POLICY STATEMENTS ON STANDARD Office Order N0.

1 Series of
2017
Logo INFECTION CONTROL OF 1.0 Creation of Infectious
STA. CRUZ COMMUNITY Control Committee of Sta.
Cruz Community Hospital
HOSPITAL Revision Code:
Page : 2
0
Section : Out-Patient / In-Patient Effective Date: 08 01 17

Subject : Creation of Infection Control Committee

This document mandates the creation of Infection Control Committee with its terms of
reference for membership, meetings and policies.

Objectives

To provide clean and safe facility that is environment friendly for both personnel and
clients and ensuring the highest standard of Infection control and sanitation, reducing
the risk of healthcare associated or nosocomial infections.

Committee Members:

Committee Members:
The Chief of Hospital and the Administrative Office is designated to be the chairman
and the vice chairman respectively, until such time this policy is revised. In the
absence of the chairman, it will be the Vice Chairman who will be in charge of the
committee. Furthermore, a Infection Control Officer will be appointed by the chairman
among its members.

The members will be composed of only all section heads and nursing staffs

Prepared by:
Noted by: Approved by:

Gilda Liboro Mateo Tajonera III Lino Marcus Viola III MD DPCP
Chief Nurse Administrative Office II Chief of Hospital
 POLICY STATEMENTS ON STANDARD Office Order N0. 1 Series of
2017
Logo INFECTION CONTROL OF 1.0 Creation of Infectious
STA. CRUZ COMMUNITY Control Committee of Sta.
Cruz Community Hospital
HOSPITAL Revision Code:
Page : 2
0
Section : Out-Patient / In-Patient Effective Date: 08 01 17

Subject Meetings and Functions of Infection Control Committee

Meetings:
The committee shall meet every quarter of the year to review, amend existing
policies on continuous quality improvement.

Functions
1) Policy formulation in regards to the infection control and sanitation of the
facility.
2) Implement policies relating to infection control.
3) Provide infection control evaluation from infection control programs
implemented.
4) Makes recommendation to address infection control challenges of the facility.
5) Organize regular training programmes for the staff for essential infection
control practices that are appropriate to their job description.
6) Assess training needs of the staff and provide required training through
awareness programmes
7) Carry out the surveillance programme.
8) Develop and disseminate infection control policies; monitor and manage
critical incidents.

Prepared by: Noted by: Approved by:

Gilda Liboro Mateo Tajonera III Lino Marcus Viola III MD DPCP
Chief Nurse Administrative Office II Chief of Hospital
 POLICY STATEMENTS ON STANDARD Office Order N0. 1 Series of
2017
Logo INFECTION CONTROL OF 1.0 Creation of Infectious
STA. CRUZ COMMUNITY Control Committee of Sta.
Cruz Community Hospital
HOSPITAL Revision Code:
Page : 2
0
Section : Out-Patient / In-Patient Effective Date: 08 01 17

Subject Policies of Infection Control Committee

Policies
The following are basic standard procedures for the protection of patients, health
workers and visitors.
1. Hand washing and antisepsis (hand hygiene);
2. Use of personal protective equipment when handling blood, body substances,
excretions and secretions
3. Appropriate handling of patient care equipment and soiled linen.
4. Prevention of needle stick/sharp injuries.
5. Environmental cleaning and spills-management
6. Appropriate handling of waste.

When to Hand wash

1. After handling any blood, body fluids, secretions, excretions and contaminated
items.
2. Between contact with different patients;
3. Between tasks and procedures on the same patient to prevent cross
contamination
4. Between different body sites;
5. Immediately after removing gloves; and
6. Using a plain soap, antimicrobial agent, such as an alcoholic handrub or
waterless antiseptic agent.
Prepared by: Noted by: Approved by:

Gilda Liboro Mateo Tajonera III Lino Marcus Viola III MD DPCP
Chief Nurse Administrative Office II Chief of Hospital
 POLICY STATEMENTS ON STANDARD Office Order N0. 1 Series of
2017
Logo INFECTION CONTROL OF 1.0 Creation of Infectious
STA. CRUZ COMMUNITY Control Committee of Sta.
Cruz Community Hospital
HOSPITAL Revision Code:
Page : 2
0
Section : Out-Patient / In-Patient Effective Date: 08 01 17

Subject Policies of Infection Control Committee

Personal Protective Equipment

All medical staff handling patients should assess whether they are at risk of exposure
to blood, body fluids, excretions or secretions and choose the appropriate items of
personal protective equipment according to their risk.

The following person/s should use personal protective equipment:

1. Health care workers who provide direct care to patients and who work in
situations where they may have contact with blood, body fluids, excretions or
secretions
2. Support staff including medical aides, cleaners, and laundry staff in situations
where they may have contact with blood, body fluids, secretions and
excretions
3. Laboratory staff, who handle patient specimens
4. Family members who provide care to patients and are in a situation where
they may have contact with blood, body fluids, secretions and excretions

Airborne Precaution
Airborne precautions are designed to reduce the transmission of diseases spread by
the airborne route. Airborne transmission occurs when droplet nuclei (evaporated
droplets) <5 micron in size are disseminated in the air. These droplet nuclei can
remain suspended in the air for some time. Droplet nuclei are the residuals of
droplets and when suspended in the air, dry and produce particles ranging in size
Prepared
from 1-5 by:
micron. These particles Noted by:
can remain suspended in Approved by:long periods of
the air for
time, especially when bound on dust particles. Diseases which spread by this mode
include open/active pulmonary tuberculosis (TB), measles, chicken pox, pulmonary
plague and haemorrhagic fever with pneumonia.
Gilda Liboro Mateo Tajonera III Lino Marcus Viola III MD DPCP
Chief Nurse Administrative Office II Chief of Hospital
 POLICY STATEMENTS ON STANDARD Office Order N0. 1 Series of
2017
Logo INFECTION CONTROL OF 1.0 Creation of Infectious
STA. CRUZ COMMUNITY Control Committee of Sta.
Cruz Community Hospital
HOSPITAL Revision Code:
Page : 2
0
Section : Out-Patient / In-Patient Effective Date: 08 01 17

Subject Policies of Infection Control Committee

The following precautions need to be taken for airborne infections:

1. Placing of patient in a single room that has a monitored negative airflow
pressure, and is often referred to as a “negative pressure room”. The air
should be discharged to the outdoors or specially filtered before it is circulated
to other areas of the health care facility.
2. Keep doors closed.
3. · Anyone who enters the room must wear a special, high filtration, particulate
respirator (e.g. N 95) mask.
4. Limit the movement and transport of the patient from the room for essential
purposes only. If transport is necessary, minimize dispersal of droplet nuclei
by masking the patient with a surgical mask.

Prepared by: Noted by: Approved by:

Gilda Liboro Mateo Tajonera III Lino Marcus Viola III MD DPCP
Chief Nurse Administrative Office II Chief of Hospital
 POLICY STATEMENTS ON STANDARD Office Order N0. 1 Series of
2017
Logo INFECTION CONTROL OF 1.0 Creation of Infectious
STA. CRUZ COMMUNITY Control Committee of Sta.
Cruz Community Hospital
HOSPITAL Revision Code:
Page : 2
0
Section : Out-Patient / In-Patient Effective Date: 08 01 17

Subject Policies of Infection Control Committee

Droplet precautions
Diseases, which are transmitted by this route, include pneumonias, pertussis,
diphtheria, influenza type B, mumps, and meningitis. Droplet transmission occurs
when there is adequate contact between the mucous membranes of the nose and
mouth or conjunctivae of a susceptible person and large particle droplets (> 5
microns).7 Droplets are usually generated from the infected person during coughing,
sneezing, talking or when health care workers undertake procedures such as
tracheal suctioning.
The following precautions need to be taken:
1. Implement standard precautions.
2. Place patient in a single room (or in a room with another patient infected by
the same pathogen).
3. Wear a surgical mask when working within 1-2 meters of the patient.
4. Place a surgical mask on the patient if transport is necessary.
5. Special air handling and ventilation are not required to prevent droplet
transmission of infection.

Prepared by: Noted by: Approved by:

Gilda Liboro Mateo Tajonera III Lino Marcus Viola III MD DPCP
Chief Nurse Administrative Office II Chief of Hospital
 POLICY STATEMENTS ON STANDARD Office Order N0. 1 Series of
2017
Logo INFECTION CONTROL OF 1.0 Creation of Infectious
STA. CRUZ COMMUNITY Control Committee of Sta.
Cruz Community Hospital
HOSPITAL Revision Code:
Page : 2
0
Section : Out-Patient / In-Patient Effective Date: 08 01 17

Subject Policies of Infection Control Committee

Contact precautions
Diseases which are transmitted by this route include colonization or infection with
multiple antibiotic resistant organisms, enteric infections and skin infections.
The following precautions need to be taken:
1. Implement standard precautions.
2. Place patient in a single room (or in a room with another patient infected by
the same pathogen). Consider the epidemiology of the disease and the patient
population when determining patient placement.
3. Wear clean, non-sterile gloves when entering the room.
4. Wear a clean, non-sterile gown when entering the room if substantial contact
with the patient, environmental surfaces or items in the patient’s room is
anticipated.
5. Limit the movement and transport of the patient from the room.
Patients should be moved for essential purposes only. If transportation is
required, use precautions to minimize the risk of transmission..

Prepared by: Noted by: Approved by:

Gilda Liboro Mateo Tajonera III Lino Marcus Viola III MD DPCP
Chief Nurse Administrative Office II Chief of Hospital