Prevention & Control of Infection HAH-PCLOL Infection Control Program DPP | ‘Applies to: All Hospital Staff Purpose: LL. To identify potentially infectious patients or staff who may transmit disease to others. 1.2, To reduce the risk of disease transmission and to ensure maximal protection for patients, visitors, and health care workers against infection. 1.3. To recommend risk reduction practices by integrating infection control principles into all standards of practice. 1.4, To monitor infections within the hospital. 1.5, To provide safe environment for patients, visitors and employees. 1.6. To achieve and minintain the Standards for Infection Control in compliance with Joint ‘Commission International Accreditation (JCIA) and other regulators. 1.7. To address the prevention of infection amongst patients, visitors and employees and other environmental issues. 1.8, To provide feedback to physicians and other healthcare providers. 20, Definitions: 2.1, Infection Control Program is @ multidisciplinary systematic approach committed to preventing health care associated infections and their related events, to improve patient care, and to minimize infection-related occupational hazards associated with the delivery of health care. 22, Infection Control Committee (ICC) is a multidisciplinary committee responsible for overseeing the Infection Control Program for the surveillance, prevention and control of infection. 23. Infection Control Committee representatives are recommended for appointment by individual department heads and approved by the CEO. 24, Infection Control Team are members of the Infection Control Committee who provide the ‘ongoing review and analysis of day-to-day activities necessary to reduce the risk of infection and to achieve the goals ofthe program. 25. Infection Control Unit Coordinators are representatives to Infection Control from each Nursing and non-Nursing units/areas. ‘There shall be an active hospital-wide infection control program. All Hussein Al-Ali Hospital employees shall be made aware of infection control policies and procedures and their responsibilities in surveillance, prevention and control. 3.3. Infection control policies and procedures and other policies related to infection control shall be reviewed and revised at least once every 2 years ot more often when deemed necessary, 34. The prevention and control methods and surveillance strategies shall be evaluated for their effectiveness throughout the hospital. Date Approved fg 3015 _[__Rvnon Dae J 2007 TaPrevention & Control of Infection | nan-rcto1 | Title: Infection Control Program Applies to: All Hospital Staff. L BI 4.0. Responsibilities: 4.1, Hussein Al-Ali Hospital Staff shal: 4.1.1. Comply with the policies in the Infection Control Manual. 4.1.2. Attend the New Hire Orientation Program on Infection Control. 4.13. Review, with their supervisor / designee, the current infection control policies and practices for their specific work area prior to commencing any working in that area 4.14. Participate in the infection control service and educational program. 42. CEO 4.2.1, Appoint the Chairman and members of the PCI committee. 43. Infection Control Committee 43.1. Refer to Infection Control Committee Policy No.02 44, Infection Control Committee Members shall 4.4.1. Recommend practices to resolve identified infection control problems in care and performance. 44.2. Monitor compliance with hospital infection control policy. 443. Recommend corrective actions to governing bodies when necessary. 4.44, Serve on or consult with, committees responsible for evaluating procedures or equipment related to infection control activities. 445. Coordinate and assist with employee new hire orientation and in-service education programs relsted to infection control 44.6. Approve the type and scope of surveillance activities including stratified infection risk, focused infection studies, and prevalence and incidence studies. 4.4.7. Detect and investigate suspected healthcare associated infections on a current, systematic basis. 4.4.8. Prompt the initiation of reporting communicable disease to Ministry of Health using the appropriate Notification Form, when indicated, 4.4.9. Determine the amount of time required to conduct infection surveillance, prevention and control activities based on several parameters: 4.49.1. Needs of the patient population. 4.4.9.2. Risk factors ofthe patient population. 44.9.3. Complexity of the services. 44.9.4, Educational needs of the personnel. 4.4.9.5. Resource and support services available. 4.4.10. Determine the appropriate definitions and criteria to recognize the existence of Health care-associated infection (HAs). Fagot 1 I Tene | (Bae Apron ay 015 [Wenn Dues. 2077 TAPCO| __ Prevention & Control of Infection HAH-PCE-O1 Title: Inf n Control Program DPP | Applies to: All Hospital Starr 4.4.11. Conduct at least annual reviews of the data trend analysis generated by surveillance activities during the past year as well as the effectiveness of prevention and control intervention strategies in reducing nosocomial infection risks and priorities or problems identified in the past year. 4.4.12, Initiate and conduct epidemiological investigations relating to infection prevention and control of infection incidents. Establish, review, and approve, at least every two years, all policies and procedures related to infection surveillance and prevention and control activities in all departments/services, 4.4.14. Monitor compliance with hospital infection control policy. 4.4.15. Ensure that ail infection control policies, practices, procedures and other policies related to infection control are developed, reviewed and revised, 4.5. Review and approve the cleaning procedures, agents and schedules that are used throughout the hospital. This review isto be done biannually or more frequently if necessary. 4.6. Clinicians shall: 4.6.1. Report immediately all suspected or confirmed healthcare associated infections (including identified as post-discharge) to the Infection Control Team. 4.6.2, Report all communicable diseases diagnosed in any patient to infection control team, 4.63. Complete the Notifiable Disease Form forall suspected or confirmed reportable diseases when first identified and submit to IPC Unit for reporting to Ministry of Health. 4.64, Set a good example in the practice of asepsis 4.7. Microbiology Laboratory Unit shall provide laboratory support for infection control activities, as follows: 4.7.1. Identify organisms to species level. 4.7.2. Provide information to determine types of culturing techniques and media to use in an ‘outbreak investigation. 4.7.3. Alert Infection Control Team of all potentially significant isolates, e.g. MRSA, VRE 5.0. Attachments: None 6.0. References: 6.1. Gulf Cooperation Council Center for Infection Control (GCC-CIC) ICM ~ 1-02 & 03 62. Infection Control Conimittee Policy No. 02 ‘Date Approved fay, 2015 | _Revnon Date 2017 ARFCLaT I Poses cJ Prevention & Control of Infection | nan-rct0 PBR = sasection Control Program DPP | Applies ‘o: Alt Hospital Statt Signatory box Prepared by: Ms. Maria Cecilia Becalas Infection Control Supervisor i =| Approved by: Dr. Hussien Hassan Satari (Chairman of Infection Control Committee Ms. Somaya Lutfy Nursing Director Dr. Ahmed Barakat Medical Director Dr. Mhmd Salah Quality Improvement Director Mr, Reda Al-Ali Chief Executive Officer cd (bi peewee 205 Resi be OT tara ag 1ee Prevention & Control of Infection HAHLPCI-02 Tile Infestion Control Committee faa DPP | Applies:o: All Hospital Statt 1.0. Purpose: 1.1. To monitor infections within the hospital 1.2, To provide the type and scope of surveillance activities and personnel input into these activites. 1.3. To provide a safe ens ironment for the patients, visitors and employees. 14, To provide advice reyarding all infection control activities within the hospital. 1.5, To ensute that corrective action is taken to remove known or potentially infectious hazards to ensure a safe environ nent for patients, staff and vistors. 1.6, To review and approve, once every 2 years or more often as necessary all procedures related to infection control surveillance, prevention and control program. 2.0, Definitio 2.1. Infection Control Committee (ICC) is « multidisciplinary committee responsible for overseeing the Infeetion Control Program for the surveillance, prevention and control of infection. 3.0. Membership: 341. The comr tee consists of multidisciplinary team members. 3.2. Members are appointed by CEO and include representation from the following: 3.241, Prevention and Control of Infection Unit 3.2.2. Employee Health 3.2.3. Internal Medicine Services 3.24, Neonatology and Pediatric Services 3.2. Surgical Services 3.2.6. Obstetrics and Gynecology Services 3.2.7, Nursing Services Department 3.28. Pharmacy Services 3.29, Microbiology Laboratory Services 3.2.10. Intensive Care unit 3.2.11, Quality Improvement and Risk Management Unit 3.2.12, Others: Guests from other departments such as: Housekeeping, Laundry & CSSD are invited when matters pertaining to their services are to be discussed. 4.1. Responsibility for the evaluation of the infectious potential of the related environment is vested in a multidisciplinary committee under the aegis of the medical staff. 4.2. The Infection Control Committee coordinates an objective and systematic review process to evaluate the quality and appropriateness of patient care as it relates to infection prevention and control. Dave Approved a 20 Reviion De 2077 THAIRCTRE z ]I__ Prevention & Control of Infection HAH-PCL02 ‘| Infection Control Committee DPP | apptiesto: all Hospitat Seatt |. Procedui SA. Meeting: S11. The committee meets at least 10 times each year. Meetings will be called by the Chaitman, Special meetings will be called when circumstances dictate. 5.1.2, All matters t9 be addressed by the Committee should be brought to the attention of the Chairman, PCI Supervisor, andlor the appropriate Committee member. 5.2. Documentation 52.1. Discussions, conclusions, recommendations, assignments, actions, and approvals are documented in the minutes of the Committee meetings. 5.22, Minutes are distributed to each committee member. 53. Reporting Relationship 5.3.1. Reports to CEO 34. Authority Sa.1. The Infection Control Committee (ICC), through its chairperson and members, is vested with the responsibility and authority to institute any appropriate prevention and control measure when it is reasonable to presume that an infectious risk to any patient or personnel exist. 5.4.2. The Director forthe Infection Prevention and Control Program of the institution has the responsibility and authority to establish polices and procedures for the instruction ofits personnel and for the overall supervision of infection prevention and control a its facilities, 6.0, Attachments: 6.1. Infection Control Tea:n ~ Contact List 6.2. Infection Control Committee Membership 6.3, Infection Control Unit Coordinators 7.0. References: 7. Gulf Cooperation Council Center for Infection Control (GCC-CIC) ICM ~ 1-02 & 03 Tages 1 (beige 20 [neo by 2077 —]Prevention & Control of Infection Je LI tsetin Conv commie | HAH-PCI-02 DPP | Appliesto: Att Hospital Statt Signatory box Prepared by: Ms. Maria Cecilia Becalas Infection Control Supervisor Approved by: Dr. Hussien Hassan Satari Chairman of Infection Control Committee Dr. Mhmd Salah Quality Improvement Director Mr. Reda Al-ALi Chief Executive Officer p) At ye ot ad] Lee iee wa Date Approve: Ty 2015 | Revson Date Du 2017 TARP I Pose datd ]Prevention & Control of Infection HAH-PCLO3 » 4 2 Title: Scope cf Service DPP | Applies to: | Prevension and Control of Infection Unit 1.0, Purpose: rf rr To define the services provided by the Prevention and Control of Infection Unit. To ensure efficient itd effective operation of the Prevention and Control of Infection Unit. 2.0. Definitions: 24. ‘The Prevention and Control of Infection Unit is a unit reports to the Chief Executive Officer (CEO) of Hussein Al Ali Hospital, which deals with Prevention and Control of Infection influencing a patients and staff health care 2.2. Structure is the organization and line of authority of the Prevention and Control of Infection Unit within Hussein AI Ali Hospital as demonstrated on the Organization Chart (Refer to Attachment a), 23. Unit Operations, for the purpose of this policy, refer to meetings, ing and orientation, continuing education, training, employee health, time off and salary actions of Prevention and Control of Infection Unit Staff 3a. The Prevention and! Control of Infection Unit shall provide services to Hussein Al-Ali Hospital patients and employees. 3.2. ‘The Prevention and Control of Infection Unit shall act as a liason between Hussein Al-Ali Hospital and community agencies. 33. Time Off; All policies and procedures regarding time off work (vacations, holidays, sick leave, ‘emergency leave, and personal leave) are described in the APP manual. The staff of the Prevention and Control of Infection Unit shall adhere to these policies and procedures, 34, Staffing: The recruitment, acquisition, and processing of new staff for the Prevention and Control of Infection Unit shall be done in secordance with Hussein Al Ali Hospital policies and procedures, Salary Actions: Pay schedules, salary increases, and promotions are governed by the policies and procedures established in the APP Manual 3.6. Orientation: 3.6.1. All new hires shall attend Hussein Al-Ali Hospital Orientation Program. 3.6.2. All new hires shall receive orientation to the Prevention and Control of Infection and their duties and responsibilities. 3.7. Employee Health: Prevention and Control of Infection Unit personnel shall abide by the policies ‘and procedures established on Employee Health Program. 3.8. Continuing Education: 3.8.1. All Prevention and Control of Infection Unit personnel shall be eligible for continuing education aid on the job training through appropriate in-service programs, videotapes, presentation; lectures, and conferences. Date Approved Tuy, 201 | Wevbion Date J. 2007 HARRCT a I Page Tos T convka Title: Scope of Service Prevention & Control of Infection | HAH-PCI-03 DPP | Applicsto: Prevention and Control of Infection Unit, education, 3.8.2. Prevention and Control of Infection staff shall be selected for in ~ Kingdom continuing 4.0. Responsibilities: (Refer o Attachment B) References: 5.1, Hussein Al-Ali Hospital APP Manual 1. New Hire Orientation P&P 6.0. Attachments: 6.1. Attachment A: Organizational Chart 6.2. Attachment B: Job Descriptions and Responsibili (“Die Raprea ay 20 [i oT] Tame :Prevention & Control of Infection HAH-PCI-03 I Fe scope Servic DPP | Applies to: Prevention and Contro of Infection Unit Signatory box Prepared by: ‘Ms. Maria Cecilia Becalas Infection Control Supervisor Approved by: q Dr. Hussien Hassan Stari Chairman of Infection Control Commitee ] Dr. Mhma Salah Quality Improvement Diretor Or. Me cla Mr. Reda Al-Ali Chief Executive Officer aan ——— ([ Date proved fay 2015 | Revon Daves ay, 2017] WAN-PCI-2 PapeaarsPrevention & Control of Infection HAHLPCLOM | Title: Prevention and Control of Infection Orientation and Education Program DPP | Arriiest:_ aN Mospta Statt 1.0, Purpose: ILA. To inform all hospitél personnel of relevant Prevention and Control of Infection policies and procedures, 12. To promote commurizaton between Prevention and Control of Infection personel and other hospital employees. 2.0. Definitions: Di. Infection Control o-ientation is 2 program designed to provide all newly hired employees with the general overview of the Prevention and Control of Infection Program. 2.3, In-service Continuing Education isan activity that promotes and supports all hospital staff in ‘maintaining Prevention and Control of Infection awareness. 3.0, Policies: ‘All newly hired employees shall receive infection and control orientation within the fest wo ‘weeks of arrival 32. Allemployees shal attend an annual infection control in-service education, 4.0. Responsibilities: 41, Prevention and Control of Infection Unit shall notify the department head of thei stat schedule for the orientation and / or in-service education. 42. All department heads shall be responsible in sending oF mandating thet respecte staff to attend snfeeibn contol orientation and in-service education as scheduled by the Prevention and Control of Infection Unit. 43. Prevention and Control of Infection Supervisor shall compute / tabulate each departments are funoe sate and shall give feedback to the Prevention and Contrl of Infection Commits 5.0, Reference: None 6.0. Attachments: None [ii pp 2005 maT TARTS i Peta 1PIE] Prevention & Control of Infection | Hanrc.o BI romeo sn con ann Onn in Fern | DPP | rots Signatory box Prepared by: Ms. Maria Cecilia Becalas Infection Control Supervisor Approved by: Dr. Hussien Hassan Satari Chairman of Infection Control Committee Dr. Mhmd Salah Quality Improvement Director ‘Mr, Reda AAI Chief Executive Officer aa = (ie pene ay Ts Revision Da 77 HARRCTDE PagetPrevention & Control of Infection HAH-PCLOS x! Respiratory Hygiene and Cough Etiquette DPP | Appicsto: AN Héspuai Set 1.0. Purpose: LA. To prevent the transmission of respiratory infection within Hussein Al Ali Hospital 2.0. Definitions: 2.1, Respiratory Hygiene / Cough Etiquette 2d. This is an element of Standard Precautions that highlights the need for prompt implementation of infection prevention measures at the first point of encounter with the facility / arxbulatory settings (e.g. reception and triage arcas) 2.1.1.2. This strategy is targeted primarily at patients and accompanying family members or friends with undiagnosed transmissible respiratory infections, and applies to any person ith signs of illness including cough, congestion, rhinorthea, or increased production of respiratory secretions when entering the facility. 3.0 Statement: 3a. Its the policy of Hussein AI-Ali Hospital that staf shall be aware of what constitutes the need for Respiratory Hygiene and Cough Etiquette, 32. Infection preventior and control measures should be implemented at the first point of contact with a potentially inctetious person within Hussein Al-Ali Hospital 4.0. Procedure: 4.1, Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection (including hospital staff), beginning at a point of entry to the facility and continuing throughout the duration of the visit: 4.1.1, Post signs ‘at entrances with instructions to patients with symptoms of respiratory infection to: 4.1.1.1. Cover the mouth and nose with a tissue when coughing or sneezing. If there is no tissue, cough or sneeze into your upper sleeve or elbow, not your hands. Dispose the used tissue in the nearest no-touch waste receptacles. Perform hand hygiene after hands have been in contact with respiratory secretions, 4.1.2. Masking and separation of persons with respiratory symptoms 41.24, Offer regular (surgical) masks to persons who are coughing. Regular (Giurgical) masks may be used to contain respiratory secretions. NOS masks are not necessary for this purpose. 4.1.2.2, When space and chair availability permit, encourage coughing persons to sit st least | meter away from others in common waiting areas. 4.2. Hand Hygiene Suppiies and other materials 42.1, Ensure that supplies for hand hygiene are adequately and consistently available (e.g, antiseptic soap, alcohol hand rub gel and disposable paper towel). Dave Approved 205 | __Revbion Dave, 2007 HARPS Lee). | copyPrevention & Control of infection —_| wars Title: Respiratory Hygiene and Cough Etiquette DPP | Applies to: All Hospital Start 42.2. Ensure the availability of materiis for adhering to Respiratory Hygiene / Cough Eriquette in waiting areas for patients and visitors. 42.3, Ensure availability of Alcohol hand rub gel on reception counter for client's use, nurse's station, doctor's lounge and offices. 4.3. Droplet precautions 43.1. Healtheare personnel are advised to observe Droplet precautions, in addition to Standard Precautions, when examining # patient with symptoms of a respiratory infection, particularly if fever is present. 43.2, These precautions shall be maintained until it is determined that the cause of symptoms is not an infectious agent that requires Transmission Based Isolation Precautions. 44. Educate Health Care Workers on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of acute respiratory illness / infection + 5.0. Attachments: 5.1, Attachment A — Cover your Cough Poster (English) 5.2, Attachment B- Cover you Cough Poster (Arabic) 6.0, References: | 6b. Centers for Disease Control and Prevention (CDC), Guide for Infection Prevention for outpatient settings; Minimum Expectations for Safe Care 62. Infection prevention & control and management guidelines for patients with MERS-CoV infection, 2nd edition, December 2014 : Scientific Advisory Council Ministry of Health, Saudi Arabia , [oor (ae prea a5 [en ae ag 2 HANPCAS I Pete)EN Prevention & Control of Infection | nanrcrs | BAM = espsors Henna Const riguate DPP | Avotis 0: an Hospitat att Prepared by: MSs. Maria Cecilia Becalas Approved by: Dr. Hussien Hassan Satari Ms, Somaya Lutfy Dr. Ahmed Barakat Signatory box Infection Control Supervisor Chairman of Infection Control Committee ‘Nursing Director Medical Director Dr. Mimd Salah Quality Improvement Director Mr. Reda Al-Ali Chief Executive Officer (Tiere ao Revonah 3007 Taw PCT I Pes ]Prevention & Control of Infection HAH-PCL-06 xX ‘Transfer Procedure of patient with confirmed MERS-CoV infection DPP | Applies to: All Hospital Staff 1.0. Purpose: LL. To establish generel guidelines and standard transfer procedure from our facility to indicated MERS-CoV Center (Inter-facility transfer), 2.0. Definitions: 2.1, Inter-facility Transfer shall mean the transfer of a patient from hospital inpatient area or other hospital area to another hospital I 3.0.Policy Statement: 3.1, Hussein AL-Ali Hospital adheres to Ministry of Health requirements in the implementation of transfer procedure of patient with confirmed MERS-CoV infection to indicated MERS-CoV Cemter. 3.2. Infection prevention and control measures should be implemented from the preparation to the actual Inter-facility ransfer of patient with confirmed MERS-CoV patient, 4.0.Procedure: 4.1. General Transfer Procedure: 4.1.1. Call MOH hotline “937” to report any confirmed MERS-CoV patient or to arrange for | transfer of the patient to a MERS-designated center like King Fahad Hospital. 4.1.2, Inform the-“Patient Referral Department” of King Fahtad Hospital through extension number 1644 for the transfer of a patient with confirmed MERS-CoV patient. | 4.13, Send a medical report in details with laboratory tests results and a copy of patient's | governmen: ID to Fax No: 5755150. Ensure that all these documents are received by “Patient's Referral Department” 4.14, After receiving the approval for patient transfer to King Fahad Hospital, send a copy of approval to “Crisis and Emergency Management” to provide us a well-equipped ambulance fo be used in transferring patient from our facility to King Fahad Hospital. 4.1.5. Prepare the patient's transfer to indicated MERS-CoV patient: 4.1.5.1, Patient should wear a surgical mask to contain secretions. 4.15.2. Use routes of transport that minimize exposures of staff, other patients, and vssitors | 4.1.6. Ensure that healtheare workers (HCW’s) who are transporting patient wear appropriate | PPE and perform hand hygiene afterwards, |. Attachments: None 6.0. References: 6.1, Infection prevention & control and management guidelines for patients with MERS CoV infection, 2% edition, December 2014 : Scientific Advisory Couneil Ministry of Health, Saudi Arabia Te Approved fay 015 [Rev Dao 9007 AREF ee ] copy |Prevention & Control of Infection HAH-PCI-06 Title: ‘Transfer Procedure of patient with confirmed MERS-CoV infection Applies to: All Hospital Staff Signatory box Prepared Ms, Maria Cecilia Becalas Infection Control Supervisor | Approved by: Dr. Hussien Hassan Satari Chairman of Infection Control Committee Dr, Mhmd Salah Quality Improvement Director Mr, Reda AL-Ali Chief Executive Officer ‘Hevaon Dario TPC I Dae Approve 1a 205 | copy |Oe Prevention & Control of Infection HAH-PCLO7 ae. Infection Control Rsk Assessment (ICRA) DPP | Applies to: all Hospital Areas, 4.6.6, Track the identified risk into risk register 4.6.7. Present the priorities to Infe approval, 4.7. Use the Priorities to Develop the IPC program goals, objectives, and activities 4.7.1, IPC department base its annual program on priorities identified in annual risk assessment 4.7.2, Develop goals for each selected priority 4.7.3. Create action plan and evaluation process 4.8. Disseminate the information Nn control committee and leadership for support and 4.8.2. Discuss the risk assessment importance and share results 4.8.2. Develop concise, clear report with key points highlighted 4.8.3. Acknowledge those who participate in the process. 4.9. Monitoring and Follow ups 4.9.1, Progress with HCAI risk assessment and any action plans developed from these will be ‘monitored by the infection Prevention and Control Committee. 4.9.2, Any high risk practices which cannot adequately be managed should be reported for ‘consideration by the Prevention and Control of infection (PC!) Committee. 4.9.3, If risk cannot be minimized, they should be recorded in the risk register. 4.9.4. Risk assessments completion will be monitored as part of the Infection Control performance monitoring, 4.10. Responsibilities 4.10.1, Chief Executive Officer 4.10. + Overall responsibilty for ensuring infection prevention and control is @ core Part of the Hussein Al-Ali Hospital governance and patient safety program 4.10.2. Infection Prevention and Control Committee Members 4.20. Has collective responsibility for ensuring assurance that appropriate and effective policies are in place to minimize the risks of health care associated infections. 4.10.3. Infection Prevention and Control practitioner 4.10.3.1, To oversee the development and implementation of infection prevention and control policies and guidance. To provide training in HCAI risk assessment and to lead risk assessment team and any action plans occurring from these are monitored through the Infection Prevention and Control (IPC) Committee. 4.10. Seep TOS | Rea DT] cna I as 1Prevention & Control of Infection HAH-PCI-07 Title: Infection Control Risk Assessment (ICRA) Applies to: All Hospital Areas 5.0. Attachments: 5.1, ICRA tool References: 6.4. Infection Contro! Risk Assessment API 2011 4.10.4. Department Heads 4-10.4.1. Are responsible for ensuring that all infection risk activities of their areas are Included in their risk register and that appropriate risk assessments for HCAI's are completed and reviewed annually or earlier if there are changes to a service or premise. 4.205, All Staff 4.10.5.1, Has the responsibilty to Identify and report to the department heads for any unidentified HAI hazards or practices for risk assessment and management. SaaS ATS | aon be aT] Taos I Partote 7Prevention & Control of Infection HAH-PCI-O7 Title: Infection Control Risk Assessment (ICRA) Ms. Somaya Lutfy Or. Ahmed Barakat Dr. Mhmd Salah Mr. Reda AL-All Applies to: All Hospital Areas Prepared by: tN Ms. Maria Cecilia Becalas Infection Control Supervisor Approved by: Ms: Sumayn Nursing Dir Nu0002! Nursing Director Medical Director Quality improvement Director Chief Executive Officer (TC itiopent a a [ein oe a7 aaPrevention & Control of Infection U: Infection Control Risk Assessment Tool acevo | RR AT sears eae omer appered — 1 ae erewiatontonddes visi | pany Bel ori) Teepe any A —e EE ‘ee resi orp oer Ga er wsemnrn eran icin rer calern ae pe dang ain oper Pept erect rw fee Tena cee teen ae isco Snape somone all oer hed pen Cngin Suntraresire iain Too nee ning ean Save ein ei Wa f==[s a = =] Enron one ef soe a etn ae oC an A = 4 evan re = — Sorel ear] [ rsp oa crac = le i in sane ain aiseset A ee Prevention & Control of Infection Unit Taree | Pony ao Seca Feseatnn se car omnes crvnintontoatetrit | ary aa eg Me aw [te pean maaan foe [ Pow] ar | eo || wiolala| wma! a | ay) | wo | wr Race sting a Cerne Cassone nee | eter eas z - sr ofa ei ToS z z — iz I Time aston ru deer ene ina dpe omnia ee ee Elston naw a Par ao aa) = fr seb & telomere ‘iy ple eee dela | esa ad a ape rae wedi aso Note: Each ris factor is rated as follows: ‘+ Probability the risk will occur ‘+ Potential Severity tthe risk occurs ‘+ Preparedness ofthe organization to address this risk 12 Risk level cleuaton is compiled by multiplying the scores foreach event. 13. Factors scoring 10 or more point re linked to @ GOAL end FOCUS in the PCI annual program.Prevention & Control of Infection HAH-PCI-08 Title: Management of Sharps and Needle Stick Injuries aa 12, 13. 14, 1s. 16. 24. Ba. 32. 33. 35. 36. 37. 38, 39. 3.10. CC .0. Purpose: 2.0, Definitions: 3.0. Policy Statement: Applies to: All Hospital Staff To establish the protocol for prompt reporting, evaluation, counseling treatment follow up of hospital staff with sharps needle stick injuries. To minimize the incidence of accidental injury occurring with needle stick/sharps, which might result in acquired infection. To introduce precautions on the handling and safe disposal of sharps, To ensure accurate reporting and management of incidents involving needle stick/sharps injury 45 they occur, whilst preserving confidentially of all persons concerned, To increase the awareness of all staff with regard to sharps and sharps injury, thus effect satisfactory codes of practice. Dispel unrealistic apprehension during performance of duties involving; 1.6.1, Patients known to be infected with HBsAg, HIV, or others, 1.6.2, Use and disposal of sharps, 1.6.3. Contact with all patients’ blood/blood products and body fluids. Sharp is anything which can puncture skin and may be contaminated with blood or other body fluid, This include sharp bone and glass as well as the more familiar category of hygodermic needles, sutures needles and blades. Sharp injuries include puncture or piercing of all kinds of sharp objects and not simply needles. Never recap needles after use. Recapping of needles Is one of the commonest causes of needle stick / sharps injury, Gloves must be worn when performing a procedure involves using of sharps or there is risk of contamination from blood or other body fluids. Hands and exposed skin surfaces should be thoroughly washed prior to putting on gloves and immediately after treatment. Breaking glass ampoules by hand must be avoided, using gloves and / or gauze swab and an ampoule is preferable. Sharps should not be passed from hand to hand (sheathed or unsheathed) Staff should ask for assistance when taking blood / blood sampling, or giving injections or Intravenous therapy, to “uncooperative” patients. Maneuver which bring the hand close to the needlepoint must be avoided. Sharps must not be left on worktops or other clinical surfaces, Following procedure, clear all equipment away immediately, Carrying sharps by hand (sheathed or unsheathed) must be avoided, Utilize injection trays, ‘dressing trolley when transporting equipment to and from the patient bedside. [eestesont ten /ini pete penn 26 [ne rr]iS Prevention & Control of Infect n DPP |Appliesto: all Hospital staff 3.41. Sharp containers should be kept in STRATEGIC LOCATIONS which maximize ease of disposal ‘and maintain safety to patients, visitors and staff. 3.12. Sharp containers must be closed properly and when % full must be disposed of safely. 3.13. Sharps must not be mixed with other waste. 3.14, Sharp container must be carried away from the body. 3.45, Ensure sealed containers only are placed in plastic waste bags which in turn are removed by domestic staff to a collection point for incineration, 3.16. Any staff not using and disposing of sharps according to policy must be reprimanded and counseled. 4.0. Procedure: 4.1, At the time of injury, consider all sharps to be potentially contaminated. The following must be followed in the event of sharps injury: 4.1.1. Immediate action: 4.111. Remove the sharp 4.1.1.2. Wash under running water 4.1.1.3. If mucous membrane and / or eyes are contaminated by splashes of body fluids, including blood, wash immediately and thoroughly with normal saline. 4.1.2, Report the incident to the nurse in-charge and inform the nursing supervisor immediately. 4.1.3. An incident report must be filled up and blood and body fluid exposure report must be completed. 4.1.4. The blood and body fluld exposure must be taken to the staff health physician / PCI Supervisor. 4.1.5. A Copy of the BBFE report must be kept in the employee health file by the employee health nurse and a copy should be sent to infection control supervisor. 4.1.6, The treating doctor of the source should be informed so that the injured staff can be screened for H8SAG, HIV, HCV Ab, HBs AB, and HBC Ab total 4.2. Responsibilities: 424, Itisa personal responsi of the staff using a sharp to dispose it safely. 4.2.2. The nurse in-charge of the area or unit will: 4.2.2.1. Ensure adequate supplies of all appropriate equipment and materials area available, 42.2.2. Ensure sharp containers are provided in sufficient numbers and located close to site of use, Danone aa Tien baw pT Taree Taetare| Prevention & Control of Infection HAH-PCl-08 & Title: ‘Management of Sharps and Needle Stick Injuries DPP |apaliesto: all Hospital staf 42.2.3, Ensure sharp containers does not constitute a hazard either by: over fill of containers or location near to uncooperative / disturbed patients and to children and visitors. 42.2.4. All Nursing staff are responsible for maintaining confidentiality with respect to individual's medical record when accidental sharps injury occurs. 42.2.5. Ensure staff members take appropriate action when injury occurs and that documentation is complete, and that all copies of the Incident Form supplemented by Blood and Body Fluids Exposure Report, are readable, 5.0, Attachment: 5.1. Blood and Body Fluid exposure form 6.0. References: 6.1. APIC 6.2. CDC i]Prevention & Control of Infection HAH-PCI-08 ee areolar DPP | Apoiies to: All Hospital Staff Signatory box Prepared by: a} Ms, Mara CeciiaBecalas Infection Control Supervisor NI Approved by: Dr Hussien Hassan Sateri Chairman of Infection Control Committee Ms. Somaya Lutfy Nursing Director Dr. Ahmed Barakat Medical Director” Dr. Mhmd Salah Quality Improvement Director Au Mr. Reda Al-Al Chief Executive Oficer [ar | J EE — ETPrevention & Control of Infection HAH-PCL-O8 Title: Health Care Associated infection Surveillance System ‘Applies to: All Hospital Areas [Ave 1.0. Purpose: LL, To establish endemic (HAI) baseline infection rates in order to facilitate the identification of epidemic episodes and assessment of special study needs, intervention measures and policy decisions. 1.2, To reduce the risk of HAI and to provide patients and personnel with optimum protection from the development of HA 1.3, To evaluate the effectiveness of control measures. 1.4. To inform Hussein Al-All Hospital staff about potential risks n the given patient population 2.0. Definitions: 2.4, Surveillance System is the collection, tabulation, and dissemination of data on the occurrence of HAI or the purpose of preventing and controlling them, 2.2. Hospital - wide Surveillance is the collection of data on all sites of HAI for all patients. 2.3. Nosocomial infection is a term that is derived from two Greek words “nosos” (disease) and “komeion” (to take care of). The term nosocomial infection is synonymous with healthcare — associated infection. Healthcare-associated Infection (HAl) is an infection that develops in a patient who is cared for in ‘any setting where healthcare is delivered (e.g. acute care hospital, chronic care facility, ambulatory clinic, dialysis center, surgicenter, home) and is related to receiving health care. e. was not incubating or present at the time healthcare was provided). 2.4.1. In ambulatory and home settings, HAl would apply to any infection that is associated with medical or surgical intervention. Since the geographic location of infection acquisition is often uncertain, the preferred term is considered to be healthcare-associated rather than healthcare- acquired, 24, 3.0. Policy Statement: 3.1. Prevention and Control of infection staff conducting surveillance shall be trained through the Use of written competency based educational program for formal training program or both, 34& Prevention end Cunt uf infectivn steff conducting survelllance shall adhere to survetliance definitions. 3.3: All completed surveillance forms shall be validated to ensure that HAI definitions are being accurately applied. 3.4, HAI surveillance reports shall be reported to Hussein Al-Ali Hospital staff through: 3.4.1, Infection Control monthly report on the PCI Committee 3.4.2, Surveillance of methicillin resistant staphylococcus aureus 3.4.3. Surveillance of vancomycin resistant enterococci 4.0. Procedures: 4.1, Prevention and Control of infection Committee shall: few and approve ti [en ne Seeman? coc) I PariPrevention & Control of Infection HAH-PC-O8 Title Health Care Associated infection Surveillance System Applies to: All Hospital Areas 4.1.2. Review surveillance results, problems and corrective actions presented by the Prevention and Control of infection Practitioners, 4.1.3. Review control measures or studies as necessary and make recommendations for ‘modifying measures undertaken, 4.1.4. Disseminate results of surveillance activities presented by Prevention and Control of Infection and communicate with the services they present. 4.2. Chairman, Prevention and Control of Infection Committee shall: 4.2.4, Serve asa consultant for surveillance and interventional activities. 4.2.2, Coordinate the activities of the Prevention and Control of infection Committee, 2.3, Report Prevention and Control of Infection Committee activities to the Medical Staff Executive Committee as required by that committee. Prevention and Control of Infection unit shall: BA. Carry outa ities designed to detect, monitor, and control HA 43.2. Collect infection surveillance data using the HAl Surveillance Form and Notification of Communicable Disease Form. 4.3.3, Calculate infection rates using surveillance data collected by the Prevention and Control of Infection Unit (for the numerator) and the admission /hospltal day/device day data provided by Department Heads. 4.3.4. Compile the data in monthly HAI control reports, Present a summary of HA surveillance reports to the PCI Committee. 4.3.6. Analyze trends and patterns in the data collected on HAl. 4.3.7. Compile data relative to antibiotic use as part of surveillance and chart review, 4.3.8. Collect data on blood and body fluid exposures; compile i quarterly to disseminate the information. 4.3.9. Collect data on surgical site infections, compile it in a report and distribute to all relevant persons and to PCI Committee members, 4.3.10. Monitor patient admissions and placement to ensure optimum control of infection through appropriate placement. 4.3.11. Investigate all potentially significant episodes of infection. 4.3.12, Implement surveillance for reportable communicable and occupational diseases among in-patients and Hussein Al-Ali Hospital personnel. initiate Notification of Communicable Disease Form. ‘@ monthly report and 4.3.13, Design, Implement and evaluate special studies and interventions carried out to control HAL, 4.3.14. Coordinate in-service education efforts for Hussein Al-All Hospital personnel on infection risks as well as their specific role in the Prevention and Control of infection surveillance syster EEE nn ae (sre rete is | rn se aT —T eaPrevention & Control of Infection HAH-PCI-08 Title: Health Care Associated infection Surveillance System Appliesto: All Hospital Areas 4a, 4s. 46. 47. aa. 43.15. Evaluate, annually, both the type and the effectiveness of surveillance activities and revise them as necessary: 4.3.15.1. Consider data trend analyses generated by the surveillance activities for the past year. 4.3.15.2. Consider new services, procedures, priorities and problems identified. 43.16. Establish the list of reportable conditions and reportable laboratory tests. Clinicians and Nurses shall: 44.4, 4.85, 4as. Be aware of the mechanism for infection surveillance. Report suspected or actual infections to Prevention and Control of Infection. Provide information on suspected or actual HA. Submit Notification of Communicable Disease Form on any patient with a reportable communicable disease, Assist in the surveillance of infections among Hussein Al-All Hospital employees. Implement recommendations made by Prevention and Control of Infection Unit for the control of HAI. Laboratory Department shall: 45.1. 45.2. 45.3. 454, Report daily laboratory results as established in the list of reportable laboratory tests. Notify the attending clinician and infection Control practitioner of any highly infectious pathogens, multiple drug-resistant organisms or clusters of unusual infections, Provide laboratory support during outbreak surveys. Notify the Prevention and Control of infection Practitioner of any change in procedures affecting surveillance. Prevention and Control of Infection Unit shall provide microbiologic sampling of Hussein Al-Alt Hospital environment, as necessary, during outbreak surveys. Department Heads shall provide data used as denominators in the calculation of HAI rates: ‘number of hospital days. Surv 43.1. lance System Collection of data: 4.8.1.1. Data to be collected includes 48.11.41. Demographic: age, sex, diagnosis, location, history, ete. 4.8.1.1.2, Interventional: antimicrobials, intubation, cannulation, etc, Surgical procedures: type, classification, date, etc, ase outcome: infected, expired, and discharged. 4.8.1.1.5. Information about clinical infection: onset, type, signs, symptoms, etc. 4.8.4.1.6. Laboratory data: cultures, antibiotic sensitivities, ete. ([oneteeroet tens a8 — | Anum bts tree OTT mae I Peale ]oi Prevention & Control of Infection HAH-PCI-09 Title: Health Care Associated Infection Surveillance System DPP |Appiiesto: all Hospital Areas 4.13, 4.8.1.4, 48.15. 48.16, 48.1.7. Risk factors: host-specific, diabetes, underlying disease. Risks related to therapy procedures, IV lines, indwelling catheters and ventilator use 4.8.1-1.8, Denominator data: hospital admission, number of hospital days, number of days of device use. Data is collected by: 4.8.1.2.1, The Prevention and Control of infection Supervisor 4.8.1.2.2, Department Heads 48.1.2.3. In-patient nursing staff Frequency of collection is dally whilst the patient Is still in the hospital followed by active surveillance during the post-discharged period, Scope of collection is Hussein AL-Ali Hospital wide, Form for data collection include: 4.8.1.5.1. HAI Surveillance Form 4.8.1.5.2. Notification of Communicable Diseases Form Sources of data collection include: 4.8.1. Microbiology culture results ~ correlated with chart review. Admitting records ~ Rounds made by the Prevention and Control of Infection Supervisor may include: iagnosis, admission date, ete 4.8.1.6.3.1. Temperature records 4,8.1.6.3.2, Patient care plans Observation of patient Chart review {Information consultation with nursing staff 4.8.1.6.3.6, X-ray reports 4.8.1.6.4. Reports by clinicians and nurses 4.8.1.6.5. Computerized data programs 48.1.6.6. Antibiotic Surveillance 4,8.1.6.7. Environmental Surveys 4,8:1.6.8. Post-discharge follow-up 4.8.1.6.9. Quality Review Reports Methods for Surveillance of SI: 4.8.1.7.1. Microbiology culture results ~ correlated with chart review. 4.8.1.7.2. Reports by clinicians and nurses to the PCI unit aad a 37 [fasion nico TT ae I rea 1Prevention & Control of Infection HAH-PCL-09 Title: Health Care Associated Infection Surveillance System Applies to: All Hospital Areas 48.3. . Population at risk (denominator data) 4.8.1.7.3, Active Surveillance through rounds & chart review of post op patients, 48.1.7.4. Phone call to discharged post-op patients 3 to 5 days after discharged. 4.8.2.1. Total number of hospital days per month is used as the denominator to determine the HAl rate, 4.8.2.2, Device days per month to determine the ICU device associated infection rates 4.8.2.3. Patients undergoing operative procedures. Evaluation of Data 4.8.3.1. Purpose: 4.83.11, To search for clusters of unusual infections. 4.8.3.1.2, To detect unusual trends ~ deviations from the baseline. 1.3. To detect cross.infection, 4.8.3.1.4, To Initiate interventions to prevent and control infections. 4.83.15. To provide information on which to base & evaluate preventive measures. 4.8.3.2. Tabulate and consolidate data to assess infection by: 48.3.2.1. Pathogen 483.22. Type 483.23. Service 48.3.2.4. Ward / Unit 4.8.3.3. Frequency of Evaluation 4.8.3.3.1, Continuous review of data as collected by Prevention and Control of Infection Practitioner to search for clusters of unusual infections and new trends, 4.8.3, Monthly review of data by Prevention and Control of infection Practitionerto evaluate the trend during a specific period. 13.3. Review of monthly reports at the Prevention and Control of Infection Committee Meeting held at least 10 times per year or as necessary, Analysis and Interpretation of Data 4.8.4.1, Infection Rate Calculation: 4.8.4,1.4, The numerators are: 4.8.4.1.1.1. Number of outcomes, e.g., HAI 4.8.4.1.1.2. Number of individuals who hecome infected C Srvievond Geter] | tnt ove Hpenoe ST fo) raePrevention & Control of Infection | HaH-Pco9 ris __Weath care scat necon Suva yam DPP |Appliesto: All Hospital Areas 4.8.4.1.2. The denominators are: 48.4.1.2.1. Number of patient admitted Number of hospital days Number of device days: e.g, ventilator days 4.8.5. Preparation and Dissemination of Data 4.8.5.1. The following reports are prepared on a monthly basis: 485.14. summary of: 4.85.1.1.1, Infection rate / 1000 hospital days 4.8,5.1.1.2. Distribution of HAI by ward and orgenism 4.8.5.1.2. Surgical site infections 4.8.5.1.2.1. Overall surgical site infection rate 4.8.5.1.2.2 Distribution of surgical infections by class (clean, clean-contaminated, contaminated, dirty) by type (elective, emergent) by surgeon, by division (general surgery and obstetrics / gynecology), by procedure (ICD-9 oF 10 CM code) 4.8.5.1.2.3, Surgical site infection rates by service (orthopedic, ‘ob/eyne, surgery, ee.) Form Blood and Body Fluid Exposure Report Antimicrobial susceptibility reports (quarterly) Annual infection control report 4.8.5.2. Dissemination of data: 8.5.2.1. Patient confidentiality s maintained in all written reports 4.8.5.2.2, All reports are submitted to the Prevention and Control of Infection Committee, the Quality Improvement Director and to specific staff to inform them of their patient's infection risk. 4.8.5.2.3, Prevention and Control of Infection Committee members distribute information to the functional areas they represent. Clinician and nurse representatives on the Prevention and Control of Infection Committee report data to the service they represent following each PCI meeting. 4.8.5.2. 5.2.5. Data on communicable diseases reported among in-petients and Hussein Al-Ali Hospital personnel is distributed to the Ministry of Health by the Prevention and Control of Infection Unit when requested, (Cans Tae I corn a]Prevention & Control of Infection | Han-pctoe Title: Health Care Associated infection Surveillance System Applies to: All Hospital Areas 4.8.5.3. Special Studies: 4.8.5.3.1, Requested by the Prevention and Control of Infection Committee. 48.5.3.2. Proposed by professional staff. 5.0. Attachment: 5.1, Attachment A -HAI Surveillance Form 5.2. SSI Post Discharge Form 6.0. References: 6.1. Guide to the Elimination of Ventilator-Associated Pneumoni: ni lon ct jance/APICEliminationGuides/VAP( 6.2. Guide to the Elimination of Catheter-Associated Urinary Tract infections (CAUTIs) 6.3, Guide to the Elimination of Catheter-Related Bloodstream Infections 64, Getting Started kit: Prevent Catheter-Associated Urinary Tract Infections; IHl.org. Central Line- Associated Bloodstream Infection (CLABSI) Event. http://www.ede.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf 6.5. Ventilator-Associated Pneumonia (VAP), http://www.cde. gov/nhsn/PDFs/pscManual/6pscVAPcurrent pdf Catheter-Associated Urinary Tract Infection (CAUTI, httpi//www.cde.gov/nhsn/péts/pscManual/7pseCAUTIcurrent.pdf COC/NHSN Surveillance Definition of Healtheare-Associated Infection and Criteria for Specific ‘Types of Infections in the Acute Care Setting http://mww.ede.gov/nhsn/PDFs/pscManual/17pscNosinfOef_current.pdt 6.8. Guideline for prevention of catheter-associated urinary tract infections 2009; edc.org. 66, 67. (tae ewe Speirs | ne Senter TaTT—] mae mare_,——_ Go Prevention & Control of Infection HAH-PCI-08 Title: Health Care Associated Infection Surveillance System DPP |Appliesto: all Hospital areas ‘Signatory box Prepared by: Mss. Maria Cecilia Becalas Infection Control Supervisor ‘Approved by: Dr, Hussien Hassan Satari Chairman of infection Control Committee Dr. Mhmd Salah Quality Improvement Director Brearley Quailty Mr. Reda AL-Ali Chief Executive Oficer eae i ‘aon Seunbei6) | Ron te eater TTT rrr rena 1— Month ofthe Survey, Patient name MR ge Floor / unit «Birth weight erams, ony atentie man Transfer ‘Admission Date. Discharge Date: Previous admission Date/ Cause: Intrnsle isk Factors ‘Community Acquired infections ‘immune disease ‘leukemia Evidence of infection prior to admission Trauma lymphoma BNo aObserved Yes, Speci, alos ouW Referred from another hospital: _GYes__GNO oan BDiabetes [Healthcare Assoclated infections by CDC Criteria ‘steroids (> 2 weeks) [Generale Local symptoms: GRedness —Qchils GAash Pam 2 Trmeptant / meenoruppreseant Local signs of infection: caSwelling «Fever Heat Pus ‘Neutropenia (PMN < 1000/mm') Radiol cal evidence ofinfection: give ove N/A ‘rttnsle Risk Factors: Devices | Device Days | [Laborstory: GHishWBC__GMighCRP___GPyurla_GGram staln nate te) ‘aura ‘Major sited, Specific Infection Site Coc Criterion (1 2 3.4 5) ‘Culture (postvest; negative=2; not dones3; other test=4) Central VE Data of onset, ‘a Mechanical ventilation Microorganism 3 Resistance, Microorganism 2, Resistance... re lal Pacnor Picadas Microorganism 3 Resistance, ‘GPeripheral ve G.Urinary condom Glumbar puncture Dialysis Major SR a Specific Infection Site Tracheostomy QT. Tube Date of onset = cocerterion (1 2 3 4 5) endoszopy ‘Rye tube Culture (positives; negativen2; not done=3; other tests) Chest tube ‘a Draining Tube Microorganism... Resistance, D8iopsy are Microorganism 2, i Resistance, Microorganism 3. Resistance, Surgical Procedure: code according to NHSN = ‘Mar site, = ‘Specific Infection Ste, eRe! “paaas) Date of onset, ‘coc criterion (1 2 3 4 5) Duration in minutes Culture (postive=1; negative=2; nt donee3; other test=4) Wound Css Microorganism 3 Resistance 7 Laparoscopy ~”GNat used Microorganism 2. Resistance, Alskindex category nanutM 02 2 3) Microorganism 3. Resistance, Main Digna “Antimlerobial therapy “Antimicrobial 2. indication) Antimicrobial 2 nlnication( } Antimicrobial 3. Indication () Antler 4. Indication () Indleation: write 1 fit isa speci indication, 2 fit isan empiric, 3if Risa surgical prophylans indication and 4 its other prophylais Fa FORESOs pale Prevention & Control of Infection Unit Data Collection for Post Discharge Surveillance for SSI Patlent Names, ‘of OPO vis J, —— Date of Operation in HAH Operation Done: DAppendectomy ‘Laparoscopic Cholecystectomy GHerniorrhaphy LS. Cesarean section Ture other, Specty Examination of patients! wounds dung follow-up vis oe: m7 No Yes, specty: Superficial ss a Deep ss ‘Organ/ space ssi + Saecific antibiotic treatment: Specity, ‘The Si request for Readmission: Name of notifying person: Signature: Signature: Signature: Note: Upon completion ofthis form, plese forward to Prevention and Cantal for infection Unt Tae romIOoPrevention & Control of Infection HAH-PCI-10 Title: Blood and Body Fluid Exposure (BBFE) ‘Applies to: All Hospital Employees a. 3a. 32. 1.0. Purpose: 12, To minimize the harmful effect of blood borne pathogens i.e. all organism transmitted by direct or indirect contact with infectious blood or body fluids ie. HIV, HBV, HCV which may found apart of entry to any staff. 2.0. Definitions: 2.1. Attending Physician: Any Physician providing medical care to the source patient. 2.2. _ Blood Borne Pathogens: All organisms transmitted by direct or indirect contact with infectious blood or body fluids e.g. HIV, Hepatitis 8 and Hepatitis C, syphilis, malaria and other diseases, 2.3. Exposure Incidents: Contact or injury, eg. puncture wound to any part of the body including the eye and a splash contact to the eye, contact with blood or other potentially infectious materials that resulted from the performance of the employee's job. 2.4, Infectious Materials: Human blood, blood products, or blood components, saliva in dental Procedures; semen; vaginal secretions; cerebrospinal, synovial, pleural, pericardial, peritoneal and amniotic fluids visibly contaminated with blood; unfixed human tissues or organs; HIV- Containing cell tissue cultures; and HIV-HBV- , or HCV-containing culture mediums or other solutions. 2.5. _ Blood and Body Fluid Exposure Panels: Laboratory tests required by Hussein Al-Ali Hospital to screen following an exposure incident. 2.6, Hussein Al-Ali Hospital Employees: Those who work in Hussein Al-Ali Hospital 2.7. Standard Precautions: An approach to controlling infections and exposure to blood and body fluid, as if they are infected with disease causing organisms, by the use of hand washing and personal protective equipment. 2.8, Supervisors: Are supervisory personnel at all levels (e.g. Department Head, unit supervisors, etc,). Department heads may delegate individuals within their departments to assume the responsibilities of supervisors described in this policy. 2.9, Treating Physician : For the purpose of this Policy, the treating physician is one of the 3.0. Policy Statement: = To establish the protocol for prompt reporting, evaluation, counseling, treatment and follow up of Hussein Al-Ali Hospital employees exposed to blood and body fluids. This is a collaborative effort that includes Employee Health Clinic, Emergency Room Department, ICU Unit, and PCI Committee, following: 2.9.4, The employee health clinic physician or the designated physician during regular working hours. 2.9.2, Emergency Room Physician outside regular working hours. Standard precautions: will be followed at all times when providing patient care, Confidentiality of both parties (exposed employee and source) is essential. apd Aas | aon De TT ree Rails ]Prevention & Control of Infection HAH-PCI-10 Tite: Blood and Body Fluid Exposure (BBFE) DPP |Appliesto: all Hospital Employees Immediate assessment after exposure. When evaluating an exposure incident, immediate assessment should include first aid measures to limit the time of exposure to the recipient (i.e. cleansing of a puncture wound, rinsing of the eyes, etc.) and prompt essessment of the source patient. 3.4. Hussein Al-Ali Hospital employees shall immediately report all blood and body fluid exposures to their Supervisor / Unit in-charge and complete all necessary forms. 4.0. Procedures: 4.1, Forms used for reporting: 4.4.1. Attachment A - Blood and Body Fluid Exposure Report is initiated at the time of Injury. 4.1.2, The Supervisor / Unit in-charge must complete the investigation and needed information in the form before submitting to Employee Health Clinic with the ‘employ 42. The employee (with the completed Blood and Body Fluid Exposure Report) will report to: 4.2.1. The Employee Health Clinic Physician ~ during regular working hours. 4.2.2. Emergency Room Physician ~if the injury occurs after regular working hours, 43. Maintaining Confidentiality of Blood and Body Fluid Exposure Report 4, Blood and Body Fluid Exposure Report should be recorded by the Employee Health Clinic Nurse. Forms willbe filed in a designated Folder in Employee Health Clinic. Note: All forms shall be retained and maintained in Employee Health Clinic for the entire length of employment. PCI Unit staff shall visit the Employee Health Clinic or the Employee Health / ‘Attending Physician on a monthly basis and as required for the purpose of data collection, 4.8, Post-Exposure Prophylaxis (PEP) and Follow-up 4.4.1. PEP and follow-up should be provided at the time of the exposure. 4, When an injury occurs, Blood and Body Fluld Exposure Report is completed. 4.8.3, _ Staff should complete the series of follow-up appointments prior to being discharged from the Employee Health clinic (i.e. initial labs, 6 weeks, 3 months and 6 months) 45. General Responsibilities / Procedures 45.1. Hussein Al-All Hospital personnel shall 4.5.1.1. Report all blood and body fluid exposures to their Supervisors / Unit-in charge immediately. 4.5.1.2. Return for post-exposure follow up on the designated dates, Appointments should be made during the First Employee Health Clinic appointment for follow-up at 6 weeks, 3 months and 6 months. aioe haa 3S | tron ie nA —T. aa i PapaDPP | Applies a Prevention & Control of Infection | HAH-PCI-10 Title: Blood and Body Fluld Exposure (BBFE) 45.2. 453. 45.4, 45.5, All Hospital Employees Supervisors / Unit in-charge shall: 4.5.2.2. Report exposure incidents by ensuring initiation of Blood and Body Fluid Exposure Report and Occurrence Report. 45.2.2. Ensure that employees are familiar with the principles and practice of post- exposure management as @ part of job orientation and on-going services, 45.2.3. Investigate all exposure incidents in their areas and take the appropriate action, Treating Physician shall Note: This includes Emergency room Physicians who provide care for Hussein Al-Ali Hospital employees exposed to blood and body flulds after regular duty hours, and. refer the employee to Employee Health Clinic on the next working day, 45.3.1, Provide care for exposed Hussein Al-Ali Hospital personnel as described in the attachments to this Policy, and document this on Blood and Body Fluid Exposure Report, 45.3.2. Order HIV, Hepatitis B and Hepatitis C testing. if patient refuses, note it on Blood and Body fluid Exposure Report and report this to the Supervisor / Unit in-charge, and PCI Unit immediately. PCI Unit will follow up with the employee, their Supervisor / Unit Head / Chief Department. 4.5.3.3. Provide staff with counseling and with information about the source patient's blood, Attending Physician (if source is hospitalized) or Employee Health Physician (If the source is an out-patient) during regular working hours shall: 4.5.4.1. Provide initial care for Hussein Al-Ali Hospital personnel exposed to blood and body fluids. 4.5.4.2. Order laboratory test of the source patient (or on the mother if the source |s neonate) for HIV, Hepatitis B and C. Note: Laboratory test for known HIV, HBV or HCV source patients do not ‘need repeating. if refuses testing, note refusal on Blood and Body Fluid Exposure Report and report this to the Supervisor / Unit in-charge and PCI unit as soon as possible, 4.5.4.3, Refer the known source patient to the laboratory for STAT blood work 4.5.4.4, Inform patient of the test results Employee Health Clinic Nurse shi 4.5.5.1. Notify employee's supervisor by telephone and email (once only) if there Is ‘one missed scheduled appointment date. (Appointment dates are 6 weeks, 3 months, and 6 months post-exposure). The Employee Health Clinic Nurse are not required to make any further attempts at ensuring compliance as this will be carried out by PCI Unit. Dae heron tS [tester a —] raise I maa 1Prevention & Control of Infection HAH-PCI-10 Title: Blood and Body Fluld Exposure (BFE) Applies to: All Hospital Employees 45.6. 45.8. 5.0. Attachment: 5.1. Attachment A- Blood and Body Fluid Exposure Report Form Reference: 6.1, _ Occupational Safety and Health Administration (OSHA) Manual 2001 45.5.2, Notify PCI unit by telephone and email, when a follow-up appointment has been missed. PCI unit will then contact the employee and aim to ensure compliance of follow-up appointment. Operating Room (OR) Personnel shall, ifan injury to OR staff occurs during a surgical Procedure, obtzin a blood specimen from the source patient for HIV, HBV and HCV test. Prevention and Control of Infection (PCi) Unit shal 45.7.1. When notified of a missed appointment PCI unit will contact the employee and will arrange follow-up appointments when compliance Is an issue. 45.7.2. Follow-up with the appropriate Supervisor / Department Head when employee refuses consent for HIV hepatitis C ond B test. Inform Employee Health Clinic of outcome. 4.5.7.3. Keep records of BBFE form and do monthly report. Assist in the investigation of exposure incidents and initiates remedial action to reduce the chance of happening again. Provide pre-test counseling for source persons if requested. Monitor compliance with the protocol established in this Policy, Contact source patients who have left the facility prior to testing when an exposure has occurred and explain that an Incident has occurred and the Necessary actions to be taken, Discuss the possible transmission of blood borne pathogens from patients to healthcare workers during these types of accidents and reassure the Patient they are not being singled out. Laboratory Department shall: 45.8.1. Inform Employee Health Clinic / attending Physician immediately regarding the test results of exposed Hussein Al-Ali Hospital employees, 4.5.8.2. Inform the attending physician and the PC! unit of the source patient's test result 45. (Tit eet oat aa Poise be naa —T. as Tae 1Prevention & Control of Infection HAH-PCL-10 ie ceased SS DPP Applies to: All Hospital Employees Signatory box Prepared by: Ms. Maria Cecilia Becalas Infection Control Supervisor Approved by: Dr. Hussien Hassan Satari Chairman of Infection Control Committee Ms, Somaya Lutfy Nursing Director (wis. Se Secu sors Nurs 0002 Dr. Ahmed Barakat Medical Director _ Dr. Mhmd Salah Quality improvement Director Mr. Reda Al-Ali Chief Executive Officer (ieee Ta oe aT ee rasa— Prevention & Control of Infection HAH-PCl-11 Tile ‘Outbreak Management Applies to: All Hospital Employees 1.0. Purpose: 41.1. To identify any outbreak early and identify factors that contributes to the outbreak in order to control it. 1.2. To develop and implement measures to prevent similar outbreaks in the future, 2.0. Definitions: 24. Outbreak is defined as an increase in the rate of an Infection or infectious agent above its ‘endemic rate or appearance of a new infection. 3.0. Policy Statement: 3.1, The Chairman of the infection Control Committee will authorize the Infection Control Team to ‘conduct the investigation for outbreaks 4.0. Procedures: 4.1. Prepare for investigation 4.11, The Microbiology Laboratory will be advised to save specimens and isolates for antimicrobial susceptibility testing and typing if possible, 4.1.2. The laboratory will be alerted to keep any subsequent isolates that may be part of the outbreak. 4.2. Confirm the existence of an outbreak 42.1. Develop a case definition to estimate the magnitude of the problem. 42.2. Compare the current incidence with usual or baseline incidence. If local data are not available, compare outbreak rate with the literature. ‘Assess the need for outside consultation and report to Ministry of Health if required, Institute early contro! measure as appropriate based on the magnitude of the problem, 4.3. Establish diagnosis of reported cases, identify agent if possible 4.3.2. Use specific criteria for the definition of a case, 43.2. Characterize the nature of the disease and signs and symptoms by reviewing patient charts. 4.3.3, Obtain appropriate laboratory specimens to identify specific agents responsible, 44. Search for additional cases, collect critical data, develop line listings, and collect specimens if indicated ‘441, Encourage reporting of new cases by laboratory, physicians, nursing staff and others as appropriate. 442, Search for other eases that may have occurred retrospectively or concurrently through laboratory reports, medical records, patient charts, physicians, nursing staff ‘and public health data, 4.4.3. Usea specific data collection form. (tates a8 | re capa ae Pari 1° iE Prevention & Control of Infection L_HAHSPctaa Title: Outbreak Management DPP |Apoliesto: All Hospital Employees. — 5.0. Attachments: 6.0. 4.11, Implement and evaluate control and preventive measures 4.11.1. Identify specific preventive and control measures based on the nature of the agent ‘and characteristics of high-risk group and sources 4.12, Initiate surveillance to: 4.12.4, Make specific recommendations to stop the outbreak and prevent further transmission 4.12.2, Determine if cases cease to occur or return to endemic level 4.12.3. Review and correct other practices related to the current situation that may contribute to an outbreak in the future 4.43. Commu vestigation and prepare written reports to include the following: 4.13.4. Introduction 4.13.1.1. Circumstances leading to recognition of the problem 4.13.1.2. Background describing the setting in which the problem occurred 4.13.2, Methods 4.13.2.1, Methods (laboratory, epidemiologic) 4.13.2.2. Case definition, case-finding, and verification of diagnosis 4.13.23. Sources of data te findings, summarize 4.13.24. Hypothesis testing, if any 4.13.3, Results 4.13.3.1, Facts only 4.13.3.2. May use table, graphs, and charts 4.13.3.3. Analysis of data and statistical conelusions 4.13.4, Discussion 4.13.4.1. Interpretation 4.13.4.2. Description of control measures 4.13.4.3. Description of other important outcomes, discoveries of new agents, reservoirs, modes of transmission, legal and economic impact 4.14, Recommendations for future surveillance and control jone Reference: 1.1. _APIC text of infection Control and Epidemiology Bape au Tees on gen aT omanA @ Prevention & Control of Infection HAH-PCI-11 DPP |Appliesto: All Hospital Employees Signatory box Prepared by: Ms. Maria Cecilia Becalas ‘Approved by: Dr. Hussien Hassan Satari Or. Mhmd Salah Mr. Reda Al-Ali Infection Control Supervisor Chairman of Infection Control Committee Quality Improvement Director Chief Executive Officer (ieee ea Ten BT iaraabea| rrevention & Control of Infection | HaH-Pci-12 DPP |Appliesto: All healthcare workers | 1.0. Purpose: 1.1. _ To provide recommendations for preventing intravascular catheter related infections. 1.2, To reduce the rate to as low as feasible given the specific population being served, the Universal presence of microorganisms in the human environment. 13, To eliminate CRBSI / CLABSI from all patient care areas. 2.0. Definitions 21, CRBS! is rigorous clinical definition, defined by precise laboratory findings that identity the CVC as the source of the BSI and, used to determine diagnosis, treatment, and possibly epidemiology of BSI in patients with 3 CVC. 2.2. CLABSI is a term used only for surveillance purposes to identify Sis that occur in the Population at risk (patients with central lines) 23. Primary bloodstream infections (BSI): Laboratory-confirmed bloadstream infections (LCBI) that are not secondary to an infection at another body site. 24, Central line: An intravascular catheter that terminates at or close to the heart or in one of the reat vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring of critically ill patients 25. Types of intravascular devices are used in most hospitals. 2.5.1, Short Term Vascular Access Devices: 2.5.1.1. Short Peripheral Venous Catheters: The most commonly used catheters. They are rarely associated with bloodstream infections. 2.5.1.2. Peripheral Arterial Catheters: Commonly used in ICU to monitor the patient's hemodynamic status. 2.5.1.3. Non-tunneled Central Venous Catheters: The most commonly used central venous catheters. It is es mated that 90% of all catheter related blood stream infections are related to CVC, 2.5.1.4. Medline Catheter: They are 3 to 8 inch peripheral catheters that are becoming an increasingly popular alternative to both short peripheral LV and CV.C. 2.5.1.5. Central Arterial Catheters: Pulmonary Artery Catheters, Swan Ganz Catheters 2.5.1.6. Pressure Monitoring Systems: Peripherally inserted central nervous catheters (pice) 2.5.2. Devices Used for Long-Term Vascular Access. 2.5.2.1, Tunneled Central Nervous Catheters, e.g, Hickman’s Broviac ete 2.5.2.1.1. In general, the rates of infections reported with the use of these catheters, cc 25.2.1.2. Have been significantly lower than those reported with use of canes non-tunnels CVC. 2.5.2.2. Total implantable intravascular devices Ste proved Augen 2S | Ren be hg 307 —] Tannen Raiamaha rrevertion & Control ot Intection HAH-PCI-12 DPP |Appliesto: All healthcare workers | 3.2.1.3. LeBl3 3.2.2, Mucosal Barrier Injury Laboratory-Confirmed Bloodstream infection (MBI-LCB!) 3.2.2.1. MBL-LCBIL 3.2.2.2. MBI-LCBI 2 Oat nopoved gt 11S Patient < 1 year of age has at least one of the following signs or symptoms: fever (>38.0°C), hypothermia (<36,0°C), apnea, or bradycardia AND Organism cultured from blood is not related to an infection at another site AND The same common commensal {i-e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacilus spp. [not 8. anthracis], Propionibacterium spp., Coagulase-negative staphylococci [including . epidermidis), viridans group streptococci, Aerococcus spp., and Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. Criterion elements must ‘occur within the Infection Window Period, the seven-day time period which includes the date the posi ve blood culture was collected, the 3 calendar days before and the 3 calendar days @ er. Pa ent of any age meets criterion 1 for LCBI with at least one blood culture rowing any of the following intestinal organisms with no other organisms Isolated : Bacteroides spp., Candida spp,, Clostridium spp., Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., Veillonella spp., or Enterobacteriaceae And patient meets at least one af the following: 1. Is an allogeneic hematopoietic stem cell transplant recipient within the past year with one of the following documented during same hospitalization as positive blood culture: a) Grade Ill or V gastrointestinal graft versus host disease [G1 GVHD] b) 21 liter diarthea in a 24-hour period {or 220 mL/kg in a 24-hour period for pa ents <18 years of age) with onset on or within 7 calendar days before the date the positive blood culture was collected 2. Is neutropenic, defined as at least two separate days with values of absolute neutrophil count (ANC) or total white blood cell count (WBC) +<500 cells/mm3 within a seven-day time period which includes the date the posi ve blood culture was collected (Day 1), the 3 calendar cays before and the 3 calendar days a er. Pa ent of any age meets criterion 2 for LCBI when the blood cultures are rowing only viridans group streptococci with no other organisms isolated ‘And patient meets at least one of the following:Title Intravascular Catheter Related Infections Nn & Control of Infection HAH-PClA2 Applies to: All healthcare workers 3.2.23. 3.2.2.4, 1. Is an allogeneic hematopoietic stem cell transplant recipient within the past year with one of the following documented during same hospitalization as positive blood culture: 2) Grade Ill or IV gastrointestinal graft versus host disease [GI GVHD) ) 21 liter diarrhea in a 24-hour period (or 220 ml/g in a 24-hour period for pa ents <18 years of age) with onset on or within 7 calendar days before the date the first positive blood culture was collected. 2. Is neutropenic, defined as at least two separate days with values of absolute neutrophil count (ANC) or total white blood cell count (WBC) +<500 cells/mm within @ seven-day time period which includes the date the posi ve blood culture was collected (Day 1), the 3 calendar days before and the 3 calendar days er. MBI-LcBI 3 Patient s1 year of age meets criterion 3 for LCBI when the blood cultures are rowing only viridans group streptococci with no other organisms isolated And patient meets at least one of the following: 4) Is an allogeneic hematopoietic stem cell transplant recipient within the ast year with one of the following documented during seme hospitalization as positive blood culture: a) Grade Il or WV gastrointestinal graft versus host disease [GI GVHD] b) 220 mU/kg diarrhea in a 24-hour period with onset on or within 7 calendar days before the date the first positive blood culture is collected, 2) Is neutropenic, defined as at least two separate days with values of absolute neutrophil count (ANC) or total white blood cell count (WBC) +<500 cells/mm3 on or within a seven-day time period which includes the date the posi ve blood culture was collected (Day 1), the 3 calendar days bbefore and the 3 calendar daysa er. (See Table 4 for example) Comments, 4, In LCBI criterion 1, the term “recognized pathogen” includes any organism Not included on the common commensal list 2. LcBt criteria 1 and 2 and MCI-LCAI criteria 1 and 2 may be used for patients of any age, including those patients <1 year of age. 3, LCBI criteria 2 and 3, if the pathogen or common commensal is identified to the species level from one blood culture, and a companion blood culture is identified with only a descriptive name, which is complementary to the companion culture (e.g,, to the genus level), then itis assumed that the organisms are the same. Bate Roped amt 1S evion Oat apo 007 Hane Panelsnaica| Freveruon & Control ot Intection | Hawerea x) | eer DPP | Apptesto: all heathcare workers 3. 4. The organism identified to the species level should be reported as the infecting organism along with its antiblogram if available. Only genus and species identification should be utilized to determine the sameness of organisms (i., matching organisms). No additional comparative methods should be used (e.g., morphology or antibiograms) because laboratory testing capabilities and protocols may vary between facilities. This wil reduce reporting variability, solely due to laboratory practice, between facili es repor ng LCBIs mee ng criterion 2. Report the organism to the genus/species level only once, and if antibiogram data are available, report the results from the most resistant panel, 4. In LCBI criteria 2 and 3, the phrase “two or more blood cultures drawn (on separate occasions” means, 1) Blood from at least two separate blood draws were collected on the same ar consecutive calendar days, and 2) were collected in @ manner which suggests that 2 separate blood draw site preparations were performed. This will reduce rmisidentification of contaminated blood cultures as LCBI. For example, blood cultures drawn from different sites (e.g., different veniounctures, @ combination of venipuncture & lumen withdrawal, or different lumens of the same central line) should undergo separate decontaminations & are considered drawn on “separate occasions” b. For pediatric patients, due to volume constraints, a blood culture may Consist of a single bottle, Therefore, to meet this part of the criterion, each bottle from two, single bottle blood draws would have to be cculture-positive for the same commensal 5. Specimen Collection Considerations: Although blood cultures drawn through central ines can have a higher rate of contamination than blood cultures collected through peripheral venipuncture 3, 4 all posi ve blood cultures, regardless of the sites from which they were collected, must be Included when conducting in-pian CLABS! surveillance. 6. In MBI-LCBI 1, 2 and 3, “No other organisms isolated” means there is no isolation in a blood culture of another recognized pathogen (e.g., 5. aureus) or common commensal (e.g., coagulase-negative staphylococci} other than listed in MBI-LCBI criterion 1, 2 or 3 that would otherwise meet LCBI criteria. If occurs, the infection should not be classified as MBI-LCB!, 2.2.5. Reporting Instructions 1. Report organisms cultured from blood as BSI-LCBI when no other site of infection is evident. 2. When another blood culture is collected during the RIT of an identified MBI-LCBI, which is positive for an organism excluded from MBI-LCBI criteria, the MBI-LCBI event is edited to become an LCBI and the organism is added, Date Roped agi) ‘even Oat Aunt] Taree 7Poruy rrevenuon & Control ot Infection | HaH-pcr-t2 vascular Catheter Related Infections DPP Apalicsto: All healthcare workers Central Line inser 3.3.1, Bundle 33.44, 3312, 3.3.13. 33.14, 3.3.15. 33.16. 33.47, 33.21. 3.3.2. Central Line Insertion Practices (CLIP) Adherence Monitoring 3. Catheter tip cultures are not used to determine whether a patient has a primary BSI 4, When there is a positive blood culture and clinical signs or symptoms of localized infection at a vascular access site, but no other infection can be found, the infection is considered a primary 85. 5. Purulent phlebitis confirmed with a positive semi quantitative culture of a catheter tip, but with either negative or no blood culture is considered a CVS-VASC, not a BSI, SST-SKIN, or a ST infection. 6. Occasionally @ patient with both peripheral and central IV lines develops a Primary bloodstream infection (L.CB!) that can clearly be attributed to the Peripheral line (i.e., pus at the insertion site and/or matching pathogen from pus and blood). 7. Report healtheare-associated BSIs that are not central line-associated You should, however, include all of the patient's central line days in the summary denominator count. tion Practices (CLIP) Hand Hygiene Appropriate skin prep 3.3.1.2.1. Chlorhexidine gluconate (CHG) for pa ent > 120 days old\ 3.3.1.2.2. CHG for pa ents < 120 days old when either there is no contraindication to CHG or contraindication is unknown 3.3.2.3, Povidone iodine, alcohol, CHG, or other specified for children <120 days old when there is contraindica on to CHG 3.3.4.24. Skin prep agent has completely dried before insertion 3.3.1.28. All S maximal sterile barriers used Sterile gloves Sterile gown cap ‘Mask worn Large sterile drape (a large sterile drape covers the patient's entire body). Central line-associated bloodstream infections (CLABSIs) can be prevented through proper placement and management of the central line. The CDC's Healthcare Infection Control Practices Advisory Committee (CDC/HICPAC) Guidelines for the Prevention of intravascular Catheter-Related Infections, 2011 recommend evidence-Based central line insertion practices known to reduce the risk of subsequent central line-associated bloodstream infection. (te Aopeoved Asm 2015 Rost 3007] coma i PapsAue) Frevention & Control of Infection HAH-PCL-12 I DPP |Appiiesto: All healthcare workers 3.3.2.2. These include hand hygiene by inserters, use of maximal sterile barriers during insertion, proper use of a skin antiseptic prior to insertion, and time to allow the skin antiseptic to dry before catheter insertion. Several centers have found it useful to monitor adherence to evidence-based central line insertion practices as a method for identifying quality improvement pportunities and strategically targeting interventions. Feedback of adherence data has been a component of multifaceted interventions that have successfully reduced CLABSI rates. 3.3.2.3. Adherence rates for specific insertion practices willbe calculated by dividing the number of central line insertions during which the recommended Practice was followed by the total number of central line insertions and mul plying the result by 100. Such calcula. ons can also be done for a bundle of practices that have been shown to reduce the incidence of CLA@S! Adherence to the bundle requires “YES” to all 4.0. Procedures: 4.1, Peripheral intravenous Lines 444, All healthcare staff have @ duty to maintain peripheral intravenous devices safely including patency of lines end prevention of complications during insertion and maintenance, It is the responsibility of the individual introducing the intravascular device to observe aseptic technique. Insertion site integrity and infusion delivery system should then be managed and maintained. 4.2. Catheter related-blood stream infection (CR-BSI) can be caused by: 4.2.1. Skin organisms (patient's own skin flora) that contaminate the catheter during insertion or migrate along the catheter track 4.2.2, Microorganisms from the hands of healthcare workers that contaminate and colonize the catheter hub during care interventions. 4.3. Education, Training and Staffing 4.3.1, Educate healthcare personnel regarding the indications for intravascular catheter use, Proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. 4.3.2, Periodically assess knowledge of and adherence to guidelines for all personnel Involved in the insertion and maintenance of intravascular catheters. 4.3.3. Designate only trained personne! who demonstrate competence for the insertion and. ‘maintenance of peripheral and central intravascular catheters. 4.3.4. Ensure appropriate nursing staff levels in ICUs. Observational studies suggest that 2 higher proportion of "poo! nurses" or an elevated patient-to-nurse ratio is associated with CRBS! in ICUs where nurses are managing patients with CVCs oa 207 Tanne Pesevoias4 Frevention & Control ot Intection HAH-PCL-12 Title Intravascular Catheter Related Infections DPP [Applies to: All healthcare workers 7. Use ultrasound guidance to place central venous catheters i ths technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique 4.4.28. Use a CVC with the minimum number of ports or lumens essential for the ‘management ofthe patient. 4.4.2.9. No recommendation can be made regarding the use of a designated lumen for parenteral nutrition. 4-42.10, Promptly remove any intravascular catheter that is no longer essential 4-42.11, When adherence to aseptic technique cannot be ensured (ie. catheters inserted during @ medical emergency}, replace the catheter as soon as soon. as possible, i.e, within 48 hours. 45. Hand Hygiene and Aseptic Technique 45:1, Perform hand hygiene procedures, either by washing hands with conventional soap and water or with aleohol-based hand rubs (ABHR). Hand hygiene should. be performed before and after palpating catheter insertion sites 26 well as betore and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained 4.5.2, Maintain aseptic technique for the insertion and care of intravascular catheter. 45.3, Wear clean gloves, rather than sterile gloves, for the insertion of peripheral Intravascular catheters, ifthe access site is not touched after the aaplicstion of skin antiseptic 45.4. Sterile gloves should be worn for the insertion of arterial, central, and midline catheters, 45.5. Use new sterile gloves before handling the new catheter when guide wire exchanges are performed, 4.5.6. Wear elther clean or sterile gloves when changing the dressing on intravascular catheters, 4.6. Maximal Sterile Barrier Precautions 46:1. Use maximal sterile barrier precautions, including the use ofa cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guide wire exchange 46.2. Use a sterie sleeve to protect pulmonary artery catheters during insertion, 47. skin Preparation 4.7. Prepare clean skin with an an sep ¢ (70% alcohol, neture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion, (aioe esa | evi ena Taneo modeAe ia. Frevention & Control ot Intection | Han-ectaa Intravascular Catheter Related Infections DPP Applies to: _Altheattheare workers 472 4.73, Prepare clean skin with a >0.5% chlorhexidine prepara_on with alcohol before central venous catheter and peripheral arterial catheter insertion and during. dressing Changes. if there is @ contraindication to chlorhexidine, tincture of iodine, an iodophor r 70% alcohol can be used as alterna ves. 'No comparison has been made between using chlorhexidine preparations with alcohol ‘and povidone iodine in alcohol to prepare clean skin, No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2 months. Antiseptics “should be allowed to dry according to the manufacturer's Tecommendation prior to placing the catheter, 4.8, Catheter Site Dressing Regimens 4.8.1, Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site 4-82. If the patient is dlaphoretic or if the site is bleeding or oozing, use a gauze dressing Until ths is resolved, 483. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. 484, Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance. 4.8.5. Do not suomerge the catheter or catheter site in water, 4.86. Replace dressings used on short-term CVC sites every 2 days for gauze dressings 4.8.7, Replace dressings used on short-term CVC sites at least every 7 days for transparent Gressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing 4.8.8. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose], until the insertion site has healed: 4.8.9. No recommendation can be made regarding the necessity for any dressing on wel healed exit sites of long-term cuffed and tunneled CVCs, 4.8.10. Ensure that catheter site care is compatible with the catheter material 4.8.11, Use a sterile sleeve for all pulmonary artery catheters. 4.8.12, Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in pa ents older than 2 months of age if the CLABSI rate is not decreasing despite adherence to basic prevention measures, including education and training, appropriate use of chlorhexidine for skin antisepsis, and MSB. (one esroved:iapon cis | neviton bo age G57] Wane Fogeloatsula Prevention & Control of Infection | HaH-pcaz DPP [Applies to: all healthcare workers 48:13. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or Bloodstream infection, the {ressing should be removed to allow thorough examination of the site. 4.8.14. Encourage patients to report any changes in their catheter site or any new discomfort to their provider. 4.9. Patient Cleansing 4.9.1. Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBS! 4.10. Catheter Securement Devices 4.10.1. Use a sutureless securement device to reduce the risk of infection for intravascular catheters 4.11. Antimicrobial/Antiseptic impregnated Catheters and Cuffs 4.11.1. Use a chlorhexidne/sitver sulfadiazine or minocycline/tifampin ~ impregnated CVC in Ratients whose catheter is expected to remain in place >5 days if 2 er successful implementation of a comprehensive strategy to reduce rates af CLABSI, the CLABS| rate is not decreasing 4.11.2. The comprehensive strategy should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier Brecau ons, and a 20.5% chlorhexidine prepara on with alcohol for skin an sepsis during CVC insertion 4.12. systemic Antibiotic Prophylaxis 4.12.1. Do not administer systemic antimicrobial prophylaxis routinely before insertion or uring use of an intravascular catheter to prevent catheter colonization or CR8SI 4.13, antibiotic/Antiseptic Ointments 4.13.1, Use povidone iodine antiseptic ointment or bacitracin/gramicidin/ polymyxin & ointment at the hemodialysis catheter ext site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the material of the hemodialysis catheter per manufacturer's recommendation 4.14 Anticoagulants 4.14.1, Do not routinely use anticoagulant therapy to reduce the vist of catheter-related infection in general patient populations. 4.15. Replacement of Peripheral and Midline Catheters 4.15.1, There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults 4.15.2. Replace peripheral catheters in children only when clinically indicated 4.15.3, Replace midline catheters only when there is@ specific indication (“tre tomo ees 208 [tevin hat 2007 —] Taner omitsaKa | Prevention & Control of Infection HAH-PCL-12 DPP |Appliesto: All healthcare workers 4.16. 447. aaa, Replacement of CVCs, Including PICCs and Hemodialysis Catheters 4.16.1. Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. 4.16.2. Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if @ noninfectious cause of fever is suspected. 6.3. Do not use guide wire exchanges routinely for non-tunneled catheters to prevent infection 4.16.4. Do not use guide wire exchanges to replace a non-tunneled catheter suspected of infection, 4.16.5. Use a guide wire exchange to replace a malfunctioning non-tunneled catheter if no evidence of infection is present. 4.16.6, Use new sterile gloves before handling the new catheter when guide wire exchanges are performed Umbilical Catheters 4.17.1. Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency in the lower extremities, or thrombosis are present, 4.17.2, Remove and do not replace umbilical venous catheters if any signs of CRBS! or thrombosis are present, 4.17.3. Cleanse the umbilical insertion site with an antiseptic before catheter insertion, Avoid tincture of iodine because of the potential effect on the neonatal thyroid. Other iodine-containing products (e.g., povidone iodine) can be used 4.17.4, Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential to promote fungal infections and antimicrobial resistance. 17.5, Add low-doses of heparin (0.25—1.0 U/ml) to the uid infused through umbilical arterial catheters, 4.17.6. Remove umbilical catheters as soon as possible when no longer needed or when any sign of vascular insufficiency to the lower extremities is observed, Optimally, umbilical artery catheters should not be le in place >5 days. 4.17.7. Umbilical venous catheters should be removed as soon as possible when no longer needed, but can be used up to 14 days if managed asep cally. 4.17.8. An umbilical catheter may be replaced if itis malfunctioning, and there is no other indication for catheter removal, and the total duration of catheterization has not exceeded 5 days for an umbilical artery catheter or 14 days for an umbilical vein catheter. Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Pediatric Patients 4.18.1. In adults, use of the radial, brachial or dorsalis pedis sites is preferred over the femoral or axillary sites of insertion to reduce the risk of infection. Date roved ATE Revo One fags 3007 | or rage ats1g DPP | Aopliesto: Kis) rrevention & Control of Infection | HaH-pcte12 Intravascular Catheter Related Infections, All healthcare workers 4.18.2. 4.18.3, 4.18.4, 418s. 4.18.6. 4.18.7. 4.18.8 4.18.9. 4.18.10. 4.38.11, 4.18.12. 4.18.13. 418.14, 4.19. Replacem: 4191. 4.19.2 4.19.3, In children, the brachial site should not be used. The radial, dorsalis pedis, and Posterior tibial sites are preferred aver the femoral or axillary sites of insertion ‘A minimum of a cap, mask, sterile gloves and 2 small sterile fenestrated drape should be used during peripheral arterial catheter insertion. During axillary or femoral artery catheter insertion, maximal sterile barrie precautions should be used. Replace arterial catheters only when there is a clinical indication Remove the arterial catheter as soon as itis no longer needed Use disposable, rather than reusable, transducer assemblies when possible Do not routinely replace arterial catheters to prevent catheter-related infections. Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced, Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile, Minimize the number of manipulations of and entries into the pressure monitoring system. Use a closed flush system (Le, continuous flush], rather than an open system (i.e, one that requires a syringe and stopcock}, to maintain the patency of the pressure monitoring catheters. When the pressure monitoring system is accessed through a diaphragm, rather than a stopcock, scrub the diaphragm with an appropriate antiseptic before accessing the system. Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit. Stenlize reusable transducers according to the manufacturers’ instructions if the use of disposable transducers is not feasible. jent of Administration Sets In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals, but at least every 7 days. Replace tubing used to administer blood, blood products, or fat emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) ‘within 24 hours of initiating the infusion. Replace tubing used to administer propofol infusions every 6 or 12 hours, when the Vial is changed, per the manufacturer's recommendation. (an arenes Ro 2 Resin Dae apt] TO TaneoRrrevention & Control of Infection Haw-Pcl-12 DPP |Apolies to: all healthcare workers 4.20. Responsibility 4.20.1. Attending Clinician When indicated, attending clinician shall order the fluids the type of catheter and fluids to be used and the fluid to replace the fluid that is about to finish The physician will also order the discontinuation of the IV fluid The physician will insert the appropriate catheter with the appropriate size using aseptic technique, 4.20.2, Nursing Personne! 4.20. ‘The nursing personnel will carry out the physician's order, 4.20.2.2. The nursing personnel will prepare the equipment for the insertion of the catheters. 4.20.2.3. If the nurse has the skill in inserting peripheral cannula, she will insert the appropriate catheter with the appropriate size using aseptic technique. The nurse will label the IV dressing with the date and time of insertion and nurse's initial 4.20. 4.20.25. The procedure will be documented in the nurses’ notes. 5.0. Attachments: SA, Summary of Recommended frequency of replacements for catheters, dressings, ‘administration sets and fluids. (Attachment A} 5.2. Central Line Bundle Checklist (Attachment 8) 6.0. Reference: 6.1. Association for Professionals in Infection Control and Epidemiology, 2009. “Guide to Elimination of Catheter Related Blood Stream Infection 6.2. Centers for Disease Control and Prevention. Outline for healthcare-associated infection surveillance. Available online at htto://www.cde gov/neidod/dhap/nhsn documents htm! 63. COC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infec onsin the acute care se ng. January 2015 6.4, Centers for Disease Control and Preven on. 2011 Guidelines for the Prevention of Intravascular Catheter Related Infection. Available online nttp://www.cdegov/ncidod) ghgp/nhsn_documents ht Deke prod moni /058 | Revion ate Aga 707 Tansec I Pepeoe Prevention & Control of Infection HaHpci13 DPP |appliesto: altheatthcare workers 3.2. Urinary tract infection (UTI) criteria’ 3.2.4. Symptomatic Urinary Tract Infection (SUTI) (Must meet at least one of the following criteria) 3.2.1.1. Symptomatic Urinary Tract Infection (SUTI} Catheter Associated UTI: (Patient must meet 1, 2, and 3 below) 3.2.1.1.1. Patient has an indwelling urinary catheter in place for the entire day on the date of event and such catheter had been in place for >2 calendar days, on that date (day of device placement = Day 1) 3.2.1.1.2. Patient has at least one of the following signs or symptoms: 214.24. Fever (>38.0°C) 3.2.1.1.2.2. Suprapubic tenderness 3.2.1.1.2.3. Costovertebral angle pain or tenderness, Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 2105 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period. 3.2.1.2. Symptomatic Urinary Tract Infection (SUTI) Catheter Associated UT! {Pa ent must meet 1,2, and 3 below) Pa ent had an indwelling urinary catheter in place for >2 calendar days which was removed on the day of, or day before the date of event. Patient has at least one of the following signs and symptoms: 3.21.2.2.1. Fever (>38.0C) 3.2.12.2.2. Suprapubic tenderness* 3.2.1.2.2.3. Costovertebral angle pain or tenderness* 3.2.1.2.2.4. Urinary urgency* 3.2.1.2.2.5. Urinary frequency” 3.2.1.2.2.6. Dysuria* * With no other recognized cause 3.2.1.2.3, Patient has urine culture with no more than two species of organisms, at least one of which is a bacteria of >105 CFU/ml. Al elements of the UTI criterion must occur during the Infection Window Period. Note: Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from UTI determination because they are clinically deemed due to another recognized cause, Dut fone Stentor 7015 | Sai ona an? [wae Tetonom Prevention & Control of Infection HAH-PCL-43 DPP |Appliesto: Allheattheare workers 3.2.21, 3.2.2.2, 3.223, 3.23.1, 3.23.2, 3.2.2. Non-Catheter-Associated Urinary Tract Infection (Non-CAUTI) (Pa ent must meet 1,2, and 3 below) One of the following is true: 33 1.1. Patient has/had an indwelling urinary catheter but it has/had not been in place >2 calendar days, or Patient did not have a urinary catheter in place on the date of event nor the day before the date of event Patient has at least ONE of the following signs or symptoms: |. Fever (>38°C) in a patient that is < 65 years of age . Suprapubic tenderness* |. Costovertebral angle pain or tendemness* Urinary frequency” Urinary urgency* Dysuria* * With no other recognized cause Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 2105 CFU/ml. All elements of the SUTI criterion must occur during the Infection Window Period. Notes: Ain indwelling urinary catheter in place at the time would constitute other recognized cause for patient complaints of “frequency” “urgency” or “dysuria” and therefore these cannot be used as symptoms when catheter isin place. Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from UTI determination. 3.2.3. CAUTI or Non-CAUTI in pa ents 1 year of age or less (Patient must meet 1, 2, and 3 below) Patient is <1 year of age (withé or without an indwelling urinary catheter) Patient has at least one of the following signs or symptoms: . Fever (>38.0°C) . Hypothermia (<36.0°C) . Apnea* |. Bradycardia* Lethargy? 3. Voriting® 7. Suprapubic tenderness* *With no other recognized cause even Dvr nunut/ 207 Tamra aoePrevention & Control of Infection | HaH-pci-13 Title: Prevention of Catheter Associated Urinary Tract Infection DPP |Apoiies to: All healthcare workers 3.25. Patient has @ urine culture with no more than two species of organisms, at least one of which is a bacteria of 2105 CFU/ml. All elements of the SUTI criterion must occur during the Infection Window Period. Notes: If pa ent had an indwelling urinary catheter in place for >2 calendar days, and catheter was in place on the date of event or the previous day the CAUTI criterion is met. If no such indwelling urinary catheter was in place, UTI (non- catheter associated) criterion is met. Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from UTI determination because they are clinically deemed cue to another recognized cause. 3.2.4. Asymptomatic Bacteremic Urinary Tract Infection (ABUTI) (Patient must meet 1, 2, and 3 below) 32. 3.2.4.2, 3.2.4.3. Patient with* or without an indwelling urinary catheter has no signs or symptoms of SUTI 1 or 2 according to age (Note: Pa ents > 65 years of age with a non-catheter-associated ABUT! may have 2 fever and stil meet the ABUTI criterion) Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 2105 CFU/m. Patient has a positive blood culture with at least one matching bacteria to the urine culture, or meets LCBI criterion 2 (without fever) and matching ‘common commensal(s) in the urine. All elements of the ABUT! criterion must ‘occur during the Infection Window Period. * Pa ent had an indwelling urinary catheter in place for >2 calendar days, with day of device placement being Day 1, and catheter was in place on the date of event or the day before. Note: "Mixed flora” Is not available in the pathogen list within NSHNV. Therefore it cannot be reported as a pathogen to meet the UT! criteria. Additionally, “mixed flora” represent at least two species of organisms. Therefore an additional organism recovered from the same culture, would represent >2 species of microorganisms. Such 2 specimen also cannot be used to meet the UTI criteria. Urinary System Infection (USI) (formerly OUT!) (kidney, ureter, bladder, urethra, or tissue surrounding the retroperitoneal or perinephric space) (Other infections of the urinary tract must meet at least one of the following criteria) 3.25.1, 3.2.5.2, Patient has microorganisms isolated from culture of fluid (excluding urine) or tissue from affected site. Patient has an abscess or other evidence of infection on gross anatomical exam, during invasive procedure, or on histopathologic exam: ‘Deke Rproved Sener / 1015 | Revlon Oat Augat 547 Tansee Tetarrevention & Control ot Intection Prevention of Catheter Associated Urinary Tract Infection | Haw-Pcras Kak x! DPP Applies to All healthcare workers 3.2.6.1.2.1, 3.2.6.1.2.2. 3.2.6.1.2.3. 3.26.1.3.1. 3.2.6.1.3.2. 3.2.6.1.3.3, 3.2.6.1.3.4, 3.2.6.1.35, 3.26.24, Procedures: 4.1. Appropriate Urinary Catheter Use 4a. needed 4aaaa. 4aaaa2, patients 411.13. cower 2. Insert Urinary catheter using aseptic technique Hand Hygiene Catheter insertion kit with sterile gloves Drape, cleaning supplies, sterile lubricant, sterile urinary catheter attached to a drainage bag Maintain urinary catheter based on recommended guidelines Secure catheter to prevent irritation of the urethra Maintain unobstructed flow, maintain the drainage ‘bag below the level of the bladder and off the floor Perform hand hygiene before and after each patient contact Provide individual labeled collection container at the bedside Review urinary catheter necessity daily, remove catheter when not needed 3.2.6.2, CAUTI Maintenance Bundle 3.2.6.2.1. Daily Documented assessment of need 2.2. Tamper evident seal is intact 2.3. Catheter secured ~ securement device in place Hand Hygiene performed for patient contact Daily meatal hygiene performed with soap and water Drainage bag emptied using a clean container /. Unobstructed flow mai tained Action Remove or Continue Insert catheters only for appropriate indications and leave in place only as long as, 4.1.1.1, Examples of Appropriate Indications for Indwelling Urethral Catheter Use Patient has acute urinary retention or bladder outlet obstruction Need for accurate measurements of urinary output in critically ill Perioperative use for selected surgical procedures: Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract (our proves: Sestenber/2015 | Revlon One Avg 017 wanes TLub Prevention & Control ot Intection | _HAH-PcI-13 EB Prevention of Catheter Associated Urinary Tract Infection DPP Apolies to: All healthcare workers 41.2. 443. 414, 41s. 4.1.1.1.3.2. Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU) 4.1.1.1.3,3. Patients anticipated to receive lrge-volume infusions or diuretics during surgery 4.1.1.1.3.4 Need for intraoperative monitoring of urinary output | 411.14 To assist in healing of open sacral or perineal wounds in| incontinent patients 4.11.15. Patient requires prolonged immobilization (e.g, potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures) 4.1.1.1.6. To improve comfort for end of lfe care if needed 4.1.1.2. Examples of Inappropriate Uses of Indwelling Catheters 4.1.1.2.1. As a substitute for nursing care of the patient or resident wit incontinence 4.1.1.2.2. As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void 4.1.1.2.3. For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anaesthesia, etc) Minimize urinary catheter use and duration of use in all patients, particularly those hhigher risk for CAUTI or mortality from catheterization such as women, the elderly, ‘and patients with impaired immunity. Use urinary catheters in operative patients only as necessary, rather than routinely For operative patients who have an indication for an indwelling catheter, remove the ‘catheter as soon as possible postopera vely, preferably within 24 hours, unless there are appropriate indications for continued use Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate 4.1.5.1. Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction 4.1.5.2. Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients. 4.1.5.3, Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction 4.1.5.4, Consider intermittent catheterization in children with myelo-meningocele and neurogenic bladder to reduce the risk of urinary tract deterioration. ao manceuk Prevention & Control of Infection |_Hat-pcras vention & Control of Infection _ ER Prevention of Catheter Associated Urinary Tract Infection DPP | Applies to: all heathcare workers 4.2, Proper Techniques for Urinary Catheter Insertion 4.2.1. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site 4.2.2. Ensure that only properly trained persons (e.g., hospital personnel, family members, (or patients themselves) who know the correct technique of aseptic catheter insertion ‘and maintenance are given this responsibilty 42.3, In the acute care hospital setting, insert urinary catheters using aseptic technique and sterile equipment, 42.3.1. Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for peri-urethral cleaning, and a single-use packet of lubricant jelly for insertion, 4.2.3.2. Routine use of antiseptic lubricants is not necessary. 4.2.4. In the non-acute care setting, clean (Le., non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization, 4.25. Properly secure indwelling catheters after insertion to prevent movement and urethral traction 4.2.6. Unless otherwise clinically indicated, consider using the smallest bore catheter Possible, consistent with good drainage, to minimize bladder neck and urethral trauma 4.2.7. If intermittent catheterization is used, perform it at regular intervals to prevent bladder over distension, 42.8. Consider using @ portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions, 4.2.8.1. If ultrasound bladder scanners are used, ensure that indications for use are Clearly stated, nursing staff are trained in their use, and equipment is adequately cleaned and disinfected in between patients. 4.3. Proper Techniques for Urinary Catheter Maintenance 4.3.1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system 43.41, If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter & collecting system using aseptic technique and sterile equioment. 43.1.2. Consider using urinary catheter systems with pre-connected, sealed catheter-tubing junctions. 4.3.2. Maintain unobstructed urine flow. 4.3.2.1, Keep the catheter and collecting tube free from kinking, 4.3.2.2. Keep the collecting bag below the level of the bladder at all times, Do not rest the bag on the floor. ‘Bete Arona Sepeber/ 2035 | Revlon Ove Rage O57 Tae TPrevention & Control of Infection le: Prevention of Catheter Associated Urinary Tract Infection kuna nie DPP Acpiiesto: All healthcare workers i rc 4.3.2.3, Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the non-sterile collecting container. | 4.3.3. Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. 4.3.4. Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such a5 antiseptic-release cartridges in the drain port] are not necessary for routine use 4.3.5. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it ls suggested to change catheters and drainage bags based on linical indications such as infection, obstruction, or when the closed system is compromised, 4.3.6. Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter Femoval post urologic surgery), do not use systemic antimicrobials routinely to Prevent CAUTI in patients requiring either short or long-term catheterization 4.3.7. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place, Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate, 4.3.8. Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended. 4.3.8.1. If obstruction is anticipated, closed continuous irrigation is suggested to Prevent obstruction, 4.3.9. Routine irrigation of the bladder with antimicrobials is not recommended. 4.3.10. Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended, 4.3.11, Clamping indwelling catheters prior to removal is not necessary. 4.8. Catheter Materials 4A. If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI, consider using antimicrobial/antiseptic-impregnated catheters. The comprehensive strategy should include, at a minimum, the high priority recommendations for urinary catheter use, aseptic insertion, and maintenance. 4.4.2. Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization, 4.4.3, Silicone might be preferable to other catheter materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction, 4.5. Management of Obstruction 4.5.1. If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter, evan awe Aga] TOT TanseeKala DPP Title: Applies to: All healthcare workers rrevention & Control ot Intection HAH-PCI-13 Prevention of Catheter Associated Urinary Tract Infection 46. a7, (Ge Assrove'seperte [201s | Revion Oat Rupe S07 Taner Specimen Collection 46.1. 46.2. 46.3. 46.4, 4.6.5. Strategies for success in preventing CAUT! include: ara. 472, 473. 47.4, 475. 476. The aualty of the urine specimen for culture Is important when determining if a true infection is present. The specimen of choice is the first morning void, since it is generally more concentrated due to the length of time the urine was in the bladder. ‘The preferred collection method is midstream, clean-catch specimen. Specimen collected from a newly inserted urine catheter is reliable, provided, proper insertion technique had been followed. Only specimens collected from a specifically designed sampling port or from the catheter directly should be submitted for analysis. Under no circumstances should 2 sample from a drainage bag be submitted for analysis. Catheter tips should not be submitted for analysis. If CAUTI is suspected, the best practice is removal of the old catheter before obtaining the specimen in order to eliminate the confounding factor of possible catheter biofilm If an indication for urinary catheterization still exist in a patient suspected of having a CAUTL, obtain the urine specimen after replacing the old one. Specimens collected from an indwelling catheter must be noted on the microbiology urine culture request. The Clinical and Laboratory Standards Institute (CLSI} Guidelines recommend that the urine specimen is cultured within 2 hours of its collec on. If the specimen cannot be cultured within 2 hours ofits collec on, to maintain the specimen integrity: 4.6.4.1. Collect urine specimen in a container with a chemical preservative (buffered boric acid). 4.6.4.2. Hold the urine specimen at 2-8 degree Celsius un I cultured, 4.6.4.3. Overgrowth of bacteria can readily occur with mishandled specimens, and this will cause a false positive or unreliable culture result. Obtain urine samples aseptically 4.6.5.1. If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/ cannula adapter after cleansing the port with a disinfectant 4.6.5.2. Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag, Adequately assess and document the need for urinary catheter based on recognized indications. Use catheters in operative patients only as necessary. Utilize the CAUTI bundle Remove urinary catheter as soon as possible (for operative patients who have an indica_on for a catheter, preferable remove within 24 hours) Alert clinicians to evaluate the necessity for urinary catheters on a daily b: Do not use catheters in patients and nursing home patients for management of incontinence,hula) Prevention & Control of Infection | HAH-PcL-13 EAB: Prevention of Ctheter Associated Urinary Tact infection DPP |Aoplies to: alt healthcare workers 4.7.7. Provide regular feedback to staff on process and / or outcome process. 4.7.8. Implement quality improvement programs to reduce catheter use and reduce the risk | of urinary tract. 4.8. _ Indications for the use of indwelling urethral catheters are limited and include the following 48.1. Perioperative use for selected surgical procedures (e.g. surgeries involving the Genitourinary tract, anticipated prolonged surgery, operative patients with urinary Incontinence, need for intraoperative hemodynamic monitoring, patients anticipated to receive large volume diuretics during surgery) 4.8.2. Urine output monitoring in critically ill patients 4.8.3. Management of acute urinary retention and urinary obstruction 4.8.4. Assistance in pressure ulcer healing for incontinent residents 4.8.5. AS an exception, at patient request, to improve comfort (ie. end-of-lfe-care) 4.9. Responsibility 4.9.1. Attending Clinician Attending clinician shall order the catheterization and the type of catheter to be used and discontinuation of the procedure. 4.9.2. Nursing Personnel 4.9.2.1. Nursing Personnel shall perform the procedure (except suprapubic) using aseptic technique, 5.0. Attachments: 5.1, CAUTI Bundle checklist (Attachment A) 6.0. Reference: 6.1. Association for Professionals in Infection Control and Epidemiology, 2009. “Guide to Elimination of Catheter Associated Urinary Tract Infections (CAUTIs) 6.2. Centers for Disease Control and Prevention. Outline for healthcare-associated infection surveillance. Available online at http://www.cde.gow/ncidod/dhap/ahsn_ documents. html 6.3, COC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. January 2015 64, Centers for Disease Control and Prevention. 2011 Guidelines for the Prevention of Catheter- Associated Urinary Tract infections htto://www.cdc.gow/ncidod/dhap/nhsn_documents.htrn! Sie ApervedSpionter] 208 | evn te ADGA IO rane T Peles 1aka) Prevention & Control of Infection HaH-Pci13 Re Tile Prevention of Catheter Associated Urinary Tract Infection DPP Aoplies to: alt heattncare workers Signatory box Prepared by: Ms. Maria Cecilia Becalas Infection Control Supervisor Approved by: Or. Hussien Hassan Satari Chairman of nection Control Committee Dr. Mhme Salah Quality Improvement Director Dr. Mamd Salat {—Suaiity Director Mr. Reda AL-Ali Chief Executive Officer | Lonstoprot:Senente 7265 [favor ei aveat aa” —[—ranpea aePrevention & Control of Infection HaH-PCl-14 oly DPP Aoplies to: Allhealtheare workers 4.3, Ventilator breathing circuits with humidifiers 3.1, It is not recommended to change routinely, on the basis of duration of use, the breathing circuit (i., ventilator tubing and exhalation valve and the attached humidifier) that is in use on an individual patient. Change the circuit when itis visibly soiled or mechanically malfunctioning, 4.3.2. However, the circuit is changed every 72 hours on an individual pa ent asa rou ne in ICU of Hussein Al Ali Hospital | 4.3.3. Ventilator Tubing: Change in between patients. For long-term patients, tubing dated and changed 72 hours, 4.3.4, Ventilator breathing circuit-tubing condensate Wear gloves and periodically drain and discard any condensate that collects in the tubing Do not allow condensate to drain toward the patient. Wear gloves also when handling the fluid Wash hands with soap and water (if hands are visibly soiled) or with aleohel hand rub after performing the procedure or handling the fluid. No recommendation can be made for placing a filter or trap at the distal fend of the expiratory-phase tubing of the breathing circuit to collect condensate. Humidifier fluids: Use sterile distilled water to fill bubbling humicitiers Humidifiers: Empty and rinse reservoir with sterile water every shift. Sterilize daly if possible. Refill with sterile water. Ventilator breathing circuits with heat-and-moisture exchangers (HMEs) No recommendation can be made for the preferential use either HME's or heated humidifiers to prevent pneumonia in patients receiving mechanically assisted ventilation, Changing HME Change an HME that is in use on a patient when it malfunetions mechanically or becomes visibly solied DO not rou nely change more frequently than every 48 hours ‘an HME that is in use on a patient. Do not change routinely (in the absence of gross contamination or malfunction) the breathing circuit attached to an HME while Its in use on a patient. 4.4. Oxygen Humicifiers 4.4.1, Follow manufacturers’ instructions for use of oxygen humidifiers ‘Date proved aga) 3S | Revion Date Roan IP Taree i Page bo 1Ob DPP Applies to: ltheatthcare workers Prevention & Control of Infection HAH-PCI-14 4. Change the humidifier-tubing {including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated 45. Oxygen masks and cannula: individual, single use. Change daily or when soiled 46. Nebulizers 4.6.1. Small-volume medication in-line and hand-held nebulizers 4.6.2. Whenever possible, use aerosolized medications in single-dose vials. If multi-dose ‘medication vials are used, follow manufacturers instructions for handling, storing, and dispensing the medications 4.7. Resuscitation bags 1. Between their uses on different patients, sterilize 4.72. No recommendation can be made about the frequency of changing hydrophobic filters placed on the connection port of resuscitation bags 4.8. Pulmonary-function testing equipment 1. Do not routinely sterilize or disinfect the internal machinery between uses on different patients 48.2, Change the mouthpiece of 2 peak flow meter or the mouthpiece and fiter of a spirometer between uses on different patients 49. _Respirometer and ventilator thermometer 49.1, Between their uses on different patients, sterilize or subject to high level disinfection, 4.20, Ambu bag and mask 4.10.1, Send to CSSD to clean with detergent, dry and sterilize in 2 type of autoclave according to manufacturer. 4.10.2. Change mask after each patient 4.21. Anesthesia Equipment 4.11.1. Anesthesia machine & breathing systems or patient circuits 4.11... Do not routinely sterilize or disinfect the internal machinery 4.11.12, Between uses on different patients, clean reusable components of the breathing system or patient circuit (e.g. face mask) inspiratory and expiratory breathing tubing, Y-piece, reservoir bag, humidifier, and tubing, and then sterilize or subject them to high-level disinfection in accordance with the device manufacturers instructions for their reprocessing 4.1.1.3, Follow published guidelines or manufacturers instructions about in-use maintenance, cleaning, and disinfection or sterilization of other components or attachments of the breathing system or patient circuit of anesthesia equipment. 4.11.1.4, Anesthesia tude (patient's circuit): single use, May be used throughout an ‘operating lst provided that appropriate fiters are in place (antes ois | Remon on Ragen 7257 —T aaa I feta]g DPP | Appiies to: Prevention & Control of Infection | Hapcirs Prevention of Health Care Assi fed Pneumonia All healthcare workers 4.12. Anaesthetic equipment in general 4aa2a. 4.12.2. 4.14.1. 4142, 4.15. Suction Equipment 4.15.1 4.15.2, 4.5.3. 4.15.4, 4.55. 4.15.6. 4.15.7. 4.16. Tracheostomy Care 4.16.1, 4.16.2. 4.16.3, 4.16.4, Artificial Airways: Single Use 4.14. Faucet aerators Keep external surfaces clean by wiping with detergent Wipe with 70% alcohol, allow a contact me of at least 30 seconds No recommendation can be made about the removal of faucet aerators from areas for immunocompetent patients, If Legionella spp. is detected in the water of a critical care unit and until Legionella spp. are no longer detected by culture, remove faucet aerators in the unit Reservoir: Suction bottles: Empty and clean daily and in between patients: Washing in detergent and dried, or disinfected with 1% Clorox solution, rinsed and dried, Preferably send to CSSD after completion of patient use to be disinfected in washing ‘machine and autoclaved. Patient tubing (patients to reservoir): Change daily and in between patients Tubing (wall to reservoir): Wiped daily with detergent. Date and change month Catheters plastic, PVC: Single use. Disposable wall / mobile unit hange when necessary, and between patients. Suctioning of respiratory tract secretions: 4.15.6.1. Wear sterile gloves when performing endotracheal suctioning 4.15.6.2. If the open-system suction is employed, use sterile, single-sue catheter. 4.1.6.3. Use only sterile fluid to remove secretions from suction catheter if it will bbe used for re-entry into the patient's lower respiratory tract. Mobile machines: Clean outside & change filter dally. Send to CSSD for decontamination, Perform tracheostomy under aseptic conditions. When changing a tracheostomy tube, wear a gown, use aseptic technique, and replace the tube with one that has undergone sterilization, No recommendation can be made for the daily application of topical antimicrobial agents(s) at the tracheostoma, In the home care setting, the inner cannula of tracheostomy tubes is disinfected after Cleaning with soap and cold water, using friction, with careful attention to mucous buildup in the lumen of the tube. The cannula should then be soaked in 3% hydrogen Peroxide for 20 minutes and rinsed with sterile water. The disinfected cannula is air dried on 2 clean towel and stored in a clean container, Bue Approves Apis BIS | Revlon Oot aga] TOT TareePrevention & Control of Infection HAH-PCL16 Ol DPP Applies to: All healthcare workers 4.17. Modifying Host Risk for Infection 4.17.1, Increasing Host Defense Against Infection: Administration of Immune Modulators 4.17.1.1, Pneumococcal vaccination: Vaccinate patients at risk for severe pneumococcal infections: 4171.11. Administer the 23-valent pneumococcal polysaccharide vaccine to persons aged > 65 years who have chronic cardiovascular disease (eg., congestive heart failure or cardiomyopathy}, chronic pulmonary disease (e.g, chronic obstructive pulmonary disease (COPD) or emphysema, but not asthma), diabetes mellitus, chronic liver disease [eg Cirrhosis), or cerebrospinal fluid (CSF) leaks, functional or anatomic asplenia,; immunocompromised persons aged >5 years with HIV infection, leukemia, lymphoma, Hodgkin's disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression (e.g. receipt of hemopoietic stem-cell transplant (HSCT|, solid-organ transplant, or immunosuppressive chemotherapy, including long-term systemic corticosteroids). 4.17.1.1.2. Adminster the 7-valent pneumococcal polysaccharide protein. conjugate vaccine to all children aged <2 years and to children aged 24-59 months who are at increased risk for pneumococcal disease (e.g. children with sickle-cell disease or other hemoglobinopathies, or children who are functionally or anatomically asplenic; children with HIV infection; children who have chronic disease, including chronic cardiac or pulmonary disease (except asthma), diabetes mellitus, or CSF leak; and children with immunocompromising conditions including malignancies, chronic renal failure or nephrotic syndrome, receipt of immnunosuppressive chemotherapy, including long-term conrticosteroids, and receipt of solid organ transplant), 4.17.1.2. No recommendation can be made for the routine administration of Preparations of granulocyte-colony stimulating factor (GCSF) or intravenous gamma globulin for prophylaxis against healthcare-associated Pneumonia. 4.17.1.3. No recommendation can be made for the routine enteral administration of glutamine for prevention of healthcare-associated pneumonia 4.17.2. Precautions for prevention of aspiration: As soon as the clinical indications for their Use resolved, remove devices such as endotracheal, tracheostomy, and/or enteral (ie, oF0- or nasogastric or jejunal) tubes from patients: (“ore here: aceon 208 | — Reva at TT —] race I BabaPrevention & Control of Infection E22) Preven’ : al DPP Applies to: neattncare workers 4.17.2.1. Prevention of aspiration associated with endotracheal intubation | 4.17.2.1.1. Use of noninvasive ventilation (NIV) to reduce the need for and duration of endotracheal intubation. When feasible and not medicaly contraindeated, use noninvasive. postive pressure ventation delved continuously by face or nose mask, instead of performing endotracheal intubation in | patients who are in respiratory failure and ore not needing | immediate intubation (e.g., those who are in hypercapneic | respiratory favre secondary to acute exacerbation of COPO or cardiogenic pulmonary edema), When feasible and rot medically contraindcate, use NIV as part of the weaning aroces (rom mechanically assisted ventilation) to shorten the period of endotracheal intubation 417.2..2. As much as possible, avoid repeat endotracheal intubation in patients who have received mechanically asisteeventlation 4.17.2.1.3. Unless contraindicated by the patient's condition, perform rotracheal rather than nasotracheal intubation on patients 4.72.14, If feasible, use an endotracheal tube with 2 dorsal lumen above the endotracheal cuff to. allow dramnage toy | antinuous or frequent intermittent suctioning) ef tracheal secretions that accumulate inthe patient's subglottic area. 4172.15. before cetiatig the cuff of an endotracheal tube in preparation for tube removal or before moving the tube, ensure that secretions are cleared from above the tube eu 4.17.2.1.6. Prevention of aspiration associated with enteral feeding 4.17.2.1.7. In the absence of medical contraindication)s), elevate at an angle of 30-45 degrees of the head of the be¢ of @ patient at high risk for aspiration (e.g, a person receiving mechanically assisted ventilation and/or who has an enteral tube in place). 4.17.2.1.8, Routinely verify appropriate placement of the feeding tube. 4.17.2.1.9. No recommendation can be made for the preferential use of small-bore tubes for enteral feeding. 4.17.2.1.10. No recommendation can be made for preferentially placing the feeding tubes, (e.g. jejunal tubes) distal to the pylorous. 4.17.2.2, Prevention or modulation of oropharyngeal colonization 4.17.22.1. Develop and implement a comprehensive oral hygiene rogram that might include the use of an antiseptic agent to achieve oropharygeal cleaning and decontamination for | patients. ee ranone ae 60hPrevention & Control of Infection HAW PCl-14 Title Prevention of Health Care Associated Pneumonia Applies to: All healthcare workers 4.17.2.2.2. No CDC recommendation can be made for the routine use of an oral chlorhexidine rinse for the prevention of healthcare. | associated pneumonia in all postoperative or critically ill patients and/or other patients at high risk for pneumonia 4.17.2.2.3. Use an oral chlothexidne gluconate (0.12%) rinse during the perioperative period on adult patients who undergo cardiac surgery. No CDC recommendation agents for oral decontamination to prevent VAP. 4.172 4.17.23. Prevention of gastric colonization 4.17.23.1. No CDC recommendation can be made for the preferential se of sucralfate, H2-antagonists, and/or antacids for stress bleeding prophylaxis in patients receiving mechanically assisted ventilation, 447.23.2. No COC recommendation can be made for the routine | selective decontamination of the digestive tract of all | ériticaly il, mecnanicaly vertiiated, or ICU patients ayy. No CDC recommendation can be made for routinely acidifying gastric feeding, 4.17.2.4. Prevention of Postoperative Pneumonia 4472.44, Instruct preoperative patients, especially those at high risk for contracting pneumonia, about taking deep breaths and ‘ambulating as soon as medically indicated in the postoperative period. Patients at high risk include those who will have abdominal aortic aneurysm repair, thoracic surgery, for emergency surgery; those who will receive general ‘anesthesia; those who are aged >60 years; those with totally dependent functional status; those who have had weight loss, 10%; those using steroids for chronic condi ons; history of COPO, or smoking during the preceding year; those with impaired sensorium, a history of cerebrovascular accident with residual neurologic deficit, or low (<8mg/dt) or high (222me/dl) blood urea nitrogen level; and those who will have received >4 units of blood before surgery. 2. Encourage all postoperative patients to take deep breaths, move about the bed, and ambulate unless medically contraindicated. 3. Use incentive spirometry on postoperative patients at high risk for pneumonia 4.17. 4.47. (“one hewons: nope 20s | Reviovone aga an? | Tanai Faget?Prevention & Control of Infection HaHPClaa 1: Ba DPP | Apoiies to: Prevention of Health Care Associated Pneumonia All healthcare workers 4.17.25. Administration of antimicrobial agents other than in selective 4.17.26. Turning or rotational therapy: No CDC recommendation can be made for 4.18. The Ventilator Care Bundle to Prevent Ventilator-Associated Pneumonia 4.18.1. The ventilator bundle is @ group of evidence based practices that, when implemented together for all patients on mechanical ventilation, result in dramatic reductions in the incidence of VAP. The ventilator bundle consist of five components that have been correlated with reduction in the rate of VAP, They include: 418.4, 4.18.1.2, 4.18.13, 4.18.1.4. Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) 4.18.1.5. Oral hygiene (recently included) 4.18.2. Compliance with the ventilator bundle can be measured by simple assessment of the ‘completion of each item. The approach has been most successful when all elements are implemented together. An “all or none” strategy. 4.17.2.4.4. No COC recommendation can be made about the routine use Of chest physiotherapy on all postoperative patients at high risk for pneumonia, decontamination of the digestive tract: 4.17.2.5.1. Systemic antimicrobial prophylaxis; No recommendation can be made about the routine administration of systemic antimicrobial agent(s) to prevent pneumonia in critically ill patients or in those receiving mechanically-assisted ventilation, 4.17.25.2. Scheduled changes in the class of antimicrobial agents used for empiric therapy: No CDC recommendation can be made for scheduled changes in the class of antimicrobial agents Used routinely for empiric treatment of suspected infections ina particular group of patients the routine use of turning or rotational therapy (i.e. placing patients on beds that turn on their longitudinal axes intermittently or continuously) for prevention of healtheare-associated pneumonia in critically ill and | immobilized patients. | Eleva on of the head of the bed between 30 and 45 degrees. Dally “sedation vacation” and daily assessment of readiness to extubate Peptic ulcer disease (PUD) prophylaxis Dine ved Aopen 3 Revion Ove hugan 3007 | vaneka Prevention & Control of Infection HAH-PCL-t4 DPP |Appiies to: altheatthcare workers 4.19. Prevention and Control of Healthcare ~Associated Legionaires Disease 4.19.1. Primary 4.19.1.1. 4.19.1.2, 4.19.1.3, 4.19.1.4, 449.1.5. 419.16, 419.7, 4.19.2. Deconta 4.19.21 prevention when no cases have been documented | Maintain @ high index of suspicion for the diagnosis of healthcare- associated Legionnaires disease and perform laboratory diagnostic tests (both culture of appropriate respiratory specimen and the urine antigen est) for legionellosis on suspected cases, especially in petients who are at high risk for acquiring the disease (e.g. patients who are immune. suppressed, including patients receiving systemic steroids; patients aged >65 years; or pa ents who have chronic underlying disease such as diabetes mellitus, congestive heart failure, and COPD) Do not perform routine culturing of water systems for Legionella spp. Because there are no transplant units whose patients are at high risk for Legionella infection, Preferentially use sterile water for rinsing nebulization devices and other semi-critical respiratory-care equipment after they have been cleaned or disinfected. If this is not feasible, rinse the device with filtered water (i.e. water that has been through a 0.2.u Iter) or tap water and then rinse with isopropyl alcohol and dry with forced air or in a drying cabinet. Use only sterile water to fill reservoirs of devices used for nebulization. Faucet aerators: If Legionella spp. Are detected in the water of @ unit and until Legionella spp. Are no longer detected by culture, remove faucet Berators in areas for severely immunocompromised patients Water-distribution system: Where practical maintain potable water at the Outlet >51 C or <20 C, especially in areas housing patients at high-risk. IF Water is maintained >51 C, use thermosta c mixing valves to prevent scalding, Primary prevention If legionellae are detected in the potable water supply of a unit, and until legioneliae are no longer detected by culture yminate the water supply If the heated water system is implicated: Decontaminate the heated water system either by superheating or by hyperchlorination. TO superheat, raise the hot water temperature to 71°C-77°C and maintain at that level while progressively flushing each outlet around the system. A minimum sh _me of 5 minutes has been recommended. Post warning signs at each outlet being flushed to prevent scald injury to patients, staff, or Visitors. If possible, perform flushing when the building has the fewest occupants (e.g, nights and weekends). Ravin Ove hapa] 107 wanseE I Pees oti?Okey) BB. eee DPP. |Avpies:o: allheattheare workers Prevention & Control of Infection | HaHpci-t4 Prevention of Health Care Associated Pneumonia 4.9. 419.23. If cooling towers or evaporative condensers are implicated, 4.19. 4.19. 4.19.26. Provide HSCT patients with sterile water for tooth brushing or drinking or 4.19.27. Do not use water from faucets with Legionella-contaminated water in 4.19.3, Secondary prevention if there is laboratory ~ confirmed hesith care associated Legionellosis: 4.19. 4.19.3.2 4.19.3.3. Ifa source of infection is identified by the epidemiologic & environmental 4.20. Prevention and Control of Healthcare-Associated Pertussis 4.20.1, Vaccination for primary prevention 4.20.1.1. No CDC recommendation can be made for routinely vaccinating adults, 4.20.2. Vaccination for secondary prevention 4.20.2.1. No COC recommendation can be made for vaccinating adults, including For systems on which thermal shock treatment is nat possible, use shock Chlorination as an alternative. Add chlorine, preferably overnight, to achieve a free chlorine residual of >2 mg/L (> 2 ppm) throughout the system. This might require chlorination of the water heater or tank to levels of 20-50 mg/t (20-50 ppm). Maintain the water pH between 7.0 and 8.0. Clean hot-water storage tanks and water heaters to remove accumulated scale and sediment, econtaminate the cooling ~ tower system Restrict severely immunocompromised patients from taking showers, Use water that is not contaminated with Legionella spp. For HSCT patients’ sponge baths, for flushing nasogastric tubes, patients; rooms to avoid creating infectious aerosols. Conduct an epidemiologic investigation through a retrospective review of ‘microbilogic, serologic, and postmortem data to identify cases, and begin an intensive prospective surveillance for additional cases of healtheare- associated Legionnaires disease. If evidence of continued transmission exists, conduct an environmental Investigation to determine the source(s) of Legionella spp. y collecting water samples from potential source(s) of Legionella spp. By collecting water samples from potential sources of aerosolized water and saving and subtyping isolates of Legionella spp. Obtained from patients and the environment, investigations, promptly decontaminate the water source 2s mentioned above. including healthcare workers, with the acellular pertussis vaccine at regular intervals (e.g. every 10 years) healthcare workers, during an institutional outbreak of pertussis ‘Date proved gs 0S ‘Revo ate: Agua 3017 nacre I rr |Prevention & Control of Infection | wanpcisa Om Bes. DPP_ Avpiiesto Prevention of Health Care Associated Pneumonia All healthcare workers 4.206. (Cee toposes toga 2013 | Reviton ie men 3007 ae 4.20.5.2, 4205.3. In conjunction with employee-health personnel, treat symptomatic healthcare personnel who are proven to have pertussis or personnel who ‘are highly suspected of having pertussis with the same antimicrobial regimen, as detailed for chemoprophylaxis of case-contacts, mentioned below. Restrict symptomatic pertussis-infected healthcare worke's from work during the rst S days of their receipt of an microbial thevapy. Use of a prophylactic antibiotic regimen for contacts with pertussis 4.20.6.1. 4.20.6.2. 4207.1. 4.20.7.2. Administer a macrolide to any person who has had close contact with persons with pertussis and who does not have hypersensitivity or intolerance to macrolides. 4.20. Except in infants aged <2 weeks, use erythromycin (ie. erythromycin estolate, 500 mg four mes daily or ‘erythromycin delayed-release tablets, 333 mg three mes) daily for adults, & 40-50 mg/kg day for children) for 14 days For patients who are intolerant to erythromycin or for infants aged <2 weeks, use any of the following regimens: azithromycin for 5-7 days (at 10-12 mg/kg/day) or for S days (at 10 mg/kg on day one followed by 4 days at S mg/kg/day) for infants and young children; or claritheomyein for 10-14 days (at S00 mg twice a day for adults or 15 ~ 20 mg/kg/day in two divided doses for children), For chemoprophylaxis of persons who have hypersensitivity or intolerance to macrolides, use (except in the case of a pregnant woman at term, 2 nursing mother, or an infant aged <2 months) trimethoprim: sulfamethoxazole for 14 days (at one double-strength tablet twice a cay for adults and 8 mg/kg/day TMP, 40 mg/kg/day SxT @ day in 2 divided doses for children) 4.20.7. Work Exclusion of Asymptomatic Healthcare Workers Exposed to Pertussis Do not exclude from patient care a healthcare worker who remains asymptomatic and is receiving chemoprophylaxis after an exposure to a case of pertussis (ie. by direct contact of one’s nasal or buccal mucosa with the respiratory secretions of an untreated person who is in the catarrhal or paroxysmal stage of pertussis). If possible, exclude an exposed, asymptomatic healthcare worker who is Unable to receive chemoprophylaxis from providing care to chile aged <4 years during the period star ng 7 days a er the worker's first possible exposure un | 14 days a er his last possible exposure to a case of pertussis.Ok) Prevention & Control of Infection Haw-pcia4 x] Prevention of Health Care Associated Pneumonia DPP Apoliesto: allheaithcare workers | 4.20.8, Limiting visitors: Do not allow persons who have symptoms of respiratory infection to visit pediatric, immunocompromised, or cardiac patients. 4.21. Prevention and Control of Healthcare ~ Associated Pulmonary Aspergillosis 4.21.1. When planning construction, demolition, and renovation activities in and around the hospital, assess whether patients at high risk for aspergillosis are likely to be exposed to high ambient-air spore counts of Aspergillus spp. from construction, demolition {and renovation sites, and if so, develop a plan to prevent such exposures, 4.21.2. During construction, demolition or renovation activities construct impermeable barriers between patient-care and construction areas to prevent dust from entering the patient-care areas 4.21.3. Direct walker traffic that come from construction areas away from patient care areas to limit the opening and closing of doors or other barriers that might cause dust ispersion, entry of contaminated air, or tracking of dust into patient care areas, 4.21.4. Do not allow fresh or dried flowers or potted plants in patient-care areas for severely immnunocompromised patients 4.21.5. When a case of aspergillosis occurs 4.21.51. Obtain and use the following information to assess whether the infection is healthcare-related or community-acquired: background rate of disease | at the hospital; presence of concurrent or recent cases, as determined by 2 review of the hospital microbiologic and histopathologic reports; length of patient's stay in the hospital before onset of aspergillosis; patient's stay at, visit of, or transfer from, other hospitals or other locations within the hospital; and the period the patient was exposed outside the healthcare facility after the onset of immunosuppression and before onset of aspergillosis. 4.21.5.2. If no evidence exists that the patient’s aspergillosis in hospital-acquired, continue routine maintenance procedures to prevent healtheare associated aspergillosis. 4.21.5.3. if evidence of possible hospital-acquired infection with Aspergillus spp. Exists, conduct an epidemiologic investigation and an environmental assessment to determine and eliminate the source of Aspergillus spp. 4.21.54. Use an antifungal biocide (e.g. copper-8-quinolinolate) that is registered with the Environmental Protection Agency for decontamination of structural materials, 4.22. Prevention and Control of Healthcare-Associated Influenza 4.22.1, Vaccination of patients: 4.22.1.1. Offer vaccine to inpatients and outpatients at high risk for complications from influenza beginning in September and throughout the influenza season, ‘Deke ores agin /FSIS [Avion One Aust 057] manne masa 7oa Be Prevention & Control of Infection | HaH-pcr-14 Prevention of Health Care Associated Pneumonia DPP Applies to: All healthcare workers 4.22.2. 4.22.3, Prevention of Person-to-Person Transmission: Apply the appropriate transmission: based precautions as mentioned in the Droplet Precautions Policy. 4.22.4. Date proved ape 4.2.1.2. Groups at risk for in uenza related complica ons include those aged >65 years adults and children aged>6 months who have chronic disorders of the pulmonary or cardiovascular system, including asthma; adults and children who have required regular medical follow-up or hospitalization Curing the preceding year because of chronic metabolic diseases (including Giabetes mellitus), renal dysfunction, or hemoglobinopathies, or immunisuprression including immunosuppression caused by medications or HIV}; children and adolescents (aged 6 months ~ 28 years) who are receiving long term aspirin therapy, and women who will be in the second (or third trimester of pregnancy during the influenza season, 4.2.1.3. In addi on, 0 er annual in uenza vaccina on to all persons aged 50-64 years, close contacts of children aged <24 months, and healthy children aged 6-23 months. Vaccination of staff 4.2.2.1. Beginning in October each year, provide inactivated influenza vaccine for all personnel including night and weekend staff. Throughout the influenza season, continue to make the vaccine available to newly hired personnel and those who initially refuse vaccination. if vaccine supply is limited, give highest priority to staff caring for patients at t=greatest risk for severe complications from influenza infection. Educate healthcare personne! about the benefits of vaccination and the potential health consequences of influenza illness for themselves and their patients. Take measures to provide all healthcare personnel convenient access to inactivated influenza vaccine at the work site, free of charge, as part of employee health program. Use of Antiviral Agents when a hospital outbreak of influenza is suspected or recognized: 4.2.4.1. Administer amantadine, rimantadine, or oseltamivir as prophylaxis to all aptients without influenza illness in the involved unit for whom the antiviral agent is not contraindicated (regardless of whether they received in uenza vaccina ons during the previous fall) for minimum of 2 weeks or un | approximately 1 week a er the end of the outbreak. Do not delay administration of the antiviral agent(s] for prophylaxis unless the results of diagnostic tests to identify the infecting strain(s) can be obtained within 12024hours a er specimen collec on. 4.2.4.2. Administer amantadine, rimantadine, oseltamivir, or zanamivir to patients acutely ll with in_uenza within 48 hours of illness onset, Choose the agent appropriate for the type of influenza virus circulating in the community Revenue Negi] 207 Tange.ow Be DPP _Aooleso: Prevention & Control of Infection HaH-Pci-14 Prevention of Health Care Associated Pneumonia All healthcare workers 4.23. Performance Indicators to assist infection control personnel in assessing personnel adherence tothe policy, the following performance measures are suggested: 4.23.1. Monitor rates of VAP; can use established benchmarks and definitions of pneumonia 4.23.2. 4.22.43, 4.22.85. 4.22.46, 4.2.4.7. If the cause of the outbreak is confirmed or believed to be influenza and 4.22.48, 4.22.49, Provide need for personnel to adhere to infection control practices that reduce the incidence of VAP. Establish a program for influenza vaccination and monitor the percentage of eligible patients Offer antiviral agent(s) (amantadine, rimantadine, or oseltamivir) for prophylaxis to unvaccinated personnel for whom the antiviral agent is not contraindicated and who are in the involved unit or taking care of patients at high risk. Consider prophyiax’s for all healthcare personnel, regardless of their vaccination status, if the outbreak is caused by a variant of influenzs that is not well matched by the vaccine. No recommendation can be made about the prophylactic administration of zanamivir to patients or personnel Discontinue the administration of influenza antiviral agents to patients or Personnel of laboratory tests confirm or strongly suggest tht influenza is not the cause of the hospital outbreak, vaccine has been administered only recently to susceptible patients and personnel, con nue prophylaxis with an an viral agent un |2 weeks a er the vaccination. To reduce the potential for transmission of drug-resistant virus, do not allow contact between persons at high risk for complications from influenza and patients or personnel who are taking an antiviral agent for treatment of con rmed or suspected in uenza during and for 2 days a er the latter discontinue treatment, Other measures in acute care hospitals: When influenza outbreaks, especially those characterized by high attack rates and severe illness, ‘occur in the community and/or hospital 422.4.9.1. Curtail or eliminate elective medical and surgical admissions, 4.22.4.9.2. Restrict cardiovascular and pulmonary surgery to emergency cases only Restrict persons with influenza or influenza-like illness from visiting patients 4.22.4.9.4. Restrict personnel with influenza or influenza-like illness from patient care feedback to the staff about the hospital VAP rates and reminders about the who receive the vaccine. Revson Oe fuga /2007 —] manne I Pagel 1ome Prevention & Control of Infection DPP Applies to: allheathcare workers 4.23.3. Before and during the influenza season, monitor and record the number of eligible healthcare personnel who receive the influenza vaccine and determine the desired unit-and-facility-specifie vaccination rates, 4.23.4. uring construction or renovation activities in the facility, moniter personnel adherence to infection-control measures (eg. use of barriers, maintenance of negative pressure room) that are aimed at minimizing dust dispersion in patient care areas. Review all cases of healthcare-associated aspergillosis to determine the presence of remediable environmental risks. 5.0. Attachments: None 6.0. Reference: 64. CDC:h_pi//mww.cde.gov/mmwr/preview/mmwrhtmi/r5303a1.ntm 6.2. Medscape: www.medscape.com/viewar cle/482702 hoped huge SOE Revi ate ua) 1077 ianecte Papel?Oe) Prevention & Control of Infection ne Title: Prevention of Health Care Associated Pneumonia DPP_|Aopiiesto:_Aheathcare workers Signatory box Prepared by’ Ms. Maria Cecilia Becalas Infection Control Supervisor Approved by: Dr, Hussien Hassan Satari br, Mamd Salah Quality Improvement Director Mr. Reda Al-All Chief executive Officer (Can toproves foaar 015 Fenson oases /20, Tansee Chairman of Infection Control Committee HAH-PCI-14 ‘ad Sole Oheeto: 4 |