LECTURE SERIES

LOCAL GUIDELINES RELATED TO

INFECTION PREVENTION &
CONTROL

CRISCARLSON C. GALENDEZ, MAN, RN, USRN, OHN

(ACEMCP INFECTION CONTROL NURSE)
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 Health Care Facilities

Historical 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 reiterated the 1986 order but with no implementing guidelines.
 2000
Need to have Standards of Infection control programs.
 2004
POST SARS- Development of Standard after collaboration with DOH and NGO professional
societies (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 the 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 programs:
1. Assess the activities
2. Assess accomplishments
3. Identify any changes in goals, objectives, structure
4. Assess the value of the program to the hospital References:
a) WHO
b) DOH
c) PHICS
d) PSMID
e) PHICNA

NATIONAL STANDARDS IN INFECTION CONTROL FOR HEALTHCARE FACILITIES

 Department of Health
 Philippine Hospital Infection Control Society
 Philippine 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
a) Very old and very young
b) Immunosuppressed patient
c) Invasive diagnostic and therapeutic procedures
d) Chronic diseases
3. Emergence of life threatening infection like SARS and other emerging infections.
4. Threat of Pathogenic Avian Flu pandemic and terrorism.

Impact of Health Care Associated Infections

 Need for hospitalization
 Income loss
 Pain and suffering
 Disfigurement
 Disability and DEATH

Question?

ARE ALL HEALTHCARE FACILITY PREPARED TO RESPOND TO EMERGING

&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 Health Care Facilities 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 national Center for 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 address 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 knowledge and expertise on institutionalizing the
implementation of quality assurance where patient safety is the key dimension.
 Anchored on DOH licensing and PHIL health Accreditation standards of safety would prevent health
care associated infection.

Scope:

 The recommended guidelines cover cleaning, disinfection and all types of sterilization processes in
hospitals and whenever applicable, in other healthcare facilities. (ex. Ambulatory surgical Clinics,
birthing areas or lying in, Dialysis center)
 This guideline also applies 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 Protective equipment. (PPE)
4. All health care facilities shall develop written policies and standard operating procedures (SOP)
involving the following:

Receiving of contaminated items

A. Handling, collection, and transport of contaminated items

B. Cleaning and other Decontamination processes
C. Packaging, preparation and sterilization
 D. Installation, care and maintenance of sterilizers.
E. Quality Control
F. 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 consumables and disinfecting agents that will be purchased 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, disinfection, and sterilization of surgical instruments and supplies.
8. There shall be a documented policy on recall procedures for failure(s) of sterilization.
9. Healthcare facilities shall promote a culture of safety by conducting patient safety rounds in the
Operating theater that focus 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 staff
d. Certificate of training from a professional organization recognized by DOH
e. Good health and personal hygiene.
f. Proper attire

2. EQUIPMENT- shall have the following:

a. Instruction Manual
b. Documented policies and procedures on installation, care and maintenance of sterilizers
including records on:
 Preventive maintenance
 Calibration
 Record keeping

3. Physical Facilities:
1. Physical Facility shall follow the planning and designs guidelines prescribed by DOH.
2. There shall be records on monitoring the safety of the environment, such as standards for water
quality, cleaning procedure, sharps and water management.
3. A centralized reprocessing unit for cleaning, disinfecting and packaging and sterilizing medical
devices for cssd and operating theaters is recommended for quality control for each hospital
4. The centralized reprocessing unit ideally shall be divided into at least three areas:
 Cleaning/decontamination area
 Packaging and sterilization area
 Sterile storage area
5. Cleaning /decontamination area which receives and processes contaminated medical devices are
regarded as dirty area and shall be physically separated from the other clean area.
6. 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.
7. Floors and walls of the reprocessing 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.
8. Ceiling and wall surfaces shall be constructed of non – shedding materials.
9. Handwashing facility shall be provided and conveniently located near all areas in which
devices are cleaned and prepared for sterilization to facilitate handwashing.
10. The facility shall have a designated area and secure area (cabinet with lock) for the
documentation purposes.
11. 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.

 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

 Packaging and sterilization area- clean

 Positive air flow (OUT)
 10 air changes/hour
 30 to 60 % humidity
 20 to 23 degrees celeus.
 Sterile storage
 Area- clean Positive airflow (OUT)
 4 air changes /hour as minimum
 <70 % humidity
 < 24 degrees centigrade - working temp.

 Quality Assurance Program

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

 Requirements of Occupational Health

 All staff involved in the reprocessing of medical devices shall be trained and
knowledgeable about the possible biologic, chemical, and environmental hazards.
 Staff shall put on appropriate PPE including gloves, gowns, eye protection and
face masks. Or shields, and respiratory protection devices during the entire
process of cleaning and
 Decontamination. PPE is optional during packing (except cap) and sterilization.

 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
 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 removes
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 is to ensure patient safety in the Philippines.

Quality Control

 Sterilization process monitoring include physical monitors, CI’s and the BI’s. 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 1:

Burial Ground Requirements
 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. The deceased died from a dangerous communicable disease and must be buried within 12 hours.
2. The family members of the deceased have requested immediate cremation without embalming or
viewing.
3. The kin opt to immediate burial
4. Religious beliefs or tradition such as Islam or Jewish – faith calls for burial within 12 hours.
5. No remains shall bury without a burial permit issued by city/municipality where the burial will
take place.
6. 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.
 The following are declared as dangerous communicable diseases:
a. Hepatitis B and C
b. Rabies
c. Invasive Group A streptococcal infection
d. Transmissible spongiform encephalopathies (CJD or mad cow)
e. HIV /AIDS
f. meningococcemia
g. Viral Hemorrhagic fevers (African Ebolas, LASSA, or Marburg)
h. Yellow fever
i. SARS
j. Other communicable disease that shall be declared by the DOH
7. 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
o 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
o 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, characterizes
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
safeguard 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.
Notes on Nursing:

“No Amount of Medical Knowledge will lessen the

Accountability for Nurses to do what Nurses do, that is, Manage
the Environment to
Promote Positive Life Process.”

CLEAN HANDS COUNT!

THANK YOU VERY MUCH

What it is and What it is not

By Florence Nightingale