Policies & Procedures Document Title:

Originating Entity : Standard Precautions

Prevention and Control of Infection
Date Originated: Document No.: 19
Approved By: Chairman of Prevention Date Revised: : 1-8-2020
and Control of Infection Committee
Date of Approval: Rev. No.: 00
Approved By: Chairman of Steering Next Revision Date : 1-8-2022
Committee.
Date of Approval: Page 1 of 5

1. Purpose:
To prevent healthcare associated transmission of infectious agents among patients, healthcare
personnel and visitors.
2. Policy:
1. Standard Precautions will be implemented with any potential exposure to blood, body
fluids, secretions, excretions (except sweat), mucous membranes, non intact skin and
potentially contaminated skin.
2. All HCWs will practice Standard precautions in setting where healthcare is delivered,
With all patients regardless of diagnosis.
3. Standard precautions will be practiced in dealing with environment when there is potential
contamination of equipments and surfaces .
4. Additional transmission-based precautions will be practiced with patients with
suspected or confirmed contagious or who may be infected or colonized with
epidemiologically significant organisms.

3.Scope of Policy:
This policy describe the Hospital Standard precautions .

4. Responsibilities:
1. All
1.1 .Physicians, nurses, technicians and personnel whenever there is a risk of contacting
blood, body fluids, secretions, excretions, mucous membranes or non intact skin of
patients or potentially contaminated equipments, instruments and surfaces .
1.2 .Housekeeping personnel
1.2.1.Will perform all environmental cleaning activities.
1.3 Infection Control Team
1.3.1.Will supervise and monitor compliance of personnel with standard precautions,
provide necessary education to staff, patients and visitors in collaboration with
nursing department and physicians .
1.4 .Hospital Administration
1.4.1.Will provide all support needed for implementation of Standard precautions
including availability of material requirements e.g. Disinfectants, personal protective
equipment ( PPE), Containers, vaccines as well as hospital isolation facilities and
administrative support to the infection control program .

5. Definitions:
 Policies & Procedures Document Title:
Originating Entity : Standard Precautions
Prevention and Control of Infection
Date Originated: Document No.: 19
Approved By: Chairman of Prevention Date Revised: : 1-8-2020
and Control of Infection Committee
Date of Approval: Rev. No.: 00
Approved By: Chairman of Steering Next Revision Date : 1-8-2022
Committee.
Date of Approval: Page 2 of 5

1. Protective measures applied by all healthcare workers with all patients in anticipation of
risk of contact with blood, body fluids, secretions, excretions or potentially contaminated
environmental surfaces to prevent transmission of microorganisms among patient and
staff in healthcare settings .

6. Procedure:
1. Hand Hygiene :
1.1 .Hand hygiene should be consistently implemented by 48 MH staff in the
following situations .
1.2 .Before and after patient contact .
1.3 .After removing gloves .
1.4 .Immediately after contact with blood, body fluids, secretions, execrations, non-
intact skin, mucous membranes or wound dressing .
1.5 .After contact with patient intact skin e.g. taking pulse, turning patient in bed .
1.6 .After contact with inanimate objects including equipment in the immediate
vicinity of the patient .
1.6.1.For further details refer to Hand Hygiene Policy .
2. Personal Protective Equipments (PPE) :
2.1 .The following will be observed when PPE are used :
2.1.1.PPE will be used according to the nature of anticipated patient interaction and
potential risk of exposure to blood, body fluids, mucous membranes, non
intact skin or potentially contaminated aerosol.
2.1.2.Staff should avoid contamination of their exposed skin or clothing during
removal of PPE .
2.1.3.PPE should be removed and discarded before leaving patient’s room .
2.2 .Gloves :
2.2.1.Gloves should be donned with anticipated contact with blood, body fluids,
secretions, execrations other than sweat, non intact skin or potentially
contaminated skin (e.g. Patient incontinent of stool or urine) .
2.2.2.Disposable medical examination gloves should be used for direct patient
care .
2.2.3.Gloves will be worn before performing vascular access procedures .
2.2.4.Gloves will be single use changed with every patient .
2.2.5.Gloves will be changed when moving from contaminated site to cleaner site
e.g. Cleaning perinea area then performing mouth hygiene .Hand hygiene
will be perfumed in between changed gloves .
2.2.6.Staff will not touch clean surfaces and items in the environment e.g.
Telephone handle with contaminated gloves .
2.2.7.Gloves will be used for cleaning the environment or medical equipment.
 Policies & Procedures Document Title:
Originating Entity : Standard Precautions
Prevention and Control of Infection
Date Originated: Document No.: 19
Approved By: Chairman of Prevention Date Revised: : 1-8-2020
and Control of Infection Committee
Date of Approval: Rev. No.: 00
Approved By: Chairman of Steering Next Revision Date : 1-8-2022
Committee.
Date of Approval: Page 3 of 5

2.2.8.Sterile gloves will be used for surgical procedures, insertion of central venous
lines, urinary catheters, lumber punctures or ET tubes .
2.3 .Gown :
2.3.1 Staff should wear repellent gown / apron any time that clothing is likely to
be soiled by splattering of blood, body fluids, secretions or excretions.
2.3.2 Gown should be worn with direct patient care or if the patient skin is
potentially colonized with MRSA e.g. patient transferred from other hospital
and kept in contact isolation pending MRSA screening results.
2.3.3 Before leaving patient’s room staff remove and discard gown then perform
hand hygiene .
2.4 .Mouth, nose and eye protection :
2.4.1 Masks with goggles/ face shield will be used as appropriate in combinations
of each according to the potential anticipated risk of splashing or splattering
of blood, body fluids, secretions, excretions and with aerosol generating
procedures e.g. Bronchoscope, suctioning of respiratory tract .
2.4.2 Surgical masks will be consistently worn during surgeries and procedures
with potential risk to the patient of contamination with HCW oropharyngeal
secretions e.g. During spinal anesthesia or insertion of CV line .
2.4.3 Respirators (N-95 masks) should be used by staff in contact with patients
suspected or known to have airborne diseases e.g. TB, Measles,
Chickenpox, SARS or Avian Flu swine flu…act.
3. Handling Needles and sharps :
3.1 Staff should NEVER RECAP NEEDLES. If recapping is necessary, use a one
handled recapping technique (scooping method) .
3.2 Used needles and small sharps should be discarded in puncture resistant containers
which are located as close as possible to the area of use .
3.3 Sharp containers will be discarded and replaced when ¾ filled .
4. Cleaning Blood or Body fluid Spills :
4.1 Wear Gloves .
4.2 Wipe up the spill with an absorbent towel .
4.3 Apply disinfectant appropriate for the size and surface contaminated (e.g. Clorox) .
5. Patient Placement :
5.1 Place a patient who contaminates the environment or who does not (or cannot be
expected to ) assist in maintaining appropriate hygiene in a single room .
5.2 If a single room is not available, consult Infection Control Team for other
alternatives .
5.3 Single room will be used whenever possible to isolate patient with highly
transmissible contract, droplet or airborne diseases, patient colonized or infected
with epidemiologically significant organism .
 Policies & Procedures Document Title:
Originating Entity : Standard Precautions
Prevention and Control of Infection
Date Originated: Document No.: 19
Approved By: Chairman of Prevention Date Revised: : 1-8-2020
and Control of Infection Committee
Date of Approval: Rev. No.: 00
Approved By: Chairman of Steering Next Revision Date : 1-8-2022
Committee.
Date of Approval: Page 4 of 5

5.4 Immunosuppressed patient will be isolated in single room with maximum barrier
nursing .
6. Respiratory hygiene / Cough etiquette :
6.1 Staff will be educated and instructed for proper respiratory hygiene and source
control of droplet and airborne infections especially during seasonal outbreaks of
viral respiratory infections.
6.2 Patients and visitors on covering mouth and nose during coughing or sneezing,
proper disposal of used tissues and hand hygiene .
6.3 Posters and signs should be put in strategic places e.g. elevators and in waiting
areas to promote respiratory hygiene .
6.4 During periods of increased prevalence of respiratory infections in community
masks should be offered to coughing patients and accompanying symptomatic
persons upon entry to hospital . They will be encouraged to keep a distance of 3
feet or more from others in waiting and closed common areas .
7. Patient Care Equipment and instruments / devices :
7.1 Patient –care equipments soiled with blood, body fluids, secretions, excretions
should be handled in a manner that prevent contamination of staff exposed skin,
mucous membranes and clothing or transfer of microorganisms to other patients
and environment.
7.2 Re- used equipment should be cleaned, disinfected / sterilized before being used to
care for other patient e.g. Dental sets .
7.3 Single – use items should be discarded properly after use and will not be re-
processed for re-use .
7.4 Staff should wear PPE for blood, body fluids, secretions, excretions according to
the anticipated level of contamination .
8. Care of the environment
8.1 Adequate procedures should be followed for routine care, cleaning and disinfection
of environmental surfaces, beds, bedrails, bedside equipments and other frequently
touched surfaces .
9. Textiles and Laundry :
9.1 Staff should adhere to policies for handling transportation and processing of used
linen especially that soiled with blood, body fluids, secretions, and excretions in a
manner that prevent contamination of personnel skin and clothing and avoids
transfer of microorganisms to patients and environment .
10. Safe injection Practices :
10.1 Disposable, sterile. Single –use needles and syringes should be used singly for
each injection or blood extraction .
10.2 Principles of infection control and aseptic technique should be re-enforced in
nursing training programs .
 Policies & Procedures Document Title:
Originating Entity : Standard Precautions
Prevention and Control of Infection
Date Originated: Document No.: 19
Approved By: Chairman of Prevention Date Revised: : 1-8-2020
and Control of Infection Committee
Date of Approval: Rev. No.: 00
Approved By: Chairman of Steering Next Revision Date : 1-8-2022
Committee.
Date of Approval: Page 5 of 5

11. Infection control precautions for social lumbar puncture procedures :

11.1 Face masks should be worn by staff during lumber puncture procedures e.g.
Spinal anesthesia, myelogram, CSF aspiration .
12. Health care workers HCWs immunization program :
12.1 Staff health program will be implemented to ensure vaccination of all susceptible
personnel to hepatitis B, Measles, Mumps, Rubella, Chickenpox, TB, Influenza
and Meningitis.
12.2 Only immune staff will handle patients with Meals, Mumps, Rubella and
Chickenpox

7. Forms Required:

Nill

8. References:

 CDC – Guidelines for Isolation Precautions : Preventing transmission of infectious agents in the
healthcare settings 2007 .
 N. Damani, infection Control Procedures, Cambridge University Press 2006 .
 G. Ayliffe et al. Control Of Hospital Infection, 4th edition Arrnold 2000 .