PANAY HEALTH CARE MULTI PURPOSE

COOPERATIVE HOSPITAL
DIALYSIS UNIT

`
VISION:

To be the premiere Dialysis unit that adheres to the highest standards of Renal Replacement Therapy.

MISSION:

PHC-MPC Dialysis Unit is committed to provide quality Renal Health Care Services available to all.

GENERAL OBJECTIVES:
Provide the highest quality standards of care in patients undergoing renal replacement therapy.

SPECIFIC OBJECTIVES:
 Assess physical, emotional and psychological needs of patient undergoing hemodialysis.
 Provide health education regarding hemodialysis and care after hemodialysis.
 Determine complications experienced during and after hemodialysis.
 Execute independent, dependent and collaborative interventions and treatment.
 Ensure infection prevention and control are observed and practiced at all times.

.
 MANUAL OF STANDARD
OPERATING PROCEDURES

Prepared by:

TEFFANY JOY H. ENRIQUEZ, RN

Head Nurse

FLORITA M. GANZON, RN., MAN

Chief Nurse

Approved by:

MARYMIL B. DIGNADICE, MD, FPCP, FPSN

Chief Nephrologists

Noted by:

GILDA L. VILLANUEVA, MD, MPA, FPCHA, FPOGS, FPCS

General Manager and Medical Director
 SECTION POLICIES
A. Daily Time Schedules

1. The Dialysis Unit is open from 6am – 6pm, Monday – Friday except on Weekends.
2. Emergency dialysis is done anytime as long as there is an available bed and the staffs are informed
immediately so that the proper preparations could be immediately.
3. If a patient comes late, his/her hours of dialysis will be reducing so that he will finish his/her dialysis session
within the prescribed shift.
4. In cases where the delay is due to circumstances beyond control (e.g. water, electricity or machine
breakdown) patients will be allowed to finish his prescribed time of hemodialysis without surcharge.

B. Schedule of Patients for Dialysis

1. Patients are equally distributed throughout the 5 working days of the dialysis unit, regardless of who the
referring nephrologist is.

2. If there is an urgent need for a patient to be dialyzed, nurse on duty should know who will be prioritized first
and see to it if there is a machine available for the patient and the regular patient be given the next slot. Attending
Nephrologist must be informed for the changes of schedules.

3. Patients are hooked according to first come first serve basis, except for emergency cases.

4. OPD patients on regular scheduled date must inform the staff 1 day prior if they cannot go to his/her treatment
session. Failure to do so and the staff have already prepared the patient’s dialyzer, materials used will be charged
on patient’s account during the next hemodialysis schedule.

5. Scheduled patients will be prioritizing over non-scheduled patients.

6. During non-office hours for emergency cases, the Physician on duty should coordinate with the Chief
Nephrologist who will be in charge of coordinating with the dialysis staff, or if the Chief Nephrologist is not
available directly with the dialysis staff.

7. The Physician on duty must inform the Nephrologist in charge regarding the emergency schedule and should
watch over the patient during the procedure.

8. Emergency cases form other hospital must be accompanied and specially endorsed by their respective nurse on
duty for the entire duration of the dialysis session.
C. Standard Operating Procedures

1. For regular OPD patients, the patients, the patient of nearest kin must sign consent for hemodialysis during his
first session at the unit. For emergency cases, the nearest of kin must sign the consent for every hemodialysis
session.

2. There should be a doctor’s order for the hemodialysis of each patient. An old standing order may be used.

3. The hemodialysis monitoring sheet should be properly filled up as indicated. A duplicate copy of the
monitoring sheet should be attached to charts of admitted patients.

4. Nursing staff and technician assigned to the patient must sign his/her name in the monitoring record sheet.

5. Relatives or companions are instructed to stay outside the dialysis room. A relative may be asked to enter the
dialysis room to meet the patient’s personal needs as necessary.

6. Avoid unnecessary noise and boisterous conversation.

7. The hemodialysis staff should always be courteous to the patients speaking to them in a low voice and
treating them with the maximum tolerance.

8. The staff should always be available to attend to patient’s needs.

9. Patients weights are taken before and after dialysis if the patient is ambulatory.

10. All blood specimens drawn in the dialysis room for chemistry should be sent to the hospital’s laboratory.
However, if blood examinations requested are not available inside the hospital, blood specimen would be sent to
other laboratories.

11. Patients should always be monitored by the charge nurse on duty and should not left alone when there is an
ongoing dialysis session.

12. The head nurse or senior nurse member of the staff should always supervise the junior staff.

13. The billing clerk will be in charge in informing the folks of the dialysis fee and will be the one to issue the
charge slip.

14. All charges must be paid to the cashier during office hours.

15. For emergency dialysis, patients and folks must be informed for the emergency fee and must settle their bills
prior to the procedure.

16. An additional Three Thousand pesos (3,000php) to the usual dialysis fee will be charged to patient’s account
for emergency dialysis.

17. Additional supplies and medications used not included in the package will be charged to the patient.

18. Professional fees of attending nephrologists will be paid to the billing clerk with the issuance of receipts of
individual nephrologists.
 MEDICAL STAFF FUNCTION

A. Chief Nephrologists

1. Overall supervision on the proper functioning of the unit.

2. Recommends purchase of equipment and other medical supplies for the use of the unit.

3. Decides on the scheduling of patients for dialysis.

4. Represents the unit in all administrative matters.

5. Recommends approval or disapproval of scientific investigations or research making in the unit.

B. Nephrologists

1. Each nephrologists active or visiting is responsible for the dialysis of his/ her own patient.

2. He or she must be around when a very ill patient is undergoing dialysis. In case where the attending
nephrologists is unable to attend the patient, a physician on duty can cover with the permission of Attending
Nephrologists.

3. In case of emergency dialysis, the nephrologist should be present to attend the dialysis procedure of his/her
patient.

4. Attending Nephrologists must inform dialysis staff regarding hemodialysis prescription ahead of schedule so
that the necessary materials will be prepared as soon as patient arrives.

C. Physician On Duty

1. The Physician on duty should evaluate and assess emergency cases or very ill patients if attending
Nephrologists is not yet around to care for the patient.

2. The physician on Duty should assist the Nephrologists and hemodialysis staff in case of emergency in the
unit.

3. The physician on duty must update the attending nephrologists for any problem during the dialysis session.
 HEAD NURSE

1. JOB SUMMARY
 Are in charge of organizing and carrying out a variety of administrative work. They are the one who
organize and plan, compile and store all the notes on patients taken by their nursing team.

2. Qualifications

Education: Bachelor of Science in Nursing Registered Nurse in the Philippines

Registered Dialysis Nurse with Certificate Of Training
Experience: At least with two (2) years of experience as a Staff Nurse in the unit.
Personal Qualities:
A. Physical and mentally healthy
B. Neat and clean in appearance, with pleasing personality.
C. Able to work well with medical and paramedical personnel.
D. Possessing leadership qualities and good communication skills
E. Diligent, resourceful and loyal, able to hold matters pertaining to patient and co-
workers personal affair in strict confidentiality.
 Other Qualifications: Member of Professional Organization (PNA,RENAP)

2. Broad Function

 Supervises and manages the administration of nursing care.

 Directs and supervises personnel under him/her.
 Manages materials and supplies.
 Coordinates for the smooth operation in the unit.
 Participates in training activities.
 Performs other duties that may be assigned from time to time.

3. Specific Tasks and Duties

A. Supervises and manages the administration of nursing care to patients in the unit particularly on the
following:
a.1 Monitoring and assessment of patient’s condition.

a.2 Carrying out of doctor’s orders on admission, discharge, transfer, diagnostic procedures, surgery,
medications and treatment.

a.3 Supervision of nurses and technicians in performing dialysis procedures in accordance with the
doctor’s order or dialysis standard operating procedure, performing such when necessary.

a.4 Proper recording and prompt reporting of patient’s condition.

a.5 Maintenance of a clean, safe and therapeutic environment.

 B. Supervises subordinates on administrative matters particularly on the following:

b.1 Preparation of work schedules of the personnel under him/her for approval by the Chief Nurse and
sees to it that this is closely adhered to, making changes or adjustment as necessary.

b.2 Recommendation of appropriate disciplinary actions on erring subordinates as per code of conduct or
discipline.

b.3 Appraisal of subordinates performances and the provision of recommendations based on results.

b.4 Recommendation of vacation leaves and other forms of leave.

b.5 Orientation and training of new recruits in the unit.

c. Ensures availability of materials and supplies in the unit.

 Ensures proper endorsement in all shifts regarding patient care, ward conditions, equipment, supplies and
personnel.
 Collaborates with the different support services through proper channels.
 Ensures compliance to hospital policies, rules and regulations.
 Ensures that patients’ records and other information are kept in confidential.
 Ensures prompt reporting and recording of medico-legal and unusual incidents through proper channels.
 Conducts/ Participates in meetings, staff development programs and research activities.
 Disseminates memos, directives, notices and other important documents and keeps them on file.

4. Training and Management

 Conducts initial interviews on nursing applicants in the unit.

 Supervises and evaluates all trainees in his/her unit and makes appropriate recommendations whether they
are hiring or for extension of training.
 Recommends the staff for training based on their assessed needs.

5. Minor activities

 Ensures the proper billing of patient care on the use of hospital equipment, materials and supplies.
 Attends to complaints of patients, relatives, doctors and personnel, and others.
 Assists in the preparation of the unit’s budget.
 Participates in the formation and revision of policies and procedures.
 Checks the patient’s chart for accuracy and completeness.
 Helps in keeping the work are clean and orderly.

6. Professional Ethics

 Follows policies and protocols of the unit and institution.

 Maintains legal and professional standards of nursing practice.
 Observes ethico-moral norms and fundamental principles of nursing care.
 7. Health education and training

 Provides information to patients and relatives regarding plan and care to be done in the hospital and at home.
 Participates in the training program of the hospital particularly hemodialysis.

8. Communication

 Use appropriate techniques in reporting, recording and relaying data.

 Report to unit manager problem regarding housekeeping, maintenance and supplies.
 Notify head nurse when absent or going on leave according to nursing office policy.

9. Professional Growth and Development

 Attend lectures and conferences set by the NSO or RENAP and Philippine Society of Nephrology
 Attend regular and emergency staff meeting set by NSO

10. Decision Making

 Set priorities in planning and implementing patient care

 Use the appropriate decision making process when coming up with alternative solutions to the problem.

11. Others

 Perform other duties and functions as maybe assigned by the immediate supervisor.

HEMODIALYSIS STAFF NURSE

1. Job Summary

 Education: Bachelor of Science in Nursing Registered Nurse in the Philippines

 Experience: On the Job Training with certification from RENAP
 Personal Qualities : Physical and mentally healthy
 Other Qualifications: Member of Professional Organization (PNA,RENAP)

2. Broad Function

 Render holistic care to the patient undergoing hemodialysis.

3. Specific Tasks and Duties

A. Pre-Dialysis

a.1. Orient the patient as well as his companions to the hospital policies.

a.2 Explain hemodialysis procedures thoroughly to the patient and his family.

a.3. Takes the patient’s baseline pre-dialysis vital signs and records it accordingly.
 a.4. Checks/verifies heparin dose and supervises dialysis technicians in the preparation of the initial dose and
maintenance dose.

a.5. Checks new orders for the dialysis bath.

B. Intra-dialysis

b.1 Carries out physician’s orders and other therapeutic regimen following prescribed standard. b.2.
Performs arterial and venous cannulation aseptically.

b.3 Extracts pre-dialysis blood works as ordered.

b.4 Performs arteriovenous shunt, subclavian catheter,

b.5 Immediately provides patient’s needs when called.

b.6 Administers medications properly as ordered.

b.7 Observe strict aseptic technique throughput the dialysis procedures.

b.8 Maintains good outflow and inflow of blood.

b.9 Ensures proper machine operation throughout the dialysis procedures.

b.10 Keeps patients informed of progress and result.

b.11 Provides diversional activities.

b.12 Assists dialysis technician in monitoring for any presence of malfunction sounded by alarm in the
machine.

b.13 Monitors and records vital signs religiously.

b.14 Records all important data observed during the entire procedures.

b.15 Checks IV fluids for discoloration.

b.16 Monitors any changes in fluid and electrolytes status based on laboratory results and pre-dialysis
weight.

b.17 Implement appropriate nursing intervention in each symptom presented.

c. Post dialysis:

c.1. Extracts blood specimen properly for post dialysis examination as ordered.

c.2 Administers medications prior to termination for dialysis as ordered.

c.3 Ensures that blood is completely returned to the patient.

c.4 Takes and records post dialysis vital signs and allows patient to rest prior to discharge.

c.5 Instructs the patient on prescribed home medications.

c.6 Reminds patients about the next dialysis schedule.

c.7 Obtains post-dialysis weight and properly document it.

4. Management skills:

A. Performs job with minimal supervision.

A. Shows ability to work with people, command their admiration, respect, trust and responsiveness.
B. As charge nurse:

c.1. Motivates the staff in achieving the organization’s objectives and in reaching their maximum potential.

c.2 Checks and counts stocks of medicines and emergency supply.

HEMODIALYSIS TECHNICIAN

1. Job specification:

Education: Must be a secondary degree holder

Experience: On the job training Personal Qualities: Physically and Mentally Healthy

2. Broad Function

A. Must be responsible for the maintenance of the machines in the unit.

B. Must be responsible for the health and safety of the patients through proper use of machines.
3. Specific Task and duties

a. Major

a.1 Performs dialysis procedures as per SOP

a.1.1 Prepares bed for the patient.

a.1.2. Prepares the medical supplies and materials needed for dialysis.

a.1.3 Prepares Hemodialysis Machine, primes the dialyzers and assist nurse in starting and closing
hemodialysis procedures.

a.1.4 Collects and sends specimen to the laboratory as ordered.

a.1.5 Monitors alarms presented by the machine during the procedure and do minor trouble

shooting if the need arises.

a.1.6 Helps maintain clean, safe and therapeutic environment.

a.1.7 Coordinates and assist nurse in relation to patient care.

a.1.8 Cleans and reprocess dialyzers for reuse.

a.1.9 Cleanses and sanitizes the dialysis machine thoroughly after each use.

B. Minor

b.1 Implement hospital policies, rules and regulations.

b.2 Sees the maintenance an d safe keeping of equipment and hospital supplies in the unit.

b.3 Participates in meeting and staff development programs.

b.4 Accomplishes incident reports as needed.

INFECTIOUS DISEASE GUIDELINES

1. Patient Handling

A. General

1. Universal precaution must be STRICTLY practiced.

2. Hand washing shall be performed before and after each patient contact and after removal of gloves.

3. All accidental needle pricks shall be reported to the head nurse.

4. The staffs when donning a pair of new gloves should refrain from touching any environmental surfaces
before puncturing the patient’s vascular access.

5. During the dialysis treatment, gloves shall be worn when touching or manipulating the patient’s fistula,
shunt or intravenous catheter IV tubing, or any patient’s body fluids ( i.e) vomitus, stool, urine blood)

6. All ancillary personnel interact with patients but do not provide hands on care (i.e maintenance) shall
wash their hands when entering and leaving the dialysis unit.

7. Linens are changed after every use.

8. The environment shall be cleaned thoroughly between each treatment and as necessary for spills of blood.

9. Waste receptacles shall not be overfilled.

B. Temporary Catheter

1. Minimize contamination in accessing the patient’s blood stream and in manipulating a catheter.

2. Sterile gloves should be worn by the nurse during catheter connect and disconnect.

3. The catheter exit should be examined at each hemodialysis treatment for sign of infections.

4. The catheter hub caps or bloodlines should be soaked in alcohol and allowed to dry prior to insertion while
the catheter lumen should be kept sterile at all times.

5. To prevent contamination, the lumen and tip should never remain to open to air. A cap or syringe should
be placed on or within the catheter connectors.

6. Catheter exit site dressings should be change at each hemodialysis treatment. Use of dry gauze dressing
and povidone iodine solution at the catheter exit site are recommended. Anti- bacterial ointment at the
catheter exit site is applied after each use when indicated.
C. Arteriovenous Fistula

1. Cannulation in the skin is chosen then cleaned first with 70% Alcohol and then with Betadine and
allowed to dry before insertion of the needle.

2. Each nurse should wear sterile gloves during each cannulation.

II. Dialysis Machine and Other Equipment

1. Each machine should be disinfected as per instruction of Machine Company prior and after use.

2. Machine exterior and control knobs should be cleaned with a disinfectant at the end of the day.

III. Dialyzer Used and Reused

1. Dialyzer can be reused. They are to be disinfected between each use.

2. Leaning areas for Hepatitis B and C patients are separate form regular patients

IV. Waste Handling

1. Separate containers for collection of non-infectious dry waste, non-infectious wet waste, and infectious
pathological waste provided.

2. Used needles are to be discarded and placed in a needle dispenser.

3. Used linen should be placed in a linen container to be brought to the laundry section.

V. Water Supply and Dialysate

1. The water used for hemodialysis is processed by a filter system which includes Reverse Osmosis.

2. Water samples are collected every month for bacteriologic count and repeated when bacteriologic count
exceeds 200cfu/ml, or when changes have been made in the disinfection procedure, the water treatment and
the hemodialysis distribution system. Water samples for chemical analysis are collected quarterly.

3. Dialysis fluid samples should also be taken when chills secondary to water contamination are suspected
or when changes are made in the water treatment system or disinfection protocol.
 4. Specimens for testing should be assessed within 30min. or refrigerated at 4degrees Celsius and assessed
within 24 hours.

5. Simultaneous occurrence of fever in the patients should alert the staff to possible water contamination by
microorganisms. This warrants blood cultures by the patients, culture from the dialysate from the affected
patient, water supply going to the machine and water used from rinsing the dialyzers in re-use processes.

VI. Hepatitis Precaution

1. All hemodialysis staff and patients should have routine testing for HBsAg, Anti-HBs and Anti-HCV upon
entry.

2. Patients negative for HBsAg and anti-HBs are given Hepatitis B vaccines at a dose of 40ug IM at 0, 1, 2
and 6months.While the staff are given a dose of 20ug at 0, 1, 2, and 6 months.

3. For non-responders a repeat dose of immunization is done.

4. Screening for HBsAg and HBs is done every 6 months for vaccine non-responders and anti-HBs
determination is done every year for vaccine responders or those with natural immunity.

VII. Meal Rules

1. Staff members should stay at the dialysis unit during their mealtime.

2. Eating and drinking shall be confined to designated areas.

3. Patients may be served meals or eat food while on hemodialysis as long as appropriate hygienic measures
are practiced. They should dispose their wastes on the garbage container assigned.

VIII. Patient’s Companion

1. Relative/ Folks should wait at the waiting area.

2. Only one companion is allowed at the bed side with the patient during dialysis as needed.
MANAGEMENT OF COMPLICATIONS DURING HEMODIALYSIS

1. Hypotension

Hypotension is the medical term for low blood pressure (less than 90/60). A blood pressure reading appears
as two numbers. The first and higher of the two is a measure of systolic pressure or the pressure in the
arteries when the heart beats and fills them with blood.

a. Place patient in Trendelenburg position

b. Fast drip PNSS 100cc or more as necessary or may give D50W 50cc as IV bolus as ordered.

c. Record on patients chart and inform his/her Attending Nephrologists.

2. Muscle Cramps

Muscle cramps are sudden, involuntary contractions that occur in various muscles. These contractions are
often painful and can affect different muscle groups. A sudden sharp pain, lasting from a few seconds to
15minutes, is the common symptom of a muscle cramp. In some cases, a bulging lump of muscle tissue
beneath the skin can accompany a cramp as well.

a. Fats drip PNSS 100cc if with concomitant hypotension

b. Give hypertonic solution: 50meq NaCl or D50 50cc as IV bolus as ordered.

c. Record on patients chart and inform his/her Attending Nephrologists.

3. Nausea or Vomiting

Patients can feel nauseous or experience vomiting for a number of reasons during and after dialysis
treatments. First of all, these symptoms are commonly associated with kidney disease. Add low blood
pressure and fluid weight gain to the mix and they are much more likely.

a. Treat Hypotension

b. Metochlopramide injection 10mg 1 amp IV as ordered.

c. Record on patients chart and inform his/her Attending Nephrologists.

4. Headache

Highly prevalent and these headaches appear to be associated with serum blood urea-nitrogen (BUN) and
blood pressure prior to and after dialysis.

a. Paracetamol tab 500mg or IV 300mg as ordered

b. Record on patients chart and inform his/her Attending Nephrologists.

5. Chest Pain

This may feel like a sharp, stabbing pain or dull ache. It may be a sign of a serious heart-problem. Frequent
causes of this in patients undergoing hemodialysis include myocardial infarction, pericarditis, pleuritis, air
embolism and gastro-esophageal reflux.

a. O2 inhalation at 2-3 lpm

b. Isosorbide dinitrate 5mg SL as ordered.

c. Request for ECG.

d. Record on patients chart and inform his/her Attending Nephrologists.

6. Itching

Limited fluid intake: Your dialysis treatment removes extra water from your body, and your limited fluid
intake between treatments can cause dry skin and trigger itchiness. Unmanaged phosphorus: Often, itching is
caused by high blood levels of phosphorus 15.

a. Chlorphenamine maleate 10mg/ml 1 amp IV as ordered.

b. Record on patients chart and inform Attending Nephrologists.

7. Chills

Chills are common complication in patients undergoing chronic hemodialysis. Hemodialysis patients
experiencing an episode of chills are usually hospitalized for broad-spectrum antibiotic therapy and observation
until an infection is ruled out.

a. Chlorphenamine maleate 10mg/amp 1 amp IV as ordered.

b. Hydrocortisone injection 100mgIV as ordered.

c. O2 inhalation at 2 lpm .

d. Record on patients chart and inform his/her Attending Nephrologists.

8. Hypertension

While hemodialysis lowers blood pressure (BP) in most hypertensive end-stage renal disease (ESRD)
patients, some patients exhibit a paradoxical increase in BP during hemodialysis. This increase in BP during
hemodialysis is termed intradialytic hypertension.
 a. Clonidine tab 150mcgSL as ordered. Repeat after 30mins if still with elevated BP.

b. If BP is persistently elevated refer to MD.

c. Record on patients chart.

STERILIZATION TECHNIQUE

Sterilization is necessary for the complete destruction or removal of all microorganisms (including spore-
forming and non-spore forming bacteria, viruses, fungi, and protozoa) that could contaminate
pharmaceuticals or other materials and thereby constitute a health hazard. Since the achievement of the
absolute state of sterility cannot be demonstrated, the sterility of a pharmaceutical preparation can be defined
only in terms of probability. The efficacy of any sterilization process will depend on the nature of the
product, the extent and type of any contamination, and the conditions under which the final product has been
prepared. The requirements for Good Manufacturing Practice should be observed throughout all stages of
manufacture and sterilization. Classical sterilization techniques using saturated steam under pressure or hot
air are the most reliable and should be used whenever possible. Other sterilization methods include filtration,
ionizing radiation (gamma and electron-beam radiation), and gas (ethylene oxide, formaldehyde).

Heating in an autoclave (steam sterilization)

Exposure of microorganisms to saturated steam under pressure in an autoclave achieves their destruction by
the irreversible denaturation of enzymes and structural proteins. The temperature at which denaturation
occurs varies inversely with the amount of water present. Sterilization in saturated steam thus requires
precise control of time, temperature, and pressure. As displacement of the air by steam is unlikely to be
readily achieved, the air should be evacuated from the autoclave before admission of steam. This method
should be used whenever possible for aqueous preparations and for surgical dressings and medical devices.

Ultraviolet (UV)

Is a form of electromagnetic radiation with wavelength from 10nm (with a corresponding frequency around
30 PHz) to 400 nm (750 THz), shorter than that of visible light, but longer than X-rays. UV radiation is
present in sunlight, and constitutes about 10% of the total electromagnetic radiation output from the Sun. It is
also produced by electric arcs and specialized lights, such as mercury-vapor lamps, tanning lamps, and black
lights. Although long-wavelength ultraviolet is not considered an ionizing radiation because its photons lack
the energy to ionize atoms, it can cause chemical reactions and causes many substances to glow or fluoresce.
Consequently, the chemical and biological effects of UV are greater than simple heating effects, and many
practical applications of UV radiation derive from its interactions with organic molecules.
Spore clear Concentrate

Concentrated Solution for Large Areas in the hospital (walls, floors & ceilings)

 For all healthcares, caring, professional and public hygiene needs.

 Product formats for non-invasive medical devices and surfaces.
 Broad spectrum efficacy with a 1 minute contact time.

PATIENT REFERRAL OR TRANSFER TO ANOTHER FACILITY

a. Patients undergoing hemodialysis treatment in free standing and hospital based HDCs should have a
completely filled up PSN Hemodialysis patient’s endorsement form.

b. The same form should be used whenever a patient is being referred or transferred to another HDC.

c. NO patient should be enrolled or accepted into the dialysis treatment program of any HDC without a
completely filled up endorsement form.

d. It is the responsibility of the Attending Nephrologists to accomplish and provide the receiving HDC of the
endorsement form.
 PATIENT REFERRAL FORM

PHILIPPINE SOCIETY OF NEPHROLOGY

HEMODIALYSIS PATIENT’S ENDORSEMENT FORM

REFERRING HEMODIALYSIS CENTER RECEIVING HDC DATE

PANAY HEALTH CARE-MULTI PURPOSE
COOPERATIVE DIALYSIS UNIT
Brgy. Estancia Kalibo, Aklan

PATIENT’S NAME DATE OF BIRTH AGE/ CONTACT NUMBER

LAST NAME SEX
FIRST NAME

MIDDLE Address:
NAME
DIAGNOSIS:

CONTACT NUMBER
PERSON TO NOTIFY IN CASE OF EMERGENCY RELATION TO PATIENT
Co- Morbid Conditions: Other attending Physicians/ Subspecialty
1.__________________________________________ 1.__________________________________________
2.__________________________________________ 2.__________________________________________
3.__________________________________________ 3.__________________________________________

Hepatitis Qualitative Quantitative Date Latest Immunization/s Dose Date

Profile
HBS Hepatitis B
Antigen Vaccine
___________1st _________2nd
3rd Dose
Anti-HBS Hepatitis B vaccine booster
Antibody
Anti-HBC Influenza vaccine
Antibody
Anti-HCV Pneumococcal vaccine
Igm
Vascular Access Access Location Surgeon Date Created Hospital
Internal Jugular Vein/
Permanent Catheter
AV FISTULA
AV GRAFT
HEMODIALYSIS PRESCRIPTION CURRENT MEDICATIONS
FREQUENCY
DURATION
DIALYZER
DIALYSATE BLOOD
FLOW RATE
BLOOD FLOW RATE
DIALYSATE BATH
DRY WEIGHT kg. BLOOD TYPE:
Complications/Problems encountered during Hemodialysis
1.________________________________________________________________________________________
2.________________________________________________________________________________________
3.________________________________________________________________________________________

Attachments Last 3 Hemodialysis Treatment Sheet

Laboratory Flow Sheets/ Results
Name and Signature of Referring Nephrologist:
INITIATING DIALYSIS USING CATHETER ACCESS

A. Take and record pre-dialysis weight and vital signs of patient.

B. Check for pre-dialysis order.
C. Counter check patient’s dialyzer before initiating dialysis. Perform hand washing.
D. Put on clean gloves, remove old dressing from catheter site, check if the dressing sticks to the
catheter due to dried blood or drainage, fill 10cc syringe with normal saline solution and moisten the
dressing until it can be easily removed.
E. Check if the sutures are intact, if not; refer to Nephrologists and surgery department. Assess the site
for erythema, swelling tenderness or secretions. If any signs and symptoms of infection are present,
notify the Nephrologists and obtain a culture if ordered.
F. Prepare the sterile tray and fill the sterile glass with normal saline solution aseptically, drop some
sterile cotton with betadine solution, drop 10cc sterile syringe inside the tray, drop the sterile gauze as
well.
G. Put on sterile gloves. Apply sterile cotton ball with betadine solution on the catheter insertion site (in
a continuous circular motion). May apply antibiotic cream/ ointment as ordered.
H. Apply sterile gauze pad to the area and fasten with tape.
I. Drape the area around the catheter tubing with sterile and gauze pad.
J. Clean the catheter limbs, port caps and clamps with betadine solution.
K. Ensuring that the catheter limb is securely clamped, removed the arterial port cap and disinfects the
tip with betadine solution. Attach the 10cc syringe, open arterial clamp and aspirate 2-3cc of blood,
close the clamp, remove the syringe and discard the blood. This is to ensure blood clots have been
removed from the arterial catheter. (Draw blood specimen for any blood laboratory exams as ordered.
L. Aspirate 5cc of NSS from sterile glass, attached to 10 cc syringe, open arterial clamp and aspirate air
left in arterial port and then flush it with 4cc NSS to preventing clotting. Close the clamp and remove
syringe.
M. Follow steps K-L for the venous catheter.
N. After checking the patency of both lumens, the patient is now ready to be hook in the machine.
Validate for any bleeding.
O. Circulating nurse or technician will stop the blood pump. Close all big clamps of the bloodlines and
IV line Disconnect arterial from venous connector; place the venous line in the drain. Disinfect the
arterial tip with sterile cotton ball soaked to betadine solution (from tip to luer lock of tubing in a
circular motion). Give the disinfected arterial tip to the nurse.
P. The nurse will get the tip tubing using sterile gauze and connect the arterial catheter. Secure that the
luer lock has been safely fastened. Open the clamp and the circulating nurse or technician will open
the big clamps of the bloodlines to initiate dialysis.
Q. Press start button of the blood pump (150ml/min), open pressure clamps of the arterial and venous to
check pressures. Let the blood pass the heparin line, then open heparin clamp and give heparin bolus
as ordered. Press the button to start the heparin timer. Press the present ultrafiltration (UF) button
ON.
R. When the blood reaches the venous drip chamber, press the arrow down button to drain some
contents making sure that level of the blood doesn’t go beyond the optical sensor of the machine.
S. Wait for the alarm and the PREPARATION END display on the screen.
 T. Close venous big clamp. Disconnect venous connector. Disinfect the venous tip with sterile cotton
ball soaked with betadine solution (from tip top luer lock of tubing in a circular motion). Give the
disinfected venous tip to the nurse.
U. The Nurse will get the tip tubing sterile gauze and connect with the venous catheter. Secure that the
luer lock has been safely fastened. Open the clamp and the circulating nurse technician will open the
big clamp of the bloodline.
V. Press start button to continue dialysis initiation. Cover the catheter with sterile gauze and anchor it
properly. Discard contaminated supplies according to hospital policy.
W. Perform hand washing. Monitor patients religiously.

TERMINATING DIALYSIS USING A CATHETER ACCESS Procedure:

A. Machine beeps when Ultrafiltration Goal (UF) is reached.

B. Press alarm on mute.
C. Put on sterile gloves.
D. Ensure that the sterile towel covering the catheter is present.
E. Clamp the arterial bloodline and arterial catheter (circulating nurse/ technician)
F. Disconnect arterial bloodline form patient’s arterial catheter (circulating nurse/ technician)
G. Attach a 10ml syringe filled with normal saline solution to patient’s arterial catheter.
H. Unclamp the catheter and flush with 5ml normal saline solution. Reclamp catheter and remove syringe.
I. Attach the arterial bloodline to normal saline (IV) using a connector aseptically.
J. Open the arterial bloodline clamp and normal saline line.
K. Press start to turn on the blood pump and slowly return the patient’s blood.
L. Machine beeps for dialysis end.
M. Clamp venous bloodline and venous catheter.
N. Disconnect the venous bloodline form the venous catheter.

Note: Patient is not connected to the machine at this time.

O. Attach syringe with 5ml saline solution to venous catheter and unclamp. Flush catheter saline. Then
reclamp.
P. Attach syringe with 2ml heparin (1000 IU/ml) to arterial catheter and venous catheter. Infuse 2ml of
heparin to each catheter and reclamp.
Q. Apply sterile caps to each catheter. Ensure that each cap is securely fastened.
R. Apply betadine or antibiotic ointment as ordered to the exit site as prophylaxis to prevent infection. Cover
exit sites with sterile dressing or adhesive dressing ensuring that catheter line is not twisted or kinked and
free of pressure. Note: Aseptic technique should be absorbed in every step.

INSERTION OF ARTERIO-VENOUS FISTULA NEEDLES IN VASCULAR ACCESS AND GRAFTS

A. Take and record pre-dialysis weight and vital signs of patient.

B. Check for pre-dialysis orders.
C. Counter check patients’ dialyzer before initiating dialysis. Perform hand washing.
 D. Prepare materials for cannulation. Put on clean gloves.
E. Palpate and inspect the access to identify potential problems and needle placement sites.
F. Prepare the access sites by swabbing with sterile cotton ball soaked with 70% isopropyl alcohol solution
beginning in the insertion site and moving outward in the continuous circular motion.
G. Apply tourniquet at the upper portion of the arm (if necessary) to engorge or enlarge the vessel.
H. Anesthetic application as ordered. Lidocaine 2 % injection intradermal. Pull skin tight so that insertion
is easier; insert the needle bevel up just under the skin where you plan to insert the fistula needle. Inject
lidocaine slowly until you observe a rise in the skin tissue (wheal). Topical anaesthetics can be applied
by swabbing it on the insertion site wait for 3-5mins.Or until the area numbs.

CANNULATION

I. The first needle to be inserted is the venous needle (non-back eye). The needle is initially inserted bevel
up form 20-35-degree angle for fistula and 45 degrees for graft. Slowly advance needle and watch for
blood flashback once the needle enters the vessel.

Level out needle angle and slowly advance needle up the center of the vain. Do not flip the needle. Tape
wings to stabilize the needle. Check for good flow. Finally apply butterfly technique in anchoring tapes
to prevent form dislodging.

J. Release the tourniquet, open the cap of the venous needle, let the blood flow until it reaches the tip and
close clamp. Blood specimens are obtained as ordered.
K. Connect a 10cc prefilled syringe with 8cc NSS. Unclamp. Aspirate and flush to check patency and to
prevent clotting. Clamp and remove syringe. Recap the tubing.
L. For the 2nd insertion with the arterial needle (with back-eye) follow steps I-J
M. After checking the patency of both lines, the patient is now ready to be hook in the machine. Validate
for any bleeding.
N. Circulating nurse or technician will stop blood pump. Close big clamps of the bloodlines and IV line.
Disconnect arterial from venous connector; place the venous line in the drain. Disinfect the arterial tip
with sterile cotton ball soaked with betadine solution ( from tip to luer lock of tubing in a circular motion
). Give the disinfected arterial tip to the nurse.
O. The nurse will get the tip tubing using sterile gauze and connect with the arterial catheter. Secure that
the luer lock has been safely fastened. Open the clamp and the circulating nurse or technician will open
the big clamps of the bloodlines to initiate dialysis.
P. Press start button of the blood pump (150ml/min), open the pressure clamps of the arterial and venous to
check pressures. Let the blood pass the heparin line, then open heparin clamp and give heparin bolus as
ordered. Press the button to start the heparin timer. Press the preset ultrafiltration (UF) Button on.
Q. When the blood reaches the venous drip chamber, press the arrow down button to drain some contents
making sure that level of the blood doesn’t go beyond the optical sensor of the machine.
R. Wait for the alarm and the PREPARATION END display on the screen.
S. Close venous big clamp. Disconnect venous connector. Disinfect the venous tip with sterile cotton ball
soaked with betadine solution (from tip top luer lock of tubing in a circular motion). Give the disinfected
venous tip to the nurse.
 T. The Nurse will get the tip tubing sterile gauze and connect with the venous catheter. Secure that the luer
lock has been safely fastened. Open the clamp and the circulating nurse technician will open the big
clamp of the bloodline.
U. Press start button to continue dialysis initiation. Cover the catheter with sterile gauze and anchor it
properly. Discard contaminated supplies according to hospital policy. 22. Do hand washing. Monitor
patients religiously.

TERMINATING DIALYSIS AND REMOVING ARTERIO-VENOUS FISTULA NEEDLES

Procedure:

A. Machine beeps when Ultrafiltration Goal (UF) is reached.

B. Press alarm off
C. Put on sterile gloves.
D. Clamp the arterial bloodline and arterial tubing.
E. Disconnect arterial bloodline from patients’ arterial tubing.
F. Attach a 10ml syringe filled with normal saline solution to patient’s arterial tubing. Unclamp the
tubing and flush with 5ml normal saline solution. Reclamp tubing and remove syringe. Recap.
G. Attach the arterial bloodline to normal saline line using a connector aseptically.
H. Open the arterial bloodline to normal saline line.
I. Press start to turn on the blood pump and slowly return the patient’s blood.
J. Machine beeps for dialysis end.
K. Clamp venous bloodline and the venous catheter.
L. Disconnect the venous bloodline form the venous catheter. Note: Patient is not connected to the
machine at this time.
M. Remove adhesives from arterial needle first. Position sterile gauze pad over the needle exit site in the
fistula or graft without applying pressure.
N. Carefully withdraw the needle. Do not apply pressure to the site until the needle is completely
pulled out to avoid damage to the fistula or graft.
O. When the needle is completely pulled out, apply firm, direct pressure to the exit site for at least
10mins or until bleeding stops.
P. While holding the pressure, it must be ensured that blood flow through the access is not slowed or
blocked.
Q. Once the site stops bleeding, at sterile dressing or tape is applied to site.
R. Before the venous needle is removed, obtain patient’s blood pressure. This is to allow medications
and interventions access if need should arise.
S. The venous needle may be removed according to the steps listed form steps L-P.
HEMODIALYSIS MACHINE OPERATION POLICIES

1. If the machine has been idle for more than 72 hours, it is recommended to run a disinfection program
(e.g. citrosteril disinfectant) before initiating a treatment.

2. Perform handwashing before and after each treatment.

3. Use clean gloves in handling and installing dialyzers, bloodlines, priming lines and priming buckets.

4. Disinfect the machine before and after each dialysis treatment. (Disinfectant: Sporeclear)

5. Always check and verify name of patient and date of first use on dialyzer.

6. Always check for the availability of dialysate solutions. Make sure that acid and bicarbonate suction tubes
are in respective containers.

7. Observe proper and correct installing of dialyzer, bloodlines and pressure monitoring lines in each
designated machine.

8. Always check and verify heparin bolus dose, infusion rate and timer.

9. Always check and verify ultrafiltration (UF) goal, duration and dialysate bath.

10. The machine may only be operated by persons who have been instructed on the proper operation and
handling of the unit. (Please see the Hemodialysis Machine Operating Instructions Manual.)

11. Always check and verify audible alarm, corrective measures must be implemented. If persistent
malfunctioning occurs, call the maintenance service (B Braun Technician)

12. All technical problems and corrective measure done must be recorder accordingly in the maintenance
logbook

REPROCESSING OF DIALYZER AND BLOODLINES BEFORE DIALYSIS

Manual Reprocessing

1. Check the patient schedule and if there is confirmation of dialysis.

2. Check designated storage for the dialyzer and bloodlines.

3. Check patient’s name, date of first use marked on the dialyzer.

4. Removed the disinfectant by removing all caps from arterial and venous.

5. Dialyzer ports should be facing the drain or sink.

6. Connect Reverses Osmosis (R.O) water tubing to arterial tubing via a connector. Open R.O clamp and
rinse for 15mins, close arterial peripheral clamps let R.O water run for 5mins this is to clean the venous line.

7. Close peripheral venous clamps; clean all tubing with R. O water.

8. Clamp R.O source; then close arterial and venous clamps.

9. Clean all dialysate ports with R. O. water.

10. Recap dialysate ports.

11. Set-up dialyzer and bloodlines on the machine.

Automated Reprocessing (Renatron)

1. Ensure proper Personal Protective Equipment is used.

2. Note that a new pair of gloves must be used for every new dialyzer to avoid cross contamination.

3. Ensure that caps and RC connectors have been properly disinfected in 1% Renalin Solution for at least 2
hours.

4. Bring the dialyzer, still connected to the bloodlines, to the Renatron drip tray.

5. Connect the dialyzer to the Renatron starting from the bottom up.

6. Remove the venous bloodline with the dialyzer venous end tilted upward. Get a sterilized RC connector
and screw in the RC connector to the venous blood port. Connect the Renatron venous tube to the venous
blood port of the dialyzer by pushing in the quick disconnects port into RC connector. (DO NOT screw into
the blood port the RC connector while it is connected to the venous tube of the Renatron. This will cause the
tubing the twist and may loosen the connection inside the Renatron.)

7. Remove venous dialysate port cap form the dialyzer and connect the venous dialysate line of the Renatron
to the venous port of the dialyzer. Place the dialysate port cap into the dirty cap container to be sterilized.

8. Remove the arterial bloodline from the dialyzer and screw in a sterilized RC connector into the dialyzer
blood port. Connect the Renatron arterial line to the arterial RC connector using the quick disconnect port.
(DO NOT screw into the Blood port the RC connector while it is connected to the Venous tube of the
Renatron . This will cause the tubing the twist and may loosen the connection inside the Renatron.

9. Program the TCV into the Renatron by pushing the HOLD TO SET button while turning the TCV control
knob to the right or left till you get the right TCV lower limit target volume. (Program 80% of the original
Dialyzer TCV or priming volume.)

10. Press Mute and Reset buttons at the same time to program the reprocessing mode to OO, CH and HF for
low flux, mid flux and high flux respectively.
 11. Press start to start the Dialyzer Reprocessing cycle. The cleaning, Testing and Disinfection cycle should
take approximately 10 minutes.

12. The Renatron should check the dialyzer’s TCV and should do the leak test.

13. If the dialyzer passes the TCV and leak tests, the Renatron should sound and show PROCESS
COMPLETE.

14. You are ready to remove the Dialyzer form the Renatron.

15. Press RESET button to release pressure from the Renatron Fluid loop. If you do not do this, you may
have splashing of fluid when you remove the tubing form the dialyzer.

16. Remove the dialyzer from the Renatron starting from the top down.

17. Disconnect the Arterial Renatron from the arterial blood port of the dialyzer using the quick Disconnect
port (DO NOT remove the RC connector by twisting the tube and or the RC connector.)

18. Remove the RC connector form the Dialyzer Blood port and place it in the dirty cap container. 19. Get a
sterilized Blood port cap and screw it into the dialyzer arterial port.

20. Remove the dialyzer arterial dialysate port form the arterial dialysate holder of the Renatron by sliding
the sleeve forward to release it.

21. Get a sterilized Dialysate port cap and securely cap the Arterial Dialysate port of the dialyzer.

22. Place the arterial end of the dialyzer lower than the venous end of the dialyzer to ensure that there are no
fluid spills when the venous blood and dialysate ports disconnected from the Renatron.

23. Remove the dialyzer venous dialysate tube of the Renatron form the dialyzer venous dialysate

POLICIES AND PROCEDURES FOR STORAGE OF WATER AND APPROPRIATE DISINFECTION

METHOD

RISKS AND HAZARDS

The literature prior to 1980 contains reports of patients’ complications attributed to malfunctions or misuse of water
treatment systems in hemodialysis. These incidents or complications can be summarized by focusing on problems
that occurred with each component.

 Filters: bacterial growth, resulting in pyrogen reactions; hemolysis, due to elution of formaldehyde from
media; particle breakthrough, causing damage to downstream equipment.
 Carbon Absorption: Bacterial growth, causing pyrogen reactions; chloramine breakthrough, due to
inadequate sizing or exhaustion of the media resulting in hemolysis; release of carbons fines, damaging the
reverse osmosis (R.O) membrane; inappropriate bypassing of carbon filter.
  Softeners: Bacterial contamination, resulting in pyrogen reactions, hypercalcemia and hypermagnesemia,
due to inadequate regeneration, improper connections and poor salt quality; hypernatremia, due to mistiming
of regeneration while patients are on dialysis.
 Ion exchange: Bacterial contamination, causing pyrogen reaction; elution of fluoride, toxic residues, and
acidic effluent due to continued use of exhausted deionization system; elution of chemical toxins and
impurities, Due to the use of industrial grade resins; patient exposure to toxic chemicals, due to inadequate
rinsing disinfectant; low pH, due to acidic effluent; nitrosamines from use without carbon filter.
 Reverse Osmosis: Bacterial contamination, due to inadequate disinfecting or membrane breakthrough;
premature failure of membrane, due to inadequate or improper pre-treatment.
 Storage: Bacterial contamination, resulting in pyrogen reactions; zinc toxicity, due to leaching from storage
tank.
 Distribution: Bacterial contamination, causing pyrogen reaction, back-siphoning of germicide form one
machine to another, due to improper distribution design.

GUIDELINES

1.) The safety alert guideline by the Food and Drug Administrative (FDA) that issued recommendations regarding
chloramines and their removal. The document states that the use of granular activated filters for removal of
chloramines should include the following.

 Whenever a change is mad in the existing water treatment system, ascertain the capacity of the carbon filter
to cope with that change by consulting with a water treatment engineer, contractor. Or consultant who is
experienced in the operation of hemodialysis water treatment systems. This is to assure that the municipal
water supply can be effectively removed with the carbon filter being used.
 Use charcoal filters containing granular activated carbon (GAC) and replace rather than regenerate the filters
when exhausted. It is recommended that the water treatment system contain two carbon filters in series.

 Test the water for chloramines as its exits the first filter at least once per patient shift. If the level of
chloramines exceeds the 0.1 ppm standard, there should be an immediate test for the chloramine level in the
water used to prepare dialysate.
 Establish systematic plan for replacing the filters in series, the exhausted first filter can be replaced with the
second, and a new carbon placed in the second position.
 Whenever a carbon filter is replaced, disinfectants thoroughly rinse the filter housing before the new filter is
installed.
QUALITY ASSURANCE FOR WATER TREATMENT SYSTEMS

Policies and Procedures

An essential facility quality assurance activity is the development, writing implementation, and evaluation of policies
and procedures for the water treatment system. All standards previously described must be incorporated into these
policies and procedures. Specifically, the policies and procedures must address the scope monitors and testing
expectations.

Comprehensive policies and procedures must also address the interrelationship of each component of the water
treatment system, as well as the various related components, such as the dialyzer, delivery system and patient. The
risks involved must be clearly identified and considered and appropriate safety measures and preventive systems
developed.

Policies and procedures must also address safe and effective operation of the water treatment system, including:

 Basic technical operation

 Use of the equipment
 Safety checks
 Preventive Maintenance
 Cleaning and disinfection
 Scheduled monitoring
 Troubleshooting and repair
 Record keeping
 Patient Monitoring

Monitoring and Evaluation

A. Daily Monitoring

To continually confirm that water produced by the system is suitable for hemodialysis purposes as well as to confirm
the integrity and proper functioning of all system components. An aggressive monitoring process must be followed.

 Temperature: Daily confirmation of temperature should be performed.

 Pressure timer check: In installations where a timer is used to actuate automatic regeneration of the water
softener, a daily check of clock set time should be performed.
 Softener Timer Check: Installations where a timer is used to actuate components assures proper operating
conditions.
 Reverse osmosis feed flow and permeate flow; Substantial reduction in product flow rate is an indication that
there is may be degrading due to sealing or other types of membrane failure associated with inadequate pre-
treatment.
  Feed water total dissolved (TDS), product water TDS, percent rejection: AAMI Standards state that (for new
RO systems) “percent rejection should be continuously monitored”. This provides an indication of the
condition of the R.O. membranes as well as helping monitor against any catastrophic compromise in
membrane integrity. The performance shall be such that the salt passage rate (100% minus the rejection rate)
does not exceed two times the salt passage rate of the equipment in at the time of its initial qualification.
 Post water softener hardness: The AAMI American National Standard for hemodialysis systems also
recommends that post water softener hardness be checked daily before dialysis begins. This confirms that
water being delivered form the softener is at acceptable limits at that time. Some experts recommends
however, that post softeners hardness also be tested at the end of the treatment day in order to confirm proper
softener sizing and regeneration protocols.
 Chloramines testing. Testing for chloramines should be performed as the water exits the first granular
activated carbon filter. 8. Audit: The reader will note the final line at the bottom of the “Water Treatment
Log” indicates “Audit”. On a daily basis, someone who is knowledgeable about the tests, measurements and
limits for the water treatment monitoring, as well as the acceptable limits set forth in the facility’s policies
and procedures for each one of those measurements, should review the results. The person performing the
test should be aware of the acceptable limits and should have performed proper notification and take
appropriate action if the tests/ measurements performed indicated results outside of acceptable limits.

B. Monthly monitoring

 Conductivity meters require recalibrating monthly, following the manufacturers recommendations.

 Microbiological testing of system components and the distribution system must be performed monthly in
the following manner:

a. Post carbon filtration: AAMI (American National Standards for Hemodialysis Systems) recommends that
“carbon tanks be monitored for excess bacterial levels exiting a carbon tank, very high levels may indicate a
load so high that downstream components are unable to adequately remove them.

b. Post reverse osmosis: If reverse osmosis system is used as a primary method for attaining
microbiologically acceptable water, bacterial levels should be assessed immediately after the R.O. to
ascertain that this goal is being achieved.

C. Patients Monitoring

The following monitoring activities relate to patients’ response as it pertains to water treatment:

 Routine blood chemistries may indicate improper inorganic chemical concentrations or organic chemical
contaminates.
 Normal intra-dialytic monitoring of patients and patient symptomology during the dialysis session can also
provide indications of chemical water contamination. Symptoms seen with improper water treatment are
presents in Table 1A.
D. Home Dialysis Monitoring

 All of the monitoring procedures described above should be performed by the home dialysis patient, home
dialysis support personnel, and reviewed by the medical director, as appropriate.

E. Other Monitoring

The following water treatment system monitoring should be performed on at least a quarterly basis:

 Safety Supplies. All safety supplies related to personnel handling of chemical toxin or biological
contaminants should be inspected.
 Trend analysis. A trend analysis comparing microbial monitoring and system function should be performed.
A tool for assisting the facility in this activity is shown as Form3.

F. Prevention

 Audit record keeping procedure semi-annually.

 Policies and procedure related to water treatment and water treatment equipment should be reviewed
annually.
 Facility standards related to the water treatment system should be reviewed annually.
 Maintenance and repair logs related to the water treatment system should be reviewed annually.
 Any utility (water, drain, electricity) requirements related to the water treatment system should be reviewed
annually.

G. Purchasing Guidelines

 Establish quality specifications for all equipment used.

 Estimate quantity requirements; allow for future growth and possible membrane degradation.
 Cite applicable standards.
 Require system validation by the vendor to assure specifications are met.
 Require the vendor to test for and/or disclose adverse conditions/substances that may affect the membrane.
 Request a detailed manual for operation, maintenance, monitoring, disinfection, safety.
 Evaluate need for service contract.

TABLE 1A
WATER CONTAMINANTS AND THE LOWEST CONCENTARTIONS ASSOCIATED WITH TOXICITY
IN THE HEMODIALYSIS SETTING
Contaminants Lowest Concentration Associated with Toxicity
(mg/l)
Aluminum 0.06
Chloramines 0.25
Fluoride 1.0
Copper 0.49
Zinc 0.2
Nitrate 21 (as N)
Sulfate 200
Calcium/ Magnesium 88 (Ca”)
Sodium 300
Microbial

TABLE 1A
SIGNS AND SYMPTOMS AND POSSIBLE WATER CONTAMINANT-RELATED CASES
Sign or Symptom Possible Water Contaminant Related Cause

Anemia Aluminum, chloramines, copper, zinc

Bone Disease Aluminum, Fluoride
Hemolysis Chloramines, Copper, Nitrates
Hypertension Calcium, Sodium
Hypotension Bacteria, endotoxin, nitrates
Metabolic Acidosis Low pH, sulfates
Muscle Weakness Calcium, Magnesium
Nausea and vomiting Bacteria, Calcium, copper, endotoxin, low pH,
Magnesium, Nitrates, Sulphates, Zinc
Neurological deterioration and encephalopathy Aluminum

TABLE 2

WATER TREATMENT SYSTEM

COMPONENT NAME COMPONENT FUNCTION OPERATOR REQUIREMENTS

Blending Valve Mixes hot and cold water to fixed Water temperature downstream of
predetermined temperature to blending valve should be monitored
achieve optimal performance from at least daily to maintain optimum
the reverse osmosis device. R.O. output and to protect R.O
membrane and patients form excess
temperature.
Bed Filter Sand, multi-media, or diatomaceous Filter should be backwashed at
earth filter used to remove suspended frequent intervals. Pressure drop
matter or colloidal material before across filter should be monitored at
downstream components. least daily.

Carbon Absorption Activated carbon in tanks used to Test Water for chloramines after the
remove chlorine, chloramine and first tank before every patient
some organics. Two tanks, each dialysis shift. If chloramines are
containing granular activated carbon <0.1mg/L (AAMI Standard),
in series, are recommended. Each immediately test water exiting the
tank should have an empty bed second tank. If these levels exceed
contact time of 3 to 5 minutes. AAMI limits, dialysis should not
Carbon Tanks should be followed by proceed. When chloramine levels
particle filters to remove carbon fines reach AAMI limit after first tank,
for tank effluent. DO not install replace carbon tank. Monitor
bypass piping. bacterial levels.
Water Softener A tank containing insoluble spheres, Test upstream for baseline. Maintain
or beads, called “resin”. The resin volume of salt in brine tank. Test
exchanges cat ions (positively post-softener water for hardness at
charged sodium ions) to remove least once daily.
calcium and magnesium from
incoming hard water. Most facilities
use “permanent” softeners which
incorporate a brine tank containing
concentrated sodium chloride
solution and a control system to
regenerate the softener at present
intervals.

Reverse Osmosis A membrane separation process for Periodic and validated disinfection
removing solvent from a solution; and cleaning should be performed to
this system pressurizes feed water on protect the R.O. membrane from
one side of a membrane. By creating scale deposition, particulate and
a pressure high enough to exceed colloidal fouling, and bacterial
osmotic pressure, reverse osmotic growth. Feed and product water
flow of water occurs across a pressures, flow rates, and ionic
semipermeable membrane, giving content (conductivity) should be
“product water” essentially free of monitored according to the
dissolved solids, microorganisms, manufacturer’s recommendations,
and endotoxin. Variation in Ph and but at least daily. Post RO bacterial
temperature can affect performance. levels should be measured at least
monthly.
Deionization Tank containing insoluble spheres or Deionizers should be equipment with
resin, which remove all types of continuous monitors (temperature
anions and cat ions and replace them compensated) indicating water ionic
with hydrogen and hydroxide ions quality of at least 1 me ohm/cm and
which combine to form water. a visual and audible alarm, should
Deionizers may be categorized as the effluent fall below that level.
“mixed bed”, containing both cat ion
and anion resin in a single vessel, or Due to the propensity for bacterial
“dual bed” where each resin type is growth in deionizers, they should be
in a separate vessel. Due to the followed by a downstream
possibility of formation of component which removes bacteria
carcinogenic nitrosamines when and endotoxin.
chlorine contacts be used upstream of
deionizers.

Storage Tanks Water tanks that stores product Monitor bacterial levels of tank
water; required/ desired in some effluent. Disinfect tank and
installations. A water level detector distribution system at intervals
controls the R.O delivery to the tank which have been validated to
and a recirculation pump maintains maintain acceptable levels of
adequate flow and pressure to the microbiological contaminants.
distribution loop. Monitor proper performance of level
The centers for Disease Control has sensors.
recommended against use of storage
tanks due to hazards related to Confirm proper tank design: airtight
bacterial contamination. However, a tank with 0.2m hydrophobic air
numbers of facilities have been able filter; constant flow with no stagnant
 to successfully use storage tanks that areas; able to be adequately
are properly designed and effectively disinfected and rinsed (bowl-shaped
disinfected at validated intervals. bottom with drain); tank material
should not add chemical
contaminants, etc.

Ultraviolet Radiation A low pressure mercury vapor lamp Monitor loss of radiant energy
protected by a quartz sleeve which output. Perform regular maintenance,
emits a bactericidal wavelength light including lamp replacement and
to water flowing past it. It should be cleaning.
noted, however, that certain bacterial
species are resistant to ultraviolet
irradiation and that this method does
not remove endotoxins. Biofilm will
decrease effectiveness.

Ultra filter A membrane filter capable of Pressure drop and flow rate across
working solely off of existing circuit the filter should be monitored on at
pressure (no special pressurization least a daily basis. Filter should be
pump is required (as with R.O.) cleaned and disinfected on a routine
which will remove smaller particles and validated interval. Post-filter
than depth filters. Ultra filter bacterial levels should be monitored.
membranes can be configured as
hollow fibers or spiral wound flat
sheets, and they can be configured as
hollow fibers or spiral wound flat
sheets and they can be operated in
either a “dead- end” or “cross-flow
filtration” mode. Ultra filters are
capable of removing bacteria and
endotoxin.
Distribution The distribution loop includes all At least monthly monitor bacterial
piping from other water treatment levels in distribution piping at point
system components, distribution where dialysis delivery connect.
pumps, pressure tanks, etc. Disinfect distribution system at
Current acceptable industry design interval which has been validated or
suggests: maintain acceptable levels of
 Constant flow through all microbiological contaminants.
distribution piping, most
commonly achieved via
“recalculating loop”
 Pipe materials which do
not degrade the chemical
or microbiological quality
of the water
 A minimum flow velocity
in piping of 1.5ft. / Sec to
discourage bacterial
colonization.
 Avoidance of any dead-
ends in piping.
 TABLE 3
AAMI REQUIREMENTS AND MANUFACTURERS
GENERAL
 Device Labelling
 Product Literature
 Initial Validation
 Materials compatibility

SUPPLIER: AUTOMATIC REGENERATION DEVICES

 Shall prevent excess levels of contaminants from entering downstream during regeneration

SUPPLIER: CARBON FILTERS

 5µ filter downstream
 Discard and replace exhausted GAC

SUPPLIER: DEIONIZATION
 Continuous resistivity monitor (>1meg ohm /cm
 Temperature compensated monitor
 Visual and audible alarm
 GAC upstream (nitrosamines)

SUPPLIER: PIPING, STORAGE TANKS

 Shall not contribute contaminants (i.e., copper, zinc, lead, bacterial, etc.)

SUPPLIER: REVERSE OSMOSIS

 Capable of AAMI spec. water
 Monitor salt passage (2x initial) slat passage – 100 – rejection rate)
 Audible and visual alarms (at highest rejection coefficient where contaminants reach unsafe
levels)

SUPPLIER: SEDIMENT FILTERS

 Opaque housing

TABLE 4
AAMI STANDARDS FOR FACILITIES/ USER
MICROBIOLOGICAL MONITORING

Should be performed at least monthly

Total viable microbial counts shall not exceed 200/ml in water used to prepare dialysate, 2000’/ml in
proportioned dialysate exiting the dialyzer.

CHEMICAL CONTAMINANTS MONITORING

Should be performed at least yearly if prepared by DI or RO, more frequently it prepared with lesser level
of treatment. AAMI maximum levels of chemical contaminants:

Contaminant Suggested maximum level (mg/l)

Calcium 2 (0.1mEq/L)
Magnesium 4 (0.3mEq/L
Sodium 7093mEq/L
Potassium 8 (0.2mEq/L)
Fluoride 0.2
Chloride 0.5
Chloramines 0.1
Nitrate (N) 2
Sulfate 100
Copper, Barium, Zinc 0.1 each
Aluminum 0.01
Arsenic, Lead, Silver 0.005 each
Cadium 0.001
Chromium 0.014
Selenium 0.09
Mercury 0.0002

The physician has ultimate responsibility for determining the quality of water used for dialysis.

230mg/L (10mEq/L where sodium concentration of the concentrate has been reduced to compensate for
the excess sodium in the water, as long as conductivity of water is being continuously monitored.

TABLE 5
AAMI RECOMMENDATIONS FOR USERS
CARBON FILTRATION
 Disposable carton
 Monitor for bacteria
 Monitor for exhaustion
DEIONIZATION
 Don’t use industrial or process resins
 One meg ohm resistivity minimum quality with temperature compensated monitor
 Be aware of preservatives and anti-freeze solutions
 Carbon Filtration for protection against nitrosamines

 Good procedures for all equipment and systems

 Monitor for bacteria
 Periodic water analysis
 In-line continuous monitoring Test kits for daily monitoring
 A procedure manual

 Don’t use copper, galvanized iron, or iron materials

 Monitor for bacteria

 Monitor pre treatment

  Monitor operation

SEDIMENT FILTERS

 Opaque filers
 Monitor pressure drop (ΔP)
 Change filters periodically and / or monitor for bacteria

WATER SOFTENERS
 Automatic regeneration with bypass during regeneration with bypass during regeneration
 Pellet slat designed for softeners
 Check timer before dialysis
 Check hardness before dialysis

TABLE 6
AAMI RECOMMENDED PRACTICE FOR REUSE OF HEMODIALYZER:
WATER REQUIREMENTS

WATER TREATMENT SYSTEM

 Must meet requirements (pressure, flow rate, chemical quality, microbiological quality, etc.) of
reprocessing equipment operating under peak conditions.

WATER USED FOR RINSING/ CLEANING DIALYZER

 The water should have a bacterial colony count of less than 200/ml and/or bacterial
lipopolysaccharide concentration of less than 1 ng/ml (5E/ml, as measured by the Limulus
amebocyte lysate assay.

WATER USED TO PREPARE (DILUTE) GERMICIDE

 The water should have a bacterial colony count of less than 200/ ml and /or bacterial
lipopolysaccharide concentration of less than 1 ng/ml (5E/ml, as measured by the Limulus
amebocyte lystate assay.

STANDARD OPERATING PROCEDURES ON BACKWASHING OF R.O SYSTEM

Purpose: To show the detailed steps on how the reverse osmosis is being backwashed. Definition: Reverse osmosis
(R.O.) – A process by which a solvent such as water is purified of solutes by being forced through a semi permeable
membrane through which the solvent, but not the solutes, may pass.

Scope: The procedure starts with the checking for enough water supplies in the water tanks and ends with the turning
of right black knobs with an arrow of the reverse osmosis module. Reference: Haemodialysis machine operation
manual.

START
 Start

Check the ample water source

Check for the salt level

Turn off R.O. module

Unplug the R.O module

Remove the black cap cover of the four

layered multimedia filter

Push and turn pointer counter clockwise to

backwash sign

Remove black cap of ion exchange

Push and turn pointer counterclockwise to back wash

sign

PROCEDURAL FLOW A

Remove black cap of granulated activated

carbon

Push and turn pointer counter clockwise to

backwash sign
 Connect the R.O module machine to electrical
source

Turn to right black knob with an arrow of R.O

module

END

Guidelines:

 Check the ample water source. Visually check raw water tanks 1 and 2. It must be full.
 Open lid of container tank and check for the salt level- must be more then ½.
 Turn off R.O module by turning the black knob with an arrow to the left.
 Unplug the R.O module machine from the electrical source
 Remove the black cap cover of the four layered multimedia filter.
 Push and turn pointer counter clockwise to backwash sign. Wait for the pointer to stop at the treated water
sign. This will take about 30mins. To one hour.
 Remove black cap of ion exchange (water softener) tank.
 Push and turn pointer counter clockwise to backwash sign. Wait for the pointer to stop to the treated water
sign. This would take 1-2 hours.
 Remove black cap of granulated activated carbon (GAC) tank.
 Push and turn pointer counter clockwise to backwash again. Wait for the pointer tos top to the water treated
water sign. This would take 30mins -1 hour.
 Connect the R.ZO module machine to electrical source.
 Turn to right black knob with an arrow of R.O module.

BACKWASHING OF R.O SYSTEM

 Check for ample water source.

 Visually check raw water tanks 1 and 2. It must be full.
 Open lid of container tank and check for the salt level must be more than ½.
 Turn off R.O module by turning the black knob with an arrow to the left.
 Unplug the R.O module machine from the electrical source.
  Remove the black cap cover of the four layered multimedia filter, push and turn pointer counter clockwise
to backwash sign. Wait for the pointer to stop the treated water sign. This would take30mins to 1 hour.
 Remove black cap of ion exchange (water softener) tank. Push and turn pointer counter clockwise to
backwash sign. This would take 1-2hrs.
 Remove the black cap of granulated activated carbon (GAC) tank. Push and turn pointer counter clockwise
to backwash sign. Wait for the pointer to stop to the treated water sign. This would take 30mins m- 1 hour.
 Connect the R.O module machine to electrical source. Turn to right black knob with an arrow of R.O
module.

SCHEDULE OF BACKWASHING

MONDAY-FRIDAY with an ample of water (R.O water tank is full)

5pm- ION EXCHANGE TANK

4pm – 4 LAYERED MULTIMEDIA FILTER TANK
-GRANULATED ACTIVATED CARBON TANK (GAC)
EVERY SATURDAY OR SUNDAY: 9AM-COMPLETE BACKWASH

COLOR CODING OF HOSPITAL WASTE

 Black – for collection of non- infectious dry waste

 Green – for collection of non- infectious wet waste
 Yellow - or collection of infectious and pathological
 Yellow with black band – for collection of chemical waste
 Orange – for collection of radioactive waste.
 Red- for collection of sharps and pressurized containers.

POLICY ON PEST AND VERMIN CONTROL

 Prepared by:

TEFFANY JOY H. ENRIQUEZ, RN

Head Nurse

FLORITA GANZON, RN, MAN

Chief Nurse

Approved by:

MARYMIL B. DIGNADICE, MD, FPCP, FPSN

Chief Nephrologist

Noted by:

GILDA L. VILLANUEVA, MD, MPA, FPCHA, FPOGS,

FPCS
General Manager and Medical Director

1. PURPOSE
The purpose of this program is to explain the criteria by the criteria by the Standard
 Operating Procedure (SOP) for pest vermin control

2. BACKGROUND
The presence of vermin or insect pests in on around a food preparation factory is a health
hazard and an indicator of poor sanitary conditions. Management must have a pest and
vermin control SOP in place, which effectively controls any such presence and prevents
possible contamination risk to product.

This document updates current systems used to control pests and vermin in export meat
establishments and incorporates comments by overseas reviewers of pest control
programs seen at establishments.

3. DEFINITIONS
Vermin: All rodents.
Animals excluded from the establishment.
Wild birds.
Pests: Insects, both flying and crawling.
Physical barrier: Device used to prevent entry of pests and vermin such as
insect screening, self-screening, self-closing doors, flaps on
chutes, air curtains, etc.
Harborage: Anything used as temporary shelter by pests or vermin.
Breeding site: A place where presence of nesting or breeding of pests or
vermin is detected.
Chemical treatments: Application of poisons or insecticides by spraying, baiting,
etc.
Pesticide Type A: Insecticide approved for use in food production areas and
amenities under specific conditions.
Pesticide Type B: Insecticide approved for external use only.
A rodenticide used strictly in accordance with labeled
Pesticide Type C: directions. Not to be used inside edible areas or amenities,
laundries, carton stores and dry goods storage areas.
A miscellaneous pesticide used strictly in accordance with
Pesticide Type D: labeled directions.
Standard Operating Procedure
SOP:
4. RESPONSIBILITIES
Works Manager

 Ensures that resources are available to carry out the scope of this program and
participates in reviews of the procedures.
 Ensure responsible persons are trained for the relevant tasks.

Quality Assurance Manager

 Informs management review meetings of pest and vermin control program and
significant findings.
 Reviews pest and vermin reports and corrective actions.
 Arranges for repairs, maintenance and installations relevant to pest and vermin
control.
 Ensures effective integration of other on-plant programs with pest and vermin
control eg, sanitation and hygiene, disposal of waste material and maintenance.
 Audits and updates pest and vermin control SOP.
 Makes available to the pest control contractor the Map of Sightings as recorded
for each calendar month.

Pest Control Contractor

 Provides regular services and responds promptly to requests for extra servicing
made by management in the event of increased activity between services or
ineffective treatment.
 Complete pest report forms specifying:
 Species targeted
 Presence of vermin activity
 Location of each pest or vermin station.
 Type of treatment i.e. chemical, physical, placement of traps and bait
stations, etc.
 The name of the chemicals and the concentration at which the chemicals
were actually used.
 Trims or replaces any rodent bait block showing signs of gnawing.
 Replaces bait and clean fly bait stations.

Hospital Pest Control Officer(s)

 Carries out the above duties where no contractor is employed.

  Daily checks all traps present inside buildings or arranges for these to be part of
the pre-operational checks.
 Weekly monitors all aspects of the pest vermin control program.
 Dispenses pesticides and rodenticides to people trained in their use.
 Determines frequency of spraying exterior surfaces of buildings resulting from
seasonal increases in numbers of flying insects.
 Implements the internal pest and vermin elimination program.

Engineer/ Maintenance Supervisor

 Maintenance of the physical barriers to pest and vermin entry.

5. PROCEDURES AND ACTIONS

5.1 GENERAL
Pest control must be regularly carried out and results of bait station checks recorded. The
management of the establishment is responsible for the pest program including the
chemicals used and actions carried out by independent pest control companies.

The activity records of bait stations checks are to be clear and unambiguous and must
include any follow up action including preventive measures required by the management.

The checklists show what should be included in the pest control program, and the
expectations of the pest controller and the company for a managed response to pest
activity.

5.2 CHEMICALS
Any pest control chemical held at the establishment shall be in clearly designated
secure cabinet or facility used only for pest control. The keys to this facility are to be
controlled and limited as far as possible. Persons issued with keys are to be
nominated in the SOP. Chemicals used shall be approved and used only in accordance
with the instrument of approval.

The use of chemicals shall be approved by a company of pest and vermin SOP.
Management is responsible for all pest chemicals, including any used by an external pest
control contractor, within the establishment.

RODENTICIDES SHALL NOT BE USED INSIDE THE EDIBLE AREA OF THE

CLINIC OR WITHIN AMENITIES, LAUNDRIES, CARTON STORES AND DRY GOOD
STORAGE AREAS.
RODENTICIDE BAITS SHALL BE REMOVED FROM THESE AREAS AND
REPLACED WITH INDICATOR BAITS, AND LIVE TRAPS.

Insecticide foggers for roach and flies must not be used where people who work in edible
departments pass form amenities to production areas. This includes change rooms,
lockers, lunchrooms, doorways, corridors, etc. where possible insecticide may remain on
protective clothing. Foggers are not to be used around animal risk areas such as ramps,
garages and holding paddocks.

Type A insecticide may be used in lockers where cockroaches are present providing the
lockers are cleaned after the spray is used after edible production working hours
(protective work clothing including aprons should not be present in lockers).

5.3 PHYSICAL BARRIERS

Physical barriers prevent pests entering building or eliminate their presence. The barrier
must be effective and usually a combination of deterrents is required achieving the
purpose. The effectiveness of these barriers is a key indicator of the effectiveness of the
company preventative maintenance program. Examples of suitable barriers are:
 Self-closing doors mounted in such a way that light cannot be seen between the
rubber door seal and the floor or door jam.
 An ante room to the external entry door into the edible areas where active. Fly
control measures can be taken to stop their further ingress into the building.
 An air curtain installed at the external doorways. The air curtain should have the
capacity to move air across the full extent the doorways at 6msec.
 Insecticutor or insect sticky pad installed in the ante room such that the light is
shrouded to the outside so as not to attract flying insects form the outside.
 Connect Amenities to the processing areas with a fly-screened passageway.

Positive pressure ventilation, which provides an outward-moving barrier to flying insects

(and dust) when doors are opened. The ventilated input air must be filtered.

On the slaughter floor air will exhaust form stock entries and chutes; however slaughter
floor air must not be forced into the chillers as this will cause condensation. Adequate
exhausting in the vicinity of the final wash may prevent this.

 A correct fitted panel installed in the livestock race designed to deny vermin
access to the slaughter floor through the knocking box after finish of daily
production.
  Drain ports covered with the fitted plate. These plates should be removable to
allow access to traps and for the clearing of blockages.
 Chutes form the edible production areas to external or inedible areas flapped or
screened at the discharge end; use of fan exhaust fitted into the chute housing to
ensure outward movement of air may be beneficial.
 Screened entrances to inedible/condemned material processing areas. If these
areas have large chutes or slides entering directly from the edible product areas,
the type of personnel entrances used for edible areas should be installed.

5.4 CLEANING SANITATION AND HOUSEKEEPING

A broad scope cleaning and sanitation program is necessary to control and prevent
pests and vermin presence within the establishment.

The cleaning and sanitation SOP should include:

 Removal of alternative food sources which may attract pests and vermin in
edible production and storage areas, dry goods, storage areas and operatives’
amenities and compete with baits.
 Squeegeeing pools of water remaining on the floor of production areas and
amenities after the cleaning operation to provide a dry environment.
 Cleaning the by-products plants so that harborage is denied and foods
sources are eliminated.
 Daily high pressure hosting of livestock yards and pens particularly of
yards that have held grain-fed animals to ensure all grain in the dung is
removed.
 Cleaning of high-traffic personnel thoroughfares during the day and at the
production shift. Boot cleaning facilities associated with production areas
should be provided to prevent meat material being carried outside.
 Cleaning of the pantry after each main work break and again at the end of the
shift. A foaming detergent should be applied weekly to achieve a thorough
clean.
 Routine cleaning of personnel lockers.
 Routine leaning under carton pallets held in stores.
 Taping or otherwise securing broken packages or cartons holding ingredients
food product and product wrapping materials and immediately cleaning up
any split food source.
 Storage of equipment and materials used for plant maintenance and
construction in designated storage facilities e.g. on racks off the floor.
  Having lidded or screened containers including trailers to hold waste
products.
 Hauling waste material in water tight trailers which do not d\spill contents.
 Receiving inedible material on curbed and drained concrete aprons to prevent
material seeping into surrounding area and any spills contained and cleaned
up without delay.
 Not holding waste material on surfaces that cannot be cleaned effectively
 Disposing of inedible product before odors result from decomposing
material.
 Ensuring vegetable is kept under control in all parts of the premises including
the effluent ponds.
 Regular mowing of grass and trimming along the edges of concrete areas.

Management should approach neighboring properties if harborage exist that could

impact on the operation of this program.

5.5 VERMIN CONTROL

Effective vermin control relies on the combination of:

 Physical barriers to deny access by vermin to edible production and

storage areas, dry goods storage areas operatives’ amenities during
production and non-production periods.
 A board scope cleaning and sanitation program to include external areas
of the plant and vigorous housekeeping.
 Chemical treatments using perimeter baiting and,
 An interior regime of indicator baits and traps to verify that no vermin
has breached the control measures and entered the premises.

5.5.1 RODENT BAITING

Rodents are controlled with rodentical baits used in a perimeter baiting regime.
Rodent bait stations are individually numbered and their location recorded on a site
map. Large establishments especially in rural areas will require a primary fence line
perimeter series of baits as well as secondary external building perimeter line of baits.
In some states where baits may only be placed near building the placement of baits
near outbuildings is encouraged to form a primary perimeter.

The perimeter-baiting regime is established with advice from the Pest Control
Contractor and takes into account prevailing conditions ate the establishment e.g.
Proximity of the by-product plant to edible production buildings, location of effluent
ponds, and other features of topography.

Baits are to be placed at strategic locations around the entire plant and any
outbuildings or facilities and be positioned so that the contents cannot be washed into
any watercourse.

The design of bait stations shall allow access to rodents but not livestock or birds.

Plant operatives, other than the company pests control officer, should be denied
access to bait stations by using simple locking devices. Where the bait station is not
of a lidded locked design, the baits shall be secured into the baits station to prevent
removal.

The rodentical baits shall be all weather wax block type or similar that ensures there
is no spillage and readily shows signs of rodent activity.

5.5.2 INTERIOR REGIME OF INDICATOR BAITS AND TRAPPING

Poisonous baits are not be used in the edible areas of the plant, amenities, carton
stores and laundries. A comprehensive program of indicator baits or traps is to be
implemented inside establishment buildings which verify whether the above
procedures and effective in excluding vermin firm the buildings. These require an
attractant and are to be checked on a daily basis preferably during the daily pre-
operational hygiene checks.
There are several types of indicator baits available;
 Sticky pads
 Chew Baits, and
 Traps e.g. “Tin Cats” types

During the cooler months, extra vigilance is needed vermin presence inside
building. Particularly check infrequently used doorways, maintenance access
ways or disused areas.

Any presence detected requires management review of the vermin control

program.
5.6 CONTROL F LARGER VERTEBRATES
 A non-injury causing trap shall be kept on plant for the capture of feral or
native animals reported to the institution’s pest control officer that may be a
hygiene threat.
 Feral animals shall be humanely destroyed while native animals shall be
handed over to wildlife authorities for relocation.
 Nesting sites for birds shall be eliminated, as far as possible by screening.
All nests shall be removed in a timely fashion to prevent egg lying.
 Details of trap setting and animals capture shall be documented.

5.7 INSECT CONTROL

Management must implement an effective program to reduce the biomass of insects
(flying and crawling) at the plant and control insects entering building using physical
barriers and actively removing them from edible production and storage areas, dry
goods storage areas and amenities.

The insect biomass reduction program should involve denial of food sources,
chemical treatment, minimizing odors, and sanitation measures.

Hide receivable and inedible areas immediately adjacent to or under slaughter floors
should be insect proofed as far as possible and all sumps covered with checker plate.
Spoon drains should be cleaned of material regularly.

5.7.1 EXTERNAL INSECT PREVENTION REGIME

Pesticide type B may be sprayed onto the external wall surfaces and the insect-
screened areas during the warmer months. Use only in the areas nominated on the site
map of the plant. It is not to be sprayed near any doorways.

“Knockdown” (pesticide type A) sprays may need to use twice daily where there is a
heavy fly problem. The first application in done before sunrise and is directed to areas
of high insect density, usually in protected areas around the rendering plant and hide
handling area, etc. The second application in done before sunrise and is directed to
areas of high insect density, usually in protected areas around the rendering plant and
hide handling area, etc. The second application is done around the middle of the day
and is directed toward the most sunlit areas of the plant’s exterior walls and insect
screened areas. Spraying shall be restricted to identified on the site map.
 Where pesticide type B is used within the rendering plant or inedible/condemned
material areas, no product to be rendered or finished rendered product held in storage
shall be contaminated.

A perimeter fly baiting regime can be established using fly-bait stations and granular
fly bait type B contracted to deny access birds. Granular fly bait should not be spread
on the ground or on bag. Where possible use non-chemical flytraps. The location of
the fly-bait stations is recorded on a site map.

These bait stations are used to intercept flies moving to the plant form other areas.
This is best achieved by positioning the bait stations at least fifty meters from the
plant, 2 to 3 meters from the ground and on the side of the facing the direction of the
prevailing summer winds.

Fly bait stations should not be placed near doorways as these attract flies that may
enter the plant.

5.7.2. INTERNAL FLYING INSECT ELIMINATION REGIME

Insectecutor devices or contained insect sticky catchers should be installed in ate-

rooms, dry goods storage areas, carton make-up rooms, etc. that have entrances to the
building exterior. Insecticutor should be located in areas capable of being darkened
and where product and any materials used with product is unaffected by fly fallout.
Each device shall be numbered and its location recorded on a site map.
The insect attracting globes should be replaced at the intervals specified by the
manufacturer as the effectiveness of the globe dissipates over time. The date a new
globe is installed, and its effective life expectancy shall be recorded.

All Insecticutor shall be cleaned out weekly.

If flying insects penetrate the external and gain access to edible production and
storage areas, dry goods storage areas and operatives amenities, the type of
intervention shall depend on the extent of the infestation and structural features of the
room.

All actions to eliminate flying insects must be both rapid and effectives as flying
insects present a high risk to product safety.
 If the infestation is limited to a few individual insects that can be kept under constant
surveillance, the insects can be destroyed by swatting them in such a way that
product, contract surfaces or packaging materials is not contaminated. Any product
contacting surfaces must be cleaned and edible product either product either
discarded or trimmed if hit by a swat.

Alternatively, insects may be caught using a portable vacuum cleaner removed from
an area by switching of the lights so that the exit doorway or a portable insect cuter
provides the only light source.

Insecticide type A may only be dispensed after all product and packaging material is
removed from the room or covered.

Insecticide type A should be sprayed in the direction of individual insects and not at
any particular surfaces.

After spraying, the contract time specified in writing by the chemical manufacturer
shall be met to allow the insects to be destroyed and the insecticide to settle or be
exhausted from the room. When the contract time has lapsed, the room shall be rinsed
with the potable water and product contract surfaces hand scoured with detergent and
rinsed with potable water and product contact surfaces hand scoured with detergent
and rinsed before product or packaging material is reintroduced. Insecticutor should
not be sprayed inside the plant pre-operationally.

6. MONITORING

All staff is responsible for reporting sightings and activity throughout the plant and its
surround. Any sightings or evidence of vermin or insects during pre-operational inspections
is to be recorded on the daily pre-operational hygiene report. These findings must be acted on
immediately and all findings drawn to the attention of the Institution Pest Control Officer or
QA Manager.

The company pest control officer shall monitor and record the following elements of the
program:
Vermin Control

 Consult pre-operational hygiene forms for reports of vermin activity.

 Check condition of rubber door seals.
 Check the number and location of the bait stations and traps against the site
map.
 Record activity if any found at rodent bait stations and traps.
 Clean bait station of any droppings and replace or trim any gnaward bait blocks.
 Secure an adhesive label to the station specifying the date of servicing.

Insect Control

 Consult pre-operational hygiene forms for reports of insect activity and air
curtain operation.
 Check condition of physical barriers.
 Checks the preventive actions take under the sanitation program are recorded.
 Record date, location and chemical used when spraying pesticide type B.
 Check effectiveness of the fly bait stations.
 Check housekeeping around inedible/condemned areas and the rendering
plant.
 Record date, location and chemical used for all interior flying insect treatments.
 Record date, unit number and presence of insect cuter.

Maintenance teams play an important role in controlling pest and vermin entry to the
plant and shall monitor the barrier for maintenance defects.

Preventative Maintenance Log/Dairy

 Check all physical barriers once a month.

7. CORRECTIVE ACTION

Corrective action for pest and vermin control shall incorporate relevant parts of this program
and needs to be specific to each establishment. Must include what is to be done if pest or
vermin are detected.

Any pest control facility requiring repair shall be reported on the company maintenance
form.
The Quality Assurance Manager shall be notified whenever internal vermin activity is
reported or when spraying is required to control insects inside building and shall ensure that
all parties meet their responsibilities.

Notify the OPS of vermin activity at indicator baits or in the perimeter baits so that corrective
action can be verified if considered appropriate.

Corrective actions arising from activity of pests and vermin in edible production and storage
areas, dry goods storage areas and operatives amenities, particularly during peak seasonal
increases, require urgent management review of all aspects of the program. Management
review meetings and actions taken must be recorded.
8. PURPOSE
The purpose of this program is to explain the criteria by the criteria by the Standard
Operating Procedure (SOP) for pest vermin control

9. BACKGROUND
The presence of vermin or insect pests in on around a food preparation factory is a health
hazard and an indicator of poor sanitary conditions. Management must have a pest and
vermin control SOP in place, which effectively controls any such presence and prevents
possible contamination risk to product.

This document updates current systems used to control pests and vermin in export meat
establishments and incorporates comments by overseas reviewers of pest control
programs seen at establishments.

10. DEFINITIONS
Vermin: All rodents.
Animals excluded from the establishment.
Wild birds.
Pests: Insects, both flying and crawling.
Physical barrier: Device used to prevent entry of pests and vermin such as
insect screening, self-screening, self-closing doors, flaps on
chutes, air curtains, etc.
Harborage: Anything used as temporary shelter by pests or vermin.
Breeding site: A place where presence of nesting or breeding of pests or
vermin is detected.
Chemical treatments: Application of poisons or insecticides by spraying, baiting,
etc.
Pesticide Type A: Insecticide approved for use in food production areas and
amenities under specific conditions.
Pesticide Type B: Insecticide approved for external use only.
A rodenticide used strictly in accordance with labeled
Pesticide Type C: directions. Not to be used inside edible areas or amenities,
laundries, carton stores and dry goods storage areas.
A miscellaneous pesticide used strictly in accordance with
Pesticide Type D: labeled directions.
Standard Operating Procedure
SOP:
11. RESPONSIBILITIES
Works Manager

 Ensures that resources are available to carry out the scope of this program and
participates in reviews of the procedures.
 Ensure responsible persons are trained for the relevant tasks.

Quality Assurance Manager

 Informs management review meetings of pest and vermin control program and
significant findings.
 Reviews pest and vermin reports and corrective actions.
 Arranges for repairs, maintenance and installations relevant to pest and vermin
control.
 Ensures effective integration of other on-plant programs with pest and vermin
control eg, sanitation and hygiene, disposal of waste material and maintenance.
 Audits and updates pest and vermin control SOP.
 Makes available to the pest control contractor the Map of Sightings as recorded
for each calendar month.

Pest Control Contractor

 Provides regular services and responds promptly to requests for extra servicing
made by management in the event of increased activity between services or
ineffective treatment.
 Complete pest report forms specifying:
 Species targeted
 Presence of vermin activity
 Location of each pest or vermin station.
 Type of treatment i.e. chemical, physical, placement of traps and bait
stations, etc.
 The name of the chemicals and the concentration at which the chemicals
were actually used.
 Trims or replaces any rodent bait block showing signs of gnawing.
 Replaces bait and clean fly bait stations.

Hospital Pest Control Officer(s)

 Carries out the above duties where no contractor is employed.

  Daily checks all traps present inside buildings or arranges for these to be part of
the pre-operational checks.
 Weekly monitors all aspects of the pest vermin control program.
 Dispenses pesticides and rodenticides to people trained in their use.
 Determines frequency of spraying exterior surfaces of buildings resulting from
seasonal increases in numbers of flying insects.
 Implements the internal pest and vermin elimination program.

Engineer/ Maintenance Supervisor

 Maintenance of the physical barriers to pest and vermin entry.

12. PROCEDURES AND ACTIONS

5.8 GENERAL
Pest control must be regularly carried out and results of bait station checks recorded. The
management of the establishment is responsible for the pest program including the
chemicals used and actions carried out by independent pest control companies.

The activity records of bait stations checks are to be clear and unambiguous and must
include any follow up action including preventive measures required by the management.

The checklists show what should be included in the pest control program, and the
expectations of the pest controller and the company for a managed response to pest
activity.

5.9 CHEMICALS
Any pest control chemical held at the establishment shall be in clearly designated
secure cabinet or facility used only for pest control. The keys to this facility are to be
controlled and limited as far as possible. Persons issued with keys are to be
nominated in the SOP. Chemicals used shall be approved and used only in accordance
with the instrument of approval.

The use of chemicals shall be approved by a company of pest and vermin SOP.
Management is responsible for all pest chemicals, including any used by an external pest
control contractor, within the establishment.

RODENTICIDES SHALL NOT BE USED INSIDE THE EDIBLE AREA OF THE

CLINIC OR WITHIN AMENITIES, LAUNDRIES, CARTON STORES AND DRY GOOD
STORAGE AREAS.
RODENTICIDE BAITS SHALL BE REMOVED FROM THESE AREAS AND
REPLACED WITH INDICATOR BAITS, AND LIVE TRAPS.

Insecticide foggers for roach and flies must not be used where people who work in edible
departments pass form amenities to production areas. This includes change rooms,
lockers, lunchrooms, doorways, corridors, etc. where possible insecticide may remain on
protective clothing. Foggers are not to be used around animal risk areas such as ramps,
garages and holding paddocks.

Type A insecticide may be used in lockers where cockroaches are present providing the
lockers are cleaned after the spray is used after edible production working hours
(protective work clothing including aprons should not be present in lockers).

5.10 PHYSICAL BARRIERS

Physical barriers prevent pests entering building or eliminate their presence. The barrier
must be effective and usually a combination of deterrents is required achieving the
purpose. The effectiveness of these barriers is a key indicator of the effectiveness of the
company preventative maintenance program. Examples of suitable barriers are:
 Self-closing doors mounted in such a way that light cannot be seen between the
rubber door seal and the floor or door jam.
 An ante room to the external entry door into the edible areas where active. Fly
control measures can be taken to stop their further ingress into the building.
 An air curtain installed at the external doorways. The air curtain should have the
capacity to move air across the full extent the doorways at 6msec.
 Insecticutor or insect sticky pad installed in the ante room such that the light is
shrouded to the outside so as not to attract flying insects form the outside.
 Connect Amenities to the processing areas with a fly-screened passageway.

Positive pressure ventilation, which provides an outward-moving barrier to flying insects

(and dust) when doors are opened. The ventilated input air must be filtered.

On the slaughter floor air will exhaust form stock entries and chutes; however slaughter
floor air must not be forced into the chillers as this will cause condensation. Adequate
exhausting in the vicinity of the final wash may prevent this.

 A correct fitted panel installed in the livestock race designed to deny vermin
access to the slaughter floor through the knocking box after finish of daily
production.
  Drain ports covered with the fitted plate. These plates should be removable to
allow access to traps and for the clearing of blockages.
 Chutes form the edible production areas to external or inedible areas flapped or
screened at the discharge end; use of fan exhaust fitted into the chute housing to
ensure outward movement of air may be beneficial.
 Screened entrances to inedible/condemned material processing areas. If these
areas have large chutes or slides entering directly from the edible product areas,
the type of personnel entrances used for edible areas should be installed.

5.11 CLEANING SANITATION AND HOUSEKEEPING

A broad scope cleaning and sanitation program is necessary to control and prevent
pests and vermin presence within the establishment.

The cleaning and sanitation SOP should include:

 Removal of alternative food sources which may attract pests and vermin in
edible production and storage areas, dry goods, storage areas and operatives’
amenities and compete with baits.
 Squeegeeing pools of water remaining on the floor of production areas and
amenities after the cleaning operation to provide a dry environment.
 Cleaning the by-products plants so that harborage is denied and foods
sources are eliminated.
 Daily high pressure hosting of livestock yards and pens particularly of
yards that have held grain-fed animals to ensure all grain in the dung is
removed.
 Cleaning of high-traffic personnel thoroughfares during the day and at the
production shift. Boot cleaning facilities associated with production areas
should be provided to prevent meat material being carried outside.
 Cleaning of the pantry after each main work break and again at the end of the
shift. A foaming detergent should be applied weekly to achieve a thorough
clean.
 Routine cleaning of personnel lockers.
 Routine leaning under carton pallets held in stores.
 Taping or otherwise securing broken packages or cartons holding ingredients
food product and product wrapping materials and immediately cleaning up
any split food source.
 Storage of equipment and materials used for plant maintenance and
construction in designated storage facilities e.g. on racks off the floor.
  Having lidded or screened containers including trailers to hold waste
products.
 Hauling waste material in water tight trailers which do not d\spill contents.
 Receiving inedible material on curbed and drained concrete aprons to prevent
material seeping into surrounding area and any spills contained and cleaned
up without delay.
 Not holding waste material on surfaces that cannot be cleaned effectively
 Disposing of inedible product before odors result from decomposing
material.
 Ensuring vegetable is kept under control in all parts of the premises including
the effluent ponds.
 Regular mowing of grass and trimming along the edges of concrete areas.

Management should approach neighboring properties if harborage exist that could

impact on the operation of this program.

5.12 VERMIN CONTROL

Effective vermin control relies on the combination of:

 Physical barriers to deny access by vermin to edible production and

storage areas, dry goods storage areas operatives’ amenities during
production and non-production periods.
 A board scope cleaning and sanitation program to include external areas
of the plant and vigorous housekeeping.
 Chemical treatments using perimeter baiting and,
 An interior regime of indicator baits and traps to verify that no vermin
has breached the control measures and entered the premises.

5.5.3 RODENT BAITING

Rodents are controlled with rodentical baits used in a perimeter baiting regime.
Rodent bait stations are individually numbered and their location recorded on a site
map. Large establishments especially in rural areas will require a primary fence line
perimeter series of baits as well as secondary external building perimeter line of baits.
In some states where baits may only be placed near building the placement of baits
near outbuildings is encouraged to form a primary perimeter.

The perimeter-baiting regime is established with advice from the Pest Control
Contractor and takes into account prevailing conditions ate the establishment e.g.
Proximity of the by-product plant to edible production buildings, location of effluent
ponds, and other features of topography.

Baits are to be placed at strategic locations around the entire plant and any
outbuildings or facilities and be positioned so that the contents cannot be washed into
any watercourse.

The design of bait stations shall allow access to rodents but not livestock or birds.

Plant operatives, other than the company pests control officer, should be denied
access to bait stations by using simple locking devices. Where the bait station is not
of a lidded locked design, the baits shall be secured into the baits station to prevent
removal.

The rodentical baits shall be all weather wax block type or similar that ensures there
is no spillage and readily shows signs of rodent activity.

5.5.4 INTERIOR REGIME OF INDICATOR BAITS AND TRAPPING

Poisonous baits are not be used in the edible areas of the plant, amenities, carton
stores and laundries. A comprehensive program of indicator baits or traps is to be
implemented inside establishment buildings which verify whether the above
procedures and effective in excluding vermin firm the buildings. These require an
attractant and are to be checked on a daily basis preferably during the daily pre-
operational hygiene checks.
There are several types of indicator baits available;
 Sticky pads
 Chew Baits, and
 Traps e.g. “Tin Cats” types

During the cooler months, extra vigilance is needed vermin presence inside
building. Particularly check infrequently used doorways, maintenance access
ways or disused areas.

Any presence detected requires management review of the vermin control

program.
5.13 CONTROL F LARGER VERTEBRATES
 A non-injury causing trap shall be kept on plant for the capture of feral or
native animals reported to the institution’s pest control officer that may be a
hygiene threat.
 Feral animals shall be humanely destroyed while native animals shall be
handed over to wildlife authorities for relocation.
 Nesting sites for birds shall be eliminated, as far as possible by screening.
All nests shall be removed in a timely fashion to prevent egg lying.
 Details of trap setting and animals capture shall be documented.

5.14 INSECT CONTROL

Management must implement an effective program to reduce the biomass of insects
(flying and crawling) at the plant and control insects entering building using physical
barriers and actively removing them from edible production and storage areas, dry
goods storage areas and amenities.

The insect biomass reduction program should involve denial of food sources,
chemical treatment, minimizing odors, and sanitation measures.

Hide receivable and inedible areas immediately adjacent to or under slaughter floors
should be insect proofed as far as possible and all sumps covered with checker plate.
Spoon drains should be cleaned of material regularly.

5.7.1 EXTERNAL INSECT PREVENTION REGIME

Pesticide type B may be sprayed onto the external wall surfaces and the insect-
screened areas during the warmer months. Use only in the areas nominated on the site
map of the plant. It is not to be sprayed near any doorways.

“Knockdown” (pesticide type A) sprays may need to use twice daily where there is a
heavy fly problem. The first application in done before sunrise and is directed to areas
of high insect density, usually in protected areas around the rendering plant and hide
handling area, etc. The second application in done before sunrise and is directed to
areas of high insect density, usually in protected areas around the rendering plant and
hide handling area, etc. The second application is done around the middle of the day
and is directed toward the most sunlit areas of the plant’s exterior walls and insect
screened areas. Spraying shall be restricted to identified on the site map.
 Where pesticide type B is used within the rendering plant or inedible/condemned
material areas, no product to be rendered or finished rendered product held in storage
shall be contaminated.

A perimeter fly baiting regime can be established using fly-bait stations and granular
fly bait type B contracted to deny access birds. Granular fly bait should not be spread
on the ground or on bag. Where possible use non-chemical flytraps. The location of
the fly-bait stations is recorded on a site map.

These bait stations are used to intercept flies moving to the plant form other areas.
This is best achieved by positioning the bait stations at least fifty meters from the
plant, 2 to 3 meters from the ground and on the side of the facing the direction of the
prevailing summer winds.

Fly bait stations should not be placed near doorways as these attract flies that may
enter the plant.

5.7.2. INTERNAL FLYING INSECT ELIMINATION REGIME

Insectecutor devices or contained insect sticky catchers should be installed in ate-

rooms, dry goods storage areas, carton make-up rooms, etc. that have entrances to the
building exterior. Insecticutor should be located in areas capable of being darkened
and where product and any materials used with product is unaffected by fly fallout.
Each device shall be numbered and its location recorded on a site map.
The insect attracting globes should be replaced at the intervals specified by the
manufacturer as the effectiveness of the globe dissipates over time. The date a new
globe is installed, and its effective life expectancy shall be recorded.

All Insecticutor shall be cleaned out weekly.

If flying insects penetrate the external and gain access to edible production and
storage areas, dry goods storage areas and operatives amenities, the type of
intervention shall depend on the extent of the infestation and structural features of the
room.

All actions to eliminate flying insects must be both rapid and effectives as flying
insects present a high risk to product safety.
 If the infestation is limited to a few individual insects that can be kept under constant
surveillance, the insects can be destroyed by swatting them in such a way that
product, contract surfaces or packaging materials is not contaminated. Any product
contacting surfaces must be cleaned and edible product either product either
discarded or trimmed if hit by a swat.

Alternatively, insects may be caught using a portable vacuum cleaner removed from
an area by switching of the lights so that the exit doorway or a portable insect cuter
provides the only light source.

Insecticide type A may only be dispensed after all product and packaging material is
removed from the room or covered.

Insecticide type A should be sprayed in the direction of individual insects and not at
any particular surfaces.

After spraying, the contract time specified in writing by the chemical manufacturer
shall be met to allow the insects to be destroyed and the insecticide to settle or be
exhausted from the room. When the contract time has lapsed, the room shall be rinsed
with the potable water and product contract surfaces hand scoured with detergent and
rinsed with potable water and product contact surfaces hand scoured with detergent
and rinsed before product or packaging material is reintroduced. Insecticutor should
not be sprayed inside the plant pre-operationally.

13. MONITORING

All staff is responsible for reporting sightings and activity throughout the plant and its
surround. Any sightings or evidence of vermin or insects during pre-operational inspections
is to be recorded on the daily pre-operational hygiene report. These findings must be acted on
immediately and all findings drawn to the attention of the Institution Pest Control Officer or
QA Manager.

The company pest control officer shall monitor and record the following elements of the
program:
Vermin Control

 Consult pre-operational hygiene forms for reports of vermin activity.

 Check condition of rubber door seals.
 Check the number and location of the bait stations and traps
against the site map.
 Record activity if any found at rodent bait stations and traps.
 Clean bait station of any droppings and replace or trim any gnawed bait
blocks.
 Secure an adhesive label to the station specifying the date of

servicing.

Insect Control

 Consult pre-operational hygiene forms for reports of insect

activity and air curtain operation.
 Check condition of physical barriers.
 Checks the preventive actions take under the sanitation program
are recorded.
 Record date, location and chemical used when spraying pesticide
type B.
 Check effectiveness of the fly bait stations.
 Check housekeeping around inedible/condemned areas and the
rendering plant.
 Record date, location and chemical used for all interior flying insect
treatments.
 Record date, unit number and presence of insect cuter.

Maintenance teams play an important role in controlling pest and vermin

entry to the plant and shall monitor the barrier for maintenance defects.

Preventative Maintenance Log/Dairy

 Check all physical barriers once a month.

14. CORRECTIVE ACTION

Corrective action for pest and vermin control shall incorporate relevant parts of
this program and needs to be specific to each establishment. Must include what is
to be done if pest or vermin are detected.

Any pest control facility requiring repair shall be reported on the company
maintenance form.
 PROTOCOL ON HOUSEKEEPING

Prepared by:

TEFFANY JOY H. ENRIQUEZ, RN

Head Nurse

FLORITA M. GANZON, RN., MAN

Chief Nurse

Approved by:

MARYMIL B. DIGNADICE, MD, FPCP, FPSN

Chief Nephrologists

Noted by:

GILDA L. VILLANUEVA, MD, MPA, FPCHA, FPOGS, FPCS

General Manager and Medical Director
FUNCTION

This department/ section provide and maintain clean, safe and sanitary facilities and
environment for hospital personnel, and patients and clients.

Headed by : Department/ Section Head

Responsible to : Chief of the AFS
Expects services/ inputs from : All hospital units
Infection Control Committee
Healthcare Waste Management Committee

Provides services/ outputs to

Internal Clients : Patients

All hospital units

Hospital personnel

Healthcare Waste Management Committee

Infection Control Committee

Conservation and Environmental Committee

External Clients : DOH

Other government agencies

Other Clients
POLICIES

 Provision and maintenance of safe, maintenance of safe, pleasant, clean and green
environment in all areas shall be assured for quality healthcare delivery.
 Housekeeping and cleaning protocols shall be strictly observed.
 Implementation of the Healthcare Waste Management Program shall be carried out.
 Proper cleaning methods, infection control standards and supplies/ equipment (PPE)
shall be strictly followed.
 Appropriate Personnel Protective Equipment (PPE) shall be provided.
 Regular program for the prevention and eradication of rodents, pests, vectors and other
vermin shall be implemented.
 Provision of adequate and relevant training program on proper waste management,
infection control practices and quality standards to Housekeeping Department/ Section
staff shall be assured.
 Safe and proper handling of equipment, materials and chemicals used for cleaning and
disinfecting shall be continuously emphasized.
 Proper storage of housekeeping carts/tools shall be observed.

RESPONSIBILITY

 Participates in the preparation and implementation of Healthcare Waste Management

and Infection Control Programs for a clean, safe, and sanitary buildings, facilities and
environment.
 Maintains cleanliness and sanitation of building and facilities.
 Reports immediately noted deficiencies and violations of set policies and procedures.
 Coordinates the repair of furniture, fixtures and other hospital facilities.
 Coordinates the implementation of infection control and healthcare waste management
programs.
 Maintains and adequate and acceptable inventory of housekeeping supplies and
equipment.

STANDARD OPERATING PROCEDURES

  Maintenance of Cleanliness and Sanitation

Procedures Person/s Responsible

____________________________________________________________________________
1. Cleans, sanitize and disinfects comfort rooms, Service janitors/ staffs
lavatories and all assigned areas Designated/
contracted
2. Keeps housekeeping tools in proper places after use.
3. Collects and places garbage at designates area for
pick-up.
4. Cleans waste cans.

Procedures Person/s Responsible

______________________________________________________________________________
1. Conducts regular inspection of waste storage Designated staff
and maintains its cleanliness and sanitation.
2. Monitors garbage collection.
3. Records collection done by contracted service
providers

_____________________________________________________________________________

4. Sweeps, collects garbage from the different hospital Service janitors/ staff
units strictly observing the policies on waste segregation. designated
/contracted
5. Transports garbage to transient storage area.
6. Stores waste at appropriate storage in color-coded trash bags.
7. Cleans/ Disinfects garbage bins, storage area and surroundings.
8. Submits monthly report to Head of Housekeeping Department/
Section

POLICY ON BUILDING/
 CLINIC MAINTENANCE

Prepared by:

TEFFANY JOY H. ENRIQUEZ, RN

Head Nurse

FLORITA M. GANZON, RN., MAN

Chief Nurse

Approved by:

MARYMIL B. DIGNADICE, MD, FPCP, FPSN

Chief Nephrologists

Noted by:

GILDA L. VILLANUEVA, MD, MPA, FPCHA, FPOGS, FPCS

General Manager and Medical Director

I. Introduction

The Panay Heath Care Multi-Purpose Cooperative Hospital has conceptualized a

policy in preventing and maintaining the continued structural integrity and reliability
 of building in order to safeguard the working environment of all personnel,
equipment and clients. The management of maintenance activities must be
institutionalized, engineered and implemented as part of health system. Quality
health service delivery can be expected only from a well maintained health facility.

I. Objective

The specific objectives of this preventative building maintenance is to ensure the

safety and sustainability of health infrastructure and availability of safe, affective
and well maintained health facility. To establish inventory and database that can be
regularly updated facilitate information required for annual planning for
maintenance execution.

II. Definition

Maintenance Strategy – a strategy within which decisions on maintenance are taken.

Maintenance Planning – deciding in advance the jobs, methods, material, tools,

machines, labor, budget, time required.

Maintenance Schedule – a comprehensive list of maintenance and its incidence.

Maintenance Budget – a budget that represents a projection of expenditures for

some future time period.

Job Order – a document requesting and written instruction detailing work to be

carried out.

Emergency Maintenance – a maintenance wherein it is necessary to put the item on

hand or to bring an item in operation immediately to avoid serious consequences.

Planned Maintenance – a maintenance organized and carried out following the

maintenance schedule or predetermined plan.

Renovation – to get an old building or facilities back into condition.

Reconstruction – replacing an old building by a new construction.

 Maintenance - a combination of any actions carried out to retain and item in, or
restore it to, an acceptance operating condition.

Cleaning - to reduce contamination to an acceptable condition.

Service – replacement of consumables needed to keep an item in operating

condition.

III. Policy Procedure

The maintenance activity is a condition of planned preventive maintenance and

corrective maintenance.

Preventive Maintenance

Preventive Maintenance is regular, repetitive work to keep building facilities in good

condition. This activity involves regular, routine cleaning such as evaluation of structural
and non-structural components of the health facilities vegetation control, etc.
importance of preventive maintenance is a measure task to track the maintenance and
repair system in a positive direction.

Corrective Maintenance

Maintenance carried out to restore (including adjustment and repair) an item which has
ceased to meet an acceptable condition. Corrective maintenance includes the activities
of major repair works. This type of maintenance is required due to ageing, calamities,
natural disaster or damage caused by users or public.

All works and materials shall be in conformity to the specified National Building Code of
the Philippines, Plumbing Code of the Philippines, Electrical Code of the Philippines and
Philippine Standard for Materials.

POLICY IN CASE OF FAILED WATER ANALYSIS

 Prepared by:

TEFFANY JOY H. ENRIQUEZ, RN

Head Nurse

FLORITA M. GANZON, RN., MAN

Chief Nurse

Approved by:

MARYMIL B. DIGNADICE, MD, FPCP, FPSN

Chief Nephrologists

Noted by:

GILDA L. VILLANUEVA, MD, MPA, FPCHA, FPOGS, FPCS

General Manager and Medical Director

Water treatment systems and dialysis machines need to be decontaminated and

disinfected periodically and whenever necessary. When test results exceed AAMI water
standard limits, the HD Unit shall temporarily cease its operations until the repeat test of the
failing parameter(s) complies with the standards. The HD Unit shall perform the following
necessary corrective actions and notify their patients of the situation.

a. Review the following procedures to isolate the potential problem.

1. Level of bacteria exiting RO machine;

2. Product water distribution system disinfection procedures;

3. Examine the distribution piping system for dead spots that may contribute to
bacterial contamination.

b. Corrective action shall be undertaken in the area of the suspected cause for results which
exceed AAMI water standard limits and may include:

1. Cleaning and disinfection/ replacement of RO machine membrane;

2. Disinfection of the product water distribution system, including the entire loop;

3. Disinfection of the water hose on the dialysis machine.

c. Conduct resampling and re-test of the affected parameter.

PROTOCOL ON HEPATITIS B AND C VIRUS
Prepared by:

TEFFANY JOY H. ENRIQUEZ, RN

Head Nurse

FLORITA M. GANZON, RN., MAN

Chief Nurse

Approved by:

MARYMIL B. DIGNADICE, MD, FPCP, FPSN

Chief Nephrologists

Noted by:

GILDA L. VILLANUEVA, MD, MPA, FPCHA, FPOGS, FPCS

General Manager and Medical Director
PURPOSE:

 To promote safety among staffs.

 To prevent transmission of blood borne viruses in health care setting.
 To be knowledgeable enough in using PPE (personal protective equipment).
 To ensure accurate procedures of proper disposal in the unit.
 To effectively demonstrate the implementation of standards for cleaning and reusing
patient care equipment.

DESCRIPTION:

The PHCMPC Hospital Dialysis Unit currently consists of 12 Dialysis beds.

1. 10 dialysis beds for patient Non-reactive to Hepatitis C and B virus.

2. 1 dialysis bed for Reactive patients.

3. 1 dialysis bed for COVID-19 POSITIVE

 The dialysis machine provided for the reactive patients is located at the far end of the
treatment area.
 It is labeled as ISOLATION AREA and equipment were located inside the space provided
wide enough for a dialysis machine, a sink, and a bed to fit in.
 Moreover, nurses can move within the designated space without interference.
 It has a glass division and a separate sliding door to avoid contact of blood or bodily
fluids to other non-reactive patients and personnel as well.

WORK PRACTICE:

Patient:

1. All patients who come to the unit for a dialysis session must present their hepatitis status
within the last 6 months of their treatment.

These include:
 Hepa B Surface Antigen (Qualitative)
 Hepa B Surface Antigen (Quantitative)
 HCV- Hepatitis C Virus Antibody Result
 Aniti HBs(HBsAb) – Antibody to Hepatitis B Surface Antigen

2. They must also process a record a record of their hepatitis B vaccination as well as other
vaccinations if any.
3. If the patient does not have any vaccination record or hepatitis status, then he/she must
submit herself to the tests provided above for strict compliance prior to dialysis procedure.

4. Referral letter must also be available upon receiving the latest laboratory results from the
patient.

5. Patient’s data must be referred to the Chief Nephrologist for evaluation before the scheduled
dialysis session.

TREATMENT AREA:

This emphasizes on the use of facilities and/or equipment intended for reactive patients only.

1. Only the patient is allowed to eat inside the isolation area. Only one folk is allowed per
patient but the reactive patients, they should stay outside and would visit their patient once the
nurse on duty will ask for their assistance.

2. Instruments used within the isolation area must be disinfected properly and autoclaved the
same day it was used with proper label. “ISOLATION INSTRUMENTS”

3. Supplies such as face mask, gloves, tapes, oxygen cannula, oxygen tank, hemodialysis kits and
needles must be readily available at bedside cabinet.

4. Emergency medicines are available in the E-cart. Medicine/s brought inside the isolation
area, although it was never administered to the patient is added in the list of isolation supplies
and must be administered only to reactive patients.

5. The use of puncture resistant needle and sharp object disposal containers top avoid
unnecessary phlebotomies. These containers are available inside the isolation area and needles
must be discarded daily at the end of last shift. The hospital personnel assigned to collect the
containers will discard the said containers based on institution’s standard protocol on waste
and sharps disposal.

6. Dialyzer Reprocessing

* With precautionary measures, the dialyzers of reactive patients are being reprocessed one at
a time; PPE is also implemented to prevent transmission of blood borne viruses.

* Manual reprocessing is done by the dialysis technician. In case the technician is not available,
the staff nurse assigned to the reactive patient will also be the one to reprocess the dialyzer.

* In cases where the said nurse needed assistance for the termination of treatment, another
nurse will be assigned to the machine and will reprocess the dialyzer. He/she will not handle
any more patient/s all throughout the shift. If he/she has –reactive patient assignment, he/she
will endorse it to other nurses.
7. Blood Transfusion

Minor to severe problems occur during blood transfusion,

Allergic reactions, fever, hemolytic reactions and blood borne infections are some of the
common complications.

1. Standard protocol such as cross matching result within 48 hrs. is considered as valid for blood
transfusion.

2. Patient’s data must be thoroughly checked. Important details are indicated on the cross
matching result provided and are labeled on the blood unit.

3. Make sure the data on the blood unit matches the information given in the cross matching
result.

4. Medications are given prior to blood transfusion as ordered by the attending physician to
avoid allergic reactions during BT.

5. Blood transfusion during dialysis:

 Patient’s vital signs are monitored every 15 minutes.

 For the 1st 10minutes, the blood flow rate of the dialysis machine is decreased to
150ml/min. Drops are regulated to 20gtts/min to monitor the patient for possible BT
reaction/s.
 After Blood Transfusion, supplies used are discarded separately including the blood bag
and tubing. A container for blood transfusion/s for both reactive and non-reactive
patients are provided and labeled as infectious.

NURSES

1. A nurse assigned to reactive patient per shift must not handle non-reactive patients. The
patient rotation is scheduled by the head nurse.

2. Double gloving is a must, provided with face shield, apron and head dress. Same technique is
also implemented in cannulating non –reactive patients. PRECAUTION must be thoroughly
practiced.

3. Vaccination: A hepatitis B vaccination as well as other vaccinations must be recorded to the

logbook provided for the staffs.

4. A logbook of hepatitis B vaccinations among patients must be checked and updated every 6
months.
5. A nurse assigned to handle reactive patients should provide information/s of her hepatitis
status and vaccinations. In case of needle stick injury, the nurse must undergo to HBsAg Titer
Test immediately.
PROTOCOL ON HUMAN IMMUNODEFICIENCY
VIRUS PRECAUTION

Prepared by:

TEFFANY JOY H. ENRIQUEZ, RN

Head Nurse

FLORITA M. GANZON, RN., MAN

Chief Nurse

Approved by:

MARYMIL B. DIGNADICE, MD, FPCP, FPSN

Chief Nephrologists

Noted by:

GILDA L. VILLANUEVA, MD, MPA, FPCHA, FPOGS, FPCS

General Manager and Medical Director
PURPOSE:

 To provide safety among staffs.

 To prevent transmission of blood borne viruses in health care settings.
 To be knowledgeable enough in using PPE (Personal Protective Equipment.
 To ensure accurate procedures of proper disposal in the unit.
 TO effectively demonstrate the implementation of standards for cleaning and reusing
patient care equipment.

DEFINITION:

Human Immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency
syndrome (AIDS), is transmitted through sexual contact and exposure to infected blood or
blood components and perinatal form mother to neonate. HIV has been isolated form blood,
semen, vaginal secretions, saliva, tears, breast milk, cerebrospinal fluid, amniotic fluid and urine
and is likely to be isolated from other body fluids, secretions, and excretions. However,
epidemiologic evidence has implicated only blood, semen, vaginal secretions and possibly
breast milk in transmission.

The increasing prevalence of HIV increases the risk that healthcare workers will be
exposed to blood form patients infected with HIV, especially when blood and body fluid
precautions are not followed for all patients. Thus, this document emphasizes the need for
health- care workers to consider ALL patients as potentially infected with HIV and /or other
blood-borne pathogens and to adhere rigorously to infection control precautions for minimizing
the risk of exposure to blood and body fluids of all patients.

DESCRIPTION:

The PHCMPC Hospital Dialysis Unit currently consists of 12 Dialysis beds.

1. 10 dialysis beds for patient Non-reactive to Hepatitis C and B virus.

2. 1 dialysis bed for Reactive patients.

3. 1 dialysis bed for COVID-19 POSITIVE

 The dialysis machine provided for the reactive patients is located at the far end
of the treatment area.
  It is labeled as ISOLATION AREA and equipment were located inside the space
provided wide enough for a dialysis machine, a sink and a bed to fit in.
 Moreover, nurses can move within the designated space without interference.

 It has a glass division and a separate sliding door to avoid contact of blood or
bodily fluids to other non – reactive patients and personnel as well.

NURSES:

 Lectures regarding HIV awareness will be conducted by the Nephrologist at least

twice a month provided by pamphlets to be given to patients/ folks.
 Infection control strategies should be used routinely in dialysis units. These
includes blood precautions and barrier techniques, such as the use of face shield,
mask double gloving, gowns and hand washing techniques.
 Precautions for needle stick injury must be observed. Recapping of needles is
prohibited.
 Needles, scalpel blades, and other sharp objects must be placed in puncture-
resistant containers for disposal.
 Syringes are also disposed in a container soaked with disinfectant.
 Bloodlines, drainage bags, and saline bottles are discarded in a yellow garbage
bag (infectious) and are collected daily by the hospital’s sanitary personnel.
 Laboratory examinations specifically HIV Screening Test and Hepatitis Screening
are done every 6 months for the prevention of possible transmission.
 If there is any circumstance whether a health care worker is tested as positive
for HIV Screening Test, he/she will then be referred top their community’s health
nurse for interviews, providing alternative means to deal with progression of the
disease as well as conducting other lab tests following the treatment process.
These data will be filed within the Department of Health’s HIV registry and will
be considered as CONFIDENTIAL.

WORK PRACTICE:

Patients:

 All patients who come to the unit for a hemodialysis session must present a
result of their HIV SCREENING TEST.
 They are considered as possible carriers of HIV unless testes with NEGATIVE
result.
  Patients who have a positive result will be referred to the local unit in their
community for HIV-AIDS surveillance and classification.
 An investigation will then take place. This is done by local health workers and
considered as confidential to determine whether possible risk factors exist.
Follow-up consultations will be mandatory not only to the patient but to other
members of the family as well.

Dialysis procedure:

Admitted patients

 Prior to HD session, the Nephrologist will order an HIV Screening Test

(CONFIDENTIAL)
 If failure to extract prior to HD, a 2cc blood specimen will be extracted from the
arterial port of the bloodlines during dialysis. The same specimen will
immediately be brought to the laboratory for screening. Result will take not
more than one hour to be released.
 PPE must strictly be followed for the safety of the health care workers whether
patient is tested negative or positive for hepatitis, HIV, and/or other nosocomial
infections to avoid transmission of pathogens of blood borne or bodily fluids.
 Patients who have not yet undergone an HIV Screening test but are suspected as
carrier of HIV/AIDS based on their clinical history and will undergo an emergency
dialysis is scheduled after all of the patients have completed their dialysis session
at any given day. This means that the said patient will be the only one left inside
the unit for a dialysis session. Only 2 nurses will be assigned to the patient
including the Nephrologist/surgeon that will initiate the HD procedure.

Outpatient/ Transient

 PPE must be followed for the safety of the health care workers whether patient is tested
negative or positive for hepatitis, HIV and /or other nosocomial infections to avoid
transmission of pathogens of blood borne or bodily fluids.
 Only 2 nurses will be assigned to the patient including the Nephrologist/ surgeon that
will initiate the HD procedure.
 HIV positive will be the last patient/s to use the dialysis machine.

The Dialysis Machine/s

DISINFECTION:

The hemodialysis machines pumps dialysis fluid into the dialyzer. The blood circulating from the
patient is separated from the dialysis fluid by a membrane.
 The dialyzer and bloodlines are considered as disposable. In most cases where dialyzer
reprocessing is done in dialysis units, the manufacturing company (BBRAUN in PHCMPC
HD Unit) provides their own cold sterilant of disinfectant solution for dialyzers. The
dilution is 175ml of cold sterilant to 5 liters of R.O water.
 Chemical germicides are being used for disinfection and sterilization of devices in the
dialysis center. The dialysis machine undergoes double disinfection and couplings are
sprayed with disinfectant prior to hot disinfection of the machine
 The solutions used (Acid and Bicarbonate) are discarded right after the treatment
HEALTHCARE WASTE MANAGEMENT

Prepared by:

TEFFANY JOY H. ENRIQUEZ, RN

Head Nurse

FLORITA M. GANZON, RN., MAN

Chief Nurse

Approved by:

MARYMIL B. DIGNADICE, MD, FPCP, FPSN

Chief Nephrologists

Noted by:

GILDA L. VILLANUEVA, MD, MPA, FPCHA, FPOGS, FPCS

General Manager and Medical Director
 WASTE MANAGEMENT

GENERAL POLICIES AND GUIDELINES

1. The Hospital shall practice waste segregation at source where waste is generated.
2. The waste shall be sorted out using color-coded plastic bags or containers that are appropriately
labelled as to the type and weight of the waste.
3. The color coded schemes for containers shall make use of the following:

Color: Containers/ Bags Types of Wastes

Black General (non-infectious, Dry wastes)
Green Non-infectious, Wey wastes (food, snacks)
Yellow Infectious and Pathologic Wastes Sharps and
Pressured containers
Red Sharps and pressured containers
Yellow and Black band Chemical wastes including heavy metals

4. Residuals of general health care wastes should join the stream of domestic refuse for proper waste
management.

Non- infectious wastes are collected by the local garbage collector and are disposed in the designated
local off-site dumpsite

Biohazard Samples

Biohazard wastes are liquid, solid or concentration of solid waste which because of its quantity,
concentration, physical, chemical or infectious characteristics may pose a substantial or potential threat to
human health or to environment when improperly treated, stored transported or disposed.

Chemical Wastes

Toxic wastes undergo pre-treatment prior to disposal. Non-chemical hazardous waste can be disposed
directly into the sink or treated as ordinary domestic waste.

Biodegradable Wastes:

A. Use of sanitary landfill.

B. Composing of biodegradable waste materials.
C. Recycling schemes.
D. Where a municipal or city collection system is available, non –hazardous waste can be disposed
directly into the sink or treated as ordinary domestic waste.

1. General Waste

 Domestic type of waste packing materials, wastewater from laundries and other substances that
do not pose special handling problem or hazard to environment.
 Can be store in a metal bin or plastic bin/bag with cover and dispose in municipal or local waste.
  Can also be incinerated provided that it is equipped with anti-pollution device.

2. Pathological Waste

 Tissues, organ and body parts, most blood and body fluids, human fetus and animal carcasses.
 Can be stored in a similar receptacle for general waste with disinfectants and tightly covered is
required to avoid emission of offensive odor.
 Must be autoclaved or incinerated.
 If properly pre-treated can be disposed together with the general waste or can be buried.

3. Chemical waste

 Chemical from diagnostic, experimental, and disinfecting procedures.

 Hazardous-toxic genotoxic, acid of pH <2, bases of pH >12, flammable.
 Should be stored in container with tight cover to prevent from spilling.
 Application of delay to decay to prevent any further damages.
 Non-hazardous can be discarded directly to the sink

4. Infectious waste

 Waste from culture and stocks of infectious agents, waste from surgery and disposable towels,
gowns, and gloves.
 Metal bin storage is required and should be separated from general waste.
 Must be autoclaved or incinerated.
 Microscope slides are discarded into a jar of disinfectants and then autoclaved or boiled.
 Blood, urine, sputum and other solid or semisolid waste should be sterilized by steam
autoclaving prior to disposal in waste container.

5. Sharps

 Needles, scalpels, syringes, blades and broken glasses.

 Should be placed in a punctured-proof container.
 Incineration, burying, sanitary land filling water waste has been cut to pieces or pulverized.

6. Pharmaceutical waste

 Pharmaceutical products, medicines that have been returned from ward.

 Expired liquid medicines can be disposed directly to the sink while tablet should be pulverized
and put in a separate container and marked “NOT FIT FOR CONSUMPTION” before disposal.

COLOR CODING OF VARIOUS WASTE

1. Black – collection of non-infectious dry waste

2. Green – for non-infectious wet waste
3. Yellow – for infectious and pathological
4. Yellow w/ black band – for chemical waste
5. Red – sharps and pressurized containers.
 POLICY ON SOLID WASTE MANAGEMENT

1. Waste Segregation and Storage

The effective management of health care waste considers the basic elements of waste minimization,
segregation and proper identification of the waste in the past, there were no incentive to separate, recycle,
or reduce waste. Appropriate handling, treatment and disposal of waste by type reduce costs and do much
to protect public health. Segregation should take place as close as possible to where the waste is generated
and should be maintained in storage areas and during transport.

Segregation is the process of separating different types of waste at the point of generation and keeping
them isolated from each other. Appropriate resource recovery and recycling technique can be applied to
each separate waste stream. Moreover the amount of hazardous waste that need to be treated will be
minimized or reduced subsequently prolonging the operational life of the disposal facility and may gain
benefit in terms of conservation of resources.

Hazardous waste should be placed in clearly marked containers that are appropriately labeled for the type
and weight of the waste. Except for sharps and fluids, hazardous wastes are generally put in plastic bags;
plastic lined cardboard boxes, or leaked proofed containers that meet specific performance standards.

To improve segregation efficiency and minimize incorrect use of containers, proper placement and
labeling of containers must be carefully determined. General waste containers placed beside infectious
waste containers tend to inflate waste volume but too few containers may lead to non-compliance.
Minimizing or eliminating the number of hazardous waste containers in patient care areas (except for
sharp container, which should be readily accessible) may further reduce waste. Facility management
should develop segregation plan that includes staff training.

2.

The most appropriated was of identifying the categories of health care waste are by sorting the waste into
color-coded plastic bags or containers. Recommended color coding scheme for health care waste is shown
in Table 1.

Color: Containers/ Bags Types of Wastes

Black General (non-infectious, Dry wastes)
Green Non-infectious, Wey wastes (food, snacks)
Yellow Infectious and Pathologic Wastes Sharps and
Pressured containers
Red Sharps and pressured containers
Yellow and Black band Chemical wastes including heavy metals
Orange Radioactive Waste

Apart from the color coding system for health care waste, the following practice should also be observed.

 Residuals of the general health care waste should join the stream of domestic refuse or municipal
solid waste for proper waste management.
  Sharps should all be collected together, regardless of whether or not they are contaminates.
Containers should be puncture proof usually made of metal or highdensity plastic) and fitted with
covers. It should be rigid and impermeable to contain not only the sharps but also any residual
liquids form syringes. To discourage abuse, containers should be tamper proof (difficult to open
or break) and needles and syringes should be rendered unusable. Where plastic or metal
containers are unavailable or too costly, containers made of dense cardboard are recommended.
 Bags and containers for infectious waste should be marked with the international infectious
substance symbol.
 Highly infectious and other hazardous waste should, whenever possible, be treated immediately
by any method recommended in this manual. It therefore needs to be package in bags that are
compatible with the proposal treatment process.
 Cytotoxic waste, most of which is produce is major hospital or research facilities, should be
collected in strong, leak proof containers clearly labeled “Cytotoxic waste”
 Radioactive wastes should be segregated according to its physical form: solid and liquid and
according to its life half-life or potency: short-live and lived in specially marked containers as
prescribed by the pertinent regulation of the Philippine Nuclear Research Institute (PNRI)
specific to such authorized practice.
 Small amount of chemical or pharmaceutical waste may be collected together with infectious
waste.
 Large quantities of obsolete or expired pharmaceuticals stored in hospital wards or departments
should be returned to the pharmacy for disposal. Other pharmaceutical waste generated at this
level, such as expired drugs or packaging containing drug residues should not be returned
because of the risk of contaminating the pharmacy. It should be deposited in the specified
container at the point of generation.
 Large quantities of chemical waste should be packed in chemical resistant containers and sent to
specialized treatment facilities (if available). The identity of the chemicals should be clearly
marked on the containers. Hazardous chemical waste of different types should never be mixed.
 Waste with a high content of heavy metals (e.g. cadmium or mercury) should be collected
separately. These wastes can be sent to waste treatment facility available in the area.
 Aerosol containers maybe collected with general health care waste once they are completely
empty. Aerosol containers should not be burnt or incinerated.
 Appropriate containers or bag holders should be placed in all locations where particular
categories of waste may be generated.
 Staff should never attempt to correct errors of segregation by removing items from a bag or
container after disposal or by placing one bag inside another bag of a different color. If general
and hazardous wastes are accidentally mixed, the mixture should be classified as hazardous
health care waste.
 Cultural and religious constraints in certain parts of the country make it unacceptable for
anatomical waste to be collected in the usual yellow bags; such waste should be disposed in
accordance with the local custom, whish commonly specifies burial.

3. Storage

 All health care waste should be collected and stored in waste storage area until transported to a
designated off-site treatment facility. This area shall be marked with a warning sign:
“CAUTION: BIOHAZARDOUS WASTE STORAGE AREA – UNAUTHORIZED PERSONS
  Storage areas for health care waste should be located within the establishment or research
facility. However, these areas should be located away from patient rooms, laboratories, hospital
function/ operation rooms or any public access area. The waste in bags or containers should be
stored in separate area, room or building of a size appropriate to the quantities of waste produced
and the frequently of collection. In cases where the health care facility lacks the space, daily
collection and disposal should be enforced.
 Cytotoxic waste should be stored separately from other waste in a designate secured location.
Radioactive waste should be stored separately in containers that prevent dispersion, and if
necessary behind lead shielding. Waste that is to be stored during radioactive decay should be
labelled with the type of radionuclide, the date and details of required storage conditions. Storage
facility for radioactive waste must bear the sign radioactive waste shall conform to the
requirements and guidelines of the PNRI.
 During the “storage of decay,” radioactive waste should be separated according to the length of
time needed for storage, for example, short-term storage (half-lives less than 30 days) and long
term storage (half-life form 30 to 65 days). Low level radioactive waste should be stored for a
minimum of ten times the half-life of the longest-lived radio nuclides in the container and until
radioactivity decays to background levels as confirmed by a radiation survey.

Requirements for Storage Facilities

 The storage area should have as impermeable, hard-standing floor with good drainage; it should
be easy to clean and disinfect.
 There should be water supply for cleaning purposes.
 The storage area should allow easy access for staff in charge of handling the waste.
 It should be possible to lock the storage area to prevent access by unauthorized persons.
 Easy access for waste collection vehicle is essential.
 There should be protection from sun, rain, strong winds, floods, etc.
 The storage area should be inaccessible to animals, insects and birds. KEEP OUT”
 There should be good lighting and adequate ventilation.
 The storage area should not be situated in the proximity of fresh food stores or food preparation
areas.
 A supply of cleaning equipment, protective clothing and waste bags or containers should be
located conveniently close to the storage area.
 Floors, walls, and ceilings of the storage must be kept clean in accordance to established
procedures, which at a minimum should include daily cleaning of floors.
 Biodegradable general and hazardous waste should not be stored longer than 2 days minimize
microbial growth, putrefaction, and odors. If the waste must be stored longer than 2 days,
applications of treatments like chemical disinfection or refrigeration at 4°C.

4. Collection and Transport of Health Care Waste

The proper collection and transportation is an important component 1 health care waste management. Its
implementation requires the direct involvement of the health care facility’s maintenance services,
housekeeping services, motor pool service personnel and cooperation of all the health care personnel.

Health care waste collection practices should be designed to achieve an efficient movement of waste form
points of generation to storage or treatment while minimizing the risk to personnel.
Suggested collection frequency on room basis is once every shift as often as necessary. Time of
collection regardless of category should be at the start of every shift.

On-site Collection

Waste should not be allowed to accumulate at the point of production. A program for their collections and
transportation should be established as part of the health care waste management plan. Nursing and other
clinical staff should insure that waste bags are tightly closed or sealed when they are about three-quarters
full. Light-gauge bags can be closed by tying neck, but heavier gauge bags probably require scaling tag of
the self-stocking type. Bags should not be closed by stapling. Sealed sharp containers should not be
placed in labelled, yellow infectious health care waste bags.

The following are recommended that should be followed by health care personnel directly involved in
waste handling and collection:

 Waste should be collected daily (or as frequently as required) and transported to the designated
central storage site or waste transfer station.
 No bags should be removed unless they are labelled with their pint of production (hospital ward
or department) and contents.
 The bags or containers should be replaced immediately with new ones of the same type.
 A supply of fresh collection bags or containers should be readily available at all locations where
waste is produced.
 Collection practice for active solid radioactive waste shall consist of distributing orange color-
coded suitable containers with the radiation symbol colored magenta or black. The collection of
active solid radioactive waste from designated storage area can only be made when the activity
(delay-decay) decays to safe level and upon the strict supervision and guidance of the
radiological health and safety officer.
 Handling, collection, transport and disposal of these materials shall be based on the guidelines
issued by PNRI.

On Site Transport

Transport of waste within the establishment could utilize wheeled trolleys, containers, or carts are
dedicated solely for the purpose. On-site transportation vehicle should meet the following specifications;

 Easy to load and unload.

 No sharp edges that could damage waste bags or containers during loading and unloading.
 Easy to clean

The on-site collection vehicles should be cleaned and disinfected daily with an appropriate disinfectant
like chlorine compounds, formaldehydes, phenolic compounds and acids. All waste bag seals should be
in-place and intact at the end of transportation.

Workers transporting the waste should be equipped with appropriated personal protective equipment
including heavy – duty gloves, coveralls, and thick-soled boots and leg protectors.
Off- Site Transportation of Health Care Waste

The health care waste generator is responsible for the safe packaging and adequate labelling of waste to
be transported off –site for the treatment and disposal. Packaging and labelling should comply with the
national regulation governing the transport of hazardous wastes (RA 6969) and maintaining that it
presents no danger to the public during transport. Likewise, the waste generators are ultimately
responsible for ensuring that their waste wastes are properly treated and disposed of in an approved
disposal facility.

Tracking of wastes could be done with the implementation of the consignment system.

Consignment Note

All health care waste to be transported to an approved off-site waste treatment facility shall be transported
only by a DENR-accredited transporter or carrier. The authorized transporter /carrier shall maintain a
completed consignment note ( see Annex 4 for a prototype Consignment note) of all health care waste
taken from the health care establishment for treatment or disposal.

By the time that waste transporter receives the waste; the transporter shall provide the waste generator
with a copy of the consignment note shall include, but not limited to the following information:

 The name, address, telephone number and accreditation number of the transporter, unless the
transporter is the generator.
 The type and quantity of waste transported
 The name, address, and telephone number, permits number, and the signature of unauthorized
representative of the approved facility receiving the waste.
 The date that the waste is collected or removed from the generator’s facility, the date that the
waste is received by the transfer station, or point of consolidation, if applicable and the date that
the waste is received by the treatment facility.
 The name, address, and telephone number, permits number, and the signature of unauthorized
representative of the approved facility receiving the waste
 If the waste generators are the ones who transport the wastes or directs a member of its staff to
transport the wastes to an approved waste treatment and disposal facility, the consignment note
for health care wastes should show the name, address and telephone number of the wastes
generator when the waste are transported to the waste treatment and disposal facility.
 The transporter of generator transporting the waste should have the consignment note in his or
her possession in the vehicle while transporting the waste. The tracking document should be
available upon demand by any traffic enforcement agency personnel. The transporter shall be
provided the facility receiving wastes with a copy of the original tracking document.
 The date that the waste is collected or removed from the generator’s facility, the date that the
waste is received by the transfer station, or point of consolidation, if applicable and the date that
the waste is received by the treatment facility.
 Contingency Plan for Health Care Waste

The development of a plan of action should be considered in the event of an accidental spill loss of
containment, equipment failure or other unexpected circumstances.

The owner/ operator of vehicles used in the transportation of health care waste should carry contingency
plans for emergencies that address the following:

 Plan for the disinfection of the truck and any contaminated surface if leaking containers is
discovered.
 A notification list of individual or agencies to be contacted in the event of a transportation
accident.
 Clean-up and decontamination of potentially contaminated surfaces; designation of back-up
transportation for the health care waste, a description of the plans for the pre-packaging and
labelling of health care waste where containers are no longer intact.
 Procedures for the management of a leaking container.

Requirements for Packaging for Off-site Collection

Waste should be packaged in sealed bags or containers to prevent spilling during handling and
transportation. The bags or containers should be rebust for their content (for example: puncture proof for
sharps and resistant to aggressive chemicals) and for normal conditions of handling and transportation,
such as vibration or changes in temperature, humidity, or atmospheric pressure. (In case of plastic bags,
minimum gauge should be at least 0.009mm)

Radioactive wastes must be packaged for off-site collection and transported in accordance with the
acceptance criteria for low level radioactive wastes established by PNRI ( A.O No. 01 series of 19990,
Annex 3)

All waste bags or containers should be labelled with the basic information about their content and about
their content and about the waste generator. This information may be written directly on the bag or
container or on pre-printed labels, securely attached. Basic information should include but not limited to
the following:

 Type of health care waste

 Form of waste and waste category
 Date of collection
 Volume/ quantity of waste
 Precaution to be taken while handling
 Emergency procedures in the event of accident or spillage
 Destination of the waste.

Requirements for Off-site Collection Vehicles

Collection vehicles used for the transport of health care wastes should not be used for the transport of any
materials that could be seriously affected by contamination such as food, livestock, people or retail goods.
The vehicle should have enclosed leak proof body and capable of being locked to secure the waste. Waste
can be loaded directly to especially designed vehicle, but it is safer to place them first in containers (e.g.
cardboard boxes or wheeled, rigid, lidded plastic or galvanized bins) Infectious and pathological waste
should be bagged in appropriate colored-coded bag or other special containers when transported. Each
package should be marked or coded for easy identification. Containers should be leak-proofed and be
fitted with self-sealing lid and be tight enough to withstand being spilled in the vehicle. Must conform the
following:

 The body of the vehicle should be of suitable size commensurate with the design of the vehicle.
 The vehicle should have totally enclosed car body with the driver seat separated from the loader
to prevent coming into contact with the waste in the vent of collision/ accident.
 There should be a suitable system for securing the load during transport.
 The vehicle should be easy to clean and the internal surface of the body should be smooth enough
that allows it to be steam cleaned and with all corners rounded. The vehicle should be cleaned at
the end of each working day and in the event of any spillage.
 The vehicle should be marked with the name and address of the waste carrier.
 The international hazard sign should be displayed on the vehicle or container, as well as the
emergency telephone number.
 Empty plastic bags, suitable protective clothing, cleaning equipment, tools and disinfectant,
together with special kits for dealing with liquid spills, should be carried in a separate
compartment in the vehicle.

Routing

Health care waste should be transported through the quickest or shortest possible route and should be
planned before the trip begins. After departure from the source, every effort should be made to avoid
further handling. If handling cannot be avoided, it should be pre-arranged and take place in
adequately designed and authorized premises. Handling equipment can be specified in the contract
established between the waste generator and transporter.
An efficient and effective collection system route should consider the following:
 Collection schedule either by route or zone.
 Assignment for the personnel responsible for the zone or area.
 Logical planning of the route (should avoid passing the collected package of waste or congested
area
 Collection system route must be laid out the farthest point of the designated transfer station and
as collection progresses towards the collection storage area
 Routes drawn shall be practicable and must consider the logical progression of health care waste
throughout the area
 Revised routing plan should be established due to circumstances arising top alteration in the
original routing plan
 Suggested collection frequency on room to room basis is once every shift or as often as
necessary. Time of collection regardless of category should be at the start of every shift.
 Health Care Waste Treatment

The purpose of treating health care waste is to change the biological and chemical character of the
waste to minimize its potential to cause harm. There are a number of terms use to denote the level of
treatment, such as decontamination, sterilization, disinfection, render harmless and kills. These terms
do not provide any mechanism of the degree of process efficiency. As such, it is critical that terms
and criteria be established that quantitatively define the level of microbial destruction accomplished
by any health care treatment process.

Sterilization is defined as a survival probability of the most resistant microorganism of concern in a

given process and disinfection is defined as low, intermediate or (using the Spaulding system)
depending on the survival probability of specific microbial groups. For medical waste disinfection,
however, the emerging international consensus is to define levels of microbial inactivation as follows:

Level 1 Inactivation of vegetative bacteria, fungi, and lipophilic viruses at a 6log10 reduction or
greater.

Level II Inactivation of vegetative bacteria, fungi, lipophilic/ hydrophilic viruses, parasites and
mycobacteria at a 6log10 reduction greater.

Level III Inactivation of vegetative bacteria, fungi, lipophilic/ hydrophilic viruses, parasites and
mycobacteria at a 6log10 reduction greater, and inactivation of B. stearomophilus spores
and B. subtilus spores at a 4los10 reduction or greater.

Level IV Inactivation of vegetative bacteria, fungi, lipophilic/ hydrophilic viruses, parasites and
mycobacteria at a 6log10 reduction greater.

Mechanical grinding devices are sometimes introduced prior to treatment, during treatment and/or at the
end of the treatment process. A few facilities insist on shredding the health care waste either as a matter
of preference or because they falsely believe that their liability will somehow be limited. Some
technologies however depend upon the shredding as an integral part of the treatment process, i.e those
systems that shred prior to treatment and during treatment. Shredders are typically a high maintenance
item due to unavoidable volumes of trapped waste in the waste stream, such as high quality stainless steel
found in orthopaedic blades, drills, reamers and prosthetic devices. Glass is also inherent in the health
care waste and over time, glass wears the cutting surfaces of the shredder blades. Therefore, if the facility
intends to shred waste either p[re or post – treatment, anticipate that a rigorous , maintenance schedule
with associate cost would be required . Shredding the waste simply to render it unrecognizable makes the
task more burdensome and more expensive than necessary and a cost benefit analysis should be
conducted prior to making that decision. Also, consider the potential down time when the shredder is out
of commission with those technologies that depend upon shredding.

Selection Criteria of Treatment Technology

On-site treatment of health care waste allows health care facility to have more control over both the
waste disposal process and waste disposal cost. Treatment system maybe a cost-effective alternative
and many manufacturers have already simplified their systems so that processing is relatively
effortless.

Hospital and other health care establishments should perform a preliminary assessment and determine
the issues that are important to the facility. Develop a list of selection criteria and rank in order of
importance. In selecting a technology, the following key points should be considered:
 Treatment efficiency
 Occupational health, safety and environmental considerations
 Volume and mass reduction
 Types and quantity of wastes for treatment and disposal/ capacity of the system
 Infrastructure and space requirements (investment and operational cost)
 Locally available treatment options for final disposal
 Training requirements for operation of the method
 Operation and maintenance considerations
 Location/ surrounding of the treatment site and disposal facility
 Social and political acceptability
 Regulatory requirements

These criteria are also applicable in selecting off-site treatment technology for health care wastes.

Health Care Waste Treatment Technologies/Processes

Incineration used to be the methods of choice in treating health care waste. However, with the
implementation of the Clean Air Act of 1999, the use of this method is no longer allowed. With this
development, alternative technologies are being looked into address the problem on health care waste
management using them aforementioned selection criteria.

Most common technologies and processes used in health care waste treatment are (1) thermal, (2)
chemical, (3) irradiation, (4) biological processes, (5) encapsulation and (6) inertization.

1. Thermal Process

Thermal processes rely on high heat to destroy pathogens (disease-causing microorganisms)

 Pyrolysis – pyrolysis is the thermal decomposition of substance and materials in the absence of
supplied molecular oxygen in the destruction chamber on which the said material is covered into
gaseous, liquid or solid form. Pyrolysis can handle the full range of health care waste. Waste
residues may be in form of greasy aggregates or slugs, recoverable, metals, or carbon black.
These residues at\re disposed of in a secure facility i.e. sanitary landfill.

 Wet and Dry Thermal Treatment – Wet Thermal or stream disinfection is based on exposure of
shredded infectious waste to high temperature, high pressure stream, and is similar to the
autoclave sterilization process. It inactivates most types of microorganisms if temperature and
contact time are sufficient. For sporulates bacteria, a minimum temperature of 121degree Celsius
is needed and exposure time of 30 minutes. For sharps, milling or crushing is recommended
mainly to eliminate physical hazards from needles, render syringes unusable and reuse waste
volume as well as increasing the surface area subject to exposure to high temperature and high
pressure stream subsequently increasing the efficiency of the treatment

 Autoclave – Autoclave uses stream sterilization to render waste harmless and is an efficient wet
thermal disinfection process. This technique has been used for many years in hospital for the
sterilization of reusable medical equipment.
Autoclaves come in a wide range of sizes. A typical autoclave designed for medical waste treats
about 100 kg per cycle (a cycle being about 1 hour) to several hundred kilograms per cycle for
larger hospitals. Autoclaves used in centralized treatment facilities can handle as much as 3,000
kg in one cycle.
The microbial inactivation efficacy of autoclaves should be checked periodically. For autoclaves
that do not shred waste during steam disinfection, color-changing indicator strips may be attached
to the outside of the yellow bag in the middle of each load and that the strip is checked to ensure
that stream penetration has occurred. In addition, a microbial test (using for example
commercially available validation kits containing bacillus stearothermophilus spore strips, vials
or packs) should be conducted periodically.

 Microwave – This technology typically incorporates some type of size reduction device.
Shredding of wastes is being done either before disinfection or after disinfection. In this process,
waste is exposed to a microwave that raises the temperature to 100°C (237.6°F) for at least
30minutes. Microorganisms are destroyed by moist heat whish irreversibly coagulates and
denatures enzymes and structural proteins.

The efficiency of microwave disinfection should be checked routinely through bacteriological

and virological tests. The microwave process is widely used in several countries and is becoming
popular. However, the system has a relatively high investment and operating costs. The process is
inappropriate for the treatment of anatomical waste and animal carcasses and will not efficiently
treat chemical or pharmaceutical waste.

2. Chemical Disinfection
Chemical disinfection is now being applied for treatment of health care waste. Chemicals like
aldehydes, chlorine compounds, phenolic compound etc. are added to waste to kill or inactivate
pathogens present in the health care waste. Chemical disinfection is most suitable in treating
blood, urine, stools and sewage. This method is also applicable in treating infectious wastes
containing pathogens. If possible, wastes should be shredded to increase the extent of contract
between waste and the disinfectant by increasing the surface area and eliminating the enclosed
space. However, application of this method should only be done when there is no available
treatment in the area to prevent environmental problems associated with the disposal of chemical
residues.

Some chemical systems use heated alkali to destroy tissues, organs, body parts, and other
pathological wastes that can be used to treat contaminated animal waste and cytotoxic waste as
well.

Chemotherapy waste (including bulk cytotoxic agents) can be treated by chemical decomposition.
Examples are: reaction with 5% sodium hypochlorite; acid hydrolysis followed by alkaline
hydrolysis; reduction using zinc powder; degradation using 30% hydrogen peroxide; or
destruction using heated alkali.

Studies showed that chlorine-based technologies’ using sodium hypochlorite and chlorine dioxide
as well as it’s by products in waste water may possibly have long-term environmental effects.
Non-chlorine based technologies are quite varied in the way they operate and the chemical agents
they employ. Others use peroxyacetic acid, ozone gas, lime-based dry powder, acid and metal
catalyst, or biodegradable disinfectants. Also, occupational and safety exposures should be
monitored when using the chemical processes.

3. Biological Processes

The process uses an enzyme mixture to decontaminate health care waste and the resulting by-
product is put through an extruder to remove water for sewage disposal. The technology is suited
for large applications and is also being developed for possible use in agricultural sector . The
technology requires regulation of temperature, pH, enzyme level, and other variable. Design
application is mainly for regional health care waste treatment center.

Composting and vermiculture as biological processes for treating and disposing of placenta
waste, as well as food waste, yard trimming and other organic waste is also recommended.

4. Radiation technology

The disposal of biologically contaminated waste from hospital, clinics and laboratories is of
particular concern. Waste containing potentially infectious microorganisms (sewage sludge,
biomedical wastes, and wastewater) is treated using irradiation systems which are currently being
used in waste treatment operations. The four main elements of the waste handling systems are:
(1) identification of the contaminated waste (2) collection (3) sterilization and (4) final disposal
or recycling.
Machines generating high energy electron beams, among other types, can sterilize a wide range of
waste. If regulations permit, the processed material can then be directed to general waste disposal
or recycling operations.

5. Encapsulation

Encapsulation involves the filling up of containers with waste, adding and immobilizing material
and sealing the containers. The process uses either cubic boxes made of high-density
polyethylene or metallic drums, that are three quarters filled with sharps or chemical or
pharmaceutical residues. The containers or boxes are then filled up with a medium such as plastic
foam, bituminous sand and cement mortar. After the medium has dried, the containers are sealed
and disposed of in landfill sites. The process is particularly appropriate for the disposal of sharps
and chemical or pharmaceutical residues. The main advantage of the processes is that it is very
effective in reducing the risk of scavengers gaining access to the health care waste.

6. Inertization

Especially suitable for pharmaceutical waste is the process of inertization that involves the
mixing of the waste with cement and other substances before disposal. This is to minimize the
risk of toxic substances contained in the waste migrating into surface water or groundwater. For
the inertization of pharmaceutical waste, the packaging should be removed, the pharmaceuticals
ground, and a mixture of water, lime and cement added. The homogenous mass produced can be
transported to a suitable storage site. Alternatively, the homogenous mixture can be transported in
liquid state to al landfill and poured into municipal waste. The process is relatively inexpensive
and can be performed using relatively unsophisticated equipment. The following is the typical
proportion for the mixture: 65% pharmaceutical waste, 15% lime, 15% cement, and 5% water.

Siting of Water Treatment Facilities

Dome treatment facilities particularly larger ones would require a new structure to house the
technology or renovate existing space. Each technology have different requirements for space,
foundation, utility service connections, ventilation and support equipment. In determining a safe
location for the facility, one must take into account the safe transfer routes, average distances
form waste sources, temporary storage requirements, as well as space allowances needed by
workers to maneuver safely around the treatment unit. The location of the facility should no cause
traffic problems as waste is brought in and out. Odor, noise the visual impact of medical waste
operations on patients and visitors, public access and security should also be considered.

In the past, the decision involving the location of the treatment system have been the
responsibility of engineers dealing with the foundation, electrical connections, sewer, HVAC
(heating ventilation and air conditioning) and utilities. By taking a team approach and involving
facility engineering, environmental services, housekeeping, safety or industrial hygiene, infection
control, and occupational health, important aspects such as occupational safety and health become
part of the decision relative to sitting and installation.
2. Waste Disposal Systems

Sanitary Landfill

Sanitary landfill is an engineered method designed to keep the waste isolated from the
environment. Appropriate engineering preparations should be completed before the site is
allowed to accept waste. There should be trained staff present on site to control operations,
organize deposits and daily coverage of waste. Some essential elements for the design and
operation of sanitary landfill are:
Access to site and working areas possible for waste delivery and site vehicles
Presence of site personnel capable of effective control of daily operations
Divisions of the site into manageable phases, appropriately prepared, before landfill starts
Adequate sealing of the base and sides of the site to minimize the movement of waste water
(leachate).
Adequate mechanisms for leach ate collection and treatment systems are necessary
Organized deposit of waste in a small area, allowing then to spread, compacted and covered daily
Surface water collection trenches around site boundaries
Construction of a final cover to minimize rainwater infiltration when each phase of the landfill is
completed.

Safe Burial on Hospital Premises

In remote locations and rural areas, the safe burial of waste in the health care premises may be the
only viable option available at the time. However, certain rules need to be established for the
health care waste management. These include:
 Access to the disposal site should be restricted to authorized personnel only
 The burial site should be lined with a material of low permeability, such as clay, if available,
to prevent pollution of any shallow groundwater that may subsequently reach nearby wells
 Only hazardous health care waste should be buried. If general health care waste were also
buried on the premises, available space would be quickly filled up.

POLICY ON LIQUID WASTE MANAGEMENT

1. CHARACTERISTIC OF WASTEWATER FORM HEALTH CARE

ESTABLISHMENT

The basic principle underlying the effective wastewater management in health care
establishments is a strict limit on discharge of hazardous liquids to sewers. The quality of waste
water form health care establishment contains potential hazardous elements including:

 Microbiological Pathogens (bacteria, viruses, and helminthes) which are easily transmitted
through water
 Small amount of hazardous chemicals form cleaning and disinfection operations;
  Hazardous chemicals and pharmaceutical waste being generated from other business
establishments (clinics, laboratories, and research centers, drug manufacturers, mortuary and
autopsy centers, cosmetics and tattoo parlors;
 Trace amounts of radioactive effluents form nuclear medicine laboratories;
 Waste water or sewage form health care establishment can be discharge into domestics
(municipal or city) sewers without pre0tretament, provide that the following requirements are
met;
 The municipal sewers are connected to efficiently operate sewage treatment plant that ensure
at least 95% removal of bacteria;
 The sludge resulting to sewage treatment plant are subjected to anaerobic digestion, leaving
no more than one helminth egg per liter in the digestive sludge;
 The hazardous wastewater having significant quantities of toxic chemical such as
formaldehyde, pharmaceuticals, radionuclides, cytotoxic drugs and antibiotics, coming from
laboratories and research centers, clinics, mortuary and autopsy centers should be discharged
to a pre-treatment/neutralization tank for sewage (toxic) neutralization and disinfection by
chlorination prior to discharge or connected to the sewage treatment plant; and
 Excreta from patients treated by cytotoxic drugs are connected separately and adequately
treated (as for other cytotoxic waste )

2. ON-SITE TREATMENT OF WASTEWATER

When a health care facility cannot access to community sewage treatment plant it
is recommended that the establishment should have their own waste water
treatment plan.

Figure 1. Schematic Diagram of wastewater treatment

Chemical
Waste

Preliminary Secondary Final

Effluent
Treatment Treatment Treatment

Domestic
Waste
Sludge
Treatment
 Primary treatment – this includes multi-chamber septic tank, comprising of primary
sedimentation tank and digestive chamber. This action results in partial biodegrading of organic
pollutants. The effluent should convey to the secondary treatment facility for further oxidation of
sewage.
 Secondary treatment- this employs a complete biological process of treatment including aeration
and sedimentation system. It involves the importance of aerobic microorganisms that ill actually
degrade the organic pollutants in the effluent. The aeration phase is the introduction or supply of
oxygen to the system for the aerobic microorganisms. The sedimentation phase is the settling of
sludge and separation of clear water effluents. This system signifies the higher purification and
degradation of parameters such as BOD, COD, TSS, oil and grease. The clear water should
convey to the tertiary treatment while the sludge shall be conveyed to the sludge treatment.
 Tertiary treatment- in order to meet the standards parameters prescribed by the DENR
administrative order No. 35 series 1990, this stage should therefore serve as the final treatment.
The clear water will pass through micro filter and chlorine disinfection before being discharge to
the nearest drainage or body of water. Due to outbreaks of enteric disease and occurrence of
water borne disease and other critical periods, UV-Hygienization is further recommended. This
process involves the use of UV-radiation of 254-mm wavelength
 Sludge treatment – a supplement to the implementing rules and regulations (IRR) of chapter 17,
“Sewage Collections And Disposal and Excreta Disposal Drainage
 Of PD 856 or the sanitation code of the Philippines, details the collection, handling, transport,
treatment and disposal of “Domestic Sewage and Septage”

Health care establishments may apply a combination of the treatment process enumerated in the
above section depending on the volume and characteristics of their waste water.

3. FACTORS TO BE CONSIDERED IN THE ESTABLISHMENT OF WASTEWATER

TREATMENT PLAN

To have an efficient and cost-effective establishment of on-site wastewater treatment plant, it is

important to have an objective approach in considering the following factors:

 Quantity of waste water for treatment and disposal

 Type of wastewater for treatment and disposal
 Location of the treatment and disposal facility
 Infrastructure requirements
  Treatment efficiency
 Locally available equipment and parts
 Space availability
 Investment and operating cost
 Operation and maintenance
 Training requirements for operation
 Regulatory requirements.

4. SAFETY REQUIREMENTS

Measure to minimize health risks should be implementing in health care establishments that cannot
afford any sewage treatment plant such as:

 Patients with enteric diseases should be isolated in wards where their excreta can be collected for
chemical disinfection. This is utmost importance in case of cholera outbreaks, for example and
strong disinfectant will be needed
 No chemicals and pharmaceuticals should be discharge in to the sewer
 Sewage from health care establishment should never be used for agriculture or aqua cultural
purposes
 Health care sewage should not be discharge into natural water bodies that are used to irrigate fruit
and vegetable crops, to produce drinking water, or for recreational purpose
 Grease, oil, and paints should not be discharged into the sewer line.

5. SANITARY REQUIREMENTS

Human excreta are the principal vehicle for the transmission and spread of a wide range of
communicable disease, and excreta from health care patients maybe expected to contain far higher
concentration of pathogens, and therefore are far more infectious, than excreta from households. This
underlines the prime importance of providing access to adequate sanitation in every health care
establishment. The health care establishment should ideally be connected to a sewage system.

6. REGULATORY REQUIREMENTS

All implementing rules and regulations of all concerned agencies (locally and national) and all
existing laws shall be strictly followed.

POLICY AND PROCEDURES FOR THE PROPER DISPOSAL OF INFECTIOUS WASTES

AND TOXIC AND HAZARDOUS SUBSTANCES

I. INTRODUCTION
Healthcare facilities generate hazardous and nonhazardous waste can result to disease or injury.
Healthcare workers, patients and those who handle such waste are exposed and are potentially at risk as a
consequence of careless management. Waste management operators outside healthcare facilities are also
at risk. Certain infection such as those carried by insects and fomites) can a pose a significant to the
community

Healthcare facilities should therefore ensure the appropriate handling, transport, storage treatment and
disposal of healthcare waste through an effective and efficient healthcare system waste management
program.

II. OBJECTIVES

a. To provide guidelines, policies and procedures on proper handling, collection, transport treatment
storage and disposal of healthcare waste.

b. To provide contamination with infectious agents coming from health care

c. To protect healthcare workers, patients and community.

III. POLICIES

a. Waste management policy outlining the accountabilities and responsibilities of manages, employees
and staff.

b. Healthcare facilities must establish a Waste Management Committee, the main function of which is
implementation of the Waste Management Policy. The Infection Control nurse shall be a core member of
this committee and shall serve as adviser/ reviewer in development of guidelines and policies. Before
implementation, all concerned staff shall be adequately trained and oriented.

c. Hazardous waste generated in the health care facility should be a proper segregated, placed in color
coded bags provided by housekeeping unit identified where it was originated (unit name) and properly
sealed and covered before transport to waste storage facility. Infectious wastes shall be transported and
covered carts. Follow MMDA ordinance on color coding [black (dry non-infectious) green (wet non-
infectious), yellow (wet and dry infectious) orange (radioactive)]

d. The waste management committee of the healthcare facility ensures that all healthcare hazardous waste
or non-hazardous is properly disposed by a duly authorized transporter.

e. Instructions on proper waste segregation shall be included in admission, handouts given to patients,
watchers and relatives.

f. Healthcare facility handling shall comply with legislation (DOH, DENR, WHO and other guidelines) to
ensure proper classification, segregation, containment, treatment and disposal of waste.

g. Healthcare facility handling waste shall wear appropriate Personal Protective Equipment including
heavy utility gloves and waterproof aprons or gowns.
h. All employees shall adhere to these policies. Staff not following policies and procedures on healthcare
waste management will be reminded, warned and subjected to disciplinary action if repeatedly
committing the same violation.

i. Records shall be kept and maintained in accordance with healthcare facility records, policies, policies
and procedures action if repeatedly committing the same violation.

IV. PROCEDURES

This procedure covers the processes involved I management of health care waste from classification to
final disposal.

a. At the point of waste generation, nursing order/ aide/ housekeeper classifies healthcare waste as a
general waste and hazardous waste. Hazardous waste shall be classified as a non – infectious and
infectious/ Pathological waste.

b. Hazardous non- infectious waste shall be classified:

 Radioactive waste – assigned healthcare worker follows aging period of ten half-lives on designated
storage room prior to disposal.
 Pharmaceutical waste- such as expired unused split and contaminated pharmaceutical products, drugs,
vaccines shall be returned to the supplies.,
 Chemical Waste- assigned healthcare worker decontaminate/ treats and disposes thru the septic tank

c. Infectious waste shall be further classified into solid and liquid.

 The area concerned treats/ decontaminates solid waste are required.

 The nursing orderly/ housekeeper healthcare worker decontaminants liquid infectious waste with Na
Hypo chloride or any available disinfectant and then flush the same into the toilet bowl.
 The assigned Nursing orderly/ housekeeper transport the treated infectious water using a covered
hand to the storage facility (the vehicle with yellow color- coded sticker on the door)

d. The accredited transporter weighs the infectious waste and records in the HAZARDOUS WASTE
MANIFEST FORM to be acknowledged by FMD stall during collection.

f. The accredited transporter disinfects the garbage facility right after hauling.

g. Records shall be kept and maintained in accordance with Control of Quality Records Policies and
Procedures.

h. All concerned personnel shall be adequately trained prior to the implementation of this procedure in
accordance with Human Resource Training Policies and Procedure
A. FLOWCHART FOR THE HEALTHCARE WASTE MANAGEMENT

Healthcare waste
generated from healthcare
facility

Classify

General Waste? NO
Hazardous

YES
Biodegradable NO Non-biodegradable NO
For sale to buyer
Waste? Waste?

Place in green trash Place in black trash

bag bag

Collected in big
black plastic bag

Transport to Storage
Area

MRF (material Recovery Facility)

 PIT

B. FLOW CHART FOR HAZARDOUS HEALTH CARE WASTE MANAGEMENT

C. FLOWCHART FOR HAZARDOUS NON- INFECTIOUS HEALTHCARE WASTE
MANAGEMENT
V. RESPONSIBILITIES NAND ACCOUNTABILITIES

 The floor or unit Nursing Aide/Order shall be responsible for proper and handling of hazardous
waste and transport to waste storage facilities.
 The housekeeper, institutional workers assigned in the waste storage facility shall check and see
it that all hazardous wastes are properly labeled and shall monitor the weighing activity of the
transporter prior to final hauling.
 The Head of Operations and Transport shall be responsible for the proper implementation and
monitoring.
 Cleaning of waste storage facility shall be the responsibility of the housekeeping of the hospital
and decontamination and disinfection by the accredited transporters.

VI. DEFINITION OF TERMS

 Biodegradable capable of being broken down especially into innocuous products by the

action of living things (such as microorganisms)
 Chemical waste is any solid, liquid, or gaseous waste material that, if improperly managed or
disposed of, may pose substantial hazards to human health and the environment (i.e from
diagnostic and experimental work, housekeeping and disinfecting procedures)
 Collection refers to the act of removing healthcare waste from source or from a communal
storage point.
 Decontamination refers to the reduction on microbiological contamination to a safe level.
 Disinfection refers to the process of killing infectious germs or use of physical means.
 Disposal refers to discharge, deport, dumping placing or release of any healthcare waste into or
any air, land and water.
 General Waste refers to waste that do not pose a special handling problem or hazard to human
health or environment.
 Hauling refers to the act of carrying or moving of the healthcare waste out of the healthcare
facility.
 Hazardous Infectious Waste refers to those containing pathogens like bacteria, viruses,
parasites of fungi in insufficient concentration or quality to cause disease in susceptible host.
 Hazardous Non-Infectious waste refers to drugs and chemicals that have been outdated or
contaminated or are to be discarded because they are no longer required.
 Healthcare Waste refers to all waste generated or produced form diagnosis treatment or
immunization of human beings or animals, research, production or testing of biological and
waste originating from minor or scattered sources.
 Non-biodegradable refers to the ability of the substance to be broken down, retaining its form
for an extended period of time.
 Pathological Wastes refers to tissues, organs, body parts, human fetus and animal carcasses,
blood and body fluids.
 Pharmaceutical Waste refers to expired, unused split and contaminated pharmaceutical
products, drugs, vaccines and sera that are no longer required.
 Radioactive waste refers to materials and paraphernalia used from nuclear medicine diagnostic
and therapeutic procedure (chemotherapy). It may be in the form of solid, liquid and gas
contaminated with radio nuclides, excreta of patients who underwent radio isotonic therapy.
 Recyclable refers to any waste stream and free from contamination that can still be converted
into suitable and beneficial use or for other purposes, including but not limited to cardboard,
office paper, drink cans, newspapers magazines and plastic.
 Recycling refers to the process of reducing the size of hospital waste by extracting domestic
trade waste for industrial use such as paper for re-pulping, metals for re-melting and plastic for
the production infectious grade.
 Segregation refers to a healthcare waste management practice by separating different waste
materials found in healthcare establishment in order to promote recycling and re-use of resources
and to reduce the volume of waste for collection and hospital.
 Sterilization refers to the reduction of microorganisms of more than 106 (more than 99. 999% of
the microorganisms are killed) achieve by physical, chemical or mechanical methods or by
eradication.
 Storage refers to the interim containment of healthcare waste after generation and prior to
collection for ultimate recovery disposal.
 NO SMOKING POLICY

Prepared by:

TEFFANY H. ENRIQUEZ, RN
Head Nurse

Approved by:

MARYMIL T. BILLONES-DIGNADICE, MD, FPCP, FPSN

Chief Nephrologist

Noted by:

GILDA L. VILLANUEVA, MD, MPA, CHA, FPCHA, FPOGS, FPCS, FICS

Medical Director/ General Management
MEMORANDUM

To: All Personnel of this Hospital Subject: SMOKE FREE POLICY

INTRODUCTION

The Panay Health Care MPC Hospital is committed to provide quality Renal Health Care Services
available to all. Our vision is – “To be the premier Dialysis unit that adheres to the highest standards of
Renal Replacement Therapy”. The Core Values of this hospital which emphasizes teamwork, honesty,
excellence, client centeredness, conscientiousness, compassion, competence and above all is quality
service.

President Rodrigo Duterte issued Executive Order No. 26 S.2017 “Providing for the Establishment of
Smoke-Free Environments in Public and Enclosed Places”. According to the presidential issuance, it is
policy of the state to guarantee the enjoyment of the right of every citizen to breathe clean air. Further,
Republic Act. No.8749or the Philippines Clean Air Act of 1999 prohibits smoking inside enclosed public
places including public vehicle and other means of transport, and other enclosed areas, and direct local
government units to implement the prohibition. Lastly, Republic Act No. 9211 or the Tobacco
Regulation Act of 2003 prohibits smoking in certain public places and prohibits the purchase and sale of
cigarettes and other tobacco products to and by minors and in certain places frequented by minors and
provides penalties for any violation of the prohibitions.

It is in this regard that Panay Health Care MPC Hospital enacts this policy to join and support the active
measures of the Department of Health, local government units, and other government bodies, to decrease
smoking behaviour by reducing the number of public areas in which smoking is permitted. As a provider
of health services, we are committed to eliminating smoking on our premises, and to assisting staff,
patients, and visitors to achieve greater health through smoking avoidance and cessation.

II. AIMS OF THE POLICY

This policy aims to:

 Guarantee a healthy working environment and protect the current and future health of its
employees, patients, folks and visitors.
 Comply with the provisions of Executive Order No. 26 S. 2017, Providing for the
Establishment of Smoke-Free Environment in Public and enclosed Places.
 Ensure that the non-smokers can work in or visits hospital premises in a smoke free
environment.
 Encourage employees to become involved in health promotion initiatives
 Demonstrate adherence to government regulations
 Set a good example to the public and enhance the image of the hospital through positive
action by promoting health and creating an environment that minimizes the health risk to
the members of the public who access the service.
  Reduce the risk associated with passive smoking which government research has shown
to be dangerous to health.
 Reduce the negative effects of littering on the environment caused by discarded cigarette
ends, which account for 50% of all litter worldwide.
 Reduce the effects on the environment from discarded cigarette ends. A cigarette butt
contains up to 4000 chemicals including hydrogen, cyanide and arsenic.
 Strive to become a good neighbour and reduce the effects of littering on local residents.

Lifestyle related diseases have been part of the provinces top ten mortality for succeeding years. Tobacco
use is one of the risk factors which contribute to the alarming increase of these diseases. Also, thousands
of people who have never smoked die each year from illnesses related to inhalation of other people’s
tobacco smoke. Second hand smoke kills. Scientific evidence has firmly established that there is no safe
level of exposure to environmental tobacco smoke (ETS) or second hand tobacco smoke (SHS) contain
thousands of known chemicals, at least 250 of which are known to be carcinogenic or otherwise toxic.
Furthermore, allowing the possession, display or selling, use and consumption of tobacco products in and
around our buildings and grounds does not portray the image of our hospital as a medical facility that is
dedicated in providing quality healthcare services in the community and does not promote a healthy
environment for our patients, employees and visitors.

Henceforth, we denounce the Tobacco Industry and its interference with our public policies and
measures that aim to protect our constituents, fundamental right to health and to a balanced and healthful
environment, and to promote a 100% smoke free and tobacco-free environment. We uphold the dignity of
our service and thus we reject any offer of assistance from, or any manner or form of partnership with the
tobacco industry and/ or persons or entities acting for or on its behalf, or to further its interest.

Under the National Law (R.A. 9211 otherwise known as the Tobacco Regulation Act of 2003, Sec 5)
Smoking shall be absolutely prohibited within the buildings and premises of public and private hospitals;
medical, dental, and optical clinics, health centers, nursing homes, dispensaries and laboratories.
Likewise, the Department of Health through Administrative Order No. 2009 – 0010 and the Civil Service
Commission through CSC Memo No. 17, s.2009 both states absolute prohibition of smoking in or on the
premises, buildings, and grounds of government agencies providing health wherein no “smoking areas”
shall be designated or established (CSC Memo No. 17, s. 2009, paragraph 1 of the policy). Moreover, the
World Health Organization in its Framework Convention on Tobacco Control which was ratified by the

Philippine Senate in 2005 states that “Effective measures to provide protection from exposure to tobacco
smoke require the total elimination of smoking and tobacco smoke in a particular space or environment in
order to create a 100% smoke-free environment. There is no safe level exposure to tobacco smoke.” Thus
increased protection would lead to a change in the perception of smoking and in behavior toward
smoking, along with a reduction of smoking itself. Assisting our employees, our patients and our visitors
to be tobacco-free is consistent with our mission. We believe that implementing tobacco-free policy is the
only effective way to protect the population from the harmful effects of tobacco products.
PURPOSE

The purpose of this Policy is to protect the people of Panay Health Care MPC Hospital from the harmful
effects of exposure to tobacco smoke especially to the patients of our hospital.

RATIONALE

 Exposure to tobacco smoke has been recognized by the World Health Organization and other
respected health authorities to cause death and serious disease in non-smokers;
 There is no known safe level of exposure to tobacco smoke;
 International guidelines advise that the only way to adequately protect the public from exposure
to tobacco smoke is to eliminate the source of smoke;
 Guarantee a healthy working environment and protect the current and future health of its
employees, patients, folks and visitors.
 Comply with the provisions of Executive Order No. 26 S. 2017, Providing for the Establishment
of Smoke-Free Environment in Public and enclosed Places.
 Ensure that the non-smokers can work in or visits hospital premises in a smoke free environment.
 Encourage employees to become involved in health promotion initiatives
 Demonstrate adherence to government regulations
 Set a good example to the public and enhance the image of the hospital through positive action
by promoting health and creating an environment that minimizes the health risk to the members
of the public who access the service.
 Reduce the risk associated with passive smoking which government research has shown to be
dangerous to health.
 Reduce the negative effects of littering on the environment caused by discarded cigarette ends,
which account for 50% of all litter worldwide.
 Reduce the effects on the environment from discarded cigarette ends. A cigarette butt contains
up to 4000 chemicals including hydrogen, cyanide and arsenic.
 Strive to become a good neighbour and reduce the effects of littering on local residents.
 CONTINGENCY PLAN

Prepared by:

TEFFANY H. ENRIQUEZ, RN
Head Nurse

Approved by:

MARYMIL T. BILLONES-DIGNADICE, MD, FPCP, FPSN

Chief Nephrologist

Noted by:

GILDA L. VILLANUEVA, MD, MPA, CHA, FPCHA, FPOGS, FPCS, FICS

Medical Director/ General Management
CLAMP AND CAP PROCEDURE

If the patient is still connected to the dialysis machine when the emergency occurs, instruct them to
remain calm and wait for instructions on what to do. If no one on the staff is available, pati8ents may
have to learn how to “Clamp and Disconnect” themselves. It is very important to remember that the
following direction are for emergency evacuation only leave vascular access needles in place until one
cab get to a safe location.

These directions are done only if no qualified dialysis personnel are available to disconnect you from
your machine:

 Clamp both access needles.

 Clamp both of then thicker bloodlines. If these lines have pinch clamps, pinch all four of the
clamps closed. Unscrew or cut only the thicker bloodlines. Never cut your access needle lines.
Never cut the line between the clamp and your access because the patient will probably bleed to
death.

KIDNEY SHAKEOUT

The Philippine Society of Nephrology will lead a disaster drill participated by volunteer hemodialysis
centers in the country. This exercise will help units enhance their disaster preparedness. The disaster drill
will be led by the Head Nephrologist of the unit, assisted by the hemodialysis staff. Volunteer patients
(not with ongoing hemodialysis) and their family can participate in the drill.

The disaster drill should not interrupt the hemodialysis sessions. Assign a nurse to continue monitoring
patients on hemodialysis while drill is ongoing.

Pre-drill

Education for all staff and patients. This can be done days in advance or just before the drill.

The head nephrologists will discuss the evacuation procedure:

 Present on important procedures for HD patients during disasters (refer to powerpoint slides)
 Drop, Cover, and Hold on - Clamp and Cap
 Instruct the patient and watchers on the unit’s evacuation procedure
 Inform patients on emergency exits of the unit and the designated evacuation area.
 Identify team leaders (from HD staff)
A.Lead for evacuation -First to identify which emergency exit is safe to use.
B. Lead patients’ evacuation area and account for the number of the evacuees.
C. Lead for Medical Records -bring important documents of the hemodialysis unit to the
evacuation area.
D. Lead for Medical Equipment -bring necessary emergency medicines and equipment to
evacuation center
Disaster Drill

Scenario: A fire brought about by faulty electrical wiring occurred in the building where you
hemodialysis is located. The fire is near the main entrance of the hemodialysis unit making it unsafe to
pass through.

A. Head Nephrologist will shout “FIRE” to alert everyone.

B. Evacuation Leader will check “Emergency Exits” and Identify which one is safe to use.

C. Unit Secretary: To call fire department ( no actual call will be made, she will just lift the phone and
shout out loud the number of the fire department) D. Patient volunteers will stimulate “ Clamp an Cap”
E. HD staff and patient volunteers will form a single line F. Lead for medical records will get important
documents. G. Lead for medical equipment to carry emergency medicines / equipment

H. Evacuation Leader will guide everyone to the emergency exit and evacuation area. Order of
Evacuation:

 Evacuation Lead- first

 Volunteer Patients and Watchers
 Lead for Medical Records
 Lead for Medical Equipment
 Hemodialysis Staff
 Head Nephrologist – last

I. Once at the evacuation area, Evacuation Lead to do the following:

 Lead the headcount of patients and hemodialysis staff and report to Head Nephrologist .
 Inform patients on location of back-up hemodialysis facility.
 Give patients the designated contact number of the hemodialysis unit for announcements on
when the HD unit will be operational again.

Post-drill Assessment
1. Open a feedback session between hemodialysis staff and volunteer patients (to
be moderated by Head Nephrologist)
 What was done well
 What could have done better?
 Suggestions from staff and patients
2. Head Nephrologists to complete form “Emergency Drill Assessment” and
submit to PSN office.
CLAMP AND CAP PROCEDURES

STEP 1. Clamp both lines which are directly connected to the needles or catheter.
 STEP 2. Clamp both of the thicker bloodlines. If the lines have pinch
clamps, pinch all four clamps completely closed.

STEP 3. Unscrew the lines between the closed clamps.

STEP 4. Cap the ports of the lines still connected to the catheter or needles.
 DROP! COVER! HOLD ON!

CONTINGENCY PLAN IN CASE OF POWER FAILURE

I. DEFINITION

Power Failure – an incident wherein a certain institution experiences total blackout

due to loss of electrical power.

II.PURPOSE

 Ensures safety among patients and personnel to avoid injuries.

 Emphasizes on proper troubleshooting in case power failure occurs.
 Accurate handling of facilities which focus mostly on dialysis machine
and R.O system.
 Proper channeling of responsibilities between the dialysis and the
hospital’s maintenance department

III. Contingency Plan covers the whole area of the unit when the safety is of priority.

 Head of the Clinic

 Staff Nurses
 Patients and folks
 Technician
 Administrative Staff

IV.INTERVENTIONS

Once power failure occurs, emergency lights will automatically function until the backup generator of
the hospital is turned on.
During the occurrence of power failure, the staff nurse must:

1. Secure the safety of his/her patient. The blood pump automatically stops, manual return of
blood must be done immediately to prevent clotting.
2. Hand cranks are readily available at the back of the dialysis machines. It is the attached to the
blood pump. The nurse will slowly rotate the blood pump using the hand crank from 5 to 10
cycles. Rapid rotation of blood pump will cause RBC breakdown or hemolysis.
3. Arterio-Venous Lumens are flushed with 10cc Plain NSS and are secured with tapes to
prevent needle dislodgement.
4. Once the blood is returned to the patient, vital signs are then taken and the nurse will re assure
the patient until the power comes back on.
5. Once electrical power is restored, the dialysis session is resumed.

6. Before hooking the patient to the dialysis machine, the nurse will perform safety checks and
assess the patient’s condition first.
7. In cases where the power failure is taking much time, roughly more than 1 hour, the dialysis
session will be terminated and the time deficit will be added on his/her dialysis session. The
Nephrologists will be then informed by the incident.

8. The nurse will ensure that her patient is well- informed about the incident and is well
aware of the possible consequences of the early termination of his/her dialysis session
on that given day.

9. An incident report must be written by the head nurse for documentation and is signed
by the head of the clinic.

CONTINGENCY PLAN FOR INJURIES

I. DEFINITION

Injury is damage to the body. This may be caused by accidents, falls, hits, weapons
and other causes.

Major trauma is injury that has potential to cause prolonged disability or

death.
(https:/en.wikipedia.org)

II. PURPOSE

 Ensures proper and immediate steps in the management of accidents inside

the unit.
 Containment of damage or injury.
 In emergency instances, detailed plans of procedures will take its effect.
 Continuously improves the scope of the responsibilities by the staff member of the unit in
 order to respond effectively when a certain situation occurs.
 Emphasizes on the developmental skills of every staff through continuing evaluation
every time an accident happens.

III. Contingency Plans covers the whole area of the unit wherein patient safety

is of priority. Personnel:

 Head of the Clinic

 Staff Nurses
 Technicians

 Administrative Staff

IV. INTERVENTIONS (Dialysis setting)

Fall– an event which results in a person coming to rest inadvertently on the ground or
floor or the other lower level.

Fall related injuries may be fatal or non-fatal though most are non-fatal.

A staff nurse must immediately attend to patients’ aid.

 STOP the blood pump.

 Quick assessment of the injuries acquired by the patient. Administer oxygen if needed.
 For Arterio-Venous Fistula, look for the needle insertion site for possible dislodgement and
immediately apply direct pressure using cherry balls.
 If patient is conscious, ask him/her about the location of the pain she is feeling after the fall.
 Use the Pain Scale 1-10 for Mild, Moderate and Severe pain.
 If ambulatory, slowly assist the patient in sitting up.
 If patient is unable to move, check for breathing pattern and administer oxygen if needed. With the
help of other staff members, move the patient swiftly as a whole while protecting the neck and
head. They must be completely aligned with the body upon moving to prevent further injury of
the spine.
 Once the patient is secured safely, take vital signs and notify the physician.
 Assessment should be done continuously from the start of the accident until the patient is checked
by the attending Physician himself.
 Carry out Physician’s orders if there is any.
 Make a detailed report of the incident and submit to the head of the clinic.

Needle stick Injuries

A penetrating stab wound from a needle (or other sharp object) that may result in exposure to
blood and other body fluids. The main concern is exposure to blood or other body fluids of
another person who may be carrying infectious disease. The pathogens of primary concern are the
Human Immunodeficiency Virus (HIV), hepatitis B (HBV) and hepatitis C Virus (HCV)
Preventive measures are crucial and play a major role in this kind of intervention.

1. Sealed, intact and non-punctured receptacles labeled as “SHARPS”.

2. At the end of the last shift, all the needles used for AVF insertion are soaked with a
disinfectant solution. These needles are sealed in a container where there is a tiny hole big
enough for the needles to pass through.

3. Instruments used for patients are labeled as positive or negative are being
autoclaved separately.

Personal Protective Equipment (PPE) is Mandatory especially for hepatitis and HIV patients.
Double Gloving is a must.

All the materials or equipment that is brought inside the isolation area will be used for
Hepatitis and HIV positive patients only.

If punctured: (STAFF)

1. Wash cuts with soap using running water.

2. If splashes happen to reach your eyes, nose or mouth, irrigate it with sterile irrigate, saline
or clean water.

3. Immediately report to your supervisor provided by a written, detailed explanation of

the incident.

4. Seek for medical treatment.

Expenses such as laboratory tests are covered by the employer depending on the extent of
the injury / injuries acquired. Applicable only during working hours.

CONTINGENCY PLAN IN DISASTER AND

PREPAREDNESS MANAGEMENT

Objectives:

 To ensure safety of the patients and staff

 To secure all important data and facilities both in clinical and business record
 To protect both hard and soft copies of all documents.
 To comply with the regulations imposed by the local government regarding strict policies
and protocols during a disaster.
 To ensure the skills development of all dialysis staff and patients’ quick and appropriate
response to disasters through a continuous training and updates.
 To collaborate with the DRSTMH Disaster Management Committee and actively
 participate during scheduled and unscheduled drills.

Standard Operating Procedures Before a Disaster

The PHCMPC Hospital continuously informs the Dialysis Unit regarding new updates
regarding strict risk reduction management policies and protocols.

In return, the dialysis unit compensates with the institution a requirement through
participation in various drills conducted by the hospital itself for collaboration with the local
government’s NDRRM Council.

Things to ALWAYS REMEMBER:

 Nearest EXIT point.
 EVACUATION area.
 The SAFEST place to do the “HEAD COUNT” and to fill up the REGISTRATION
LIST. Such events are documented by the Dialysis Unit’s staff in charge.

Disaster preparedness and response are always included in the patient’s guidelines to
promote safety and calmness. Patient education plays a major role in evacuation process.

Standard Operating Procedures After a Disaster

Medical Records Officer:

 Upon arrival to the evacuation area, he/she will start the head count until the head of
clinic arrives.
 The same personnel will start the

registration list. Staff Nurse (nearest to the exit point)

 Will notify the first Emergency Response team to arrive at the area about what happened
inside the unit at the start of the disaster/ calamity for documentation of the local
government.

Staff Nurses and Dialysis Technician (emergency kit and medicine cart)

 Continuous assessment of the patient’s status.

 Helps the Head of the clinic in attending the needs of the patient and/ or the
personnel injured.

Head of the clinic:

 Will inform the Emergency Response Team about the status of the building since he/she
is the last one to leave the building. This is for documentation and for the quick and brief
 assessment of the response team’s safety upon entering the building to look for possible
survivors.
 Prioritize patient status. Those who needs her urgent attention

CONTINGENCY PLAN IN CASE OF WATER SYSTEM/ REVERSE OSMOSIS BREAKDOWN

I. Water Treatment system – collection of water purification devices and associated

piping, pumps, valves, gauges etc. That together produce purifies water for
hemodialysis applications and delivers it to the point of use.

1. Raw Water Storage Tank

2. Booster Tank
3. Pressure Tank
4. Multimedia Filter
5. Water Softener
6. Brine Tank
7. Granular Activated Carbon Filter
8. R.O. pre filter
9. Reverse Osmosis Machine

II. WATER TREATMENT SYSTEM / REVERSE OSMOSIS MACHINE BREAKDOWN:

1. The dialysis technician must initially inform the head nurse sop that the patients will be
notified ahead of time for them to think of the possible option in case the troubleshooting will
not work but the end of the day.
2. The Chief Nephrologists and physician on duty will be informed of the said.
3. The technician will then call the R.O engineer and the hospital’s maintenance department.
During the process, the technician will report everything that is happening during the trouble
shooting procedure to the R.O engineer thru phone.
4. A written report of the technician which is signed by the head nurse will then be
emailed to the engineer.
5. Once the R.O Engineer/ Technician will visit the unit, he will conduct inspection
and safety checks to the whole Water Treatment and R.O Machine.
6. An equipment service report will be filled, signed by the head nurse indicating the
service/s done on Preventive Maintenance both in electrical and mechanical checking.

CONTINGENCY PLAN IN CASE OF HEMODIALYSIS MACHINE

BREAKDOWN I. CHARACTERISTICS

Machine name: Bbraun

Dialog + Number of
 Machine: 12 Engineer:
Mr. Carlo Avila
B.Braun Avitum Philippines

II. OBJECTIVES

 To promote safety among the patients and staffs.

 To ensure preventive machine maintenance.
 To monitor the effectiveness and functions of hemodialysis machine/s.

III. TECHNICAL SAFETY INSPECTIONS:

 Disinfection records: The machine records the time and date of disinfection
 Visual inspections: Physical Appearance of the hemodialysis machines.
 Function Inspections: The machine must function properly and accurately
depending on the task to be performed.

IV. MACHINE BREAKDOWN

1. The dialysis technician must initially inform the head nurse as what the patients
will be notified ahead of time for them to think of the possible options in the care of
the machine/s will not be fixed by the end of the day.
2. In cases where 1 or 2 machines have problems in their functions, the HD session of
patients will be adjusted accordingly.
3. The chief nephrologists and the physician on duty will be informed of the said
problem.
4. The technician will then call the engineer and notify the problem. Usually, if the
engineer will not be able to come earlier within the day, a telephone order form him is
done followed by a written incidental report by the technician signed the head nurse.
5. The engineer will then come to the unit as soon as possible for inspection of the
said machine/s.
6. He will then records his time and date of arrival and will be logged in the
preventive maintenance logbook for documentation.

The technical safety inspection (TSI) shall be performed and documented every
12months, according to the specified checklist and with reference to the service
manual and instructions for use and shall be documented. – B Braun Avitum
Philippines.
 CONTINGENCY PLAN ON PANDEMIC (COVID-19
INFECTION)

CONTINGENCY PLAN ON PANDEMIC (COVID-19 INFECTION)

INTRODUCTION

Images Source: Wikipedia.com

The Philippines was declared under a state of Public Health Emergency due to acceleration
and expansion of Corona Virus Disease 2019 (COVID-19) cases as it scaled up as global
pandemic on March 08, 2020 per the World Health Organization (WHO). With the infection
breaching more land territories, the capacity of health facilities are expected to be fully utilized
exhausting all resources of healthcare system.
 In effect, the Department of Health executed through Memorandum No. 2020 - 0072 known
as Interim Guidelines 2019 Novel Corona Virus Acute Respiratory (nCOV-2019) Response in
Hospitals and other Health Facilities in preparation for the progressing global contagion and as
first case of local transmission was confirmed on March 7, 2020 in the country.

The Local Inter-Agency Task Force (IATF) for Covid-19 in Aklan Province has primarily
pinned its promulgation by directing all confirmed positive COVID-19 at Dr. Rafael S.
Tumbukon PMemorial Hospital while heightened quarantine measures were enacted both in
regional and provincial levels.

Pursuant to Region VI DOH Advisory dated March 17, 2020 to Medical Directors among
Level 2 and 3 Hospitals in response to monitor cases of COVID-19 in the Region IV, Panay
Health Care Multi - Purpose Cooperative correspondingly responded by activating the Hospital
Incident Command System and rightly structuring the operation group and policies for deliberate
case handling under the facilitation of the Hospital Infection Prevention and Control Program,
thus the creation and approval of HOSPITAL EMERGENCY INCIDENT COMMAND
SYSTEM.

This program has been developed to establish strategic and operational procedures for
preparedness and response in adaptation to guidelines and directives provided by the World
Health Organization, Center for Disease Control and Prevention, Department of Health,
Philippine Society for Microbiology and Infectious Diseases for COVID -19 management and
control.

GOAL

This Plan is intended to ensure smooth, coordinated, appropriate, efficient and effective
response to health emergency while remaining self-sufficient and remain functional at the
optimum level for at least seven days after the initial impact of emergencies and disasters up
until all services and resources have been restored to normal.

OBJECTIVES

The health emergency incident command process describes an ordered sequence of actions
that aims to accomplish the following:

I. Recognition of the health emergency;

II. Predict/ pre-empt and qualify impact severity of disaster in the hospital;
III. Implement the following identified actions commensurate to the emergency:
a) Timely activation of the incident command system and operation center;
 b) Application of communication and coordination system indicated for emergency among
other agencies and within the hospital;
c) Resource check-in, identification and augmentation for sustainability of operation;
d) Proper delegation of work assignments to personnel capable of efficiently implementing
the plans;
e) Orderly transition of hospital operation to higher restriction level in terms of safety and
security;
f) Appropriate use reporting tools for evaluation and monitoring of the ongoing strategies
and operation in achieving objectives;
IV. To revise the objectives, strategies, and tactics as dictated by incident circumstances.
 A. COMMAND AND COORDINATION

I. HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM STRUCTURE

II. ROLE AND RESPONSIBILITY

 Hospital Incident Commander

o Provides overall direction in overseeing the health emergency operation and its
management
 Hospital Liaison Officer
o Serves as incident contact person for representatives from other agency
 Hospital Public Information Officer
o Provides information and communication plan both internal and external to the hospital
 Hospital Safety and Security Officer
o Monitors and ensures the safety and security of the hospital personnel and facility
 Hospital Planning Section Chief
o Organizes and directs all aspects of planning, from an initial action plan to continuing
plan (sustainability of operation) as incident develop and records concerns
 Hospital Operations Section Chief
o Provides response direction for patient management i.e during surge, for triage, transfer,
external response, Infection Prevention and Control
 Hospital Logistics Section
o Oversees all logistical requirements needed to support response; organizes and directs
the necessary maintenance of the physical environment; facilitates the acquisition of
supplies and services necessary to carry out the functions of the hospital
 Hospital Finance Section Chief
o Monitors the utilization of financial assets and provides administrative support required
in the operations; Supervises documentation of expenditures relevant to the incident
 Surveillance Unit Leader
o Leads in the collection, analysis and interpretation of outcome - specific data for use in
planning, implementing and evaluating hospital policies and practices
 Triage Unit Leader
o Heads the overall triage operation and in the decision-making for appropriate
classification and management of patients in the Emergency Department, coordination/
referral to and fromother agencies and within the hospital, and in the deliberation and
submission of daily reports
 Emergency Management and Treatment Unit Leader
o Directs the general organization and
management of the resources and responsibilities for dealing with all patients for
confinement in the Emergency Department, including the implementation of standard policies,
coordination to other agencies, and planning and implementation of surge strategies and
procedures

 Infection Control and Prevention Leader infectious agents

o Serves as unit head for directing prevention and Unit control of transmission of not
exclusive to COVID 19 and overseas cleaning, sterilization, disinfection, and aseptic
procedures in the area; Assists in the fulfillment of Environment of Care mission of the
hospital and directs infection control education and communications in the unit
 Emergency Transport Unit Leader
o Directs unit operation for emergency and non-emergency transport/transfer of
patientwithin the hospital or those coordinated/referred from/ to different institutions,
including provisionof specialized level of care as needed
 Health Emergency Management Unit Leader
o Develops, manages, and coordinates emergency management programs in the unit;
Monitors the assigned staff during both routine and emergency operations and
recommends and implements goals and objectives for providing emergency services and
training

B. ACTIVATION OF THE HEALTH EMERGENCY INCIDENT

COMMAND SYSTEM

III. PROCEDURES

The activation of HEICS begins with the receipt of flag call or information from the Aklan
Provincial Health Office should their bed capacity to accommodate COVID-19 nears packing up
or demographic indicators on test previse prevalence of positive cases more than what they can
handle in an earlier time period. The first case admission shall be the determination to start about
for ICS implementation as meticulous, systematic and critically plan of action will be required
similarly that of in any extreme type of disaster or patient surge.

Upon receipt of the information, the emergency operation department shall validate the call
which includes the time, number of patients, their case classification and relevant assistance
necessary. The information must be relayed to the incident commander, who in turn shall
activate the Health Emergency Incident Command System for COVID-19. All units shall then
proceed to the hospital meeting room as soon as possible or depending on the urgency of the
situation. A pre-operation briefing and logistics check shall be carried out.

Verification of Report

Step 1:

 Exact, complete and reliable details from the source/caller;

 Verify through Provincial Health Officer II, Dr. Victor A. Santamaria or
Provincial Health Officer I, Dr. Cornelio V. Cuachon, Jr.

- If reliable, dispatch assessment teams

- If not reliable, verify with:

Aklan Provincial Department Health Office

Tel. No. (036) 268-5917

Step 2:

 Whom to Report:
Dr. Gilda L. Villanueva

General Manager and Medical Director/ Responsible Officer

Tel. Nos. (036) 262-3438

(036) 500-3015

CP Nos: +63917-6225777

+63999-8131000

Niño Milan J. Andrade, RN, Incident Commander

CP No: +63928-5520190

Step 3:

 Initial action upon confirmation for need to activate PHC MPC ICS for COVID 19
Operations;
 Contact the following for immediate planning:

Dr. Joanne B. Bautista, Infection Prevention & Control Officer/ Incident Operation Chief

CP Nos: +63917-7172000

+63939-9059567

Dr. Juliet L. Macahilas, Chief of Clinics/ Planning Chief

CP No. +63928-5520177

Florita M. Ganzon, RN, Chief Nurse

CP No. +63909-1584708

Sherlyn C. Gentil, RN, Liaison Officer

CP No. +63949-8677418

Ma. Amparo Joy M. Tefora, RN, Infection Prevention & Control Coordinator / Information
Officer

CP No. +63928-0046514

Mr. Karl Raymund R. Oquendo, Safety & Security Chief

CP No. +63998-574098
 Ms. Emehilda R. Peralta, Finance Chief

Tel. No. (036) 274-7150

CP No. +63907-7760223

Ms. Lizel P. Constantino, Logistics Chief

CP No. +63938-27075998

Jandelle C. Taluyo, RN, Surveillance Unit Leader

CP No. +6326-9953634

Daniel R. Villanueva, RN, Triage Unit Leader

CP No. +6316-5352979

Marlon Joseph S. Icamina, RN, Emegency Management and Treatment Unit Leader

CP No. +6329-9697704

Rhoda V. Rapiz, RN, Infection Prevention and Control Unit Leader

CP No. +6327-4405483

Mr. Rhandy M. Macabate, Emergency Transport Unit Leader

CP No. +6326-7000103

Jesus Bienvenido C. Pinacate, RN, Health Emergency Management Unit Leader

CP No. +6327-9388572

Step 4:

 Designate personnel to deploy for immediate pulmonary ward evaluation - as the area is
presently utilized for non-COVID 19 patients;
 Immediate staffing, supply and equipment inventory submission - Ambulance, ER, Pulmo
Ward, ICU, OR/DR and pharmacy;
 Schedule for meeting with Incident Command Team;
 ICS activation order;
 Risk communication and devices;
 Hospital intra and inter-referral process and transport/transfer;
 Relocation plan and implementation of presently confined patient ward (non-COVID19)
to other stations;
 Creation of schedule and shifting with appropriate capability inventory in anticipation
for long period of operation;
 Day to day monitoring and evaluation of operation reports;
 Accommodation of staff - during operation and for quarantine;
 Local resource augmentation - memorandum of agreement/ understanding review;
  Operation contingency and sustainability plans; and,
 Waste disposal and treatment;
 Document everything. Spokesperson now given the authority to function;
 Done with evaluating the magnitude of the incident;
 Reports on the most vital and comprehensive overview of the situation disseminated to
technical working members and staff to be deployed in the Pulmo Unit ; and,
 Immediate implementation of the rest of the approved and discussed matters required in the
operation

Step 5:

 Response report to Provincial Health Office regarding status of operation and preparedness
capacity

IV. STEPS/ TASKS IN HEICS ACTIVATION

Incident Pre-Operation During Operation Post Operation

(a day or days before) (Arrival of first

patient until discharge
of last)

Transfer/ Activation of HEICS Conduct of Continuous conduct

admission of (IC to assume position meetings to evaluate of meetings to
positive COVID-19 and to designate key incoming reports, evaluate reports/
members information from information;
patients; upsurge of
(predetermined/ quad media and
confinement rate assigned already); appropriate agencies
e.g. DOH, PHO, Regular review of
WHO plans for
Review and improvement or
familiarization of job amendment
action sheets / Development, especially during
policies; approval, and incident escalation;
dissemination of
initial incident
Organization of action plan of Anticipation for
respective teams; implementation; logistical
requirements and
ensuring its
Provision of Making of strategic sustained support
instructions of any decisions and both in logistics and
report or information overall guidance to human resources
needed e.g health the implementing needed;
agency algorithms/ team;
 directives;

Establishment of Continuous
Activation of database of all reporting to higher
command center and logical resources authorities and
schedule of meetings; available in the providing feedback
more often during the Central Supply to the field;
first days but gradually Unit;
reducing in frequency
as incident is Decision for the
managed/ operations Identification of start of recovery
become adaptable; augmentation team and rehabilitation
for standby and phase and
ready for preparation of its
Inventory of resources, deployment with plan;
both material and needed supply of
human resources; resources;
Conduct of post
evaluation and
Structuring of Continuous review of response;
strategies and reporting to higher and,
development of tool authorities and
for monitoring and providing feedback;
evaluation; and, Proper
documentation

Record keeping Ensuring report and

implementation their proper
documentation
V. INFECTION PREVENTION AND CONTROL PROGRAM COMMITTEE
 The Infection Control and Prevention Program Committee shall be the cornerstone for the
delivery of safe and effective high-quality healthcare in the hospital. Each area/unit is
represented to ensure efficient and well-coordinated program implementation for prevention and
management of infection.

During early onset of emergency highly concerning infection management, these designated
personnel shall initially be operating as members of the response team at least on the first 24
hours. Staffing transition shall then be taking place following a meeting to evaluate for the
succeeding response needs and planning for functional strategies to achieve the set goals of the
operation.

PULMONARY UNIT ORGANIZATIONAL STRUCTURE

 The Pulmonary Unit is a special complex care area primarily managed by the Office of the
Nursing Services with direct coordination of the Infection Prevention and Prevention Program
for patient care. The complex unit shall be composed of pulmonary ward for low to middle risk
confinement not requiring intensive care, pulmonary ICU for those indicated with
supportive/assistive devices and critical care and the pulmonary OR/DR area for maternity cases
due for delivery and patient requiring surgery. Triage management meanwhile shall be under the
directive of the Emergency Department for appropriate classification of patient until transport.

SURGE CAPACITY GUIDELINES AND PROCEDURES

Major inclusive implementation made along with the creation of the Incident Command
System for Health Emergency is the immediate conversion of one patient area (Medical Surgical
Ward) to Pulmonary Unit. Should local transmission rise become out of control, and hence need
augmentation facility shall be made available.

Creating the unit for respiratory cases, which might be COVID-19 infected, ensures that the
infection is contained and the rest of patients and staff shall be secured and safe. The unit, which
will be enclosed from other areas, can handle as much as 20 patients (30% of the hospital’s 71
operational bed capacity at the moment) in all four wards and an intensive care unit for five
patients, Operating and Delivery Rooms for OB and surgical cases, and staffing program of
nurses, physicians and allied healthcare personnel involved or necessitated in the care of patients.

The following are the general set of procedures indicated for admitting patients in PHCMPC
in the event of increase in the number of COVID 19 positive cases to ensure that Infection
Prevention and Control Protocols are upheld:

a) Per approved hospital policy in compliance to respond in the ongoing health crisis, the
Pulmonary Unit shall be converted to isolation complex exclusive for confirmed
COVID-19 positive patients with indicated needs for hospitalization only. The complex
which is located on the ground floor and previously operating as the Medical-Surgical
Ward, shall have the following bed allocations:
i. Male medical ward 5
ii. Female medical ward 5
iii. Male medical PHIC ward 3
iv. Female medical PHIC ward 3
v. Patients requiring mechanical 5
Ventilator

b) Individuals who tested positive but are asymptomatic, without underlying critical health
condition or classified as low-risk for hospitalization and not necessarily requiring
medical attention shall not be admitted in the area. Instead, they will be referred to
government designated COVID 19 isolation or quarantine facilities;
c) Hospital personnel (nurses and physician) who are to receive the patient (with
confirmed positive result) from referring facilities and provide medical management
from the emergency department to the Pulmonary Complex shall be the same. Once a
referral is confirmed, the nurse and physician assigned from the Pulmonary Complex
shall be fetched via the hospital transport vehicle going to ER isolation. The same team
shall accompany the patient once bound for transfer and confinement in the complex.
d) All procedures and tests shall be performed in the complex i.e. x-ray, ultrasound, blood
extractions. Patient transfer for procedures such as CT-scan, 2D Echo and dialysis will
be carried out following the designed traffic and route of transfer and with proper
protective devices. All these units shall be disinfected afterwards.
e) An Isolation Operating and Delivery Rooms were made available in the unit for OB-
Gyne patients due for delivery or surgical procedure with infectious respiratory
condition. Within are subdivisions for delivery and surgery cases, substerile area, and
sections for hand scrubbing, stockpiling and cleaning of surgical instruments.
i. The Isolation - OR is a well-organized unit dedicated for aseptic procedures for
both major or minor cases. The environment is perfected with homogenous light set-up
with illumination intended for operation and working space of approximately 8 x 10 ft
which enables flexibility in the movement of personnel. The unit is also centralized and
provisioned with hospital-grade air purifiers. Along with are the equipment indicated for
the setup:
1. Operating table;
2. Anesthesia Machine;
3. Cardiac Monitor;
4. Emergency Resuscitative Devices
5. Crash Cart;
6. Dressing Cart; and,
7. Suction Machine
8. Hospital Grade Air Filter

ii. Isolation - DR. Similarly, this unit setup is completed with equipment and
supplies necessitated to attend for vaginal deliveries only. The area is semi-sterile,
unlike the OR unit, and is provided with wash area. Meanwhile, gynecologic
emegencies i.e.: ectopic pregnancy and C-Section will be performed in the designated
Isolation - Operating Room. (See attached guidelines for OR cases.
f) Each ward, which has designated toilet and bathroom for patients, is also provided with
hospital grade air purifier to minimize or prevent the spread of infection. The Pulmonary
Intensive Care Unit is also built with exhaust equipment facilitating negative air
pressure;
g) Patients to be confined in the area shall be transferred via the hospital transport facility
from the ER-Isolation Room to the loading bay of the Pulmo Complex without passing
thru the main hospital building. Staff will have different passage for entrance and exit
that is situated in the nurse’s station;
h) The wearing of appropriate Personal Preventive Equipment shall be strictly observed as
indicated in the policy
i) Strictly no visitors or folks shall be allowed in the entire confinement period. Update on
the patient’s case shall be made thru phone call by the medical personnel assigned ;
j) All personnel assigned in the area will not be permitted strictly to move out of the unit
at all times to prevent breaching of infection control and prevention measures. Foods
will be served in the area while temporary lounges are provided as well for dining;

k) Staffing accommodation shall be provided by PHC MPC administration and

management. A Memorandum of Understanding with La Esperanza has been executed
for staff requiring to be quarantined;
l) An 8-bed dormitory within the hospital compound but outside the hospital building is
provided for nurses who need to rest after rendering overtime and have difficulty to go
home at night.
 C. HEALTHCARE MANAGEMENT PROCESS

1. SCREENING, TRIAGE AND ISOLATION

 Prior to allowing patients for admission, screening and classifying them is requisite as to
where they should be admitted. The Emergency Department shall have standard procedures in
prioritizing patient for care and in isolating them from one another shall it be needed including
its company or folks. A triage personnel solely assigned to perform patient case classification is
in place prior ER entrance.

All patients with infectious respiratory condition shall be admitted in the Pulmonary
Complex including those indicated for critical care as a Pulmonary Intensive Care Unit shall be
made operational as part of the unit.

An algorithm on COVID19 Management produced by the Philippine Society for

Microbiology and Infectious Disease was adapted by PHC MPC in classifying for patient care
and management as of April 07, 2020. This process has been adapted in the Out Patient
Department that caters for consultation where a strict disclosure for signs, symptoms and travel
history must be obtained.

The triage area is equipped with a desk with physical enclosure and instructional materials.
As much as possible, social distancing is upheld at all times beginning with history and physical
evaluation. Foot bathing and hand sanitation for decontamination shall be observed too including
by watchers entering the area.
 COVID - 19 TRIAGE FORM

Name: ________________________________________ Age/Sex: _________Date:__________Time:

_________

Address: __________________________________________________ Contact No.

________________________

Patient Watcher OPD

A. Do you have any travel history on the last 14 days? (Nagbyahe halin sa ibang nasyon/syudad/probinsya sa
sueod it daywang domingo)?
_______ Yes (Huo) What Place/Country (Ano nga lugar?) ______________

_______ No (Uwa) Date of arrival in Aklan (Petsa it pag-abot sa Aklan): ______________

B. Do you have any of the following symptoms? (Ano nga mga sintomas ing habatyagan)?
_______ Cough (Ubo) _______ Difficulty of Breathing (Lisdan mag ginhawa/ nahapo)

_______ Colds (Sip-on) _______ Diarrhea (pandiho it mabasa)

_______ Fever (Eagnat) _______ Sore Throat (sakit do tutunlan) Others: Specify:
______________

C. Do you have any of the following Co-Morbid Conditions? May iba pa nga mga masakit o kondisyon sa eawas?
_______ Diabetes _______ Hypertension (High blood) _______ Others

_______ Asthma (Hika) _______ Heart Disease (Sakit sa puso)

D. Do you have any contact with a CONFIRMED or PROBABLE CASE of COVID-19 infection involved in:
(May kontak sa isaea nga kompirmado o posible nga may kasong Covid-19 infection nga nag):

D.1. Providing direct care, working with Health Care Workers (HCWs) infected with COVID-19 visiting or
staying in the same close environment of a Covid-19 patient.
 (Direkta nga nagtatap sa pasyente nga may o gina suspetsahan nga may Covid 19, na katrabaho do
mga health care workers nga nagtatap sa pasyente nga may covid 19 o naka bisita sa pasyente nga
positibo o gina suspetsahan nga may Covid 19).

______ Yes (Huo) ______ No (Uwa)

D.2. Working together in close proximity or sharing the same environment with covid-19 patient

(Gatrabaho sa sangka lugar kon siin may una nga pasyente nga nag positibo o gina dudahan nga
kaso it Covid 19 sa kapareho nga lugar o kwarto).

______ Yes (Huo) ______ No (Uwa)

D.3. Traveling together with Covid-19 patient in any kind of conveyance.

(Nagbyahe kaibahan sa kaparehong paeanawon ro sangka tawo nga positibo o gina suspetsahan
nga may Covid 19).

______ Yes (Huo) ______ No (Uwa)

E. Additional Findings:

______ O2 Saturation via pulse oximetry <95%

F. Chest X-ray Radiographic Interpretation (pre-reading): ______________________________

DISPOSITION: _______ To ER Isolation ______ To Clean ER/ To OPD/Lab

I have understood the importance of the questions being asked with regards to my case. I attest that the
information given,. to the best of my knowledge are true.

I understand the moral and legal implications in disclosing false facts, and withholding information from the
hospital staff, I am well aware of the possible negative consequences of such act to the medical staff, non-
medical personnel, other patients, and the rest of the community.
RA 9271. Quarantine Act of 2004

Section 4.2 “… Individual found to be infected or has been exposed to infection considered as dangerous
contact, maybe isolated at any facility…”

Section 8.a “fine of 20,000 to 50,000 or be imprisoned for 1 to 6 months or both

________________________________________

Name and Signature of Patient/Representative

____________________________

Name and Signature of Triage Officer

COVID-19 CHECKLIST

Patient’s Name: _________________________________________ Birthday _______________Age:

________

Address: ________________________________________________ Contact No: _____________________

I. MEDICAL SCREENING GENERAL GUIDELINES

a. All patients at the Emergency Room, whether triaged to the Isolation-ER or the Clean-
ER, will be screened by resident-on-duty/attending physician using the screening form
(See Appendix 3 Form)

b. The latest DOH COVID-19 algorithm will be used to determine the assessment category
in terms of COVID-19 (Appendix A).

c. Any patient assessed to be person PROBABLE or SUSPECT CASE will be re-triaged

to the Isolation-ER by the Resident - on - duty;

d. Relatives of the identified “Probable or Suspect Case” will be registered and appraised
of their possible risk of exposure and managed accordingly;

e. Patients who are assessed as “not Probable or Suspect Case” will be managed at the
Clean-ER accordingly and will be admitted to a regular room/ward;

f. All patients that fits the criteria as suspect case will be admitted in our Isolation ward.
From ER-Isolation they will be brought to the said unit via loading bay thru transport
 vehicle located at the left side of the hospital (See ground plan for patient transport from
ER to Pulmo Unit);

g. For an instance that there is more than one patient that has arrived, evaluating them
should not be done simultaneously as much as possible. After triage, a designated area for
waiting or patient standby point prior management especially in the event of surge is
identified - the clean ER and OPD section;

h. The patient case and information will also be inscribed to another database purposely for
Department of Health tracking system; and,

i. All personnel during the transport shall wear appropriate PPE

II. PERSONAL PROTECTIVE EQUIPMENT (PPE)

Overall, personnel in the hospital has a minimum

required set of PPE in conformity to Hospital Infection
Control and Prevention Standards that should be worn at
all times.

Before undertaking any procedure, staff should assess

any likely exposure and ensure PPE is worn that
provides adequate protection against the risks associated
with the procedure or task being undertaken.

All staff should be trained in the proper use of all PPE

that they may be required to wear. In addition, Staff who
have had and recovered from COVID-19 should continue to follow infection control precautions,
including the PPE recommended.

A. Minimum PPE Requirements for the following personnel:

a. Triage officer assigned for patient classification outside the ER where initial contact or
exposure to WALK IN patient takes place
i. medical/surgical mask;
ii. face shield; and,
 iii. isolation gown

b. Nursing/ medical/laboratory staff providing direct care to suspect, probable or confirmed

COVID-19 WITHOUT AEROSOL GENERATING PROCEDURES (AGP):
i. surgical mask;
ii. goggles or face shield;
iii. gown; and,
iv. gloves

c. Nursing/ medical/laboratory staff providing direct care to suspect, probable or confirmed

COVID-19 WITH AEROSOL GENERATING PROCEDURES
(AGP):
i. respirator (N95);

ii. face shield

iii. gown; and,

iv. gloves

d. Administrative staff not working or passing through the clinical working areas and must
be observing physical distancing of not less than one meter and regular hand
hygiene
i. surgical mask

B. General Guideline in Using PPEs

I. All basic PPEs must be located close to the point of use;

II. Storage are of these PPEs must be clean and dry to prevent contamination until required for
use (expiry dates must be adhered to);
III. Single-use PPEs must be disposed rightly after used;
IV. PPEs, at least mask or gloves, must be changed immediately after each patient and/or
following completion of a procedure or task; and,
V. Disposal of them after use into the correct waste stream is critical i.e. Healthcare/clinical
waste (this may require disposal via yellow bag waste)

C. How to Put On (Don) PPE for Personnel

1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct
(based on training).
 2. Perform hand hygiene.
3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by
other healthcare personnel.
4. Put on N95 filtering face piece respirator or higher (use a facemask if a respirator is
not available). If the respirator has a nosepiece, it should be fitted to the nose with both
hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask
should be extended under chin. Both your mouth and nose should be protected. Do not
wear respirator/facemask under your chin or store in scrubs pocket between patients.*
1. Respirator: Respirator straps should be placed on crown of head (top strap) and
base of neck (bottom strap). Perform a user seal check each time you put on the
respirator.
2. Facemask: Mask ties should be secured on crown of head (top tie) and base of
neck (bottom tie). If mask has loops, hook them appropriately around your ears.
5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece
elastomeric respirator, select the proper eye protection to ensure that the respirator does
not interfere with the correct positioning of the eye protection, and the eye protection
does not affect the fit or seal of the respirator. Face shields provide full face coverage.
Goggles also provide excellent protection for eyes, but fogging is common.
6. Put on gloves. Gloves should cover the cuff (wrist) of gown.
7. Healthcare personnel may now enter patient room.

D. How to Take Off (Doff) PPE Gear

1. Remove gloves. Ensure glove removal does not cause additional contamination of hands.
Gloves can be removed using more than one technique (e.g., glove-in-glove or bird
beak).
2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken
rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to
the shoulders and carefully pull gown down and away from the body. Rolling the gown
down is an acceptable approach. Dispose in trash receptacle. *
3. Perform hand hygiene.
4. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the
strap and pulling upwards and away from head. Do not touch the front of face shield or
goggles.
5. Remove and discard respirator (or facemask if used instead of respirator). Do not
touch the front of the respirator or facemask.*

1. Respirator: Remove the bottom strap by touching only the strap and bring it
carefully over the head. Grasp the top strap and bring it carefully over the head,
and then pull the respirator away from the face without touching the front of the
respirator.
2. Facemask: Carefully untie (or unhook from the ears) and pull away from face
without touching the front.

6. Perform hand hygiene after removing the respirator/facemask and before putting it
on again if your workplace is practicing reuse.
E. Personal Protective Equipment for Suspected or Confirmed COVID-19 Patients in the
Pulmonary Complex

HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection
should adhere to Standard Precautions and use a N95 mask or equivalent or higher-level
respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. When
available, respirators (instead of facemasks) are preferred; they should be prioritized for
situations where respiratory protection is most important and the care of patients with pathogens
requiring Airborne Precautions.

 Hand Hygiene
o HCP should perform hand hygiene before and after all patient contact, contact
with potentially infectious material, and before putting on and after removing
PPE, including gloves. Hand hygiene after removing PPE is particularly important
to remove any pathogens that might have been transferred to bare hands during
the removal process.
o HCP should perform hand hygiene by using ABHS with 60-95% alcohol or
washing hands with soap and water for at least 20 seconds. If hands are visibly
soiled, use soap and water before returning to ABHS.
o Healthcare facilities should ensure that hand hygiene supplies are readily
available to all personnel in every care location.

 Personal Protective Equipment Training

appropriate PPE is selected and provider to and provided to health care providers in
accordance with.

HCP must receive training on and demonstrate an understanding of:

o when to use PPE

o what PPE is necessary
o how to properly don, use, and doff PPE in a manner to prevent self-contamination
o how to properly dispose of or disinfect and maintain PPE
o the limitations of PPE.

Any reusable PPE must be properly cleaned, decontaminated, and maintained after
and between uses.

The PPE recommended when caring for a patient with suspected or confirmed COVID-
19 includes the following:

 Respirator or Facemask 

o Put on an N95 respirator (or equivalent or higher-level respirator) or facemask (if

a respirator is not available) before entry into the patient room or care area.
o N95 respirators or respirators that offer a higher level of protection should be used
instead of a facemask when performing or present for an aerosol generating
procedure. See appendix for respirator definition.
 o Disposable respirators and facemasks should be removed and discarded after
exiting the patient’s room or care area and closing the door unless implementing
extended use or reuse. Perform hand hygiene after removing the respirator or
facemask.

 If reusable respirators (e.g., powered air-purifying respirators [PAPRs] or

elastomeric respirators) are used, they should also be removed after
exiting the patient’s room or care area. They must be cleaned and
disinfected according to manufacturer’s reprocessing instructions prior to
re-use.

 Eye Protection

o Put on eye protection (i.e., goggles or a disposable face shield that covers the
front and sides of the face) upon entry to the patient room or care area.

 Personal eyeglasses and contact lenses are NOT considered adequate eye
protection.

o Ensure that eye protection is compatible with the respirator so there is not
interference with proper positioning of the eye protection or with the fit or seal of
the respirator.
o Remove eye protection after leaving the patient room or care area, unless
implementing extended use.
o Reusable eye protection (e.g., goggles) must be cleaned and disinfected according
to manufacturer’s reprocessing instructions prior to re-use. Disposable eye
protection should be discarded after use unless following protocols for extended
use or reuse.

 Gloves

o Put on clean, non-sterile gloves upon entry into the patient room or care area.

 Change gloves if they become torn or heavily contaminated.

o Remove and discard gloves before leaving the patient room or care area, and
immediately perform hand hygiene.

 Gowns

o Put on a clean isolation gown upon entry into the patient room or area. Change the
gown if it becomes soiled. Remove and discard the gown in a dedicated container
for waste or linen before leaving the patient room or care area. Disposable gowns
should be discarded after use. Cloth gowns should be laundered after each use.
F. Aerosol Generating Procedures (AGPs)

 Some procedures performed on patients with suspected or confirmed SARS-CoV-2

infection could generate infectious aerosols. Procedures that pose such risk should be
performed cautiously and avoided if possible.
 If performed, the following should occur:

o HCP in the room should wear an N95 or equivalent or higher-level respirator, eye
protection, gloves, and a gown.
o The number of HCP present during the procedure should be limited to only those
essential for patient care and procedure support. Visitors should not be present for
the procedure.
o AGPs should ideally take place in an Airborne infection isolation room (AIIR).
during intubation or bagging, an aerosol box shall be used to minimize spread of
pathogens in the air.
o Clean and disinfect procedure room surfaces promptly as described in the section
on environmental infection control below.

Source:https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?
CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control
%2Fcontrol-recommendations.html

G. Disposing of PPE Waste Correctly & Safely

Personal protection equipment, or PPE, is an important part of the overall safety program of
any medical facility. There are many different types of PPE out there ranging from gloves to
full-body hazmat suits. In a lot of cases, PPE can be reused multiple times without any issues. In
other situations, however, it will be just a one-time use item.

Your setting will have certain procedures for moving, removing, or destroying infectious
materials. Consider all stages: from storage, through handling and bagging, to transportation and
laundering.

General Guidelines in PPE Disposal

1. Minimise contact, i.e. handle materials as little as possible and transfer them via routes
that minimize exposure to others.
2. Discard materials into a suitable container or bag. It must conform to the required
standards
3. Use bags that are marked or coloured for infectious waste. This includes orange or yellow
bags (or signs), and text or symbols indicating the bag contains hazardous waste for
treatment or incineration.
4. Transfer non-disposable infectious materials safely to the sterilisation department for
decontamination. You must adhere to the local policy for cleaning the equipment.
5. Always use puncture-resistant containers sharps, as they will not leak.
6. Use pierce-proof waste containers and close them in between use for safety.
7. Never fill a bag or container more than ¾ full.
8. Never over fill waste receptacles.
 9. Remove waste in accordance with local clinical waste disposal policy; it may be collected
by the relevant authorities, removed by an infection control team, or incinerated.

I. STAFFING REQUIREMENT

COVID - 19 patient management pertaining to staffing is the most critical need for
sustainability of operation. At least three nurses in the ward per shift of 12 hours has to be
assigned (10 all in all) while two advance care nurses in the Pulmo ICU per shit of 12 hours shall
also be required (5 all in all). These nurses are officially PHCMPC employed and have the
minimum requirement of Basic Life Support (for Ward) and Advance Cardio-vascular Life
Support Training (for ICU). Meanwhile, another set of requirement shall be obtained to qualify
for duty in the Pulmonary Isolation Complex. Shall these personnel become infected, the hospital
has prepared 5 more personnel for the ward and three more for the ICU. The rest are the
healthcare management requirements for operation in the unit to be observed and complied by
the staff:

1. Staff nurses assigned at the Isolation ward receives a comprehensive training and
competency in performing Covid-19 control practices and procedures that includes the
proper PPE Donning and Doffing technique;

Lecture on 2019 nCOV Infection, Prevention and Control dated January 27, 2020 for all
employees. Held at BEE Mart , PHCMPC
COVID 19 Core Team Update Meeting with Lecture and Practice Demonstration on

PPE Donning and Doffing dated March 20, 2020.

Re-Orientation on Infection Control and Updates on COVID-19 dated June 18, 2020, and held
at the Bee Mart, PHCMPC
 2. Medical and nursing staff were as much as possible encouraged to acquire vaccination
against common flu.

3. Regular health examination is provided to hospital staff especially those who will be
assigned in the infectious and critical units;

4. The Infection control committee shall perform exposure risk assessment regularly at the
end of duty of all health care
personnel;

5. Regular decontamination such as taking a

bath, change of uniform and necessary
personal hygiene regimens to prevent;

6. Strict wearing of appropriate Personal

Protective Equipment is to be observed at
all times except for meal breaks;

7. Obligatory stay in the COVID-19 isolation area at all times and limit their frequency of
moving in and out of the isolation wards or patient contact as much as possible to
reduce the chance of inadvertently getting infected and spreading the virus;

8. Immediate isolation and screening of staff who develops any relevant symptoms such as
fever, sore throat, cough, and/or diarrhea. Declaration of physical health is mandatory);
and,

9. All front-line staff including medical technicians, radiology technicians and utility personnel
who completed their scheduled period of duty in the isolation complex and are to
resume to normal life, a swab test for SAR-CoV-2 shall be provided. If result is positive,
they shall be isolated collectively at a specified area for 14 days before being discharged from
medical observation.

J. Exposure Risk Assessment Tool

RISK ASSESSMENT FOR HEALTHCARE PERSONNEL EXPOSED TO

SUSPECTED/CONFIRMED COVID-19

HEALTH WORKER INFORMATION

Name: _________________________________________ Age: _______ Sex: M ______

F_______ Date:___________ Address: _________________________Contact #:
_____________________ Type of Healthcare Personnel:
__________________________________ Unit:________________

HEALTHCARE WORKER INTERACTION

Multiple COVID-19 patients in Healthcare Facility? YES or NO ( )

Date of first exposure to COVID-19 patient:

Confirmed: ___ PUI:___ PUM:___ SARI:___

HEALTH CARE WORKER ACTIVITIES

A. Did you provide direct care to a □ Yes □ No

confirmed/suspected/probable/SARI patient?
B. Did you have face-to-face contact (within 1 meter)?
C.Are you present when any aerosol generating
procedures (AGP) was performed on the patient? □ Yes □ No

D. If yes what type?________________________

E. Did you have direct contact with the environment of □ Yes □ No

the patient? e.g. bed, linen, medical equipment,
bathroom etc.

□ Yes □ No

ADHERENCE TO INFECTION PREVENTION AND CONTROL (IPC) DU

A. During the period of a health care interaction with a □ Yes □ No

COVID-19 patient, did you wear personal protective
equipment (PPE)? If yes, for each item of PPE below,
indicate how often you used it:

1. Single gloves □ Always, as recommended

□ Most of the time (50% or more but

not 100%)

□ Occasionally (20% to under 50%)

 □ Rarely (less than 20% of the time)

2.Medical Mask/N95mask □ Always, as recommended

□ Most of the time

□ Occasionally

□ Rarely

3.Face shield or goggles/protective glasses □ Always, as recommended

□ Most of the time

□ Occasionally

□ Rarely

4.Isolation gowon/cover all □ Always, as recommended

□ Most of the time

□ Occasionally

□ Rarely

B. During aerosol generating procedures on the □ Always, as recommended

COVID19 patient, did you remove and replace your
PPE according to protocol (e.g when medical mask □ Most of the time
became wet, disposed the wet PPE in the waste bin, □ Occasionally
performed HH?
□ Rarely

C. During aerosol generating procedures on the □ Always, as recommended

COVID- 19 case, did you perform hand hygiene before
and after touching the COVID-19 patient? NB: □ Most of the time
Irrespective of wearing gloves □ Occasionally

□ Rarely

D. During aerosol generating procedures on the □ Always, as recommended

COVID19 case, did you perform hand hygiene before
and after any clean or aseptic procedure was performed □ Most of the time
(e.g. inserting: peripheric vascular catheter, urinary □ Occasionally
catheter, intubation, etc.)?
□ Rarely

E. During aerosol generating procedures on the □ Always, as recommended

COVID19 case, did you perform hand hygiene after
touching the COVID-19 patient’s surroundings (bed, □ Most of the time
door handle, etc)? Note: This is irrespective of wearing
gloves □ Occasionally

□ Rarely

F. During aerosol generating procedures on the □ Always, as recommended

COVID19 case, were high touch surfaces
decontaminated frequently (at least three times daily)? □ Most of the time

□ Occasionally

□ Rarely

ACCIDENTS WITH BIOLOGICAL MATERIAL

A. During the period of a health care interaction with a □ Yes □ No

COVID-19 infected patient, did you have any episode
of accident with biological fluid/respiratory secretions?
If yes which type of accident
□ Splash of biological fluid/respiratory secretions in the
mucous membrane of eyes

□ Splash of biological fluid/respiratory secretions in the

mucous membrane of mouth/nose

□ Splash of biological fluid/respiratory secretions on

non-intact skin

□ Puncture/sharp accident with any material

contaminated with biological fluid/respiratory secretions

Interviewer Name: ______________________ Date: ____________

Interviewed: ______________________

K. Risk categorization of health workers exposed to COVID-19 virus

High risk for COVID-19 infection The health worker did not respond ‘Always, as
recommended’ to Questions: 4A – 4F AND/OR responded ‘Yes’ to 5.

All other health workers should be considered low risk for COVID-19 virus infection.

Management of health workers exposed to COVID-19 virus

 Recommendations for health workers with high risk for infection:

 Stop all health care interaction with patients for a period of 14 days after the last day of
exposure to a confirmed COVID-19 patient;
 Be tested for COVID-19 virus infection;
 Quarantine for 14 days in a designated health care facility.
 Provide psychosocial support to HCW during quarantine, or duration of illness if HCW
becomes a confirmed COVID-19 case;
 Refresher infection prevention and control training for the health care facility staff, including
HCWs at high risk for infection once he/she returns to work at the end of the 14-day period.

Recommendations for health workers with low risk for COVID-19 infection:

 Self-monitor temperature and respiratory symptoms daily for 14 days after the last day of
exposure to a COVID-19 patient. HCWs should be advised to call health care facility if
he/she develop any symptoms suggestive of COVID-19;
 Reinforce contact and droplet precautions when caring for all patients with acute respiratory
illness2 and standard precautions to take care of all patients;
 Reinforce airborne precautions for aerosol generating procedures on all suspect and
confirmed COVID-19 patients;
 Reinforce the rational, correct and consistent use of personal protective equipment when
exposed to confirmed COVID-19 patients;
 Apply WHO’s “My 5 Moments for Hand Hygiene” before touching a patient, before any
clean or aseptic procedure, after exposure to body fluid, after touching a patient, and after
touching patient’s surroundings;
 Practice respiratory etiquette at all times.

II. INTER-HOSPITAL TRANSFER/REFERRAL OF PATIENTS

a. COVID-19 positive patients will only be accepted for transfer in PHCMPC once a flag
call or confirmation from Aklan Provincial Health Office is made presumably when
DRSTMH can no longer accommodate the increase in number of their admission;
 b. Prior to transport from DRSTMH, these patients must be endorsed completely and
properly to resident on-duty to prepare the Emergency Department and staffing;

c. Patients for transfer shall wear medical masks during the entire process of admission until
transfer to Pulmo Complex;

d. A dedicated ambulance shall do the transfer as facilitated by ER staff while the

accompanying folks shall be made to stay for evaluation of ER physician shall
confinement or quarantine be made;

e. All personnel during the transport shall wear appropriate PPE at all times (Appendix )

III. TRAFFIC FLOW OF PATIENTS AND STAFF

a. General Guideline for transport of COVID-19 patients upon Admission

1. From Emergency Department - Isolation Room, patient will be admitted to New

Pulmonary Complex via transport vehicle;

2. Moving and transporting patients out of isolation area are avoided unless medically
necessary. There will be designated equipment for special procedures in the unit i.e.
portable X-ray and ultrasound machines. All medical supplies for patient care will be
stockpile in the unit for their own consumption;

3. If transport is required, a predetermined transport routes clear of any individual will be

utilized for procedures i.e. 2D Echo, CT - Scan, or and haemodialysis procedures;

4. If intubated, a sealed hood should be placed over the patient that covers the head and
torso and a transport vent shall be used during the transfer. The sealed hood should be
cleaned and disinfected using bleach solution/sodium Hypochlorite solution 1:100
dilution, let stay for 2 to 3 minutes, rinse, then clean with soap and water;

5. If not intubated, patients should wear surgical mask and isolation gown;
6. Healthcare workers who are transporting patients should perform hand hygiene and wear
appropriate PPE (gowns, gloves, N95 mask, goggles/ face shield) as recommended and
notify the area receiving the patient of any necessary precautions as early as possible
before the patient’s arrival;
7. Healthcare workers shall routinely clean and disinfect surfaces with which the patient is
in contact;

8. Limit the number of HCWs who are in contact with suspected or confirmed COVID19
patients; and,

9. Maintain a record of all persons entering a patient’s room, including staff.

 PATIENT TRAFFIC FROM EMERGENCY DEPARTMENT TO
PULMONARY COMPLEX

Pulmonary Complex Emergency Department

A - Operating Room J - ED Isolation/ holding

Room

B - Delivery Area K - ED Clean Area

C - Nurse’s Station L - ED Entrance/ patient

receiving passage
 D - Male Medical Ward

E - Intensive Care Unit

F - Female Medical Ward

G - Female Surgical Ward

H - Male Surgical Ward

I - Entrance for Patients

After evaluation and classification at the ED Isolation (J), COVID-19 positive patients are
transported to Pulmo Complex via the hospital transport vehicle thru the unit entrance (I) - red
arrows serve as route of vehicle from the Emergency Department Entrance (L) to the Pulmonary
Complex. Also, these patients are only accommodated in the Isolation Room of Emergency
Department and will never be allowed to reach the ED Clean area (K) where non-COVID19
patients are managed for admission.

Before conversion to Pulmo Complex of Medical Surgical Ward, the center alley (blue
broken line) serves as the route going to the area. However, since it has to be closed to contain
infection, outside road is utilized as part of the contingency.
PULMONARY COMPLEX FLOOR PLAN
 This floor plan describes the patient distribution, capacity and division in the pulmonary unit
that can accommodate a total of 20 beds for confinement. A makeshift OR/DR unit is also made
available shall delivery and surgical procedures be needed.

The passage located at the bottom part (West) shall be intended for patient’s entrance and
exit only. Staff’s access is located at the left portion (South) of the unit that directs directly to the
Pulmo-medical ward nurse’s station.

All bed is secured to be at least three meters distanced from one another. Surgical (red) and
medical (blue) cases were also grouped differently from male to female patients. Intensive care
unit (yellow) will have different confined working area for staff nurses and comfort room.

Personnel assigned in the Complex are provided with house for accommodation outside the
unit but is within the hospital vicinity (Bee Mart) which will be contained and exclusively for
them. A vehicle for their transport going in and out of the unit will be arranged by the
management. After two weeks of rendering duty, a quarantine facility will be provided shall they
become infected with COVID-19 disease.

VI. AMBULANCE POST COVEYANCE

a. All linen should be managed as per local policy for the management of infectious
linen at the receiving unit;
b. All waste should be disposed of as category B clinical waste, as per local policy, at
the receiving unit.
c. The crew are to remove PPE in the designated area identified within the receiving
unit;
d. All disposable PPE is to be disposed of as category B clinical waste, as per local
policy, at the receiving unit.

III. DECONTAMINATION

As coronaviruses have a lipid envelope, a wide range of disinfectants are effective. PPE and

good infection prevention and control precautions are effective at minimizing risk but can never
eliminate it.

1. Wear PPE. Providers should wear full PPE from start to finish on any call where COVID-
19 is suspected. The suggested COVID-19 PPE ensemble includes a disposable gown, N95
mask, eye protection, gloves and face shield. Providers should retain the full PPE ensemble
while disinfecting the patient care compartment, as many disinfectants can irritate skin, eyes
and mucous membranes. Remove the gown and gloves first, then facial protection. Place all
PPE in a red biohazard bag, then seal and dispose of the soiled gear in a proper receptacle
and perform handwashing.
2. Provide Ventilation. Light and air can be key allies in the fight against airborne virus
particles. The CDC guidelines recommend leaving the rear doors of the ambulance open
after transporting the patient to allow enough air exchange to remove potentially infectious
particles. The time to complete transfer of the patient to the receiving facility and complete
all documentation should provide sufficient air exchange. But airborne particles are only a
fraction of the threat. Airing out the patient care compartment does not address surface
contamination, which requires the application of a broad-spectrum disinfectant.

 Use of an approved disinfectant. The broad-spectrum d7 solution has proved effective for

ambulance decontamination such Hydrogen Peroxide or Sodium Hypochlorite. The patented
disinfectant formula can neutralize various contaminants, including viruses similar to those
that cause covid-19, within minutes when properly applied, because the detergents in the
formula break down the outer shell of the viral particles so it can break down the genetic
material inside.

 For Cleaning:
I. Use of Soap and Detergent and Water

 For Disinfecting
I. 70% Ethyl Alcohol Sodium
II. 0.5% Sodium Hypochlorite Solution (Equivalent to 5000 ppm) for surfaces
contaminated with excreta, blood, vomitus, or other bodily secretions and allow
disinfectants to sit in at least 30 minutes
III. O.1% Sodium Hypochlorite Solution (Equivalent to 1000ppm) for surfaces not
contaminated with bodily secretions

Decontamination of Patients and Watchers

Everyone to enter either in the Isolation room or directly to the clean emergency room for
admission shall observe decontamination process. Apart from patients and their accompanying
watchers, healthcare practitioners and allied staff passing through the area are obliged to
regularly sanitize and have a temperature check. The following are the equipment and facilities
made available in strategic locations for decontamination purposes:
a) Pedal-operated hand washing systems. These are sinks built on the following strategic
areas for the purpose of sanitation of hands without risk of re-contamination after
washing:

i. Before entrance to ER triage area;

ii. Before entrance to lobby main door; and,

iii. Upon entrance of Pulmo Complex

b) Use of alcohol spray and installed alcohol dispensers. Spraying of alcohol is done by
the triage officer and security guard to everyone entering the hospital. Alcohol dispensers
are placed outside doors or corners bound to another department or areas where transactions
or passing of persons are more usual than others.

c) Footbath mats. Sanitizing footbath mats are designed to aggressively clean dirt, debris
and other contaminants and bacteria from footwear before entering the hospital floors i.e.
ED triage area OPD and main lobby entrances.

d) Emergency Department decontamination area. Located within the ER Isolation, this

section is equipped with water system to manually remove or clean any dirt, contaminants,
bodily fluids or hazardous elements acquired / from patients to minimize infection risk they
or the hospital staff may have.

e) Infection Control and Prevention Instructional materials. These are IEC materials
such as posters for infection management, flowcharts for coordination and treatment and
reminders on handwashing’s significance and technique that must be observed within the
hospital.
 Apart from IEC reminders, the hospital
ensures that social distancing is observed thru
fixed installation of separators of chair for
waiting patients
 IV. HOSPITAL DISINFECTION AND TREATMENT PROTOCOLS

1. Disinfection Procedures
(Adopted from, Handbook of COVID-19 Prevention and Treatment (2020) produced by
The First Affiliated Hospital, Zhejiang University School of Medicine (FAHZU).

a) Disinfection of floors and walls by housekeeping

 Visible pollutants shall be completely removed before disinfection and
handled in accordance with disposal procedures of blood and bodily fluid spills;
 Disinfect the floor and walls with 1000 mg/L chlorine-containing disinfectant; and,
 Carry out disinfection three times a day for the corridors, daily for patient room,
every other day for comfort rooms, and repeat the procedure at any time when
there is contamination. This can be done by the personnel who provides patient
care.

b) Disinfection of Object Surfaces

 Visible pollutants should be completely removed before disinfection and handled in
accordance with disposal procedure of blood and bodily fluid spill;
 Wipe the surfaces of objects with 1000mg/L chlorine-containing disinfectant or
wipes with effective chlorine; wait for 30minutes and then rinse with clean water.
Perform disinfection procedure three times a day (repeat at any time when
contamination is suspected); and,
 Wipe cleaner regions first, then more contaminated regions: first, wipe the
object surfaces that are not frequently touched, and then wipe the object surfaces
that are frequently touched (once an object surface is wiped clean, replace the used
wipe with a new one)

c) Air Disinfection
 Plasma air sterilizers can be used and continuously run for air disinfection
in an environment with human activity; alternatively, use portable HEPA filter
for air cleaning every 4 hours for the ante rooms; and,
 If there is no plasma air sterilizers, use ultraviolet lamps for 1 hour each time.
Perform this operation three times a day

d) Disposal of Fecal Matter and Sewage

 Before being discharged into the municipal drainage system, fecal matter and
sewage must be disinfected by treating with chlorine-containing disinfectant
 (for the initial treatment, the active chlorine must be more than 40 mg/L)
and make sure that the disinfection time is at least 1.5hours; and,
 The concentration of total residual chlorine in the disinfected sewage should reach
10 g/L.

2. Disposal Procedures for Spills of COVID-19 Patient blood/fluids.

For spills of a small volume (<10ml) of blood/bodily fluids:

a. Option 1: The spills should be covered with chlorine-containing disinfecting wipes

(containing 5 g/L effective chlorine) and carefully removed, then the
surfaces of the object should be wiped twice with chlorine-containing
disinfecting wipes (containing 500 mg/L effective chlorine);

b. Option 2: Completely cover the spill with disinfectant powder or bleach powder
containing water-absorbing ingredients or completely cover it with disposable
water-absorbing materials and then pour a sufficient amount of 10,000 mg/L
chlorine-containing disinfectant onto the water absorbing material (or cover
with a dry towel which will be subjected to high-level disinfection). Leave for at
least 30minutes before carefully removing the spill. Fecal matter, secretions, vomit,
etc. from patients shall be collected into special containers and a spill-to-disinfectant
ratio of 1:2;

c. After removing the spills, disinfect the surfaces of the polluted environment or
objects;

d. Containers that hold the contaminants can be soaked and disinfected with 5 g/L
effective chlorine;

e. The collected pollutants should be disposed as medical wastes; and,

f. The used items should be put into double-layer medical waste bags and disposed of
as medical wastes.

3. Disinfection procedures for infectious fabrics of suspected or confirmed patients

A. Infectious fabrics
1. Clothes, bed sheets, bed covers and pillowcases used by patients;
2. Ward area bed curtains; and,
3. Floor towels used for environmental cleaning

B. Collection methods
1. First, pack the fabrics into a disposable water-soluble plastic bag and seal the bag
with matching cable ties;
 2. Then, pack this bag into another plastic bag, seal the bag with ties;
3. Finally, pack the plastic bag into a yellow fabric bag and seal the bag with cable
ties; and
4. And attach a special infection label and the department name, send the bag to
the laundry room.

C. Storage and Washing

1. Infectious fabrics should be separated from other infectious fabrics (non-COVID-19)
and washed in a dedicated washing machine;
2. Wash and disinfect these fabrics with chlorine-containing disinfectant at 90o C for at
least 20 minutes.

D. Disinfection of transport tools

1. Special transport tools should be used specifically for transporting infectious fabrics;
2. The tools shall be disinfected immediately each time after being used for transporting
infectious fabrics; and,
3. The transport tools should be wiped with chlorine-containing disinfectant (with 1000
mg/L active chlorine). Leave disinfectant for 30 minutes before wiping the tools clean
with clean water

E. Disposal procedure for covid-19 related medical waste

a. All wastes generated from suspected or confirmed patients shall be disposed of as
highly infectious medical waste;
b. Put the medical waste into a double-layer medical waste bag, seal the bag with ties
and spray the bag with 1000 mg/L chlorine-containing disinfectant;
c. Put sharp objects into a special plastic box, seal the box ,and spray the box with
1000mg/L chlorine-containing disinfectant;
d. Put the bagged waste into a special waste transfer box, attach a special
infection label and transfer it;
e. Transfer the waste to a temporary storage point for medical waste along a specified
route at a fixed time point and store the waste separately at a fixed location;
f. The medical waste shall be collected and disposed of by an approved medical waste
disposal provider.
 V. LINEN AND WASTE MANAGEMENT

A. PPE to be used:
a) Heavy Duty gloves, surgical mask, goggles, gown, an apron if the gown is not fluid-
filled resistant, and boots or closed shoes.
B. Procedure:
a) Carefully remove any solid excrement;
b) Put in a covered bucket to be disposed of in a toilet or latrine;
c) Use clearly labelled leak proof bags or containers;
d) Washing Machine;
i. Use warm water at 60-90 degrees celcius
ii. Dry according to routine procedures
e) Non-Washing Machine;
i. Soaked in hot water and soap in a large drum using a stick to stir but be careful to
avoid splashing;
ii. Soak in 0.05 chlorine for approximately 30 minutes;
iii. Rinse with clean water;
iv. Excreta should be carefully removed with towels and safely disposed in a toilet or
latrine
f) If the towels are single use, they should be treated as infectious waste;
g) If the towels are reusable, they should be treated as soiled linens

VI. PROCEDURE ON SAFE MANAGEMENT OF A DEAD BODY (DOH Guideline:

Department Memorandum No. 2020-0158)

Removal of the Body from Isolation Room or Area in a Health Care Facility

A. All drains, tubes and catheters shall be removed with extreme caution;
B. Implants (I.e. pacemakers, orthopedic implants) in the cadaver shall not be removed to
minimize exposure of personnel handling the body;
C. Wound drainage and needle puncture holes shall be disinfected and dressed with
impermeable material;
D. Wrap the body with clothe and place it in an airtight cadaver bag that is leak proof and zip or
close tightly with tapes or bandage strips;
E. Decontaminate the surface of the bag with Hypochlorite solution (50-100ppm or 1 part
bleach in 4 parts of water); and,
F. Ensure that the body is fully sealed in an impermeable airtight cadaver bag before being
removed from the isolation room and before transfer to crematorium or mortuary, to avoid
leakage of body fluid.
Transfer to Funeral Home/Crematorium

A. At no instance shall unzipping of the cadaver bag be permitted or the body removed;
B. Embalming and hygienic preparation, such as cleaning of the body, tidying of the hair,
trimming of nails, or shaving shall not be allowed; and,
C. The vehicle used for transport shall be disinfected immediately following proper disinfection
protocol.

VII. SPECIMEN COLLECTION AND TRANSPORT

1. Specimen collection for suspected cases will be done at Dr. Rafael S. Tumbokon
Hospital.
2. Patient will be brought to DRSTMH for specimen collection thru ambulance
accompanied by the assigned nurse on duty.
3. PPE should be worn by the nurse on duty and the ambulance driver at all times.
4. A logbook including names, dates, and activities of all workers present during specimen
processing and transport should be kept to assist in future follow-up if necessary.

VIII. PROCUREMENT POLICIES and PROCEDURES

A. Emergency Procurement. All basic necessities for COVID-19 management entailing

safety and protection of staff are provided and maintained to be sufficient for long term
supply as much as possible. Large scale procurement requires board approval and passes
through official standard processes. Suppliers were identified. If not, local purchases are
made in the event of emergencies.

B. Stock Level. (see inventory of stocks)

C. Donation.
C.1.) As of the moment, the hospital has prepositioned 200 pcs of PPEs from donation.

D. Supply Management.
D.1.) All dispensed hospital products are accounted and controlled all the time since
sourcing of supplier in the recent times have been not too easy.
 D.2.) Inventory at Central Supply Department is updated every day while those at the
stations are done every shift. Replenishment is done on regular basis.

IX. VISITOR MANAGEMENT AND EXCLUSION

Patient Visitor and Watcher Restrictions:

A. No visitors and watchers are permitted for Confirmed Covid patients. However, for
probable or suspect case the following must be followed per approval by the Infection
Control Committee:
 one watcher per patient at end-of-life;
 two parents/caregivers for pediatric patients;
 One watcher for patient in Labor & Delivery;
 one watcher for patient undergoing urgent/emergency surgery;
 one visitor to accompany patient for hospital discharge;

B. Any watcher who lives in the same household as a COVID-19 positive person is not
permitted. Approved watchers will be asked whether they live in the same household as a
COVID-19 positive person.
 If the patient has been in the hospital for more than 14 days, the household contact
can be approved as an exception.
 Patients with disabilities may designate one support person to accompany, visit and
stay with them in the hospital. A support person is defined as someone who is
legally authorized to make decisions for the individual with disabilities, a family
member, a personal care assistant, or a disability service provider. In this situation,
the support person will be permitted to visit even in the instance that the support
person is a household contact of the patient. Other reasonable accommodations for
individuals with disabilities may be approved by the Medical Director , NSO and/or
Infection Prevention & Control Committee, provided the accommodations comply
with all infection prevention policies.
C. No visitors/watchers under the age of 18 are permitted, unless they are parents of
padiatric patients.
D. Family, friends and loved ones are encouraged to use electronic devices and applications
(apps) to connect with patients (i.e., smartphones, tablets, FaceTime, Skype, etc.).

Guidance for Approved Visitors/Watchers From Exceptions:

 All approved visitors must log in at the designated area and wear a face mask throughout
the duration of their visit.
 All approved visitors will be screened for flu-like symptoms, such as fever, cough or
shortness of breath, and will not be permitted if symptomatic.
 Family members or friends of any approved visitors will not be permitted to enter the
facility or to wait in lobbies or common areas, including any/all areas of the hospital—
 lobbies, waiting areas, common spaces, cafeteria, and/or any other area within the care
location.
 Approved visitors must gown in Personal Protective Equipment (PPE)—surgical mask,
isolation gown, face shield (eye protection), and gloves.
 Approved visitors must not be ill or show symptoms of illness.
 Prior to entering a patients room, watchers/visitors will be provided with instructions on
hand hygiene, limiting surfaces touched, and use of PPEs.
 A record for all visitors will be maintained for record purposes.
PATIENTS FOR REFFERRAL TO RURAL
HEALTH UNITS
COVID-19 SCREENING FORM

(For Residents Only)

Name: __________________________________ Age: ______ Sex: ________ Date: _______

Attending MD: ____________________________________

Admitting Diagnosis: _______________________________

Any of the following in the last two weeks?

YES NO REMARKS

International Travel in the last 2 weeks

Close Contact with confirmed COVID – 19 case

(direct care/same closed environment/travelling
together in close proximity)

Local travel (community with local transmission)

SYMPTOMS

Fever (Temp > 37.8 C

Symptoms of URTI (sore throat, colds)

Cough

Difficulty of Breathing

Diarrhea

Clinical Parameters Diagnosis Disposition Chest X-Ray

Findings

____ RR >30/min _____ Probable Case

____ O2 Sat <92% at

RA
_____ Suspect Case
____ Blood Pressure
____Rales/crackles
others:
_____ Confirmed

CONTACT TRACING:

(1) Name:___________________________________Age:___________Disposition:_____________
Address:_________________________________________________________________________
_

(2) Name:___________________________________Age:___________Disposition:_____________
Address:__________________________________________________________________________

(3) Name:___________________________________Age:___________Disposition:_____________
Address:__________________________________________________________________________

(4) Name:___________________________________Age:___________Disposition:_____________
Address:__________________________________________________________________________
For additional contacts, please use separate sheet.

I have understood the importance of the questions being asked with regards to my case. I attest
that the information given are true and to the best of my knowledge. I understand the moral and
legal implications in disclosing false facts, and withholding information from the hospital staff. I
am well aware of the possible negative consequences of such act to the medical staff, non-
medical personnel, other patients and the rest of the community.

RA 9271 Quarantine Act of 2004

Section 4.2 “…. Individual found to be infected or has been exposed to infection considered as
dangerous contact, may be isolated any facility…” Section 8.a “fine of 20, 0000 to 50,0000 or be
imprisoned for 1 to 6 months or both

_____________________________

Signature of the patient

Screened by: _______________________________ Name and Signature: __________________

References:

www.gptwaste.com
XIX. LOGISTICS AND RESOURCE AUGMENTATION

Resources Needed Provisioning Indicator Remarks

Institution/ Body

Additional Fund PHC MPC Board Resolution No. Php 200,000

064, Series of 2017 Emergency Fund for
procurement of
emergency provisions

Transport vehicles PHC MPC Volunteer Memorandum of 8 vehicles on-call

Transport Brigade Agreement

Essential Drugs and RJL Pharmacy Memorandum of Executed

Medical Supplies Agreement

Mercury Drugs Store Mercury Drugs Store Memorandum of Ongoing

Agreement

Blood and Blood Philippine Red Cross Memorandum of Pending for Approval
Products Agreement

Food Groceries Stocks Royal Supermarket Memorandum of Pending for Approval

Agreement

Meat Products Navarra Food Memorandum of Executed

Products Agreement

Rice and Grain Puis Farmers Memorandum of Executed

Products Association Agreement

Cadaver Management San Fernando Funeral Memorandum of Executed

for Non-COVID19 Homes Agreement
Patients

Cadaver Management Donguines Funeral Memorandum of Pending for Approval

for Non-COVID19 Homes Agreement
Patients

Accommodation and La Esperanza Hotel Memorandum of Ongoing. Can

Quarantine Facility Agreement accommodate as
much as 20 personnel
with individual rooms
Accommodation for Bee Mart Memorandum of Ongoing. 8 bed-
Staff Nurses within Agreement dormitory type room
PHC MPC premises