Policy On Infection and Prevention Control

Document No.
:
Rev. No.: 0
JONI VILLANUEVA JVGH-ICC-CM-01
GENERAL HOSPITAL
NATIONAL ROAD,IGULOT, Implementation
BOCAUE, BULACAN Date: Page No.:
1/101
QUALITY MANAGEMENT SYSTEM
This is a controlled document, property of Joni Villanueva General Document Title:
Hospital and should not be reproduced without the permission of JVGH Infection Prevention and Control
Administration.
TABLE OF CONTENTS
Introduction 3
Vision 4
Mission 4
Program, Scope, and Objectives 4
Infection Prevention and Control Program 5
Functions 8
Functions of the ICC Chairman/ ICC Physician 9
Functions of the Infection Control Nurse (ICN) 10
Organizational Chart 12
Membership 13
Operating Schedule 13
Room Location and Contact Number 14
POLICIES AND GUIDELIES ON INFECTION CONTROL FOR ALL
HOSPITAL AREAS
Admission policy 15
Admission policy for communicable diseases 15
Flowchart of triaging 15
Hand Hygiene 16
Standard precaution 27
Transmission Based Precaution 35
Isolation Precaution 39
Cleaning, Disinfection, and Sterilization of Medical Equipment 45
Recommended & Checked
Prepared by: Reviewed & Checked by: Approved by:
by:
Rachel Joy H. Divina, RN Joanna Lyn T. Alejandro, Arnold V. Silva MD, FPCP,
Infection Control Nurse MD Reagan P. Sangalang, MD FPSMO
Infection Control Chairman Quality Assurance Officer OIC-Medical Center Chief I
Date: Date: Date: Date:
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Administration.
Routine and Terminal Cleaning of Patient Care Areas 56

Guidelines on Health Care-Associated infection 59
Management of Needle Stick Injuries and Blood and Body Fluid 75
Exposure
Surveillance of Nosocomial Infections 78
Healthcare Waste Management 81
Guidelines for Support Services
Linen Handling 89
Nutrition and Dietetics Service 92
Mortuary 97
References 101

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Introduction
Nosocomial infections or Hospital-Acquired Infections (HAls) not only prolong the hospital
stay and increase the cost of hospitalization, they also result in increased morbidity and mortality.
Hence, the Joni Villanueva General Hospital- Infection Prevention and Control Committee (ICC)
has prepared this ICC Manual to increase awareness among all hospital staff regarding the
prevention and control of nosocomial infections or HAls.
The ICC addresses factors related to the spread of infections within the hospital setting
(whether patient-to-patient, from patients to staff and from staff to patients, or among staff),
including prevention, monitoring/investigation of demonstrates or suspected spread of infection
and management.
The safety of the patients and employees lies in the understanding and conscientious
application of these basic principles, especially for those patients with infections or diminished
resistance to infection.
The ICC Manual constitutes the infection control policies, guidelines and procedure
implemented and monitored for safe practice at the Joni Villanueva General Hospital.

by:
Joanna Lyn T. Alejandro,

Rachel Joy H. Divina, RN MD Reagan P. Sangalang, MD Arnold V. Silva MD, FPCP,
Infection Control Nurse FPSMO
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Vision
Health facility capable of providing excellent care and effective management of healthcare-
associated infections toward patient and personnel
Mission
To provide safe and quality care to patients, their families, healthcare workers, and the
community through sound evidence-based infection prevention and control practices.
Program, Scope, and Objectives
The scope of ICC encompasses all hospital departments and services dealing with the delivery
of healthcare services. All hospital employees are responsible to follow the ICC program to
detect, prevent and control infections within the facility.
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QUALITY MANAGEMENT SYSTEM Document Title:

This is a controlled document, property of Joni Villanueva General
Hospital and should not be reproduced without the permission of JVGH
Infection Prevention and Control
Administration. Program
INFECTION PREVENTION AND CONTROL PROGRAM
The Infection Prevention and Control (IPC) Program is a multidisciplinary systematic

approach committed to preventing health care-associated infections and their related events, to
improve patients care, and to minimize infection related hazards associated with delivery of
health care.
This program involves the collaboration of many programs and services within the hospital
and is designed to meet the intent of the International Standardization Organization (ISO) and
guidelines of Department of Health (DOH). Infection prevention and control measures reflect the
efficacy of the program to protect patients, health care providers, visitors and others from
infections while aiming to decrease the overall human and financial cost, through an efficient and
evidence- based program.
In addition, the program aims to provide primary support and resource for Joni Villanueva
General Hospital to implement a credible educational program and successfully achieve and
sustain professional and internationally recognized accreditation.
Goal
This ICP is formulated to establish guidelines and procedures designed to minimize the
risk of transmission of infectious diseases to patients, hospital staff, and other clients who are
associated with the medical care and treatment of patients.
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Objectives
1. To allow for a systematic, coordinated, and continuous approach to improving performance,

focusing on surveillance, prevention, and control of infections throughout the organization.
2. To ensure that LCP has a functioning coordinated process in place to reduce the risks of
nosocomial infections in patients, staff and other clients.
Scope of the ICP
1. Surveillance, identification, analysis, monitoring, and reporting of infections/hospital acquired

infections.
2. Recommendation for supplies and equipment.
3. Review and revision of policies, procedures and clinical protocols relating to infection control.
4. Selection of criteria for the identification of infections/hospital acquired infections.
5. New employee orientation to infection control techniques and standard precautions.
6. Performance improvement activities.
General Policies
1. All patient care, laboratory procedures and equipment management at JVGH is to be carried
out in an environment and with techniques consistent with local standards.
2. All medical, nursing and support staff care and services are given within their level of
competence without regard to infectious disease status.
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3. Specific strategies for treatment of individuals with an infectious disease should be discussed
with the attending physician or with the Infection Control Physician prior to treatment.
4. It is the responsibility of the individual providing care (clinical procedures, laboratory and
other diagnostic procedures) to ensure that appropriate health care is rendered in a safe
environment, with appropriately processed and handled instruments and materials to minimize
chances of contamination and subsequent disease transmission.
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Hospital and should not be reproduced without the permission of JVGH Infection Control Committee
Administration.
INTRODUCTION
The implementation of an effective and comprehensive infection control program is an

essential key to the quality care provided by the health care institution. Such effort is made
possible through the organizational endeavor of the Infection Control Committee (ICC). This
multidisciplinary team is not only responsible for the day-to-day running of the infection control
programs but is also responsible for setting priorities, applying evidence-based practice and
advising hospital administrators on issues relating to infection control
It is the responsibility of hospital administrator to ensure that adequate resources are given
to the hospital Infection Control Committee. He/she should also managerially ensure that full
support is afforded to the ICC so that agreed infection control protocols and procedures are
applied effectively.
Functions
The Infection Control Committee is tasked to develop an effective and comprehensive

infection control program for the hospital. The committee should discuss routine surveillance
reports from the ICT, outbreaks of nosocomial infection, needle stick injury incidents, health
care worker immunization and education, purchasing of equipment, etc. In addition, it is
important that the members of the committee voice areas of concern including any problems
relating to either infection control practice or policy, in particular highlighting areas which have
not been addressed within their own sphere of responsibility.
The role of the ICC is to ensure that an effective infection control program has been
planned, coordinate its implementation, and evaluate the impact of such measures. Whilst they
will actively participate in most of these areas, some aspects of the infection control program
may all under the remit of others. In such cases the ICC will provide advice and direction,
ultimately ensuring that all tasks reach completion. It is important to ensure that there is
provision made for 24-hour access to the ICC for advice on infection prevention and control of
infection, which would include both medical and nursing advice.

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Administration.
The role of the ICC can be summarized as follows:
1. Production of an annual infection control program with clearly defined objectives.

2. Production of written policies and procedures on infection control, including regular evaluation
and update.
3. Education of all grades of staff in infection control policy, practice and procedures relevant to
their own area of practice.
4. Surveillance of infection to detect outbreaks a earliest opportunity and provide data that should be
evaluated to allow for any change in practice or allocation of resource to prevent hospital-acquired
infections.
5. Provide advice to all grades of staff on all matters in relation to infection prevention and control
on a day-to-day basis.
6. Participate in the audit activity.
7. Conduct researches.
Functions of the ICC Chairman/ ICC Physician
The role responsibilities of the ICP are summarized as follows:
a. Serves as a specialist advisor and takes a leading role in the effective functioning of the
ICT.
b. Should be an active member of the hospital Infection Control Committee (ICC) and may
act as its chairman.

c. Assists the hospital ICC in drawing up annual plans, policies and long-term program for the
prevention of hospital infection
d. Advises the chief executive/hospital administrator directly on all aspects of infection control
in the hospital an on the implementation of agreed policies.
e. Participates in the preparation of tender documents for the support services and advises on
infection aspects.
f. Is involved in setting quality standards, surveillance and audit with regard to hospital
infection.

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Functions of the Infection Control Nurse (ICN)
An Infection Control Nurse or Practitioner is a registered nurse with an additional academic

education and practical training which enables him or her to act as a specialist advisor in all
matters relating to infection control. A recognized qualification in infection control should be
held which will allow recognition of the ICN as a specialist practitioner.
The ICN is usually the only full-time practitioner in the ICC and therefore takes the key
role in day-to-day infection control activities, with the ICP providing the lead role.
The role and responsibility of the ICN is summarized as follows.
a. Serves as a specialist advisor and takes a leading role in the effective functioning of the ICC.
b. Should be an active member of the hospital ICC.
c. Assists the hospital ICC in drawing up annual plans and policies for infection control.
d. Provides specialist-nursing input in the identification, prevention, monitoring, and control of

infection within the hospital.
e. Participate in surveillance, investigation, and control of infection in the hospital. vi. Identify,
investigate and monitor infections, hazardous practice and procedures. vi. Advice to the
contracting departments, participating in the preparation of documents relating to service
specifications and quality standards.
f. Ongoing contribution to the development and implementation of infection control policy and
procedure, participating in audit, and monitoring tools related to infection control and
infectious diseases.
g. Presentation of educational programs and membership of relevant committees where

infection control input is required.

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It is essential that the ICN should have an expert knowledge of both general and specialist
nursing practice and must also have an understanding not only of the functioning of clinical areas
but also operational areas and services. He or she must also be able to communicate effectively
with all grades of staff, negotiate and effect change, and influence practice.

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JONI VILLANUEVA Document No.:

GENERAL HOSPITAL Rev. No.: 0
NATIONAL ROAD,IGULOT, JVGH-ICC-CM-01
BOCAUE, BULACAN
Implementation Page No.:
Date: 13/101
Administration.
Membership
Members of the Infection Control Committee
The membership of the hospital ICCs should reflect the spectrum of clinical services and
administrative arrangements of the health care establishments so that policy decisions take
account of implementation issues.
The Joni Villanueva General Hospital Infection Control Committee comprises the following:
1 ICC Chairman
2 ICC Nurses
3 ICC Members:
a. Chief Administrative Officer
b. Chief Nursing Officer
c. Head, Laboratory Department
d. Head, Pharmacy Department
e. Head, Dietary Department
f. Head, Maintenance
g. OPD-Senior Nurse
h. Head, Housekeeping Services
i. Head, Supply Section
j. X-ray Technician
k. Janitorial Supervisor
l. All Chief Residents
m. All Nurse Supervisors
Additionally, representatives from all the departments may be invited as necessary. The
ICC shall hold a regular meeting every 3 months or as the need arises.
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Administration.
Operating Schedule:
The ICC Office is open from 8:00 AM to 5:00 PM, Monday to Friday.
ICC problems are referred first to the IC Nurse.
Room Location and Contact Numbers:
1st Floor, Joni Villanueva General Hospital, Igulot, Bocaue, Bulacan

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BOCAUE, BULACAN
Date:
15/101
Admission Policy for Communicable
Administration. Diseases
ADMISSION POLICY FOR COMMUNICABLE DISEASES
Objective:
To notify the medical and nursing service that will receive patients into the hospital of the risk of
a potentially infectious patient being admitted.
Communicable diseases may be admitted to this hospital provided that:
1. Thereshallbeproperfacilitiesand/oradequateequipmentnecessaryforthecareofsuch
2. infectious disease patient.
3. The patient may be removed from isolation according to the rules established by the Infection
Prevention and Control Committee
4. All infectious diseases should be admitted in a single room, observing appropriate isolation
precautions. If a single room is not available, patients may be cohorted observing a 1-meter
bed apart with the same case depending on the severity of the disease which needs a single
room.
5. The following communicable disease may be admitted to the general wards with Standard
Precautions / Contact Precautions:
a. Acute gastroenteritis
b. Bacillary dysentery
c. Salmonella
d. Viral hepatitis
e. Amoebiasis
f. Cholera
6. Postpartum mothers and their babies should not be admitted to wards together with patients
with a communicable disease
***Refer to Appendix D for Flowchart of Triaging

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Hospital and should not be reproduced without the permission of JVGH Hand Hygiene
Administration.
Hands of healthcare workers serve as critical reservoirs of infectious agents. Hand hygiene is
the single most important strategy to remove or destroy these pathogens from their hands and
prevent the spread of infection. All Staff involved in patient care must apply appropriate hand
hygiene practices to reduce the transmission of microorganisms to patients, staff and visitors.
The practice of hand hygiene shall be strictly observed by all medical practitioners, nursing
staff, ancillary associates and hospital visitors at all time as indicated.
Indications for Hand washing:
A. WHO Five moments for Hand Hygiene
 Before touching a patient

 Before clean/ aseptic procedure.
 After body fluids exposure risk.
 After touching a patient.
 After touching the patient surroundings

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B. Other Indications for Hand Hygiene
 When hands are visibly dirty or contaminated with proteinaceous material or are visibly
soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and
water or an antimicrobial soap and water.
 If hands are not visibly soiled, use an alcohol-based hand rub for routinely
decontaminating hands in all other clinical situations.
 Alternatively, wash hands with an antimicrobial soap and water in all clinical situations.
 Decontaminate hands before having direct contact with patients.
 Decontaminate hands before donning sterile gloves when inserting a central
intravascular catheter.
 Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular
catheters, or other invasive devices that do not require a surgical procedure.
 Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse
or blood pressure, and lifting a patient).
 Decontaminate hands after contact with body fluids or excretions, mucous membranes,
nonintact skin, and wound dressings if hands are not visibly soiled.
 Decontaminate hands if moving from a contaminated-body site to a clean-body site
during patient care.
 Decontaminate hands after contact with inanimate objects (including medical
equipment) in the immediate vicinity of the patient.
 Decontaminate hands after removing gloves.
 Before eating and after using a restroom, wash hands with a non-antimicrobial soap and
water or with an antimicrobial soap and water.
 Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to
washing hands with non-antimicrobial soap and water. Because they are not as effective
as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for
reducing bacterial counts on the hands of HCWs, they are not a substitute for using an
alcohol-based hand rub or antimicrobial soap.
 Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water
if exposure to Bacillus anthracis is suspected or proven. The physical action of washing
and rinsing hands under such circumstances. is recommended because alcohols,
chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores

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Hand-hygiene Methods
1. Hand rubbing
Sanitize hands using an alcohol-based hand rub if hands are not visibly soiled.
Technique:
a. Apply a palmful of the product in a cupped hand, covering all surfaces.

b. Rub Hands palm by palm.
c. Right palm over left dorsum with interlaced fingers and vice versa.
d. Palm to palm with fingers interlaced.
e. Back of fingers to opposing palms with fingers interlocked.
f. Rotational rubbing of left thumb clasped in right palm and vice versa.
g. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left
palm and vice versa.
h. Once dry, your hands are safe

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2. Handwashing
Wash hands with soap and water:
 When hands are visibly dirty or visibly soiled with blood or other body fluids
 If alcohol-based hand rub is not available or cannot be used (e.g., due to allergic reaction)
 After using the toilet.
 Before and After: smoking, eating or preparing food
 If exposure to potential spore-forming pathogens is strongly suspected or proven,
including outbreaks of Clostridium difficile and diarrheal diseases.
 Do not use soap and alcohol-based hand rub concomitantly.
Technique
a. Wet hands with water.

b. Apply enough soap to cover all hand surfaces
c. Rub hands palm to palm
d. Right palm over left dorsum with interlaced fingers and vice versa.
e. Palm to palm with fingers interlaced
f. Back of fingers to opposing palms with fingers interlocked
g. Rotational rubbing of left thumb clasped in right palm and vice versa.
h. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left
palm and vice versa
i. Rinse hands with water
j. Dry hands thoroughly with a singly use towel.
k. Use towel to turn off faucet
l. Your hands are now safe
Prepared by: Reviewed & Checked by: Recommended & Checked Approved by:
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3. Antiseptic handwashing
Use antimicrobial soap.
Surgical Hand Antisepsis
 Keep natural nails short and well-maintained; do not wear artificial nails or nail-polish.
 Remove rings, watches, and bracelets before beginning the surgical hand-hygiene.
 General hand-hygiene should be performed immediately after surgical gloves are
removed and before any further activities are undertaken.
 Practice surgical hand antisepsis using either; A. Alcohol-based Antiseptic Hand rub
with persistent activity OR B. Antiseptic Hand Wash protocols.
A. Alcohol-based Antiseptic Hand Rub Protocol
a. Wash hands with soap & water.

b. Remove debris from underneath fingernails using a nail cleaner under running water;
rinse and dry hands.
c. Dispense the manufacturer’s recommended amount of the hospital approved alcohol-
based hand rub product.
d. Apply the product to the hands and forearms, following the manufacturer’s written
directions.
e. Rub thoroughly until dry.
f. Repeat the process if indicated in the manufacturer’s written directions.
g. Hold hands higher than elbows and away from surgical attire.
h. In the OR, don a sterile surgical gown and gloves

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BOCAUE, BULACAN
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Administration.

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B. Antiseptic Hand Wash protocols
a. Remove debris from underneath fingernails using a nail cleaner under running water
b. Dispense the hospital approved antimicrobial scrub agent (e.g., 4% Chlorhexidine based
soap) according to the manufacturer‘s written directions.
c. Apply the antimicrobial agent to wet hands and forearms and scrub them for the length of
time recommended by the manufacturer, usually 2–6 minutes.
d. Use a soft nonabrasive sponge if recommended by manufacturers and discard it in
appropriate container. Brushes are not recommended for surgical hand preparation.
e. Visualize each finger, hand, and arm as having four sides. Wash all four side effectively.
f. Repeat this process for opposite fingers, hand, and arm.
g. Repeat this process if directed to do so by the manufacturer’s written directions for use.
h. Avoid splashing surgical attire. (For water conservation, turn water off when it is not directly
in use, if possible).
i. Hold hands higher than elbows and away from surgical attire.
j. In the OR, dry hands and arms with a sterile towel before donning a sterile surgical gown
and gloves.
Hand Care
Healthy skin is intact. This means the skin is free from nicks, cuts, scrapes, cracks, and
rashes.
Dry skin is susceptible to damage; Symptoms of dry skin may include flaking, redness,
itching, burning, or cracking. Germs can attach more easily to dry skin and enter our bodies
through skin cracks.
Tips to prevent dry skin:
1. Add moisture to skin by soaking in warm water, then applying lotions that contain water
or humectants (ingredients such as glycerin that attract and hold moisture in the skin).
2. Wear light cotton gloves for several hours or overnight after the above steps.
3. Other suggestions include:
a. Wash hands with warm, not hot water

b. Pat skin dry, rather than rubbing
c. Use hand moisturizers often, preferably when skin is damp
d. Avoid leaving soap on hands, as it dries skin.
e. Apply lotion often to help maintain the integrity of the skin and to reduce skin irritation.
f. Staff with patient contact may only use hospital approved lotion.

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Infection Control Nurse Quality Assurance Officer FPSMO
Infection Control Chairman
OIC-Medical Center Chief I
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Fingernails
 Keep nails short and clean

 Avoid nail varnish
 Avoid artificial fingernails or nail enhancements including, but not limited to overlays,
wraps, tips, or attached decorations.
Medical Assessment
 Any suspicion of dermatological condition must be evaluated by an Employee Health

Physician or appropriate medical service.
 HCWs who have exudative lesions or weeping dermatitis should refrain from all direct
patient care and from handling patient care equipment until the condition resolves.

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Infection Control Nurse Quality Assurance Officer FPSMO
Infection Control Chairman
OIC-Medical Center Chief I
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Hospital and should not be reproduced without the permission of JVGH Standard Precaution
Administration.
STANDARD PRECAUTION
Standard Precautions combine the major features of Universal precaution and body
substance isolation and are based on the principle that all blood, body fluid, secretions, excretions
except sweat, non-intact skin and mucous membrane may contain transmissible agents. They are
designed for the care of ALL patients in hospital regardless of their suspected or confirmed
infection status.
Purpose
1. To prevent the risk of cross transfer of microorganisms between patients, Health Care
Workers, visitors and environment, directly or indirectly
2. To protect all Health Care Workers and visitors from exposure to known and unknown
source of infections.
3. To reduce the rate of nosocomial infection at Joni Villanueva General Hospital
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PROTOCOL FOR APPLICATION OF STANDARD PRECAUTIONS FOR THE CARE OF ALL PATIENTS
IN ALL HEALTHCARE SETTINGS
COMPONENT RECOMMENDATIONS
Hand hygiene After touching blood, body fluids, secretions,

excretions, contaminated items; immediately
after removing gloves; between patient
contacts.
Personal protective equipment (PPE)
Gloves For touching blood, body fluids, secretions,

excretions, contaminated items; for touching
mucous membranes and nonintact skin
Gown During procedures and patient-care activities
when contact of clothing/exposed skin with
blood/body fluids, secretions, and excretions is
anticipated.
Mask, eye protection (goggles), face During procedures and patient-care activities
shield likely to generate splashes or sprays of blood,
body fluids, secretions, especially suctioning,
endotracheal intubation
Soiled patient-care equipment Handle in a manner that prevents transfer of
microorganisms to others and to the
environment; wear gloves if visibly
contaminated; perform hand hygiene.
Environmental control Develop procedures for routine care, cleaning,
and disinfection of environmental surfaces,
especially frequently touched surfaces in
patient-care areas.
Textiles and laundry Handle in a manner that prevents transfer of
microorganisms to others and to the
environment
Prepared by: Reviewed & Checked by: Recommended & Checked Approved by:
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Needles and other sharps Do not recap, bend, break, or hand-manipulate

used needles; if recapping is required, use a
one-handed scoop technique only; use safety
features when available; place used sharps in
puncture- resistant container
Patient resuscitation Use mouthpiece, resuscitation bag, other
ventilation devices to prevent contact with
mouth and oral secretions
Patient placement Prioritize for single-patient room if patient is at
increased risk of transmission, is likely to
contaminate the environment, does not
maintain appropriate hygiene, or is at increased
risk of acquiring infection or developing adverse
outcome following infection.
Respiratory hygiene/cough etiquette Instruct symptomatic persons to cover
(source containment of infectious mouth/nose when sneezing/coughing; use
respiratory secretions in symptomatic tissues and dispose in no-touch receptacle;
patients, beginning at initial point of observe hand hygiene after soiling of hands
encounter e.g., triage and reception with respiratory secretions; wear surgical mask
areas in emergency departments and if tolerated or maintain spatial separation, 1
clinics) meter if possible
Lumbar Puncture Wear a surgical mask when placing a catheter
or injecting material in to the spinal canal or
subdural space. (i.e., during myelograms,
lumbar puncture and spinal or epidural
anesthesia)
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Safe Injection Practice a. Use aseptic technique to avoid contamination of

sterile injection equipment
b. Do not administer medications from a syringe to

multiple patients, even if the needle or cannula on the
syringe is changed. Needles, cannulae and syringes are
sterile, single-use items; they should not be reused for
another patient nor to access a medication or solution
that might be used for a subsequent patient
c. Use fluid infusion and administration sets (i.e.,

intravenous bags, tubing and connectors) for one
patient only and dispose appropriately after use.
Consider a syringe or needle/cannula contaminated

once it has been used to enter or connect to a patient's
intravenous infusion bag or administration set.
d. Use single-dose vials for parenteral medications

whenever possible
e. Do not administer medications from single- dose

vials or ampules to multiple patients or combine
leftover contents for later use.
f. If multidose vials must be used, both the needle or

cannula and syringe used to access the multidose vial
must be sterile.
g. Do not keep multidose vials in the immediate patient

treatment area and store in accordance with the
manufacturer's recommendations; discard if sterility is
compromised or questionable
h. Do not use bags or bottles of intravenous
solution as a common source of supply for
multiple patients
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Procedures
Hand Hygiene
Perform hand hygiene following the WHO 5 Moment approach (Before touching a patient;
Before clean/ aseptic procedure; After body fluids exposure risk; After touching a patient; After
touching patient surroundings). (Refer to Policy on Hand hygiene)
Personal Protective Equipment
Use appropriate PPEs to prevent skin and mucous membrane exposures. However, most routine
patient care activities at the bedside do not require the use of PPEs (gloves, gowns/ plastic
aprons).
The proper Sequence of donning and doffing of personal protective equipment should be
executed as follows:
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*Hand hygiene must be performed if hands become contaminated during any step.
1. Gloves
a. Wear gloves whenever contact with blood and body substances, contaminated items and
surfaces is likely.
b. Wear and change gloves between tasks/procedures on the same patient.
c. Remove gloves promptly after use and before touching non- contaminated items and
environmental surfaces.
d. Wash hands immediately after gloves are removed.
e. Use nonsterile gloves for examinations and other nonsterile procedures,
f. Use sterile gloves for sterile procedures.
g. Gloves are not to be worn after leaving patient room/ procedure area.
2. Gowns
a. Wear a long sleeve, water and fluid resistant gown/plastic apron to protect skin and clothing
during procedures and patient-care activities when contact of clothing/exposed skin with
blood/body fluids, secretions, and excretions is anticipated.
b. Change the gown/plastic apron for each patient and/or procedure.
c. Gown / aprons are not to be worn after leaving patient room/ procedure area.
3. Mask
a. Wear a surgical mask in conjunction with protective eye/face wear during procedures and
patient- care activities likely to generate splashes or sprays of blood, body fluids, secretions,
especially suctioning, endotracheal intubation
b. Change mask between patients and sooner if mask becomes wet, moist or not intact.
4. Protective eye/ face wear
a. Wear protective eye / face wear in required combination to prevent eye/face contamination
by aerosolized body substances during procedures and patient-care activities likely to
generate splashes or sprays of blood, body fluids, secretions, especially suctioning,
endotracheal intubation
b. Wash and disinfect visibly soiled face reusable shields or protective eyewear, after soiling
and prior to reuse.

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5. Resuscitation Devices
Use mouthpiece, resuscitation bag or other ventilation devices to prevent contact with mouth and
oral secretions.
6. Handling/disposal of Needles / sharps
a. Dispose of used sharp items in an approved puncture resistant container immediately after
use, at the point of use or as close to point of use as possible.
b. Do not fixate used sharp items on any environmental surfaces.
c. Do not recap or manipulate needles using both hands because this increases the risk of
injury. If recapping or manipulation of the needle is deemed essential, then use either a one-
handed ―scoop‖ technique or a mechanical device designed to hold the needle sheath.
d. Before attempting to remove needles from non-disposable aspirating syringes, recap them
with either a one-handed ―scoop‖ technique or a mechanical device designed to hold the
needle sheath.
e. Closed sharp containers when ¾ full.
7. Linen
a. Handle/transport soiled laundry in a safe manner:

b. Do not shake the items or handle them in any way that may aerosolize infectious agents to
prevent contamination of air, skin/ mucous membrane exposure, contamination of personal
clothing, or transferring microorganisms to other patients/environment.
c. Avoid contact of one's body and personal clothing with the soiled items being handled
d. Place soiled items in an impervious laundry bag or designated bin. Close the bag and bin
securely.
e. Wrap wet linen in another piece of linen to avoid soaking of bag.
f. When laundry chutes are used, ensure that they are properly designed, maintained, and used
in a manner to minimize dispersion of aerosols from contaminated items
8. Medical Waste
a. Place biomedical waste in identifiable yellow bags with bio-hazards label or designated
containers.
b. Securely tie/close bags/containers and remove as a single unit for appropriate disposal.

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9. Patient Care Equipment
a. Handle used patient care equipment in a manner that prevents skin and mucous membrane
exposures, contamination of clothing and transfer of microorganisms to other patients /
environment.
b. Commonly used equipment must be clean and disinfected with hospital approved
disinfectants, between patients.
c. Do not reuse disposable equipment.
d. Ensure reusable equipment is properly transported in leak proof container to CSSD for
reprocessing before using on another patient.
10. Laboratory Specimens
Handle all specimens with gloves.
a. Place laboratory specimens in designated, appropriately sealed containers.

b. Label containers with appropriate patient data.
c. Transfer to the laboratory in an upright position and as promptly as possible.
d. Ensure that requisition is completed fully (i.e., specification site is critical for lab analysis
and clinical interpretation).
11. Cleaning of room should be daily and after discharge
Room cleaning as per housekeeping policies is all that is required. (Refer to policy on
Housekeeping)
12. Cough Etiquette
a. Cover nose and mouth with a tissue when coughing or sneezing.

b. Dispose of the used tissue in the nearest waste receptacle.
c. Clean hands with soap and water, an alcohol-based hand rub, or antiseptic hand wash after
touching respiratory secretions or handling contaminated objects.
d. Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and
dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory
secretions; wear surgical mask if tolerated or maintain spatial separation, > 1 meter if
possible.

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Hospital and should not be reproduced without the permission of JVGH Transmission-Based Precaution
Administration.
TRANSMISSION BASED PRECAUTION
Contact Precaution
Direct-contact transmission involves skin-to-skin contact and physical transfer of

microorganisms to a susceptible host from an infected or colonized person, such as occurs when
personnel tum patients, bathe patients, or perform other patient-care activities that require
physical contact. Direct-contact transmission also can occur between two patients (e.g. by hand
contact), with one serving as the source of infectious microorganisms and the other as a
susceptible host. indirect-contact object, usually inanimate, in the patient's environment.
Contact Precautions apply to specified patients known or suspected to be infected or

colonized (presence of microorganism in or on patient but without clinical signs and symptoms of
infection) with epidemiologically important microorganisms that can be transmitted by direct or
indirect contact
 Place the patient in an isolation room and limit access.

 Wear gloves during contact with patient and with infectious body fluids or contaminated
items. Reinforce hand washing throughout the health facility
 Wear two layers of protective clothing.
 Limit movement of the patient from the isolation room to other areas.
 Avoid sharing equipment between patients. Designate equipment for each patient, if supplies
allow. If sharing equipment is unavoidable, clean and disinfect & before use with the next
patient.

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Droplet Precaution
Droplet Transmission involves contact of the conjunctiva or the mucous membranes of the
nose or mouth of the susceptible person with large particle droplets (larger than 5 um in size)
containing microorganisms generated from a person who has a clinical disease or who is a carrier
of the microorganism Droplets are generated from the source person primarily during coughing.
sneezing, or talking and during the performance of certain procedures such as suctioning and
bronchoscopy.
Transmission via large-particle droplets requires close contact between source and recipient
persons, because droplets do not remain suspended in the air and generally travel only short
distances, usually 3 feet or less, through the air. Because droplets do not remain suspended in the
air, special air handling and ventilation are not required to prevent droplet transmission.
Droplet Precautions apply to any patient known or suspected to be infected with

epidemiologically important pathogens that can be transmitted by infectious droplets:
 Place the patient in an isolation room.

 Wear an N95 mask or another biosafety mask when working within 3 ft of the patient.
 Limit movement of the patient from the room to other areas. If patient must be moved, place
a surgical mask on the patient.

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Airborne Precaution
Airborne Precaution are precautions designed to reduce the risk of airborne transmission by
airborne droplet nuclei (5 um or smaller in size, that remain suspended in the air and can be
widely dispersed by air currents within a room or over a long distance)
The following precautions must be taken:
1. Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
disease that is transmitted by the airborne route.
2. Use single room with negative air pressure system (Airborne Infection Isolation Room). Door
must be kept closed at all times.
3. Put the Airborne Isolation sign on the door.
4. Wear a respiratory protection (N95 respirator) for Pulmonary MTB before entering the room.
Fit testing should be done for staff before wearing N95 masks. Remove the mask when
outside the room.
5. Place a surgical mask on the patient if he/she is to leave the room.
6. Keep patient in the room during the infectious period.
7. Check with visitors and staff for their immune status to the disease and instruct them
regarding use of protective apparel and conduct in isolation room.
8. Emphasize proper personal hygiene and hand hygiene.
9. Notify Infection Prevention staff that patient is in isolation.
10. Notify other departments that would be receiving patient of his/her isolation status.
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11. Patients diagnosed with the same disease can be cohorted assuming that no other infections are
present. Doors and windows must be kept closed.
12. Health Care Workers who are not immune to Measles and Varicella must not enter Isolation Room.
13. Discontinue isolation precautions in consultation with infection prevention team as per reference
guide.
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Hospital and should not be reproduced without the permission of JVGH Isolation Precaution
Administration.
ISOLATION PRECAUTION
Patients with any of the following diseases should be placed in isolation or single rooms.
When a single room is not available, place the patient in a room with a patient/patients who has
active infection with the same microorganism but with no other Infection (cohorting). When a
single room is not available and cohorting is not achievable, consider the epidemiology of the
microorganism and the patient population when determining patient placement. Consultation with
infection control professionals is advised before patient placement. Use Standard Precautions for
the care of all patients.
Airborne Precautions:
1. Tuberculosis (suspect or confirmed)

2. Varicella (including disseminated zoster)
3. Measles
Droplet Precautions:
1. Invasive Haemophilus influenzae type b disease. including meningitis, pneumonia, epiglottitis,

and sepsis
2. Invasive Neisseria meningitides disease, incl ding meningitis. pneumonia, and sepsis
3. Other serious bacterial respiratory infections spread by droplet transmission, including:
 Diphtheria (pharyngeal)
 Mycoplasma pneumonia
 Pertussis
 Pneumonic plague
4. Serious viral infections spread by droplet transmission, 1 including.
 Adenovirus+
 Rubella
 Parvovirus B19
 influenza
 SARS
 Mumps
 Avian or Bird Flu

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5. Viral / hemorrhagic conjunctivitis

6. Viral hemorrhagic infections (Ebola, Lassa, or Marburg)
*certain infections require more than one type of precaution
Procedure in the Use of Single Room/Isolation Room
 Consult with the Infection Control Staff to verify proper patient placement as necessary.
 Use single room with hand hygiene and toilet facilities for isolation purposes.
 Use single room with negative pressure for airborne isolation precautions.
 Post the appropriate isolation sign on the door to indicate the isolation precaution(s) required.
 Place the necessary PPE outside the single isolation room.
 Consult with Infection Control staff if there is a need to cohort patients with identical
organisms/ disease.
Indication for a Single Room
1. Single-patient rooms are always indicated for patients placed on Airborne Precautions
and in a Protective Environment.
2. Single-patient rooms are preferred for:
a. patients who require Contact or Droplet Precautions

b. patients who have conditions that facilitate transmission of infectious material to other
patients (e.g., draining wounds, stool incontinence, uncontained secretions such from
infants with suspected viral respiratory or gastrointestinal infections) and for those who
are at increased risk of acquisition and adverse outcomes resulting from HAI (e.g.,
immunosuppression, open wounds, indwelling catheters, anticipated prolonged length
of stay, total dependence on HCWs for activities of daily living).
3. During a suspected or proven outbreak caused by a pathogen whose reservoir is the

gastrointestinal tract, use of single patient rooms with private bathrooms limits
opportunities for transmission, especially when the colonized or infected patient has poor
personal hygiene habits, fecal incontinence, or cannot be expected to assist in maintaining
procedures that prevent transmission of microorganisms (e.g., infants, children, and
patients with altered mental status or developmental delay).

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4. Patient factors (e.g. the ability of patient to comply with basic hygiene and infection
control practices) are important determinants of infection transmission risks, and the need
for a single- patient room and/or private bathroom for any patient is best determined on a
case-by-case basis.
5. Patient is placed in a single room for the duration of communicability/ infectious period of
the disease.
Admission Process
1. Attending physician documents confirmed or suspected infectious status of patient that

requires isolation.
2. Admitting wards (OPD, ER) notifies Infection Control staff.
3. Infection control staff in collaboration with attending physician will determine the need for
isolation, confirmed or suspected cases considered for admission.
4.The receiving ward and admission office shall notify infection control staff when a patient is
placed in single room isolation.
5. If a single room, in an off- service ward is utilized, the Admissions Department shall
transfer the patient to the appropriate service ward as soon as the required room becomes
available.
6. The infection control staff shall assess monitor patient’s progress and advise when isolation
in a single room should be discontinued.
7. The ward staff shall notify the Admissions office when isolation is discontinued.

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TRANSPORTING PATIENTS ON ISOLATION PRECAUTION
To provide clear guidelines for safely transporting of potentially infectious patients to

prevent/ minimize infection transmission.
Procedures
1. All Staff must observe Standard Precautions at all times.

2. Infectious patients should not be transferred to another hospital unless it is clinically
indicated and the transporting body and the receiving facility are informed about the patient
infectious status.
3. For some highly fatal infectious diseases, if transportation of the patient is deemed highly
necessary, consult Infectious disease and infection control staff before transfer.
4. For transportation of patients from the community to the hospital; staff should follow
standard precautions
Policy
1. Transport of patients in isolation should be limited for essential purposes only.

2. When patient transporting is necessary, appropriate barriers (e.g., masks, impervious
dressing) will be used to reduce potential contamination of the environment and spread of
infection
Ambulance Guidelines
1. Ambulance staff should strictly adopt the following:

a. Remove watches and all wrist and hand jewelry before the beginning of the shift.
b. Strictly apply ―bare below the elbows‖ clothing policy to prevent the spread of
infection from contaminated sleeves and to aid effective hand-hygiene.
2. Hand Hygiene:
a. If soap and water are not available clean hands with detergent wipes first, followed by
thorough drying with paper towels and then applying alcohol gel. Alcohol gel should
only be used on visibly clean hands.
b. Use soap and water to clean hands wherever possible.

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3. Personal Protective Equipment (PPEs):
a. All vehicles used for patient transfer should carry a stock of PPE for use by the staff.
b. All PPEs must be discarded as clinical waste.
c. Gloves must not be worn when driving to and from a scene or for longer than
necessary.
4. Environmental Cleanliness:
a. Ambulance interiors should be thoroughly cleaned using a hospital approved

disinfectant.
b. All equipment used for patient transport and care such as monitors, carry chairs, and
stretchers should be cleaned using hospital approved detergent or soap and water and
wiped with paper towels followed by the use of hospital approved disinfectant or
chlorine-based fluid if the patient has diarrhea. This process should be done after every
patient use.
c. Linen should be changed after every patient and should be collected as soiled linen
Transfer of the patient within the hospital (Between Departments).
1. Sending Department: The Head Nurse of the Ward/Unit will assist in the following:
a. Notify the department to which the patient is to be transported of the patient
isolation precautions status.
b. Instruct the patient of ways he/she can assist in maintaining appropriate precautions
to prevent transmission of the infection.
c. Dress wounds with impervious dressings as required.
d. Dress the patient in a clean gown.
e. Explain to the patient the need for the protective apparel he/she is required to wear.
f. Put a surgical mask on the patient who is in airborne isolation.
g. Place the patient on a stretcher/wheelchair as appropriate and cover wheelchair/
stretcher with a sheet.
h. Cover the patient with a clean sheet.
i. Transport the patient to the area as required.

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Administration.
2. In The Receiving Department: The Head Nurse of the Ward/Unit will assist in the
following:
a. Maintain patient with protective apparel in place.
b. Expedite procedure to minimize patient stay.
c. Observe specific isolation techniques.
d. Perform hand hygiene before and after contact with patient.
e. Arrange for patient’s return to ward as soon as possible.
f. Change linen, clean equipment and environmental surfaces as indicated before the next
patient.
g. Return the patient to the isolation room as soon as circumstances allow.
There is no need to empty the investigation or procedure rooms from equipment when
investigating an infected patient. Equipment that are not in use should be kept covered with a dust
cover or be stored in a cupboard, as for all patients.
Staff transferring the patient should do the following:
1. Transport patients by the most direct routes to their destination. Avoid contact with
employees and visitors as much as possible.
2. Wear a disposable apron and gloves if physical contact with the patient under contact
isolation is required for the transfer or if contact with body fluids is likely. After the
transfer (before contact with another patient) protective clothing must be removed and
hand hygiene should be followed.
3. Do not wear protective equipment if no physical contact with the patient. However,
hands must be decontaminated with alcohol-based hand rub or hand washing before
another patient contact.
4. Clean and disinfect wheelchair or stretcher with detergent wipes followed by an
approved hospital disinfectant.
5. Cleaning of wheelchairs will be focused on the seat, armrest, and backrest. While
cleaning of the stretchers will focus on the upper and lower surface of the stretcher pad.
The metal portion of both will be inspected for contamination with blood and body fluids
and once removed by disinfectant wipes, all surfaces should be decontaminated with a
hospital approved disinfectant.

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This is a controlled document, property of Joni Villanueva General Cleaning, Disinfection and
Hospital and should not be reproduced without the permission of JVGH Sterilization of Medical
Administration.
Equipment
Cleaning, Disinfection and Sterilization of Medical Equipment
Introduction
Medical equipment and surgical instruments are examples of devices that are essential to the
care of patients; however, because they typically are designed for reuse, they also can transmit
pathogens if any of the steps involved in reprocessing, cleaning, disinfection, or sterilization are
inadequate or experience failures. Because the vast majority of pathogens are present in organic
matter, e.g. visible soil, the first step in reprocessing, cleaning, is the most important. Any
failure to remove soil at this point creates the potential for transmission of infection as the
efficacy of subsequent disinfection or sterilization will be compromised. Decontamination is the
process by which microorganisms are removed or destroyed in order to render an object safe. It
includes:
• Cleaning.
• Disinfection, and
• Sterilization.
All hospitals and health care facilities should have a decontamination policy and help staff to
decide what decontamination process should be used for which item of equipment.
Definition:
Cleaning is the physical removal of foreign material (e.g., dust, soil) and organic
material (e.g. blood, secretions, excretions, microorganisms) from objects and surfaces.
Cleaning physically removes rather than kills microorganisms. It is accomplished with water,
detergents, and mechanical action. Cleaning must be performed before disinfection or
sterilization.
Decontamination refers to the process of cleaning that removes pathogenic

microorganisms from objects so that they are safe to handle, use, or discard.
Disinfection describes a process that eliminates many or all-pathogenic microorganisms

from inanimate objects, except for bacterial spores, e.g. disinfection of environmental surface
with a sodium hypochlorite solution.
Sterilization refers to a physical or chemical process that completely kills or destroys all
forms of viable microorganisms from an object, including spores. This is usually carried out in
an autoclave.
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Cleaning, Disinfection and Sterilization of
Administration. Medical Equipment
Cleaning and Disinfection
Routine cleaning and disinfection are necessary to maintain a standard of cleanliness,

reduce microbial contamination and control or minimize the spread of infectious agents from
infected/colonized patients to other patients or HCWs. Medical equipment also requires
decontamination for safe patient care.
There are four categories of healthcare equipment (based on the method of cleaning and
frequency of cleaning):
a. Single use (disposable): Items that are designed for one-time usage on one patient e.g.
sterile syringes, dressing sets & urinary catheters;
b. Single patient use: Items that are reusable on the same patients e.g. NG feeding syringe
(syringe to be replaced twice a week);
c. Reusable instruments: Instruments that can be decontaminated and reused;
d. Reusable equipment: Equipment that can be decontaminated and reused.
Spaulding Classification
The Spaulding Classification of medical devices is a clear and logical classification

method that has been retained, refined, and successfully used by HCWs for assessment of the
level of disinfection or sterilization needed for medical devices according to critical, semi critical
and non-critical items and type of cleaning required.
Refer to Table 1 below for Spaulding’s classification of medical devices and required level of
processing/reprocessing.

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Table 1: Spaulding's Classification of Medical Devices and Required Level of

Processing/Reprocessing
Classification Definition Level of Examples
Processing/Reprocessing
Critical Equipment/device Cleaning followed by Surgical
that enters sterile sterilization instruments, biopsy
tissues, including instruments
vascular system
Semi-critical Equipment/device Cleaning followed by Respiratory therapy

that comes into high-level disinfection equipment,
contact with non- (as a minimum). anesthesia
intact skin or Sterilization is preferred. equipment,
mucous Laryngoscope
membranes but do blade
not penetrate them
Non-critical Equipment/device Cleaning followed by ECG machines, pulse

that touches only low-level disinfection. oximeter, bedpans,
intact skin and not urinals, commodes,
mucous blood pressure cuffs,
membranes, or crutches, computers,
does not directly bed rails, bedside
touch the patient tables, patient
furniture and floors
Disinfection of Healthcare Equipment
A great number of disinfectants are used alone or in combination (e.g. hydrogen

peroxide and peracetic acid) in the healthcare setting. These include alcohols, chlorine and
chlorine compounds, glutaraldehyde, orthophtaladehyde, hydrogen peroxide, iodophors,
peracetic acid, and quaternary ammonium compounds (QUATs). In most instances, a given
product is selected for the intended use and applied in an efficient manner. Caution must be
exercised when using on electronic medical equipment.
In general, shared items e.g. BP cuffs, thermometer should be disinfected in between

each patient use.

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Detergents and Cleaning Agents
“Detergents” or “soaps” are cleaning agents that make no antimicrobial claims. Their
cleaning activity can be attributed to their detergent properties, which result in removal of dirt,
soil and various organic substances. However, the use of a detergent solution improves the quality
of cleaning
Disinfectants
When using a disinfectant, it is important that an item or surface be free from visible soil
and other organic items before applying disinfectant. Otherwise, the effectiveness of disinfectants
will be reduced or eliminated. Use the disinfectant according to manufacturer’s instructions on
dilution and contact time.
Refer to Table 2 below for types of chemical disinfectants.
Table 2: Types of Chemical Disinfectants

Disinfectant Recommended Use Precautions
Alcohol Rapidly bactericidal, Flammable, toxic, to be used in cool
tuberculocidal, and well-ventilated area, avoid
E.g. Isopropyl, Ethyl alcohol, fungicidal and virucidal but do inhalation
methylated spirit. not destroy bacteria and spores Observe fire code restrictions for
Smooth metal surfaces, tabletops storage of alcohol
and other surface on which To be kept away from heat
bleach cannot be used. sources, electrical equipment,
Effectively to disinfect non- flames and hot surfaces
critical items such as oral and
rectal thermometers, hospital
mobiles, BP cuffs and
stethoscopes etc.

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Disinfectant Recommended Use Precautions
Quaternary Ammonium Commonly used in general Relatively non-toxic and less
Compounds (QUATs) environmental cleaning of corrosive. Dilutions in use may
noncritical surfaces, such as get contaminated and grow Gram
floors, furniture, and walls negative bacteria.
E.g. Alkyl dimethyl benzyl DO NOT use QUATs to disinfect
ammonium chloride, Alkyl instruments.
dimethyl ethyl benzyl
ammonium chloride
Chlorine /Sodium Kills fast and has broad PPE are required while handling
hypochlorite Spectrum actions against a wide and using undiluted
range of Gram negative and Corrosiveness to metals
E.g. Sodium Gram- positive bacteria and Flammable, toxic, to be used in
dichloroisocyanurate spores. cool and well- ventilated area,
(NaDCC)] Recommended for avoid inhalation
environmental surfaces, Low cost
noncritical equipment, blood Rapid action
spills. Readily available
Hydrogen Peroxide Isolation room surfaces Safe for environment

Enhanced Action Clinic and procedure room Non-toxic
Formulation 0.5% surfaces Rapid action
Low-level disinfection is Available in a wipe
(7% solution diluted 1:16) achieved after 5 minutes of Active in the presence of organic
contact at 20°C or according to materials
manufacturer instruction Excellent cleaning ability due to
detergent properties
Hydrogen peroxide 3% Noncritical equipment used for Low cost

home healthcare Rapid action
Floors, walls, furnishings Safe for environment
Disinfection is achieved with a Store in cool place, protect from
3% solution after 10 minutes of light
contact

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Sterilization
Sterilization is the elimination of all disease-producing microorganisms, including spores

(e.g. Clostridium and Bacillus species) and prions that are not susceptible to routine
sterilization. Sterilization is used on critical medical equipment/devices and various semi-
critical medical equipment/devices.
Medical equipment / devices that have contact with sterile body tissues or fluids are
considered critical equipment / devices. They must be sterilized because microbial
contamination could result in disease transmission. Whenever possible, semi-critical
equipment/devices should be sterilized. When sterilization is not possible, semi-critical
equipment/devices should be cleaned followed by high-level disinfection. The settings need to
have written policies and procedures for sterilization of medical equipment / devices processes.
Physical arrangements of processing areas are presented schematically in four references.
Selection of sterilizers should be done in consultation with the Infection Prevention Team
in institutional practices. Good communication is required between the primary care center and
the manufacturer of the sterilizer to ensure:
a) Manufacturers provide specific, written instruction on installation and use of

equipment;
b) Storage and transportation practices maintain sterility to the point of use;
c) Manufacturers are specific as to which medical equipment/devices can be sterilized in
their machines and the recommended sterilization methods.
They must be installed according to the manufacturer’s instructions and be commissioned

and maintained appropriately in compliance with the manufacturer’s instructions.
Equipment Use and Preventive Maintenance
Table-top sterilizers undergo frequent use, wear, and tear. The manufacturer’s
recommendations should be consulted for guidance on a preventive maintenance program
including regular inspection of gaskets and seals.
Sterilization processes may be mechanical, chemical, or biological. Monitoring should be

done when a sterilizer is first installed before use and in routine performance assessments. The
daily operation of every sterilizer must be reviewed and documented. A logbook should be kept
for this purpose. Any malfunction must be noted, and appropriate action taken.
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Physical monitors
A physical monitor is a device that monitors the physical parameters of a sterilizer such as time,
temperature and pressure that are measured during the sterilization process and recorded on completion of
each cycle.
Biological monitors
Biological indicators (BIs) are the most accepted means for monitoring sterilization because they
directly assess the procedure's effectiveness in killing micro-organisms. Spores used are more resistant and
present in greater numbers than common microbial contaminants found on patient care items. Therefore,
an inactivated BI signifies that other potential pathogens in the load have been killed.
Conduct BI at least weekly for steam sterilizers. Follow the manufacturer's directions concerning
the appropriate placement of the BI in the sterilizer.
Alternatively, the use of disposable sterile instruments should be considered in situation where there
is no feasibility of sterilization to be done in ambulatory setting.
Chemical Indicators (CI)
A chemical indicator (CI) is a system that responds to a change in one or more predefined process
variables with a chemical or physical change. There are six classes of chemical indicators.
Refer to Table 3 below for international types of steam chemical indicators.

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Document Title:
Cleaning, Disinfection, and Sterilization of
Table 3: International types of Steam Chemical Indicators
Type Definition Type Use Examples

I Process indicator to differentiate To indicate that item has Indicator tapes
processed from non-processed been directly exposed to indicator labels
items sterilization process,
usually applied outside of
packages.
II Indicator for use in specific tests To evaluate sterilizer Bowie-Dick test

performance
III Single variable indicator to For pack control Temperature

indicate when a stated value has monitoring but not as tubes
been reached e.g. temperature at useful as Class IV or V
specific location in chamber indicators; for exposure
control monitoring
IV Multi-variable indicator that For pack control Paper strips

reacts to 2 or more critical
variables in sterilization cycle
V Integrating indicator that reacts release loads that do not

to all critical variables in the contain implants
sterilization process (time,
temperature, presence of steam)
and has stated values that
correlate to a BI at 3
time/temperature relationships
VI Emulating indicator that reacts As internal pack control

to all critical variables (time,
temperature, presence of steam)
for specified sterilisation cycle
(e.g. 10 min, 18 min, 40 min)

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Document Title:
Storage
Sterile and single-use disposable items should be stored in an enclosed space, such as
closed or covered cabinets that allow the packaged item to remain sterile. The storage area should
be dedicated for storage only, be free of clutter and wiped clean at regular intervals. They should
be stored above floor level away from direct sunlight and water in a secure dry and cool
environment. They should not be stored under sinks or in other locations where they might
become wet and contaminated.
Storage practices for packaged sterilized instruments may be either date or event related.
Dating assists in the recall of instruments should concerns arise with the results of sterilization
tests. Some health care facilities date every sterilized package and use shelf-life practices (e.g.
“first in, first out”). Others use event-related practices. The latter approach recognizes that the
packaged instruments should remain sterile indefinitely unless an event causes them to become
contaminated (e.g. torn or wet packaging).
Packages containing sterile instruments should be inspected before use to verify barrier
integrity and dryness. If packaging is compromised, the instruments should be cleaned, packaged,
and sterilized again.
Monitoring and System Failures
Improper reprocessing includes, but is not limited to, the following situations:
 The load contains a positive BI;

 An incorrect reprocessing method was used on the equipment/device
 Reprocessing equipment indicators fail to reach correct parameters (e.g.
temperature, pressure, exposure time);
 CI or monitoring tape has not changed color;
 There is doubt about the sterility of medical equipment /devices.
Written procedures must be established for the recall and reprocessing of improperly
reprocessed medical equipment / devices. All equipment / devices in each processed load
must be recorded to enable tracking in the event of a recall. The recall procedure should
include:
 Designation of department and staff responsible for executing the recall;

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 Identification of the medical equipment/devices to be recalled; if recall is due to a failed

BI, the recall should include the medical devices in the failed load as well as all other
devices processed in the sterilizer since the last successfully sterilized load;
 Assessment of patient risk;
 Procedure for subsequent notification of designated staff or patients.
Reprocessing/ Re-use of Single Use Devices
Single use devices are primarily made from various forms of plastic, rubber, and occasionally
some metal, which has a polished/stainless coating. In general, these products are intended for
disposal after a single episode of use. Plastic contains polymers. Polymers can break down during
cleaning and sterilizing due to the chemicals (and perhaps temperature) used in these processes.
This could have serious consequences for the patient.Expiration dates on sterile single use devices
not only pertain to sterility, but more importantly to the natural degradation of polymers with age.
Plastics and rubber retain their condition for a number of years then deteriorate rapidly with age,
unlike stainless steel.
Procedure
1. All SUDs will be for a single episode of usage only.

2. If a SUD has the potential for a subsequent reuse, this must be stated in writing by the
manufacturer.
3. SUDs that can be safely resterilized must have written guidelines from the manufacturer on
the cleaning and sterilizing methods, as well as the number of times the item can be
reprocessed. This applies to unopened expired devices or opened but unused devices.
4. Used SUDs will not be reprocessed for a second use.
5. Departments or individuals that require a SUD to be reprocessed must provide the
manufacturer’s written guidelines to CSSD. If the information is not immediately available,
the requestor should seek assistance from the manufacturer or manufacturer’s agent. CSSD
cannot accept any SUD for reprocessing without this document.
6. The decision to reprocess single use devices must be based on clear and certain evidence that
there will be no harm to the patient from the use of a resterilized SUD.
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Document Title:
7. Each SUD that is being considered for reprocessing must be evaluated by the requestor/end
user and approved by the Division Head, and the Director of the Infection Control
Department/unit, based on the following criteria:
a. Type of use, i.e. invasive or non-invasive.

b. Risk to the patient, e.g. infection, mechanical defects or degradation caused by
reprocessing.
c. Ethical, moral and legal implications.
d. Costs incurred.
8. A Request for Reprocessing a Disposable Single Use Device form must be completed and
submitted to CSSD Manager. CSSD Manager will assesses item and discusses findings with
Infection control to decide/ recommend the appropriate course of action to be taken within an
Administrative Directive.
9. Aged SUDs, i.e. those that are a long time beyond their expired shelf life, will not be
reprocessed or reused due to the natural deterioration with age of polymers and other
materials in these disposable products. Signs of age are often identifiable by discoloration
and occasionally by smell and stickiness.
10. Any SUD that is being considered for reprocessing will be carefully examined for signs of
material deterioration or defect such as cracking, splitting, tear or break, which indicates that
the device is unfit for use.
11. Where a difference of opinion occurs between the requestor and the CSSD in-charge on the
feasibility of reprocessing a SUD, the chairman of the Infection Control Department will
arbitrate. The latter may consult with other knowledgeable persons, as deemed appropriate.
12. In the event of a life-and-death emergency where no other SUD is available except a used
device, the decision to reprocess the used device will be taken jointly by the requestor, CSSD
In-charge and the Chairman of the Infection Control Department.
13. Prior to the issuance of a reprocessed single use device from CSSD, it will be visibly
inspected for signs of damage or deterioration.
14. Discard used SUDs as per hospital waste disposal protocol.

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Hospital and should not be reproduced without the permission of JVGH Routine and Terminal Cleaning of
Administration. Patient Care Areas
ROUTINE AND TERMINAL CLEANING OF PATIENT CARE AREAS
1. The Housekeeping Services staff assigned to do cleaning and disinfecting tasks in all patient
areas must be properly trained and supervised.
2. The rubber or disposable gloves, must be worn when:
a. preparing disinfectant or cleaning solutions

b. applying disinfectant or cleaning solutions by hand to wipes and/or surfaces
c. handling waste / trash containers
3. The appropriate personal protective equipment (PPE) should be worn by the housekeeping staff
when cleaning areas used by patients known or suspected to be infected with an acute
respiratory disease (ARD) of potential concern, i.e. novel influenza A (H1N1): gloves, gown,
N95 mask, eye goggles.
4. Hand hygiene must be performed immediately after removing gloves and other PPE.
5. In special areas (i.e. MICU, SICU, STU), consider dedicated cleaning personnel for these areas
alone.
6. Daily routine cleaning should include all horizontal surfaces such as floors, tables and
nightstands; and all surfaces that are frequently touched by the patient and healthcare
personnel such as bedrails, call buttons, telephones, and the toilet and lavatory in the
bedroom.
7. Examination tables and surrounding equipment that have been used by patients
8. known or suspected to be infected with an acute respiratory disease (ARD) of potential

concern, ie. Novel influenza A (H1N1), should be wiped with disinfectants immediately after
use.

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Routine and Terminal Cleaning of
9. Terminal cleaning after patient discharge or transfer must include:
a. All of the horizontal surface covered in the routine cleaning PLUS

b. Obviously soiled vertical surfaces
c. Surfaces frequently touched by the patient or HCWs such as doorknobs, switches and
remote control.
d. All other durable equipment in the room such as bed, wheel chair, IV stand and
commode.
10. Clean and disinfect surfaces that are touched routinely by hand (e.g. doorknobs. bed rails,
bedside- and over-bed tables, bathroom surfaces pull-up bars, television controls, call buttons)
on a more frequent schedule than that used for large housekeeping surfaces.
11.Clean large housekeeping surfaces (e.g. floors) in patient-care areas with detergent /
disinfectants (in accordance with manufacturer's instructions) at least daily and terminally cleaned
at patient discharge.
12. Clean bathroom surfaces daily first with detergent and water, and then disinfect with a dilute
solution (1:100 volume/volume) of household chlorine bleach (sodium hypochlorite) or other
approved disinfectant.
13. Avoid large-surface cleaning methods that produce mists or aerosols or disperse dust in
patient-care areas (e.g. use wet dusting techniques, wipe application of cleaning and/or
disinfectant solutions).
14. There is no need to disinfect walls, window drapes and other vertical surfaces unless
obviously soiled.
15. Follow manufacturer instructions for proper use of disinfectants, especially with regards to the
proper concentration of product and the time the product should come in contact with the surface
being disinfected. Some disinfectants suitable for this purpose include:
a. Sodium hypochlorite 0.1% (1 part bleach in 100 parts water - to be used on non-metal
surfaces or equipment
b. Alcohol - for use on smaller surfaces
c. Phenolic compounds
d. Quaternary ammonium compounds
e. Peroxygen compounds
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15. Good ventilation of the area is necessary during and immediately after the process of
disinfection, regardless of the type of disinfectant used.
16. Detergent and water are adequate for cleaning surfaces in nonpatient-care areas (e.g.
administrative offices).
17. All cloths used must be dampened before use. Dusting with a dry cloth or sweeping may lead
to aerosolization and should be avoided.
18. Solutions, cloths, and mop heads should be changed regularly.
19. All cleaning equipment (i.e. mops and rugs) should be washed thoroughly and dried after each
use
20. Re-usable mop heads should be laundered and dried after every use.

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Guidelines on Healthcare Associated
Administration. Infections
SURGICAL SITE INFECTION (SSI)
Responsibilities
Health educator
a. Educate the patient to stop smoking; if patient does not want to comply , advise him/her to
avoid smoking for a minimum of 30 days prior to surgery
b. Educate patients not to shave hair prior to admission
c. Educate the patient and family regarding incision care and symptoms of SSI such as:
1. fever
2. pus coming from the wound,
3. redness around the wound,
4. foul odor
5. sharp new pain coming from the wound,
6. the need to report such symptoms.
Surgeon
a. Pre-operatively, keep the patient ‘s hospital stays as short as possible

b. Order Management of Multidrug Resistant Organisms (MDROs) screening if the patient is
admitted to a high-risk area.
c. If possible, apply Methicillin Resistant Staphylococcus aureus (MRSA) decolonization
protocol before elective high-risk surgeries (e.g. cardiothoracic and orthopaedic surgeries).
Consult Infection Control if needed.
d. Postpone elective operations for infected patients until the infection resolves.
e. Write an order to check blood glucose levels on all patients (diabetic and nondiabetic)
going for surgery on admission.
f. Consult appropriate subspecialty for preoperative assessment and controlling chronic
medical illnesses ( e.g. DM)
g. Cooperate with Infection Control to implement necessary actions and preventive measures
as needed
h. Prescribe antimicrobial prophylaxis

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i. Ensure the following data are documented by theatre charge nurse:
1. Wound class,
2. time incision was made and closed,
3. duration of surgery,
4. ASA score
j. Notify infection control staff when SSI is suspected/diagnosed.

k. Fill-out Post Discharge SSI Surveillance Form. Submit completed forms to infection control
as early as possible
l. Inform Diabetologist /Physician to follow-up patients who require insulin infusion protocol
to control blood glucose level during surgery.
Anesthetist
a. Administer prophylactic antibiotics

b. Intra-operatively, monitor blood glucose level and follow hospital approved insulin
infusion protocol to control blood glucose levels in diabetic. Start the same protocol for
non-diabetic patients who have 2 readings of blood glucose levels ≥12 mmol/L measured
one hour apart.
c. Maintain the patient’s Core Temperature at > 360C. (Does not apply to cardiac surgery).
Diabetologist/Physicians
Preoperatively
 Control blood glucose in diabetic patients if possible
 Write an order to start hospital approved insulin infusion protocol to monitor and control
blood glucose levels on diabetic patients
Postoperatively
 Ensure that the hospital approved insulin infusion protocol is implemented; keep blood
glucose level controlled. Take other suitable actions if blood glucose is not controlled by the
protocol
 Follow-up patients who require insulin infusion protocol to control blood glucose level
during surgery.

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Patient primary nurse
a. Ensure all preoperative measures are taken
1. Ensure that the patient takes a preoperative shower or bed-bath the patient using soap and
water either the night before or on the morning of the surgery
2. Follow the hospital approved insulin infusion protocol as per doctor‘s order.
3. Remove hair preoperatively (if ordered by the surgeon) using an electric clipper just
before sending the patient to the OR.( see procedures )
4. Examine the wound and inform the surgeon in charge and infection control practitioner if
there are signs of infection
5. Report new SSIs to the Infection Control Practitioner
Theatre Unit Manager/ Head Nurse
a. Ensure all theatre staff are adherent to this policy

b. Ensure adherence to Traffic Control measures in operating theatre.
c. Allow only necessary personnel to enter the operating room.
d. Ensure unnecessary and excessive talking is avoided
e. Ensure that environmental cleaning practices are followed.
Operating room Staff
a. Clean and disinfect Theatre table and room equipment

b. Wash re-usable instruments and remove any blood or debris before transport to CSSD;
c. ensure instruments remain moist during transport to facilitate cleaning and disinfection.
Operating room charge nurse
a. Conduct a visual inspection for cleanliness before case (carts, supplies, and instrument sets
are brought into the room).
b. Ensure equipment from outside are damp dusted before bringing into the OR.
c. Ensure all necessary equipment and surgical instruments are in the OR before the operation
begins
d. Ensure theatre surfaces in close contact to or near patients, such as the operating table or
instrument trolley, are disinfected with a hospital approved disinfectant before being used for
the next patient.

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e. Notify recovery areas of patients on Contact Precautions i.e. allow them to recover in the
operating theatre or in an area not occupied by other patients to avoid possible contamination
of the usual recovery area.
f. Document the following data (Wound class, time incision was made and closed, ASA
score and duration of surgery i.e., surgery start & end time).
Circulating Nurse
a. Intra-operatively and on arrival to the recovery room, maintain the patient’s core temperature
e.g., > 360C by applying the following:
 Use warmed forced air blankets preoperatively, during surgery and in the recovery room,
 Use warming blankets under patients on the operating table.
b. Preoperatively, use caps/hats and booties on patients. (Does not apply to cardiac surgery).
c. Maintain Sterility as follows:
 Use sterile drapes to establish a sterile field; constantly monitor it to maintain sterility
 Maintain sterility for all items introduced within the sterile field
 Assemble sterile equipment and solutions immediately prior to use. Do not set up ahead
of time (covering with a drape does not ensure sterility).
d. Ensure soiled items are not stored in the same area with clean or sterile items.
e. Ensure a clean surgical environment is maintained.
f. Perform flash sterilization for items that will be used immediately
Infection Control Department
a. Perform surveillance to detect SSI rate; provide feedback to consultants through heads of
Surgical Departments in a confidential manner.
b. Monitor compliance of personnel involved in care of surgical patients to this policy
c. Educate health care workers on preventive measures of SSI

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Procedures
Appropriate Hair Removal
1. Whenever possible, hair should be left at the surgical site.

2. If the hair will interfere with the procedure, write an order to clip it in the ward just before
sending the patient to the OR;
 Remove hair only from the area to be incised.

 DO NOT shave patients using razors.
Surgical attire and Drapes

All operating team members must do the following:
 First don hair covering and ensure it contains all hair; hoods should be used to contain all
facial hair including beards and sideburns.
 Wear pants and tops (surgical scrub attire) that cover as much of the body as possible, place
tops inside the trousers to minimize shedding.
 Wear a surgical mask in the restricted zones of the operating room suite.
 Remove covering and surgical scrub attire before leaving outside unrestricted zone, surgeons
and theatre staff should not wear with surgical scrub attire outside the theatre.
All scrubbed surgical team members should:
 Wear sterile disposable (single use) surgical gown & sterile gloves inside the Operating Room.
Do not walk around outside the Theatre with it.
 Use drapes impermeable to liquids and microbial contamination.
 Change surgical attire when soiled by blood or other potentially infectious materials.
 Wear sterile latex gloves. (For latex or powder allergies, wear hypoallergenic and latex free
gloves).
 Put on gloves after donning a sterile gown. If gloves are punctured during the operation,
change promptly as safety permits.
 Do not wear shoe covers for the prevention of SSIs. Wear dedicated shoes (not sandals) to
prevent blood/body fluid exposure.
 All personnel moving within or around a sterile field should do so in a manner that maintains
the sterile field.
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Surgical Hand/forearm hygiene
 Keep natural nails short and well-maintained; do not wear artificial nails or nail-polish.
 Remove rings, watches, and bracelets before beginning the surgical hand scrub.
 Practice surgical hand antisepsis using either Alcohol-based Antiseptic Hand Rub OR
Antiseptic Hand Wash protocols
Skin Antisepsis
 Using friction, apply the hospital approved antiseptic in concentric circles starting at the
proposed incision site and move towards the periphery discard after periphery has been
reached.
 Use gentle preparation technique when preparing fragile skin (e.g., diabetes, skin ulceration).
 Prepare an area large enough to extend the incision or create new incisions or drain sites if
necessary.
 The antiseptic preferred for skin antisepsis is 2% aqueous chlorhexidine plus 70% alcohol
(best option). If not available, other antiseptics include iodophors, or Povidone iodine used
singly or in combination with 70% alcohol.
 Allow antiseptic to dry completely before draping the patient (i.e. before the incision).
 Avoid the use of chlorhexidine gluconate and/or alcohol-based products on mucous
membranes.
 Do not use chlorhexidine gluconate above the chin (e.g. neurosurgery procedures)
 Do not use chlorhexidine for skin antisepsis on patients < 2 months.
Surgical Site Care
Intra-operatively
 Use delayed primary skin closure or leave an incision open to heal by second intention if the
surgeon considers that the site is heavily contaminated e.g., Class III and IV.
 If necessary, use a closed suction drain. Place the drain through a separate incision distant
from the operative site; remove it as soon as possible.
 Handle tissue gently, maintain hemostasis, minimize devitalized/necrotic tissue and foreign
bodies, minimize non-absorbable sutures and eradicate dead space at the surgical site.
 During surgical procedures, contain contamination within the immediate vicinity of the
surgical field if possible.

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Post operatively
 Protect a primarily closed incision with a sterile dressing for 24 to 48 hours; use aseptic
technique for dressing changes. Alternatively apply a semi- occlusive transparent and dressing
until staples are removed.
 Observe aseptic technique and Standard Precautions during dressing changes, Perform hand-
hygiene before and after patient contact.
 Do not touch an open or fresh wound unless wearing sterile gloves.
 Use clean, non-sterile gloves to remove dressings; for wound cleaning, practice hand-hygiene
and put on sterile gloves.
 Wear a face-shield mask and gown for wound cleaning /irrigation.
 Change dressings over closed wounds if they are wet or if the patient has signs and symptoms
of infection (e.g., cellulitis or unusual wound pain), evaluate the wound and report findings to
surgeon.
 Place used dressings and disposable equipment in the plastic bag provided in the dressing
pack; dispose appropriately into a container with orange bag
Prophylactic Antibiotics
 Administer prophylactic antibiotics as ordered
Blood Glucose Monitoring
 Write an order to check blood glucose levels on all patients (diabetic and nondiabetic) going
for surgery pre-operatively on admission.
 Keep blood glucose level controlled and maintained as per the hospital approved insulin
infusion protocol.

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APPENDICES
Appendix 1 : Surgical Wound Classification
Appendix 2 : Diagnostic Criteria for Surgical Site Infection (SSI)
Appendix 1
Surgical Wound Classification
Class I/Clean:
An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary,
genital, or uninfected urinary tract is not entered. In addition, clean wounds are primarily closed and, if
necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt)
trauma should be included in this category if they meet the criteria.
Class II/Clean-Contaminated:
An operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under
controlled conditions and without unusual contamination. Specifically, operations involving the biliary
tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or
major break in technique is encountered.
Class III/Contaminated:
Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open
cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute,
nonpurulent inflammation is encountered are included in this category.
Class IV/Dirty-Infected:
Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or
perforated viscera. This definition suggests that the organisms causing postoperative infection were
present in the operative field before the operation.

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Appendix 2
Diagnostic Criteria for Surgical Site Infection (SSI)
A SUPERFICIAL INCISSIONAL SSI must meet the following criterion:
Infection occurs within 30 days after the operation that involves only skin or subcutaneous
tissue of the incision and at least one of the following:
a. Purulent drainage, with or without laboratory confirmation, from the superficial incision.
b. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial
incision.
c. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling,
redness, or heat and superficial incision is deliberately opened by surgeon, unless incision is culture-
negative.
d. Diagnosis of superficial incisional SSI by the surgeon or attending physician.
Do not report the following conditions as SSI:
 Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration).
 Infection of an episiotomy or newborn circumcision site.
 Infected burn wound.
 Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI).
Note: Specific criteria are used for identifying infected episiotomy and circumcision sites and
burn wounds.
A DEEP INCISIONAL SSI must meet the following criterion:
Infection occurs within 30 days after the operation if no implant is left in place or within 1
year if implant is in place and the infection appears to be related to the operation and involves
deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the following:
 Purulent drainage from the deep incision but not from the organ/space component of the surgical
site.
 A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient
has at least one of the following signs or symptoms: fever (>38ºC), localized pain, or tenderness,
unless site is culture-negative.

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 An abscess or other evidence of infection involving the deep incision is found on direct
examination, during reoperation, or by histopathologic or radiologic examination.
 Diagnosis of a deep incisional SSI by a surgeon or attending physician.
Notes:
1. Report infection that involves both superficial and deep incision sites as deep incisional SSI.
2. Report an organ/space SSI that drains through the incision as a deep incisional SSI.
An Organ/Space SSI must meet the following criterion:
Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if
implant is in place and the infection appears to be related to the operation and involves any part
of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated
during an operation and at least one of the following:
 Purulent drainage from a drain that is placed through a stab wound into the organ/space.
 Organisms isolated from an aseptically obtained culture of fluid or tissue in the
organ/space.
 An abscess or other evidence of infection involving the organ/space that is found on direct
examination, during reoperation, or by histopathologic or radiologic examination.
 Diagnosis of an organ/space SSI by a surgeon or attending physician.

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CATHETER ASSOCIATED URINARY TRACT INFECTION (CAUTI)
Purpose
1. To reduce the risk of acquiring a hospital-acquired urinary tract infection.

2. To provide and implement guidelines for urinary catheter usage, insertion, and maintenance
3. To improve Healthcare Workers (HCWs) competence in the inserting and maintenance of
urinary catheters.
Policy
1. All HCWs inserting and handling urinary catheters shall adhere to this policy.
2. Only trained, deemed competent and dedicated personnel are permitted to insert urinary
catheters.
3. Nurses are not permitted to, or must not proceed with inserting a urinary catheter if the patient
has the following (in these instances a Physician must insert the catheter):
a. Have a urethral stricture.
b. Have trauma, including an old injury.
c. Be on anti-coagulant treatment.
d. Have a bleeding tendency.
e. Encounter difficulty during the procedure.
4. Male nurses may only insert urinary catheter for male patients only and female nurses for
female patients only.
5. In all instances urinary catheters should be inserted for valid medical reasons only, and be
removed as soon as no longer indicated (refer to Appendix 1: PSMMC criteria for acceptable
indications for the use of indwelling urinary catheters).
6. If catheterization is unavoidable, to minimize urethral trauma use as small a catheter as
possible that permits proper drainage.
7. For urinary catheter usage in operative patients remove the catheter as soon as possible
postoperatively. If possible, within 24 hours unless there are appropriate and documented
medical indications for continual use.
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8. Avoid the use of routine urinary catheterization for the treatment of incontinence. Urinary
catheters should not be used solely for the convenience of patient-care personnel. In this
instance consider other methods of management as discussed below (e.g. condom catheters or
in-and-out catheterization), as individually appropriate and upon discussion with the attending
Physician.
9. Consider using the following alternatives to indwelling urethral or supra-pubic catheterization:
a. Condom catheters in co-operative male patients without urinary retention or bladder outlet
obstruction.
b. Intermittent catheterization in patients with spinal cord injury and/or bladder emptying
dysfunction.
c. Intermittent catheterization in children with myelomeningocele and/or with a neurogenic
bladder.
Responsibilities
Physician
a. Write the order for catheter insertion and removal.

b. Prior to entering the order for insertion of a urinary catheter the Physician must check one or
more of the indications for catheter insertion. This form is filed within the patient’s chart.
c. On a daily basis re-assess the need for the urinary catheter. Completed forms are to be
forwarded to Infection Control.
Nursing
a. Ensure appropriate supplies are available for catheter insertion, i.e. urinary catheter care packs
containing all items including the appropriate size and type of urinary catheter.
b. Ensure that all care items – hand hygiene supplies, individual containers for drainage, and
hygiene supplies for meatal cleaning are available.
c. Ensure the following is documented in the patient‘s record in a standard format:
 Indications for insertion,

 Date and time of insertion,
 Individual who inserted catheter, and
 Date and time of catheter removal.
d. Using the Daily Reminder Form, remind the responsible physician to reassess the need for
urinary catheter.

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Infection Control
 Collaborate with concerned departments (i.e. Nursing, Urology, Emergency, etc.) to

educate healthcare personnel involved in the insertion, care, and maintenance of urinary
catheters regarding Catheter-Associated Urinary Tract Infection (CAUTI) prevention,
including alternatives to indwelling catheters and procedures for catheter insertion,
management and removal, and use of the insertion checklist.
 When feasible, provide performance feedback to Staff on what proportion of catheters
inserted meet hospital-approved criteria.
Procedure
1. Hand Hygiene
Hand hygiene must be performed with an antimicrobial soap and water or an alcohol handrub
before insertion and immediately before and after any manipulation of the catheter site or
drainage system.
2. Catheter Insertion Techniques
 Perform hand hygiene immediately before insertion.

 Insert catheters using aseptic technique and sterile equipment.
 Sterile gloves, drape, sponges, and appropriate antiseptic solution for peri-urethral
cleansing, and a single-use packet of sterile lubricant jelly should be used for insertion.
 Unless clinically indicated, consider using the smallest bore catheter possible, consistent
with good drainage, to minimize bladder neck and urethral trauma.
 Secure indwelling catheters after insertion to prevent movement and urethral traction.

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3. Documentation for Catheter Insertion
 The following information must be documented in the patient’s medical record after
catheter insertion:
 Indication(s) for catheter insertion
 Date and time of catheter insertion
 Individual who inserted the catheter
 The date and time of removal of the catheter.
4. Daily Reminders to Physicians to Remove Catheters from Patients When No Longer

Indicated:
 Every Physician who has assigned catheterized patients will receive from the designated
clinical area In-Charge Nurse a daily reminder to evaluate each patient to determine further
need for catheterization.
 Physicians must assess the ongoing need for an indwelling catheter every day and remove
or have the catheter removed when no longer indicated.
 Indwelling catheters must be removed immediately when no longer indicated.
 Each day that a Physician decides to leave an indwelling urinary catheter in place the
Physician must check off the most appropriate indication for catheterization. If ―other‖ is
checked, the physician must enter a valid indication for the catheter to remain indwelling.
 The physician may indicate that the catheter be removed and replaced with intermittent
catheterization for a post-operative patient or the catheter be removed from a male patient
followed by placement of a condom catheter.
5. Closed Sterile Drainage
 Maintain a sterile, continuously closed drainage system.

 Do not disconnect the catheter and drainage tube unless the catheter is to be irrigated, as per
Physician order and using an aseptic technique.
 Use aseptic technique when replace the collecting system.
 Using aseptic technique replace the collecting system if the catheter-tubing junction
disconnects or leakage occur in the system.

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6. Irrigation
 Avoid catheter irrigation unless an obstruction is anticipated (i.e. due to bleeding post-
prostatic or bladder surgery).
 The catheter-tubing junction must be disinfected before disconnection.
 If obstruction is anticipated Physician may order closed continuous irrigation.
 To relieve an obstruction due to clots, mucus, or other causes, use an intermittent method of
irrigation
 Do not perform continuous irrigation of the bladder with antimicrobials as a routine
infection prevention measure.
7. Specimen Collection: Obtain urine samples aseptically.
 If small volumes of fresh urine are needed for examination (i.e., urinalysis or culture),
aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter
after cleansing the port with 70% alcohol. (Note: urine specimens are to be promptly
transport to the laboratory for analysis).
 Obtain larger volumes of urine for special analysis (not culture) aseptically from the
drainage bag.
8. Urinary Flow and Collection Bag
 Maintain unobstructed urine flow. (Note: occasionally it is necessary to temporarily

obstruct the catheter for specimen collection or other medical purposes)
 To achieve a free flow of urine:
a. Keep the catheter and collection tubing from kinking
b. Empty the collecting bag regularly, using a separate collecting container for each
patient, and avoid allowing the draining spigot to touch the collecting container
c. Replace poorly functioning or obstructed catheters
d. Keep the collection bags always below the level of the bladder.
e. Bags should never touch the floor.
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This is a controlled document, property of Joni Villanueva General Guidelines on Healthcare Associated
9. Management of Obstruction
 If obstruction occurs and it is likely that the catheter material is contributing to obstruction, then the
catheter should be changed.
 If the catheter becomes obstructed it should be removed, and replaced if deemed medically
necessary.
 If there is a continuing need for bladder catheterization, a new catheter should be inserted using the
same aseptic technique described above. The newly inserted catheter must be connected to a new
sterile closed drainage system
10. Perineal Care
 The perineum should be cleaned daily to reduce colonization of the perineal skin by bacteria.
 Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place.
Routine hygiene (i.e. cleaning of the meatal surface during daily bathing) is adequate.
11.Catheter Change
 Indwelling catheters should not be changed at routine, fixed intervals.

 Change catheters based on clinical indications such as infection, obstruction, or when the closed
system is compromised.

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Management of Needlestick Injuries
Administration. and Blood and Body Exposure
1. Susceptible to HBV:
 Has documented anti-HBs level < 10 IU/L when tested 1-2 months following the
complete HB vaccine series.
Has no history of HB vaccination.
MANAGEMENT OF NEEDLE STICK INJURIES AND BLOOD AND BODY FLUID

EXPOSURE
Purpose
 To provide clear guidelines for the management of percutaneous (needlestick/sharps)

injuries and significant mucocutaneous (blood/body fluid) occupational exposures in Health
care workers.
 To assist in the prevention and control of occupationally-acquired infections and hazards
particularly related to hospital work.
 To identify infection risk related to employment and to institute appropriate preventive
measures.
 To assess and determine the immune status and immunization requirements of employees
for Hepatitis B and institute the appropriate measures.
 To provide treatment and medical advice to individual employees and to act as resource for
employees to obtain care.
Definitions:
2. Percutaneous Injury: A needlestick or cut with a sharp object.

3. Mucocutaneous Exposure: exposure of a mucous membrane (eyes, nose or mouth) or
chapped, with abrasions or dermatitic skin with blood, tissue or other body fluids that are
potentially infectious.
4. Immune to HBV:
 Has a documented anti-HBs level ≥ 10 IU/L when tested 1-2 months following the
complete HB vaccine series.

 Is Anti-HBc negative.
5. Non-responder:
 A HCW who has completed two series of HB vaccine and was anti-HBs negative
(<10 IU/L) when tested 1-2 months after receiving the 3rd dose of the second series of
vaccine.

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6. Unknown HBV status:

 No results available from previous testing for suitable HBV serologic markers (anti-HBs
for post-vaccination response, Anti-HBc for natural infection) regardless of whether the
HCW has received HB immunization or has a clinical history of Hepatitis B
A. First Aid
1. Percutaneous injuries (Needle stick/Sharp Injuries)
 Wash generously with soap and water
 Cleanse with alcohol wipes
 Cover with appropriate bandages
2. Mucocutaneous exposures (Body fluid Exposure)
 Remove contaminated clothing (if necessary)
 Irrigate affected area with copious amounts of water (10 minutes).
 For Eye Exposure: First remove contact lenses then irrigate.
B. Reporting the Injury

1. The employee should report the incident to their supervisor and document the incident
2. The incident report should include:
 Time and date of incident.
 Location.
 Department of employee.
 Main Responsible Nurse (MRN) Who is taking care of the source patient.
 Description of incident, including first aid measures.
3. The report should be signed by supervisor; a copy sent to Infection Prevention and
Control and other appropriate department as per institution policy.
4. Attend the OPD during normal working hours or the ER after hours or on the weekend. It
is important:
 To take the incident form for physician documentation.
 To report the injury within 24 hours of the incident for risk assessment and prophylaxis
where indicated. Since documentation of any exposure management is essential to
support future compensation claims, notification must be made within 72 hours.
 That all employees report to the OPD despite attendance at ER, as the OPD Physician is
responsible for determining the need and type of follow-up.

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5. It is the responsibility of the Employee Health physician/OPD to take the history from
the employee and document the details in the employee’s Medical Record.
History should include:
 Mechanism of injury.
 Site of injury.
 Amount and type of blood/body fluid and an indication of the severity of the
exposure e.g. degree of penetration of the needle, inoculation.
 Immediate action taken (first aid).
 Main responsible nurse taking care of the patient
 serology status of the employee
6. It is the responsibility of the EHC/ER physician to draw the following baseline labs
(as required) on the Employee after counseling.
 HBsAg.
 Anti-HBs.
 Anti-HCV.
 Anti-HIV I/II
7. The charge nurse will notify the patient Main Responsible Physician (MRP) of the incident.
8. It is the responsibility of the MRP or one of his junior staff to order the following baseline
serology on the source patient after counseling.
 HBsAg.
 Anti-HCV.
 Anti-HIV I/II

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Hospital and should not be reproduced without the permission of JVGH Surveillance on Nosocomial Infection
Administration.
SURVEILLANCE OF NOSOCOMIAL INFECTION
Policy
The key to an effective infection control program is an effective surveillance system.
Principles of Surveillance of Nosocomial Infections
Surveillance is defined as close and continuing observation of an individual or group

(patients or personnel). Its goal in the hospital is the collection accurate reliable and timely data
on infections and notifiable diseases acquired within the hospital.
Basic epidemiologic techniques are used to perform surveillance or clinical ward rounds, to
analyze rates of infection, and to incorporate the data generated in decision making.
Surveillance for nosocomial infections involves identifying patients who are colonized or
infected, assessing the risk of transmission of infection between patients, proving transmission of
a given strain from one patient to another, and more generally, detecting hospital outbreaks.
Surveillance data may also include information on risk factors (including exposure to
procedures), etiologic agents and antimicrobial susceptibility. An active surveillance system
assists the clinician in making an accurate diagnosis and prescribing therapy by providing the
knowledge of disease occurrence and antibiotic resistance patterns.
With increasing resistance and the fact that many nosocomial infections are caused by
resistant microbes, surveillance and control of resistance has become critical.
Susceptibility patterns can be monitored for emergence of resistant microorganisms: when

resistant microorganisms are identified, appropriate isolation precautions should be instituted.

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Administration.
Definitions of Nosocomial Infections
Nosocomial infection is defined as any infection occurring 48 hours after hospital admission. The
following table presents the criteria of specific nosocomial infections:
Nosocomial Pneumonia:
 New or increased production of purulent sputum and/or fever ≥ 31°C with
 Clinical signs (le rales, dullness to percussion) and/or
 CXR showing new or progressive infiltrate, consolidation, cavitation, or pleural effusio
not attributable to another disease
Urinary Tract Infection (UTI):

Symptomatic Infection
 Positive result on urine culture (2 10° microorganisms/mL) and
 One of the following clinical signs: fever 2 38°C, urgency, frequency, dysuria loin pain,
loin / suprapubic tenderness
Asymptomatic Bacteriuria
 Urine culture of = 10° microorganisms/mL of no more than 2 species in the presence or
absence of a catheter
 no fever present (> 36°C), urgency, frequency, dysuria, or loin/suprapubic tenderness
Bloodstream Infection:
Primary bloodstream infection refers to a bacteremia (or fungemia) for which there was no
documented distal source and includes those infect ons resulting from an IV line or arterial line
infection
 Clinical sepsis has one of the following clinical signs or symptoms with no other
recognized cause:
- fever (2 38°C); hypotension (systolic blood pressure ≤ 90 mm Hg); or oliguria (< 20
mL/h); plus all of the following:
- blood culture not performed or no organism detected in blood; no apparent infection at
another site; and the physician administers appropriate antimicrobial therapy for sepsis

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Surgical Site Infection (SI):

 Any infection occurring within 30 days of an operative or accidental procedure involving
a break in the designated epithelial surface with any of the following:
 At least one sign or symptom of infection is present, such as pain or tenderness, localized
swelling, redness, or heat;
 Pus or culture-positive fluid discharges from a closed incision;
 A surgeon opens a closed incision, unless it is culture-negative;
 Incision dehiscence unless culture results are negative;
- Abscess diagnosed postoperatively using imaging techniques; and
- Discharge of pus from beneath a drain.
Process of Surveillance
1. The Infection Control Nurse (ICN) shall make periodic weekly rounds in all patient care areas
(wards and ER) to monitor nosocomial infections
2. If a nosocomial infection is suspected / confirmed, the physician or fellow-in-charge shall

complete the nosocomial infection surveillance (NIS) form and attach it in the patient's chart.
The ICN shall collect completed NIS forms
3. The ICN shall prepare a monthly summary of nosocomial infections and compute infection
rates.
4. Monthly / semi-annual / annual summary of nosocomial infections shall be presented by the

ICN during the ICC meeting. Data shall be analyzed for trends or clusters.
5. The microbiology laboratory shall provide the ICC with the antibiotic susceptibility report of
isolated pathogens in the hospital. Susceptibility trends will be analyzed which will be the
basis for the hospital antibiogram.
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Hospital and should not be reproduced without the permission of JVGH Healthcare Waste Management
Administration.
HEALTHCARE WASTE MANAGEMENT
Policy
The proper handling of waste material in the hospital is of vital importance in the prevention,
containment and management of nosocomial infections,
Definitions
Hospital waste refers to all waste, biological or non-biological, discarded and not intended for
further use.
Medical or clinical waste is a subset of hospital waste, and refers to materials generated as a result
of patient diagnosis and treatment, or immunization of humans or animals
Infectious waste is a subset of medical waste, and refers to that portion of medical waste that is
definitely or is potentially contaminated with pathogenic or disease-producing microorganisms,
and therefore can transmit infectious diseases.
Hospital Waste Segregation
Segregation is the process of separating different types of waste at the point of generation and
keeping them isolated from each other. Segregation at source should always be the responsibility
of the waste producer. Segregation should take place as close as possible to where the waste is
generated and should be maintained in storage areas and during transport. The most appropriate
way of identifying the categories of health care waste is by sorting the waste into color-coded
plastic bags or containers.
Recommended color-coding scheme for health care waste is shown in the table.
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Table 1: Color Coding Schemes for Containers
Type of Waste
Color of Container/Bag
Black Non-infectious dry waste
Green Non-infectious wet waste
Yellow Infectious and Pathological Waste
Yellow with black band Chemical Waste/heavy metals
Red Sharps and Pressurized containers
Orange Radioactive Waste
Care and Disposal of Waste and Trash
1. Waste baskets or containers lines with plastic bags should te available in patients rooms,
waiting areas and treatment rooms
2. At the end of the day or as needed, these plastic liners should be secured and discarded in
larger plastic bags. These should be removed from the premises to a designated pickup point
for proper disposal.
3. Residuals of the general health care waste should join the stream of domestic refuse or
municipal solid waste for proper waste management.
4. After use, all IV bottles should be emptied in a sink, and the sink immediately flushed with
running water. If left around, portions of IV fluid containing antibiotics could be hazardous
(culture media).
5. Used IV tubings and catheters should be discarded in containers for infectious wastes (yellow-
coded)
6. All other glass bottles should be thoroughly washed if this is to be recycled for patient use.
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Administration.
7. Sharps should all be collected together, regardless of whether or not they are contaminated.
Containers should be puncture-proof (usually made of metal or high-density plastic) and fitted
with covers. It should be rigid and impermeable to contain not only the sharps but also any
residual liquids from syringes. To discourage abuse, containers should be tamper-proof
(difficult to open or break) and needles and syringes should be rendered unusable.
8. Used disposable syringes should be discarded in another container and disposed in a similar
way.
Liquid Waste from General Patient-Care Areas
1. Liquid waste (blood, feces, vomitus, urine, sputum and other body fluids such as
nasopharyngeal secretions) can usually be flushed down the sewer.
3. Personnel who are handling body wastes / fluids should always wear gloves.
5. Personnel who are handling body wastes / fluids should always wear gloves.
6. Particular care must always be observed when disposing of liquid waste in order to avoid
splashing waste on walls, furniture and the immediate environment.
7. In the event that there is spillage, the area should be immediately cleaned with an approved
disinfectant. Hands should be washed.
8. It is important that personnel avoid contamination of their clothing during the handling of
liquid waste. Wearing of gowns is recommended

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9. Hands should be washed even after gloves are worn when liquid waste is disposed of. The
wearing of gloves does not preclude handwashing.
10. Containers used to collect liquid waste such as blood, feces, sputum and urine should not be
flushed into the sewage system as they are likely to clog the system.
Solid Waste
1. Solid waste from rooms housing patients with communicable diseases requiring isolation
should be double-bagged or contained in plastic bag at the point of generation just before
transport and treated as "CONTAMINATED or INFECTIOUS* waste.
2. Designated personnel in operating rooms and special-care units are required to transport human
tissue to the pathology laboratory in addition to following the same general principles of caring
for both liquid and solid waste.
3. Tissue and other body parts should always be considered potentially infectious and should be
properly placed in durable leak-proof containers.
4. Solid waste that has been generated in the patient care area and that has not been in contact
with patients includes materials such as paper, boxes, cardboard packaging and glass and
plastic containers. Waste of a similar nature is also generated from administrative areas or non-
patient care areas. These items must be disposed of.
5. Foods, bottles, cans, cartons and packing materials also generated within hospital service areas
such as the dining facility must be disposed of.
6. Meticulous care should be exercised in handling all items at all times to avoid physical injury
to personnel handling them.

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Administration.
7. In order to ensure protection to patients and hospital personnel from both infectious and
physical hazards, waste should be placed in containers at the point of generation.
8. All waste generated in the patient's room, with the exception of needles, syringes and other
sharp objects, should be placed in plastic bags in the room for transport to a central collection
point. This collection point should be clearly identified on each ward unit.
9. Ideally, mechanical devices of various types (syringes and needle cutters) should be used
throughout the hospital for accomplishing the destruction of needles and syringes.
10. Used needles should be immediately placed in a puncture-proof container and rendered
unusable.
11. Syringe and needle cutters are to be emptied into proper collection and disposal receptacles at
least daily. This cutting equipment should be located in supervised areas.
12. Used disposable syringes may be disposed of in large plastic bags and treated as infectious
waste.
Chemical, Pharmaceutical, Cytotoxic and Radioactive Wastes
1. Small amounts of chemical or pharmaceutical waste may be collected together with infectious
waste
2. Large quantities of chemical waste should be packed in chemical resistant containers and sent
to specialized treatment facilities (if available). The identity of the chemicals should be clearly
marked on the containers. Hazardous chemical waste of different types should never be mixed.
3. Large quantities of obsolete or expired pharmaceuticals stored in hospital wards or departments

should be returned to the pharmacy for disposal. Other pharmaceutical waste generated at this
level, such as expired drugs or packaging containing drug residues should not be returned because
of the risk of contaminating the pharmacy. It should be deposited in the specified container at the
point of generation.

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Administration. Healthcare Waste Management
4. Cytotoxic waste should be collected in strong, leak-proof containers clearly labeled

“CYTOTOXIC WASTES”.
5. Radioactive wastes should be segregated according to its physical form (solid & liquid and
according to its half-life or potency) in especially marked containers as prescribed by the
pertinent regulation of the Philippine Nuclear Research Institute (PNRI) specific to such
authorized practice.
Transport of Solid Waste
Extreme care should be taken to protect the patient, the handler and other hospital personnel
when transporting hospital wastes. Environmental contamination and injury to handlers must be
considered. Proper personal protective equipments (PPEs) should be used (gloves, gowns, aprons)
Waste should not be allowed to accumulate in any hospital area, especially hospital corridors
and patient-care areas. Frequent collection times should be posted by environmental hygiene
personnel and pick-up times adhered to.

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Administration.
HANDLING AND DISPOSITION OF INFECTIOUS WASTE
The collection, handling and disposition of infectious waste constitute a major policy and
procedure decision in the hospital.
General Principles:
1. The distinction of whether something is or is not contaminated waste rests with the
professional staff. Good judgment and discretion must be used in determining what is
"infectious waste". As a frame of reference anything with blood or feces must be given
particular attention and treated as potentially contaminated or infectious waste.
2. Potentially contaminated or infectious waste include the following:
a. Patient wastes such as dressings, bandages, materials with blood, feces, secretions and other
exudates, and surgical wastes. Disposable materials used for the collection of body fluids
and wastes originating from isolation procedures are also included in the category of patient
waste, since this is waste originating in the patient-care areas.
b. Laboratory waste of a potentially infectious nature:
 Blood and all blood products

 Pathologic waste from infected humans and animals, boy tissues from human autopsies
 Stool and other body exudates
 Microbiological cultures
 Contaminated specimen containers and specimen slides
 Disposable Petri dishes, pipettes
 Medical wastes requiring special handling, including disposable needles, syringes and
glass slides
Note:
Waste that contains hazardous material such as certain chemicals and radioactive materials
require special handling

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3. Color-coded plastic bags such as yellow or red are to be used only for the disposal of infectious
waste.
4. In the event that the bags might be punctured by sharp objects, the bags should be placed in
special cardboard boxes marked "INFECTIOUS WASTE" or "BIOHAZARD".
5. Indiscriminate use of these plastic bags for the disposal of general waste defeats the purpose of
the color-coded bags, which is to identify infectious waste as opposed to non-infectious.

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Guidelines for Support Services:
Administration. Linen Handling
LINEN HANDLING
The provision of clean linen is a fundamental requirement for patient care. Linen used in
health care can become soiled with blood, stool or other body fluids containing numbers of
pathogenic microorganisms. Handling or processing of soiled linen can present an infection risk
to both staff and patients.
Soiled Linen: are those that have been used and are dirty, or stained by body perspiration, or
other substances especially on the surface.
Contaminated Linen: are those that are soiled by blood or have been in touch with other
potentially infectious materials (OPIM).
Handling
a. All staff handling soiled linen must adhere to standard precautions and wear gloves and
aprons.
b. Hands must be washed following any handling procedure.
c. Care must be taken to remove any extraneous items from dirty linen before it is placed in
laundry bags.
d. Collect soiled linen in such a way as to minimize microbial dissemination into the
environment. Handle linen as little as possible with minimal agitation to prevent gross
microbial contamination of the air and the persons handling the linen.
e. Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
center by folding or rolling the soiled spot into the center. This is to reduce the risk of
contamination and prevent leakage soaking through.
f. Place soiled linen in linen bags at the area where it is generated. Cloth bags are adequate for
the majority of soiled linen.
g. Consider linen from isolation room as general soiled linen.
h. Double bagging is not necessary unless the primary bag is soaked through.
i. Linen bags must never be more than two thirds full, and must be secured before removal.
j. Contaminated linen and clothing that has been contaminated with body substances, such as
urine, feces or blood, should be put in a red water-soluble bag before being placed in the
appropriate linen bag. This linen should not be sorted prior to washing but placed in the bag
into the washer.

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Storage and transportation
a. Do not pre-rinse or sort soiled linen in patient care areas.

b. Soiled linen storage and processing areas must be separate from clean linen storage,
patient care areas, food preparation areas, and clean equipment storage areas.
c. Transport soiled linen in covered carts. Wash and disinfect carts on a routine basis.
These carts should never be used to transport clean linen.
The Laundry
a. The laundry’s size should obviously be adequate to accommodate the volume of items that
it is expected to process.
b. There should be adequate space for separate areas designated for receipt of
contaminated items and for storage of cleaned items.
c. The floors and walls should be made of durable materials that are impervious and easy to
clean.
d. Cleaning of the area should take place on a daily basis.
e. The air ventilation system should be designed to direct the flow of air from the clean
(positive pressure) to the contaminated (negative pressure) area.
f. Lighting systems should be adequate to provide the level of illumination that is convenient
with the task being performed.
g. Hand hygiene facilities should be conveniently located in the work areas, as well as in the
lounges and rest rooms.
h. Emergency eyewash/shower equipment should be readily available, with unobstructed
access, particularly in locations where laundering chemicals are used and where personnel
are exposed to blood borne pathogens in the regular performance of their tasks.
i. No eating, drinking or smoking is permitted in the Laundry.
The Laundering Process
Contamination will be removed by:
a. Mechanical washing
b. Drying including tumble drying
c. Ironing

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GENERAL HOSPITAL
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Washing And Rinsing
The laundering process is designed to remove organic soil and render the linen clean. High or low
temperature washing can be used in washing linen:
a. High temperature: A temperature of at least 710C for a minimum of 25 minutes is

commonly recommended for hot water washing.
b. Low temperature: Lower temperature of 220C-500C can satisfactorily reduce microbial
contamination if the cycle of the washer, the wash detergent, and the amount of chlorine
(bleach) to reach a total available chlorine residual of 50-150ppm is monitored and
controlled.
1. Soiled Linen
a. Disinfectants are generally not needed when soiling is at low levels.
b. Some modern fabrics require lower washing temperatures. They should be washed
separately.
2. Contaminated Linen
a. Temperature required for washing contaminated linen is similar to that used for soiled linen.
b. Contaminated items which cannot be laundered on a hot wash can be disinfected by adding
hypochlorite (bleach) at 150 parts per million to the final rinse.
c. Always take care that the machine is not overloaded or it will not wash effectively.
d. Soiled or contaminated items, which are not washable, should be dry-cleaned.
Manual Reprocessing Steps:
If laundry services with hot water are not available, reprocess soiled linens manually according to
the following:
1. Immerse in detergent solution and use mechanical action (e.g., scrubbing) to remove soil.
2. Disinfect by one of these methods:
 Immersing the linen in boiling water or
 Immersing the linen in disinfectant solution for the required contact time and rinsing with
clean water to remove residue
3. Allowing to fully dry, ideally in the sun.

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Hospital and should not be reproduced without the permission of JVGH Guidelines for Support Services:
Administration.
Nutrition and Dietetics Service
NUTRITION AND DIETETICS SERVICE
In a hospital setting food-related illnesses are contagious not only limited to patients but also
to healthcare workers who have been exposed to environment where infectious diseases are being
treated. Nutrition and Dietetics Service are particularly at risk due to dietary staff that come and
go to ward in distributing meals to patients. In some hospital, dietary staff even come back to
collect soiled food trays from the patients for sterilization and reuse. It is highly regarded that the
operation of Dietetics service must maintain a clean vicinity and zero-prone to infection outbreak.
According to Cleveland Clinic, infectious diseases usually spread from person to person, through
contaminated food or water and through bug bites. Hence, here are guidelines to dietary personnel
to control or limit the degree of exposure to these infectious diseases and same time to avoid
risking other patients that may be brought by the dietary personnel or by the food being prepared
and its source.
I.Rationale
Setting up a system or standard that every dietary personnel must follow is essential to avoid
being at risk of food-borne illnesses, to maintain the dietary vicinity free of pathogen infection,
and making sure that food of patients are safe for consumption. The operation of Dietetics Service
must be kept clean, sanitized and safe since it is where nourishment for the patients is being
produced.
Policy
1. Personnel
a. Dietary personnel are obligated to report to their supervisor about their health as it can
cause transmission of diseases to co-workers and through food. It is expected that dietary
staffs must be free of communicable diseases such as Hepa A, skin lesions, boils,
respiratory infections, or diarrhea.
b. All dietary personnel must have a health certificate renewed annually.
c. Proper attire and hygiene for food handlers. Wearing of hair net or cap, freshly laundered
uniforms, and safety shoes are strictly observed. Nails should be trimmed and no nail
polish.
d. Smoking is strictly prohibited.
e. Proper handwashing is highly and always advised. Hand hygiene shall be performed with
soap and water before work, after using the toilet, before and after eating, after handling
raw foods, after contact with unclean equipment, work surfaces, soiled clothing,
washcloths, and many more that may pose infection outbreak.
f. Restrooms should be conveniently located near the department and should not open
directly into food service areas.

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Administration. Nutrition and Dietetics Service
g. Dietary personnel in direct contact with food will wear disposable hand gloves. When
returning to the work area, head cap and hand gloves must be thrown before entry of the
dietary and perform hand hygiene. Use of disinfectant spray if available. Wear new head cap
and hand gloves upon entry in the dietary. Gloves should be changed, and hand hygiene
performed whenever it is contaminated by touching soiled surfaces such as floors, waste cans,
surfaces, etc.
h. Dietetics Service should be strictly for dietary personnel only. Unauthorized persons should
not be allowed.
2. Patients
a. Isolation Patient Service
a.1. Clean gloves are worn to deliver food or pick up the soiled tray of a patient.
a.2. Gowns should be worn if there will be direct patient contact or whenever clothing may
contact surfaces in the room. Gloves/gown should be removed and hand hygiene performed
upon leaving the patient’s room and before handling the food for the next patient.
b. Regular Patient Service
b.1. Individual portions of food consumed by the patient will be discarded.
b.2. Hand hygiene should be performed prior to delivery of food to patients and after.
Gloves should be worn and be thrown after leaving the ward. Hand hygiene must be
performed afterwards.
3. Food Supplies
a. Obtained food and food supplies should be from an approved source who follows and
observe HACCP procedures. Hazard Analysis Critical Control Point (HACCP) is a
systematic approach to the identification, evaluation, and control of food safety hazards.
b. Products should be delivered in appropriate vehicles (refrigerated, enclosed vehicles).
Frozen products shall maintain its state and dry goods should remain dry upon delivery.
Vegetables must not be wilting. Fruits must have zero holes. All items should be free of
defect and safe for consumption.
c. Selected supplier must offer quality products derived from safe and sanitary conditions.
d. All eggs should be served to patients are well-done or well-cooked. Poached or fried eggs
will not be prepared for inpatients.

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4. Food Products and Storage

a. Upon arrival, all food should be inspected for damage, rodent or insect infestation and
spoilage. Anything found to be of defect or damaged should be rejected.
b. Food items should be stored at their designated areas: Cold storage and Dry storage.
c. All food should be stored in clean wrappers or containers with covers.
d. Store eggs in original container at 33°F to 41°F.
e. Maintain cleanliness to all storage areas and vehicles for food transport. The area must
have a proper lighting, ventilation, and air circulation.
f. Food must be stored 6” above the floor in clean racks.
g. Shelving must allow for cleaning under the bottom shelf or be flush with the floor and
away from walls to facilitate cleaning and reduce places for pests to find refuge. Floor
drains that may allow for contamination by sewerage backflow are prohibited.
h. Practice First-In First-Out (FIFO) or First-Expiry First Out (FEFO). All goods should be
monitored on its expiration dates.
i. Toxic cleaning material and nonfood items should be properly labeled and stored away
from food products.
j. Refrigerate cut leafy vegetables if not to be used yet. Recipes using cut tomatoes must be
refrigerated if not to be served yet.
k. When washing vegetables and fruits, use running water as applied to meats, poultry, and
fish.
l. Refrigerator and freezer temperatures must be monitored and recorded on a daily basis to
assure that appropriate temperatures are maintained. These daily temperature logs will be
kept for 90 days. Temperature above or below the acceptable range should be notified to
supervisor immediately.
m. Dietary vicinity must be free from rodents and insects.
n. Proper ventilation, lighting and humidity should be controlled to prevent both
condensation and the growth of microorganisms. Cleaning schedules and monitoring for
cleanliness, temperature, ventilation, and pest infestation shall be implemented.

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JONI VILLANUEVA
GENERAL HOSPITAL
95/101

5. Food Preparation and Service
a. Raw foods, fruits and vegetables should be thoroughly washed under running water before
use.
b. Frozen foods can be thawed under refrigeration temperatures of 41°F or below or by
submerging under a running water. Thawed food should not be refrozen.
c. Food with an abnormal appearance or odor, broken packages, and swollen cans should be
discarded.
d. Hot held foods will be kept above 140°F. Cold held foods will be kept at 41°F or below.
e. Left over should be avoided as much as possible to avoid reheating of food. If such
situations cannot be avoided, it should reach an internal temperature of at least 165°F for
15 seconds. Within 2 hours the food being served, it shall be reheated with mentioned
temperature. Reheat commercially processed and packaged ready-to-heat food to an
internal temperature of at least 135°F.
f. Food should be served as soon as possible.
g. All food must all be wrapped or covered when on hold.
6. Equipment and Utensils

a. Separate cutting boards for meats, fruits and vegetables, cooked foods and are color
coded.
b. All equipment and utensils should be durable, functional and food grade in material. Easy
to clean and sanitize.
c. Cooking surfaces should be cleaned once a day with germicide. Nonfood contact surfaces
should be cleaned at such intervals to keep them clean and sanitary conditions.
d. Cleaning is necessary or rinse of water to these items is necessary before use.
e. Clean utensils and pans will be always stored on clean surfaces.

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7. Daily Cleaning
a. Ranges and grills should be cleaned daily.
b. All working tables and counters are cleaned and sanitized frequently as needed.
c. All floor surfaces must be wet mopped daily. Mops and brooms should not be left in food
preparation areas.
d. All garbage is removed and handled safely for sanitation purposes. Garbage cans should
be stored away from food preparation areas.
8. Suspected Foodborne Outbreak

a. Immediately notify Infection and Prevention Control Committee
b. Save a suspected food for investigation.
c. Document departmental conditions at the time of preparation of suspected food. Provide a
list of foods served during suspected time interval, as well as a list of food handlers.
d. Implement and supervise control measures to prevent further occurrence of the illness.
e. While investigation is undergoing, food for the patients will come from outsource.
Emergency fund will be requested and utilized until the Dietetics Service may continue to
operate.

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BOCAUE, BULACAN
Date: 97/101
Administration. Mortuary
MORTUARY
All dead bodies (including stillborn and products of miscarriage) body parts are potentially
infectious and standard precautions should be implemented for every case.
The risk of acquiring an infection can be greatly reduced by:
1. Covering cuts or lesions with waterproof dressings.

2. Careful cleaning of any injuries sustained during procedures.
3. Good personal hygiene.
4. The use of appropriate protective clothing.
Purpose
To provide clear infection control standards and guidelines on the appropriate care of the body
following death to protect Health Care Workers (HCWs), morgue mortuary staff and families
from potential infectious exposures.
Policy
All staff involved in handling dead bodies and body parts must adhere to this policy. It is
recognized that the body of the deceased person, the body of the stillborn baby, products of
miscarriages and body parts should be handled with respect and dignified manner as there is
potential risk of contamination. Standard Precautions shall be maintained for all cases. Further
infection control precautions are taken as appropriate on a case-to-case basis.

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BOCAUE, BULACAN
Date:
98/101
Procedures
a. Nurses /Staff/Ward Nurse:
a. Adhere to standard precautions and use appropriate Personnel Protection Equipment (PPE) at
all times.
b. After physician declares death:
1. Remove all disposable tubes and lines appropriately.

2. Dress all wounds with impervious material to prevent oozing of body fluids or bleeding
from wounds or previous catheter sites.
3. Request appropriate body bag sizes and place body in body bag.
4. For Body identification, transportation, and checking into the mortuary refer to Hospital
wide policies and procedure relating to handling of Dead Bodies, Stillborn, Products of
miscarriage, and body parts.
5. If the patient had a known infectious disease, the body tag should be labelled with the
appropriate category (see appendix A)
6. The nurse in charge, or shift coordinator will inform the morgue Supervisor if the
deceased was known to harbor an infectious agent. (This information will also be
confirmed in writing on the identified tag).
2. Mortuary Staff
a. All mortuary staff should be evaluated in the Occupational Health Clinic on a yearly basis for
regular check- up, and at any other time as deemed necessary; such as after an exposure to
body fluid or blood.
b. Mortuary staff and especially body washers should receive annually education on the proper
infection control practices i.e., hand hygiene, modes of disease transmission, importance of
PPE and how to apply these practices.
c. Adhere to standard precautions at all times.
d. Avoid direct contact with blood and body fluids.
e. Use PPE (face mask, goggles, gown, plastic apron, plastic boots, etc.) as indicated or in
consultation with Infection Control and dispose mentioned items (with the exception of the
rubber boots) after washing each cadaver, by putting them in waste disposal.

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f. Decontaminate linen, environmental surfaces, instruments and transport trolleys according

to hospital policy.
g. Morgue equipment must be kept clean:
1. Refrigerators
2. Gurneys
3. Trolleys
4. Tables
5. All other equipment used in the morgue
3. Housekeeping is responsible for cleaning the environment of the morgue.
4. Disposal of contaminated and bio hazardous waste:
a. Place all disposable items, soiled linens and sharps into appropriate collecting containers.
Refer to Infectious Waste Management policy
b. Storage of Bodies and body parts:
c. Bodies and body parts are to be delivered to the morgue wrapped and labeled with
identification.
d. Bodies and body parts must be logged in the morgue log book (time of arrival, etc)
e. Bodies and Body parts must be stored, in body bags, and in a refrigerated storage area this is
maintained at 1.1˚C-4.4˚C (34-40˚F) until claimed.
5. Infection Control Practitioner:
To conduct regular inspection (monthly/quarterly) of the mortuary and advice the Death Section
Supervisor and the Housekeeping Department on protection measures and control of infection at
the Mortuary.

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Appendix A: Infection Diseases Category:
Diseases Precautions Bagging Viewing

Categ
ories
I All dead bodies not listed Standard Yes Allowed
under category 2. Precautions
II All dead bodies with: Strict Yes Not allowed
Standard
Anthrax, Plague, Rabies, Precautions
Small Pox, Yellow fever,
Viral Hepatitis B & C,
HIV, SARS, Avian
Influenza, Viral
Hemorrhagic Fever,
Creutzfeldt- Jacob
disease with necropsy,
other infectious disease
as advised by the
infectious disease
specialist or physicians/
infection control
practitioner or
microbiologist
*For Proper Handling of the remains of suspect, probable and confirmed COVID 19 cases please refer
to DOH Department Memorandum 2020-0158.

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Administration.
References
WHO Guidelines on Hand-hygiene in Health Care, (2009).
CDC Guidelines, www.cdc.gov
Centre for Disease Control and Prevention (CDC), Guideline for Isolation Precautions: Preventing
Transmission of Infectious Agents in Healthcare Settings 2007
Centre for Disease Control. Guideline for Isolation Precautions. Preventing Transmission of
Infectious Agents in Healthcare Settings. Draft. June 2004.
GCC Infection Prevention and Control Manual. 2009.
Immunization of Health-Care Personnel, Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Vol. 60 / No. 7
November 25, 2011
Centers for Disease Control and Prevention. Immunization of Health-Care Workers:
recommendations of the Advisory on Immunization Practices (ACIP) and the Hospital
Infection Control Practices Advisory Committee (HICPAC).
Centers for Disease Control and Prevention. Workbook for designing, implementing, and
evaluating a sharp injury prevention program. 2008
National Institute for Occupational Safety and Health. Preventing Needlestick Injuries in Health
Care Settings.1999
Department of Health - National Standards in Infection Prevention and Control for Health
Facilities, Third Edition, 2021

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Administration.
Appendixes
Appendix D: Flowchart of Triage

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Hospital and should not be reproduced without the permission of JVGH XXXXXXXXXXXXXX
Administration.

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Policy On Infection and Prevention Control

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Routine and Terminal Cleaning of Patient Care Areas 56

Recommended & Checked

Recommended & Checked

Joanna Lyn T. Alejandro,

Date: Date: Date: Date:

Program, Scope, and Objectives

Date: Date: Date: Date:

QUALITY MANAGEMENT SYSTEM Document Title:

INFECTION PREVENTION AND CONTROL PROGRAM

The Infection Prevention and Control (IPC) Program is a multidisciplinary systematic

Date: Date: Date: Date:

QUALITY MANAGEMENT SYSTEM Document Title:

1. To allow for a systematic, coordinated, and continuous approach to improving performance,

Scope of the ICP

1. Surveillance, identification, analysis, monitoring, and reporting of infections/hospital acquired

2. Recommendation for supplies and equipment.

4. Selection of criteria for the identification of infections/hospital acquired infections.

5. New employee orientation to infection control techniques and standard precautions.

6. Performance improvement activities.

Date: Date: Date: Date:

QUALITY MANAGEMENT SYSTEM Document Title:

Date: Date: Date: Date:

The implementation of an effective and comprehensive infection control program is an

The Infection Control Committee is tasked to develop an effective and comprehensive

Recommended & Checked

Date: Date: Date: Date:

The role of the ICC can be summarized as follows:

1. Production of an annual infection control program with clearly defined objectives.

Functions of the ICC Chairman/ ICC Physician

The role responsibilities of the ICP are summarized as follows:

act as its chairman.

Recommended & Checked

Date: Date: Date: Date:

An Infection Control Nurse or Practitioner is a registered nurse with an additional academic

The role and responsibility of the ICN is summarized as follows.

b. Should be an active member of the hospital ICC.

d. Provides specialist-nursing input in the identification, prevention, monitoring, and control of

g. Presentation of educational programs and membership of relevant committees where

Recommended & Checked

Date: Date: Date: Date:

Recommended & Checked

Date: Date: Date: Date:

Recommended & Checked

Date: Date: Date: Date:

JONI VILLANUEVA Document No.:

Date: Date: Date: Date:

JONI VILLANUEVA Document No.:

ICC problems are referred first to the IC Nurse.

Room Location and Contact Numbers:

1st Floor, Joni Villanueva General Hospital, Igulot, Bocaue, Bulacan

Recommended & Checked

Date: Date: Date: Date:

JONI VILLANUEVA Document No.:

Communicable diseases may be admitted to this hospital provided that:

***Refer to Appendix D for Flowchart of Triaging

Date: Date: Date: Date:

Indications for Hand washing:

A. WHO Five moments for Hand Hygiene

 Before touching a patient

Recommended & Checked

Date: Date: Date: Date: