GREEN CRESCENT HOSPITAL INFECTION CONTROL DEPARTMENT

Infection Control Program

2020 - 2021

I. Introduction

Improving the quality of life of the individual and the family is the mission
of Green Crescent Hospital. Infection Control Department is created in order to decrease
the risk of infection among patients, staff and visitors through prevention, early
investigation and control of infections. The program serves all departments such as
Emergency Room, Out-Patient & Dental Department, Male Ward, Intensive Care Unit,
Operating Room, Female Ward, Nursery, Delivery Room, Neonatal Intensive Care Unit,
Employee Health Clinic, CSSD, Dietary services, Pharmacy, Laboratory, Radiology,
Physiotherapy, and Housekeeping and includes cleanliness and safe environment. The
guidelines, policies and procedures is based on scientific knowledge and accepted
practice from national and international sources such as World Health Organization
(WHO), Centers for Disease Control and Prevention (CDC), Association of Professionals
in Infection Control and Epidemiology (APIC), Gulf Countries Council (GCC), and
Ministry of Health-Saudi Arabia (MOH).It is supported by the Executive Vice President.
The Infection Control Department is composed of a Infection Control (IC) Chairman, IC
Consultant, IC Supervisor and IC Practitioner. It is monitored, implemented and
coordinated by Infection Control Department. The Infection Control Committee serves as
the oversight in ensuring that activities are carried out according to program.

Green Crescent Hospital is a professional private sector health care

hospital in Riyadh. Established in 1401H/1981G by Dr. Wael Shafiq Buraik, it has
focused on advanced medical services and sustained a reputation for quality, and has
become the example followed by other hospital and medical centers. We strive to provide
our members/ customer with the best health care services at the best prices using the best
techniques. The Inpatient services with 55 beds.

II. Mission, Vision and Values Statement

MISSION:
Continuously to reduce the risk of infection for hospital patients, personnel,
and visitors by employing the principles and practices of infection prevention
and control.

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VISION:
Infection Control measures are implemented by all staff and part of their
daily practice, reflected in all indicators kept at lowest level.

VALUES:
We work as a team to reach our goals (teamwork) and always striving for
improvement by looking for new ways to do things and solve problems. We
do respect our colleagues, patients and the community and acting with
honesty in accordance with our core values.

III. Program Objectives

The Infection Control Program has the following objectives:

o Provide a safe environment of care for patients, staff – trainees and
visitors
o Identify and reduce the risk of acquiring and transmitting infections
among patients, family, staff and visitors also volunteers through
education and information dissemination.
o Prevent the transmission of infectious agents among patients, staff and
visitors by implementing proper cost-effective infection control practices.
o Periodically review and update standards of infection control practices
including standards for sanitation and cleanliness, based on current
scientific knowledge, accepted practice guidelines, applicable rules and
regulations.
o Periodically assess and monitor infection control practices utilizing
various quality and
o Performance improvement tools to influence management support and
decisions.
o Minimize morbidity and mortality associated to Healthcare Associated
Infections (HAI) through surveillance, prevention and control measures.
o To evaluate the Infection Control services in the hospital.

IV. Program Components

The Infection Control Program at Green Crescent Hospital (GCH) includes the
following on and ongoing basis:
o Surveillance of HAI in each concerned department
o Educate all GCH staff categories about Infection control appropriate
practices

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o Select and implement best techniques to minimize adverse outcomes

o Evaluate and monitor the results and revise techniques as needed.

o This program includes the following:
- Infection Control Committee
- Infection Control Manual

V. Infection Control Committee

o The Infection Control Committee provides a forum for multidisciplinary
input, cooperation and information sharing.
o The members of the committee is a wide representation of disciplines such
as management, physicians, clinical microbiology, pharmacy, nursing,
central supply, maintenance, environmental services, education and
training.
o The committee is empowered by and has a reporting relationship directly
to the Executive Leadership, either administration or medical staff, to
promote program visibility and effectiveness.
o The committee is the ultimate authority in overseeing prevention and
control of infection activities.
o The major activities of the committee are as follow:
- Review and approve a yearly program for surveillance of HAI
and its prevention
- Review epidemiological surveillance of communicable disease/
HAI's data and identify areas for intervention and recommend
actions for improvement as applicable
- Assess and promote improved practice at all levels of GCH
o Ensure appropriate staff training in infection control and safety
o Review and provide input into investigation of epidemics and report to
appropriate authorities
o Communicate and cooperate with other committees of GCH with common
interests such as Pharmaceutical & Therapeutic Committee, Facility &
Safety Management and Blood Utilization.
o The committee meets quarterly and each meeting is agenda-based and the
proceeding of each meeting is recorded.

VI. Infection Control Staff

oThe staff is composed of Infection Control Practitioner and Infection Control
Supervisor
oInfection Control Practitioner/s, who are nurses and by job descriptions,
trained and develop specific competencies for infection control practices
oInfection Control Supervisor, who is allied health professionals (Laboratory
Technician, Microbiologists)

VII. Infection Control Activities

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The Infection Control has the following responsibilities:

1. Prevention of Infections through risk bases approach, focusing on
reducing risk of healthcare-associated infections (HAIs) among
patients, healthcare workers, visitors and others (trainees –
volunteers) , throughout the organization.
- A systematic and proactive surveillance activity is used as an
important component for gathering and analyzing data that
guides risk assessment.
- Risk events in the

 Geographical location and community environment;

 Potential infections (ventilator-associated pneumonia
[VAP], catheter and central line-associated bloodstream
infections [CLABS], catheter-associated urinary tract
infection [CAUTI], multi-drug resistant organisms [MDRO],
and surgical site infections [SSI]);
 Employee/Patient Exposure-related;
 Emergency Preparedness;
 Environment of care, management of supplies, equipment
and others;
 Proper antibiotic utilization [prophylaxis, abuse/
misuse/disuse);
 Conduct of Infection Control Risk Assessment (ICRA)
before any demolition, renovation and/or construction of
facilities commence, in coordination with Environment of
Care;
 All above are applied in all area concerned according scope
of services.

o Review and evaluation of products like disinfectants and chemicals for

infection prevention purposes, including equipments for the same
purpose, like soap dispensers, waste bins, etc.

o Periodic review and update of infection prevention and control-related

policies, procedures and practice guidelines more over national laws.

o Coordination of surveillance activities.

 Surveillance is defined as the systematic process of collection,

consolidation, and analysis of data concerning distribution and

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determinants of a given disease or event followed by the

dissemination of that information to those who can improve the
outcome (Refer to Table 1).

 Surveillance activities shall be active, passive, prospective,

retrospective, laboratory-based, priority-directed and risk
assessment-based (See Appendix A)

 Target surveillance activities for device-associated HAIs

are done on the high-risk areas such as: Adult ICU and
NICU for VAP, CLABSI and CAUTI.
 Target surveillance activities for SSI's are done at the
General and Executive ward respectively.
 Other surveillance activities include staff’s compliance to
recommended practice and standards:
 Hand Hygiene
 Use of Personal Protective Equipments (PPE)
 Expanded Precautions (isolation), in addition to
Standard Precautions
 Waste Management and Used Sharps Disposal
 Exposure to Blood and Body Fluids
 Needle sticks and contaminated sharps injuries
 Exposure to Blood and body fluids, other than needle
sticks, like splashes and spills
 Prompt investigation of Outbreaks, to contain the epidemic at
the soonest possible time.
 Notifying Ministry of Health (MOH) of reportable diseases.

○ Records Management.

 Maintains copies of HAIs discussed and reported, including actions

implemented;
 Monthly report of collection of all infection control activities
reported to the IC Committee including employee health
statistics, staff and patient education, review of Infection Control
Manual with all infection control-related policies and procedures
and guidelines, reviewed and updated on a regular basis;
 References, where infection prevention and control practice are
based and referred to.

o Staff Education

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 Orientation of newly hired staff

 Continuous education, training and work shops
o Patient Education, in coordination with Health Educators, Nursing and Social
Services, as applicable.
o Supervision of adherence to Expanded Precautions (Isolations).

o Monitoring of Employee Health (EH)/Healthcare Worker (HCW) Program .

Includes:
 New employee screening, for HCV, Hepatitis B, TB by Mantoux testing
(PPD), Childhood diseases screen for Varicella Mumps, Rubeola and
Rubella;
 Annual Check-up for all the staff including annual PPD testing
 Immunizations/Vaccinations
 Exposure to Blood and Body Fluids
 Needle sticks and contaminated sharps injuries;
 Exposure to Blood and body fluids, other than needle sticks, like
splashes and spills.

IX. INFECTION CONTROL MANUAL

 The Prevention and Control of Infection Manual is a compilation of
recommended instructions and practices in the form of policies,
procedures, guidelines and protocols, for patient care.

 The manual is organized by the Infection Control Team, approved by the

Infection Control Committee and endorsed by the Chief Executive Officer
for distribution to all areas for patient care staff and some support
services.

 It is an important tool in guiding daily infection prevention and control

practice; it is therefore regularly reviewed and updated in a timely
manner.

 The manual must be readily available and within easy reach at all times;
all concerned staff are expected to be knowledgeable about the contents
of the manual and refer to it with much ease and competence.

 IC manual is available on GCH Intranet.

X. EVALUATION OF Infection Control Program

 Quarterly evaluation of the program by assessment of the Infection

Control Performance Indicators (HAI) and the variance from the
benchmark/ target measures

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 A target goal of reducing the risk of HAI’s for all patients, employees and
visitors (0% compliance rate for HAI’s and 95% hand hygiene compliance)
 Program shall be revised every two years or upon need which is earlier

XI REFERENCES
1- Infection control manual 3rd edition (ministry of national guard)

2- “Requirements for Infrastructure and Essential Activities of Infection Control and

Epidemiology in Hospitals: A Consensus Panel Report”, Association of
Professionals in Infection Control and Epidemiology (APIC) Society of Healthcare
Epidemiology of America (SHEA), 2012.

3- “Infection Control Guidelines on Programs”, Queensland Health, Australia, 2008.

4- “Reducing Harm to Patients from Healthcare Associated Infections: An Australian

Model for Acute Care Hospitals”, Australian Commission on Safety and Quality in
Healthcare, June 2009.

5- “Core Components for Infection Prevention and Control Program,”, WHO, Report
of Informal Network on Infection Prevention and Control in Health Care, Geneva
Switzerland, June 2008.

6- Friedman, C and Newson W., “Basic Concepts of Infection Control: 2 nd Edition,

Revised 2011”, International Federation of Infection Control [IFIC].

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APPROVAL:
Prepared by:

Infection Control Practitioner Signature Date

Reviewed by:
(Involved)

Head of Infection Control/IP&C Signature Date

Committee Chairman

Chief Nursing Officer Signature Date

Medical Director Signature Date

Director of Quality
Management and Patient Signature Date
Safety

Approved by:

Chief Executive Officer Signature Date

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