FOREWORD

Dear Colleagues of the Veterans Regional Hospital,

In the effort to fulfill our continuous advocacy and unrelenting commitment to further
improve the quality of our service to patients, this manual for infection control has been reviewed
and updated.

Included in this manual are new and revised policies, procedures, recommendations and
guidelines, some have been developed by our institution, while others have been based on
international standards adapted to our local setting.

Our purpose is to strengthen and sustain effective strategies in controlling and preventing
healthcare acquired infections through collaborative work, training and research; thus reducing the
risk of healthcare associated infection for our patients and the improvement of the work
environment for our healthcare workers. Let us all be compliant to these infection control
guidelines.

For your constant vigilance.

DOMINADOR D. WAYET JR., MD, FPAFP, FPAFP-IDTM, FPSVI

Chairman, Infection Prevention and Control Committee

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 TABLE OF CONTENTS

FOREWORD …………………………………………………………………………….. 1
Table of Contents ………………………………………………………………………. 2
Objectives of the Infection Control Manual ………………………………………….. 5
Authorization for Implementation / Updating responsibility ………………………….. 6
Background Information of VRH – IPCC ………………………………………….. 7
Mission and Vision of the IPCU ………………………………………………….. 8
Policy of referral to hospital infection control unit ……………………………………. 9
 When and How to contact the IPCU
Organizational Structure of the IPCU …………………………………………………. 10

POLICIES AND GUIDELINES ON INFECTION CONTROL FOR ALL HOSPITAL

AREAS
Admission Policy 11
 Admission policy of highly communicable diseases …………………………. 14
 Admission Policy of Infectious Cases to the Medical Ward …………………. 16
 Policy for reporting highly communicable and reportable diseases …………. 18
 List of notifiable diseases / syndromes …………………………………. 23
 Isolation policy of communicable diseases …………………………………. 25
 Special precaution in ward where isolation facilities are not available …. 30
 Flow chart on triaging …………………………………………………. 31

Guidelines for hand hygiene 33

 Hand washing technique with soap and water …………………………. 34
 Hand hygiene technique with alcohol – based formulation …………………. 35

Guidelines for cleaning, Disinfection and Sterilization 36

 Policies on Sterilization and Disinfection …………………………. 37
 Procedures of sterilization and disinfection on clinical items …………. 37
 Standard Operating Procedure on disinfection and sterilization …………. 47
 Patient Transport Facility (Ambulance) Service …………………………. 54

Guidelines for The Garbage / Hospital Waste / Infectious Waste Management 56

 Policies related to garbage, hospital and infectious waste disposal …………. 56
 Procedures for garbage, hospital and infectious waste management …………. 56
 Types of Quarantine …………………………………………………. 57
 Algorithm for garbage, hospital waste and infectious waste management …… 58
 Needle Stick Injury …………………………………………………. 59
 Procedures for safe sharps management / sharp disposal policy …………. 60
 Guidelines for housekeeping and environment care for all hospital areas …. 65

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Guidelines for Protection of Healthcare Workers (Occupational Health)
 Guidelines to reduce transmission of infection of VRH Personnel to patients…. 70
 Guidelines to protect VRH Healthcare workers from Occupational Infections… 70
 Summary of Immunization of Pregnant healthcare workers …………………… 75

Basic Clinical Procedures with Emphasis on Infection Control 76

 Hand washing and hand hygiene …………………………………………. 76
 Insertion of peripheral intravenous lines …………………………………. 76
 Giving IV medication …………………………………………………. 77
 Site care …………………………………………………………………. 78
 Insertion of Foley catheter …………………………………………………. 78
 Care of indwelling urinary catheter …………………………………………. 79
 Wound care (surgical dressing change) …………………………………. 80
 Venous blood extraction …………………………………………………. 80
 Collecting specimen for blood culture …………………………………. 81
 Suctioning …………………………………………………………………. 81
 Tracheostomy care …………………………………………………………. 83
 Care of respiratory tubings …………………………………………………. 84

Guidelines for The Prevention of Healthcare Acquired Infections 85

 Guidelines for prevention of catheter – associated urinary tract infections …. 85
 Guidelines for prevention of healthcare acquired pneumonia …………. 88
 Guidelines for prevention of intravenous catheter – related infections …. 91

POLICIES AND GUIDELINES ON INFECTION CONTROL FOR

HIGH – RISK AREAS 95
General policies and guidelines on infection control for high-risk areas …………. 95
Infection control in the Medical / Surgical Intensive Care Unit …………………. 96
Infection control in the Neonatal Intensive Care Unit …………………………. 97
Infection control in The Emergency Room Department …………………………. 100
Infection control in the Operating Room …………………………………………. 101
Infection control in the Endoscopy Unit …………………………………………. 107
Infection control in the Respiratory Unit …………………………………………. 109
Infection Control in the Mortuary …………………………………………. 113

POLICIES AND GUIDELINES ON INFECTION CONTROL FOR HOSPITAL

AUXILLIARY SERVICE DEPARTMENTS / UNITS 114
Infection control in the Laboratory ………………………………………… 114
Infection control in the Dietary Department ………………………………………… 115
Infection control in the Laundry and Linen Section ………………………………… 117
Infection control in the Pharmacy Department ………………………………… 118
Infection Control in the Radiology Department ………………………………… 121

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POLICIES AND GUIDELINES ON INFECTION CONTROL FOR
SPECIFIC DISEASES 122
Infection control for specific disease: terms and definitions ……………… 122
Meningococcemia ……………………………………………………… 123
Mumps ……………………………………………………………… 124
Rabies ……………………………………………………………… 125
Rubella ……………………………………………………………… 127
Rubeola (measles) ……………………………………………………………… 128
Varicella (chicken pox) ……………………………………………………… 129
Varicella zoster (shingles) ……………………………………………………… 132

POLICIES AND GUIDELINES ON OUTBREAK INVESTIGATION 133

Management of an outbreak ……………………………………………………… 133
Outbreak control team ……………………………………………………… 134
Checklist of actions ……………………………………………………… 135

POLICIES AND GUIDELINES ON INFECTION CONTROL ON SELECTION AND

PURCHASE OF PRODUCTS FOR CHEMICAL STERILIZATION, DISINFECTION
AND ANTISEPSIS 136
Selection and Purchase ……………………………………………… 136
Methods for testing disinfectants ……………………………………………… 137

ANTIBIOTIC POLICY IN VRH 138

Monitoring of antibiotic resistance ………………………………………………. 138
Usage and function ………………………………………………. 139

EDUCATION AND TRAINING 140

Education and training of ICU staff and VRH personnel ………………………. 140
Lay education for the public ……………………………………………….

VRH FORMS 141

Healthcare associated infection surveillance form ………………………………. 142
Antibiotic resistance form ………………………………………………. 143
Occupational accident / incident form – NSI ……………………………...... 145
Assessment tool ………………………………………………………………. 146

REFERENCES ………………………………………………………………. 149

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 OBJECTIVES OF THE INFECTION PREVENTION AND CONTROL MANUAL

The Objectives of the Infection Prevention and Control Manual are as follows:

1. To document all policies, procedures, recommendations and guidelines which will be the
standard of care on infection control for all health care workers to know and follow.

2. To make the manual available and accessible to all healthcare workers at all times at all
identified hospital work areas and relevant offices.

3. To provide the necessary information to healthcare workers on the updated policies related
to control and prevention of infections related to patient care from admission to discharge
to outpatient follow up.

4. To provide to every VRH healthcare worker recommendations to optimize employee health

opportunities related to the reduction of their risk for infections while working at the
hospital.

5. To provide guidelines and pathways to follow in the event of outbreaks of infections,

exposure to highly communicable infections and undue events where infection is possible
such as in needle stick injuries.

6. To make available to all hospital areas and units recommendations to make the work
environment safer for patients and healthcare workers.

7. All staff will understand the impact of infection control practice to enable them to discharge
their personal responsibilities to patients and other staff, visitors and themselves.

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 Authorization for Implementation / Updating Responsibilities

The implementation of the contents of the infection control manual shall be authorized and

approved by the medical center chief.

Updating of the infection control manual shall be the responsibility of the designated authority

defined below, with signature.

DOMINADOR D. WAYET JR., MD, FPAFP, FPAFP-IDTM, FPSVI

Chairman, Infection Prevention and Control Committee (IPCC)

CIRILO R. GALINDEZ, MD, MHA, CESO V

Medical Center Chief II

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 HOSPITAL PREVENTION AND CONTROL UNIT

BACKGROUND INFORMATION ON THE VRH – INFECTION PREVENTION AND

CONTROL COMMITTEE

The Veterans Regional Hospital – Infection Prevention and Control Committee or IPCC is
the hospital unit that deals with the control and prevention of infections of patients and hospital
staff. The unit created from the long – standing Infection Control Committee.

The VRH – IPCC works under the office of the Medical Center Chief II. It coordinates
closely with the Department of Medicine, Surgery, Pediatrics / Neonatology and Obstetrics –
Gynecology. Its scope of responsibility is hospital wide and embraces the hospital departments
and services dealing with the delivery and support of patient care. Its current organization includes
representatives from all clinical departments, hospital units and divisions. Al employees in the
hospital are responsible to follow the infection control, program to detect, prevent and control
infection within the facility.

The IPCC is both policy – generating and policy – implementing.

Its areas of responsibility include:

 Education / in – service orientation on infection prevention and control of all VRH

employees and house staff.
 Waste segregation and management
 Control of antibiotic use and monitoring of antimicrobial resistance.
 Prevention, management and counselling of exposure of VRH employees to
infectious diseases.
 Targeted surveillance of priority infection in high risk areas. Reporting and
analyzing healthcare acquired infections.
 Supervision and monitoring of disinfection, sterilization of equipment, instruments
and hospital areas.
 Recommend proposals and protocols to be conducted for patient care
improvement.
 Formulation of policies and procedures for all departments.
 Sustained in-service orientation, education and compliance for all staff relative to
infection prevention in an infection chain.

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 MISSION AND VISION OF INFECTION PREVENTION AND CONTRO UNIT

VISION

A premier hospital in Region 2 by 2020 rendering quality healthcare services, training and research

development.

MISSION

To be instrument of change towards improvement in processes and relationships within the

hospital in order that hospital associated infection rates are decreased and infectious diseases are

managed in a timely and effective manner, minimizing risks to other patients and to staff.

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 POLICY FOR REFERRAL TO HOSPITAL INFECTION PREVENTION AND
CONTROL UNIT

When to Refer to the IPC Unit

 If you have any concerns / questions / requests for investigation or report of unusual
number or type of infections.

 Accidental exposure to communicable diseases, needle stick injuries and mucosal splashes.

 Report of Highly Communicable Infections.

 Any questions related to employee health, immunization

How to report

 For urgent concerns directly call 1040 and relay concern to the IPCC staff on line. Monday
to Friday 8 am – 5 pm.

 Written reports with relevant details of any suspected outbreak for unusual events are
encouraged.

 Exposures and needlestick injuries have to be reported in person for full evaluation of
event, with ER record.

The IPCC Office is located at the 2nd Floor Old Administrative Building (Bldg. 2), of the Veterans
Regional Hospital

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 INFECTION CONTROL COMMITTEE
ORGANIZATIONAL CHART

NAPOLEON A. OBAÑA, MD, FPCHA, CESe

Medical Center Chief II
Medical Nursing
HOPPS Finance
Service Service
DANILO ANTONIO A. ALEJANDRO, MD, FPPS
s s
Adviser – Infection Control Committee

DOMINADOR D. WAYET, MD, FPAFP-IDTM, FPSVI, FPSPPTM

Chairman, Infection Control Committee

Auxillary Health Service CORE MEMBERS CLINICAL DIVISION

Pharmacy FREDERICK FABIAN, MD MARY ANNE B. NAUI, MD ANA LIZA R TORRALBA, MD

ANGELI MERCI PORTO, MD OB-GYNE

Radiology CORAZON S. LAPITAN, RN, MSN NELSON TAN, MD
DEPARTMENT
DARYL GRACE A. BASAT, MD Internal Medicine
Engineering NOVELO P. LISNANG, RN PILAR D. PANGANIBAN, RMT

Dietary MARCELO O. DALIGCON MELODY P. PANITIO Pediatric / Neonatology

JUAN B. PASION
Anatomic and Clinical
Laboratory Surgery / Anesthetic

Linen and Laundry Family and Community

Medicine
Housekeeping / Waste
LINK NURSES
Management
TB DOTS
Central Supply and
Sterilization Unit
JEANETTE T. BUEN
Infection Control Committee - Secretary
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 POLICIES AND GUIDELINES OF THE INFECTION CONTROL FOR ALL
HOSPITAL AREAS

ADMISSION POLICY
Objective:
To alert medical and nursing staff receiving patients into hospital of the risk of a potentially
infectious patient being admitted.
I. In accordance with the policies established by the Infection Prevention and Control Committee,
Communicable diseases maybe admitted to this hospital provided that:

a) The patient’s physician is primarily responsible for the isolation of his infectious patient.
b) There shall be proper facilities and/or adequate equipment necessary for the care of such
infectious disease patient.

If there is neglect in the proper care and isolation technique by the attending physician, the
chairman of the Infection Control Committee or any of his designated representatives shall
have the authority to institute such proper isolation as deemed necessary.

II. The patient may be removed from isolation by his physician according to the rules established
by the Infection Prevention and Control Committee or at the discretion of the chairman of the
IPCC.

III. Generally, all communicable diseases/infectious diseases should be admitted in a single /

private room, observing appropriate isolation precaution. If single room is not available,
patients maybe cohorted observing 1-meter bed apart with the same case depending on the
severity of the disease which needs a single room.

IV. The following communicable diseases maybe admitted to general wards provided necessary
precautions shall be observed as per recommendations of IPCC:

a) Upper Respiratory Tract Infections:

1. Group A Hemolytic Streptococcus
2. Staphylococcus coagulase positive
b) Lower Respiratory Tract Infections:
c) Viral or bacterial pneumonias
d) PTB; except for positive AFB smear on sputum exam; hemoptysis, suspected MDR – TB
should be placed in a single room.
1. Viral encephalitis
2. Meningitis
3. Dengue Fever
4. Malaria
5. Leptospirosis

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V. The following communicable disease may be admitted to the general wards with Standard
Precautions / Contact Precautions:

a. Acute gastroenteritis
b. Bacillary (shigellosis) dysentery
c. Salmonella (typhoid or GI type)
d. Viral hepatitis A, B, C
e. Amoebiasis
f. Cholera

VI. The following communicable diseases should be transferred to San Lazaro Hospital or
Research Institute for Tropical Medicine (RITM).

a. Diphtheria
b. Acute Poliomyelitis
c. Rabies
d. HIV
e. Avian Flu
f. Suspected SARS
g. Tetanus
h. Meningococcemia

VII. In transferring patients, necessary referral protocol shall be observed; calling – up the
Institution providing clinical information regarding the case. Likewise, the patient for
transfer will be provided with transportation facilities to be arranged with the Nurse on Duty
/ Nurse Supervisor or the Senior House Officer after office hours.

VIII. The following communicable diseases maybe admitted in a single room or cohorted (Place
with other patient with the same or similar infectious organisms in one area/room):
a. Measles
b. Chickenpox
c. Rubella
d. Mumps
IX. Patient with communicable disease and with concomitant surgical condition or maybe
admitted if the attending physician / resident deemed it necessarily be admitted, provided
they take necessary precaution.

X. Post – partum mothers and their babies should not be admitted in the wards together with
patient with communicable disease.

XI. Pregnant patients and postpartum patients with the following conditions will be admitted in
an isolation room.

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a) Those with active Varicella (they are communicable after crusting of skin lesions. They
are no longer communicable if 3 days has passed with no appearance of new varicella
lesion).
b) Those with Rubella infection
c) Those with Measles infection
These diseases are high transmissible and can cause an outbreak in the Nursery and Maternity
Ward, which may cause neonatal and maternal morbidity and mortality. If these patients are
in very advanced labor and can no longer be transferred to another hospital the mother should
be isolated from the time of admission until the time of discharge. The medical and
paramedical staff should be cohorted from other personnel and other patients. For neonates
with varicella, rubella and measles, mothers should be placed in a single room.

All pregnant woman in labor with unknown Hepatitis B sera status should have STAT
HBsAg determination upon admission.

The neonates of HBsAg mothers should receive Hepatitis B immunoglobulin and Hepatitis
B vaccine within 12 hours after birth.

If maternal Hepatitis B status is still unknown prior to discharge, both mother and baby
should receive Hepatitis B vaccination as soon as possible after birth.

All postpartum women with negative or unknown sero status are highly encouraged to
receive the following vaccination after delivery:

 Tetanus toxoid
 MMR

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 ADMISSION POLICIES OF HIGHLY COMMUNICABLE DISEASE

Objective:

To clearly define the specific infectious diseases which are admissible and those infections which
should be referred to identified referral centers.

Rationale:

Patients with certain infections requiring facilities beyond the current capability of the VRH will
be referred accordingly to the DOH – designated referral centers.

A. CASES WHICH SHOULD NOT BE ADMITTED TO THE VRH

The following are the infectious diseases which require special additional precautions for
patients. Since this area presently not available at our institution, whether suspected or
confirmed, these cases must NOT be admitted and should be referred for transfer to
identified DOH referral centers including:

 San Lazaro Hospital (SLH) Tel No. 309 – 9541 in Sta Cruz, Manila
 Research Institute for Tropical Medicine (RITM) Tel No. 807 – 2628 in Alabang,
Muntinlupa

1. Avian Influenza
2. Severe Acute Respiratory Syndrome (SARS)
3. Rabies

B. CASES WHICH SHOULD BE ADMITTED TO A SOURCE ISOLATION OR

SINGLE ROOM

The following are the infectious diseases which require patients to be in a source isolation
room in the isolation unit or at least a single room if admitted at the pay ward as soon as
suspected or diagnosed:
1. Diphtheria
2. Meningococcal infection
3. Poliomyelitis
4. Rubeola (Measles)
5. MDR (+) smear

C. CASES WHICH COULD BE ADMITTED TO THE GENERAL WARDS

The following are the infectious diseases which may be admitted to the wards or to the
shared rooms (in the pay areas) as long as the following isolation precautions will be
observed:
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 1. Acute gastroenteritis - Standard and Contact Precautions
2. Dengue fever or Dengue Hemorrhagic fever - Standard Precaution
3. HIV (cd4 COUNT >200) - Standard Precaution
4. Hepatitis A - Standard and Contact Precaution
5. Hepatitis B or C - Standard Precaution
6. Influenza - Standard Precaution
7. Malaria - Standard Precaution
8. Meningitis - Standard Precaution
9. Mumps - Standard Precaution
10. Pneumonia - Standard Precaution
11. Rubella - Standard Precaution
12. Tetanus - Standard Precaution
13. Typhoid and paratyphoid fever - Standard Precaution
14. Viral encephalitis - Standard Precaution

D. Patients already admitted in the hospital for other life-threatening conditions requiring
intensive care and monitoring suspected or diagnosed to have highly communicable
infection shall be transferred to the designated isolation room in the ICU.

E. These policies should be complied with the Emergency Room and all other services. Each
clinical department should identify one room where source isolation precautions can be
properly observed.

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 ADMISSION POLICY OF INFECTIOUS CASES TO THE MEDICAL WARDS

The Department of Medicine wards and medical intensive care unit is considered the model for
infection control in the hospital. The department has invested space and resources to create source
isolation rooms. Source isolation rooms are necessary to prevent transfer of highly communicable
microorganisms from infected patients to the staff and other patients. These areas will admit cases
as follows:

A. PATIENTS WITH COMMUNICABLE DISEASES:

1. The source isolation room at the CD Medical ward with 6 bed occupancy will be used
to primarily admit pulmonary tuberculosis (PTB) cases complicated with other medical
problems in following order decreasing priority:
a. Culture proven multidrug resistant tuberculosis (MDR TB)
b. Smear (+) PTB cases who are MDR suspects
c. Smear (+) cavitary PTB
d. Cavitary PTB pending sputum smear results

The above cases may be transferred out to the general wards after two weeks of
effective anti-TB medications AND documentation of conversion of a positive sputum
AFB to negative; or if work-up for suspected TB cases returns negative.

2. Highly communicable airborne infections such as measles and chickenpox also require
admission to a source isolation room. ICU must be informed early.

3. Droplet infections which have grace morbidity or cause significant fear among health
care workers such as diphtheria, meningococcal infections and polio are candidates for
source isolation admission.

4. Patient with PTB – MDR cannot be accommodated in the isolation rooms and other
smear negative active PTB should be grouped together along the beds near the windows
facing the garden. Patients and watchers should be asked to wear a face mask.

5. To assist the medical and nursing staff in identifying potentially infectious cases, color
coded identifiers will be placed in patients’ chart.

COLOR CODE ISOLATION PRECAUTION

White Standard
Yellow Airborne
Pink Identified blood borne infection (HIV, Hepa B, Hepa C)
Blue Droplet
Green Contact

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B. IMMUNOCOMPROMISED PATIENTS

1. Protective isolation rooms in the ward (Pedia, Medical, Surgical, OB-Gyne) should be
restricted to the patients in immune compromised states but WITHOUT any highly
infectious diseases such as systemic viral infection or respiratory, skin or catheter-
related urinary tract infection.

2. Neutropenic patients with fever with no definite infectious focus should be carefully
assessed by the ward service before admission to the protective isolation room.

3. If patients initially admitted to these areas develop healthcare acquired infections or

urinary tract with catheter, they should be transferred out to the general wards and
placed in designated areas.

4. Entry into the isolation rooms should be limited to physicians and nurse directly
involved ion patient care. Service rounds to these patients should be done outside the
isolation room.

5. Patients in protective isolation rooms should NOT be in preceptorials.

6. Visitors of patients should be limited to a single watcher at any given time. They must
have similarly no respiratory nor skin infections. Belongings transported to the hospital
should be limited to patients needs only.

In transferring patients to either agency, proper referral protocol should be observed as

follows: call up and inform the physician on duty (POD) of the institution; and provide
the necessary information (clinical abstract) about the case. The patient for transfer
shall be provided with transportation facilities like ambulance equipped with oxygen
(O2) tanks and emergency medicines.

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 POLICY FOR REPORTING HIGLY COMMUNICABLE AND REPORTABLE
DISEASES

Objective:

To develop and implement an effective reporting system of highly communicable diseases.

Rationale:

The control of spread of highly communicable diseases at the Veterans Regional Hospital from
patients to other patients and hospital staff depends on four interdependent strategies:
 Early reporting
 Early detection with clinical and microbiological confirmation
 Early isolation of infectious source
 Early and timely administration of exposure prophylaxis

Purpose:

Earlier reporting may limit unnecessary unprotected potentially harmful exposure to highly
communicable diseases.

These should be observed whenever appropriate, whether the patient is in emergency room or in
single room at the pay ward or in the intensive care units.
The following diseases should be promptly reported to the IPCC because either they are highly
communicable diseases and/or may be highly pathogenic. A patient suspected or confirmed to
have any of these infections must be reported immediately to the IPCC within 6 hours from time
the diagnosis was made, whether tentative or confirmed. If a healthcare worker or student is
inadvertently exposed to any of these infections without sufficient protective equipment, he or she
SHOULD REPORT as soon as possible.

Some infections are reportable but NOT highly communicable. The report may be submitted
within 3 days of diagnosis. Risk of transmission to HCW is considered low and exposure need
not be reported.

Highly communicable diseases reportable to IPCC

1. The following are the highly communicable diseases which should be reported to IPCC
within 6 hours:
 Acquired immunodeficiency syndrome (AIDS)
 Anthrax
 Avian influenza
 Chickenpox
 Diphtheria

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  Hepatitis B
 Hepatitis C
 Human immune deficiency virus infection
 Measles
 Meningococcemia and other meningococcal infection
 Mumps
 Pertussis
 Rabies
 Rubella
 Severe acute respiratory syndrome

2. The following are highly communicable diseases which must be reported to IPCC up to 3
days of diagnosis:
 Cholera
 Malaria
 Leprosy
 Leptospirosis
 Neonatal / non-neonatal tetanus
 Paralytic shellfish poisoning
 Viral encephalitis
 Viral meningitis

Who makes the report?

All cases must be reported to the IPCC or by Infection Control link physician or link nurse

1. At the emergency room, the resident-in-charge / link nurse of the patient suspected or
confirmed with a communicable infection id responsible for reporting the event/exposure.

2. At the wards, the IC link nurse / physician is responsible for reporting the event / exposure
to the IPCC.

3. At the pay ward, the Infection control link nurse / physician is responsible for reporting the
diagnosis / event directly to the IPCC.

4. In all areas, nurse-in-charge or link nurse should likewise report to the IPCC.

What should be done if a highly communicable infection is suspected?

After the report is sent, resident-in-charge is expected to do the following appropriate steps
according to the specific type of infection suspected or diagnosed:

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 Avian Influenza, SARS, Anthrax
1. Direct patient to the isolation unit
2. Refer to the IPC chairman for opinion and co-management
3. Immediately isolate the patient in isolation unit under strict airborne precautions.
4. If possible make arrangement for transfer to San Lazaro Hospital or the Research Institute
for Tropical Medicine, if stable.
5. Transport the patient with trained and supervised Emergency Medical personnel.
6. Quarantine exposed HCW to pay areas/infirmary rooms.

 Rabies
1. Refer to the IPCC Chairman for opinion and co-management
2. Immediately isolate the patient in isolation unit. Maintain droplet precaution
3. Make arrangement for transfer to San Lazaro Hospital or the Research Institute for Tropical
Medicine, if stable.
4. Transport the patient with trained and supervised Emergency Medical personnel.

 Chickenpox / Varicella Infection

1. Assess need for admission. If admission is truly required, isolate in single room or isolation
room with airborne precautions. Consider discharge to home if the patient is not
immunocompromised and no other co-morbidities exist.
2. Confirm diagnosis by varicella antibody testing.
3. Keep patient in isolation until all the vesicular lesions have crusted and dried up.

 Measles
1. Assess need for admission. If admission is truly required, isolate in single room or isolation
room with airborne precautions.
2. Confirm diagnosis by measles-specific IgM antibody
3. Maintain a patient with measles in isolation for 4 days from onset of rash in otherwise
healthy patients and up to entire duration of rash for immunocompromised individuals.

 Meningococcemia
1. Refer to the Infectious Disease Specialist (IPCC) for opinion and co-management
2. Immediately isolate the patient in isolation room if at the ER or the isolation room at the
Medical/Pediatric Wards or a single room if at the pay ward. Observe droplet precautions.
3. Transfer patient to the isolation unit with strict droplet precautions observed.
4. Collect specimen (blood, CSF, skin lesions) for microbiologic studies. Inform the
laboratory that meningococcal infection is being considered.
5. Start antibiotics IV ASAP.
6. Keep patient in isolation at least until after 24 hours on IV antibiotics.

 Diphtheria
1. Refer to the Infectious Disease Specialist (IPCC) for opinion and co-management
2. Immediately isolate the patient in isolation room if at the ER or the isolation room at the
Medical/Pediatric Wards or a single room if at the pay ward. Strictly observe droplet
precautions.
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 3. Transfer patient to the isolation unit with strict droplet precautions observed.
4. Collect specimen (throat swab for gram stain and culture of C. diphtheria) for
microbiologic studies. Inform the laboratory that diphtheria infection is being considered.
Laboratory staff to collect specimen.
5. Start antibiotics IV ASAP.
6. Maintain patient in isolation at least 4 days from the time antibiotics are started.

 Mumps, Rubella
1. Assess need for admission. If admission is truly required, isolate in single room or isolation
room with droplet precautions.
2. Confirm diagnosis by antibody testing. Viral isolation is suggested depending on clinical
situation.
3. For mumps, maintain patient in droplet isolation up to 8 days from onset of parotitis. For
postnatal rubella, maintain the patient in droplet isolation up to 7 days from onset of rash.
Babies suspected to have congenital rubella are considered contagious up to one year or
until nasopharyngeal or urine viral cultures become negative. For influenza, droplet
precautions must be maintain during entire hospital stay.

 HIV/AIDS, Hepatitis B, Hepatitis C

1. In the hospital setting, transmission may occur if there is recognized or unrecognized
contact with blood or body fluids of infected patient. Such accidental exposures should be
referred to IPCC within 24 hours.
2. No other forms of isolation are necessary for patients with HIV/AIDS, Hepatitis B or C
other than standard precautions during entire duration of treatment or lifetime.

Disease Who must receive PEP What to give When to give How long
to observe
Meningococcal  Direct contact with oral  Ciprofloxacin 500mg Within 24 hours 10 days
secretions of patient single dose of diagnosis
 Those who intubated the  If pregnant, Ceftriaxone
patient without mask 250 IM single dose
 All exposed within 3 feet
of patient without mask
Hepatitis B  Needlestick injuries, If immunization is Month 0, 1, 6 6 months
mucosal exposures incomplete or anti hep B
 Other exposures to HBV – antibody <10,
infected blood / blood  Complete Hep B vaccine
products x 3 doses
 Hepatitis B Within 7 days 6 months
immunoglobulin at
0.06ml/kg IM
HIV  Direct contact to HIV  Antiretroviral regimen for Start within 24 6 months
infected blood and body 28 days, exact regimen hours exposure
fluids thru needlestick based on individual
injuries, mucous membrane assessment
or non-intact skin

21
Diphtheria  Direct contact with oral  Regardless of Give as soon as 14 days
secretions immunization status, those possible
 Exposure within 3 feet of exposed should receive
patient without plain Benzathine Pen G 1.2ml
surgical mask IM single dose or
Erythromycin 250mg QID
x 7 days
 Update immunization
status

22
 LIST OF NOTIFIABLE DISEASES

Category I Category II
(Immediately Notifiable) (Weekly Notifiable)

*Acute Flaccid Paralysis Acute bloody Diarrhea

Anthrax Acute Encephalitis Syndrome
Human Avian Influenza Acute Hemorrhagic Fever Syndrome
*Measles Acute Viral Hepatitis
Meningococcal Disease Bacterial Meningitis
*Neonatal Tetanus Cholera
Paralytic Shellfish Poisoning Dengue
Rabies Diphtheria
Severe Acute Respiratory Syndrome (SARS) Influenza – like illness
Outbreaks Leptospirosis
- Cluster of disease Malaria
- Unusual disease or threat Non-neonatal tetanus
Pertussis
Typhoid and Paratyphoid Fever

Category I: Notify simultaneously the CHD-NCR and NEC within 24 hours of detection and
advance copy of the Case Investigation Form (CIF) is submitted as soon as possible.

Category II: Report all cases of notifiable diseases/syndromes every Friday of the week to CHD-
NCR using the Case Report Form (CRF)
*Diseases under Vaccine Preventable Disease: Surveillance

23
 ISOLATION POLICY

Once the patient with communicable disease is admitted the following shall be done. Classify the
type of isolation technique: Expanded Precautions.
Expanded Precautions – are for patients who are known or suspected to be infected with
epidemiologically important pathogens that require additional control measures to prevent
transmission.
Expanded Precautions Categories:
 Contact Precautions * Airborne Infection Isolation (AII)
 Droplet Precautions * Protective Equipment (PE)

CONTACT PRECAUTIONS:
Use contact precautions for patients with known/suspected infections or evidence of syndromes
that represent an increased risk of contamination Transmission, including colonization or infection
with MDRO’s (multi drug resistant organism).

 Clostridium Difficile (DI)

 Rotavirus (DI)
 Congenital Rubella (until 1 year of age)
 Decubitus Ulcer, infected (DI)
 Hepatitis A, diapered
 Abscess (Draining, major)
 Cellulitis, uncontrolled drainage
 Gonococcal Conjunctivitis
 Acute viral (hemorrhagic) conjunctivitis
 Cutaneous Diphtheria (C, CN)
 Furunculosis – Staphylococcus (C, DI)
 Gastroenteritis – Cholera
 Shigella species (C, DI)
 Hemorrhagic fever (Lassa & Ebola) (C, DI)
 Human immunodeficiency virus (HIV) infection (C, S)
 Skin, wound or burn (C, CN)
 Parainfluenza virus infection, respiratory in infants and young children (C, DI)
 Respiratory infectious disease, Acute (if not covered elsewhere)
Infants & young children (C, DI)
 Scabies (C, U 24 hrs.)
DI –
C – Contact
S - Standard

24
 ISOLATION POLICY OF COMMUNICABLE DISEASES

Rationale:

Infectious diseases are generally transmitted in predictable modes of transmission. Specific

isolation precaution procedures for identified groups of infections have been developed and have
been previously shown to reduce risk of transmission if implemented well.

Purpose:

The isolation precaution policy is meant to define how health care workers at the VRH should
handle patients with transmissible infection and the proper protective equipment to use to
prevent the transmission.

A. MODE OF TRANSMISSION OF PATHOGENS

1. Pathogens can be transmitted by 3 main methods:
 Airborne
 Droplet
 Contact
2.Other mechanisms of transmission
 Vehicle transmission by contaminated water supply, solutions, blood, multi-doses
vials
 Vectors by animals, insects

B. POLICIES
1. Standard Precautions
All VRH healthcare workers must observed Standard Precautions when caring for
each and every patient.

Standard precautions comprise a set of patient care procedures based on the premise
that certain infection, particularly blood borne infections, are NOT readily identifiable
based on patient’s history, physical examination and other patient data, that these
infections may be unduly passed to healthcare workers, and that proper barriers are
available and easy to wear to prevent such transmission. It is strongly advised to regard
all patients a) blood; b) body fluid, excretions and secretions except sweat; c) non intact
skin; and d) mucous membrane as potentially infectious and good practice of standard
precautions will reduce the risk for transmission of both recognized and unrecognized
infections.

Standard precautions must be observed for ALL patients receiving care in any health
care setting whether at the outpatient department (OPD), emergency room (ER),
operating room (OR), intensive care units (ICUs), regardless of diagnosis, age, sex,
educational or economic background.

25
Standard precautions include the following and require that barriers (gloves, mask,
gown, goggles) to be worn whenever there is risk of contact with patients’ blood and
body fluids.
a. Hand hygiene – hands should be wash after ALL patient contact whether or not
gloves are worn. Hands should be washed immediately after gloves are removed,
before and after patient contact, and anytime one handles blood, body fluid,
secretions or excretions or potentially contaminated items or equipment. Use of
alcohol-based hand rub can only be an alternative if the hands were not visibly
soiled by patients’’ blood or fluids, in which case the hands must be washed first
with soap and water.
b. Wear gloves – gloves should be worn when touching blood, body fluids, secretions,
excretions. Mucous membrane, broken skin or contaminated objects. Clean non-
0sterile gloves are sufficient for use in standard precautions. Change between tasks
within same patient. Remove gloves promptly before touching non-contaminated
surfaces and dispose gloves properly. Wash hands after gloves are removed.
c. Wear mask or Eye Protection – mask and eye protection should be worn during
procedures that are likely to result in splashing of blood, body fluids, secretions and
excretions.
d. Wear gown – a gown should be worn to protect the skin and clothing during
procedures that are likely to result in splashing of blood, body fluids, secretions and
excretions. A clean non-sterile gown is adequate for standard precautions. Remove
gown before leaving patients room. Wash hands after disposal of gown.
e. Properly dispose patients’ feces, urine, other secretions and materials contaminated
with blood and body fluids to prevent unnecessary exposure of patients, HCWs or
visitors to such materials.
f. Reprocess equipment properly. Handle used patient-care equipment soiled with
blood, body fluids, secretions and excretions in a manner that prevents skin and
mucous membrane exposures, contamination of clothing and transfer of
microorganisms to other patients and environments. Ensure that reusable
equipment is not used for the care of another patient until it has been cleaned and
reprocessed appropriately. Ensure that single-use items are discarded properly.
Directions for correct cleaning, disinfection or sterilization should be followed
strictly particularly when reprocessing.
g. Carefully handle soiled linen and transport these in a sturdy bag. One bag may be
used if the article is not likely to leak or contaminate the outside of the bag,
otherwise use two bags.
h. Sharp instruments and needles should be handled with care. Do not reap needles
using bare hands. Used device (forceps) to recap safely, never manipulate needles
from syringes using bare hands. Use needles, scalpels, blades and other sharp items
should be placed in an appropriate, puncture-resistant container which is near and
visible to the HCW.
i. No special precautions are needed for dishes, glasses, cups and eating utensils.
disposable or reusable dishes can be used in patients on isolation precautions. Hot
water and detergent in hospitals are sufficient to decontaminate these articles.
j. Patients requiring standard precautions: ALL PATIENTS
26
2. AIRBORNE PRECAUTIONS
Whenever possible, airborne isolation precautions should be observed for infectious
transmitted by airborne route through minute respiratory droplets less than 5 microns
and these include: pulmonary and laryngeal tuberculosis, chickenpox, and measles.
Healthcare workers taking care of patients needing airborne precautions should strictly
observe standard precautions plus the following components of airborne isolation:

a. Placement of patient in source isolation room – patient should be admitted to a

source isolation room or at least a single room. The source isolation room should
be provided with negative pressure achieve by exhaust fans, with air exchanges
estimated to allow the required 6-12 air exchanges per hour. The column of air
passed through an ultraviolet light before being discharged out into the
environment. Single rooms at the pay floor may be acceptable alternatives since
the ventilation system is isolated per room and not centralized. Keep doors of
rooms closed.
b. Hand hygiene – strictly follow hand hygiene before and after seeing patient.
c. Wear an N95 mask when entering the room- Respiratory protection must be worn
by all individuals when entering the isolation room. An N95 mask must be used.
Ordinary surgical mask may not efficiently protect the health worker.
d. Limit visitors. Only healthcare staff necessary in the care of patient should enter
the room.
e. These patients will not be part of preceptorials for nursing students.
f. Patient Transport – limit movement and transport of patient. Patients need to wear
surgical masks when they are transported out in their room.
g. Patients requiring airborne isolation precaution – patients suspected or diagnosed
as having:
 Laryngeal tuberculosis
 Measles
 Varicella including disseminated zoster
 All cases suspected to have multi-drug resistant tuberculosis (MDRTB) (+)
smear
 SARS
 Avian influenza

3. DROPLET PRECAUTIONS
Patients with infections transmitted by droplets larger than 5 microns require that VRH
healthcare workers caring for these patients to observe standard precautions and the
following components of droplet isolation precautions:
a. Room Placement – in VRH, practice of droplet precautions may be very difficult
in open wards. Thus, whenever possible, place the patient in a single room or the
isolation room. Otherwise, it is acceptable to do cohorting with other patients with
the same active infection. If still not possible, place the patient near the window
and at least one meter away from the next patient. Make sure the flow of ventilation
is towards the window.
b. Hand hygiene – strictly follow hand hygiene before and after contact with patient.
27
 c. A plain surgical mask is sufficient – wear at least surgical mask if within less than
1-meter distance from the patient. However, it is easier to remember to put on the
mask upon entering the room. The patient must likewise wear a surgical mask at
all times.
d. Limit patient transport. If transport is necessary, have patient wear a surgical mask.
e. Patients requiring droplet precautions – patients suspected or diagnosed having:
 Invasive hemophilus influenza type B infection
 Invasive neissera meningitis disease
 Mycoplasma pneumonia
 Streptococcal pharyngitis
 Influenza
 Diphtheria, mumps, pertussis, rubella

4. CONTACT ISOLATION PRECAUTIONS

Healthcare workers must observe contact precautions in addition to standard
precautions whenever there is a risk that direct (skin to skin) contact and indirect (skin
to inanimate object or equipment) can cause transmission of infectious organisms.
Observe the following strictly:
a. Patient Placement – if the source isolation is available. Place patients needing
contact isolation in source isolation room. Placement of the patient in a single room
is an alternative. When a single room is not available place the patient with another
patient infected with the same organism (cohorting) but with no other infection. If
the only option is to put patient in the ward, have a box of clean gloves available at
bedside at all times.
b. Hand hygiene – strictly follow the hand hygiene before and after seeing patient.
c. Gloves are vital components of contact precautions – gloves (clean, non-sterile
gloves are sufficient) should be worn when touching patients’ secretion. During
patient contact, change gloves after contact with infected materials; remove gloves
before leaving the room; and wash hand immediately with soap and water. Do not
touch potentially contaminated surface, equipment or utensils.
d. Gowns – gowns (clean, non-sterile) should be worn when entering the room;
remove before leaving the patient environment and be careful not to contaminate
your clothes.
e. Patient care equipment – whenever possible, limit use of non-critical patient care
equipment to a single patient.
f. Patients requiring contact precautions – suspected or diagnosed case of:
 Diarrhea or gastroenteritis
 Respiratory infection (bronchitis, croup)
 Infection or colonization by multidrug resistant organism
 Abscess, draining wound
 Skin infection: herpes simplex, zoster, scabies, impetigo, pediculosis,
conjunctivitis

28
C. IMPLEMENTATION OF ISOLATION PRECAUTION
Sensitive to the needs, perception and attitudes of patients and their families and visitors,
as well as the safety of healthcare workers, the following color coding scheme should be
implemented in both charity and pay areas of VRH:

COLOR CODE ISOLATION PRECAUTION

White Standard
Yellow Airborne
Pink Identified blood borne infection (HIV, Hepa B, Hepa C)
Blue Droplet
Green Contact

29
 SPECIAL PRECAUTION IN WARD WHERE ISOLATION FACILITIES ARE NOT
AVAILABLE

Ideally, isolation of patients harboring harmful pathogens is essential. However, due to certain
difficulties in obtaining isolation cubicles on the wards those patients have been nursed separately.
The following procedures are recommended:

1. Move the patient next to a hand wash basin; this will minimize spreading of the organism
when the patient moves around.
2. Put divider to separate the patient from the rest.
3. Notify the janitorial staff so that the area will be cleaned last.
4. Wear protective clothing as describe for that particular organism.
a) Wear gloves at all times when dealing with the patients; particularly wound
dressing, urinary or other catheter.
b) Wear masks (when necessary)
c) Wash hands and dry thoroughly before moving on to another patient.
5. Restrict patient movement and patient visitors as much as possible.
6. Remove all bed linens; curtains etc., and send for laundry, properly labeled and placed in
a yellow plastic bag.
7. Wipe over the area with soap and water. Dry.
8. Allow at least 12 hours IF POSSIBLE before admitting another patient to that bed.

RECOMMENDATION: COHORTING

30
 31

FLOWCHART ON TRIAGING PATIENT WITH ACUTE REPIRATORY TRACT INFECTIONS

ER CONSULT

WITH COUGH / COLD

WITHOUT COUGH / COLD

KNOWN PTB NOT KNOWN PTB

With fever Without
& rash fever & rash
REFER TO WITH DYSPNEA WITHOUT DYSPNEA
TB TRIAGE
Prioritize Direct to Manage
DO CHEST X-RAY DIRECT TO Prioritize consult OPD (during accordingly
OPD (during Consult (after office hour) (after office
office hour) office hour) hour)
(+) PTB (-) PTB

Admit to Admit to ward

ward or manage
accordingly

31
 FLOWCHART ON TRIAGING PATIENT WITH ACUTE REPIRATORY TRACT INFECTIONS

OPD CONSULT

MEDICAL
NON MEDICAL

WITH COUGH / COLD WITHOUT

COUGH / COLD Dental

DO CHEST
STI With fever Animal Others
X-RAY
& rash Bite

(+) PTB (-) PTB

Direct to Direct Manage Manage
SACCL to ER accordingly accordingly
Direct to Manage
PPMD accordingly

32
 GUIDELINES FOR HAND HYGIENE

Objective: To define the proper hand hygiene techniques for all health care workers.

Rationale: Hand hygiene is critical and basic control strategy. Proper compliance to hand hygiene
has been shown to reduce health-care related infections. It is the most cost effective strategy to
reduce nosocomial infections and antimicrobial resistance. All healthcare workers must know and
practice the proper techniques of hand hygiene.

A. Indication to Perform Hand Hygiene

1. When should a healthcare worker perform hand hygiene
a. Before and every after direct patient contact
b. Every time gloves are removed
c. Before handling an invasive device
d. After contact with anybody fluid, blood, mucous membrane. Non-intact skin and
wound dressing
e. When moving from a contaminated site to a clean site within the same patient.
f. After handling inanimate objects within the immediate vicinity of the patient
g. Before handling medication
h. Before handling foods

2. What to use for proper hand hygiene?

a. Use soap and water
b. Use alcohol or alcohol-based hand rub for all other clinical situations. Alcohol-
based hand rub is currently the medium of choice for its efficacy and efficiency.
Soap and water is the alternative except for the situations listed above.

B. Handwashing Technique
For routine hand washing, a vigorous rubbing together of all surfaces of lathered hands
for at least 10 seconds, followed by thorough rinsing under a stream of water, is
recommended. See figure on the succeeding page.
C. Hand Hygiene Technique with Alcohol or Alcohol-Based Hand rub Disinfectant
1. Alcohol and other alcohol containing hand rub gels or solutions are the media of choice
for hand hygiene in healthcare settings because of their efficacy of antimicrobial killing
and efficiency in terms of time saved walking to and from sinks.
2. However, if the hands are grossly soiled with blood, saliva, urine, fecal material or other
body fluids, wash hand first thoroughly with liberal amounts of water and soap, before
using alcohol or alcohol-based disinfectant.
3. Do not wash hands after using alcohol or alcohol-based disinfectant.
4. Choose the hand disinfectant according to the preferences of the HCW. Alcohol can
cause drying in some individuals.
5. Use these agents using the basic steps in hand hygiene as recommended by the WHO.

33
D. Hand Hygiene Facilities
1. Handwashing facilities should be conveniently located throughout the hospital.
2. A sink should be located close to every patient room. More than one sink per room
may be necessary if a large room is used for several patients.
3. Handwashing facilities should be located in or adjacent to rooms where diagnostic or
invasive procedures that require handwashing are performed (e.g. cardiac
catheterization, bronchoscopy, sigmoidoscopy, etc.)
4. Alcohol-based disinfectants will be purchased by the hospital and made available to
several areas in the hospital according to the need assessment of the IPCC.

HAND-WASHING TECHNIQUE WITH SOAP AND WATER

hand surfaces with fingers interlaced

fingers interlocked rotational movement circular motion

Rub each wrist with Rinse hands with Use elbow to turn Dry thoroughly with a
opposite hand Water off tap single-use towel

34
35
 GUIDELINES FOR CLEANING, DISINFECTION AND STERILIZATION

Objective: To define the standards and procedures for cleaning, disinfection and sterilization of
patient-care equipment to be implemented at the Veterans Regional Hospital.

DEFINITIONS:

 Sterilization refers to a validated process used to render a product free from viable
microorganisms. It should achieve the complete killing or removal of all types of micro-
organisms, including spores which are usually resistant to heat and other disinfectants.
 Sterilant refers to chemical and physical agents which, under controlled conditions, can
kill spores, viruses, bacteria.
 Disinfection refers to a process used to reduce the number of viable micro-organisms on
an item. The process may not necessarily ensure the inactivation of some microbial agents
such as spores and prions.
 High-level Disinfection is a term used to disinfection procedure that can be expected to
destroy vegetative microorganisms, most fungal spores, tubercle bacilli, and small nonlipid
viruses.
 Disinfectant refers to a chemical or physical agent which can destroy vegetative
microorganisms.
 Antiseptic is the term often used for disinfectants used for skin or applied to living tissues.
In this manual, disinfectant is the preferred term to be used.
 Cleaning is the mechanical and physical process of removing visible debris from used
items. All items for disinfection and sterilization require thorough cleaning prior to the
standard sterilization processes.

RATIONALE: The rationale for cleaning, disinfecting, or sterilizing patient-care equipment can
be understood more readily if medical devices, equipment, and surgical materials are divided into
three general categories: 1) critical items; 2) semi-critical items; and non-critical items based
on the potential risk of infection involved in their use. This categorization of medical devices also
is based on the original suggestion by Spaulding.

 Critical items - Instruments or objects that are introduced directly into the bloodstream or
into other normally sterile areas of the body. At the time of use these items must be sterile;
either newly opened from sterile packs or if reprocessed, have undergone sterilization.
Examples: surgical instruments, cardiac catheters, implants, pertinent components of
heart lung oxygenator, and blood compartment of a hemodialyzer

 Semi-critical items - These instruments or items come in contact with intact mucous
membranes. They do not ordinarily penetrate body surfaces. At the time of use, these
items are generally preferred to have undergone sterilization whenever possible. But the
sterilization process may not always be possible in certain equipment; at a minimum, a
high-level disinfection procedure should be done.

36
 In most cases, meticulous physical cleaning followed by an appropriate high-level
disinfection treatment gives the user a reasonable degree of assurance that the items are
free of pathogens.
Examples: non-invasive flexible and rigid fiberoptic endoscopes, endotracheal tubes,
anesthesia breathing, circuits and cytoscopes
 Non-critical items – these instruments or items do not ordinarily touch the patient or only
touch the intact skin. These items are rarely, if ever transmit disease. Consequently,
washing with a detergent may be sufficient; sometimes use of a disinfectant may be
necessary.
Examples: crutches, bed boards, blood pressure cuffs, bedpans

A. Policies on Sterilization and Disinfection

The VRH will observe the high levels of sterilization and disinfection for all patient-care
equipment and follow only standard procedures to achieve these. Because of limited resources,
many items meant for a single use are reprocessed for re-use. Sterilization and proper
disinfection are thus vital parts of hospital operations. The maintenance of sterilizers,
availability of disinfectants as well as the related education of the hospital staff are recognized
as priority activities to ensure smooth implementation of these operations.

B. Procedures for Sterilization and Disinfection on Clinical Items

1. General procedures related to Sterilization and Disinfection
a. Physician must alert the nursing staff regarding planned procedures which will
require the use of sterile instruments, materials or equipment so that they could be
prepared with sufficient time.
b. Reuse of items meant for single use must be done only when absolutely necessary
and after following sterilization protocol.
c. An item should not be used if its sterility is questionable, e.g. its package is
punctures, torn or wet.
d. Every sterilized package must be labelled with the date of sterilization, autoclave
number and sterilizer used.
e. Sterilized items must be handled carefully and stored in a dry, well-ventilated,
limited access area until use.
f. The storage area must be clean and free of dust, insects, vermin and extreme
temperature and humidity.
g. Care must be done to use only sterile materials during sterile procedures. For
instance, tap water MUST NOT be used for irrigation. Instead, use only sterile
irrigation or saline water for such purposes.

2. Sterilization Process at VRH

a. Indicators of Sterilization
 All critical items, medical devices and patient-care equipment that would
enter normally sterile cavities, tissues or would invade the vascular system
or any area through which blood flows should either be new from a sterile
pack or must have been subjected to sterilization procedure before each use.

37
  Laparoscope, arthroscopes and other scopes that enter normally sterile
tissues should be subjected to sterilization procedure before each use; if this
is not feasible, they should receive at the minimum high level disinfection.

b. Cleaning
All objects to be disinfected or sterilized should first be thoroughly cleaned to
remove all organic matter (blood, tissue) and other residues.

c. Method of Sterilization
i. Whenever sterilization is indicated, steam sterilization should be used
unless the object to be sterilized will be damaged by heat, pressure or
moisture or is otherwise inappropriate for steam sterilization. In this case,
another acceptable sterilization should be used.
ii. The following are available at VRH for sterilization at various areas.

Table I: Sterilization procedures available at VRH designed to achieve complete

elimination and destruction of all types of microorganisms.

Method Items / Materials Required Length of Exposure Where Found

0
Physical Heat and moisture resistant At least 30 min if 250 F CSSU
Steam under items: linen, most surgical At least 15 min if 260 0F
pressure or instruments
autoclave
Chemical Heat sensitive items 45 – 80 min at 50 0C OR
a. Gas Plasma
(sterrad)
b. Ethylene Heats or moist sensitive 3–6 hrs exposure plus aeration OR
Oxide Gas items period of 12 – 24 hrs
c. Immersion in Heat sensitive items like At least 8 – 10 hours soaking Wards,
activated sensitive OR equipment followed by rinsing with CSSU, OR,
Glutaraldehyde sterile water DR
2% Solution
OR – Operating room; CSSU – Central Supply & Sterilization Unit; DR – Delivery room

iii. Flash sterilization [ 270 0F (132 0C) for 3 minutes in a gravity displacement
steam sterilizer] should be done only in situation where there is no other it
is not recommended for implantable items.

d. Biological monitoring of Sterilizers

i. All sterilizers should be monitored at least once a week with commercial
preparations of spores intended specifically for that of sterilizer (i.e. Bacillus
Stearothermophilus for steam sterilizers and Bacillus Subtilis for ethylyne
oxide).

38
 ii. Every load that contains implantable objects should be monitored. The
implantable objects should not be used until the spore test is found to be
negative at 48 hours.
iii. If spores are not killed in routine spore test repeated. objects, other than
implantable apparatus, do not need to be recalled because of a single
positive spore test unless the sterilizer or the sterilization procedure is
defective.
iv. If spore test remains positive, use of the sterilizer should be discounted until
serviced.

e. Chemical Indictors
Chemical indicators that will show a package has been through a sterilization cycle
should be visible on the outside of each package sterilized. The Bowie-dick
autoclave test used at VRH.

f. Use and Preventive maintenance

Manufacturers’ instructions’ should be followed for use and maintenance of
sterilizers.
g. In the event of outbreak of any of the sterilizers / autoclave machine, kindly
inform immediately the office of the Engineering and Facilities Management
for further advice.

3. Disinfection Procedures at the VRH

a. Indictors for Disinfection

i. Critical items that cannot be sterilized should undergo high-level
disinfection
ii. Semi-critical items including all endoscopes, cytoscopes should undergo
high-level disinfection
b. Cleaning before disinfection
Through mechanical cleaning of used items should be done before disinfection
process.
c. Methods of Disinfection
The algorithm for disinfection and sterilization should be followed. The
manufacturers manual of each of the individual items and equipment should also
be consulted to get the best results.
Many items meant for single use may have to be reprocessed in the VRH setting.
The basic principles of thoroughly cleaning and proper use of disinfectants or
sterilants be followed. The specific and unique instructions to some reprocessing
procedures will be found below as follows:
 Sterilization of Respiratory Equipment
 Disinfection of Endoscopes
 Disinfection of items for the Nursery
 Disinfection of Linen

39
 d. Types of Disinfectants

Disinfectants Recommended Use Precautions

Sodium Disinfection of material  Should be used in well-ventilated areas
Hypochlorite 1% contaminated with blood and  Protective clothing required while
in-use dilution or body fluids handling and using undiluted
10,000ppm av Cl2  Use 10,000ppm for blood  Not to be mixed with strong acids to
spillage from patient with avoid release of chlorine gas
Also avail very Hep B or HIV  Corrosive to metals
strong 5% solution  Use 2500ppm for laboratory  Prepare daily
(100,000ppm av discard jars
Cl2 to be diluted  Use 100ppm for general
1:5 in tap water) environmental disinfection
Glutaraldehyde For disinfection of  Eye and nasal irritant, may cause
(2%) endoscopes, respiratory asthma, and skin allergies, hence
therapy equipment and for should be used in well-fitting lids
materials that are destroyed  Eye protection, plastic apron and
by heat. Can work as a gloves should be worn while handling
sterilant if contact time is 6-8
hours and if used under
strictly controlled condition.
Detergent with Cleaning endoscopes,
enzyme surgical instruments before
disinfection
Bleaching powder Toilets, bathrooms may be  Eye and nasal irritant, may cause
7g/liter with 70% used in place if liquid bleach asthma, and skin allergies, hence
available chlorine is not available should be used in well-fitting lids
 Eye protection, plastic apron and
gloves should be worn while handling
Alcohol (70%) Smooth metal surfaces, table  Flammable, toxic to be used in well-
Isopropyl, Ethyl tops and other surfaces on ventilated area, avoid inhalation
Alcohol, which bleach cannot be used  To be kept way from heat sources,
Methylated spirit like thermometers, probes, electrical equipment, flames, hot
electronic equipment surfaces
surfaces. Good skin  Should be allowed to dry completely
disinfectant
Chlorhexidine For skin and mucous  Inactivated by soap, organic matter
combined with membranes, preoperative  Relatively nontoxic
alcohol or skin preparation, disinfection  Should be allowed contact with brain
detergents of hands meninges, eye or middle ear
Iodophor Povidone For skin preparation and  May have skin reaction
Iodine surgical hand disinfection

40
 Quaternary Antiseptic for cleaning dirty  Relatively nontoxic
Ammonium wounds (low level  Dilutions in use are likely to get
Compounds disinfection only) contaminated and grow gram negative
bacteria
 Should be used in correct dilution
 Should be changed every 8 hours
 Stock bottle should not be topped up
Phenolic Confined to environmental  Toxic when applied to skin
disinfection

i. Chlorine – releasing agents like sodium hypochlorite (i.e. Chlorox) are well-used in VRH
because they are cheap and very effective disinfectants. They rapidly act to kill against
viruses, fungi, bacteria and spores. They are particularly recommended where special
hazards of viral infections exist (i.e. Hepatitis B, Human Immunodeficiency Virus or
HIV, and the severe acute respiratory syndrome or SARS virus).
ii. Glutaraldehyde is the disinfectant of choice for heat sensitive items particularly flexible
endoscopes. It is usually available as 2% alkaline solution that needs to be activated. It
is non-damaging to metals, plastics and rubber and is effective against negative
organisms (Hepatitis B and HIV), virus and fungi. Longer contact time (greater than 43
hours) will increase its sporicidal activity.
iii. Alcohol as 70% Ethyl Alcohol or as 60% isopropyl alcohol are effective and rapidly
acting disinfectants with the additional advantage that they evaporate and leave treated
surfaces dry. They should be used for smooth clean surfaces like trolley tops,
thermometers and the like as their penetration is poor. Items contaminated with blood
and secretions a should be washed first prior to alcohol use.
*Alcohol is also a good skin disinfectant. No additives are needed for skin disinfectant prior
to injections. Addition of emollients, 60% – 70% alcohol rubbed on until the skin is dry
is an effective agent for the rapid disinfection of physically clean hands especially if
handwashing facilities are not readily accessible from bedside such as in some of our
VRH wards and pay rooms.
iv. Chlorhexidine is another useful skin disinfectant. Its use in VRH will be restricted to
areas with outbreaks of difficult to explain resistant pathogens. Additional data will be
necessary to approve this agent for disinfection of surgeons’ hands prior to procedures.
v. Iodophor are complexes of iodine and solubilizers which possess the same activity as
iodine, but are non-irritant and do not stain the skin. Mainly used for hand disinfection
(povidone-iodine), they are most useful as surgical scrubs and pre-operative preparation
of the skin at the operative site. Iodine is only antiseptic shown to have a useful sporicidal
action on the skin.
vi. Quaternary Ammonium Compounds and Phenolic are low risk disinfection and there are
confined mainly for environmental disinfection.

e. Commonly encountered clinical situations requiring disinfectants

41
DISINFECTION OF SKIN AND MUCOUS MEMBRANE
i. Routine injections, venipuncture use 70% isopropyl alcohol to disinfect planned
puncture site.
ii. Venipuncture for drawing blood culture use 2% tincture of iodine to disinfect planned
site of venipuncture in concentric circles going outward; allow 30-60 seconds to dry
before venipuncture
iii. Periurethral preparation for obtaining urine for urinalysis and urine culture. Use liquid
or bath soap only plus gentle mechanical cleaning of the periurethral area.
iv. Periurethral preparation before insertion of Foley catheters – use liquid or bath soap
followed by betadine soap
v. Minor surgical procedures – use 2% tincture of iodine for patient skin preparation.
vi. Operating room surgical procedures – routine for skin preparation: 1) preoperative skin
cleansing for 5 minutes with betadine surgical scrub; 2) rinse and dry; and 3) paint skin
with betadine antiseptic solution.
vii. Skin preparation of patients undergoing central line replacement, cardiac catheterization
or angiography – use of chlorhexidine recommended to reduce post-procedure
infections.

*Note: for iodine allergic patients: use 70% alcohol or iodophors (betadine)

DISINFECTION OF PATIENT CARE EQUIPMENT

i. For reprocessing of the following instruments – use glutaraldehyde, rinse all residual
chemical with sterile water afterwards
ii. Individual thermometer – wipe with alcohol before and after use
iii. Stethoscopes – wipe with alcohol at the start and end of the day
iv. Infant incubators – wash with detergent then wipe with alcohol after every baby
v. Anesthesia equipment – 2% glutaraldehyde x 30 min
vi. Laryngoscope blades – 6-7.5% hydrogen peroxide x 20 min

DISINFECTION OF INFECTIOUS SPILLAGE

Spillage of blood fluids, feces – cover with cloth with 0.5% sodium hypochlorite for 10 minutes.
Clean and repeat disinfection with 0.05% sodium hypochlorite. If spill is small – remove visible
material with tissue or any paper, then disinfect with Sodium Hypochlorite 1:10 dilution. If spill
is large – blood area with zonrox 1:100 or hospital disinfectant may use common household bleach.
Refer to manufacturers guide for dilution.

DISINFECTION OF THE ENVIRONMENT

Specific instruction for disinfection and sterilization of specific types of environment

i. Single use or Disposable Items
As much as possible, item or devices meant for single use should be changed and disposed
after their meant use. This is particularly true when they cannot be cleaned and sterilized
or disinfected within altering their physical integrity and function. Reprocessing
42
 procedures that result in residual toxicity or compromise the overall safety of the equipment
should not be done in these items.

ii. Processing Reusable Equipment

All previously used equipment to be sterilized or disinfectant should be thoroughly cleaned
to remove all blood, tissue or other residues. It should be decontaminated before or during
cleaning if it is marked “contaminated” and received from patients in certain types of
isolation.

iii. Reprocessing Respiratory Equipment – Disinfection and Sterilization

1. Respiratory therapy equipment that touches mucous membranes should be
decontaminate the sterilized before use on other patients; if this is not feasible, it should
receive high-level disinfection.
2. Breathing circuits (including tubing and exhaustion valve), medication nebulizers and
their reservoirs, venture wall nebulizers and their reservoirs and cascade humidifiers
and their reservoirs, should be sterilized or receive high-level disinfection.
3. Since coolant chambers for ultrasonic nebulizers are difficult adequately, these
chambers should be gas-sterilized (ethylene oxide) or have at least 30 minutes of
contact time with high-level disinfectant.
4. The internal machinery of ventilators and breathing machines should not be routinely
sterilized or disinfected between patients. Disinfection or sterilization may be
necessary only after a machine is potentially contaminated by extremely dangerous
agents, such as Lassa Fever Virus.
5. Respirometers and other equipment used to monitor several patients in succession
should not directly touch parts of the breathing circuit. Rather, extension pieces should
be used between the equipment and breathing circuit and should be changed between
patients. If no extension piece is used and such monitoring equipment is directly
connected to contaminated equipment, the monitoring equipment should be sterilized
or receive high-level disinfection before use on other patients.
6. Once they have been used for 1 patient, hand powered station resuscitation bags (i.e.
ambubags) should be sterilized or received high-level disinfection before this is used
on other patients.

iv. Proper maintenance of Respiratory Equipment

1. Fluid reservoirs should be filled immediately before (nut not far in advance) use. Fluids
to use should be sterile. If there is a residual fluid from previous shift, discard all of
these before replenishing with fresh supply of sterile fluid. Fluids should not be added
to replenish partially filled reservoirs.
2. Water that has condensed in tubing should be discarded and not allowed to drain back
into the reservoir.
3. Nebulizers (including medication nebulizers) and their reservoirs and cascade (high
volume) humidifiers and their reservoir should be changed and replaced with sterilized
or disinfected once every 24 hours.
4. Reusable humidifier reservoirs for use with wall oxygen outlets should be cleaned,
rinsed out and then dried daily.
43
 5. The tubing (including any nasal prongs) and any mask use to deliver oxygen from a
wall outlet should be changed with new items between patients.
6. Breathing circuits (including ventilator tubings) should be routinely changed and
replaced every seven days. They could be changed earlier if visibly soiled.
7. When a respiratory therapy machine is used to treat multiple patients, the breathing
circuits should be changed between patients and replace with new or sterilized or
disinfected one.

v. Disinfection of Gastrointestinal Endoscopes

1. Because of the vital importance and specialized nature of the proper implementation of
standard practice of cleaning and disinfection of endoscopes, only persons who have
been trained and have the ability to understand and consistently follow instructions to
endoscope disinfection should be given the responsibility to reprocess endoscopes.
These personnel should also have been vaccinated against Hepa B and monitored for
TB.
2. Non-immersible equipment should be phased out.
3. Meticulous cleaning of the endoscopes and its accessories with a detergent is
recommended immediately after its use.
4. Endoscopes that pass through normally sterile tissue should be subjected to a
sterilization procedure before each use, if this is not feasible, they should receive at
least high-level disinfection. This disinfection should be followed by a thorough rinse
with sterile water.
5. All immersible internal and external surfaces should be in contact with the disinfectant
for at least 20 minutes. The disinfecting agent should be 2% glutaraldehyde as the
agent of choice, with hydrogen peroxide or peracetic acid as alternative agents. A timer
is ideal to have. Note that 2% activated alkaline glutaraldehyde is effective against
negative bacteria, fungi and most viruses. Two minutes’ exposure inactivates most
infective agents including HIV and enteroviruses. Hepatitis B virus is destroyed in 2.5
minutes. Mycobacterium tuberculosis is destroyed in 20 minutes. Atypical
mycobacteria are killed in 60-75 minutes and some bacterial spores require three or
more hours.
6. After chemical disinfection, endoscopes must be rinsed with sterile water, followed by
70% ethyl or isopropyl; alcohol rinse and thoroughly drying.
7. Reusable accessories that penetrate mucosal barriers should be mechanically cleaned
then sterilized between each patient uses ort used once and discarded.
8. All unit with endoscopic procedures should maintain a logbook of all procedures with
the name of each of the patients, medical record number, date done, endoscopist and
instrument used.
9. Endoscopy – related infections whether suspected or confirmed should be reported to
the ICU.
10. Endoscopist and staff of the Gastrointestinal Unit should have the appropriate personal
protective equipment (PPE) anticipating splashes. These PPE include plastic gowns
and aprons, gloves, goggles.
11. The following specific steps are recommended to be implemented:

44
At the start of the day
 Instruments to be used for the day should be checked for any faults.
 If the instruments were cleaned on the previous day, the scopes can be soaked for
10 minutes at the start of the day
 All channels should be flushed with the disinfectant. The valves should be
disinfected.
 After disinfection, the valves and endoscopes should be rinsed in sterile water and
ensure that all traces of disinfectant are removed from the channels, control body
and eyepiece. Dry the endoscopes and insert the valves.
 The instrument can then be plugged into the light source and connected to the
suction pump. Air should be blown through all the channels to expel excess fluid.

Between Cases
 Before disconnecting for light source or video processor, the air/wate4r
channels should be flushed with water for at least 15 seconds to ensure that the
blood, mucus and other debris are expelled. The biopsy and suction channels
should also be flushed.
 The equipment should be inspected for obvious leaks or damage before
immersing into an enzymatic detergent.
 The outer surface of the endoscope can be cleaned carefully with a flexible
brush.
 All channels should next be irrigated with an enzymatic detergent. Suction
and air insufflation should be use to removed fluid residue.
 The endoscope is next disinfected with 2% activated glutaraldehyde for at least
20 minutes. Ensure that all channels are filled with disinfectants.
 Rinse the instrument with sterile water as done at the start of the day.
 The relevant surfaces such as the top of the endoscopy trolley should be wiped
clean between patients with alcohol. Once the endoscope has been disinfected,
rinsed and dried, fresh valves should be inserted and the instrument placed on
the clean surface ready to use.

After the last case

 Endoscopes should be tested for leaks, cleaned and disinfected as above for at
least 20 minutes in 2% glutaraldehyde
 Endoscopes should be dried before storage. Seventy percent alcohol may be
aspirated through the channels to assist in drying. Thorough drying reduced
the risk or subsequent microbial proliferation.
 Endoscopes are stored hinging vertically in a designated ventilated cupboard,
not in their transit cases
 All valves should also be cleaned, disinfected and rinsed.

45
vi. Disinfection of Nursery Items
i. All critical and semi-critical items as above.
ii. non-critical patient care items as below:
Bassinet:
 After a neonate has been discharged, the bassinet or incubator should be
thoroughly cleaned and disinfected. Meticulously scrub all areas of the
bassinet.
 A bassinet or incubator should never be disinfected when occupied. If an
infant is staying in the nursery for an extended period of time, the child
should be periodically transferred to a different bassinet that has been
cleaned and disinfected.
 Replace mattresses if there is a break in the covering surface.

Incubator:
 Incubators should be cleaned with detergents
 Water reservoirs for humidifiers should be drained and refilled with sterile
water every 24 hours
 Cleaning of incubators should be done between patients

vii. Proper Disinfection of Hospital Linen

1. Since all used hospital linen are likely to be contaminated, they should be handled with
minimum disturbance and transported in impermeable plastic bags
2. Disinfect soiled contaminated linen with 0.5% - 1% sodium hypochlorite for 15
minutes then wash with detergent.

46
 STANDARD OPERATING PROCEDURE FOR CLEANING, DISINFECTION AND
STERILIZATION

PURPOSE
 To provide standard guidelines to minimize transmission of microorganisms through
adequate methods of cleaning, disinfecting and sterilization

SCOPE
 This standard operating procedure covers the processes for cleaning, disinfecting and
sterilizing. This shall include all healthcare personnel who are the said procedures.

DEFINITION OF TERMS
TERM DEFINITION
Cleaning The process of removing all or a significant amount of the pathogens from
contaminated surfaces and items
Chemical Monitor physical conditions within the sterilizer so personnel can check
Indicators for proper packaging, loading or performance of sterilizers
Disinfection The thermal or chemical destruction of pathogenic and other types of
microorganisms. Less lethal than sterilization because it destroys
recognized pathogenic microorganisms but not necessarily all microbial
forms (bacterial spores).
Sterilization The process by which all types of microorganisms including spores are
destroyed.

RESPONSIBILITIES
DESIGNATE RESPONSIBILITY
ICC Chairman Formulates policies regarding cleaning, disinfecting and sterilizing
in accordance to Infection Control updates.
ICC Nurse Checks the work of Housekeeping Personnel if it is aligned with
the existing policy. Works together with staff nurses in updates
regarding cleaning and disinfecting.
ICC Link Nurse Identifies equipment that need cleaning, disinfecting and sterilizing
within their respective wards. Coordinates with the Infection
Control Committee regarding special cleaning and disinfecting
procedures.
Housekeeping Personnel Responsible in performing cleaning and disinfection of areas
assigned to them.
OR Personnel Responsible in performing sterilization of certain equipment.
Institutional Workers In – charge in cleaning O2 tanks before bringing to the wards.
Nursing Attendants In-charge in cleaning BP apparatus and stethoscopes in the wards.

47
PROCEDURE OUTLINE
KEY ACTIVITIES PERSONS RESPONSIBLE
CLEANING  Routine Cleaning  Staff Nurse
 Cleaning Agents  Housekeeping Personnel
 Special Cleaning
 Terminal Cleaning
Disinfection  Level of disinfection  ICC Nurse
 Guidelines on Airborne Machine  Staff Nurse
 Housekeeping Personnel
Sterilization  Drying  Staff Nurse
 Packaging
 Sterility Maintenance
 Distribution

CLEANING

 Routine cleaning

a. Routine cleaning is necessary to ensure that the hospital environment is clean, since
infectious agents are capable of surviving in the environment surfaces for many hours
or even days.
 Thorough cleaning is required before high level disinfection
 All horizontal surfaces shall be cleaned in patient care areas every day and
when visibly soiled.
 Clean and disinfect surface of examination tables/other equipment I direct
contact with patients.
 Damp rather than dry dusting or sweeping shall be performed
 Clean and dry all cleaning equipment after each use
 Clean less heavily contaminated areas first and change cleaning solutions and
cloths/mops frequently
 Wet mopping is done with a double bucket technique. When a single bucket
is used, the solution shall be changed more frequently because of increased
microbiologic load

 Cleaning Agents

a. A detergent is acceptable for surface cleaning of most areas

b. A low or intermediate grade disinfectant (a germicidal) may be preferable for
cleaning in nurseries, pediatric setting, critical care unit, burn unit, emergency rooms,
operating theaters

48
Special Cleaning

a. Special organisms of epidemiological significance: special environmental in

techniques are advocated for organisms such as Clostridium difficile, methicillin-
resistant Staphylococcus aureus or diarrheal diseases. During an outbreak, thorough
environmental cleaning with soap and water and disinfection with surfanios aero sept
may be required.

b. Blood Spills:

 Appropriate personal protective equipment shall be worn for cleaning up a

blood spill. Gloves shall be worn. Overalls or aprons, as well as boots shall be
worn for large blood spills. Personal protective equipment shall be changed if
torn or soiled, and always removed before leaving the location of the spill. If
with a possibility of a splash, the worker shall wear a face shield and plastic
apron.
 The blood spill area shall be decontaminated and cleaned before applying a
disinfectant. 0.5% (5000 ppm) sodium hypochlorite is recommended for
disinfecting small spills. Large spills can be disinfected using 1.0% (10,000
ppm0 sodium hypochlorite.
 Excess blood and body fluids shall be removed with disposable towels that
then should be discarded in a plastic-lined waste receptacle. After cleaning,
the area shall be disinfected for 10 minutes with an intermediate-level
chemical disinfectant such as sodium hypochlorite household bleach.
Concentrations ranging from approximately 500 ppm (1:10 dilution of
household bleach) are effective, depending on the amount of organic material,
(e.g. blood or mucus) present on the surface to be cleaned and disinfected. A
1:100 dilutions (0.05%) sodium hypochlorite may be sufficient if the surface
is hard and smooth, and has been adequately cleaned.

Terminal Cleaning

a. Upon discharge of a patient, the room, cubicle or bed space, bed, bedside equipment
and environmental surfaces shall be thoroughly cleaned before another patient is
admitted.
b. Terminal cleaning shall primarily be directed toward those items that have been in
direct contact with the patient or in contact with the patient’s excretions, secretions,
blood, or body fluids.
c. Housekeeping personnel shall use the same precautions to protect themselves during
terminal cleaning that they would use for routine cleaning.

49
 d. Masks are not needed unless the room was occupied by a patient for whom there were
airborne precautions and insufficient time has elapsed to allow clearing of the air of
potential airborne organisms.
e. All disposable items shall be discarded immediately in the appropriate receptacle.
f. Reusable items that have been in direct contact with the patient or with the patient’s
excretions, secretions, blood, or body fluids shall be reprocessed as appropriate to the
item.
g. Routine washing of walls, blinds, and curtains is not indicated. These shall be cleaned
if visibly soiled.
h. For highly infectious cases, in addition to the usual terminal cleaning procedure, we
can use the airborne machine (wipe the surface with clean cloth in a circular motion
after spraying to evenly spread the solution and air dry for 30 minutes) for: beds,
bedside tables; equipment; apparatus. The next patient can occupy the bed 30 minutes
after the application.

Cleaning Protocols of Oxygen tank and Oxygen Humidifier

a. The institutional workers should clean oxygen tank with water and detergent before
bringing to the ward.
b. Put on oxygen tank sleeve to be borrowed from the linen section and to be changed
after a week, unless visibly soiled
c. Install new oxygen humidifier to newly admitted patient with oxygen inhalation.

 Cleaning Protocols for BP Apparatus and Stethoscope

a. The nursing attendant on night shift should wipe the BP apparatus and stethoscope
with alcohol 70% to all metal and rubber surfaces every 24 hours.
b. The BP cuff cloth should be washed with soap and water and to be rinsed with
hypochlorite solution 1:100 dilutions and to let it dry before using again and place
date and label by the nursing attendant on night shift ever week.
c. Must be washed and cleaned immediately for highly infectious cases and in cases of
splashes of body fluids, blood and vomitus before using to other patients.

 Cleaning Protocols on Cleaning Suction Apparatus

a. Suction tubing should be changed every 24 hours; suction tip every shift and suction
tubings are not reusable.
b. Gloves and masks should be worn, remove suction bottle from machine; discard all
tubings to infectious bin; wash drainage collection bottle, rubber cap with liquid
detergent soap; rinse thoroughly; immerse and soak the bottle and cap with
hypochlorite (1:10 dilution) for 10-20 minutes; rinse with sterile water and allow to
dry.

50
DISINFECTION

Level of Disinfection

1. Non-Critical
 Items come in contact with intact skin but not mucous membranes. Rarely transmit
disease. Can be cleansed with detergent and low level disinfectant solution.
2. Semi-Critical
 Items come in contact with mucous membranes and requires decontamination and
either intermediate or high level of disinfection or sterilization
3. Critical Items
 Enter directly into the blood stream or into other normal sterile area of the body
(requires sterilization)

AIRBORNE SPRAY PROCEDURE

 Clean vertical and horizontal surfaces in that collect dust with soap and water by
housekeeping personnel
 Damp mop/wipe the entire surfaces with clean cloth by housekeeping personnel
 Use of the airborne machine until surfaces is entirely covered (spray depends on the area
measurement) by housekeeping section
 Allow contact time of 1 hour and 30 minutes (do not open/enter the room) by the staff
nurse
 Allow to air dry for 30 minutes (turn on exhaust fan) by staff nurse
 Safe to enter the room

Things to be done by the Requesting Section Before Airborne Spray

 All surfaces of the room must be thoroughly cleaned with soap and water. Ensure
that no physical/organic debris remains.
 All equipment inside the room must be visibly clean
 All garbage must be emptied / discarded
 Close or cover conditioning vents and exhaust fans.
 Close and cover all windows and doors including all possible outlets of the mist.
 Cover all sensitive equipment (e.g. cardiac monitors. Defibrillator and computers).

51
STERILIZATION
a. Guidelines for preparing items for disinfection and sterilization by immersion:
 Items should be clean and free of organic debris and blood.
 Items should be washed thoroughly in water, and dried prior to immersion.
 Items to be sterilized or disinfected should be placed in a container deep enough to
completely immerse them.
 Be certain that items are dry before submerging so that the solution will not be
diluted.
 Lumen of instruments of tubings must be completely filled with solution.
b. Drying of Instruments
 Use of drying cabinets – temperature within the range of 65°C - 75°C
 Manual drying should be avoided unless lint free materials is used.
 Items should not be routinely dried in ambient air.
 Alcohol or other flammable liquids should not be used as drying agents, except in the
case of endoscopes

c. Packaging
• Materials for packaging include:
 Paper which prevents contamination if intact, maintains sterility for a long period,
can act as sterile field, and can also be used to wrap dirty devices after the procedure.
 Selected plastics; only polyethylene and polypropylene are suitable for sterilization
with ethylene oxide.
 Non-woven disposable textiles.
 Containers can be used only if they contain material intended for a single treatment
procedure for a single patient
d. Sterility Maintenance
• After sterilization, items should be placed in low traffic area.
• Steam load should be allowed to cool for a minimum of 30 minutes.
• Never transport warm items from the sterilizer to cold surface (racks, shelves, counters,
etc.) as this can cause condensation to form, resulting in contamination.
• Sterile items that are torn or wet are considered contaminated and should be reprocessed.
• Sterility maintenance bags (dust covers) may be used to protect items that could be
subjected to environmental challenges for multiple handling before use.
• Close or cover cabinets are ideal for storing sterile items.
• They limit dust accumulation, minimize handling and inadvertent contact.

52
e. Distribution
• Sterile items should be visually inspected for integrity and labeling prior to being issued.
• Transporting sterile items in “uncontrolled environments” should be in a covered or
enclosed cart with a solid bottom shelf.
• Carts should be decontaminated and dried before reuse for transporting sterile supplies.
• Transporting sterile items inside plastic bags or boxes should be arranged within the
containers as to prevent crushing, damage or contamination .

53
 PATIENT TRANSPORT FACILITY (AMBULANCE) SERVICE

5.1 Cleaning should pay particular attention to any areas where dirt is likely to be transferred
to the crew’s hands (ex: door handles). The usual detergent based cleaning agents are
satisfactory for general exterior vehicle cleaning, however, if the exterior has become
contaminated with blood or body fluids, the detergent clean should be followed by
disinfection to eradicate the potential source of infection. PPE should be worn in this case
and these items must be disposed of into the yellow clinical waste bag.

5.2 Any dry dirt/dust on the floor or surrounding areas should be removed using a vacuum
cleaner. Using the designated blue mop, the floor should be cleaned with fresh hot water
and soap/detergent solution at the beginning of every shift, or at the earliest available
opportunity. If the mop becomes contaminated with body fluids, it should be changed
immediately. Otherwise, mops (preferably with disposable mop heads) should be changed
regularly (at least weekly). Re-usable mop heads should be laundered weekly. Furniture
and equipment should be washed as above using a disposable cloth and dried thoroughly
with a disposable paper towel. Ambulance interior surfaces and sensitive equipment
should be cleaned with sanitizing surface wipes.

5.3 At the end of shift clinical waste bags should not be left on a vehicle; they should be
removed, tied and put in the nearest clinical waste bin. Sharps boxes may be left on the
vehicle but should be in the closed position. The interior of the vehicle should be checked
for sharps and other discarded clinical waste and removed.

5.4 When cleaning the vehicle, protective household rubber gloves must always be worn, and
doors and windows must be opened to ensure adequate ventilation. These protective
measures are to protect against the harmful qualities of the cleaning agents. Disinfectants
are classified as irritants, meaning that regular and prolonged skin exposure can lead to
sensitization of the skin and, in chronic cases to dermatitis and eczema.

5.5 Vehicle cleaning should take place after each patient journey. It is good practice to use
sanitizing surface wipes to clean all surfaces that may have been contaminated, including
stretcher handles and clinical surfaces. This need only takes a few minutes.

5.6 Where an ambulance has become contaminated with blood or body fluid, cleaning must
take place on completion of the call. Decontamination should normally be carried out
where there is access to water and cleaning equipment, such as at hospital or one station.
Remember to use PPE as appropriate and discard ant disposable items that have been
contact with blood or body fluids as clinical waste. It is advisable to provide as much
ventilation as possible during cleaning activities.

54
5.7 Utilize Personal Protective Equipment (PPE) as required.

5.8 Remove all equipment and consumables from ambulance.

5.9 Carefully inspect floor, side door tracks, clamp tracks and any other risk areas for blood
spillages and sharps. Any hazards identified must be dealt with according to the Infection
Control Policy. An incident report form must be completed if hazardous sharps are found.

5.10 Vacuum ambulance floor.

5.11 Patient entrance and doorsteps, flood area, must be kept swept, mopped, cleaned and must
be damp (sanitized) wiped.

5.12 Windows must be damp (sanitized) wiped and cleaned with glass cleaner.

5.13 Door panels and pockets – all rubbish removed from pockets, clean with hot soapy water,
disinfect and dry.

5.14 Cab floor – rubbish removed, vacuumed, clean with hot soapy water, dried.

55
 GUIDELINES FOR GARBAGE / HOSPITAL WASTE / INFECTIOUS WASTE
MANAGEMENT

Objectives:

 To enumerate the guidelines for hospital waste and garbage management

 To highlight waste management particularly disposal of infectious and sharps waste
 To strengthen implementation of safe sharps program
 To define guidelines for environmental cleaning and housekeeping to maintain VRH clean at all
times.

Rationale:

Risk for transmission of infections may occur if the environment immediately around the patients
and healthcare workers is not clean or may have soiled articles, infectious wastes or contaminated
surfaces or equipment. A clean, well maintained healthcare environment is vital in a hospital
operations and reflects the commitment in achieving a high standard.

A. POLICIES RELATED TO GARBAGE, HOSPITAL AND INFECTOUS WASTE

DISPOSAL
1. The VRH will responsibly manage and dispose its garbage and all hospital infectious
wastes so that these do not cause any undue harm nor necessary exposure to its patients,
staff and community.
2. The VRH would strictly observe waste segregation.
3. The VRH would advocate a safe sharps management program to reduce the risk for
needlestick injury and its related morbidities.
4. The VRH will abide by all ordinances and national laws and administrative orders related
to waste disposal.
5. The hospital waste management should select the appropriate collection storage and
transportation system based on the category of hospital waste generated by the hospital.
6. The sanitary disposal of hospital waste needs much closer attention by the hospital
authorities concerned in order to promote health and preserve the environment.

Disposal procedure should meet hospital infection control policies consistent with local
regulation (LGU).

B. PROCEDURES FOR GARBAGE, HOSPITAL AND INFECTIOUS WASTE

MANAGEMENT
1. Segregate garbage and hospital waste according to the following color-coded scheme
a. Yellow – infectious waste, dry or wet potentially hazardous
b. Green – non-infectious WET waste
c. Black – non-infectious DRY waste
d. Orange – radioactive waste

56
 2. Infectious wastes have been defined as: waste wastes capable of producing an
infectious disease. They include laboratory waste from pathology and microbiology,
patient waste, and medical waste like used sharps.
3. Infectious wastes should be placed in leak-resistant biohazard bags and transported
to a secure areas awaiting the daily pick up by the subcontractor for waste disposal.
Hospital and other designated personnel in charge of an orderly disposal of garbage and
other wastes must be provided with adequate barriers and protective wear for their safety.
4. The subcontractor is responsible for decontamination of infectious wastes prior to
its disposal into a secure landfill.

C. TYPES OF QUARANTINE

Clean cases ………………………. 30 minutes

MDR, Chemotherapy, droplet precaution on expired patient ……… 1 hour

Active PTB, Measles, Varicella, Disseminated Herpes Zoster ……. 12 hours

Use of Disinfecting Machine ……………………… 24 hours

MRSA Infection, Staphylococcus Infection and other super bugs

 Isolate patient; cohorting
 Appropriate PPE
 Hand Hygiene
 Disinfection of equipment

57
 ALGORITHM FOR GARBAGE, HOSPITAL WASTE AND INFECTIOUS WASTE MANAGEMENT
2. WASTE
TCGU FROM PATIENT
MUNICIPAL CARE AREA
GOVERNMENT

W B NON CLINICAL CLINICAL

A E
R D
WET LIQUID RADIOACTIVE
D / WET DRY
and DRY WASTE WASTE
/ R
U O
N O NON INFECTIOUS
INFECTIOUS INFECTIOUS
I M
T S
PLACED IN PLASTIC GROCERY BAG
COLLECTED COLLECTED PLACED IN
D BY HCW BY HCW ORANGE BAG
E Empty to Empty to WITH SIGN
S green black coded EMPTY TO BY HCW
S EMPTY TO
I coded trash plastic bag / DOUBLE BAG
I YELLOW
G can / plastic trash can YELLOW
T PLASTIC BAG
N bag PLASTIC
E / TRASH CAN
A
T
E
COLLECTED AND TRANSPORTED BY HOUSEKEEPING SERVICES
D

STORED AND TREATED WITH

STORAGE STORED AT DISPOSAL TREATED AT SEPTIC
SITE FOR NOW SODIUM
SITE DISPOSAL SITE VAULT
INFECTIOUS WASTE 58 HYPOCHLORITE
FOR INFECTIOUS AT SEPTIC VAULT

DISPOSAL COLLECTED BY COLLECTED BY LGU

SITE LGU MUNICIPAL MUNICIPAL
GOVERMENT GOVERNMENT
 NEEDLE STICK INJURY

Group at risk: Physicians

Nurses
Laboratory Personnel
Institutional workers
Garbage collectors

Preventive Measures:
1. Mandatory vaccination in Hepatitis B, C and HIV (if available)
2. Hand washing after each patient contact with blood and body fluids.
3. Disposable gloves should be worn whenever working with blood and body fluids.
4. Wear appropriate PPE whenever in contact with infected cases, blood and body fluids.
5. Cover any wounds or abrasions with waterproof plasters.
6. Immediate and safe disposal of all sharps into appropriate puncture-proof containers.
7. No overfilling of sharps containers.
8. NEVER re-sheath needles.

Management of Injuries
1. Scrub the wounded area with soap and water or germicidal soap.
2. Consult designated house physician within 2 hours after the incident. Provide information on:
a. How injury occurred
b. What fluids were exposed
c. Social and medical history
d. HIV antibody status, Hepatitis B surface antigen status, hepatitis C antigen status of source
patient, if available.
3. House physician will prescribe anti-virus or any appropriate medications.
4. Laboratory examinations to be done-baseline for HIV, Hepatitis C antigen and Hepatitis C. re-
testing may be required after 6 weeks, 3 months and 6 months.
5. Need for birth control while on chemoprophylaxis may be advised.
6. Monitor the following:
a. For HIV chemoprophylaxis
 CBC, electrolytes, kidney profile, liver profile, every 2 weeks while under medication
b. For Hepatitis B
 Request for HBsAg and HBsAB
c. For Hepatitis C
 Determine Hepatitis C RNA at 2 weeks and 6 weeks’ post-exposure
 Hepatitis C antibody test on 3 months and 6 months’ post-exposure
 LFTs determination at 2 weeks, 6 weeks, 3 months and 6 months’ post-exposure
7. Tetanus-diphtheria toxoid booster and Hepatitis B booster dose may be administered.

Risk Management
1. House physician and involved division to meet to review workplace procedure policies.
2. Assignment of injured staff to less exposed workplace.
3. Monitor injured staff.
59
C. PROCEDURES FOR SAFE SHARPS MANAGEMENT

1. All clinical areas should have at least two puncture resistant, leak proof containers for
safe disposal of used needles and other sharps at any given time, one in use one in
stock.
2. Needles and other sharps used for any patient procedure should be placed into a
puncture-resistant container intended for sharps disposal immediately after use without
recapping.
3. Recapping of used needles must not be done under any routine circumstances. If
absolutely necessary, use one hand scooping technique to recap. This will avoid injury
to the user.
4. Fill the used sharps containers to three-fourths full only and seal. Put them in yellow
bags and dispose as infectious waste. Do not allow these containers to be re-opened or
emptied and do not allow the contents to be manipulated, reused or sold.
5. Do not leave sharps unattended.
6. Sharps should be pre-treated with 1% Sodium Hypochlorite prior to transport.

Purpose: The intention of this policy is to avert and reduce the risk of exposure to blood
borne (BBV). To promote awareness of each healthcare workers’ duty in the safe
management of sharps and occupational exposure. To provide a framework for the
education of healthcare workers in the safe handling of sharps.
Scope: This policy applies to all Veterans Regional Hospital healthcare staff. This policy
should be used in conjunction with the VRH Policy Document for needle stick
injury and other exposure incidents. Adherence to the recommendations will also
provide protection from BBV infection to patients and other persons present in the
healthcare setting.

SAFE HANDLING OF SHARPS

The most efficient method of Blood-borne V transmission in Healthcare is by percutaneous

exposure to infected blood. Many percutaneous injuries are preventable. Such injuries may occur
while hollow bore needles are being prepared for disposal, (e.g.: while attempting to re-sheath a
needle manually after venipuncture). Implementation of the following procedures for the safe
handling and disposal of sharps will reduce the risks:

1. Avoid the use of sharps if possible

2. All staff who handle sharps should be immunized against hepatitis B.
3. Sharp containers in use must comply with DOH Standards.
4. Sharp containers must be assembled correctly with identification label signed including the
name of ward, hospital, date and signature.
5. Sharp containers should be available at the point of use, including drug, cardiac arrest
trolleys and within a tray device with room for an integral container.
6. When transporting a used syringe (e.g.: arterial blood sampling) remove the needle using
a removal device and attach a blind hub prior to transportation.
7. Avoid re-sheathing needles manually and re-sheath as a last resort.
60
 8. To re-sheath safely, place sheath on a flat surface. Only re-sheath needles if a device is
available to allow this to be done using one hand only. If such a device is not immediately
accessible, the single handed scoop method may be used (e.g.: the HCW holds the barrel
of the syringe and scoops the needles cap from a hard, flat surface on to the end of the
needle). Only when the needle tip is covered should re-sheathing be completed with the
other hand. Re-sheathing devices should be decontaminated regularly.
9. In certain situations, it may necessary to remove the needle from the syringe (e.g.: when
performing blood gases). In this instance use either needle-removing device located on
some sharp containers or re-sheath needle using technique described above and then
remove needle. Needle forceps or other suitable devices should be readily available.
10. Remove needles and attach blind hubs to syringes containing arterial blood which are to
be sent to the laboratory. Intravascular guide wires and glass slides must be disposed of as
sharps.
11. Do not pass sharps from hand to hand. Use kidney dish/tray.
12. When using sharps during a procedure, ensure that they do not become obscured by
dressing, paper toweling or drapes.
13. Ask for assistance when taking blood/giving injections to uncooperative or confused
patients.

SAFE DISPOSAL OF SHARPS

1. A sharp disposal container is provided for the safe disposal of all sharps needles, syringes,
ampules and administration sets. Please use it PROPERLY to reduce the risk of inoculation
accidents.
2. Overfilling or blood spilling may prove hazardous to staff. The container should be ¾ filled
only. DO NOT OVERFILL, it should be closable.
3. In case of an inoculation accidents, the following steps are advised:
a) Wash area under the tap water immediately
b) Inform your supervisor
c) Consult ER ROD
d) Inform a member of Infection Control team
e) Try to identify the source of needle or sharp
f) Obtain a sample blood from injured party and source (when possible)
g) Send both samples correctly labeled with words “HEPATITIS RISK”
4. If the contact is known Hepatitis carrier (HbsAg +) immediately immunization is advised. It
is vital that hyper-immune gamma globulin be administered within 48 hours of inoculation
accident.
5. Filled up NSI form and ER record and sent to IPCC office. NSI form is available at the IPCC.
6. Inspect the Waste bag before removal/transport in case of inappropriate disposal of sharps.
7. Never discard needles, syringes or any sharps (e.g.: ampules, broken glass, broken vials) in a
polythene plastic bag.
8. Discard sharps at the point of use into a sharps container and immediately following use.
9. Discard disposable syringes and needles wherever possible as a single unit, into sharps
containers.

61
10. Sharps such as small quantities of broken glass, drug vials, used needles, razors, blades etc.
must be carefully disposed of into approved sharps containers. (DOH Standard)
11. Do not attempt to transfer contents of small sharps containers into larger containers.
12. Do not dispose of sharps in containers used for storage of other wastes, or place used sharps
containers in clinical waste bags.
13. Do not leave sharps lying around.
14. Do not insert fingers / hand past the level of the lid.
15. Close the aperture / lid upon the disposal of each sharp at the patients bed side.
16. Ensure sharp containers are free from protruding sharps.
17. Once full the container aperture must be locked, tagged and signed with identification label.
18. The person locking the sharps container must tag it with “Sharps”.
19. Do not re-sheathed bent needles.

SAFE STORAGE OF SHARPS

1. Ensure sharp containers are located/positioned/stored appropriately in the ward/unit.

2. Ensure sharp containers are used in accordance with ergonomic manual handling principles
(e.g.: using brackets)
3. Ensure sharp containers are located / stored safely away from the public and out of reach
of children.
4. All sharps containers must be disposed of into yellow wheel containers or stores I suitable
locked area in-accordance with the DOH Standards.
5. Sharp containers must be stored in a locked holding area while awaiting collection for
disposal.

SAFE TRANSPORATION OF SHARPS

1. Transport a sharp container by the handle and away from the body.
2. Sharp containers must be transported and placed in an upright position.
3. Personnel involved in the removal of sharp containers for disposal must wear heavy duty
gloves and protective clothing.
4. If a sharp object is found, protect self, remove item carefully and place into sharp
containers. Do not physically handle a sharp object use a dustpan to manipulate the sharp
instead.
5. The designated person responsible for the removal / disposal of sharp containers must
ensure sharp containers are tagged, sealed/locked before removal for disposal.
6. Inform the department head or designated if there is a breach in the system. (IPCC)

EDUCATION AND TRAINING

1. Supervisors should be aware of the action required following an inoculation injury.

2. All healthcare workers can identify where the safe handling and disposal of sharps policy
is located.
3. Healthcare workers should attend education and training at induction and yearly thereafter.
Each head/supervisor should have a record of staff training.
62
 4. Ensure standard precautions poster is available in each clinical area for the management of
sharps / inoculation injury.

MEASURE TO REDUCE RISK DURING SURGICAL PROCEDURES

1. Most percutaneous injuries in the operating theater or during obstetric/ midwifery

procedures are caused by sharp suture needles.
2. Double gloving does not “prevent” sharps injury, but has been shown to effect up two a
six0fold decrease in inner glove puncture. In the event of percutaneous injury, the volume
of blood transmitted may also be reduced due to the enhanced wiping effect of two layers
of glove.
3. The use of blunt-tipped needles can further reduce the incidence of glove puncture and
percutaneous injury. Although unsuitable for suturing skin and bowel, they can be used
effectively for all other components of abdominal closure. For skin and bowel closure,
stapling devices area safer alternative to sharp suture needles.
4. In order to minimize the risk of injury, the tasks of each member of the surgical team should
be outlined. Specific hazards and measures to reduce the risks from these should be
identified for each team member and should be reviewed periodically.

REDUCING THE RISK OF PERCUTANEOUS EXPOSURE: METHODS,

PROCEDURES AND EQUIPMENT

The following measures may reduce the risk of percutaneous exposure and should be considered
where practicable
1. Have no more than one person working in an open wound/body cavity at any time.
2. Use a “hands-free” technique where the same sharp instrument is not touched by more
than one person at the same time, avoid hand to hand passing of sharp instruments during
an operation.
3. Assure safer passage of necessary sharp needles and instruments via a” neutral zone”
announce when a sharp instrument or needle is placed there. The “neutral zone” may be a
tray, kidney basin or an identified area in the operative field.
4. Ensure that scalpels and sharp needles are not left exposed in the operative field, but always
removed promptly by the scrub nurse having been deposited in the neutral zone by the
operator or assistant.
5. Use instruments rather than fingers for retraction and for holding tissues while suturing.
6. Use instruments to handle needles and to remove scalpel blades.
7. Direct sharp needles and instruments away from own non-dominant or assistants hand.
8. Remove sharp suture needles before tying suture; tie suture with instruments rather than
fingers. Alternative equipment and procedure should be considered where practicable.
9. Eliminate any unnecessary use of sharp instruments and needles (e.g.: by appropriate
substitution of electrocautery, blunt-tipped needles and stapling devices)
10. Opt for alternative less invasive surgical procedures where practicable and effective.
Avoid scalpel injuries associated with assembly/disassembly, by using scalpels which are
either disposable, have retractable blades or which incorporate a blade release device.

63
 11. Avoid the use of sharp clips for surgical drapes; blunt clips are available as area disposable
drapes incorporating self-adhesive operating film.
12. Consider double gloving with a larger pair of gloves innermost for optimum comfort.

REDUCING THE RISK OF BLOOD – SKIN CONTACT

1. If a glove puncture is suspected or recognized, rescrub if possible and reglove as soon as

safety permits.
2. Change gloves regularly if performing or assisting with a prolonged surgical procedure
even if no glove puncture is suspected or recognized.
3. Wear protective clothing for body, eyes and face according to risk assessment.
4. Choose water proof gowns or wear a surgical gown with waterproof cuffs and sleeves and
a plastic apron underneath if blood contact and therefore “strikethrough” is considered a
risk – such as procedures anticipated to involve high blood loss.
5. If legs or feet may be contaminated (as in obstetric and some other procedures performed
in the lithotomy position), ensure that impermeable gown/apron covers legs and wear
impermeable footwear. Wellington or calf length overbooks are preferable to shoes or
clogs. Surgical drapes with “catch-basins” are available to reduce the risk of leg and foot
contamination.
6. Wear protective headwear and surgical mask. Male HCWs should consider wearing hood
rather than caps to protect freshly shaven cheeks and necks.
7. Ensure that all blood is cleaned from a patient’s skin at the end of an operation before
patient leaves theater. Remove protective clothing including footwear on leaving the
contaminated area. All contaminated reusable protective clothing, including footwear,
should be subjected to cleaning and disinfection or sterilization with appropriate
precautions for those undertaking it. Footwear should be adequately decontaminated after
use.
8. Measures to reduce eye and other facial exposure protect mucous membrane of eyes with
protective eyewear. This should prevent splash injuries (including lateral splashes) without
loss of visual acuity and without discomfort. Face shields may be considered appropriate
for procedures which involve a risk of splatter of blood including aerosols or other
potentially infectious material.

64
GUIDELINES FOR HOUSEKEEPING AND ENVIRONMENTAL CARE FOR ALL
HOSPITAL AREAS

1. All patient areas must be clean at all times. Clean is defined as: visibly free of all dust,
soil, unnecessary moisture and other foreign materials.
a. Routine Cleaning – done daily to ensure a clean and dust free hospital environment;
includes surfaces, floors, beds, bedside tables, cabinets. Methods vary depending on
level of contamination
 Administrative offices – normal domestic cleaning
 Patient areas – clean with wet mop using detergent and sometime disinfectant
 High risk areas – clean with detergent and disinfectant solution
 All horizontal surfaces – clean every shift
 All toilet areas – clean every shift
b. Regular cleaning – predetermined schedule according to use and need of particular
items: medical equipment, furniture, furnishings and appliances (like refrigerator, air-
conditioning unit) usually on a weekly basis using clean damp cloth, soap and water or
as recommended by manufacturer.
c. Interim cleaning – done between patients undergoing diagnostic, therapeutic, invasive
procedures. Require the use of soap and water and disinfectant.
d. Terminal cleaning – general and thorough cleaning of patients’ room, beds and
bedside after discharge in preparation foie new admission.
e. Special cleaning – for isolation rooms or single rooms where the previous patient was
a case of tuberculosis or other airborne infections, the germicidal lamp or ultraviolet
(UV) light may be used f or air disinfection. The closed room is exposed to UV light
for 4 – 8 hours with special instructions from the ICU.

2. Bed spacing
Bed must be kept at least 1 meter (approximately 3 feet) apart from each other.

3. Hand Hygiene facilities

All sinks must be kept clean and free of clutter. Water, soap and drying towels must be
available at all times for use of staff.

4. Cleaning of floors
The double-bucket system should be used to clean hospital floors. Brooms re-disperse dust
and bacteria into the air and should not be used in all patient areas where food and medicine
are prepared. The following defines the double-bucket system technique:
a. Assemble a unit consisting of two buckets, a wringer and a mop
b. Fill bucket no. 1 with cleaning compound diluted for use. Place 1 gallon of water in
bucket no. 2 and add the appropriate amount of cleaning compound.
c. Set wringer over bucket 2
d. Place mop in bucket no. 1. Then wring mop lightly for wet mopping, more for damp
mopping in bucket no. 2. Then mop.
e. Mop floor using the figure of 8 motion or forward and backward strokes under and
around equipment. Turn mop head every five strokes.
65
 f. Mop about 100 sq. ft.
g. Rinse in bucket no. 2 and wring as dry as possible.
h. Dip mop into bucket no.1 and wring as needed into bucket no.2
i. Continue mopping until area is finished or until solution in bucket no.1 is gone.
j. Rinse both buckets and the mop.

5. Walls and Ceiling

a. Walls and ceilings are unlikely to be a significant infection hazard as small numbers of
bacteria adhere to clean, smooth, dry and intact-painted walls and ceilings.
b. Cleaning of walls should be done periodically to avoid accumulation of dust (monthly
in areas where there are no anticipated splashes to the walls; weekly in high risk areas
/ intensive care areas, daily in operating rooms, procedure rooms and emergency rooms
where routinely may occur).
c.
6. Bathrooms toilets, patient sinks
Bathrooms, toilets and sinks should be cleaned and disinfected daily. Detergents and
available disinfecting solutions (phenolic) should be used.

7. Laundry and Hospital Linen

a. Careful handling and sorting of soiled linen must be observed.
b. When sorting soiled linen, avoid contaminating bare hands and clothing with spoilage.
Wear gloves and plastic aprons.
c. Place soiled linen in sturdy, leak proof laundry bags.
d. Transport laundry bags to laundry area in such a manner that contamination of other
areas is minimized.
e. Wash and disinfect with 0.5 – 1% sodium hypochlorite for 15 minutes.

8. Practical applications
Environment Routine or Preferred method of Cleaning
Ampules Wipe neck with alcohol
Bed frames Wash with detergent and dry. May apply disinfectant if grossly
contaminated.
Bedpans / Urinals Flush with germicidal soap and water. Disinfect at least once a day
Floors (dry cleaning) Wash with detergent and hot water; rinse and dry
Floors (wet cleaning) Vacuum clean; dust attracting dry mop. Do not use broom
Furniture and fittings 2 – bucket system
Linen Damp dust locker tops with detergent solution
Mattresses/ Pillows Decontaminate infectious linen first with 0.5 – 1 Na Hypochlorite
for 15 minutes before mixing with ordinary linen
Mops (dry attracting) Water impermeable cover, wash with detergent solution and dry
Mops (wet) Do not use if overload or for more than two days without
reprocessing or washing
Rooms (terminal Wash surfaces with detergent and dry. May apply chlorine or
cleaning and phenolics
disinfection)
66
 INFECTION CONTROL POLICY IN HOUSEKEEPING

PURPOSE
To define the method in the proper cleaning and maintaining the hospital

METHOD
The Institutional Workers shall perform the following:

1. Room/Ward Cleaning

a. To be perform daily

 Materials needed: zonrox, surfanios, commercially prepared powder

detergent, plastic sweep, clean rugs, broom
 Dilution of zonrox depends on manufacturers guide; 1:10 (1 part of zonrox +
9 parts of water)
 Clean ceilings using broom ceiling or long handed wood with a damp cloth
wrapped around the end.
 Clean dirts on walls and wipe by using damp cloth oak in a solution of
detergent.
 Wipe window panes by using damp cloth soak in a detergent solution.
 Pick up all rubbish and trashes on floors and corners of the room.
 Damp rashes then dry dusting shall be performed. Remove all paraphernalia
and things tables for under sweeping then return it back. Mopping of floors
shall also be performed twice in every shift or as needed arises specially in
wards.
 Scrub all stubborn stains, gums, spots or sticky objects on course of sweeping.
 Mop the floor staring from corner to corner in a figure of 8 stroke with
disinfectant solution, remove all the paraphernalia and things including under
tables on course of mopping.
 Clean doors, door jambs and door knobs.

b. To be perform weekly
 Clean and wipe with damp cloth soak in mild solutions all wall frames, wall
hangings, light diffuser, aircon, telephone cord and handset, table tops and
other furniture and fixtures.
 Thorough cleaning of ceilings may be done weekly or as the need arises.

2. Cleaning of Comfort Rooms

 Flush toilet bowls, then put bowl cleaner
 Clean ceilings, first by using water and powder detergent

67
  Scrub the toilet walls from top to bottom, surfaces, floor corners using brush and
scrubbing pads soak in a solution of water and soap detergent, disinfectant or
cleansers then wipe it dry. This cleaning of walls of comfort rooms shall be done
on a weekly basis or as need arises.
 Scrub urinals, bowls lavatories with solutions, rinse thoroughly, then wipe it dry.
 Clean doors, door knobs and door jambs with a damp cloth soak in a mild solution
with disinfectant.
 Mop dry toilet floors in a figure of 8 stroke using a yellow coded mop.
 Change rug.
 Leave it with fragrant smell.

3. Cleaning of Windows
 Clean window sill pads and ledges, removing all dusts, dirt and cobweb present
using coconut midrib.
 Clean both inside and outside portion of glass panels up and down stroke with
glass cleaner leaving no streaks, and avoid spills of solution on inside and outside
lower walls.

4. Cleaning of Rooms in Special Patient Areas

The following are special patient areas:
4.1. MICU
4.2. PACU / SICU
4.3. OR / DR
4.4. CD WARDS
4.5. ISOLATION Rooms
4.6. NICU
4.7. PICU

Aside from the daily cleaning routines of all special areas, IW’s shall have schedules for
general cleaning, but upon discharge of patients in isolation rooms, they shall be
automatically and thoroughly being cleaned following the room/ward cleaning
instructions method.
 Empty all trash cans, clean with water and powder detergent and disinfect them
after.
 Ready for admission.

5. Cleaning in AREA with an OUTBREAK of Communicable Disease

5.1. Start with basic cleaning using water and commercially powder detergent.
5.2. Use zonrox 1:10 dilution (1L of zonrox + 9L of water or 1 part of zonrox + 9
parts of water).
5.3. Use surfanios for surfaces 20ml surfanios mixed with 8 Liter of water.
NOTE: can double strength surfanios 40ml: 8L of water
5.4. Use Airborne Machine

68
 a. Vacate the area, quarantine/close for 3 days. Post “NO ENTRY” signage.
b. Clean, sanitize, disinfect the area and apply with complete PPE’s (Proper
Protective Equipment) daily for consecutive 3 days or it can be fumigated
with disinfectant machine at one time.
c. Disinfectant solutions to be used may vary in every cases so that viruses may
not become friendly to the solution.
d. Ready for use.

6. Cleaning of walls and ceilings of Stairways, Hallways and Corridors

a. Sweep and mop with commercially prepared detergent.
b. Clean walls from top to bottom.
c. Clean wall hangings.
d. Include cleaning of balusters.
e. Remove cobwebs and clean.
f. Thorough cleaning of these areas will be done monthly.
g. Outside building walls shall also be cleaned 2x a year.

7. Cleaning of Ramps
a. Sweep rubbish and trashes
b. Scrub/brush stains and dirts.
c. Remove stagnant waters, clean thoroughly with soap and water or other cleansers.
d. Brush wallings attached to the ramps
e. Cleaning of ramps is done daily.

8. Cleaning and Maintaining of Hospital Grounds

a. Sweep
 In front lobby road of trauma and main building
 Middle stairways going down and maintain its cleanliness
 Road going down the highway
 All roads within the hospital vicinity
 Road going up the pit
 Bantay lodge and surroundings
 Back premises of hospital buildings
b. Collect waste at once on course of sweeping, segregate and dispose
c. Remove all dead leaves, rubbish and trashes on outdoor plants
d. Cut undesirable shrubs and branches of trees
e. Plant ornamental, vegetable plant and trees
f. Do grass cutting
g. Maintain all landscape in the hospital surroundings
h. Maintain and water all plants regularly

69
GUIDELINES FOR PROTECTION OF HEALTHCARE WORKER (OCCUPATIONAL
HEALTH)

Objective: To enumerate ways by which risk for occupationally – acquired infections can be
reduced.

A. GUIDELINES TO REDUCE TRANSMISION OF INFECTION OF PERSONNEL

TO PATIENT

1. Upon employment, new applicants must show proof of protection by previous infection
or previous immunization against Hepatitis B, tetanus-diphtheria, mumps, rubella and
chicken pox.
2. Proper attire particularly in specific areas n=must be strictly observed. Only clean
clothing without any trace of blood, body fluids nor spillage of other materials should
be used in all patient areas.
3. Healthcare workers who are ill with fever, rash, undiagnosed cough <2 weeks,
unexplained weight loss, active suppurative lesions and/or jaundice should seek
consultation for early management prior to continuing work in any of the patient areas,
especially among those assigned in high-0risk areas with immunocompromised
patients: Burn unit, Nursery, ICUs.
4. Diagnosed TB should be treated for at least 2 months with regular anti-TB medicines
and show proof of negative sputum smear before resuming work.
5. Diagnosed chickenpox must have ALL skin lesions dry and crushed before resuming
work.
6. Diagnosed Hepatitis B surface antigen (HBsAg) positive individuals must be cleared
by the VRH before being allowed to work in any patient care. They should not be
assigned in areas with invasive procedures.

B. GUIDELINES TO PROTECT HEALTHCARE WORKERS FROM

OCCUPATIONAL INFECTIONS

Tuberculosis Precautions
1. General Recommendation
a. The management of highly communicable illnesses transmitted by airborne route
is best when patients are in isolation rooms or single private rooms, these illnesses
include AFB (+) Pulmonary Tuberculosis particularly proven or suspect Multi-drug
resistant Tuberculosis, Chickenpox and Measles. Certain infections transmitted by
droplets such as Meningococcal infections are also best managed in isolation rooms
or single private rooms.
i. In the event that isolation rooms are not available at the time of patient
admission, the option to transfer or refer to another facility that can provide
at least equivalent care and the necessary isolation should be considered
seriously.

70
 ii. In the event certain patients with highly communicable illnesses have to be
admitted to wards, the service in charge should coordinate closely with the
IPCC and its Infectious Disease Physician.
iii. IPCC will advise the VRH promptly and accordingly when unusual global
or regional outbreaks such as SARS, Avian Influenza and other emerging
infections would occur.
b. Isolation rooms meant to function as source isolation for infectious cases should be
constructed with the recommended ventilation of 12 air exchanges per hour.
c. Our general wards housing 10 or more patients without partitions are best
maintained with natural ventilation.
d. Areas that opt to shift from natural ventilation to mechanical ventilation /
centralized air-conditioning should still consider the necessary air exchanges and
air flow route as well as the anticipated burden of communicable illnesses do that
infection to staff and other patients is still minimized.

2. Specific Recommendations for management of Pulmonary Tuberculosis

a. Efficient diagnosis and management should be followed in these illnesses (with
special attention of TB) and this includes the following strategies:
i. Early detection thru low threshold of suspicion for a possible diagnosis of
TB
 Patients with active pulmonary or laryngeal TB are MOST
INFECTIOUS during the time they are diagnosed, not isolated and
not on any anti-TB meds.
 Include TB in regular lecture series and orientations of all healthcare
workers especially new employees.
ii. Early initiation of TB diagnostic work-up and efficient release of results
 Order sputum AFB for all areas of: a) cough > 2weeks; b)
unexplained fever; c) CXR infiltrates with no other diagnosis; or d)
TB suspected or diagnosed in other sites
 In addition to sputum AFB, order sputum TB culture when patient
had no previous intake of anti-TB medicines, when there is a case
of NDR TB at home, patient is immunocompromised.
 Include in training how to coach for good sputum specimen
collection.
 Negative tests will be released with other results.
 Positive AFB tests should be called to the nurse station for
immediate action on same day of the test.
iii. Early initiation of adequate quadruple anti-tb meds
 Availability of 1st line anti-TB meds at all times (INH, Rifampicin,
PZA and Ethambutol) in tablet and suspension form.
 Consider having an arrangement with the DOH for free anti-TB
meds/networking with Manila Government.
 Dispense medicines by Directly Observed Therapy (DOT) with the
nurse-in-charge trained to do DOT

71
iv. Isolation of suspected or confirmed TB for a week
 Ideally, the CDC recommends two weeks of isolation with intake of
anti-TB meds before patients are significantly less infectious.
However, our isolation rooms are very limited. Hong Kong
experience show that 1 week may be sufficient.
 Therefore, in general, isolation of suspected or confirmed cases
(except MDR-TB) should be at least 2 weeks in the wards but may
shortened to one week I periods when new suspected or confirmed
cases need to be handled.
 All patients suspected or confirmed to have active TB should be
asked to purchase and wear a surgical mask if their pulmonary status
can tolerate. This act alone, whether patient is in the isolation room
in the general wards or the ER/OPD, is a good isolation measure.
 For VRH medicine and pediatric wards, TB patients in isolation
NOT suspected to have MDR-TB should stay for at least 1 week and
then considered for transfer to general wards or discharged.
 Patients in the MICU will stay in the isolation room for at least 2
weeks.
 Patients in isolation suspected to have MDR-TB should remain in
isolation until discharged or until conversion of sputum AFB to
negative or significant improvement in the CXR.
 Patients proven to have MDR –TB are better managed thru the
DOTS PLUS program.
 Admission and discharge to and from isolation rooms will be upon
full discretion of the resident on duty and resident-in-charge; but the
IPCC may give their recommendations as needed.
 When isolation is not possible, patients suspected or confirmed to
have active TB should be placed together near the open windows of
wards. For these non-isolated patients, resident-in-charge should
confirm the ICU and the ward head nurse so other precautions
should be applied.
v. Engineering Controls through Proper Ventilation
 Isolation rooms should have its own ventilation source and exhaust,
air that comes from isolation rooms should not re-circulate into the
general air circulation.
vi. Proper use of PPE
 Use of PPE should be regarded only as second line precaution
especially in situations where the above cannot be properly
implemented. In the long run wide non-judicious use of PPE is
probably going to be more expensive and non-sustainable.
 PPE for active TB include mainly the N95 mask.
 Whenever possible the N95 mask will be provided to personnel who
need them. This include those directly handling patients in the

72
 isolation areas, pay ward or other designated areas where active TB
is present.
 Physicians and nurses taking care of patients in the charity or pay
wards are obliged to report (personally or by phone) location of
active TB patients (priority on sputum AFB (+), laryngeal TB or
presence of cavitary lesions on CXR) to the IPCC and recommend
staff who would need N95 masks.
 In the event N95 cannot be provided, physicians and other personnel
are encouraged to purchase their own N95 masks.
 The N95 masks should be well fitting and produce a seal over the
face. It can be used for TB as long as it is physically intact, dry and
not visibly soiled. N95 should not be shared between personnel and
kept in a manner that the shape is not distorted.

3. Post-exposure management after TB exposure

a. Baseline chest x-ray for all staff who had close contact with the index case
(including consultants, nurses etc.)
b. Baseline sputum AFB x 3 for ALL staff who had close contact (including
consultants, nurses etc.)
c. For all those within symptoms of cough or fever, sputum AFB and TB culture
should be done.
d. For all those with previously documented negative PPD, repeat PPD.
e. Repeat chest x-ray and sputum AFB studies in 3 months for ALL staff who had
close contact with index case if baseline studies are negative for active disease.

73
Hepatitis B Precautions

 POST EXPOSURE MANAGEMENT FOR HEPATITIS B EXPOSURE / NEEDLE

STICK INJURY

Healthcare worker (HCW)

sustains sharp injury or
mucosal exposure

Report to IPCC

Evaluate exposed HCW

Previously Yes Anti-HBs

Y No further treatment.
vaccinated >100 Reassure HCW
for Hep B

No
Anti-HBs Yes Hep B vaccine x 1
HBsAg
(+) HBsAg >10 but dose. Repeat anti-
anti-HBs
<100 HBs in 28 days

(-) HBsAg
No

Give Hep B immunoglobulin Refer to IDS for Hep B Give Hep B immunoglobulin as
as 0.06IU/kg IM infection evaluation 0.06IU/kg IM Restart primary
initiate Hep B vaccine vaccination

74
C. SUMMARY OF IMMUNIZATION FOR PREGNANT HEALTHCARE WORKERS

Vaccine Recommendation
BCG Use if indicated
Hepatitis A Use if indicated
Hepatitis B Recommended
Influenza Recommended if mother will be in 2nd or 3rd trimester of pregnancy
during influenza season (June – March)
Measles – Mumps - Rubella Contraindicated
Meningococcus Use if indicated
Polio IPV or OPV Use if indicated
Pneumococcal Use if indicated
Rabies Use if indicated
Tetanus / Diphtheria Recommended
Typhoid inactivated and V1 Use if indicated
Typhoid ty21a Use if indicated
Varicella Contraindicated

D. SMMARY OF IMMUNIZATION FOR ALL ADULT FILIPINOS TO BE

FOLLOWED BY VRH EMPLOYEES

Age Group 19 – 49 50 – 65 >65

Vaccine
Tetanus Diphtheria Every 10 years – REQUIRED
Influenza Every year if Every year - Every year –
immunocompromised REQUIRED REQUIRED
Pneumococcal One dose if One dose One dose –
immunocompromised recommended
Hepatitis B 3 doses (0, 1-2 months, 4-6 months) – REQUIRED
Hepatitis A 2 doses (0, 6-12 months)
Varicella 2 doses (0, 4-8 weeks) – IF STILL SUSCEPTIBLE
MMR 2 doses (0, 1 month) – IF STILL SUSCEPTIBLE

75
BASIC CLINICAL PROCEDURES WITH EMPHASIS ON INFECTION CONTROL

A. HANDWASHING AND HAND HYGIENE

 When to perform hand washing and hand hygiene
1. Hands are visibly dirty or contaminated with proteinaceous material or are
visibly soiled with blood or other body fluids. In such cases, wash hands with
soap and water.
2. If hands are not visibly soiled, use an alcohol based hand rub for routinely
decontaminating hands in all other clinical situations.
3. Decontaminate hands before having direct contact with patients.
4. Decontaminate hand before donning sterile gloves.
5. Decontaminate hands before when inserting a central intravenous catheter.
6. Decontaminate hands before inserting indwelling urinary catheters, peripheral
vascular catheters, or other invasive devices that do not require a surgical
procedure.
7. Decontaminate hands after contact with patients’ intact skin (e.g. when taking
a pulse or blood pressure and lifting a patient.)
8. Decontaminate hands after contact with body fluids or excretions, mucous
soiled membranes, non-intact skin and wound dressing if hands are not visibly
9. Decontaminate hands if moving from a contaminated body site to a clean
body site during patient care.
10. Decontaminate hands after contact with inanimate objects (including medical
equipment) I the immediate vicinity of the patient.
11. Decontaminate hands after removing gloves.
12. Before eating.
13. After using a bathroom.
 Procedure of Hand Hygiene 6 Steps with 5 Repetitions Each Step
1. Palm to palm.
2. Dorsum of right hand Rubbed by palm of left hand and vice versa.
3. Palm to palm with fingers interspersed.
4. Rotational rubbing of dorsum of finger of right hand against left palm and
vice versa.
5. Rotational cleaning of thumbs.
6. Back and forth rubbing of right fingertips against left palm and vice versa.

B. INSERTION OF PERIPHERAL INTRAVENOUS LINES

1. Prepare all needs prior to the procedure: sterile IV catheter or butterfly needle, sterile
cotton balls, povidone iodine, 70% isopropyl alcohol

Note: Newly opened sterile cotton balls and newly soaked cotton balls are preferable
over one that has been in a container and left standing for some time.

2. Disinfect hands or do hand hygiene with alcohol only if the hands are not grossly
dirty and one has not hand washed earlier.
3. Clean gloves can be used when inserting IV catheter.
76
 4. Clean the previously identified insertion site with povidone iodine and apply with
friction using a circular motion starting at the center of the field moving outward to
the periphery, covering a wide area around the insertion site. Allow to remain on the
skin for about 2 minutes.
5. Decolorize with alcohol and again allow to dry.
6. Insert the IV catheter over the chosen site.
7. Place a sterile 2x2 gauze pad under the hub of the needle. Apply a second 2x2 pad
over the insertion site and secure with a tape. Avoid bulky dressings.
8. Securely anchor the IV catheter.
9. Record the following on the nurses’ note: date, time, site, type of IV device, and
name of personnel who did the procedure.
Note:
 IV insertion site must be inspected daily (observing) proper asepsis for cannula –
related complications such as phlebitis, pain erythema, infiltration and blockage
or leakage of the tube or needle with each dressing change and every time a new
IV bottle is hung.
 Using aseptic technique, the dressing should be changed every 24 – 48 hours and
as needed when dressing is wet or contaminated is suspected. This should be
recorded.
 Changing of peripheral IV catheter is done as necessary.

C. GIVING IV MEDICATION
Administration of IV Medications is best done by adhering to the following steps:
1. Prepare all the materials needed on a tray.
2. Perform proper hand washing using soap and water to remove visible dirt or other
organic materials.
3. Dry hands and afterwards bring the needed materials at the bedside by means of
trolley.
4. Identify the syringe and match it with patients’ bed number and medications.
5. Used only opened sterile cotton balls and add alcohol.
6. Sterile the IV tubing cord with 70% alcohol and dispose of cotton balls in a separate
container. Sterilize as well the diaphragm of the vial before inserting a syringe.
7. Push medications slowly and disposed of the syringe properly into a puncture –
resistant container.
Note:
 The aspirating needle should be different from the needle for IV push.
 The aspirating needle should not be left inserted into the drug vial.
 Use single-dose vial for medications when possible.
 Do not combine the left over content of single-use vials for later use.
 Refrigerate multi-dose vials after they are opened if recommended by the
manufacturer.
 Use a sterile device to access a multi-dose vial and avoid touch contamination
of the device before penetrating the access diaphragm.
 Discard multi-dose vials if sterility is compromised.

77
 Administration of Total Parenteral Nutrition (TPN)
1. Strict adherence to stringent aseptic technique is absolutely essential to the control of
infection during hyper alimentation. Possible sources of infection are:
a. Contamination of the bloodstream due to inadequate surgical asepsis at the time
of catheter insertion.
b. Introduction of an unsterile catheter.
c. Failure to change the infusion sets and dressing at recommended intervals.
d. Contamination of the nutritional fluids during the preparation and use.
e. Leaving the catheter in place for prolonged periods.
2. The insertion site must be inspected every 24 – 48 hours. The insertion site and the
catheter must be cleansed and dressed daily.
3. U se of the TPN catheter for any other purposes other than delivery of hyper
alimentation solution is contraindicated. No other IV solutions or “piggy-back”
medications are to be given through this route.
4. The TPN system should not be used to measure central venous pressure.
5. It is recommended that the task of dressing changes be performed by the same person
each time if possible to detect signs of possible infection early.
6. A new sterile catheter should be inserted aseptically at a different site if signs of
inflammation purulence, thrombosis or extravasation of fluid are observed.
7. If signs of inflammation are noted, the catheter must be removed immediately, and
approximately 5 cm of the distal end of the catheter should be cut off with sterile
scissors, placed in a sterile container and taken to the laboratory for semi quantitative
culturing.
8. There is no exact determination regarding frequency with which the insertion site
should be changed. Use individual judgment.

D. SITE CARE (for umbilical vein catheter, femoral vein central vascular catheter)
1. Remove jewelry and other accessories, and wash before any procedure.
Handwashing is done using soap and water followed by roper drying of the hands.
2. For site care, cutaneous antiseptic such as povidone iodine or chlorhexidine is used.
3. Topical antimicrobials can also be used at the insertion site, after which dry a gauzed
dressing is applied.
4. For catheter care, minimize the number of interruptions to the integrity of the line.
5. Observe aseptic technique always. Wash hands, use sterile gloves and drapes and
prepare the port of hub with antiseptic or 70% alcohol prior to accessing the site.
6. Monitor sites for signs and symptoms of infection or extravasation.

E. INSERTION OF FOLEY CATHETER – URINARY CATHETERIZATION

1. General Guidelines
a. Urinary catheterization should be performed only when a physician determines
that there is a specific and adequate medical indication.
b. Urinary catheterization should be viewed as a minor surgical procedure and
aseptic precautions should be strictly observed.

78
 c. When indwelling urinary catheter is used, it should be connected immediately to a
sterile closed drainage system and the system is not opened for irrigation or
specimen collections.
d. Catheter should not irrigate unless obstruction is imminent.
e. Urinary specimens may be obtained from the distal end of the catheter using a
sterile needle and syringe. Area of puncture should be disinfected with iodine
alcohol.
f. When it is necessary to change the catheter and drainage system, the new unit
should be changed under the same strict aseptic conditions. The catheter should
be changed only when it is no longer functioning to its capacity.
2. Procedure
a. The patient supine on a bed or examination table.
b. For a male, legs are kept straight. For a female, the knees are flexed sharply and
spread wide apart to expose the perineum.
c. Have all things ready at bedside. Equipment includes a catheter small enough to
pass easily without trauma, lubricant, cotton balls, forceps, kidney basin for
collection, culture tubes, specimen bottles, drapes and gloves, and appropriate
antiseptic solution.
d. Wash hands thoroughly. Put on gloves.
e. Drapes are placed to expose the meatus and surrounding skin to be prepared.
f. For the female patient, the labia are separated with the thumb and index finger of
the operator’s non-dominant hand. For the male, the penis is held with the
operator’s non-dominant hand. This hand is now contaminated and should remain
in this position until the catheter is in place.
g. The glans penis or labia are then thoroughly cleansed with cotton balls soaked
with antiseptic solution using sterile gloves and sterile forceps. For the female,
cleaning is done from the urinary meatus moving outward. Repeat cleansing
three times. For the male, start cleaning from the tip of the penis moving
downward. Discard forceps after cleaning.
h. Lubricate catheter. If catheter touches anything except the sterile gloves, drapes
or meatus it must be discarded and changed.
i. Roll the distal end of the catheter on gloves palms and insert slowly and carefully
the other end so as to minimize trauma. A traumatic catheterization is likely to
result in infection. If difficulty is encountered, seek expert consultation.

F. CARE OF INDWELLING URINARY CATHETER

1. Daily perineal flushing or cleaning.
2. For the female, gently separate the labia and pull up catheter. For the male, retract
the foreskin if present. With a cotton ball soaked with betadine, rub side of catheter
with a downward movement – one stroke for each cotton ball.
3. Repeat procedure until all sides of catheter are cleansed.
4. Clean around urethral meatus going outward.
5. Antimicrobial ointment may be applied around the exposed portion of the catheter.
6. Tape catheter to patient: male – tape to hypogastrium; female – tape to inner thigh
7. Catheter care should be done at least twice a day
79
 8. If irrigation occurs at the urinary meatus, discontinue use of betadine and
antimicrobial ointment.

G. WOUND DRESSING (Surgical Dressing Change)

Procedure for Sterile Dressing Change
1. Wash hands.
2. Collect all sterile items necessary for wound care and dressing change before starting
the procedure.
3. Keep patient well covered to maintain warmth and provide minimum exposure.
4. Aseptic wound care requires strict aseptic precautions at all times.
5. Have all necessary materials including a sterile set of dressing instruments available
in a sterile pack. Instruments should include scissors and 2 hemostats if sutures or
drains are to be removed. Special drugs, sterile irrigation solutions or surgical
instruments may be needed in the dressing procedure.
6. Dressing may be applied directly either from a bedside cart or in a room modified or
designed for the purpose (treatment room). Some extensive dressing changes are
done in the OR under optimal sterile conditions; an anesthetic can be used if required.
7. Place equipment on an over bed table. Open up sterile dressing trays or sterile
packages.
8. Pour an adequate amount of antiseptic solution into sterile container.
9. Gently remove tape and check skin under tape for redness or irritation.
10. Strict handwashing for at least 2 minutes under running water with an iodophor
solution is absolutely necessary before donning sterile gloves.
11. In some instances, as with immunocompromised patients, a mask should be worn
during dressing changes.
12. Avoid bulky dressings. The locations and surgical characteristics of each wound
determine shape, weight, consistency and size of dressing.
13. Sterile gloves should be worn to remove soiled dressing, to cleanse the wound with
sterile antimicrobial solution if necessary and to apply fresh sterile dressing.
14. Dressings re4moved from the patients must be regarded as contaminated whether or
not clinical evidence of infection is present.
15. Wash hands after each dressing change to avoid cross contamination.

H. VENOUS BLOOD EXTRACTION

1. Wash hands
2. Prepare materials needed.
3. Identify patient by name
4. Introduce self to patient.
5. Explain nature of procedure
6. Wear clean non-sterile gloves.
7. Select and position the venipuncture site.
8. Swab venipuncture with 70% alcohol.
9. Apply tourniquet correctly
10. Stabilize vein without touching the are already disinfected.
11. Insert needle level up
80
 12. Extract adequate amount of blood
13. Transfer blood drawn to the proper tubes and handle accordingly.
14. Instruct patient on post extraction hemostasis.
15. Smile and thank patient.
16. Discard sharps properly.
17. Remove gloves and wash hands.

I. COLLECTING SPECIMEN FOR BLOOD CULTURE

1. Wash hands
2. Gather the necessary materials
3. Identify patient by name
4. Explain procedure to patient.
5. Identify venipuncture sites
6. Scrub site with 70% alcohol.
7. Then apply 10% povidone-iodine starting at the site then outward in concentric circles
for 60 seconds. Allow to dry untouched.
8. Disinfect top of blood CS bottles with alcohol or povidone-iodine.
9. Wear clean gloves. If the disinfected site needs to be palpated again, disinfect the tip
of gloves fingers or use sterile gloves.
10. Collect blood specimen with sterile syringe and needle. For adults: 10-30 ml of blood
per bottle, for children: 1-5 ml of blood per bottle.
11. Directly inoculate the blood by inversion to prevent clotting.
12. Swab puncture site with alcohol to remove the povidone iodine.
13. Advise the patient to apply pressure.
14. Remove gloves and wash hands.
15. Send specimen to the lab immediately. Do not refrigerate.

J. SUCTIONING
1. General Guidelines on the Principle of Suctioning
a. Indications for suctioning must be observed (noisy respiratory, restlessness,
increases pulse and respiratory rate)
b. Infection is a risk of overly aggressive suctioning.
ii. nasal and oral suctioning are sterile procedure; hands must be washed before
doing the procedure.
iii. Tracheal suctioning is sterile procedure; sterile gloves, solution and sterile
catheter must be used.
iv. Separate equipment must always be used to suction nose or mouth; never
suction the trachea with a catheter previously used for nasal or oral
suctioning.
v. Catheter must not be used more than 2 times. This should be discarded for
cleaning and sterilized before re-use.
c. Select an appropriate suction catheter
i. Never use a closed tip catheter such as urinary catheter. This kind pushed
mucus plugs of it.

81
 ii. Soft plastic catheters must be used. A transparent one is recommended to
observe for consistency of the suction materials.
iii. The size of the catheter must be proportionate to the diameter of the orifice
to be suctioned. Too small catheters might not remove thick secretions or
mucus plugs. Large catheters occlude the orifice opening which may cause
excessive pressure predisposing to atelectasis or lobar collapse. A rule of
thumb is that the suction catheter should not occupy more than of the
internal diameter of the tube in place.
d. Suction procedures must be done gently.
i. Catheters must be lubricated with water and carefully inserted.
ii. Suction must not be applied when inserting the catheter.
iii. Catheter must not be moved up and down with a poking or a jabbing motion.
e. Suction periods must be brief
i. Suctioning periods should not exceed 15 seconds.
ii. Patient must be allowed to rest for at least 3 minutes before applying
another suctioning.
iii. If indicated, oxygen must be administered between intervals of
suctioning. Effective oxygenation must not be interrupted during
the course of suctioning.
f. Excessive suctioning pressure should be avoided. The lowest level pressure must
be used or gradually increases depending on the amount and consistency of
secretions to be suctioned.

2. Suctioning through Endotracheal tubings

a. Prepare all materials needed.
b. Perform proper hand hygiene.
c. After opening the bottle of sterile water, use 2 (two) separate smaller clean bottles
wherein one puts sterile water to be used for suctioning.
d. It is better to use gloves when suctioning. Wear clean gloves and used forceps in
picking up the suction catheter for the endotracheal tube.
e. Dip in the sterile water fort the tube before suctioning.\
f. Gently pass the catheter through the bronchus 20-30 cm and gradually close the
adapter to start suctioning in a rotating motion. The catheter must not be moved up
and down with a poking or a jabbing motion.
g. Allow oxygenation before repeating suctioning.
h. Dip it again in the same water fort the tube before placing it back into its wrapper.
i. Ideally, it should be changed after each use. However, if it could not be done,
change at least for every shift.
j. A separate suction catheter is sued for the mouth and nares. Suction the mouth and
the nose/nares gently.
k. Dip it in the separate bottle for the oral and nasal suction catheter.
l. Dispose of the water in both smaller bottles after each use.
m. Apart from wearing gloves, although it was not done here, it is best used a mask
while suctioning patients.

82
 3. Tracheostomy Tube Suctioning
a. Hands must be washed before suctioning.
b. Before starting to suction, the following is done to minimized contamination of
gloved hands.
i. Sterile glove is worn on one hand. Gloved hand must pick up sterile objects
only. Sterile suction forceps may be used if gloves are not readily available.
ii. With the gloved hand holding the sterile suction catheter and the ungloved hand
at the adaptor, the catheter is connected to the suction machine.
c. The procedure must be started by observing the following:
i. The catheter must be inserted with the suction machine turned off or with the
adaptor kept opened.
ii. The catheter is passed through the bronchus 20-30 cm (8-12 inches) unless
contraindicated. The adaptor is gradually closed to start suctioning.
iii. The catheter must be slowly withdrawn on rotating motion taking care the
catheter does not rub against mucous membranes.
d. Patient must be oxygenated when necessary.
e. Procedure is repeated when needed following the general guidelines.

4. Oral and Nasal Suctioning

a. Thorough handwashing should be done.
b. Clean gloves or suction forceps may be used to protect hands.
c. Tap water may be used for lubricating catheters.
d. Insert catheter with the suction machine turned off or with the adaptor kept opened.
e. Pass the tube into the nose or mouth, then gradually close adaptor of suction
catheter to start suctioning.
f. Slowly withdraw in rotating motion.
g. Rinse catheter with tap water and repeat procedure when necessary following the
general guidelines.

K. TRACHESTOMY TUBE CARE

Care for Tracheostomy site and tube.
1. Clean tracheostomy tube site daily using strict aseptic technique. If with no known
sensitivity to iodine, use iodophor solution.
2. Inner cannula of the tracheostomy tube should be changed every 2 – 3 hours if there
are copious secretions. Sterile gloves should be worn and sterile cannula should be used
for each change.
3. Procedure for cleaning inner cannula:
Soak with hydrogen peroxide 6% or activated glutaraldehyde for 30 minutes then rinse
with sterile water.
4. Remove soiled tracheostomy dressing.
5. Wash hands again and wear gloves.
Note: It may be necessary to give oxygen support before and during the procedure.
6. Carefully clean the skin adjacent to the stoma site, and the skin underneath the flanges
of the tub using cotton balls soaked in antimicrobial solution (iodophor)
7. Allow area to dry then apply sterile dressing.
83
 Cutting should be pre-shaped. Never cut gauze. Cutting may lead to aspiration of loose
strings.
Change tie around the neck,

L. CARE FOR RESPIRATORY TUBINGS

1. Reprocess/recycle respiratory and accessories
i.Decontamination
ii.Mechanical washing and cleaning
iii.Functional check
iv.Disinfection\
v.Rinsing with sterile water
vi.Drying
vii.Packaging
2. Proper storage after disinfection.
Segregate suction tubing, place in a plastic bag.
3. Assemble ventilator tubing per set and place under a pouch.
4. Assemble ambubag, check if ambubag is functioning properly, wrap in sterile cloth and
place inside a code cart.
5. Wrap disinfected humidifiers with sterile clothe and place inside cabinet.
6. Hand dry disinfected suction bottles ready for use.
7. Assure availability of respiratory tubing and accessories
8. Monitor using the schedules as follows:
a. Change connector tubing daily.
b. Change ventilator 3-5 days.
c. Drain and rinse with soap and water and disinfect the suction drainage bottle every
shift as necessary.
d. Change 02 humidifier daily using distilled water.

84
GUIDELINES FOR THE PREVENTION OF HEALTHCARE ACQUIRED INFECTION

Objective: To provide guidelines to reduce the risk of patients admitted at VRH to develop
healthcare acquired infections.

Rationale: While the risk for healthcare acquired infections be reduced to zero, it is estimated that
much as 30% of infections can be prevented with proper infection control practices.

A. GUIDELINES FOR PREVENTION OF CATHETER – ASSOCIATED URINARY

TRACT INFECTION (CA - UTI)

1. The Foley Catheter as The Most Important Risk Factor

The most important risk factor for catheter – associated urinary tract infection (CA-
UTI) is the duration of the Foley catheter, CA-UTI can be prevented if the used of
Foley catheter is limited only when clinically indicated and when catheter are removed
when the clinical indication has resolved.

2. Personnel
a. Only persons (e.g. hospital personnel) who knows the correct technique of aseptic
insertion and maintenance of the catheter should handle catheters.
b. Hospital personnel and others who take care of catheters should be given periodic
in-service training stressing the correct technique and potential complications of
urinary catheterization.

3. Catheter Use
a. Urinary catheters should be inserted only when clinically indicated and left in place
only for as long as necessary.
b. For selected patients, other methods of urinary drainage such as condom catheter
drainage and intermittent urethral catheterization can be useful alternatives to
indwelling urethral catheterization.

4. Hand Hygiene
 Hand hygiene is mandatory immediately before and after any manipulation of
the catheter site or apparatus.\

5. Catheter Insertion
a. Gloves should be inserted using aseptic technique and sterile equipment.
b. Gloves, drape, sponges, and appropriate antiseptic cleaning and lubricant jelly
should be used for insertion.
c. The smallest catheter size for the patient that would still provide good drainage
consistently should be used to minimized urethral trauma.
d. Indwelling catheters should be properly secured after insertion to prevent
movement and urethral traction.

85
6. Closed Sterile Drainage
a. A sterile closed drainage system should be maintained at all times.
b. The catheter and drainage tube should never be disconnected unless the catheter
must be irrigated.
c. If a break in the closed system should occur, like disconnection or leakage, the
collecting system should be replaced using aseptic technique. Disinfect the catheter
– tubing junction.

7. Irrigation
a. Irrigation should be avoided unless obstruction is anticipated (e.g. as might occur
with bleeding after prostatic or bladder surgery). Only in these instances, closed
continuous irrigation may be used to prevent obstruction. To relieve obstruction
due to clots, mucus, or other causes, an intermittent method of irrigation may be
used. Continuous irrigation of the bladder with antimicrobials has not proven to be
useful and should not be performed as a routine infection prevention measure.
b. The catheter – tubing junction should be disinfected with povidone – iodine before
disconnection.
c. A large – volume sterile syringe and sterile irritant should be used for irrigation.
The person performing irrigation should use aseptic technique (use of sterile
gloves).
d. If the catheter becomes obstructed and can be kept patent only by frequent
irrigation, consider the need to change the catheter as the catheter itself may be
contributing to the obstruction.

8. Specimen Collection
a. If small volume of fresh urine is needed for examination, urine may be obtained
from the distal end of the catheter, or preferably the sampling port if present. The
site should be cleansed with disinfectant. Aspirate urine using a sterile needle and
syringe.
b. . larger volumes of urine for special analysis should be obtained aseptically from
the drainage bag.

9. Urinary Flow
a. Unobstructed flow should be maintained.
 Occasionally, it is necessary to temporarily obstruct the catheter for specimen
collection or other medical purposes.
b. To achieve free flow of urine:
 the catheter and collecting tube should be kept from being kinked.
 The collecting bag should be emptied regularly using a separate collecting
container for each patient. The drainage port and non-sterile collecting
container should never come in contact.
 Poorly functioning or obstructed catheters should be irrigated or replaced if
necessary.
 Collecting bags should always be kept below the level of the bladder.

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10. Meatal Care
a. Daily meatal care with disinfectants Is not recommended as studies shown no
benefit and may only increase risk for infection from manipulation.
b. Daily patient bath or shower is all that is necessary to maintain meatal hygiene.

11. Catheter Change Interval

a. Indwelling catheters should not be changed at arbitrary fixed intervals.
b. Foley catheter change is recommended if there is obvious breech in aseptic
condition of the closed system, if there is an obstruction to the flow, if there is a
suspected or confirmed bacterial or fungal infection.

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B. GUIDELINES FOR PREVENTION OF HEALTHCARE ACQUIRED
PNEUMONIA

1. The Ventilator – Associated Pneumonia (VAP) Prevention Bundle

Care bundles are new innovations in health care which have been shown to create
significant improvements when each and every component of the bundle is
implemented. The VRH VAP includes 5 critical aspects of care of a mechanically
ventilated patient which should be strictly followed for every patient to reduce the risk
for VAP. All intensive care units with adult patients should implement the VAP bundle
as follows:
 Do hand hygiene before and after taking care of your patients.
 Keep patients’ head elevated 30 – 45 at all times.
 Suction secretions with proper technique.
 Give patient peptic ulcer disease prophylaxis
 Clean oral cavity with povidone – iodine oral solutions per shift.

2. Hand Hygiene (Guidelines for Hand Hygiene)

a. All VRH personnel should comply with proper hand hygiene before and after every
direct and indirect contact with every patient, particularly those patients who are
mechanically ventilated.
b. Hands should be washed after contact with respiratory secretions, whether or not
gloves are worn.
c. Hands should be washed before and after contact with a patient who is intubated or
has had a recent tracheostomy.

3. Breathing
a. Patients at risk for pneumonia should have their heads raised at an angel of a at least
30.
b. This strategy is safe, effective in reducing VAP, and does not cost any amount of
money other than the vigilance of the health care worker to implement it.
c. The contraindications to head elevation are hypotension and immediate post –
operative period after a neurosurgical procedure.

4. Suctioning of Respiratory Tract

a. Risk of cross-contamination and excessive trauma increase with frequent
suctioning. Thus suctioning should not be done routinely but only when needed to
reduce substantial secretions, which may be indicated by increases respiratory
difficulties or easily audible “garbling” breathing sounds.
b. Suctioning should be performed using “no-touch” technique or gloves on both
hands. Clean gloves should be used for each suctioning. It is not necessary to use
sterile gloves for suctioning.
c. A sterile catheter should be used for each series of suctioning defined a single
suctioning or repeated suctioning done with only one brief periods intervening to
clear or flush the catheter.

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 d. If tenacious mucous a problem and flushing of the catheter is required, sterile fluid
should be used (250 ml bottles with sterile water) to remove secretions from it; fluid
that becomes contaminated during use of for one series of suctioning should then
be discarded.
e. Suction catheters should be used only once and then discarded or set aside for
reprocessing. Follow steps for disinfection of suction catheters.
f. Suction collection tubing (up to the canister) should always be changed between
patients.
g. Suction collection canister when used on one patient need not be routinely changed
or emptied. Unless used in short-term care units (recovery or emergency room),
suction collection canisters should be changed between uses on different patients.
If used in short-term care units, suction collection canister need not be changed
between patients but should be changed daily. Once they are changed. Suction
collection canisters should be sterilized or receive high-level disinfection.

5. Gastrointestinal Prophylaxis
 The clinician may opt for any regimen for PUD prophylaxis. They have been
shown to reduce the risk for VAP among mechanically ventilated patients.

6. Povidone - iodine Oral Swab

a. The oral cavity can be heavily colonized with bacteria among immobile patients who are
mechanically ventilated. Various studies and randomized study have shown benefit in this
simple patient care activity.
b. Povidone – iodine is applied by cotton swabs to clean the oral cavity per nursing
shift.

7. Patients with Tracheostomy

a. Tracheostomy should be performed under aseptic conditions in an operating
room, except when strong clinical indications for emergency or bedside
operation intervene.
b. Until recent tracheostomy wound has had time to heal or form granulation tissue
around the tube, “no touch” technique should be used or sterile gloves should be
worn on both hands for all manipulations at the tracheostomy tissue.
c. When a tracheostomy tube requires changing, a sterile tube or one that has
received high-level disinfection should be used. Aseptic technique, including the
use of sterile gloves and drapes, should be used when a tube is changed.

8. Perioperative Measures for Prevention of postoperative Pneumonia

a. Patients who will receive anesthesia for an abdominal or thoracic operation or
who have substantial pulmonary dysfunction, such as patients with chronic
obstructive lung disease, a musculoskeletal abnormality of the chest, or abnormal
pulmonary function s tests, should receive preoperative and post-operative

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 therapy and instruction designed to prevent post-operative pulmonary
complications such as pneumonia.
b. Whenever appropriate, preoperative therapy should include treatment and
resolution of pulmonary infections, efforts to facilitate removal of respiratory
secretions (for example: by use of bronchodilators and postural drainage and
percussion), and discontinuance of smoking by the patient.
c. Preoperative instruction should include discussions of the importance in the
postoperative period of frequent coughing, taking deep breaths, and ambulating
(as soon as medically indicated). During the discussions, the patient should
demonstrate and practice adequate coughing and deep breathing.
d. An incentive spirometer should be used for preoperative instruction in deep
breathing and for postoperative care.
e. Postoperative therapy and instruction should be designed to encourage frequent
coughing, deep breathing and unless medically contraindicated, moving about tin
the bed and ambulating.
f. If conservative measures do not remove retained pulmonary secretions., postural
drainage and percussion should be done to assist the patient in expectorating
sputum.
g. Pain that interferes coughing and deep breathing should be controlled, for
example, by use of analgesics, appropriate wound support for abdominal wounds
(such as tightly placing across the abdomen), and regional nerve blocks.
 Caution: Narcotics may reduce the urge to cough and breathe deeply.
h. Systemic antibiotics should not be routinely used to prevent postoperative
pneumonia.

9. Protection of Patients from Other Infected Patients or Staff

a. Patients with potentially transmissible respiratory or resistant infections should
be isolated. Isolation Precaution Policy of Communicable Disease
b. Personnel with respiratory infections should be assigned to the direct care of
high-risk patients, e.g. neonates, young infants, patients with chronic obstructive
lung disease, or immunocompromised patients.

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C. GUIDELINES FOR PREVENTION OF INTRAVENOUS CATHETER –
RELATED INFECTIONS

1. The Intravenous (IV) Central Catheter Care Bundle

Similar to the VAP bundle, the IV central catheter care bundle to reduce the risk for
infection related to the insertion of central lines include 5 steps that should be
performed together during the catheter insertion. These include:
 Hand hygiene
 Maximal barrier precautions upon insertion
 Daily review of line necessity with prompt removal of unnecessary lines
 Use of chlorhexidine as skin antisepsis
 Optimal catheter site selection, with subclavian or internal jugular vein as
preferred site central IV catheters should be inserted with aseptic technique
and sterile equipment. Sterile gloves and head to toe drape are required.
Routine changing is not required but central catheters must be removed as
soon as indication for its insertion has been resolved. For central catheters
that must remain in place for prolonged periods, the insertion site should be
inspected and dressed with a new sterile dressing every 48 – 72 hours.

2. Indication for Use

a. Intravenous therapy should be used only for definite therapeutic or diagnostic
indications.
b. All central catheters should be removed when they are no longer medically
indicated or if they are strongly suspected of causing sepsis.

3. Hand hygiene: Guidelines for hand Hygiene

a. Hospital personnel should wash their hands before inserting IV catheter.
b. Soap and water is adequate for handwashing for most insertions but an antiseptic
should be used before insertion of central catheters and cannulas requiring a cut
down.
c. Sterile gloves should be worn to insertion of central cannulas and when
performing cut down.

4. Maximal Barrier Precautions upon Insertion

a. For the patient, maximal barrier precaution means covering the patient with drape
from head to toes with a sterile drape with a small opening for the site of
insertion.
b. For the physician and assistants performing the procedure, maximal barrier
precautions mean strict compliance with handwashing, wearing cap, mask, sterile
gown and gloves.
c. While this combination may entail cost, the benefit of reduction in risk for
infection outweighs that cost.
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5. Choice of Site
a. In adults, the subclavian and internal jugular sites should be preferred as they are
less likely to have catheter - related infection than the femoral.
b. All catheters inserted into a lower extremity should be changed as soon as a
satisfactory site can be established elsewhere.

6. Site Preparation for Central IV Catheters

a. The IV site should be scrubbed with an antiseptic prior to puncture.
b. Chlorhexidine 2% in 70% alcohol is now the preferred antiseptic but povidone-
iodine, iodophors or 70% alcohol can be used. The chlorhexidine should be
applied liberally using a back and forth friction scrub for at least 30 seconds and
allowed to dry for at least 2 minutes before puncture.

7. Asepsis for Peripheral Catheters

a. Prepare the skin puncture and insertion site with chlorhexidine or 70% alcohol.
b. The person who will insert the peripheral IV lines should perform good hand
hygiene and wear clean gloves.
c. After insertion, the catheter should be secured to stabilized it at the insertion site.
d. A sterile dressing, either sterile gauze or transparent dressing should be applied to
cover the insertion site. A dressing, not the tape, should cover the wound.
e. The date of the insertion should be recorded in a place where it can be easily
found.
f. Change the catheter only when needed.
g. The infusate tubings should be changed not more frequently than every 3 days,
more frequently like every 24 hours when the tubings are used for blood product
transfusion.
h. Patients with IV peripheral devices should be evaluated at least daily for evidence
of a catheter related complications. This evaluation should include gentle
palpation of the insertion site through the intact dressing. If the patient has an
unexplained fever or there is pain or tenderness at the insertion site, the dressing
should be removed and the IV site inspected.

8. Maintenance of IV System (Peripheral or Central Lines)

a. Do not routinely change peripheral nor central catheters. They can remain in
place as long as there are no signs of local infection (redness, warmth, tenderness
or discharge at the insertion site) and the clinical indication for their insertion
remains.
b. For catheters that must remain in place for prolonged periods, the IV sites should
be routinely inspected and dresses with a new sterile gauze every 48 hours or a
new transparent dressing every 7 days.
c. IV administration tubing, including “piggy-back” tubing, may be changed every
72 hours.
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 d. Tubing used for hyper alimentation should be routinely changed every 48 hours.
e. Tubing should also be changed after the administration of blood, blood products,
or lipid emulsions; at most every 24 hours after blood infusion.
f. Blood specimens should not be withdrawn through IV tubing except in an
emergency or when immediate discontinuation of the catheter and tubing is
planned.
g. The infusate tubing should be changed not more frequently than every 3 days,
more frequently like every 24 hours when the tubing is used for blood product
transfusion.

9. Changing parts of the IV System for Infection or Phlebitis

a. The entire IV system (catheter, administration set, and fluid) should be changed
immediately if purulent thrombophlebitis, cellulitis or IV related bacteremia is
noted or strongly suspected.

10. Culturing for Suspected IV-Related Infections

a. If an IV system is to be discontinued because of suspected IV related infection
such as purulent thrombophlebitis or bacteremia, the skin at the skin-catheter
junction should be disinfected with povidone-iodine then wiped with alcohol and
the alcohol allowed to dry before catheter is pulled out for sending to the
laboratory for culture.
b. If an IV system is discontinued because of suspected fluid contamination, the
fluid should be cultured and the implicated bottle saved. If contamination of a
fluid is confirmed, the implicated bottle and the remaining units of the implicated
lot should be saved; and the lot numbers of fluid and additives should be
recorded. This occurrence should be reported to the IPCC.

11. Quality Control During and After Admixture

a. Ideally, parenteral and hyper alimentation fluids should be compounded at the
pharmacy under laminar-flow hood unless clinical urgency requires admixture in
patient-care areas. It can be prepared and done at the wards aseptically.
b. Personnel should wash their hands before admixing parenteral.
c. All containers of parenteral fluid should be checked for visible turbidity, leaks,
cracks and particulate matter and for the manufacturer’s expiration date before
admixing and before use. If a problem is found, the fluid should not be used and
should be sent to (or remain in) the pharmacy.
d. Single-dose vials should be used for admixture whenever possible. When
multiple-use containers intended for intravenous use are opened, they should be
marked with the date and time that the container is entered. The product label or
package insert should be consulted to determine if refrigeration of the container is
necessary.

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e. A distinctive supplementary label should be attached to each admixed parenteral
stating, as a minimum, the additives and their dosage, the date and time of
compounding, the expiration time and the person who did the compounding.
f. All admixed fluids should be refrigerated or started within 6 hours of admixing.
g. If necessary, admixed parenteral may be stored in the refrigerator for up to a week
before used provided refrigeration is continuous and begins immediately after
admixing. Other factors such as stability of ingredients, may indicate a shorter
storage time.
 This recommendation is intended to prevent waste of parenteral that are
admixed for immediate use but, unexpectedly cannot be used.
h. Once started, all parenteral should be completely used or discarded within 24
hours.
i. Infusions of lipid emulsions should be completed within 12 hours of starting.

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POLICIES AND GUIDELINES ON INFECTION CONTROL FOR HIGH RISK AREAS
General Policies and Guidelines on Infection Control for High-Risk Areas

Objective: To list the policies and guidelines of infection control for clinical areas at high-risk
for infections.

Rationale: Certain areas in the hospital are at higher risk for infections because areas may have
generally sicker patients or they have conditions which increase their risk for infections. Sticker
compliance to infection control is required for these areas.

General Policies:
a. The following are the high-risk clinical areas at the VRH where the compliance to
infection control is a priority: all intensive care units (medical, surgical, pediatric,
neonatal, OB), nursery, delivery rooms, operating rooms.
b. All VRH personnel, contract of service and working in the high-risk areas must be
familiar with the following guidelines. General policies and specific guidelines for the
prevention of infection in each of the high-risk areas are necessary because of the
patients’ increase susceptibility to infection and the uniqueness of the patient population
in each of the areas.
c. All high-risk areas have basic requirements. These are handwashing facilities,
recommended attire of personnel, good health of personnel free from communicable
disease and a very clean environment, standard procedures such as cleaning, disinfecting
and sterilizing equipment and supplies, proper disposal of used items and wastes, and
cleaning the environment assume a special significance in these areas.
d. Hand hygiene is a critically important infection control measure in all high-risk areas.
Distribution of hand disinfectants as well as other hand hygiene facilities such as bedside
dispensers is prioritized in these areas.
e. A three-minute hand washing with iodophor soap or chlorhexidine soap is recommended
at the beginning of each shift and after meals, breaks and use of comfort rooms for all
personnel who have posts in the high-risk areas. Al residents, nurses, nurse aide must
comply.
f. Barrier protective clothing such as cover gowns, scrub suits or dresses or laboratory coats
are recommended in all high-risk areas. When a worker leaves the work area, a cover
gown must be worn over the scrub suit or dress. Cover gowns worn within the area must
be removed when leaving and replaced on return to the areas.
g. Persons with any type of infection or disease such as active respiratory disease, furuncles,
or diarrhea will not be allowed to enter the high-risk areas during overt disease or
infection.
h. Strict visitor control is mandatory.
i. Nursing students rotating in these high-risk areas should have orientation and training in
infection control prior to their rotation. As much as possible, the patients in high-risk
areas will not be assigned to group preceptorships.
j. Smoking, eating or drinking alcoholic in nurses’ station or patient areas are NOT
allowed.

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 INFECTION CONTROL IN THE MEDICAL / SURGICAL INTENSIVE CARE UNIT

A. Special Requirement of the Medical and Surgical ICU’s

a. Admission to the ICU will follow the specific admission of the unit. An ICU patient with
a highly communicable disease will be admitted to the ICU isolation room.
b. If a critically ill patient with highly communicable infection warrants ICU admission and
there is no isolation room available, the case will be referred to the Infection Control Unit
for case to case recommendation.
c. Patients with highly or multiple resistant microorganisms will be admitted only Ito
isolation rooms. The admitting officer may refuse an admission from another hospital
with highly resistant infections if there are no available isolation rooms, otherwise VRH
has the isolation unit available to accommodate patients.
d. Each ICU must have at least one isolation room for airborne infections.
e. Hand washing fixtures should be made available preferably one for every ICU bed. In
open bed ICU areas, at least one for every three beds plus accessible sink to all beds at
the nurses’ station. These must have soap and rolled towels at all times.
f. The code cart or emergency cart must be kept clean and fully equipped at all times. It
must also contain stocks of hand disinfectants at all times for emergency cases.
g. There must be an identified medication station for storage, preparation and distribution of
medicine for the ICU. This area must be kept clean and dry at all times with regular
environmental cleaning at least twice a day.
h. A clean staff area with toilet and hand washing facilities must be accessible within the
ICU area.

B. Special Requirements for the ICU Staff and Visitors

a. The staff must be oriented to the barrier clothing practices at the time of duty and comply
accordingly. These include gowns, hair and foot wear.
b. There must be a rack of gowns for family and visitors of patients. Gowns should be worn
over street clothes by all visitors. Used gowns will be replaced every after visiting hour.
c. ICU staff and rotating residents will follow all infection control guidelines specially:
hand hygiene, basic clinical procedures and prevention of healthcare acquired infections.
d. Strict asepsis mandatory for all procedures. Use of sterile equipment should be followed.
e. Wearing clean gloves and other barrier equipment (gowns, goggles, masks) for handling
oral secretions, blood, blood products and contaminated materials will be strictly
observed and monitored. Washing of hands after gloves are removed is mandatory.
f. At eh end of 24 hours, discard any opened bottles of irrigating intravenous solutions.
g. Use of multiple dose vials should be minimized. Discard opened vials within 24 hours.

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 INFECTION CONTROL IN THE NEONATAL INTENSIVE CARE UNIT

A. SPECIAL ATTIRE REQUIREMENT FOR THE NEONATAL ICU STAFF AND

VISITORS

1. For NURSES, NURSING ATTENDANTS, UTILITY WORKERS ON DUTY

Upon entry to ICU, change to freshly laundered scrub suit is a must. Change to slippers
dedicated to this area alone is also recommended. Socks are required if slippers do not
cover dorsum of feet. Nail polish and hand jewelry are not allowed. Long hair must
be restrained.

Movements of these personnel during duty should be limited to the area. If they have
to leave the area, they must change back to the prescribed uniform. Ensure wearing of
masks and gowns whenever necessary according to prescribed precautions.

2. For RESIDENTS ON 24 HOUR DUTIES

Unlike other ICUs, these medical personnel on duty MUST also change to clean scrub
suites and slippers when on duty in this specific area. Change to slippers dedicated to
this area alone is also recommended. Socks are required if slippers do not cover dorsum
of feet. Nail polish and hand jewelry are not allowed. Long hair must be restrained.
If they have to leave the area, change back to their street clothes/uniforms.

If the doctor has to go the Delivery Room to receive a neonate, the doctor should leave
the NICU with a blazer/coat or smock gown; cap, mask, slippers and surgical scrub at
the OR, and wear a sterile long sleeved gown before he/she receives the neonate. On
the way back to NICU, continue to wear sterile gown if carrying neonate. If neonate
will be in a transport bassinet, doctor may ungown and wear his/her blazer or smock
gown.

3. For CONSULTANTS, RESIDENTS, STUDENTS NOT ON DUTY

The area will provide hospital gowns and slippers for these transient medical personnel
for use over their uniforms/clothes while inside the NICU.

4. FOR OTHER VRH PERSONNEL providing direct contact patient services

The NICU will also provide hospital gowns and slippers to personnel having direct
contact with patients (Radiology technician, physical therapists, phlebotomies, EKG
technician, etc.). Nail polish and hand jewelry are not allowed. Long hair must be
restrained.

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 5. For PATIENT FAMILY and RELATIVES
Because of high risk for infection of patients in the NICU, visitors are not allowed.
Nursing in the Neonatal ICUs should be advised with gowns and slippers when inside
the unit. Handwashing to elbow must also be done. Nail polish, hand jewelry and
unrestrained long hair will not be allowed. They must be taught good hygiene and
advised daily bath.

B. SPECIAL PROCEDURES AT THE NEONATAL ICU AND NURSERY

1. BATHING OF NEWBORN
a. Take the temperature – be sure the temperature is not below 36.5
b. Thermo regulate the baby
c. Prepare the things needed
i. Basin with lukewarm water
ii. Baby soap
iii. Oil (c/o relatives)
iv. Baby dress
v. Towel
vi. Comb with soft bristles
vii. Droplight
viii. Cotton balls, blanket or flannel cloth
d. Hand washing
e. Turn off the air conditioner / electric fan
f. Test the water temperature by dipping the elbow
g. For babies with abundant vernix, use baby oil
h. Hold the baby properly
i. Use wet sterile cotton for cleaning the eyes from inner to outer cantus and discard
after use.
j. Clean the face with soft cloth in an “S” stroke motion, starting from forehead – nose
– chin.
k. Wet hair thoroughly and apply baby shampoo, use comb to remove blood clots.
l. Rinse hair thoroughly
m. Use soft cloth with soap to clean the baby. Give particular attention to armpit,
inguinal area, ear lobes and other creases.
n. Rinse baby in lukewarm water. Be sure to cover both ears with cotton balls or
fingers.
o. Pat baby to dry
p. Wrap baby with blanket under droplight

2. DIAPER CHANGE
a. Prepare materials needed:
i. Right-sized diaper (disposable/linen)
ii. Clips/pins (optional)
iii. Kidney basin with wet cotton balls
iv. Dry cotton balls
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 b. Wash hands prior to procedure
c. Clean genital area with wet cotton balls with lukewarm water
i. Baby girl – up and down stroke
ii. If genital area is contaminated with stools, wash with soap and lukewarm
water
d. Dry the area.
e. Apply diaper properly

3. CARE OF INCUBATOR
a. Terminal Cleaning
i. Wear proper barriers
ii. Unplug cord
iii. Gather used specimen
iv. Drain water from humidifier
v. Disassemble parts including mattress
vi. Loosen knob to remove the inner wall
vii. Wash all parts with soap and water
viii. Clean and rinse thoroughly in running water
ix. Dry with clean cloth. Air dry as necessary
x. Re-assemble parts
b. Daily care
i. Wash with soap and water the inner and outer area of incubator
ii. Dry with clean cloth. Air dry as necessary
iii. Air to dry small spare parts
iv. Use distilled water for humidifier

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 INFECTION CONTROL IN THE EMERGENCY ROOM DEPARTMENT

 SPECIAL REQUIREMENTS FOR INFECTION CONTROL FOR ER STAFF

1. Because of the high prevalence of Hepatitis B, Hepatitis C and tuberculosis among

Filipinos, healthcare workers in the emergency room and receiving areas need to be
vigilant and protect themselves from blood borne and airborne infection. They should
recognize and attempt to isolate quickly all patients with infections posing a risk to
nearby personnel, patient and visitors.
2. The nature of medical care and operations at the emergency room requires all ER
personnel to be familiar with basic infection control policies and procedure. Training and
education for ER staff should be done periodically for orientation to new staff and
refresher for ole personnel.
3. The ER should be equipped with hand hygiene facilities which are accessible
immediately top all healthcare workers who need them urgently.
4. The ER should also equip with personnel protective equipment easily accessible to all
healthcare workers who need them urgently. These include adequate supply of clean
gloves, surgical masks, N95 masks, gowns, goggles, face shield.
5. Hand hygiene should be observed before and after every patient contact.
6. Standard precaution must be complied with at all times. Clean gloves should be worn
even contact with blood, body fluids, mucous membranes and non-intact skin is likely.
7. Face masks (both plain surgical and N95 masks) should be made available to all
healthcare workers while in the ER.
8. The triage person should be trained to identify probable highly transmissible infection.
9. In general, patient who appear very ill, and especially with cough should be isolated from
other patients.
10. The ICU will advise ER if any national or regional infectious threats are likely.

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 INFECTION CONTROL IN THE OPERATING ROOM

A. MOST SALIENT POINTS FOR THE OPERATING ROOM

1. Operating rooms in the VRH should observe the three-zone concept and strictly
follow.
2. Temperature within all OR complexes must be kept and maintained at 18 0C – 240C.
Air conditioning units must be installed in all theaters to meet this temperature
requirement. Electric fans are not to be used within any OR unit.
3. Humidity must be kept between 40 – 60%.
4. All ORs must be well-ventilated; the Engineering Units (OETS) should regularly
check areas to make sure that there is at least 20 exchange/hour.
5. Any breakdown of equipment that would not allow the OR theaters to maintain above
requirements should be reported immediately.
6. Personnel Clothing
a. The proper OR attire must be worn inside any OR complexes at all times. Each
personnel must be in a scrub-suit, OR cap, mask, shoe cover or OR-dedicated
slippers.
b. The scrub suits must not be worn outside the OR.
c. Street clothes must not be worn inside the OR.
d. Jewelry are discouraged. Fingernails must be kept short. No nail polish.
7. All personnel must follow aseptic procedures as indicated.

B. GENERAL GUIDELINES

1. The Operating Room Environment

a. Design and Traffic

 The operating room complex should be isolated from the rest of the
hospital traffic flow.
 It is rational to establish a protective zone around the sterile area.
 The flow of traffic is controlled such that certain areas are maintained as
sterile as follows:

UNRESTRICTED AREA: Patient reception area, locker rooms, lounges,

offices.

SEMI-RESTRICTED AREA: The post-anesthesia care unit (PACU)

storage areas for clean and sterile supplies, work areas for storage and
processing of instruments and corridors to restricted areas of the operating
room suites. Traffic is limited to authorized personnel and patients only.

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 RESTRICTED AREA: The operating room theaters, clean core and
scrub areas. These areas are designated by a RED LINE in the VRH OR.
Personnel must wear scrub attire, surgical masks and dedicated OR
footwear in these areas.

Only personnel vital to the procedure will be allowed inside operating

theaters when there is an ongoing procedure.

 Patients transported to the OR via ward stretchers are transferred to OR

stretchers
 All other equipment’s from the wards or other areas should only be
brought inside the OR only. If vey necessary, this equipment must be
cleaned with damp cloth and/or disinfectants as indicted in manufacturer’s
manual before bringing into the OR complex

b. Cleaning Procedure
 Under usual circumstances, 10 minutes’ intervals between cases to
thoroughly clean sterile area should be sufficient.
 There is no need to dedicate certain areas for “septic procedures”
 When possible, septic patients specially cases known to have resistant
organisms such as Methicillin Resistant Staphylococcus Aureus (MRSA)
may be placed at the end of the OR list
 Cleaning will be done on a routine schedule as follows:

i. OPERATING THEATERS
 Prior to first scheduled procedure of the day, all horizontal surfaces
including counter-tops, equipment, and surgical lights should be
damp-dusted with a disinfectant.
 During surgical procedures, contamination should be confined and
contained around sterile field.
 Terminal cleaning will be done at the conclusion of each case and
this include:
 Clean all surface tops
 Clean all instrument carts
 Dispose all used equipment, instruments and materials
appropriately
 General cleaning every weekend should be done and this include:
 Clean all surface tops
 Clean all instrument carts
 Disinfect all floors with clean mops
 Disinfect all walls
 Clean machine according to manufacturers’
recommendations

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 ii. RECOVERY ROOMS/POST ANESTHESIA CARE UNITS
 Daily routine with or without patients
 Clean all surface tops
 Clean all instrument carts
 Disinfect all floors with clean mops
 Special attention to cleaning and disinfecting sinks and
faucets
 General cleaning every weekend when without patients
 Clean all surface tops
 Clean all instrument carts
 Disinfect all floors with clean mops
 Special attention to cleaning and disinfecting sinks and
faucets
 Disinfect all walls and surfaces

iii. UNRESTRICTED AREAS will be cleaned daily as regular

rooms are cleaned

c. VENTILATION
i. The VRH operating rooms must comply with international
standards.
ii. A positive pressure system must be in place. There must be at
least 20 exchanges per hour.
iii. The flow of the centralized air must be from clean areas to less
sterile areas.
iv. A system to remove airborne bacteria and other spores is ideal.
v. The system should provide comfortable conditions for patient and
staff.
vi. Humidity must be maintained between 40 – 60%

2. Sterilization and Disinfection of Equipment and Instruments for The Operating

Room
a. Any item that comes in contact with the surgical fields must be sterile.
b. All OR personnel, surgeons, students and observers must know and strictly adhere
to the aseptic technique.
c. Sterilization is the process by which all microorganisms including all the spores
are killed.

The processes of sterilization used are the following:

i. Autoclave or steam under pressure: For heat and moisture resistant items such
as linen, surgical instruments rubber suction tubings. The length of exposure
in the autoclave is either 30 minutes at a temperature of 25 0F, 15 minutes at a
temperature of 260F or 3 minutes at a temperature of 270F.
ii. Sterrad or Plasma

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 iii. Ethylene oxide Gas Sterilization: For heat or moisture sensitive products. The
length of exposure is 3 – 6 hours plus aeration period of 12 – 24 hours.
iv. Immersion in Activated Glutaraldehyde 2% solution –cold sterilization. This
option for sterilization should be reserved only in emergency purposes/flash
sterilization or materials that cannot be sterilized by any other means.
d. DISINFECTION is the process by which all microorganisms excluding spores are
killed
e. All items to be sterilized should be properly cleaned to reduce the burden of
contamination.
f. All wrapped articles to be sterilized should be packaged of materials that meet the
criteria recommended by the CSSU.
g. Chemical indicators should be used to indicate that items exposed to the process
have been truly sterilized.
h. Sterilized items should be labeled with the date of sterilization, autoclave number
and the sterilizer used.
i. Sterilized items should be carefully handled and only when necessary. they should
be stored in well-ventilated clean areas with controlled temperature and humidity.
j. All wrapped sterilized items should remain untouched on the sterilized rack or
carriage until adequately cooled.
k. The contents of any sterilized package should be considered contaminated if the
integrity of the packaging is visibly damaged.
l. All wrapped sterilized packages should be handled and stores in a manner which
minimized stress and pressure. The storage areas should provide protection
against dust, insects, vermin and extremes of temperature and humidity.
m. Preventive maintenance of all sterilizers should be performed according to
manufacturer’s service manual.

3. Operating Room Personnel

i. All individuals: surgeons, anesthesiologist, OR nurses and others who enter sterile
zone are part of the OR team.
ii. The OR team should be kept to the minimum.
iii. No one whose presence is not essential should be admitted to the OR.
iv. Movements within the OR must be reduced. Doors must be kept closed during an
OR procedure.
v. Fitness of the team member for duty at the OR:
 No one with a boil or septic lesion of the skin or eczema should remain at the
OR.
 Staff with respiratory infections must also be excluded from the team until
recovery is achieved.
 Hepatitis B s antigen carriers with “Hepatitis B e antigen” should refrain from
performing work at the operating room.
vi. Showers tend to increase the number of bacteria-carrying particles dispersed from
the skin. Staff should therefore not take showers immediately before procedures
at the operating rooms.
vii. Clothing recommended for the OR
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  Remove outer clothes before putting on OR clothes. There is no evidence
that the underclothes need to be removed as well.
 The scrub suit for the OR must be an effective barrier to bacteria and other
particles. Considerations for choice of material include: breathability of
material, ability to withstand repeated washing and autoclaving, ability to
resist fluid penetration, antistatic, low lining and cost effective.
 Conventional cotton clothing gives some protection against contact
contamination and comfortable to wear but may still allow bacteria from
skin escape.
 OR suit made of tightly woven material (e.g. ventile) reduce dispersal of
bacteria.
 Footwear must be either rubber or plastic boots or overshoes made of
waterproof material shoes must fit properly below action must be avoided.
 All OR personnel must keep their hair clean and tidy at all times while I
the OR. AS headgear such as an OR cap must be worn while in the
premises.
 A surgical mask must be worn at all times while in the OR complex. The
mask should cover the nose and mouth. It should be changed after each
operation or it becomes damp. Face shields which cover the face
definitely required if splashing with blood is likely.

4. Preparation of the Patient for Surgical Procedures

a. Each patient must be prepared optimally so that pre-operative risks are reduced.
b. Assess risk of patient for infection and attempt to correct these factors and
minimized risk
i. Control of other infections
ii. Control of diabetes
iii. Correction of anemia, etc.
iv. Segregation of carriers (TB, MRSA)
v. Adequate preoperative antibiotic prophylaxis
c. Shaving: If it is necessary to shave site of operation. Shaving should be deferred
until the day of operation. Therefore, avoid shaving: clipping or use of depilatory
creams preferred.
d. It is customary for patients to have bath or shower before OR. To be able to
reduce likelihood for infection, use antiseptic detergent.
e. In certain specified procedures, the use of prophylactic antimicrobial agents has
been seen to be beneficial in reducing risk of infection. The VRH should follow
the recommendations set by the Philippine College of Surgeons regarding:
i. optimal choice of antibiotic
ii. optimal timing
iii. Optimal dose
iv. Optimal duration

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5. General Guidelines During Operative Procedures
a. Standard precautions must be observed for all cases and all patients.
b. Depending on diagnosis, the rest of isolation precautions must be followed such
as: droplet, airborne and contact
c. As much as possible, a patient with highly communicable infections should have
received adequate treatment before being subjected to surgical procedures.
d. Aseptic technique should be observed at all times.
e. Preparing the operative site
1. Agents recommended for skin
 0.5% chlorhexidine
 1% iodine in 70% alcohol
 Alcoholic povidone-iodine applied with friction for at least 2 minutes
 Alcohol solutions more effective and rapidly acting
2. Agents for mucous membranes
 Aqueous solutions of iodine (lugol’s or povidone-iodine)
 Aqueous solutions of chlorhexidine

6. Special Recommendation for Special Procedures or Patients

a. Transplant procedures are especially sensitive procedures which require extra
preparations.

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 INFECTION CONTROL IN THE ENDOSCOPY UNIT

A. REPROCESSING OF FLEXIBLE ENDOSCOPES

A clean and disinfected equipment should be provided to every patient undergoing

endoscopic procedure. Reprocessing of the equipment should be carried out immediate
before each individual endoscopic procedure.

Reprocessing of flexible endoscopes includes:

 Decontamination
 High-level disinfection

1. Decontamination

a. Immediate Action
(i) Wipe off excessive mucus from the insertion tube immediately after the
endoscope is removed from the patients.
(ii) Inspect the endoscope for any dents, bite marks and cracks.
(iii) Flush the air and water channel for 10 – 15 seconds to expel any refluxed
blood and mucus. (A special cleaning air and water channel adaptor is
available for some endoscopes.)
(iv) Aspirate enzymatic detergent solution through the suction/biopsy
channel to remove gross debris.
(v) Dismantle all movable valves including air and water channel, suction
and biopsy valves.

b. Leakage Test
(i) Attach water resistant cap.
(ii) Perform leakage test before cleaning procedure.
(iii)If leakage is detected, send the endoscope for repair.

c. Mechanical Cleaning
(i) Clean the endoscope with enzymatic detergent solution.
(ii) Use an appropriate cleansing brush to brush through all the channel until
no debris is seen, ensuring that it emerges from the distal and proximal
ends.
(iii) The cleansing brush should be cleaned with a soft toothbrush if debris is
detected.
(iv) Flush all the channels with enzymatic detergent solution with syringe (a
special channel irritator is available for some endoscope).
(v) Rinse all traces of enzymatic detergent solution from all channels and
wipe off excess moisture on endoscope before immersion into disinfection
solution.
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 2. High-Level Disinfection

a. The use and actions of disinfectant solutions:

Disinfectant Solutions Brand Name Immersion Time

Glutaraldehyde Cidex 2% Gastrointestinal Endoscope: 10 minutes at 20 – 25 0C
Asep 2% (Intermediate Disinfection)
Totacid 2%
Bronchoscope and Duodenoscope: 20 mins at 20 – 25 0C
(High Level Disinfection)

(for TB – 60 minutes is advisable)

Peracetic Acid 0.35% 5 minutes (10 minutes period will be achieved sporicidal
activity)

b. Manual Disinfection
i. Completely immerse the endoscope and fill up all channels with
disinfectant, make sure no air remain within channels.
ii. Fill up the auxiliary channel or elevator channel with disinfectant if any.
iii. Soak the endoscope for the amount of time and at the temperature
recommended.
iv. Expel all residual disinfectant with syringe or with special channel
irrigator.
v. Rinse the disinfected endoscope with running water (preferable sterile
water) and final flush with 70% alcohol. For bronchoscope, rinse with
sterile water.
vi. Wipe and dry the endoscope with 70% alcohol.

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 INFECTION CONTROL IN THE RESPIRATORY UNIT

Purpose
To describe Infection Control standards for the respiratory therapy services and to avoid
any improper handling of respiratory care equipment that might lead to increased incidence
of Healthcare associated infections.
Scope
All Staff and patients with doctor’s order to hook to Mechanical Ventilator.

Responsibility
3.1 The Chief of Medical Professional Staff is responsible for the approval of this
policy and procedure.

3.2 The Respiratory Unit Head is responsible for the review and for the
recommendation for the approval of this policy and procedure

3.3 The Respiratory Unit Head and Staff are responsible for the implementation and
maintenance of this policy and procedure.

Definition
4.1 Modes of Transmissions of infection:

4.1.1 Contact transmission

 The most common form of transmitting diseases and virus. There are two
types of contact transmission: direct and indirect.

 Direct contact transmission occurs when there is physical contact between

an infected person and a susceptible person.

 Indirect contact transmission occurs when there is no direct human-to-

human contact. Contact occurs from a reservoir to contaminated surfaces
or objects

4.1.2 Droplet transmission

 occurs when bacteria or viruses travel on relatively large
respiratory droplets that people sneeze, cough, drip, or exhale. They travel
only short distances before settling, usually less than 3 feet. These
droplets are loaded with infectious particles
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 4.1.3 Airborne transmission
 occurs when bacteria or viruses travel on dust particles or on small
respiratory droplets that may become aerosolized when people sneeze,
cough, laugh, or exhale. They hang in the air much like invisible smoke.
They can travel on air currents over considerable distances

4.1.4 Parenteral transmission

 is defined as that which occurs outside of the alimentary tract, such as in
subcutaneous, intravenous, intramuscular, and intrasternal injections.

4.1.5 Common vehicle transmission

 Spread of disease agent from a source that is common to those who acquire
the disease, water, milk, air, or syringe contaminated by infectious or
noxious agents.

4.1.6 Vector transmission

 The spread of an infectious agent from one individual to another,
usually through contact withbodily excretions or fluids, such as sputumor
blood, that contain the agent.

POLICY STATEMENTS
5.1 Consistent use of Routine Practices, including a Risk Assessment that takes into
consideration the patient infection status, the characteristics of the patient and the
type of care activities to be performed:

• Hand Hygiene
• Personal Protective Equipment (PPE)
• Needlesticks and Sharps Injuries Prevention & Safe Injection Practices
• Cleaning, Disinfection & Sterilization of Medical Devices
• Waste Disposal
• Performing a Risk Assessment

5.2 Use standard precautions for all patient care.

5.3 Use personal protective equipment (PPE) singly or in combination for any /all of
the following procedures as indicated.

5.3.1 Wear gloves for handling respiratory secretions and objects

contaminated with respiratory secretions of any patient

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 5.3.2 Wear facial protection when contamination of the face with
aerosolized particles is likely.

5.3.3 Wear gown when soiling with respiratory secretions from a patient
is likely

5.4 Hand hygiene, Wash or cleanse hands thoroughly before and after all contact with
the patient and the patient’s environment.

5.5 Mechanical Ventilation and Circuit Changes:

 Ensure that patient is positioned with head elevated at 30°-45° except

during postural drainage procedures, to minimize aspiration of secretions,

 Use high-efficiency bacterial filters in the breathing circuit of the

ventilation unit.

 Use filters on the inspiratory limb to eliminate contaminated fluids from

entering the inspired gas thereby contaminating of the ventilator.

 Place bacterial filters appropriately to avoid any potential interference to

the operating characteristics of the ventilator by impeding high gas flows.

 Carefully test reusable filters periodically to ensure efficient functioning

 Use closed continuous-feed humidification on all ventilator circuits to

minimize/prevent aerosols thus preventing transmission of bacteria from
the humidifier reservoir to patients

 Heated humidification systems often operate at temperatures that reduce/

eliminate bacterial pathogens. Use sterile water only to fill humidifiers and
change every 24 hours.

 Sterilize or disinfect circuits, humidifiers and nebulizers between patients.

 Drain and discard condensate that collects in the tubing of the ventilator to
prevent it draining towards the patient.

 Micro-organisms contaminate condensate and must be treated as waste and

properly dispose of it through the standard hospital waste system
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5.6 Nebulizers
 Change disposable large volume nebulizers every 72 hrs,
 Sterilize or disinfect nebulizers between patients. Sterilize/disinfect or rinse
with sterile water and air dry after each treatment on the same patient.

 Remove inline nebulizers from the ventilator circuit between treatments,

5.7 Suction catheters

 Open Suction System: Sterile Single-use catheters

 Use sterile single catheters and sterile technique when suctioning with open
systems. Use sterile water to flush catheter while suctioning.

 Carefully dispose of used catheter in regular hospital waste system.

 Use sterile gloves and a surgical mask for suctioning. (N95/Particulate

mask for PMTB)

 Closed-suction systems;

 Use only sterile fluid to flush secretions from the suction catheter.

6.14 Cleaning and disinfection of respiratory-care devices

 Thoroughly clean all equipment before disinfection and/or sterilization

 Use only sterile water when a device needs to be rinsed after it has been
disinfected. Tap water or locally prepared distilled water may harbor
microorganisms that can cause pneumonia.

 Do not reprocess equipment and devices that are manufactured “for single
use only

 Proper cleaning and sterilization or high-level disinfection of reusable

equipment is important to reduce infection. Respiratory-care devices have
been classified as semi critical because they come into contact with mucous
membranes but do not ordinarily penetrate body surfaces

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 INFECTION CONTROL IN THE MORTUARY

Policy Statement
The dead body, whether previously infected or not, may be a source of infection and
mortuary and post mortem staff are at risk. The risk of infection is not high if adequate
precautions are taken.

a) Cleanliness of the mortuary is essential (c/o morgue technician)

b) Good personal hygiene of staff is a must.

c) Post mortem room should be mechanically ventilated.

d) Fly proofing should be efficient (cat/rats are not allowed)

e) A shower, soap and towel should be available for the staff.

f) When performing post-mortem exam, the pathologist and mortuary technician should
completely change their outer clothing.

g) Disposable plastic apron, disposable gloves and rubber boots should be worn.

h) A wash basin, towels or disposable paper towel, soap, antiseptic hand washing preparation
(povidone-iodine) and 70% alcohol should be available on leaving the post-mortem room.

i) Staff should wash their hands thoroughly after handling any contaminated surface or
material, irrespective whether gloves are worn and always on leaving the post-mortem
room.

j) All pre-existing cuts or open lesions on the hands should be covered with a water proof
dressing.

k) The room and other equipment should be thoroughly cleaned with chlorine releasing agents
and should immediately rinse after.

l) Linen should be sent in a soiled bag and treated as “infectious” by the laundry.

m) Dressing, waste materials and body tissues should be sealed in plastic bags and treated as
clinical waste.

n) Special precautions should be taken with certain infections.

 Untreated pulmonary TB – filter type mask should be worn by operator.
 HBV, HCV, or HIV infection – should be avoided unless absolutely essential.
 Special care is essential to avoid cuts and needle pricks.
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 POLICIES AND GUIDELIENS ON INFECTION CONTROL FOR HOSPITAL
AUXILLIARY SERVICE DEPARTMENTS / UNITS

INFECTION CONTROL IN THE LABORATORY DEPARTMENT

The laboratory is a high risk area for infection since it receives specimens of patients from the
different unit of the hospital. These specimens may harbor potentially agents.

1. Wear gloves and laboratory gowns when handling specimen and performing laboratory
procedures.
2. Minimize injury by performing procedures with care and vigilance.
3. Wearing of face shields when performing tests which may cause splashes including test for
Human Immunodeficiency Virus (HIV).
4. Handwashing must be done before and after performance of laboratory procedure.
5. Work areas and tables must be cleaned with soap and water and disinfectant every after use.
6. Culture media are boiled before discarding and before cleaning Petri dished for reuse. (Ideally,
it should be autoclave.)
7. Test tubes, slides and pipettes are soaked in sodium hypochlorite 5% for one hour before
cleaning with detergent with water.
8. Use glove in cleaning glassware.
9. Used needles must immediately be placed in puncture-resistant containers.
10. Disposable syringes, pipette tips, disposable tubes and empty blood bags are placed in yellow
garbage bags and collected by the janitorial services every day.
11. Blood donors and blood units are screened for the presence of syphilis, malaria, hepatitis B
and the Human Immunodeficiency Virus (HIV).
12. Floors area disinfected daily with phenolic compounds.
13. Surveillance for antibiotic resistance is done continuously. If data shows patterns of a possible
outbreak or a new highly resistant pattern, please report immediately to the Infection
Prevention and Control Unit (IPCU).

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 INFECTION CONTROL IN THE DIETARY DEPARTMENT

Prevention of the introduction of food-borne illnesses in the hospital is a major concern of the
dietary department. These illnesses, once introduced in the hospital are dangerous to both patients
and staff. Unsanitary working condition and practices such as improper purchase of food,
improper storage of food after purchase, improper preparation and utilization of food, improper
method of serving food, poor personal hygiene practices, poor waste disposal and lack of care in
handling equipment and utensils are among the factors that could lead to infection in the dietary
department that could readily be transmitted to the patients and staff.

Measures to stop the possibility of contamination and transfer of infection should be strictly
enforced. To achieve these, certain general principles of care should be foremost in mind.

B. PHYSICAL PLANT SANITATION

1. Floors
a. Floors are scrubbed once a day and mopped twice a day or as needed, clean mop heads
are used.

2. Work Areas
a. Adequate lighting is maintained in all working areas
b. The storage area provides for dry storage of staples and refrigeration of perishables,
both of which are maintained at the right temperature and cleaned regularly.
c. Kitchen doors and windows are properly screened and cleaned.
d. Sink for handwashing are provided with soap at all times.
e. Dishwashing area adequately supplied with hot water.
f. The scullery is provided with covered trash cans for both wet and dry garbage.

3. Equipment and Kitchenware

a. Ovens and ranges are cleaned daily to avoid the buildup of grease, odors and food
particles that can in turn foster a moist environment in which microorganisms could
proliferate.
b. Dishing out counters, stainless steel tables are cleaned daily and thoroughly washed
once a week.
c. Refrigerators are cleaned and defrosted weekly. Walk-in refrigerators are maintained
at proper temperature.
d. Dishwashing machine is maintained properly.
e. Food coverage are washed with soap and water splashed with hot water after use.

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C. FOOD SANITATION

Certain general principles of care are foremost in mind in the prevention of infection in the
food handling areas. These general principles involve the following:

1. Purchase of food from reliable suppliers

a. Upon receipts, goods area checked against specifications of the purchase order. Goods
are carefully inspected for signs of spoilage, infestation, mishandling, etc.
b. Badly dented or inflated cans are rejected.

2. Proper storage of food after purchase

a. Meats to be used the following day are pre-cooked and properly labelled before
freezing. Fruits and vegetables are washed and the decaying portions removed before
being stored in the vegetable crisper.
b. Dried fish are stored at room temperature properly prote4cted from insects.
c. Hot foods are allowed to cool at room temperature before refrigeration.
d. First-in first-out storage are used in storing canned products.
e. Expired canned products are properly discarded.

3. Proper preparation and utilization of food

a. Hands are washed thoroughly before starting with the preparation of food.
b. Separate cutting boards are provided for the following:
i. Meat and poultry
ii. Fruits and vegetables
iii. Prepared foods
c. All food handlers are required to wear hairnets and caps during preparation.
d. Food is kept covered between the time of preparation and the time of service.
e. All food and beverages are handled with spoons and tongs to minimize manual
handling of food.
f. Individual portions of food served but not consumed by the patient are discarded
appropriately.

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 INFECTION CONTROL IN THE LAUNDRY AND LINEN DEPARTMENT

A. CAPABILITIES AND PROCEDURES

2. Clean Linen
a. Issued to various wards/units beds on the number of soiled turned-over.
b. Transported from the Clean Linen Room by personnel-in-charge in carts. Clean linen
is properly covered with plastics.
3. Soiled Linen
a. Transported from the various wards/units in laundry bags.
b. Sorted, counted and recorded according to kind and color.
4. Soiled Contaminated linen
a. Transported to soiled linen area in plastic bags, properly labelled.
b. Sorted, counted and recorded as to kind and color.
c. Decontaminated in 0.5 – 1% solution of sodium hypochlorite (chlorox) for 15 minutes.
d. Removed from the tubs and allowed to drip.
e. Ready to be laundered.

B. POLICIES
1. Decontamination of contaminated linen.
2. Use of gloves, gowns, masks and caps when handling soiled linens.
3. Good ventilation.

C. GUIDELINES ON PROPER HANDLING OF CONTAMINATED LINEN

1. Do not incinerate contaminated linen.
2. In the following conditions as certified by the Infection Control Team, linen used shall be
considered dangerously contaminated
a. Hepatitis B
b. Dysentery / Cholera
c. Typhoid / Hepatitis A
d. AIDS
e. Infected burns
f. Disseminated staphylococcal infections
3. Linen Identified with the above shall be handled as follows:
a. Handle with the use of gloves, masks and gowns
b. Avoid direct contact with skin or clothing
c. Avoid spillage contaminated linen in separate soiled linen and store in specified area
until ready for transport to Linen Section.
d. Wash hands thoroughly with soap and water after handling soiled/contaminated linen.
4. At the Linen Section:
a. Apply precautions
b. Transfer received linen into big containers filled with 0.5 – 1% sodium hypochlorite
and soak for at least 15 minutes.
c. Remove linen from container, allow to drip then place in plastic bags and seal.

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 INFECTION CONTROL IN THE PHARMACY DEPARTMENT

A. ESTABLISHED PHARMACY POLICIES

The responsibility of the pharmacy in infection control extends into the following areas.
Antibiotics use review, education and asepsis in the preparation of pharmaceutical products.

1. Antibiotics Use Review

An important clinical responsibility of the pharmacy in promoting the rational use of

antibiotics and other antimicrobial agents is in assisting the Hospital Infection Control Unit
in minimizing the development of resistance strains of microorganisms.

FUNCTIONS Related to this activity include:

a. Working with the Therapeutic Committee in controlling the number and types of
antibiotic use and microbial admitted to the formulary.
b. Collaborating with the IPCU in establishing policies to prophylactic antibiotic use and
restricted use of specific antibiotics.
c. Generating and analyzing quantitative data on antimicrobial use.
d. Working with the microbiology laboratory to improve microbial sensitivity screening
test.

2. Educational Activities

Pharmacy’s responsibilities in this area are to extend educational information to other

health professionals.
a. Drug bulletin issues in antimicrobial activity and decontaminating agents and other
related topics.
b. Drug information to in-patient and ambulatory care patients in compliance with
prescribed directions for antibiotics and other drug, safe and appropriate drug use and
instructions in storage conditions.

3. Asepsis in Pharmaceutical Preparations

This are concerns the established internal pharmacy policies and procedures on the aseptic
technique in the preparation and handling of sterile products particularly the IV admixture.

B. GENERAL MEASURES FOLLOWED IN ASEPSIS

1. Use of Cleanroom
a. Must be kept as clean and particulate free as possible.
b. Working tables and floors are wet-mopped regularly with soap and water followed
by a disinfectant.
c. Cardboard and other particle-generating material should not enter the cleanroom.
118
 d. All materials entering the cleanroom should be sanitized.
e. To permit adequate floor cleaning, drugs and supplies are stores in shelves above
the floor.

2. Use and Maintenance of laminar Floor Hood

Laminar flow units do not sterilize materials but do provide an aseptic work area.
HEPA (High Efficiency Particulate Air) filters are 99.97% effective in filtering out
microorganisms 0.3m or bigger. Care should be exercised to avoid contaminating this
work environment.

a. The blower of the hood must remain ON at all times. If the blower is turned off for
any reason, the hood should not be used for at least 15-30 minutes after restoration
of the normal function.
b. At the beginning of each shift, the sidewalls and workbench should be cleaned and
sanitized with 70% alcohol. This should be repeated at regular intervals during the
shift and after any spills.
c. The microbial load in the hood should be minimized by wiping all items with an
appropriate disinfectant before placing them inside.
d. The proper arrangement of items in the hood is essential. Items should be arranged
in a manner that prevents interruption of the unidirectional airflow of the hood, and
at least 6 inches inside the front edge.
e. The hood must not be overloaded with unnecessary equipment.

3. Working Personnel

Staff are major source of bacteria and particles within the cleanroom environment,
pharmacy personnel must observe the following before entering the critical area:

a. Thorough washing of hands and forearms for an appropriate length of time with an
appropriate antimicrobial hand wash (povidone-iodine scrub)
b. Put on protective clothing. This should be made from close woven, non-shedding,
lint-free material. Hair covering and overshoes, face masks and gloves should be
worn. Glove (non-powdered and washed) should be rinsed frequently with 70%
alcohol.
c. Staff with open sores on their hands, upper respiratory tract infections or other
communicable disease should not work in the area.

4. End Product Evaluation

Visual inspection of the end product is done for presence of particulate matter, proper
labelling and correct t intravenous solutions according to right additives, volume and
strength. (When checking for particular matter, the solution bottle should be inverted
and the solution swirled gently. It should be held in front of well illuminated light and

119
 dark background to detect particles. Those solution showing visual particulate4s
should be discarded or re-filled).

5. Continuing Education and Training of Personnel

a. Personnel assigned in this area of activity have been chosen due to acceptable
personal health habits and area capable of developing or following well-organized
work routines. They are also able to tolerate close supervision and critical
feedback.
b. They are also subjected to regular physical examination, validated and documented
in accordance with IPCU guidelines and policy.
c. They have acquired and periodically evaluated on the skills to operate
pharmaceutical apparatus, instruments and equipment.
d. They follow oral and written instructions with accuracy and dependability.
e. Training should include septic technique, sterile area contamination factors, upkeep
of facilities, equipment and supplies, sterile product calculations, basic concept of
aseptic compounding and general conduct in the controlled area.

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 INFECTION CONTROL IN THE RADIOLOGY DEPARTMENT
The Radiology section performs diagnostic procedures which require radiology personnel to have
a direct contact with people and occasionally with their blood and body secretion during
radiological procedures. Proper techniques should be observed in order to prevent the spread of
infection:
A. All staff assigned in the radiology section shall:
1. Submit for annual physical check-up
2. Attend training/orientation on basic infection control
3. Follow infection control standard precaution at all times
4. Practice good personal hygiene

B. Personal protective equipment

1. Head of Radiology shall ensure the availability of PPE in the area
2. All staff shall wear appropriate PPE when doing radiologic procedures

C. Radiologic Procedures
1. Radiologic technologist (RT) on duty shall screen all request from the clinical area
for radiologic procedures and prepare schedule of patients with suspected or with
confirmed communicable and highly contagious disease.

2. RT on duty shall:
-Wear particulate mask when performing procedures to patient with airborne diseases
-Wear gloves and dressings for open wounds
-Wash hand before and after contact with patients and other contaminated surfaces
-Follow the physician orders while maintaining aseptic technique during contrast
media studies
-Instruct respiratory hygiene for patients with respiratory diseases.

D. Cleaning of X-ray Equipment

1. Radiology Equipment shall be cleaned after each use with an EPA approved
disinfectant (Sodium Hypochlorite)
2. A thorough cleaning of all x-ray equipment and surfaces shall be performed monthly.

E. Environmental Cleaning
1. Radiology section shall be cleaned every shift and decontaminate every end of the day
or as needed.
2. Bed linen shall be changed daily or as needed
3. Curtains shall be changed monthly or as needed
4. Waste shall be segregated and disposed properly
5. Sharp should be disposed in a puncture proof container

121
 POLICIES AND GUIDELINES ON INFECTION CONTROL FOR SPECIFIC
DISEASES

Infection Control for Specific Diseases: Terms and Definitions

1. Direct Contact
 Body-surface to body-surface contact
 Physical transfer of microorganisms between susceptible host and an infected or
colonized person.

2. Indirect Contact
 Contact of susceptible host with contaminated objects (instruments, hands).

3. Contact Precautions
 Private room or cohorting
 Change of gloves when contaminated
 Gloves when entering room
 Removal of gloves and handwashing when leaving room
 Gown when entering room if substantial contact is anticipated
 Dedicated non-critical patient care equipment

4. Droplet Contact
 Conjunctival, nasal or oral mucosa contact with droplets containing
microorganisms generated from an infected person (coughing, sneezing, talking,
suctioning, bronchoscopy) that are propelled a short distance.

5. Droplet Precautions
 Private room, cohorting or spatial separation
 Mask within 3 feet of patient
 Mask patient during transport

6. Airborne Transmission
 Contact with droplet nuclei containing microorganisms that can remain suspended
in the air for long periods or to contact with dust particles containing an infectious
agent that can be widely disseminated by air currents (3ums in diameter)
 Have to be in a distance of 3 feet from patient, e.g. measles, TB, chickenpox

7. Airborne Precautions:
 Private room with appropriate ventilation
 Respiratory precautions (masks)
 Limitation of patient movement from room

122
 MENINGOCOCCEMIA

A. Agent : N Meningitis or meningococci groups B, C, Q, Y

and W135
B. Epidemiology : Carriage rate among normal population = 10%
C. Transmission : Droplet spread
Direct contact from carries or infected individuals

D. Symptoms : Meningococcemia
Meningitis
E. Incubation Period : 2 – 10 days
F. Period of Communicability : until 24 hours after initiation of antimicrobial therapy
G. Source of Isolation : Droplet precautions
H. Immunization : Not recommended except to control sero group C
outbreaks for laboratory personnel who are expose
to N meningitides
I. Exposure Definition : Intensive, unprotected (without wearing mask) with
infected patient (e.g. mouth-to-mouth,
oropharyngeal exam)
J. Susceptible Definition : Universal
K. Post-exposure Prophylaxis : As soon as possible after exposure
Rifampicin 600mg every 12 hours’ x 2 days
Ceftriaxone 125mg IM
Ciprofloxacin 500mg PO single dose

Source Case

Confirm Diagnosis Patient Start treatment with

Penicillin immediately

HCW

Determine
Exposure

YES
Exposure
1. Mouth to mouth resuscitation
2. Intubation / ET tube management
3. Oropharyngeal exam
123
Pose Exposure Prophylaxis
Rifampicin 600mg po q 12
Ceftriaxone 125 mg IM x 1 dose
Ciprofloxacin 500mg po OD
 MUMPS

A. Incubation Period : 12 – 25 days

B. Period of Communicability : 6-10 days before onset of parotitis and 9 days after
clinical disease
C. Source of Isolation : Droplet precautions
D. Exposure Definition : Direct contact with respiratory secretions or saliva
E. Susceptible : No history of physician diagnosed mumps
No Serologic evidence of immunity
F. Serologic :
G. Work Restriction :

Mumps (parotitis)

Source Case

Confirm Diagnosis Patient 1. Early discharge

2. Source isolation: Airborne
and Droplet Precautions
3. Immune Personnel
HCW

Immunity
Immune
Status Physician diagnosed Mumps No further intervention
Documented vaccination with MMR

Non-Immune

Serologic Positive
Test No further intervention

Negative

Exclude from work 12 –

25 days post exposure

124
Active Mumps exclude
from work up to 9 days
after parotitis
 RABIES

A. Epidemiology : Incidence: 6-8million/population

B. Incubation Period : 1 – 3 months or longer
C. Period of Communicability : unknown in humans
D. Source of Isolation : Standard precautions
E. Exposure Definition : bite or non-bite exposure to saliva
F. Susceptible Definition : Universal susceptibility
G. No Prophylaxis is necessary for the following:

1. Contact with blood, stool

2. Contact with potentially infectious material in direct contact with intact skin
3. Needlestick injuries where the needle came in contact with blood only
4. Sharing of food / drink with patient
5. Casual contact such as history taking, physical examination, being in the same
room
H. The following will require prophylaxis
1. Bites or scabies with penetration of skin
2. Exposure to patients’ saliva or other potentially infectious materials in contact
with mucous membrane (oral, conjunctival, genital) or broken skin (cut,
scratch, abrasion)
3. Scalpel, nicks or needlestick injuries if these were in contact with CSF, Nervous
tissue, ocular tissue or internal organs
I. Management of contact of rabid patients:

1. Category I : Sharing of food / drink with patient, casual contact

Treatment : No prophylaxis required but may give pre-exposure
prophylaxis

2. Category II : Licking of broken skin, superficial bites without bleeding

Treatment : Give vaccine

3. Category III : Bites with bleed

a. Splashing or splattering of saliva or CSF or other infectious body fluids into
eyes/mouth
b. Scalpel nicks or needlestick injuries where the needle is in contact with CSF,
nervous tissue, ocular tissue, internal organs, saliva or other infectious body fluids
c. Mouth-to-mouth resuscitation, licking or intact mucosa as eyes, lips, vulva

Treatment : Vaccine and RIG

J. Post Exposure Prophylaxis

1. Passive Immunization
a. IG: Equine Rabies Immunoglobulin (ERIG)
125
 i. 40 “u”/kg on day 0
ii. Anti-rabies serum (ARS Berna): 50kg
iii. Pasture anti-rabies serum (PARS)
b. IG: Human Rabies Immunoglobulin (HRIG)
i. 20 “u”/kg on day 0
ii. Immugram (Sanofi): 50 kg
2. Active Immunization
a. Purified Vero Cell Rabies vaccine (PVRV)
i. Verorab : 0.1 ml 2 sites ID on D0, D3, D7, D30
ii. Verorab : 0.5 ml site IM on D0, D3, D7, D14 and D30
b. Purified Duck Embryo Vaccine (PDEV)
i. Lyssavac N : 0.2 ml sites ID on D0, D3, D7 and 1 site on D20 and D90
ii. 8 site ID regimen: 8 sites D0, 4 sites D7, 1 site D30 and D90
iii. 1.0 ml 1 site IM on D0, D3, D7, D14 and D28

K. Pre-exposure Prophylaxis
 Purified Vero Cell Rabies vaccine (PVRV)
Verorab (Sanofi) : 0.1 ml 1 site ID on D0, D7, D28 and D30

RABIES
Source Case

Confirm Diagnosis Patient Transfer to San Lazaro

Hospital or RITM

HCW

YES Local Wound care

Bite Licks
On Mucous Post Exposure Prophylaxis
Membrane 1. HRIG: 40 u/kg on D0 (RITM)
ERIG: 20 u/kg on D0
2. Vaccine
NO PVRV: 0.1 ml on 2 sites on D0, D3, D7; 1
site on D30 and D90

Mucous
Membrane
NO
Exposure Non- No further intervention
intact skin

YES
Pre-exposure Prophylaxis 126
PVRV: 0.1 ml ID on D0,
D7, D28 or D30
 RUBELLA

A. Incubation Period : 12 – 23 days

B. Period of Communicability : 7 days before until 5–7 days after rash onset
C. Source of Isolation : Droplet precautions
D. Exposure Definition : Contact with nasopharyngeal droplets from
infected patients
E. Susceptible : No documented vaccination to MMR
F. Serologic Evidence of Immunity : IgG, IgM
G. Post-exposure Prophylaxis : Exposed – exclude from duty 7-12 days post
exposure
Active – exclude from duty 5 days after rash
appears

RUBELLA
1. Early discharge
Source Case Patient 2. Airborne and Droplet Precautions
3. Immune Personnel

Confirm Diagnosis

HCW

Immune
Determine
Exposure No further intervention
YES Physician diagnosed Rubella
Documented vaccination with MMR
Non-immune Not sure

serologic Positive
test No further intervention

Negative
Exclude from work 7 – 21
days post exposure

Active Rubella
Exclude from work 5 days
after rash appears 127
 RUBEOLA (MEASLES)

A. Incubation Period : 5 – 12 days

B. Period of Communicability : Several days before until 3-4 days after rash onset
Longer for immunocompromised
C. Source of Isolation : Airborne and Droplet precautions
Susceptible should not provide direct care to
patients
D. Exposure Definition : Direct contact with droplets from respiratory
secretions
E. Susceptible : No history of physician diagnosed measles
F. Serologic Evidence of Immunity : IgG
G. Post-exposure Prophylaxis : None
H. Work Restriction : Exposed – exclude from duty for 5-21 days
after exposure
Active – exclude from duty for 7 days after
rash onset

RUBEOLA (MEASLES)

1.Early discharge
Source Case Patient 2.Airborne and Droplet Precautions
3.Immune Personnel

Confirm Diagnosis

HCW

Immune
Immunity
Status No further intervention
YES Physician diagnosed Rubeola
Documented vaccination with Measles
Non-immune Not sure

Immunize with MMR

0.5 ml SQ, 2 doses, 1 month apart

Active Measles
Exclude from work 7 days
after rash onset 128
 VARICELLA (CHICKENPOX)

A. Agent : Varicella zoster virus (VZV)

B. Epidemiology : Pre-school, young, school-aged children
Highly communicable
C. Symptoms : Fever
Malaise
D. High Risk Patients : Newborn infants of mothers with varicella shortly
before delivery (5 days before and 2 days after)
Infants of 38 weeks gestation or birth weight less
than 1000 grams
Adults
Immunocompromised adults
Pregnant women
E. Period of Communicability : 2 days before onset of rash until lesions have crusted
F. Incubation Period : 10 – 21 days after exposure of susceptible individuals
Post exposure VZIG: 28 days after exposure
G. Source of Isolation : Airborne and contact precautions
H. Immunization : Routine testing not necessary because 99%
seropositive after the 2nd dose
I. Exposure Definition : Contact with vesicles
3 – 6 feet close proximity or in a room >/hour
J. Hospital Acquired : Sharing of the same two to four bed hospital room
Prolonged direct face to face contact with patients
(Nurses, doctors)
K. Susceptibility : Immune:
Varicella by History – Serologic immunity (97-99%)
Negative or uncertain – Serologic immunity (71-
93%)
Non-Immune:
No reliable history of varicella – Seronegative
L. Serologic Test (ELISA) : IgG

M. Post-exposure Prophylaxis : Varicella Zoster Immunoglobulin (VZIG)

1. Prepared from plasma from routine screening of donors (+) for VZ
2. Not known : Lifelong immunity
Decrease evidence of herpes zoster
3. Prolonged incubation period: 28 days
4. Recommendation for use:
a. Immunocompromised children
b. Newborn infants of mothers with varicella shortly before delivery
c. Postnatal exposure of newborn infants
5. Adults
a. Immunocompromised adults
129
 b. Pregnant women
6. Dosage : vials 125 u/vials/10kg up to maximum of 625 u IM

N. Vaccination : Varicella vaccine

1. Immunization : two 0.5ml doses SQ 4-8 weeks apart
2. Preventing illness
3. Modifying varicella
4. Used within 3-5 days following exposure
5. Adverse reaction : Rash which occurred due to wild type virus
(occurring within 2 weeks)
6. Serious (4%)
a. Encephalitis
b. Ataxia
c. Erythema multiform
d. Steven Johnson’s Syndrome
e. Pneumonia
f. Thrombocytopenia
g. Seizures
h. Neuropathy
i. Herpes Zoster 2.6/100,000
7. Acyclovir
a. Dose: 10 to 20 mg/kg every 6 hours
b. Day 7 through day 17 post exposure
c. Used to prevent disease in high-risk children
d. 40-80 mg/kg/day in 4 divided doses
e. Given 7-9 days after exposure

O. Work Restrictions
1. Post exposure: exclude from duty
a. 10 – 21 days after exposure
b. 10 – 28 days if VZIG given
2. Vaccinated exposure: serotest for antibody; if negative exclude from duty or monitor
daily for symptoms
3. Infected: exclude until lesions have crushed

130
 VARICELLA (CHICKENPOX)

Source Case

1.Early discharge
Confirm Diagnosis Patient 2.Airborne and contact Precautions
3.Immune Personnel

HCW

Immune
Immunity
Status No further intervention
Prior History of Chickenpox

Non-immune

Positive
serologic
No further intervention
test

Negative

Post exposure prophylaxis

1. ACYCLOVIR: 20-40 mg/kg q day x 7 days
2. VARICELLA VACCINE: 0.5 ml 5Q x 2 doses, last dose after 4 weeks

Exclude from work 10 - 28 days post exposure

VZV Infection (Chickenpox)

Exclude from work until lesions have crushed

131
 VARICELLA ZOSTER (SHINGLE)

Local Manifestation of reactivation of latent varicella infection in the dorsal root ganglia

A. Agent : Varicella zoster virus (VZV)

B. Signs and Symptoms : Painful vesicular rash in a dermatomal distribution
C. Period of Communicability : skin lesions until it has crusted
D. Exposure Definition : Contact with vesicles primarily
 Articles freshly soiled by discharges from
vesicles or mucous membrane of infected people
E. Susceptible Individuals : Infectious 10-21 days following exposure
Negative history or seronegative
F. Source isolation : Localized: Standard Precautions
Disseminated or Immunocompromised: Airborne
and contact precautions
G. Work Restrictions
1. Post exposure : Restrict from patient contact 10-21 days
2. Localized zoster
a. Do not care for high risk patients
b. Cover lesions in other situations
3. Immunosuppressed with zoster

H. Prevention and Control : Isolated room with contact and respiratory isolation
precautions

Source Case
4. Early discharge
Confirm Patient 5. Airborne and contact Precautions
Diagnosis 6. Immune Personnel

HCW

Immune
Immunity
Status No further intervention
Prior History of Chickenpox

Non-immune
Positive
serologic
test No further intervention

Negative
Post exposure prophylaxis
3. ACYCLOVIR: 20-40 mg/kg q day x 7 days
4. VARICELLA VACCINE: 0.5 ml 5Q x 2 doses, last dose after 4 weeks

Exclude from work 10 - 28 days post exposure 132

VZV Infection (Chickenpox)

Exclude from work until lesions have crushed
 POLICIES AND GUIDELINES ON OUTBREAK INVESTIGATION

Management of an Outbreak

Outbreaks vary in extent and severity. It is the responsibility of the Infection Prevention and
Control Unit (IPCU) to draw up detailed policy and plan for the management of outbreaks in the
hospital or community. Management of an outbreak requires the expertise of an infection control
doctor who is usually the person identified to take the leading role. Arrangements will have to be
made by the Infection Control Doctor to form an outbreak control team, as the control of any
outbreak requires the cooperation of people from various disciplines.

In the event of a national infectious disease outbreak, it is vital that close coordination occurs with
the national/state health authority and the various health facilities as well as supporting ministries
– media, trade, community/home affairs, communication, etc. Each country’s emergency
preparedness plans should include that for an infectious disease outbreak. A strong central source
of command is vital for smooth coordination of resources and actions. Within each healthcare
facility, the basic mechanics set for the effective management a health acquired infection outbreak
is an adequate base for the establishment of a larger team to meet with the increased demands. The
outbreak control team will need expansion to include more representatives from the facility: e.g.
pharmacy, supplies, housekeeping, engineering, etc. A continual system of infection control
training and audit is required to help disseminate quick pertinent infection control measures for
the particular infectious disease concerned. Daily regular communication with clear updates on
the situation with hospital staff and patients is necessary to keep morale up and good cooperation
from all on the preventive measures instituted.

133
 Outbreak Control Team

A. COMPOSITION OF THE OUTBREAK CONTROL TEAM

1. IPCU Representatives – Infection Prevention and Control Chairman and Infection Control
Nurse
2. Medical Center Chief
3. Clinical head / Senior resident / Infection Control Link Physician / IC Link Nurse

B. RESPONSIBILITIES OF THE OUTBREAK CONTROL TEAM

1. Ensure continual care of patients

2. Clarify resource implications
a. Additional staff / supplies required
b. Media handling
3. Agree upon and coordinate policy decisions
4. Review progress
5. Define the end of the outbreak

134
 CHECKLIST OF ACTION

A. INVESTIGATION
1. Confirm outbreak and provide case definition
2. Demonstrate outbreak – compare current rates with pre-epidemic rates
3. Analyze cases – line-listing with time, person and place
4. Do literature search, if indicated
5. Conduct microbiology investigations to confirm reservoir and mode of transmission
6. Conduct microbiological screening of patients and staff (if necessary)
7. Conduct serological screening of patients, staff and other contacts, if necessary
8. Follow-up patients, staff, visitors, etc.
B. COMMUNICATION
1. Inform hospital authorities – senior management
2. Consult infectious disease doctor
3. Inform departmental heads, microbiology head
4. In major outbreaks, inform other services – clinical support, ambulance, general
practitioners and primary health physicians
5. Arrange for media release, if necessary
C. MANAGEMENT
1. Define isolation facilities / ward
2. Define type of isolation precautions
3. Inform nursing, medical and paramedical staff of isolation precautions
4. Increase clinical staff f- nursing and medical
5. Increase support services staff – housekeeping, laundry, central sterile services
department
6. Increase laboratory assistance
7. Increase clerical staff, telephones, IT equipment
8. Keep diary of interviews and progress notes
9. Plot epidemic curve and geographical areas involved.
10. Review charts of infected persons and develop list of potential risk factors
11. Formulate hypothesis about likely reservoir and mode of transmission
12. Perform case-control study and typing studies
13. Review and update control measures
14. Continue surveillance for secondary cases and efficacy of control measures
D. CONTROL
1. Implement isolation policies
2. Administer active/passive immunization where needed
3. Administer antibiotic prophylaxis, where necessary
4. Define patient admission, transfer and discharge policy
5. Define visiting arrangements.
6. Evaluate control measures
E. END OF OUTBREAK
1. Announce end of outbreak to relevant authorities informed earlier
2. Compile report
3. Change policies and practices if necessary
135
POLICIES AND GUIDELINES ON INFECTION CONTROL ON SELECTION AND
PURCHASE OF PRODUCTS FOR CHEMICAL STERILIZATION, DISINFECTION
AND ANTISEPSIS

Selection and Purchase

1. Manufacturers or distribution shall categorize their products properly according to their

intended use in the hospital and should fall under one of the following:
a. CHEMICAL STERILANT – used for all the purpose of destroying all forms of
microbial life including fungal and bacterial spores
b. DISINFECTANT – used to inactive virtually all pathogenic microorganisms but not
necessarily all microbial forms (spores) on inanimate objects
c. ANTISEPTIC – formulated for use on skin or tissue and should not be intended for use
in inanimate objects
2. The prescribed manufacturer’s formulation of every product should pass all of the tests for
the following, preferably before the process of bidding.
a. Sterility
b. Efficacy
c. Acceptability
3. The manufacturer and/or distributor will coordinate with the Therapeutics Committee for
testing of their products. A formal letter addressed to the chair of the Therapeutics
Committee is requested to indicate: request for the Therapeutics Committee to perform the
products tests as well as stating the product category, active and other ingredients,
indications, clear instructions with the full product brochure if possible.
After 5 working days, the Therapeutics Committee will return the request with quotation
of cost for laboratory testing which will be shouldered by the company and the actual tests
to be performed as well as anticipated duration of testing, the list of end-users to test for
acceptability will remain confidential to the Therapeutics Committee alone.
The testing will start as soon as the above requirements are settled. The company may
submit the original product for testing the Therapeutics Committee any time after
settlement of requirements.
4. From the Therapeutics Committee, the original product will be sent initially by pharmacy
for re-formulation according to the manufacturer’s instruction on the proper dilution.
5. The acceptability testing will entail use if the testing of the product with actual critical or
semi-critical instruments as the case may be and would also involve the assessment of at
least three end-users (physicians or nurse blinded to the product identifications).
6. The Therapeutics Committee will release a certificate of PASSED or FAILED accordingly.
The decision of the Therapeutics Committee will be final.
7. Re-testing of a product which has previously failed one or all the tests will be entertained
only after 6 months have lapsed since the previous test.

136
 METHODS FOR TESTING DISINFECTANTS

1. Formulate as prescribed by manufacturer

2. Baseline sterility testing within 24 hours’ preparation
Baseline efficacy testing within 24 hours’ preparation
3. Efficacy testing at 2 weeks (14 days)
4. Efficacy testing at 4 weeks (28 days)
5. Acceptability testing of instruments will be done by 2 separate end-users (i.e. MD and RN)
using a checklist
6. Results will be recorded and interpreted by Therapeutics Committee

Note:

*Two instruments previously inoculated with known organism (i.e. Bacillus sp) will be immersed
in disinfectant for 8 hours.

*Instruments will be rinsed in sterile water and dried. The laboratory will process microbiologic
testing.

137
 ANTIBIOTIC POLICY IN VRH

Monitoring of Antibiotic Resistance

To promote rational antibiotic use and to prevent or delay emergence of resistance bacterial strains,
the use of some antibiotics shall be restricted in VRH.

Antibiotics shall be classified as follows:

A. NON-RESTRICTED ANTIBIOTICS
Issuance of these antibiotics do not require approval of the Antibiotics Surveillance and
Control Team, but their use should be based on some clinical judgement.
1. Parenteral
Examples: Penicillin G Na Succinate
Ampicillin Na Co-trimoxazole
2. Oral
Examples: Oxacillin/Cloxacillin Na Co-trimoxazole
Chloramphenicol Erythromycin
Pen VK Metronidazole
Amoxicillin Nalidix Acid
Cloxacillin Nitrofurantoin
3. Other Formulation
Examples: Metronidazole sup / vaginal tab
B. RESTRICTED ANTIBIOTICS
The issuance of these antibiotics requires approval from the Antibiotics Monitoring Office
of the Hospital Infection Control Unit. Antibiotics may be prescribed for empiric, definite
treatment or prophylactic use.
1. Empiric Therapy – treatment of suspected serious or life-threatening infection
pending results of culture and sensitivity tests. Initial dose may be issued for 24 hours
but subsequent doses will need approval from the ASCT.
2. Definite Therapy – treatment of serious/life-threatening infection documented by
culture and sensitivity tests as indicated in the ICC request. A 7-day automatic stop
order shall be implemented.
3. Prophylaxis – prevention of infectious complications in high risk setting (refer to
Guidelines for Antimicrobial Therapy). Issuance of antibiotics and number doses will
be based on approval SOP of the department.
C. VERY RESTRICTED ANTIBIOTICS
Issuance of these antibiotics requires approval by the Chairman of the IPCC. Therefore,
only very limited stocks should be made available in the Pharmacy.
Indication:
For treatment of life-threatening infection documented by culture and sensitivity test
indicating resistance to other effective and less expensive antibiotics
Examples: Aminoglycosides Carbapenem
Cephalosporins Quinolones
Extended Spectrum Penicillin
138
 MONITORING OF ANTIBIOTIC USAGE AND FUNCTION

The monitoring of the usage of these antibiotics is done by the Antibiotics Monitoring Officers of
the VRH in cooperation with Pharmacy Department. The Infection Prevention and Control
Committee Antibiotics Surveillance and representatives from major clinical departments shall
control the use of the restricted drugs through regular rounds and evaluation of patients needing
these drugs.

 For Prophylactic use – a minimum of 24 hours’ dose will be provided.

 For Empiric use – a three-day dose on a 24-hour basis will be provided until revised
or approved by the committee

 For Therapeutic use – a seven-day automatic stop order shall be implementation

The IPCC upon the approval of the Pharmacy and Therapeutics Committee, shall be responsible
for recommending RESTRICTED and VERY RESTRICTED antibiotics.

139
 EDUCATION AND TRAINING

Education and Training of ICU Staff and VRH Personnel

Education and training for continual medical education and updates would be a cornerstone for
personnel development. This will achieve by attendance to national and international conferences
/ conventions and meetings on infectious diseases and infection control. Training workshops
offered by the DOH will also be welcome, bench-marking activities in tertiary government
hospital. Finally, in-house seminars / workshops on various topics given by Training Office will
be attended to by the responsible staff and cascaded to the rest of the unit.

Education and Training of VRH Personnel

The IPCC will be responsible for the training and education related to infection control of VRH
personnel, particularly physicians, nurses and other paramedical staff. Student affiliates may also
be included if there are lectures for information dissemination and updates are effective strategies
cascaded for continuing education.

Example of lecture series suggested

Topic Month Medical Nursing Support series /

Administration
1. Basic Infection Control
in 30 minutes. What we
all know for QMS
2.Reducing needle stick
injury and other avoidable
exposure
3.Prevention of healthcare
acquired infections
4.VRH preparedness for
infection – related
diseases
5. Employee health
Note: Attendance is
required

140
VRH FORMS

141
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144
145
146
147
148
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Rutala W.A., Weber DJ and the Healthcare Infection Control Practices Advisory Committee
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