INFECTION PREVENTION AND

CONTROLPOLICY

2022

FASTER MEDICAL CARE

DOHA,QATAR
 Infection Prevention and Control Policy

CONTENT
1 Introduction
1.1 Definition of IPC
1.3 Chain of infection
1.4 Contamination
2 Goal, Principles and Objectives
2.1 Goal
2.2 Key Policy Principles
2.3 Objectives
3 Hand Hygiene
3.1 Importance of Hand Hygiene
3.2 5 moments of Hand Hygiene
3.3 Types and steps of Hand washing
4 Personal Protective Equipment (PPE)
5 Hospital Acquired Infection (HAIs)
5.1  Central line–associated bloodstream infections (CLABSI)
5.2  Catheter-associated urinary tract infections (CAUTI)
5.3  Methicillin-resistant Staphylococcus Aureus(MRSA)
5.4  Prevention of Clostridium difficile Infection (CDI)
5.5  Intravascular catheter-related infection (BSI)
5.6  Ventilator associated Event(VAE)
5.7  Surgical site infection(SSI)
5.8  Monitoring HAIs
5.9  HAI prevention routine activities
5.9
6 Multidrug-resistant organisms (MDRO)
7 Injection safety.
8 Isolation precautions.
9 Respiratory Hygiene/Cough Etiquette
10 Disinfection and sterilization.
11 Environmental infection control.
12 Health care worker care and protection
13 Outbreak management and preparedness
1; Introduction:
Infection is the one of the leading causes of the preventable death in hospitals every year. In hospitals
and other medical facilities, where sick people congregate, there are numerous opportunities for
microorganisms to spread among patients, attenders, and staff members. Up to 70% of these infections
can be avoided by proper method of Infection control measures.IPC programmes can make healthcare
safer and more affordable by preventing the suffering, loss of life and cost caused by healthcare-
associated infections.

1.1 Definition of IPC

Infection:

A proliferation of pathogenic bacteria that invade bodily tissue and cause tissue damage that can lead to
disease. Invasion and proliferation of microorganisms that are not ordinarily present in the body,
including as bacteria, viruses, and parasites. The spread of an illness through the blood or lymphatic
vessels might cause it to become systemic or it can stay localized.

Infection Prevention:

Infection prevention refers to Policies and Procedures used to minimize the risk of spreading infection,
especially in health care facilities.

1.3. Chain of infection

The presence of a pathogen does not mean that an infection will begin. In order for infectious disease to
spread several necessary steps must occur. These steps are known as Chain of infection. An infection
will develop only if chain remains intact these links are
 CAUSATIVE AGENT

SUSCESPTABLE
HOST RESERVOIR

PORTAL OF PORTAL OF
ENTRY EXIT

MODE OF
TRANSMISSION

Breaking the chain of Infection:

Health professionals must come into contact with some potentially infectious objects in order to deliver
healthcare, but in many situations, we can stop the spread of the infection. Breaking the infection chain
is the only method to prevent infection. To stop the spread of infection and prevent it, the nurse must
adhere to a set of guidelines and practices.
Breaking the chain-I (the causative agent).
Rapid and accurate identification of organisms:
 Routinely send blood cultures, Urine culture, Skin swabs, and tracheal aspirate culture.
 Send endotracheal tube tip, urinary catheter tip and central line tip for culture after removal.
Control or eliminate infectious agent
 Proper cleaning of by the water and mechanical action with or without detergents.
 Disinfection.
 Sterilization of contaminated objects.
High level of disinfectants.
 Activated glutaraldehyde (cidex-2%).
  Sodium hypo chloride (1%).
 Carbolic solution (5%).
 Bleaching Powder 1%.
Low level Disinfectant
 Methylated spirit 70%
 Betadine solution 10%
 Savlone 1%

Breaking the chain-II (Reservoir).

Measure to control or eliminate of reservoir of infection
Employee Health
 Immunization of health personnel’s e.g. Hepatitis B vaccine.
 Regular checkup for early detection of any communicable disease.
 Restriction from work of patient contact when infected with communicable disease.
Environmental disease:
 Cleaning with hospital approved clear disinfectant e.g. Phenol.
 Through cleaning of bed and bedside equipment’s before admitting new patient.
 Separate mops should be used for cleaning of unit (twice a day).
 Damp dusting should be done.
 Drains should be patent.
Handling of linen.
 Keep bedsheet dry and clean.
 Change sheets every day.
 Do not shakes blanket and linen.
 Do not throw them on floor.
 Soiled linen counting should be done in separate place.
Pest control.
 Measures to be taken to avoid their entry into unit prevent e.g. proper sealing, cleaning and
draining.
 Patient diet should be kept in covered containers.
 Keep fly trappers on each bedside of patient.
 Pesticide spray should be used weekly.
Visitors control:
 Traffic should be restricted except for doctors, nurses and other supportive staffs.
 Allow only one attendant(3-4 hours)
  Keep the doors and windows closed.
Breaking the chain of infection.III (portal of Exit)
 Practice aseptic precaution.
 Avoid talking directly into client’s mouth to prevent the droplets infection.
 Wearing of mask is compulsory if the nurse is infected or she is dealing with the patient
those who are infected.
 Careful handling of wastes like urine, faeces, emesis and blood is important.
 Disposable gloves should be worn to prevent direct contact with the wastes or infected
materials.
Breaking the chain of infection.IV (Mode of Transmission)
Contact Precautions:
 Single patient room.
 Staff to perform hand hygiene put on PPE prior to enter the patient room and when
anticipating the contact with the patient or their surroundings.
 Remove apron, gown, and gloves after leaving room.
 Clean and disinfect non-disposable equipment and items when removed from patient room
Droplet Precautions:
 Single patient room.
 Staff to perform hand hygiene put on surgical mask prior to enter the patient room and
dispose of mask after leaving the room and perform hand hygiene.
 Instruct the patient about the respiratory hygiene and cough etiquette.
 Limit patient movement outside the room to medically necessary purposes.
Airborne Prevention:
 Single negatively pressured room.
 Door to remain closed.
 Staff to perform hand hygiene put on N95/P2 mask prior to enter the patient room and
dispose of mask after leaving the room and perform hand hygiene.
 Instruct the patient about the respiratory hygiene and cough etiquette.
Breaking the chain of infection V. (Portal of Entry)
 Maintain integrity of skin and mucous membrane.
 Prepare position of tubing etc. may prevent injuries and skin breakdown.
 Turning and positioning the debilitated client.
 Ensure the personal hygiene of the patient regularly.
 Proper disposable of contaminated syringes and needle regularly.
 Proper handling of catheters and drainage set etc.
 Care should be taken while collecting and handling the specimen.
Breaking the chain of infection VI (Susceptible Host)
 Regular personal hygiene.
 Maintaining adequate intake.
 Encourage deep breathing exercise.
 Encourage proper immunization of children and adult client.
Maintaining Healing Process.
 Promotion of intake of well-balanced diet containing essential protein, vitamins, fats and
carbohydrate.
 Institution measures to improve appetite of patient.
 Helping the client to identify the methods to relieve stress.

1.4: Contamination
Contamination may happen if viruses are unintentionally transferred from a source to a host's orifice or
artificial body hole, where they subsequently begin to multiply and cause damage.

2: Purpose, Principles and Objectives

2.1 Purpose,
This document incorporates IPC practices that are evidence-based, recognised globally, and standard for
HCFs in Qatar. Its main goals are to enhance IPC improvement at the HCW of Faster Medical care and
to manage HAIs.

2.2 Objectives,
The goal is to reduce the risk of HAIs for patients, healthcare providers, and visitors. This is
accomplished by:

 Enabling and supporting all types of HCWs to follow thorough IPC practices at all levels of care.
 Delivering safe and high-quality healthcare and enhancing outcomes by lowering morbidity and
death.

2.3 Policy Principles,

2.3.1: The burden of HAIs, Antimicrobial Resistance (AMR), outbreaks of highly contagious diseases,
as well as the security of the healthcare system and healthcare workers will all be directly impacted by
the adoption of this strategy.

2.3.2: Patient centered approach

Infections related with healthcare have a part in infection prevention, as do patients and their families.
The organizational policy must emphasize how crucial it is to include the perspectives of patients and
their families in the program's elements.

2.3.3:Prevention
Risks of infection must be identified with the utmost care. Once hazards have been recognized, steps
must be made to lower or eliminate them.

2.3.4: Health care worker safety.

The achievement of healthcare safety depends critically on the health and safety of healthcare personnel.
With each plan, course of action, and intervention, their safety must be taken into account.

3.Hand Hygiene:
3.1: Importance of Hand Hygiene:
The most crucial step in preventing the spread of illnesses among patients and DHCP is good hand
hygiene. Before performing routine patient care  education and training programs should go into great
detail about the indications and strategies for hand hygiene practices.

3.2: Hand washing policy& procedure.

YOUR 5 MOMENTS OF HAND HYGIENE

Before touching a patient

 Before clean/aseptic Procedure

After Body fluid exposure risk

After touching a patient

After touching patient surroundings

3.3:Types and steps of Hand washing
Handwashing Guidelines (WHO)
4: Personal Protective Equipment (PPE).
Physical barriers used alone or in combination to shield mucous membranes, airways, skin, and clothing
from contact with infectious substances are known as personal protective equipment (PPE). PPE ought
to be worn by:

 HCWs who give patients direct care and who might come into touch with their blood, bodily
fluids, excretions, or secretions;
 In circumstances where they might come into contact with blood, body fluids, secretions, and
excretions, support employees like cleaners and laundry staff.
 Care provider handling patient specimens;
 Family members who assist with patient care and may come into touch with blood, bodily fluids,
secretions, or excretions;
The most common personal protective equipments in health care settings are
o Gloves
o Apron or Gown
o Mask
o Eye protection
o Footwear
o Hair covers

INJECTION SAFETY (IPC, POLICY AND PROCEDURE)

 Use aseptic technique to avoid contamination of sterile injection equipment
  Do not administer medications from a syringe to multiple patients, even if the needle or cannula
on the syringe is changed.
 Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one
patient only and dispose appropriately after use.
 Use single-dose vials for parenteral medications whenever possible.
 Do not administer medications from single-dose vials or ampules to multiple patients or combine
leftover contents for later use.
  If multidose vials must be used, both the needle or cannula and syringe used to access the
multidose vial must be sterile.
 Infection control practices for special lumbar puncture procedures Wear a surgical mask when
placing a catheter or injecting material into the spinal canal or subdural space
 AD: auto-disable syringe for immunization RUP: syringe with a re-use prevention feature SIP:
syringe with a sharps injury protection feature is recommended.

BIOMEDICAL WASTE MANAGEMENT(BMW).

 The key step in waste management is to distinguish between infectious and non-infectious
waste. 
 In a waste management program, biologic waste should first be separated from non-biologic
waste (paper, glass, plastic).
 Biologic waste should then be separated into infectious and non-infectious waste. Non-infectious
waste can be collected in regular black bags and treated as residential waste.
 Sharp infectious waste must be placed in rigid, puncture proof, and impermeable containers that
bear the universal biologic hazard symbol and should be removed from use and discarded when
the container is ¾ full.
 Incineration is the preferred treatment method for sharps as it eliminates microorganisms and any
possibility of puncture wounds. Other methods for treatment of infectious waste include steam
sterilization and chemical treatment.
 Non-sharp infectious waste should be collected in leak-resistant biohazard bags and sent for
incineration. 
 Disposal equipment, including sharps containers, garbage bags, and bins, should be readily
available and easily accessible throughout all patient areas.
  Infectious waste should be treated soon after discarding.

INFECTION CONTROL ASSESSMENT

I. Self-assessment tool for Nurses

II. Departmental Assessment.

INFECTION CONTROL ASSESSMENT TOOL

1 Personnel wear, neat uniform and appropriate clothing

2 Good personal hygiene, including hair and body cleanliness is
practiced.
3 Finger nails are cleaned and trimmed.
4 Hair is neat and off the colour
5 Personnel follow strict clothing and linen handling procedure to
avoid contaminating their clothes.
6 Disposable gloves are worn when handling contaminated
equipment.
7 Suspected I nfections are reported so appropriate action can be
taken
8 All jewellery in hands are removed and washed whenever required.
9 Personnel’s are oriented to infection control policies when hired
and this orientation is documented.
10 Personnel attend department and facility wise infection control in-
service programs
11 Personal review isolation procedure at least annually.
12 Personnel’s are screened for infectious diseases when hired and at
other times when necessary.