Republicof the Philippines

Department of Health
OFFICE OF THE SECRETARY
DEC 09 2022
ADMINISTRATIVE ORDER
No. 2022 -_

0.5
SUBJECT: Revised National Policy on Infection Prevention and Control in All
Public and Private Health Facilities

I. RATIONALE

The revision of Administrative Order (AO) No. 2016-0002, known as the

“National Policy on Infection Prevention and Control (IPC) in Healthcare Facilities,” is
precipitated by the need to align with the eight (8) core components of the World Health
Organization’s (WHO) Infection Prevention and Control, formulated in 2016 and
developed further in 2019, which are vital in the effective and efficient implementation of
IPC programs in
all health facilities in the country. These components include: 1) IPC
program, 2) IPC guidelines, 3) IPC education and training, 4) Healthcare-associated
infection surveillance, 5) Multimodal strategy, 6) Monitoring, audit, and feedback, 7)
Workload, staffing and bed occupancy
at
the facility level, and 8) Built environment,
materials, and equipment for infection prevention and control. Further, the framework and
provisions of this Order are anchored on the National Standards in Infection Prevention
and Control for Health Facilities, 3rd edition, published by the Department of Health
(DOH) in 2021.

The emergence of the COVID-19 pandemic in 2020, amplified the urgency to

revise the National Policy on IPC to strengthen IPC programs across health facilities all
and thus better manage the COVID-19, other emerging infectious diseases, and future all
public health emergencies.

This Order aims to strengthen the healthcare service delivery by focusing on

sustainable, manageable, and critical interventions that optimize available resources,
supported by evidence and sufficient groundwork for IPC. This Order shall include
systems that will drive better execution of the IPC program such as mechanisms for
reporting and feedback. Ultimately, this shall contribute to quality patient-centered care
for all Filipinos, as aligned with the Republic Act (RA) No. 11223 otherwise known as
the Universal Health Care (UHC) Act and the AO No. 2022-0038 or the Health Sector
Strategy for 2023-2028.

Il. OBJECTIVE

The Order shall provide guidance

effective establishment, implementation,
tomonitoring
all public andprivate health facilities in the
and evaluation of the Infection
Prevention and Control Program.

III.SCOPE OF APPLICATION

This Order shall apply to DOH Central Office bureaus, units and attached
agencies, Centers for Health Development, DOH Hospitals, Local Government Units

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Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ¢ Trunk Line 651-7800 local 1108, 1111 to 13
Direct Line: 711-9502 to 03 Fax: 743-1829 e URL: http://www.doh.gov.ph; e-mail: dohosec@doh.gov.ph
 (LGUs), all public and private health facilities, health professional societies, and other
relevant stakeholders.

In the case ofthe Ministry of Health - Bangsamoro Autonomous Region of Muslim

Mindanao (MOH-BARMM), the adoption of this Order shall be in accordance with the
applicable provisions of RA 11054 or
the “Bangsamoro Organic Act” and the subsequent
laws and issuances by the Bangsamoro government.

IV. DEFINITION OF TERMS

-
A. Antimicrobial Resistance (AMR) refers to the defense mechanism developed by a
microorganism (including bacteria, viruses, and some parasites) against an
antimicrobial drug to which it was previously sensitive. AMR, which is a consequence
of the use or misuse of an antimicrobial agent, ensues when a microorganism mutates
or acquires a resistant gene. Resistant organisms withstand attack by antimicrobial or
antiparasitic agents so that standard treatments become ineffective, allowing infections
to persist and spread (A.O. No. 2019-0002, entitled “Implementing Guidelines on the
Philippine Antimicrobial Stewardship (AMS) Program for Hospitals”).

B. Antimicrobial Stewardship (AMS) - refers to the multidisciplinary, multi-

intervention, coordinated approach to improve the appropriate use of antimicrobials
by promoting the selection of the optimal antimicrobial drug regimen to ensure the
right choice of antibiotic, right route of administration, right dose, right time, and right
duration to minimize harm to the patient and future patients. (A.O. No. 2019-0002).

C, Core Components — refers to the identified strategies to prevent current and future

threats from infectious diseases, combat rising AMR, and improve the overall quality
of healthcare delivery. These shall provide a systematic approach and foundation to
the establishment and strengthening of IPC programs
level.
at the national and health facility

D. Healthcare-Associated Infection (HAD) - refers to an infection occurring in a patient

during the process of care in a hospital or other health care facility, which was not
present or incubating at the time of admission. Healthcare-associated infections can
also appear after discharge. They also include occupational infections among staff.
(World Health Organization, Healthcare-associated infections fact sheet).

E. Health Facilities - refers to all facilities providing preventive, promotive, curative,

restorative, and rehabilitative care in the Philippines (AO 2016-0002). This includes
but isnot limited to Level 1, 2, 3, and specialty hospitals, treatment and rehabilitation
centers, infirmaries, birthing clinics, clinical and diagnostic laboratories, outpatient
clinics, and hemodialysis clinics (AO No. 2012-0012, entitled “Rules and regulations
Governing the New Classification of Hospitals and Other Health Facilities in the
Philippines).

1. Primary Care Facility - refers to the institution that delivers primary care services
which shall be licensed or registered by the DOH as mandated by the R.A. No.
11223 and its Implementing Rules and Regulations (AO No. 2020-0047 [Rules
and Regulations Governing the Licensure of Primary Care Facilities in the
Philippines]).

2
 2. Secondary Care Facility - refers to Level 1 and level 2 hospitals (A.O. No. 2012-
0012).

3. Tertiary Care Facility - refers to Level 3 and specialty hospitals (A.O. No. 2012-
0012).

F. Infection Prevention and Control (IPC) - refers to the discipline composed of

measures, practices, protocols and procedures towards preventing and controlling
the development of new infections acquired in healthcare settings.

G.
that oversees IPC program implementation in
health facilities -
Infection Prevention and Control Committee (IPCC) refers to the committee

H. Infection Prevention and Control Unit (IPCU) - refers to a unit in charge of

implementing the IPC program and its day-to-day activities in a health facility

I. Multimodal strategies - refer to strategies using several elements implemented in an

integrated way with the aim of improving an outcome and changing behavior. They
include tools, such as bundles and checklists, developed by multidisciplinary teams
that take into account local conditions.

J. Surveillance - refers to the ongoing and systematic collection, analysis,

interpretation, and dissemination of data regarding a public health event (such as
HAIs) for use in public health action to reduce morbidity and mortality and to
improve health. (International Federation of Infection Control [IFIC Basic Concepts
of Infection Control]).

K. Water from an Improved Source - refers to a water supply that by nature of its
construction is adequately protected from outside contamination, particularly fecal
matter.

- GENERAL GUIDELINES

A. All public and private health facilities shall adopt the National Policy on Infection
Prevention and Control (IPC).

B. The National Policy on IPC shall be part of the overall initiatives in improving
patient safety, quality of care, management of emerging infectious diseases, the
AMS program, and the current facility licensing standards of the DOH.

C. The National Policy on IPC shall be based on the World Health Organization’s eight
(8) core components of IPC.

D. All public and private health facilities shall establish effective and efficient IPC
programs that involve multidisciplinary and multimodal strategies to prevent and
control the spread of infections. The IPC Committee, in partnership with the AMS
Committee, the Health Care Waste Management Committee, the Patient Safety
Committee, and the Pharmacy and Therapeutics Committee, shall lead these efforts
and enable a streamlined approach in implementing IPC programs.
VI.SPECIFIC GUIDELINES

The following eight (8) core components, detailed in the Manual of National
Standards in Infection Prevention and Control for Health Facilities (2021) —
https://bit.ly/IPCManual3rdEdition, shall serve as the framework for the health facilities’
IPC programs. Refer to Annex B for the Minimum Requirements for the Infection
Prevention and Control Program.

A. Infection Prevention and Control Program Management and Structure

1. Health facilities shall implement an efficient and effective IPC program.

2. Health facilities shall create an infection control management structure under the
Head of Office with sufficient resources and clear lines of responsibility between
the IPCC and IPCU.
a. The IPCC shall:
i. Oversee the IPC program implementation, coordinate with, and
provide recommendations to the IPCU;
ii. Bea multidisciplinary committee composed of representatives from
the various health facility departments involved in IPC activities.
b. The IPCU shall be in charge of the day-to-day operations in the
implementation of the IPC program, and shall be composed of the following
staffing complement:
i. For Primary Care and Other Health Facilities: An IPC-trained
designated healthcare officer, with dedicated time to the
implementation of IPC activities in coordination with the primary
care physician in charge of the facility;
ii. For Secondary Care Facilities: A full-time IPC healthcare officer
(e.g., IPC nurse or physician), following a 1:100 IPC officer to bed
capacity ratio; and,
iii. For Tertiary Care Facilities: A full-time IPC Unit Head (preferably
an infectious disease specialist), full-time IPC Nurses (following a
1:100 IPC Nurse to bed capacity ratio), and an IPC Surveillance
Officer.

3. The comprehensive staffing, roles and responsibilities, overall composition of

the infection prevention and control management structure, and the specific
functions of the IPCU are specified in the Manual of National Standards in IPC
for Health Facilities, 2021.

B. Infection Prevention and Control Guidelines, Policies, and Procedures

1. Health facilities shall have written guidelines, policies, and procedures for
infection prevention and control within their facility. These shall include but are
not limited to the following:
a. hand hygiene
b. standard and transmission-based precautions
c. triage of infectious patients
d. aseptic techniques

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by
 cleaning, disinfection, and sterilization of medical devices and equipment
environmental cleaning and disinfection
healthcare waste management
a safe injection practices
prevention of highly communicable infections
outbreak investigation
other guidelines, policies, and procedures as appropriate to the level of health
facility

2. There shall be an approved plan for dissemination, implementation, and

monitoring of infection control policies, guidelines, and procedures.

3. Health facilities shall have policies on healthcare worker protection and

occupational safety against infectious diseases, such as COVID-19, blood-borne
infections (e.g., HIV, hepatitis B, etc.), and other emerging infectious diseases.
These shall include but are not limited to the following:
vaccination,
of
post-exposure prophylaxis,

eae
PPE use and
fit testing,
work arrangements, and
testing as necessary.

C. Infection Prevention and Control Education and Training

1. The health facility shall allot adequate resources for the required capacity-
building activities for IPC.

2. In addition, the IPCU shall conduct regular infection prevention and control
educational programs focusing on relevant topics appropriate for specific
clinical settings.

3. The IPCU shall conduct periodic evaluation or assessment of education/training

programs tomeasure its effectiveness to the staff involved in IPC.

D. Healthcare-Associated Infection Surveillance

1. The IPC Unit shall take charge of the implementation of the outbreak
investigation and over-all surveillance process in health facilities for HAI, as
guided by policies and procedures on HAI Surveillance.

2. The IPCU shall collect and analyze HAI data, using standard reporting forms
appropriate to their health facility context, and shall provide reports to the IPCC
at least annually or as necessary. A separate issuance shall be disseminated
which sha!l cover the definition of HAI in the Philippine setting, surveillance
process, monitoring, and reporting at the health facility level.

3. The IPCU shall coordinate with the Microbiology, Pharmacy, Antimicrobial

Stewardship Committee, and the Pharmacy Therapeutics Committee for the
establishment, development, implementation, monitoring, and evaluation of the
IPC program in the facility.

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E. Multimodal Strategies

1. The health facility shall implement infection prevention and control programs
using multimodal strategies.

2. The five-step approach to IPC improvement shall be followed by the facility to

support the implementation of the IPC program and activities, which is grounded
in the principles of successful change and improvement in
health care.

The five-step approach to IPC includes preparation for action, conduct baseline
assessment, develop and execute an action plan, evaluate impact, and develop
an ongoing action plan and review schedule to sustain the program over the long
term.

F. Monitoring, Audit, and Feedback of Infection Prevention and Control

1. There shall be a well-defined monitoring plan in place with clear objectives,

targets, and activities aligned to the standard IPC indicators, such as infection
rates, including device-related infections and non-device related infections,
based on the priorities identified by the health care facility.

2. Reporting shall be done quarterly, except during outbreaks, wherein reports shall
be submitted to the IPCC and feedback shall be given
relevant staff in real-time as necessary.
to
all audited persons and

3. There shall be available tools to collect data in a systematic way. Refer to Annex
E of the National Standards in Infection Prevention and Control for Health
Facilities, 2021.

G. Workload, Staffing, and Bed Occupancy

at the Facility Level
1. All health facilities with inpatient service shall strive to maintain the ideal bed
occupancy rate of 80-85%. In cases of increasing bed occupancy, surge capacity
management plans shall be instituted, to ensure that Infection Prevention and
Control Standards are maintained to reduce the risks of HAIs and spread of
AMR.

2. Appropriate staffing levels shall be assessed according to patient workload using

national! or international standards.

3. The design of hospital wards shall be according to the standard designs set by
the Department of Health, to reduce overcrowding (e.g., Manual on Technical
Guidelines for Hospital Planning and Design 100-Bed Hospital [Level 2] and for
250-Bed Hospital [Level 3]).

H. Built Environment, Materials, and Equipment for Infection Prevention and

Control

1. The health facility shall ensure constant access to a clean and sufficient quantity

we”
 of water from an improved source on the premises to allow the performance of
basic IPC measures, including but not limited to hand hygiene, environmental
cleaning, laundry, decontamination of medical devices, and health care waste
management. These shall be in accordance with the Health Care Waste
Management Manual, 4th Edition. (bit.ly(DOHHFDBManuals).

2. The facility layout shall allow adequate natural or mechanical ventilation,

decontamination of reusable medical devices, triage, and space for temporary
cohorting/isolation/physical separation,
of infectious pathogens.
if
necessary, to prevent the transmission

3. The health facility shall ensure the availability of sufficient and appropriate IPC
supplies and equipment such as mops, detergent, disinfectant, PPE, and
sterilization, and reliable power/energy supply for performing
minimum
all
all
IPC measures,
standard and
according to requirements/SOPs, including
transmission-based precautions, as applicable. Adequate lighting shall be
available during working or operating hours for providing continuous and safe
care.

VII. ROLES AND RESPONSIBILITIES

A. The Health Facility Development Bureau (HFDB) shall:

1. Lead in the formulation of policies, guidelines, and standards for infection

prevention and control in
all health facilities;

2. Provide the overall direction for infection prevention and control programs of
health facilities;

3. Provide technical assistance on infection prevention and control to Health

Facility Development Units and health facilities;

4. Facilitate [PC-related capacity-building initiatives in the CHDs and health

facilities;

5. Facilitate the cascade of National Standards in IPC for Health Facilities 2021,
and its subsequent revisions; and

6. Develop frameworks and tools for the monitoring of the health facilities’
compliance with national standards.

B. The Health Facilities and Services Regulatory Bureau (HFSRB) shall:

1, Utilize the national standards in IPC as the basis for establishment the minimum
licensing requirements for all health facilities; and

2. Ensure that infection prevention and control programs are functional in the
health facilities.

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C. The Pharmaceutical Division (PD) shall:
1. Provide technical assistance to the HFDB on Antimicrobial Stewardship and
Antimicrobial Surveillance in health facilities; and

Collaborate with the HFDB on the overall monitoring of the implementation of

the IPC program in health facilities in conjunction with existing Antimicrobial
Stewardship and Surveillance programs.

D. The Epidemiology Bureau (EB) shall:

1. Develop, oversee the implementation of, and assist in enforcing compliance to

policies, standards, and guidelines on the screening, diagnosis, assessment, case
and cluster investigation, contact tracing, and reporting of HAIs and other
emerging and re-emerging infectious diseases to support the IPC programs of
health facilities;

Capacitate Regional and Local Epidemiology and Surveillance Units (ESU) on

the application of above-mentioned guidelines and associated training packages
for their use in capacitating IPCUs; and

Provide technical assistance to Regional and Local Epidemiology and

Surveillance Units on establishing linkages and reporting mechanisms with
Hospital IPCUs and ESUs.

E. The Disease Prevention and Control Bureau shall:

1. Identify, appraise, and endorse Clinical Practice Guidelines for infectious

diseases that are of public health importance, for adoption in the health facilities,
or for utilization by concerned agencies in their respective policy formulation,
in accordance with the administrative issuances related to the National Practice
Guideline Program and the Omnibus Health Guidelines per Life stage; and

Collaborate with the HFDB and other relevant stakeholders for the development
of standards of care and protocols on managing infectious diseases, including
emerging and re-emerging infectious diseases (EREID) and HAIs.

F. Health Professional Societies shall:

Assist in the overall policy development for infection prevention and control;

Train and capacitate respective society members in infection prevention and

control standards; and

Advocate for infection prevention and control in their respective groups.

S\
 G. Centers for Health Development through the Health Facility Development Unit
(HFDU) and Ministry of Health - Bangsamoro Autonomous Region of Muslim
Mindanao (MOH-BARMM) shall:

1. Ensure the provision of appropriate budget, facilities, and other resources for the
Health Facility Development Unit to carry out its activities and functionsfor the
IPC program;

2. Advocate for the Infection Prevention and Control program in all health
facilities;

3. Designate one (1) IPC Officer and organize regional teams to assist in the
implementation of the IPC Program in health facilities and to manage progress
of the program in their respective region, especially through training,
monitoring, evaluation and reporting;

4. Facilitate the annual celebration of National IPC Week in their respective

regions;

5. Provide technical assistance to health facilities related to the program

implementation;

6. Lead and facilitate the reporting system through the collection, consolidation,
validation, and analysis of data, as well as preparation and dissemination of
Quarterly and Annual Reports generated by DOH hospitals, LGU-managed
hospitals, school-run hospitals, hospitals under the Department of National
Defense, and other health facilities; and

7. Submit an annual report to HFDB with recommendations for policy and program
improvements as a feedback mechanism.

H. All Health Facilities shall:

1. Implement efficiently and effectively the infection prevention and control

program in the health facility;

2. Establish, organize, monitor, and support the activities of the IPC Committee
and the IPC Unit;

3. Address efficiently and effectively all IPC concerns and issues

healthcare facility level; and
occurring
at the
4. Coordinate with the CHD about the status of IPC programs in health facilities.
VIL. FUNDING MECHANISM

Health facilities and their administrative arm shall allocate budget for the
implementation of their respective IPC programs. This shall be included in their respective
annual budget. The allocation shall be for the following items: payment of salaries and
allowances for infection control personnel and committees, capacity-building for IPC

4
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 personnel, PPE, infrastructure and equipment relative to IPC, and other materials and
supplies essential to the implementation of the IPC program, as
prescribed in this policy
and in the Manual of National Standards in IPC for Health Facilities 2021.

This shall serve as the minimum requirements and the health facility may allocate
more, as the need arises (i.e., anew emerging infectious disease, etc.). All the expenditures
shall be subject to the usual government accounting rules and regulations, as may be
applicable.

IX. REPEALING CLAUSE

Administrative Order No. 2016-0002 or the National Policy on Infection

Prevention and Control in Healthcare Facilities, and all other issuances, rules, and
regulations inconsistent with or contrary to this Order, shall be repealed, amended or
modified accordingly.

X. EFFECTIVITY

This Order shall take effect fifteen (15) days following its publication in a
newspaper of general circulation, and upon filing of three (3) certified copies to the Office
of the National Administrative Register, University of the Philippines Law Center.

MARIA ROSARIO S. VERGEIRE, MD, MPH,

Officer-irj-Charge,
CESO
IT
Department of Health

10
 Annex A. References
Department of Health. (2012). Administrative Order No. 2012-0012, “Rules and regulations
Governing the New Classification of Hospitals and Other Health Facilities in the
Philippines.”

Department of Health. (2016). Administrative Order No. 2016-0002, “National Policy on Infection
Prevention and Control in Healthcare Facilities”

Department of Health. (2019). Administrative Order No. 2019-0002, “Implementing Guidelines

on the Philippine Antimicrobial Stewardship (AMS) Program for Hospitals.”

Department of Health. (2021). National Standards in Infection Prevention and Control for Health
Facilities (3rd ed.).

Friedman, C., & Newsom, W. (2016). FIC Basic Concepts of Infection Control. United Kingdom,
International Federation of Infection Control.

Republic the Philippines. (2018). Republic Act No. 11223, "An Act Instituting Universal Health
of

Care for All Filipinos, Prescribing Reforms in the Health Care System, and Appropriating
Funds Therefor".

World Health Organization. (2016). Healthcare-associated infections fact sheet. Retrieved from
https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
~—
Annex B. Minimum Requirements For The Infection Prevention And Control Program

Core Primary Care and Other Health Secondary Care Tertiary Care
Component Facilities Facilities Facilities

IPC trained health care officer Functional IPC program
Core e IPC program must have @ IPC program must have
Component 1: clearly defined objectives clearly defined
based on local epidemiology objectives based on
IPC Program and priorities according to local epidemiology
risk assessment and functions and priorities
that align with and contribute according to risk
to the prevention of HAI and assessment and
combating AMR through IPC functions that align
good practices. with and contribute to
e@
Dedicated budget for IPC the prevention of HAI
implementation as stipulated and combating AMR
in the national policy in IPC. through IPC good
e Trained IPC link person, with practices with
dedicated (part-) time in each measurable outcome
Functional IPC program
e IPC program must have clearly
defined objectives based on local
epidemiology and priorities
according to risk assessment and
functions that align with and
contribute to the prevention of
HAI and combating AMR through
IPC good practices with
measurable outcome indicators
and set future targets.
© Dedicated budget for IPC
implementation as stipulated in the
national policy in IPC.
@ Trained full time unit head, at least

primary health care facility. indicators. one full-time IPC nurse with
e@
One JPC-trained health care e Dedicated budget for dedicated time per 100 beds and
officer at the next IPC implementation as IPC surveillance officer.
administrative level (for stipulated in the e IPC committee actively supporting
example, district/LGU) to national policy in IPC. the IPC unit
supervise the IPC link @ Trained IPC focal point

professionals in primary (one full-time trained

© Quality microbiological laboratory
health care facilities. IPC Officer [nurse or support
e Smaller healthcare facilities doctor]) as per the
within the geographic area recommended ratio of
shall link with bigger 1:100 beds with
 facilitates for infection dedicated timeto carry
prevention and control out IPC activities in all
services through their facilities IPC
designated representative. committee actively
supporting the IPC
unit
@
Microbiology
laboratory

Core Facility-adapted standard All requirements as for the primary health care facility level, with
Component 2: operating procedures (SOPs) and additional SOPs on
their monitoring e Standard and transmission-based precautions (for example,
IPC Guidelines e Evidence-based facility- detailed, specific SOPs for the prevention of transmission of
adapted SOPs based on the airborne pathogens and multi-drug resistant organisms’
national IPC guidelines. transmission);
e At a minimum, the facility e Aseptic technique for invasive procedures including surgery;
SOPs should include @
Specific SOPs to prevent the most prevalent HAIs based on the
o Hand hygiene local context/ epidemiology, including device-associated infections
o Decontamination of and surgical site infections;
medical devices and e@
Occupational health (specific detailed SOP).
patient care @ Outbreak Investigation, Management, and Preparedness (including
equipment emerging and re-emerging infections)
o Environmental e Reporting of highly transmissible and notifiable infectious disease
cleaning Pre-employment policy
o Health care waste
management
0 Injection safety
o HCW protection (for
example, post-
exposure prophylaxis,
vaccinations)
o Aseptic techniques

=2
 o Triage of infectious
patients
o Basic principles of
standard and
transmission-based
precautions.
e Routine monitoring of the
implementation of at least
some of the IPC guidelines/
SOPs.

Core IPC training for all clinical and IPC training for all clinical IPC training for all clinical and non-
Component 3: non-clinical staff upon hire, and non-clinical staff upon clinical staff upon hire, annually, or as
annually or as needed hire, annually, or as needed needed
IPC Education e@ All clinical and non-clinical @ All clinical and non- e All clinical and non-clinical staff
and Training staff must receive appropriate clinical staff must must receive appropriate
education and training on the receive appropriate education and training on the
facility IPC guidelines/SOPs education and training facility IPC guidelines/SOPs upon
upon employment and on the facility IPC employment and annually.
annually. guidelines/SOPs upon
employment and
annually.

Core e HAI surveillance as a © Active HAI e HAI surveillance should be

Component 4: minimum requirement at the surveillance should be conducted and include the
primary facility level should conducted and include following information:
HAI follow national standards. the following o Enabling structures and
Surveillance information: supporting resources need
information on AMR: to be in place (for
o Enabling example, dependable
structures and laboratories, medical
 supporting records, trained staff),
resources need directed by an appropriate
to be in place method of surveillance;
(for example, o The method of
dependable surveillance should be
laboratories, directed by the
medical priorities/plans of the
records, facility and/or country.
trained staff), o Antibiogram or Antibiotic
directed by an Resistance Patterns
appropriate @ Timely and regular feedback
method of needs to be provided to key
surveillance; stakeholders in order to lead to
© The method of appropriate action, in particular to
surveillance the hospital administration.
should be
directed by the
priorities/plans
of the facility
and/or
country.
o Antibiogram
or Antibiotic
Resistance
Patterns
e Timely and regular
feedback needs to be
provided to key
stakeholders in order
to lead to appropriate
action, in particular to

oa
 the hospital
administration.

Core Multimodal strategies for priority Multimodal strategies for Multimodal strategies for all IPC
Component 5: IPC interventions priority IPC interventions interventions
e Use of multimodal strategies e@
Use of multimodal e Use of multimodal strategies to
Multimodal — at the very least to strategies — at the very implement interventions to
Strategies implement interventions to least to implement improve each one of the standard
improve hand hygiene, safe interventions to and transmission-based
injection practices, improve each one of precautions, triage, and those
decontamination of medical the standard and targeted at the reduction of
instruments, devices and transmission-based specific infections (for example,
environmental cleaning. precautions, and surgical site infections or catheter-
triage. associated infections) in high-risk
areas/patient groups, in line with
local priorities.

Core © Monitoring of IPC structural e A person responsible for the conduct of the periodic or continuous
Component 6: and process indicators should monitoring of selected indicators for process and structure,
be putin place at primary care informed by the priorities of the facility or the country.
Monitoring, level, based on IPC priorities e Hand hygiene is an essential process indicator to be monitored.
Auditing and identified in the other Timely and regular feedback needs to be provided to key stakeholders in
Feedback components. This requires order to lead to appropriate action, particularly to the hospital
decisions at the national level
and implementation support
administration.

at the sub- national level.

Core e To reduce overcrowding: a e To standardize bed occupancy:

Component 7: system for patient flow, a
(including
o Establish a system to manage the use of space in the facility
and to establish the standard bed capacity for the facility;
triage system
Workload, referral system) and a system o Hospital administration enforcement of the system
Staffing and for the management of developed;
Bed Occupancy consultations should be o No more than one patient per bed;
 established according to
if
o Spacing
of at least one metre between the of
edgesbeds;
Overall occupancy should not exceed the designed total bed
existing guidelines, o
available. capacity of the facility.
To optimize staffing levels:
assessment of appropriate e To reduce overcrowding and optimizing staffing levels: same
staffing levels, depending on
the categories identified when
minimum requirements as for primary health care.
using WHO/national tools
(national norms on
patient/staff ratio), and
development of an
appropriate plan.

Core Water should always be A safe and sufficient quantity of water should be available for all
Component 8: available from a source on the required IPC measures and specific medical activities, including for
premises (such as a deep drinking, and piped inside the facility at all times - at a minimum
Built borehole or a treated, safely to high-risk wards (for example, maternity ward, operating room/s,
Environment, managed piped water supply) intensive care unit).
Materials, and to perform basic JPC A minimum of two functional, improved sanitation facilities that
Equipment for measures, including hand safely contain waste available for outpatient wards should be
ec hygiene, environmental available and one per 20 beds for inpatient wards; all should be
cleaning, laundry, equipped with menstrual hygiene facilities.
decontamination of medical Functional hand hygiene facilities should always be available at
devices and health care waste points of care, toilets and service areas (for example, the
management according to decontamination unit), which include ABHR and soap, water and
national guidelines. single-use towels (or if unavailable, clean reusable towels) at points
A minimum of two of care and service areas, and soap, water and single-use towels (or
functional, improved if unavailable, clean reusable towels) within 5 metres of toilets.
sanitation facilities should be Sufficient and appropriately labelled bins to allow for health care
available on-site, one for waste segregation should be available and used (less than 5 metres
patients and the other for from point of generation) and waste should be treated and disposed
staff; both should be of safely via autoclaving, and/or buried in a lined, protected pit.
equipped with menstrual
hygiene facilities.
Functional hand hygiene
facilities should always be
available at points of
care/toilets and include soap,
water and single-use towels
(or if unavailable, clean
reusable towels) or alcohol-
based handrub (ABHR) at
points of care and soap, water
and single-use towels (or if
unavailable, clean reusable
towels) within 5 metres of
toilets.
Sufficient and appropriately
labelled bins to allow for
The facility should be designed to allow adequate ventilation
(natural or mechanical, as needed) to prevent transmission of
pathogens.
Sufficient and appropriate supplies and equipment and reliable
power/energy should be available for performing all IPC practices,
including standard and transmission-based precautions, according
to minimum requirements/SOPs; reliable electricity should be
available to provide lighting to clinical areas for providing
continuous and safe care, at a minimum to high-risk wards (for
example, maternity ward, operating room/s, intensive care unit).
The facility should have a dedicated space/area for performing the
decontamination and reprocessing of medical devices (that is, a
decontamination unit) according to minimum requirements/ SOPs.
The facility should have adequate single isolation rooms or
atleast
one room for cohorting patients with similar pathogens or
syndromesif the number of isolation rooms is insufficient.

health care waste segregation

should be available and used
(less than 5 metres from point
of generation); waste should
be treated and disposed of
safely via autoclaving, and/or
buried in a lined, protected
pit.
The facility layout should
allow adequate natural
ventilation, decontamination
of reusable medical devices,
triage and space for
temporary cohorting/

==
isolation/ physical separation
if necessary.
Sufficient and appropriate
IPC supplies and equipment
(for example, mops,
detergent, disinfectant,
personal protective
equipment (PPE) and
sterilization) and
power/energy (for example,
fuel) should be available for
performing all basic IPC
measures according to
minimum requirements/
SOPs, including all standard
precautions, as applicable;
lighting should be available
during working hours for
providing care.