LOCAL GUIDELINES

RELATED TO INFECTION

PREVENTION & CONTROL

Vangie. A. America, R.N.

May 17, 2017

Crown Plaza Hotel

OBJECTIVES:

1. To update infection control practitioners with the local guidelines related to Infection Prevention and Control.

2. To guide the participants in implementing local guidelines related to infection prevention and control.

Development of Standard for Infection Control in HCF.

Historical background:Background:

1986- DOH Department Order to create 3 important

committees

1993- Philippine Hospital Infection Control Society an

affiliate of the pHil Hospital Association

1996 DOH reitedrated the 1986 order but with no

implementing guidelines

2000 Need to have Standards of Infection control programs

• 2004- POST SARS- Development of Standard after collaboratuon with DOH and NGO professional societeies (PHICS, PHICNA<<PSMID)

• Technical working Group created to develop and formulate standards

Department Order No. 1187 (2004)

Subject: Strengthening of Hospital Infection Control Program (HICP) in DOH Hospitals

- Creation of HICC

- designation of Hospital Infection control Program

- Surveillance officer

- Development of Hospital Policies and standard

operational procedure

Administrative Order No. 2016-002- January 18, 2016

Subject: National Policy on Infection prevention and Control in Healthcare Facilities.

• Enabling all healthcare facilities to implement IPC in mandatory considering the development and spread of antimicrobial resistant organisms and the emergence of new infectious agents.

General Guideline:• Infection Prevention and Control is a vital component of

quality healthcare and patient safety, thus, all healthcare facilities in th Phil. shall implement IPC program effectively.

Establishing IPC program:

• Identify interested and key hospital personnel as members of the ICC/ICT

•Accomplish a written description of the program (Infection Control Plan)

•Goals, objectives, structure

• Specific surveillance, prevention, control, education, and training activities

Establishing a program

•Disseminate information

• Implement and monitor

•Annual evaluation on the IC program

•Assess the activities

•Assess accomplishments

• Identify any changes in goals, objectives, structure

•Assess the value of the program to the hospital

References:

WHO

DOH

PHICS ,PSMID,PHICNA

NATIONAL STANDARDS IN INFECTION CONTROL FOR HEALTHCARE FACILITIES

• Department of Health

• Philippine Hospital Infection Control Society

• Phili[ppine Hospital Infection Control Nurses Association

Why is Infection control Important?

1. Increasing incidence of health care associated infection caused by antibiotic resistant organisms.

2. More susceptible patients admitted in HCF

- very old and very young

- Immunosuppressed patient

- Invasive diagnostic and therapeutic procedures

- chronic diseases

3. Emergence of life threatening infection like SARS and other emerging infections.

4. Threat of Pathogeninc Avian Flu pandemic and terrorism.

Impact of HCAI:

- need for hospitalization

- income loss

- pain and suffering

- Disfigurement

- Disability

- Death

Question?

•ARE ALL HEALTHCARE FACILITY PREPARED TO RESPOND TO

EMERGING AND RE-EMERGING INFECTIONS?

COUNTRY PREPAREDNESS:

•Means the capability of the HCF to prevent and control highly transmissible infection through:

“ EFFECTIVE NATIONAL INFECTION CONTROL PROGRAM WITH UNIVERSALLY ACCEPTED STANDARDS” implemented by all HCF and coordinated by the chief of hospital..

NATIONAL POLICY ON INFECTION PREVENTION AND CONTROL IN HEALTH CARE FACILITY:

• Draft/proposals/presentations during PHICS convention

• Sept. 27,2012- creation of the nationasl Cneter gfor Health Facility development

• Technical working group for the Development of National Policy on IPC.

• January 8, 2016 finally signed.

Requirements:

• There are written guidelines, policies, and procedures that adress IPC and detection the healthcare facility.

DOH GUIDELINES ON Disinfection and Sterilization:

• AnneX B: Administrative Order No. 2012-0012• Pursuant to AO 2011- 0020 entitled “

Streamlining of Licensure and Accreditation of Hospitals”

Streamlining of regulatory processes shall recognize DOH licensed hospitals as Center for safety without a need for a separate survey by PHILHEALTH.

- Patient safety and infection control are indicators that health regulatory body deemed it necessary and that stakeholders should be equipped with knowlegde and expertise on institutionalizing the implementation of quality assurance where patient safety is the key dimension.

• Anchored on DOH licensing and PHILhealth Acreditation standards of safety would prevent health care associated infection.

Scope:

A. The recommended guidelines covers cleaning, disinfection and all typres of sterilization processes in hospitals and whenever applicable, in other healthcare facilities.( ex. Ambulatory surgical Clinics, birthing areas or lying in , Dialysis center)

B. This guideline also apply to reusable medical devices in CSSD and operating theaters in hospitals.

General Guidelines:

1. All health care facilities shall follow good infection control

and prevention practices in accordance with DOH guidelines and accepted international standards.

2. All items to be disinfected or sterilized shall follow the Spaulding classifications system based on their degrees of risk of infection during patient care.

3. Proper precautions shall be implemented to protect the staff, including provision for adequate ventilation and use of Personal Proective equipment.(PPE)

4.All health care facilities shall developwritten policies and standard operating procedures (SOP) involving the following:

A.. Recieving of contaminated items

B. Handling, collection, and transport of contaminated items

C. Cleaning and other Decontamination processes

D. Packaging, preparation and sterilization

E. Installation, care and maintenance of sterilizers.

F. Quality Control

g.Quality process improvement

5.The hospital staff shall establish policies and procedures to ensure the safe and effective use of instruments sets and interdisciplinary collaboration between CSSD , surgical services and loaning corporation,.

6.The head of the surgical department , chief nurse or infection control officer shall evaluate sterilization equipment or cosumables and disinfecting agents that will be purchsed for and utilized in the facility ( with the assistance of Consultants and Senior Staff,)

7. The surgical services team shall work collaboratively with CSSD staff to establish a quality control program to monitor the cleaning, disinfecction, and sterilization of surgical instruments and supplies.

8.There shall be a documented policies on recall procedures for failure(s) of sterilization.

9. Healthcare facicilies shall promote a culture of safety by conducting patient safety rounds in the Operating theater that focos on the environment and best practices.

Specific Guidelines:

1. PERSONNEL- staff shall possess the following:

a. Training and continuing education.

b. Qualifications and training of staff in sterile processing

C. Qualifications and training of service staffD.Certificate of training from a professional organizationrecognized by DOHE. Good health and personal hygiene.F. Proper attire.

2. EQUIPMENT- shall have the following :a. Instruction Manualb. Documented polilcies and procedures on installation, care

and maintenance of sterilizers including records on1. preventive maintenance

• 2. Calibration

• 3.Record keeping

Physical Facilities:

a. Physical Facility shall follow the planning and designs guidelines prescribed by DOH.

b. There shall be records on monitoring the safety of the environment, such as standards for water quality, cleaning procedure, sharps and water management.

c. A centralized reprocessing unit for cleaning, disinfecting and packaging and sterilizing medical devices for cssd and opreating theaters is recommmended for quality control for each hospital

D. The centralized reprocessing unit ideally shall be divided into at lest three areas:

1. Cleaning/decontamination area2. Packaging and sterilization area3. Sterile storage area

E. Cleaning /decontamination area which receives and processes contaminated medical devices are regarde as dirty area and shall be physically separated from the other clean area.

F. Unidirectional /one way traffic of medical devices from the dirty area to the clean areas is recommended. All new renovated reprocessing units shall adopt this in the design.

G. Floors and walls of the reporocessing unit shall be constructed

of material capable of withstanding chemical agents used for

reprocessing. Floors in the cleaning and decontamination area

shall be made of non-slippery material.

H. Ceiling and wall surfaces shall be constructed of non –shedding materias.

I. Handwashing facilitiy shall be provided and conveniently located near all areas inwhich devices are cleaned and prepared for sterilization to facilitate handwashing.

J. The facility shall have a designated area and secure area ((cabinet with lock) for the documentation purposes.

K. Recommended ventilation, humidity and temperature requirement of different areas in the central processing department. All new and renovated reprocessing units shall comply with the requirements.

1. Cleaning /decontamination area – dirty

Air flow – negative (In)

10 air changes per hour

30 to 60 % - relative humidity

less than 24 ) degrees centigrade – working temperature

2. Packaging and sterilization area- clean

- Positve air flow (Out)

10 air changes/hour

30 to 60 % humidity

20 to 23 degrees celeus

3. Sterile storage area- clean

Positive airflow (Out)

4 air changes /hour as minimum

<70 % humidity

< 24 degress centigrade - working temp.

4.Quality Assurance Program

a. A quality assurance system shall be established to ensure proper sterilization and to routinely monitor the entire process

5. Requirements of Occupational Health

a. All staff involved in the reprocessing of medical devices shall be trained and knowledgeable about the possible biologic, chemincal, and environmental hazards.

b. Staff shall put on appropriate PPE including gloves, gowns, eye protection and face masks. Or shields, and respirastory protection devices during the entire process of cleaning and decontamination.PPE is optional during packing (except cap) and sterilization.

6. Documentation and Reporting

a. Standard operating procedure (SOP) shall be formulated in every reprocessing unit in the hospital to define and standardize work practice. The SOPs shall be aligned with these guidelines . Risk management of encountered hazard in the sterilization process shall be part of the SOP’s and available at all times.

b. the equipment maintenance , sterilization records and all other quality control documents shall be retained for at least 5 years.

c. All incidents, including sentinel events, that may potentially cause harm to patients or staff shall be documented and reported.

Requirements for Process of Sterilization:

A. Level of reprocessing of medical devices shall be selected based on the level of risk classified according to the Spaulding Classifications.( Critical, Semi-critical and non critical).

B. Cleaning and Chemical Disinfection

A. All medical devices shall be cleaned before any reprocessing to achieve disinfection and sterility . Effective cleaning can physically remove large numbers of microorganisms. It also remove organic matter which may bind and inactivate chemical activity of disinfectant.

C. Sterilization:

All medical devices shall be cleaned/decontaminated before sterilization either through steam or chemical vapor /gas ( ethylene oxide, hydrogen peroxide). The sterilization process should be validated and closely monitored physically, chemically and biologically. Before sterilization cleaned /decontaminated medical devices must be packed using wrap materials that allow penetration of the sterilant. ( Steam and chemical vapor/gas are the only acceptable sterilization method s to ensure patient safety in the Philippines.

• Quality Control

• Sterilization process monitoring include physical monitors , Cisand the BIs. Each of these devices plays a distinct and specific role in sterilization process monitoring and each is indispensable to sterility assurance.

GUIDELINES ON HIV:

Republic ACT 8504- “ Philippine AIDS PREVENTION AND CONTROL ACT OF 1998”

Article 11 : section 13

Guidelines on surgical and similar procedures-

The DOH in consultation and in coordination with concerned professional organizations and hospital associations , shall issue guidelines on precautions against HIV transmission during surgical, dental, embalming tattooing or similar procedure . The DOH shall also likewise issue guidelines on the handling and disposition of cadavers, body fluids wastes of person known or believed to be HIV positive

All necessary PPE such as gloves, mask, goggles and gowns shall be made available to all physicians, and healthcare providers and similarly exposed personnel at all times.

Administrative order No.2009-0016- May 20,2009

Subject: Policies and guidelines on the prevention of Mother to child Transmission(PMTCT) of HIV

Components of PMTCT:

Management of labor and delivery of HIV positive pregnant women:

HIV infected pregnant women who are about to deliver should be referred and admitted to the nearest treatment hub. The attending physician should consider vaginal delivery if the following criteria are satisfied:

1. HIV medications have been taken during pregnancy

2. No previous uterine surgery or elective cesarean section

3.No signs and symptoms of STI

4. No indications of prolonged labor

Cesarean section is recommended if vaginal delivery cannot be performed due to presence of contraindications. Cesarean section should be scheduled prior to the rupture of the membrane.

HIV pregnant women need not be isolated during labor and delivery because of their HIV status . Hospital staff must use standard precautions in all patients regardless of their status.

• Counseling of HIV infected mother regarding feeding option should include information about the risk and benefits of breast feeding.

• Exclusive breast feeding is strongly recommended for the first 6 months of life.

Administrative order No.2010-0033- Dec.6,2010

Subject: Revised implementing rules and regulations of PD 856 Code on sanitation in the Philippines-Disposal of Dead persons

General Guidelines: Article I: Section !:

Burial Ground Requirements

1.1 The requirement for a death certificate before burial may be waved in the case of special circumstances when the death certificate cannot be issued on time. These include but are limited to :

1.1a the deceased died from a dangerous communicable disease and must be buried within 12 hours.

1.1b The family members of the deceased have requested immediate cremation without embalming or viewing.

1.1 c he kin opt to immediate burial

1.1d Religious beliefs or tradition such as Islam or Jewish – faith calls for burial within 12 hours.

1.2 No remains shall buried without a burial permit issued by city/municipality where the burial will take place

1.3 Funeral parlors or embalming establishment s shall not hold unclaimed bodies longer than 60 days or sanction shall be imposed by the local health authority.

1.4 The following are declared as dangerous communicable diseases:1.4 a Hepatitis B and C1.4 b Rabies1.4 c Invasive group A streptococcal infections1.4 d Transmissible spongiform encephalopathies (CJD or

mad cow)1.4e HIV /AIDS

1.4f meningococcemia 1.4g Viral Hemorrhagic fevers( African Ebolas, LASSA, or

Marburg)1.4h Yellow fever1.4 I SARS1.4j Other communicable disease that shall be declared by the DOH

• 1.5 The remains shall be placed in a plastic cadaver bag or other durable , airtight container at the point of death and a biohazard tag attached, provided that the container shall not be opened for viewing or any other purpose prior to burial or cremation.

DOH ANTIMICROBIAL STEWARDSHIP PROGRAM IN HOSPITALS (AMS)

• Is the concerted implementation of systematic ,multidisciplinary , multi pronged interventions in both public and private hospitals in the Philippines in order to improve appropriate use of antimicrobials , which is essential for preventing the emergence and spread of antimicrobial resistance (AMR).

Specifically the AMS Program aims to:

1.Promote rational and optimal antimicrobial therapy.

2. To improve patient outcomes and decrease healthcare

costs by reducing unnecessary antimicrobial use , adverse drug events, mortality and morbidity from infections (including secondary infections caused by resistant pathogens.

3. to foster awareness on the global and country situation on the threat of AMR and the compelling need to address it.

4. Effect positive behavior and or institutional changes through educational and persuasive interventions towards improving the use of antimicrobials by the prescribers, dispensers and other health professionals and the patient.

CORE ELEMENTS OF AMS PROGRAM:

1. LEADERSHIP

A dedicated multidisciplinary AMS committee and Team supported by the hospital administration, shall be responsible to successfully implement, perform and monitor the AMS Program in each Hospital

2. POLICIES, GUIDELINES, CLINICAL PATHWAYS

Antibiotic policies and standardized clinical guidelines and clinical pathways on the treatment and prophylaxis of infections provide evidence –based guidance to clinicians and other healthcare professionals on the management of infectious diseases and in the selection of the most appropriate antimicrobial agent.

3. SURVEILLANCE OF ANTIMICROBIAL UTILIZATION (AMU) AND ANTIMICROBIAL RESISTANCE (AMR)

AMU & AMR are intricately related surveillance of AMU provides important insights into prescribing patterns that may explain for the evolution of AMR , and is useful in the development and evaluation of AMS interventions. AMR surveillance allows for the development of an antibiogram that informs empiric antimicrobial choice, characterises the impact of AMS activities on resistance and identification of specific AMR problem areas that needs to be addressed notwithstanding infection control measures.

4. ACTION

The AMS Program employs a coordinated multi-pronged , multi-disciplinary approach to safeguad and optimize use of all antimicrobials used within the hospital. Active interaction between the AMS team and prescribers ( and other healthcare professionals) is pivotal in encouraging compliance to AMS interventions and being able to effectively persuade and influence change in prescribing practices.

AMS- CORE ELEMENT

5.Education:

AMS practitioners need to gain COMPETENCY THROUGH COMPREHENSIVE EDUCATION AND CLINICAL TRAINING TO EFFECTIVELY AND SAFELY PERFORM AMS INTERVENTIONS.

EDUCATION OF ALL HEALTHCARE PROFESSIONALS ON THE PRINCIPLES OF JUDICIOUS USE OF ANTIMICROBIALS IS ALSO NECESSARY TO ENABLE POSITIVE BAHAVIOURAL CHANGE.

6. PERFORMANCE EVALUATION:

MEASURING PROCESS AND CLINICAL INDICATORS TPO ASSESS THE OVERALL QUALITY MANAGEMENT IMPROVEMENT AND EFFECTIVENESS OF AMS INTERVENTIONS IS FUNDAMENTAL IN GUIDING THE PROGRSSIVE IMPLEMENTATION OF THE PROGRAM TOWARDS ACHIEVING THE GOAL TO COMBAT AMR.

Thank you!!!!