and Employment Labor Advisory no. 04-20 Guidelines on 2019 Novela
Coronavirus (2019-ncov) Prevention and Control at the Workplace
https://www.dole.gov.ph/news/labor-advisory-no-04-20-guidelines-on-2019-novela-
coronavirus-2019-ncov-prevention-and-control-at-the-workplace/
16. The “Who, What, Where, When, How and Why” of Personal Protective Equipment from WRHA
Infection Prevention and Control Learning Booklet. wrha.mb.ca/ipc
17. WHO Guidelines on Infection prevention and control of epidemic- and pandemic-prone acute
respiratory infections in health care 2014.
18. Public Health England. Guidance to 2019-nCoV Infection Prevention and Control. 3 February 2020.
19. Communicable Disease Network Australia. Novel Coronavirus 2019 (2019-nCoV)CDNA National
Guidelines for Public Health Units
https://www1.health.gov.au/internet/main/publishing.nsf/Content/7A8654A8CB144F5FCA2584F8001
F91E2/$File/2019-nCoV-interim%20SoNG-v1.5.pdf
20. CDC Coronavirus Disease 2019 (nCoV) Infection Control
https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html
21. CDC Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece
Respirators in Healthcare Settings
22. Reusability of Facemasks During an Influenza Pandemic: Facing the Flu (2006) Chapter 3: Use and
Reuse of Respiratory Protective Devices for Influenza Control.
https://www.nap.edu/read/11637/chapter/5#46
23. CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2019 Update.
24. Department of Health Government of Western Australia. Advise in Handling Soiled Linen in the
Context of Novel Coronavirus.
2020.https://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Infectiou
s%20diseases/PDF/Coronavirus/Coronavirus%20information%20Department%20of%20Health
%20advice%20on%20handling%20linen%20to%20laundry%20services.pdf
25. WHO. Risks posed by dead bodies.
https://www.who.int/diseasecontrol_emergencies/guidelines/risks/en/
26. Precautions for Handling and disposal of dead bodies. Department of Health Hospital Authority
Food and Environmental Hygiene Department The 10th edition, 2014 (Last reviewed: February
2020).
https://www1.health.gov.au/internet/main/publishing.nsf/Content/7A8654A8CB144F5FCA258
4F8001F91E2/$File/2019-nCoV-interim%20SoNG-v1.5.pdf).
27. Hong Kong Department of Health. Precautions in Handling and Disposal of Dead Bodies. Hospital
Authority Food and Environmental Hygiene Department February 2020.
https://www.chp.gov.hk/files/pdf/grp-guideline-hp-ic-
precautions_for_handling_and_disposal_of_dead_bodies_en.pdf
92 IPC HEALS
Created by:
Frances Roxanne CRUZ, Erickah Mary Therese DY
93 IPC HEALS
Johna Pauline MANDAC, Anna Francesca MULLES, Alissandra Abby OCAMPO
of UPCM Class 2018
CHAPTER 13
HEALTHCARE WORKER SAFETY: S of HEALS

I. IMMUNIZATION FOR HEALTHCARE WORKERS
Jemelyn U. Garcia MD
LEARNING OUTCOMES
At the end of this chapter, the Healthcare facility administrator should be able to:
1) Understand the general principles of immunization
2) Identify the various immunization strategies which can protect health care
workers
WHAT IS IMMUNIZATION?
Immunization provides protection from infectious diseases and is usually
indicated by the presence of antibody very specific to a particular antigen.
WHO ARE THE HEALTHCARE WORKERS?

Healthcare worker (HCW) is defined as all persons working in a healthcare
setting who have the potential for exposure to patients and/or to infectious
materials, including body substances, contaminated medical supplies and
equipment, contaminated environmental surfaces, or contaminated air.1
HCWs include, but are not limited to, physicians, nurses, nursing assistants,
therapists, technicians, emergency medical service personnel, dental personnel,
pharmacists, laboratory personnel, autopsy personnel, students and trainees,
contractual personnel, home healthcare personnel, and persons not directly
involved in patient care (e.g., clerical, dietary, house-keeping, laundry, security,
maintenance, billing, chaplains, and volunteers) but potentially exposed to
infectious agents that can be transmitted to and from HCW and patients.
HOW CAN HEALTH CARE FACILITY ADMINISTRATORS SHOW THEIR

SUPPORT FOR THE HCWs?
In this chapter we would like to convince hospital leadership that there are
many ways to care for the HCWs. One most cost-efficient way is by supporting
their immunization.
WHAT VACCINES ARE RECOMMENDED FOR ALL FILIPINO HCWs?

Table 10 shows the list of recommended vaccines for Filipino HCW. It also shows the
required schedule of the vaccines to achieve desired antibody levels.
94 IPC HEALS
Table 10. List of Highly Recommended Immunization for the HCWs
CHAPTER REFERENCES:
1) Centers for Disease Control and Prevention. Immunization of Healthcare Personnel: Recommendations of
the Advisory Committee on Immunization Practices. MMWR 2011;60(7):1-46.
2) Centers for Disease Control and Prevention. CDC Guidance for Evaluating Health-Care Personnel for
Hepatitis B Virus Protection and Administering Postexposure Management. MMWR 2013;62(10):1-19.
3) Faoagali JL, Darcy D. Chickenpox outbreak among the staff of a large, urban adult hospital: costs of
monitoring and control. Am J Infect Control. 1995;23(4):247.
4) Philippine Society of Microbobiology and Infectious Disease (PSMID). Handbook on Adult Immunization
for Filipinos 2012. 2nd edition.
5) Kim D, Bridges C, Harriman K. Advisory Committee on Immunization Practices Recommended
Immunization Schedule for Adults Aged 19 Years or Older: United States, 2015. Ann Intern Med.
2015;162:214-223.
6) Potter J, Stoot DJ, Roberts MA, Elder AG, O'Donnell B, Knight PV, Carman WF. Influenza vaccination of
health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis.
1997;175(1):1.
7) Philippine Society of Microbobiology and Infectious Disease (PSMID). Recommended Immunization for
Filipino Healthcare Workers 2012.
8) Saxen H, Virtanen M. Randomized, placebo-controlled double blind study on the efficacy of influenza
immunization on absenteeism of healthcare workers. Pediatr Infect Dis J 1999;18:779.
9) https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-treatment-of-
diphtheria?source=machineLearning&search=diphtheria%20prophylaxis&selectedTitle=1~150&sectionRan
k=1&anchor=H13#H13
10) Department of Health. Philippine Revised Guidelines for Management of Rabies Exposure (AO2018-
0013)
11) (http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm)
12) http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html)
95 IPC HEALS
Created by:
Pierre Aldwin ARCEO, Jasmine Therese ARCILLA
Joshua Vincent BAROÑA, Ronell BASA
96 IPC HEALS
of UPCM Class 2018
CHAPTER 14
HEALTHCARE WORKER SAFETY: S in HEALS

II. Needlestick Management and Prevention
Jemelyn U. Garcia MD
LEARNING OUTCOMES:
At the end of the chapter, the healthcare facility administrator should be
able to:
1. Know when an occupational event or exposure may have put the HCW at
risk for transmission of a pathogen from a patient or other HCWs
2. Describe what constitutes appropriate timely action to minimize the risk
of transmission in the event of an exposure.
3. Review the available safer needleless systems and weigh the benefits
versus the costs of these newer technologies.
What is a NEEDLESTICK INJURY?

● WHO reports in the World Health Report 2002, that of the 35 million health-
care workers (HCW), 2 million experience percutaneous exposure to infectious
diseases each year10. Needlestick injuries (NSI) are the most common cause of
occupational exposure to blood and the primary cause of blood-borne infections
among HCWs1.
● The most common blood-borne infections from NSIs are hepatitis B, hepatitis C
and HIV infections. The risk of transmission of hepatitis B from a single
needlestick exposure varies according to the hepatitis B e antigen (HBeAg)
status of the source case. It ranges from 1% to 6% for HBeAg-negative blood,
and up to 22% to 31% for HBeAg-positive blood. Hepatitis C seroconversion
after NSI among non-immune HCWs has been reported at 1-10%, but most
studies have reported less than 3% transmission rate.
● Pooled data from these studies suggest that the average risk for HIV
transmission associated with percutaneous exposures to blood- contaminated
sharp objects that have been used on HIV-infected individuals is reported to be
0.32% (21 infections associated with 6498 exposures; 95% confidence interval
of 0.18% to 0.46%)7. On the average, the risk of blood-borne infections from a
needlestick injury is 30% for hepatitis B, 3 % for hepatitis C and 0.3% for HIV
infection.
Why should administrators be knowledgeable of Needlestick Injuries?

● Administrators need to be aware of the occurences of needlestick injuries
(NSI) in the health facility. There are significant costs attributed to NSIs.
97 IPC HEALS
● The cost could be both monetary as well as non-monetary.
● Monetary costs include workup for direct costs of diagnostic tests,
immunoglobulin, immunization.
● Nonmonetary costs include absent days, emotional distress, physical
disability and legal problems).
● Because of all the potential complications they can cause, NSIs should be
prevented and managed well.
● Administrators must consider investing on strategies to reduce NSIs such
in the figure below.
LEAST EFFECTIVE MOST EFFECTIVE
Figure 23. Hierarchy of Controls to Prevent NSIs
From Least effective to Most Effective Strategies

● PPE: barriers and filters between the HCW and the hazard. Examples: eye
goggles, gloves, masks, gowns
● Work Practice Controls: No recapping, placing sharps containers at eye-
level and at arms reach, emptying sharps containers before they are full,
establishing safe handling and disposing of sharps devices before
beginning a procedure.
● Administrative Controls: Policies to limit exposure to hazard. Example:
creation of committees, removing unsafe devices, consistent training
● Engineering Controls: Safe sharps with advanced technology
● Elimination of Hazard: removal of sharps and needles; use of needleless
systems
98 IPC HEALS
CHAPTER REFERENCES
1) Centers for Disease Control and Prevention. National Institute for Occupational Safety and
Health (NIOSH) NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings, 1999.
Publication No. 2000-108. <www.cdc.gov/niosh/2000-108.html>.
2) Philippine Society for Microbiology and Infectious Diseases.Handbook on Adult
Immunization 2009.
3) https://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html#needlestick_injuries
4) https://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html#needlelesssystem
5) http://www.uptodate.com/contents/prevention-of-hepatitis-b-virus-and-hepatitis-c-virus-
infection-among-healthcare-providers
6) http://www.uptodate.com/contents/management-of-healthcare-personnel-exposed-to-
hiv?source=machineLearning&search=needlestick+injury+or+percutaneous+injury+and+heal
thcare+workers&selectedTitle=2~150&sectionRank=1&anchor=H14#H1
7) Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases, 8th edition.
8) Department of Health. Post Exposure Management for HIV, Hepatitis B & C in the
Healthcare Settings. National AIDS and STI Prevention and Control Program 2009.
9) Updated U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis
(2001)
10) Wilburn S, Eijkemans G. Preventing Needlestick Injuries among Healthcare Workers: A
WHO–ICN Collaboration. Int J Occup Environ Health 2004;10:451–456.
11) WHO Guidelines on Post-Exposure Prophylaxis for HIV and the Use of Cotrimoxazole
Prophylaxis for HIV-Related Infections Among Adults, Adolescents and Children:
Recommendations for a Public Health Approach December 2014 Supplement to the 2013
Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV
Infection
12) : http://www.uptodate.com/contents/management-of-healthcare-personnel-exposed-
tohiv?source=machineLearning&search=needlestick+injury+or+percutaneous+injury+a
nd+healthcare+workers&selectedTitle=2~150&sectionRank=1&anchor=H14#H14
99 IPC HEALS
Created by:
Vernon CHUABLO
of UPCM Class 2018
100 IPC HEALS

CHAPTER 15
OUTBREAK INVESTIGATION IN THE HEALTHCARE

SETTING
LEARNING OUTCOMES
At the end of this chapter, the healthcare facility administrator should be
able to:
1. Define what an outbreak it in the healthcare facility setting
2. Recognize when it is necessary to initiate outbreak investigation.
3. Lead and support the development of firm definitive actions to prevent
future outbreaks.
CHAPTER SUMMARY
An outbreak or an epidemic is the occurence of more cases
of disease than expected in a given area or among a specific
group of patients or clinical area/ward/unit or over the
entire hospital over a particular period of time.
Thus the purpose of an Outbreak Investigation in the healthcare

setting is to immediately find the source or cause of the Outbreak,
address the gaps in IPC and prevent the next potential infections.
HOW SHOULD HEALTHCARE ADMINISTRATORS RESPOND TO A POSSIBLE

OUTBREAK IN HIS/HER FACILITY?
● All efforts of IPC is to precisely avoid the occurence of outbreaks.
● Nevertheless, if such outbreaks will occur, hospital administrators should continue to be
firm and insist on having constant communication with the team doing the footwork of
the outbreak investigation.
● Action should be prompt and follow the general steps recommended:
o DESCRIPTIVE STEPS:
▪ Is it an outbreak?
▪ Confirm the diagnosis.
▪ Define, find, count the cases.
▪ Analyze the data: When? Where? Who? Why?
o ANALYSIS:
▪ Generate a hypothesis
▪ Test the hypothesis
▪ Compare the hypothesis with the facts
▪ Conduct complementary studies
o SYNTHESIS and ACTION
▪ Write a report and communicate to administration and staff
▪ Make a plan/measure to prevent future outbreaks
101 IPC HEALS

CHAPTER REFERENCES:
1. US Department of Health and Human Services Centers for Disease Control and
Prevention. Principles of Epidemiology in Public Health Practice , Third Edition An
Introduction to Applied Epidemiology and Biostatistics 2006, Update May 2012. Atlanta
GA USA
2. http://sphweb.bumc.bu.edu/otlt/MPHModules/PH/Outbreak/Outbreak_print.html
3. https://www.healthknowledge.org.uk/public-health-textbook/disease-causation-
diagnostic/2g-communicable-disease/outbreak-investigation
4. Merrill RM Principles of Epidemiology Workbook: Exercises and Activities 2018 Jones
and Bartlett Learning LLC
http://publichealth.jbpub.com/merrill/epidemiologyworkbook/
102 IPC HEALS

Created by:
Karl SEPARA, Karen Nicole SY
Patrick Leo REBATO, Ivi TORRES, Florendo BETANCOR Jr.
of UPCM Class 2018
103 IPC HEALS

CHAPTER 16
Surveillance of HAI: S of HEALS

LEARNING OUTCOMES
At the end of this chapter, the health facility leader and administrator should be
able to:
1) Know that surveillance activities are vital components of IPC;
2) Formulate a plan for surveillance in one's institution;
3) List the Key Performance indicators (KPI) periodically reported by the ICC.
WHAT IS SURVEILLANCE?
● Surveillance is a comprehensive method of measuring outcomes and related
processes of care, analyzing the data, and providing information to members of
the health care team to assist in improving those outcomes.
● Surveillance is an essential component of effective clinical programs designed to
reduce the frequency of adverse events such as infection or injury.
● Although there is no single or ‘‘right’’ method of surveillance design or
implementation, sound epidemiologic principles must form the foundation of
effective systems and be understood by key participants in the surveillance
program and supported by senior management.
KEY MESSAGES FOR THIS CHAPTER:
WHAT ABOUT IPC SURVEILLANCE MUST HOSPITAL

ADMINISTRATORS KNOW?
● After setting up the robust IPC program according to the National Standards of
Infection Control set by the Technical Working Group on Development of Standards
In Infection Control for Healthcare Facilities together with the Department of Health, the
next task of the infection control committees is to assure that the IPC program is also
104 IPC HEALS

sustainable.
● For this to happen, surveillance with measurements need to be taken consistently,
analyzed and reported. The subsequent prompt actions for quality improvement
cycles can be done as indicated.
● Thus MEASUREMENT is essential to monitoring success and
helps guide the IPC committees and teams towards reaching specific targets and
intervention goals.
● Measurements allow a quick, real time evaluation of whether one strategy is
working or not working.
● Measurements provide basis or proof to inspire other HCWs to improve the quality
of patient services towards safety.
● The measurement methodology in surveillance activities of IPC does not require the
large sample sizes required in research methodologies. Instead these are based on
small frequent samplings based on The Model for Improvement. Using the Plan-Do-
Study-Act (PDSA) cycle; a "trial and learn" approach to improve is followed.
● Infection Control Committees must decide on the measures that they will get over
time to monitor the success of their IPC programs. The following measures below
may serve as a guide. IPC programs must identify their own needs and targets. The
measures can also evolve over time. Surveillance methods must be regularly
assessed to adapt to the changing needs of the program.
Table 11. Example of Key Performance Indicators or Quality Indicators

which must be measured by the ICC
Meas ures Institutional Type of
Goal Measure
Measure 1: Percent Appropriate Hand Hygiene Practice by at least 80% Process Measure
Health Care Workers (HCW)
Measure 2: Volume of Alcohol Based Hand Rub Used for the Increase baseline Process
Area being Monitored Measure
Measure 3: Volume of Hand Hygiene Soap Used for the Area Increase baseline Process
being Monitored Measure
Measure 4: Percent Availability of Hand Hygiene Products at 95% Process

Bedside or Patient Areas being Monitored - Bundle Measure
Compliance
Measure 5: Number of Gowns Used for the Area being Increase 50% Process Measure
Monitored
Measure 6: Number of Boxes of Gloves Used for the Area Increase 50% Process Measure
being Monitored
Measure 7: Measure Percent Appropriate Environmental 100% Process Measure

Cleaning Practice
Measure 8: Reduction in Mean Time to Placement on Contact Decrease 50% Process

Precautions Measure
Measure 9: Percentage Inappropriate request for restricted Reduce by 50% Process Measure
antibiotics
105 IPC HEALS

Measure 10 - Incidence of HAI-MRSA Clinical Isolates per Reduce by 50% Outcome
1000 Patient Days Measure
Measure 11 - Incidence of HAI-MDR Acinetobacter baumanii Reduce by 50% Outcome

Clinical Isolates per 1000 Patient Days Measure
CHAPTER REFERENCES
1) Horan TC, Gaynes RP. Surveillance of nosocomial infections. In: Mayhall CG, editor.
2) Hospital Epidemiology and Infection Control. 3rd ed. Philadelphia: Williams & Wilkins;
2004. p.1659-1702.
3) Lee TB, Baker OG, Lee JT, Scheckler WE, Steele L, Laxton CE. Recommended practices for
surveillance. Am J Infect Control 1998; 26:277-88.
4) Arias KM. Surveillance. APIC Text of Infection Control & Epidemiology. 2nd ed.
Washington,DC: APIC; 2005. p. 3.1-3.18.
5) National Nosocomial Infections Surveillance (NNIS) System Manual, July 2002.
6) National Healthcare Safety Network (NHSN) Patient Safety Component Protocol, May
1,2006. (Available from http://www.cdc.gov/ncidod/hip/ nhsn/members).
7) Haley RW. Surveillance by objective: a new priority-directed approach to the control of
nosocomial infections. Am J Infect Control 1985;13:78-89.
8) Haley RW, Gaynes RP, Aber RC, Bennett JV. Surveillance of nosocomial infections.
In:Bennett JV, Brachman PS, Sanford JP, eds. Hospital Infections. 3rd ed. Boston, MA:
Bennett and Brachman; 1992. p. 79-108.
9) Mangram J, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of
surgical site infection. Infect Control Hosp Epidemiol 1999; 20:247-78.
10) CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report,
data summary from January 1992 through June 2004, issued October 2004. Am J Infect
Control2004;32:470-85.
106 IPC HEALS

Created by:
Andrea Isabel T. CONTRERAS, Riza Paula M. LABAGNOY,
Vannah Marjolaine C. LEE, Marie Abigail R. LIM, Ma. Sergia Fatima P. SUCALDITO
UPCM CLass 2018
107 IPC HEALS

CHAPTER 17
DIFFICULT SITUATIONS IN INFECTION PREVENTION

AND CONTROL
Maria Lourdes Bernadeth V. Manipon RN, MSN
LEARNING OUTCOMES
At the end of this chapter, the health facility leader and administrator should be
able to:
1) identify the various difficult situations encountered in the practice of IPC;
2) understand the responses and actions to address the difficult situations.
108 IPC HEALS

WHAT ARE THE VARIOUS DIFFICULTIES ENCOUNTERED IN INFECTION
CONTROL?
● Many factors play a very important role not only in preventing Healthcare-
associated Infections (HAI) but also in implementing Infection Control policies and
guidelines. As highlighted in the previous chapters, there are a lot of interventions
that need to be implemented in order to develop efficient infection control
programs in all health care settings. It is because of this reality that difficult
situations cannot be avoided and will soon rise and challenge the sustainability
infection control programs.
● Barriers exist on a number of levels through which the individual healthcare worker
experience. The implementation is also influenced by resources, general approaches
to quality, and perception. The potential barriers are outlined in the table below
from the WHO Patient Safety Solutions of 20071. It is therefore important for all
healthcare facilities, especially its administrators, to always evaluate, innovate and
take on the challenge.
A. Unsupported Programs (Financial constraints)

Demonstrating the value of infection prevention to managers and
administrators is still one of the major challenges of most developing countries
today. HAIs consume resources, prolong the patient’s hospital stay and are only
partially reimbursed at best, because hospital administrators and managers do
not realize that preventing such infections entails investing in programs
wherein, provision of medical supplies and other expenditures are needed.
Administrators worry that they cannot afford to implement these precautions,
but the truth is, they cannot afford not to. Many studies and financial reports
have stated that these infections erode hospital profits.
Other studies on the cost of infections found that when a patient develops an
infection after surgery, the cost of care increases 119%, on average, at a
teaching hospital, and 101% at a community hospital. While the cost of care
increases for pneumonia after surgery by 89% at a teaching hospital and 76% of
a community hospital; urinary tract infections by 47% in a teaching hospital
versus 35% of a community hospital; mechanical complications by 57% at a
teaching hospital and 52% of a community hospital; and pulmonary comprise of
83% at a teaching hospital and 94% at a community hospital2 .
In the Philippines, infection preventionists have been continuously striving to

change the perception of most of its administrators and even those healthcare
professionals, who can only recognize the burden of these infections and yet do
not support its financial requirement.
The inexorable growth in health care costs force administrators to respond to

scarcity and work toward extracting greater value from health care resources.
This is true especially in government hospitals wherein much burden is given to
the infection preventionists to stretch their programs on limited available
resources. Providing proof to health administrators of the cost-effectiveness of
infection control programs is crucial to infection control practitioners if they
expect to receive any financial allocation or investment for the establishment of
109 IPC HEALS

such programs.
Making the case

Communicating well to the language of the hospital administration is one of the
key strategies that infection control practitioners should learn. Most hospital
administrators approve fund allocations depending on the projected return of
investment. And unfortunately, most administrators see infection prevention
and control programs as cost centers. Perencevich, et al.3 and Murphy and
Whiting4 say that a business case exists if the intervention realizes a financial
return on investment through hospital profit, loss reduction, or cost avoidance
in a reasonable time frame.
The primary cost of HAIs to the hospital is the loss of bed days due to prolonged
hospital stay of the patients. Comparing the cost of an infection prevention and
control program or intervention to the benefits which is lowering rates of HAI
and preventing harm and death, is the best method for justifying the investment
in prevention efforts5. The Pennsylvania Patient Safety Authority (PPSA)6 in
2010 has identified a process of building up your case, which can be divided by
the following steps:
● Prepare a summary. State the intervention to be proposed with a brief
description of why it should be implemented and the financial implications
of nor pursuing it.
● Identify a financial partner. Identify and include necessary departments
in the hospital and review existing proposals and financial reports.
● Frame the problem. Select an HAI or a population within the last year or
current year to be analyzed. Select a number of cases of patients. Develop
potential solutions based on these cases. Always correlate data with the
same timeline or period and be able to present your investigation in a direct
and concise manner.
● Meet with key administrators. Before the start of the analysis, obtain
agreement that is the issue of institutional concerns and has the support of
leadership. Administrators can help identify individuals or department that
may be affected by the proposal and also help identify the critical costs and
factors that should be included. Always make sure to obtain the consent
from each unit head for each proposal to be made.
● Determine the costs associated. Emphasize the complications that would
not have occurred during a hospital stay without the HAI. Identify actual
costs and reimbursement, and calculate the difference between profits with
and without an HAI. Use available hospital administrative data for the
amount of costs that are reimbursed. An alternative method of calculating
the attributed cost of an HAI is to multiply the mean increase in length of
stay for HAI cases by the mean daily cost for a hospital stay. Estimate
additional revenue gained by filling the additional bed days available.
● Determine which costs can be avoided. Use proposed or actual past
reduced infection rates. Calculate the gross margin for the case by
subtracting the expenses from the reimbursement. Compares the gross
margin for the case to the gross margin of similar case without HAI.
● Calculate financial impact. Subtract the upfront and future outlay costs
from the estimated cost savings. Determine the annual cost of an infection
110 IPC HEALS

prevention and control program, as well as the salary and benefits.
● Make the case. Once the analysis of the HAIs of the organization is
completed use this information to target an area that has significant
opportunity for improvement and then set the target for elimination of this
HAI. Develop an implementation plan, determine the current support for
the initiative, and answer anticipated questions before presenting.
● Identify process defects. Institute necessary systems or practice strategies
where indicated.
● Measure results. Collect outcomes, and costs of implementation, data to
allow comparison with units where the intervention has not yet been
implemented. Prospectively collect data once programs are in effect can
illustrate subtle outcome rates or continued improvement associated with
the intervention.
B. Noncompliance Issues (Behavioral)

Noncompliance is the lack of right behavior or refusal to act in accordance with
the existing laws or policies. This has been well documented among all
healthcare facilities, and adherence to its guidelines has been one of the major
concerns of most, if not all7.
Compliance issues will always be part of the IPC. The way the staff of the
hospital, including the paramedical staff behaves and views the IPC guidelines
and protocols will always entail difficulties. Among the many guidelines, hand
hygiene remains the simplest, most effective measure for preventing hospital
infections. However, it is also the most documented strategy that has the lowest
compliance rates7, and varies between hospital wards, among professional
categories of healthcare workers, according to working conditions, as well as
according to the definitions used in different studies and institutions8. Barriers
found to contribute to noncompliance are skin irritation from the soap or hand
rub solution, lack or shortage of supplies, inaccessible sinks and wearing of
gloves.
Many attempts have been made in order to improve healthcare workers’

adherence to hand hygiene practices. The WHO has developed Guidelines on
Hand hygiene in Healthcare to be able to provide medical professionals,
administrators and even health authorities with a thorough review of evidence
on hand hygiene, including specific recommendations to improve practices and
its compliance rates. However, not a single approach has been effective in
improving hand hygiene compliance9.
One of the main concern and cornerstone of IPC is how healthcare workers view
their individual responsibilities to the IPC, and they need to be aware of how
they play in maintaining a safe care environment for their patients and the
overall culture of their hospitals and institutions. The improvement of
understanding of organizational and behavioral change is needed to effectively
implement IPC measures such as hand hygiene.
● Make good hand hygiene part of the culture. Organizations that

emphasize good hand hygiene as part of the overall emphasis on safety
can improve hand hygiene compliance. By committing to improved hand
hygiene at all levels of an organization, the organization can make hand
hygiene part of the overall safety focus. Leadership support is critical in
111 IPC HEALS

this effort because staff will pay close attention to what organization
leadership say and does. Identifying role models within the staff may
improve compliance, also by watching a peer thoroughly wash his or her
hands or use a hand rub, staff members can be encouraged to improve
their hand hygiene habits.
● Staff Education. Knowledge leads to behavioral change, which can be a

powerful deterrent to spreading the infection. To overcome the staff
member’s lack of knowledge regarding the importance of hand hygiene,
it is important to have varied, thorough, and timely education
opportunities. In-services, posters, buttons, pamphlets, and so forth can
all improve awareness of the importance of hand hygiene and identify
when it is better to use soap than an alcohol-based hand rub. Before
designing education efforts, it may be helpful to survey staff members
about their awareness of the importance and proper methods of hand
hygiene. This can help focus education efforts and address areas where
staff knowledge is deficient.
● Educate the client. Good hand hygiene is not just an issue for
organization staff. Clients and their families, when applicable, should
also be educated on the importance of good hand hygiene and how to
effectively clean hands. This is also based on the parameter that they
should also be educated and directed towards independence and self-
administration. Deeming a client capable of self-administration and their
parents will empower them to take responsibility for their own care.
Education efforts should involve two-way conversations between staff
and the client or his or her own family.
The Infection Control Committee should consider teaching children and

their parents to ensure that they were effective and efficient. Staff
members should encourage clients to regularly wash their hands and
provide opportunities for them to do so. Including clients in
interventions to improve hand hygiene can also improve compliance.
● Positive feedback. One of the drivers of hand hygiene compliance

improvement is constant and immediate feedback. Rather than the
noncompliance of the staff, the compliance rates could be reported in
aggregate as opposed to individually to avoid an association of
punishment. Positive reinforcements can help motivate staff to perform
at the highest level.
Whatever methods the Infection Control Committee uses to improve hand

hygiene compliance, it is important to monitor compliance over time and do this
in several ways. Surveillance and observation can identify whether staff
behaviors are changing. In addition, staff members and clients should be given
regular feedback about their hand hygiene efforts so that continuous
improvement can be realized.
C. Surveillance (Program evaluation)

An infection control program is a dynamic entity that requires constant
information, analysis and response. The hospital must engage in surveillance
activities to identify new infection control issues, outbreaks or situations that
112 IPC HEALS

require attention. Accurate infection control surveillance is critical for making
real improvements in quality care and patient safety.
The surveillance data that an organization collects varies depending on the

infection risks present. These risks vary, based on geographic location,
community environment, services provided, season of the year and so forth.
Data should be collected on clients and staff as well as visitors, students, and
volunteers as warranted. In choosing what data to collect, an organization
should not only consider its client population and services provided, but also
what data are available, accessible and meaningful. To identify what type of data
an organization should collect as part of its surveillance efforts, it is helpful to
examine high-risk, high-volume, and problem-prone areas10.
● Record review. Organizations can collect data regarding infections

from a variety of records. Review of records for surveillance measures
can be done through automated means or manually, depending on the
size and scope of the organization’s activities. Computers and software
significantly ease the data collection process. Although data may be
collected manually, electronic programs can sort and analyze data and
generate rates, graphs, charts and reports. Sources of data might include,
but not limited to, the following, medical records, financial services,
information services, quality/utilization management, surgical database,
administrative/management reports, risk management, public health
reports, community agencies, occupational/employee health, resources
records and marketing reports.
The collection of infection data for surveillance purposes should be done

using validated, published definitions for HAIs. If the definitions that are
used to categorize an infection are not standardized, a health care
setting’s infection rate cannot be accurately compared to either their
own historical infection rates or to external benchmarks.
At times, the motivation for conducting surveillance is driven by a

specific infectious outbreak or area of concern. It is however
recommended that an established surveillance system or an active
surveillance is in place so as to track the changes in the area or unit. This
will enable quick retrieval, analysis of data and higher level of sensitivity
for case finding.
● Surveys and interviews. These could include surveys of the staffs. By

interviewing staff members and asking them what activities put them or
their clients at risk for infection, organizations can learn firsthand about
new and emerging infection control risks, environmental issues, and
other risks the organization wants to proactively identify.
● Reporting systems. These systems allow the staff to phone, e-mail, or

write reports about clients with infections. When a cluster of infections
is reported, infection control professionals or the committee should take
immediate action to address the infection and control its spread.
Reporting systems may involve a passive approach to surveillance at
least, which relies on the staff to report issues. For organizations to
overcome underreporting issues, they must create an environment that
113 IPC HEALS

makes reporting issues easy for all staff. This can be accomplished by
ensuring that staff know who to contact, how to contact them, and when
to contact them to report infection control issues.
In addition, it is important to issue a quick response to infection control

concerns brought forward by the staff. The staff members must feel that
by reporting, they are helping improve the safety of clients and decrease
infection across the hospital.
● Data analysis. To be effective, data must be analyzed. As part of the
surveillance process, organizations should regularly analyze the
collected data to determine patterns and trends. By monitoring data
over time, an organization can also determine the effectiveness of
infection control strategies and identify areas that still need work.
The recommendation is to calculate incidence density rates. Other areas

of analysis will involve, where medical devices are inserted and/or
surgical procedures are performed, rates of device-associated or
surgical site infection should also be calculated on an ongoing basis. It
may be useful in hospitals to stratify rates of surgical site infections by
standardized risk ratios or rates in order to compare the rates to other
hospitals. An electronic spreadsheet/ or database and/or statistical
analysis program could be to store data and calculate HAI rates, to
maximize infection prevention and control resources and reduce the
potential for errors associated with manual calculations.
● Interpretation of data. Surveillance data require interpretation to

identify areas where improvements to infection prevention and control
practices can be implemented to lower the risk of HAI. One way to
analyze data is through benchmarking. Internal benchmarking involves
looking at an organization’s own data over time and/or comparing it to
data from other areas of hospital or other medical institutions. Internal
benchmarking can help an organization determine whether infection
control efforts are effective in reducing infections and where
opportunities for improvement exist.
External benchmarking allows an organization to compare itself to

others. This can highlight problem areas as well as areas of success. It is,
however essential that the same case finding methods are used, the
same case definitions are applied and the same methods for risk
stratification are employed. Hospitals can benchmark data, whether
internally or externally, an organization must use measures that have
standardized and uniform definitions and methods for data collection
and risk adjustment. This allows an organization to compare and have
an accurate picture of well its infection control programs are doing.
● Evaluation. Periodic review of the surveillance system should be part of

regular Infection Control Committee meetings and should include an
assessment of the outcomes to which the surveillance system
contributes. Evaluation should include how information produced by a
surveillance system is used to reduce the risk of healthcare associated
infections. Outcome evaluation should also take place at least annually
and a realignment of surveillance objectives undertaken when indicated.
114 IPC HEALS

The steps provided in the previous chapter will assist infection
prevention and control professionals to develop and implement their
surveillance programs in a manner that will permit comparisons with
their peers and allow them to quickly detect early increases in
healthcare associated infections that may indicate the presence of an
outbreak.
● Communication of Results. Communication of surveillance data should

take place on an ongoing, systematic basis and be targeted to those with
the ability to change infection prevention and control practice.
Communication may be targeted but not limited to, Infection Prevention
and Control Committee, which provides an aggregate picture of all
infections of interest in the hospital, a particular patient or resident care
area or specialty care area, focused on the risk of specific types of
infections that are of importance to these groups, patient or resident
care staff following the identification of an emerging risk of infection, to
remind or notify of the required precautions in infection prevention and
control, and the local public health unit when there is a reportable
communicable disease event11.
D. Implementation Concerns (Leadership, Staffing level)

Infection control is a hospital-wide function. Addressing infection prevention
and control requires a facility wide program and is everybody’s responsibility.
Healthcare facilities have a legal responsibility to provide a safe work
115 IPC HEALS

environment, safe systems of work and a safe environment for patients and
visitors. Clinical governance refers to the system by which managers and
clinicians in each healthcare facility share responsibility and are held
accountable for patient care. This involves minimizing risks to patients and staff,
and continuously monitoring and improving the quality of clinical care.
Health administrators should also be oriented towards the importance of the

infection control program. Health care workers should be equipped with the
requisite knowledge, skills and attitudes for good infection control practices.
● Open lines of communication. Constant communication with the staff and

other healthcare personnel should be done. This is to ensure that the
management is addressing the issues of the areas or unit effectively and
efficiently. Management meetings could be done on a monthly or quarterly
basis. Topics can be staffing concerns, shortage of supplies, ineffective
leadership, program evaluation and such. Keeping the line of
communication between the staff and the management will not only give an
encouraging atmosphere to the organization, but will also be used by the
management as an opportunity to easily implement programs not limited to
infection prevention and control.
● Clear roles and priorities. Equally, infection control staff does not work
within a clinical hierarchy in the same way as other nurses or doctors. This
is in order to fulfill their infection control responsibilities; staff in the
infection control team must have the authority to examine policies,
procedures, and practices throughout the hospital. That is why it is
recommended that the Infection Control Committee should be under the
Medical Director. This is because the Infection Control Committee members
must be able to scrutinize the practices of even the most senior medical
consultants as this might otherwise bring gaps in the management of
infection control that will put the hospital service at risk.
The Infection Control Committee must have the necessary authority and
recognition within the hospital service to enable them to do their job
properly; and need to communicate effectively and establish credibility with
staff and managers at all levels, so that their guidance is readily accepted
and applied.
In order to do this, it is necessary to examine, the role and organization of

infection control committees and the existence of infection control
representatives or links in the other areas of the hospital, and the roles and
responsibilities of other healthcare personnel and professionals that will be
accountable for the promotion and prevention of infection risks (e,g,
pharmacists). Others to consider are the ways on how the infection control
staff work together with other hospital services such as occupational health
and laboratory services12.
● Transformational leadership. Leadership plays a critical role in hospital

infection prevention and control programs13. In their study they found out
that successful leaders (1) cultivated a culture of clinical excellence and
effectively communicated it to staff; (2) they are focused on overcoming
barriers and dealt directly with resistant staff or process issues that
116 IPC HEALS

impeded prevention of HAI; (3) they also inspired their employees; and (4)
thought strategically while acting locally, which involved politicking before
crucial committee votes, leveraging personal prestige to move initiatives
forward, and forming partnerships across disciplines.
Good leaders are therefore expected to motivate staff by creating high

expectations, modelling appropriate behavior, and providing personal
attention to followers by giving respect and responsibility. Hospital
epidemiologists and infection preventionists often played more important
leadership roles in their hospital’s patient safety activities than other senior
hospital staff and managers. Therefore, good leadership plays a key role in
infection prevention, because the difficult process of translating the findings
of infection prevention research into practice can be eased by these types of
leaders.
Conclusion
Until recently, infection was considered the inevitable risk you faced if you were
hospitalized. Now, there is compelling evidence that nearly all hospital infections are
preventable when hospital staff, clean their hands and adhere to other low-cost
infection prevention measures. While this reality has already been well researched and
communicated, implementation of infection control programs and protocols is still
faced with many challenges and difficulties.
Difficulties such as financial constraints, behavioral issues of the staff, no established

surveillance programs and other implementation concerns are just some of the things
that the Infection Control Committee might face.
The evidence is compelling that taking action to invest in an effective infection control
program can have a profound positive impact on the hospital, and improve patient
safety and satisfaction. Application of practical guidelines to develop infection
prevention and control business case will assist hospital preventionists to justify and
expand much-needed programs. This also requires acknowledging the high-risk nature
of the hospital’s activities, as well as investing in programs, allocating resources needed
for optimal programs, and making infection prevention a hospital-wide priority.
Improving practices frequently implies modifying healthcare workers' behavior, a key

challenge of today's infection control. A multifaceted approach involving promotional,
behavioral and systems change will enable improvement to the compliance of hand
hygiene, associated with the reduction of overall Hospital-acquired Infection (HAI)
prevalence and cross transmission8. Successful strategies to improve infection control
practices result from a multidimensional aspect.
With an emergence of antibiotic-resistant organisms, an active surveillance is one of the

major difficulties that Infection Control Committees find difficult to establish.
Surveillance systems go beyond the collection of information which is necessary not
only in monitoring the program but also in the reduction of frequency of HAIs.
Surveillance involves mechanisms by which the knowledge gained through it is
delivered to those who can use it to direct resources where needed to improve health.
Amongst all of these, difficulties in infection control can also imply a lack of good
leadership. Leadership plays a key role in infection prevention and that the challenging
process of translating the findings of infection prevention research into practice.
117 IPC HEALS

CHAPTER REFERENCES:
1) World Health Organization Patient Safety Solutions 2007
http://www.who.int/patientsafety/events/07/02_05_2007/en/
2) Kane, N. M., & Siergrist, Jr., R. B. (2002, August 12). Understanding Rising Hospital
Inpatient Costs: Key Components of Cost and the Impact of Poor Quality. ResearchGate ,
1-57.
3) Perencevich, E. N., Stone, P. W., Wright, S. B., & Carmeli, Y. (2007). Raising Standards
While Watching the Bottom Line Making a Business Case for Infection Control. Infection
Control and Hospital Epidemiology , 28 (10), 1121-1133.
4) Callery, S., Gournis, E., Kolbe, F., O'Callaghan, C., Crowcroft, N., Nisbet, C., et al. (2014,
July). Best Practices for Surveillance of Health Care-associated Infections in Patient and
Resident Populations. Retrieved June 2017, from Public Health Ontario:
http://www.publichealthontario.ca/en/eRepository/Surveillance_3-3_ENGLISH_2011-
10-28%20FINAL.pdf
5) Pyrek, K. M. (2013). Understanding HAI Burden, Demonstrating ROI Essential to Making a
Business Case. Infection Control Today.
6) Pennssylvania Patient Safety Authority
http: patientsafety.pa.gov/ADVISORIES/documents/201009_home.pdf
7) Creedon, S. A. (2006). Infection control: Behavioral issues for Healthcare workers.
Clinical Governance: An International Journal , 11 (4), 316-325.
8) Pittet, D. (2001). Improving Adherence to Hand Hygiene Practice: A Multidisciplinary
Approach. Emerging Infectious Diseases , 7 (2).
9) Gould, D., Moralejo, D., Drey, N., & Chudleigh, J. (2010). Interventions to improve hand h
ygiene compliance in patient care. Cochrane Database of Systematic Reviews (9).
10) Cockshut, L., Pillow, M., Wyllie, C., Norris, E., Harris, J., Pew, C., et al. (2006). How to Meet
118 IPC HEALS

the Most Challenging Joint Commission Requirements for Behavioral Health Care. USA:
Joint Commission Resources Mission
11) Vearncombe, M., Armstrong, I., Beauparlant, W., Bialachowski, A., Callery, S., Dennis, J., et
al. (2014). Best Practices for Surveillance of Healthcare-Associated Infections (3rd ed.).
Toronto, Ontario, Canada: Queen’s Printer for Ontario.
119 IPC HEALS

Doh Infection Prevention & Control Training Manual: Volume II For Health Facility Administrators

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Doh Infection Prevention & Control Training Manual: Volume II For Health Facility Administrators

Uploaded by

Copyright:

Available Formats

DOH INFECTION PREVENTION

& CONTROL TRAINING MANUAL

Volume II for Health Facility Administrators

The UPCM IPC Working Group

Send correspondence to:

Hospital Infection Control Unit (HICU)

MARIA LIZA ANTOINETTE M. GONZALES MD, MSc.

MARIA LOURDES BERNADETH V. MANIPON RN, MSN

MARIA NICOLETTE M. MARIANO MD

CECILIA G. PENA RN, MAN

ARACELI OCAMPO-BALABAGNO PHD RN

Most of us always feel there are problems in our hospital which do

In behalf of the UPCM Study Group, I would like to extend our

Let us all continue this very challenging yet fascinating, "road-less-

Salamat at Mabuhay tayong lahat!

Regina Berba MD MSc

Preface: A NEW TOOL FOR TEACHING IPC TO HEALTHCARE WORKERS...... 15

Chapter 1 Basic Epidemiology of Healthcare Associated Infections.................... 25

Chapter 2 The Burden of HAI in the Philippines........................................................... 38

Chapter 3 Hand Hygiene.......................................................................................................... 41

Chapter 4 Environmental Care for IPC………................................................................... 52

Chapter 5 Isolation Precautions and Personal Protective Equipment ................ 56

Chapter 6 Battle against Antimicrobial Resistance................................................... 59

Chapter 7 Antimicrobial Stewardship.............................................................................. 62

Chapter 8 Lowering of HAI via Bundles........................................................................... 68

Chapter 9 Infection Control in High Risk Areas: Intensive Care Units............... 73

Chapter 10 Infection Control in High Risk Areas: Operating Rooms................... 77

Chapter 11 Infection Control for Special Infections: Tuberculosis ...................... 79

Chapter 12 Infection Control for Emerging Infections: COVID-19……………….. 87

Chapter 13 Immunization of Healthcare Workers........................................................ 91

Chapter 14 Needlestick Injury Prevention and Management ................................. 94

Chapter 15 Outbreak Investigation. in Healthcare Facilities.................................. 98

Chapter 16 Surveillance ------------------------------------------------------------------101

Chapter 17 Difficult Situations.............................................................................................. 105

GLOSSARY OF TERMS AND ACRONYMS

AIDS: Acquired Immune Deficiency Syndrome

Antimicrobial agent: Any agent that kills or suppresses the growth of

Antiseptic: A substance that prevents or arrests the growth or action

Asepsis: Prevention of contact with microorganisms.

Autoclave: A machine which sterilizes instruments or other objects usually

Bacterial Count: Method of reporting an estimate of the number of bacteria per

Bactericide: A substance with the capacity to kill bacteria.

BHFS: Bureau of Health Facilities and Standards

Bioburden: Amount and types of viable microorganisms contaminating an

Biofilm: Mix of bacteria and other material that is clings to a surface of an

Biologic indicator: Used to monitor the sterilization process. This contains a

CAUTI: Catheter-associated Urinary Tract Infection

Ceiling limit: The amount of airborne chemical contaminants which

Chemical indicator: Used to monitor the sterilization process. Designed to have a

Colonization The sustained presence of replicating infectious agents on or in

Contaminated: State of having actual or potential contact with microorganisms

CLABSI: Central Line-associated Blood Stream Infection

Cleaning: Process of removing visible soilage, blood, substances, and all

Culture: Growth of microbiologic organisms on a nutrient medium.

Culture Medium: Prepared substance which encourage the growth of

Decontamination Process of removing, inactivating or destroying pathogens so that

Detergent: Cleaning agent with a hydrophilic and a lipophilic component.

Disinfectant: A chemical agent used to destroy microorganisms but not kill

Disinfection: Process of eradicating of microorganisms from materials except

DOH: Department of Health

Endoscope: An instrument used to examine or deliver treatment to hollow

Enzyme cleaner: A solution used before disinfection to facilitate the removal of

Fomite Any inanimate object capable of carrying infectious organisms