LUMBIS RANCES GENERAL HOSPITAL

PHIC ACCRED No.: H05010131 LIC NO.: 05-058-13-020-H-2-2

DTI No.: 01264099 TIN No.: 109-018-258-000
Smart:0919-947-83-00Globe:0916-518-91-93 EMAIL ADD.:[email protected]
NATIONAL ROAD, BRGY. ILAOR SUR, OAS, ALBAY

POLICIES AND PROCEDURES ON ISOLATION OF NOSOCOMIAL INFECTION

I – INTRODUCTION

All accredited hospitals are required to have an Infection Control Committee (ICC). The
responsibility of the hospital on the control of infection extends to its personnel and to the
person visiting the patient.

II – Objective

To specify infection surveillance procedures.

III – POLICY DESCRIPTION

All personnel handling specimen which may harbour potentially infectious agent should be
protected against this occupational hazards. To decrease the risks of transmission, this policy is
proposed and recommended.

IV – DEFINITIONS

Nosocomial infections are infections that present themselves in hospitalized patients in whom
the infection was not present or incubating at the time of admission. An infection that presents
on admission can only be classified as nosocomial if it is directly related to a previous
admission. The term Nosocomial will include the vast majority of potentially preventable
infections. In this facility the Infection Control Committee has determined an infection that
develops three days after admission is nosocomial.

V – RESPONSIBILITIES

1. Nursing staff are often the first to observe changes related to possible failure of Infection
Control Standards Communication of concerns to the Infection Control Chairman are crucial
and need to follow guidelines detailed in the Infection Report policy to ensure that accurate
timely reporting of diagnosed infection is achieved.
2. Surveillance and reporting of patient infection, environmental contamination, communicable
disease.
3. Attend to identify the reservoir, sources and method of transmission.
4. Initiate appropriate measure to limit further spread of infection.
5. Maintain continuous record of its infection after admission.
6. Review all infection data with the chairman ICC.

VII – MONITORING
It’s the continuous observation of the occurrence of potentials infectious disease outbreaks in
the hospital among patients and personnel. It entails collection of data to evaluate the
accurate, reliable and prompt reporting of infection within the hospital premises.

VIII – DISSEMINATION

1. Unit meeting
2. Feedback report of Nursing Audit
3. Health teaching orientation of all personnel
SECTION CONCERNED:
Medical/Nursing Service/Admin/Ancillary

PERSONS RESPONSIBLE:
Medical Officers
Staff Nurses
Institutional Workers
X-ray Tech
Med Tech

AVA R, REODIQUE, RN.

Infection Control Nurse

MELBA O. ALANO, RN, MAN

Chief Nurse

Noted by:

EMMAN M. VALENCIANO, RM, RN, MD

Interim Medical Director
 LUMBIS RANCES GENERAL HOSPITAL
PHIC ACCRED No.: H05010131 LIC NO.: 05-058-13-020-H-2-2
DTI No.: 01264099 TIN No.: 109-018-258-000
Smart:0919-947-83-00Globe:0916-518-91-93 EMAIL ADD.:[email protected]
NATIONAL ROAD, BRGY. ILAOR SUR, OAS, ALBAY

INFECTION CONTROL COMMITTEE

Chairperson: Emman M. Valenciano, RM, RN, MAN, MD

Medical Director

Members: Ava Reodique – Infection Control Nurse

Raul D. Samaniego – X-ray tech/ Compliance Officer
Donna Sarte – Med Tech

ROLES AND FUNCTIONS OF ICC:

1. Determine the method of surveillance and reporting.

2. Determine the criteria for reporting of infection.
3. Review records of all infected patients.
4. Review with the medical audit committee the use of antibiotics and anti-infective.
5. Recommendation in relation to selection of equipment used for sterilization.
6. Prepare and update procedure manuals of aseptic techniques used in hospital staff.
7. Determine the policy on screening and immunization of hospital staff.
8. Determine the content and methodology of training program for hospital staff in prevention
and control of hospital infection.

EFFECTIVE CONTROL MEASURES:

1. PEOPLE – The people in the hospital are significant carrier. The most important factor is the
failure of the hospital staff to wash their hands often enough between patients to prevent
spread of cross infections. Adequate hand washing facilities must be available in all areas.

2. ASEPTIC TECHNIQUE – Strict adherence to aseptic technique even procedures are done
outside OR.
3. SEGREGATION of contaminated materials and instruments, there must be a system for
contaminated linen, sputum cups, bedpans, and similar items separately to minimize the
chances of getting mixed up with the clean ones.

4. DISINFECTION PRACTICES – Selection of appropriate disinfectants for different purposes is

important. The following should be checked: a). Appropriate choice b). Appropriate
concentration c). Appropriate contact time d). Appropriate method.

5. STERILIZATION PRACTICES. An efficient central sterilization department ensures supply of

property sterilized articles to all users of the hospital.

6. GOOD HOUSEKEEPING. Cleaning of OR walls, floors, tables and fixtures should be organized
as a scheduled programs at predetermined intervals and use of appropriate disinfectants is
strongly advocated.

7. ANTIBIOTIC POLICY. Use of antibiotics must be monitored and controlled.

The major problem in involvement of organisms showing of multi drug resistance.

8. AIR HYGIENE IN OPERATING AND DELIVERY ROOM. Clogging of air filters of the air
conditioning system renders the ventilation in OR/DR. The filters should be frequently cleaned.

9. DEVELOPING A SENSE OF AWARENESS. This is the single most important factor in the c0ntrol
of hospital infection. A high sense of awareness and training goes a long way in controlling
hospital infection.
 LUMBIS RANCES GENERAL HOSPITAL
PHIC ACCRED No.: H05010131 LIC NO.: 05-058-13-020-H-2-2
DTI No.: 01264099 TIN No.: 109-018-258-000
Smart:0919-947-83-00Globe:0916-518-91-93 EMAIL ADD.:[email protected]
NATIONAL ROAD, BRGY. ILAOR SUR, OAS, ALBAY

POLICY AND PROCEDURE ON CASE CONTAINMENT

Objective:
To protect personnel and patient from infectious organisms that might be carried on through
droplets in the air or on the equipment or materials used.

Policy:
To establish a policy and implement a standard procedure on case containment, which includes
procedures on reverse isolation, prophylaxis management of accidental exposure.

Procedure:
Reverse Isolation: Isolation procedures designed to protect a patient from infectious organisms
that might be carried by staff, other patients, or visitors or on droplets in the air or on
equipment or materials.
Standard Precautions includes the use of one or combinations of the following practices. The
level of use will always depend on the anticipated contact with the patient;

 Handwashing, the most important method

 Use of latex or other protective gloves
 Masks, eye protection and/or face shield
 Gowns
 Proper handling of soiled patient care equipment
 Proper environmental cleaning
 Minimal handling of soiled linen
 Proper disposal of needles and other sharp equipment such as scalpels
 Placement in a private room for patients who cannot maintain appropriate
cleanliness or contain body fluids

Prophylaxis Management Procedure:

Personnel exposed to known cases shall undergo prophylaxis management based on current
clinical studies management. Management of these cases shall be based on the following; type
of illness, level of exposure and current prophylactic procedures for common illness.
Example:
Tuberculosis
Personnel exposed to active cases shall be observed for signs and symptoms of TB. A baseline
Chest X-ray shall be done as initial screening procedure.
Varicella
Personnel are exposed to persons with varicella, these personnel are potentially infective
during the incubation period (10-21 days after exposure).
All cases of exposure shall be documented and reported and monitored by the Committee for
evaluation and reference purposes.

Responsibility: Infection Control Committee

Dissemination: This policy shall be disseminated through meetings and memorandums.

MELBA O. ALANO, RN, MAN Noted:

Chief Nurse

EMMAN VALENCIANO, RM, RM, MD.

Medical Director
 LUMBIS RANCES GENERAL HOSPITAL
PHIC ACCRED No.: H05010131 LIC NO.: 05-058-13-020-H-2-2
DTI No.: 01264099 TIN No.: 109-018-258-000
Smart:0919-947-83-00Globe:0916-518-91-93 EMAIL ADD.:[email protected]
NATIONAL ROAD, BRGY. ILAOR SUR, OAS, ALBAY

HOSPITAL INFECTION CONTROL PROGRAM

GOALS/OBJECTIVES:

1. To prevent exposure to staff and patients.

2. To reduce the spread of infection by prompt recognition, separation and provision of
services.
3. To lower the risk of an infection during the period of hospitalization.

PURPOSE:

1. To develop a surveillance system for monitoring.

2. To develop policies and procedures for infection control.
3. To encourage and provide continuing medical programs.

BASIC ELEMENTS

1. Providing a system of identification and reporting of infection.

2. Providing a system for keeping records of infection in patients and personnel.
3. Providing a good hygiene, aseptic technique and sterilization and disinfection
practices.
4. Providing the staff, orientation and CME in infection prevention and control.
5. Providing for coordination with all departments and with medical audit committee in
quality assurance.

RESPONSIBILITIES:

1. Surveillance and reporting of patient infection, environmental contamination,

communicable disease.
2. Attend to identify the reservoir, sources and method of transmission.
3. In initiate appropriate measure to limit further spread of infection.
4. Maintain continuous record of its infection after admission.
5. Review all infection data with the chairman ICC.
 LUMBIS RANCES GENERAL HOSPITAL
PHIC ACCRED No.: H05010131 LIC NO.: 05-058-13-020-H-2-2
DTI No.: 01264099 TIN No.: 109-018-258-000
Smart:0919-947-83-00Globe:0916-518-91-93 EMAIL ADD.:[email protected]
NATIONAL ROAD, BRGY. ILAOR SUR, OAS, ALBAY

POLICY AND PROCEDURES FOR INFECTION CONTROL OUTBREAK

INVESTIGATION AND GENERAL PREVENTIVE MEASURES

PURPOSE:
To establish a standard procedure on prevention of Nosocomial infection, outbreak
investigation and preventive measures.

SCOPE:
1. General Policy
2. Medical Staff
3. QAC/Infection Control Section

PROCEDURE

1. The Committee shall develop a surveillance system to monitor incidence of nosocomial

infection. This will then be reported to the committee on a regular basis.
2. In case of an emergency (outbreak), investigation in the form of chart review shall be
started and final report shall be submitted to the committee.
3. A report of the “outbreak” shall be also submitted to the RHU for reference and action.
4. The Committee shall establish a comprehensive preventive program aimed at reducing
the risk to staff and patient in the hospital.
5. All activities shall then be documented and a report of the same shall be submitted to
the MANCOM for reference and further action if necessary.

RESPONSIBILITY:

QAC/Infection Control Section

Medical Staff

MELBA O. ALANO, RN, MAN

Chief Nurse

Noted:

EMMAN VALENCIANO, RM, RN, MD.

Medical Director
 LUMBIS RANCES GENERAL HOSPITAL
PHIC ACCRED No.: H05010131 LIC NO.: 05-058-13-020-H-2-2
DTI No.: 01264099 TIN No.: 109-018-258-000
Smart:0919-947-83-00Globe:0916-518-91-93 EMAIL ADD.:[email protected]
NATIONAL ROAD, BRGY. ILAOR SUR, OAS, ALBAY

RISK MANAGEMENT POLICY

PURPOSE:
A safe environment with sound operating policies and procedures is critical to
preventing and/or minimizing losses. The QAC shall conduct a review of risk management
policies and procedures on an annual basis to ensure adherence to, and effectiveness of same.
Such review shall form part of the minutes of the meeting at which the review takes place.

Safety Standards:

It is the policy of the hospital that the safety of its employees is of utmost importance.
In that respect, the following are considered to constitute the minimum security and safety
requirements of the institution.

A. Employee Safety
All employees are advised that their personal health and safety and that of fellow
employees and members are of prime concern to this institution. Staff well be
instructed that at no time should risk be taken that could endanger employee/member
safety. In the event of a robbery, staff is advised to follow the robber’s instruction at all
times. DO NOT PLAY HERO – don’t endanger your life or the life of fellow
employees/members. Do as instructed.

B. Fire Safety
Fire extinguishers shall be installed of a quality and quantity sufficient to meet the
minimum standards of safety. An alarm system shall be installed in the areas as an early
warning device. Fire extinguishers should be inspected at least annually. A Fire and
Emergency Drill shall be established in coordination with the Local Municipal Fire
Department.

C. Health and Safety Standards

The hospital shall adhere to the standards in the Labor Code.

D. Equipment
Equipment in use by employees shall meet the standards of safety, function and
occupational health. All equipment shall receive scheduled maintenance. Where
applicable, testing of equipment will be performed on monthly, quarterly or manual
basis as required.

INSURANCE
The hospital shall provide an adequate insurance program to protect the interest of the
institution.
 LUMBIS RANCES GENERAL HOSPITAL
PHIC ACCRED No.: H05010131 LIC NO.: 05-058-13-020-H-2-2
DTI No.: 01264099 TIN No.: 109-018-258-000
Smart:0919-947-83-00Globe:0916-518-91-93 EMAIL ADD.:[email protected]
NATIONAL ROAD, BRGY. ILAOR SUR, OAS, ALBAY

CONTACT PRECAUTIONS

Transmission by contact is always a risk for healthcare workers; additional precautions

should be taken to avoid the risk of infection through direct contact.

Some common respiratory pathogens can be spread through the contamination of a

patient’s hands, the hands of a healthcare worker or an environmental surface.

Hands can transmit thee diseases by having direct contact with a contaminated surface,
followed by contact with either another body surface such as the conjunctival or nasal mucosa
or by contaminating another intermediate area.

PRINCIPLES
Contact