Local Guidelines in Infection Prevention and Control
RELATED TO INFECTION
PREVENTION & CONTROL
Vangie. A. America, R.N.
May 17, 2017
Crown Plaza Hotel
1. To update infection control practitioners with the local
guidelines related to Infection Prevention and Control.
2. To guide the participants in implementing local guidelines
related to infection prevention and control.
Development of Standard for Infection Control
1986- DOH Department Order to create 3 important
1993- Philippine Hospital Infection Control Society an
affiliate of the pHil Hospital Association
1996 DOH reitedrated the 1986 order but with no
2000 Need to have Standards of Infection control
• 2004- POST SARS- Development of Standard after
collaboratuon with DOH and NGO professional
societeies (PHICS, PHICNA<<PSMID)
• Technical working Group created to develop and
Department Order No. 1187 (2004)
Subject: Strengthening of Hospital Infection Control
Program (HICP) in DOH Hospitals
- Creation of HICC
- designation of Hospital Infection control Program
- Surveillance officer
- Development of Hospital Policies and standard
Administrative Order No. 2016-002- January 18,
Subject: National Policy on Infection prevention and Control in
• Enabling all healthcare facilities to implement IPC in
mandatory considering the development and spread of
antimicrobial resistant organisms and the emergence of new
• Infection Prevention and Control is a vital component of
quality healthcare and patient safety, thus, all healthcare
facilities in th Phil. shall implement IPC program effectively.
Establishing IPC program:
•Identify interested and key hospital personnel as members of
•Accomplish a written description of the program (Infection
•Goals, objectives, structure
•Specific surveillance, prevention, control, education, and
Establishing a program
•Implement and monitor
•Annual evaluation on the IC program
•Assess the activities
•Identify any changes in goals, objectives, structure
•Assess the value of the program to the hospital
NATIONAL STANDARDS IN INFECTION
CONTROL FOR HEALTHCARE FACILITIES
• Department of Health
• Philippine Hospital Infection Control Society
• Phili[ppine Hospital Infection Control Nurses
Why is Infection control Important?
1. Increasing incidence of health care associated infection
caused by antibiotic resistant organisms.
2. More susceptible patients admitted in HCF
- very old and very young
- Immunosuppressed patient
- Invasive diagnostic and therapeutic procedures
- chronic diseases
3. Emergence of life threatening infection like SARS and other
4. Threat of Pathogeninc Avian Flu pandemic and terrorism.
Impact of HCAI:
- need for hospitalization
- income loss
- pain and suffering
•ARE ALL HEALTHCARE FACILITY
PREPARED TO RESPOND TO
EMERGING AND RE-EMERGING
•Means the capability of the HCF to prevent
and control highly transmissible infection
“ EFFECTIVE NATIONAL INFECTION
CONTROL PROGRAM WITH UNIVERSALLY
ACCEPTED STANDARDS” implemented by all
HCF and coordinated by the chief of
NATIONAL POLICY ON INFECTION PREVENTION
AND CONTROL IN HEALTH CARE FACILITY:
• Draft/proposals/presentations during PHICS convention
• Sept. 27,2012- creation of the nationasl Cneter gfor Health
• Technical working group for the Development of National Policy
• January 8, 2016 finally signed.
• There are written guidelines, policies, and procedures that
adress IPC and detection the healthcare facility.
DOH GUIDELINES ON Disinfection and
• AnneX B: Administrative Order No. 2012-0012
• Pursuant to AO 2011- 0020 entitled “
Streamlining of Licensure and Accreditation of Hospitals”
Streamlining of regulatory processes shall recognize DOH licensed
hospitals as Center for safety without a need for a separate survey by
- Patient safety and infection control are indicators that health
regulatory body deemed it necessary and that stakeholders should be
equipped with knowlegde and expertise on institutionalizing the
implementation of quality assurance where patient safety is the key
• Anchored on DOH licensing and PHILhealth Acreditation
standards of safety would prevent health care associated
A. The recommended guidelines covers cleaning, disinfection
and all typres of sterilization processes in hospitals and
whenever applicable, in other healthcare facilities.( ex.
Ambulatory surgical Clinics, birthing areas or lying in , Dialysis
B. This guideline also apply to reusable medical devices in CSSD
and operating theaters in hospitals.
1. All health care facilities shall follow good infection control
and prevention practices in accordance with DOH guidelines
and accepted international standards.
2. All items to be disinfected or sterilized shall follow the
Spaulding classifications system based on their degrees of risk
of infection during patient care.
3. Proper precautions shall be implemented to protect the staff,
including provision for adequate ventilation and use of
Personal Proective equipment.(PPE)
4.All health care facilities shall developwritten policies and
standard operating procedures (SOP) involving the following:
A.. Recieving of contaminated items
B. Handling, collection, and transport of contaminated items
C. Cleaning and other Decontamination processes
D. Packaging, preparation and sterilization
E. Installation, care and maintenance of sterilizers.
F. Quality Control
g.Quality process improvement
5.The hospital staff shall establish policies and procedures to ensure
the safe and effective use of instruments sets and interdisciplinary
collaboration between CSSD , surgical services and loaning
6.The head of the surgical department , chief nurse or infection
control officer shall evaluate sterilization equipment or cosumables
and disinfecting agents that will be purchsed for and utilized in the
facility ( with the assistance of Consultants and Senior Staff,)
7. The surgical services team shall work collaboratively with CSSD staff
to establish a quality control program to monitor the cleaning,
disinfecction, and sterilization of surgical instruments and supplies.
8.There shall be a documented policies on recall procedures for
failure(s) of sterilization.
9. Healthcare facicilies shall promote a culture of safety by
conducting patient safety rounds in the Operating theater that
focos on the environment and best practices.
1. PERSONNEL- staff shall possess the following:
a. Training and continuing education.
b. Qualifications and training of staff in sterile processing
C. Qualifications and training of service staff
D.Certificate of training from a professional organizationrecognized
E. Good health and personal hygiene.
F. Proper attire.
2. EQUIPMENT- shall have the following :
a. Instruction Manual
b. Documented polilcies and procedures on installation, care
and maintenance of sterilizers including records on
1. preventive maintenance
• 2. Calibration
• 3.Record keeping
a. Physical Facility shall follow the planning and designs
guidelines prescribed by DOH.
b. There shall be records on monitoring the safety of the
environment, such as standards for water quality, cleaning
procedure, sharps and water management.
c. A centralized reprocessing unit for cleaning, disinfecting and
packaging and sterilizing medical devices for cssd and opreating
theaters is recommmended for quality control for each hospital
D. The centralized reprocessing unit ideally shall be divided into
at lest three areas:
1. Cleaning/decontamination area
2. Packaging and sterilization area
3. Sterile storage area
E. Cleaning /decontamination area which receives and processes
contaminated medical devices are regarde as dirty area and
shall be physically separated from the other clean area.
F. Unidirectional /one way traffic of medical devices from the
dirty area to the clean areas is recommended. All new
renovated reprocessing units shall adopt this in the design.
G. Floors and walls of the reporocessing unit shall be constructed
of material capable of withstanding chemical agents used for
reprocessing. Floors in the cleaning and decontamination area
shall be made of non-slippery material.
H. Ceiling and wall surfaces shall be constructed of non –
I. Handwashing facilitiy shall be provided and conveniently
located near all areas inwhich devices are cleaned and
prepared for sterilization to facilitate handwashing.
J. The facility shall have a designated area and secure area
((cabinet with lock) for the documentation purposes.
K. Recommended ventilation, humidity and temperature requirement of
different areas in the central processing department. All new and
renovated reprocessing units shall comply with the requirements.
1. Cleaning /decontamination area – dirty
Air flow – negative (In)
10 air changes per hour
30 to 60 % - relative humidity
less than 24 ) degrees centigrade – working temperature
2. Packaging and sterilization area- clean
- Positve air flow (Out)
10 air changes/hour
30 to 60 % humidity
20 to 23 degrees celeus
3. Sterile storage area- clean
Positive airflow (Out)
4 air changes /hour as minimum
<70 % humidity
< 24 degress centigrade - working temp.
4.Quality Assurance Program
a. A quality assurance system shall be established to ensure proper
sterilization and to routinely monitor the entire process
5. Requirements of Occupational Health
a. All staff involved in the reprocessing of medical devices shall be
trained and knowledgeable about the possible biologic, chemincal,
and environmental hazards.
b. Staff shall put on appropriate PPE including gloves, gowns, eye
protection and face masks. Or shields, and respirastory protection
devices during the entire process of cleaning and
decontamination.PPE is optional during packing (except cap) and
6. Documentation and Reporting
a. Standard operating procedure (SOP) shall be formulated
in every reprocessing unit in the hospital to define and standardize
work practice. The SOPs shall be aligned with these guidelines .
Risk management of encountered hazard in the sterilization
process shall be part of the SOP’s and available at all times.
b. the equipment maintenance , sterilization records and all
other quality control documents shall be retained for at least 5
c. All incidents, including sentinel events, that may
potentially cause harm to patients or staff shall be documented
Requirements for Process of Sterilization:
A. Level of reprocessing of medical devices shall be selected
based on the level of risk classified according to the Spaulding
Classifications.( Critical, Semi-critical and non critical).
B. Cleaning and Chemical Disinfection
A. All medical devices shall be cleaned before any reprocessing to
achieve disinfection and sterility . Effective cleaning can physically
remove large numbers of microorganisms. It also remove organic
matter which may bind and inactivate chemical activity of
All medical devices shall be cleaned/decontaminated before
sterilization either through steam or chemical vapor /gas (
ethylene oxide, hydrogen peroxide). The sterilization process
should be validated and closely monitored physically, chemically
and biologically. Before sterilization cleaned /decontaminated
medical devices must be packed using wrap materials that allow
penetration of the sterilant. ( Steam and chemical vapor/gas are
the only acceptable sterilization method s to ensure patient safety
in the Philippines.
• Quality Control
• Sterilization process monitoring include physical monitors , Cis
and the BIs. Each of these devices plays a distinct and specific
role in sterilization process monitoring and each is
indispensable to sterility assurance.
GUIDELINES ON HIV:
Republic ACT 8504- “ Philippine AIDS PREVENTION AND CONTROL ACT OF 1998”
Article 11 : section 13
Guidelines on surgical and similar procedures-
The DOH in consultation and in coordination with concerned professional
organizations and hospital associations , shall issue guidelines on precautions against
HIV transmission during surgical, dental, embalming tattooing or similar procedure .
The DOH shall also likewise issue guidelines on the handling and disposition of
cadavers, body fluids wastes of person known or believed to be HIV positive
All necessary PPE such as gloves, mask, goggles and gowns shall be made available to
all physicians, and healthcare providers and similarly exposed personnel at all times.
Administrative order No.2009-0016- May 20,2009
Subject: Policies and guidelines on the prevention of Mother to
child Transmission(PMTCT) of HIV
Components of PMTCT:
Management of labor and delivery of HIV positive pregnant
HIV infected pregnant women who are about to deliver
should be referred and admitted to the nearest treatment hub.
The attending physician should consider vaginal delivery if the
following criteria are satisfied:
1. HIV medications have been taken during pregnancy
2. No previous uterine surgery or elective cesarean section
3.No signs and symptoms of STI
4. No indications of prolonged labor
Cesarean section is recommended if vaginal delivery cannot be
performed due to presence of contraindications. Cesarean section
should be scheduled prior to the rupture of the membrane.
HIV pregnant women need not be isolated during labor and
delivery because of their HIV status . Hospital staff must use
standard precautions in all patients regardless of their status.
• Counseling of HIV infected mother regarding feeding option
should include information about the risk and benefits of
• Exclusive breast feeding is strongly recommended for the first 6
months of life.
Administrative order No.2010-0033- Dec.6,2010
Subject: Revised implementing rules and regulations of PD 856 Code
on sanitation in the Philippines-Disposal of Dead persons
General Guidelines: Article I: Section !:
Burial Ground Requirements
1.1 The requirement for a death certificate before burial may be
waved in the case of special circumstances when the death
certificate cannot be issued on time. These include but are limited to
1.1a the deceased died from a dangerous communicable
disease and must be buried within 12 hours.
1.1b The family members of the deceased have requested
immediate cremation without embalming or viewing.
1.1 c he kin opt to immediate burial
1.1d Religious beliefs or tradition such as Islam or Jewish – faith
calls for burial within 12 hours.
1.2 No remains shall buried without a burial permit issued by
city/municipality where the burial will take place
1.3 Funeral parlors or embalming establishment s shall not hold
unclaimed bodies longer than 60 days or sanction shall be imposed
by the local health authority.
1.4 The following are declared as dangerous communicable diseases:
1.4 a Hepatitis B and C
1.4 b Rabies
1.4 c Invasive group A streptococcal infections
1.4 d Transmissible spongiform encephalopathies (CJD or
1.4e HIV /AIDS
1.4g Viral Hemorrhagic fevers( African Ebolas, LASSA, or
1.4h Yellow fever
1.4 I SARS
1.4j Other communicable disease that shall be declared by the DOH
• 1.5 The remains shall be placed in a plastic cadaver bag or other
durable , airtight container at the point of death and a biohazard
tag attached, provided that the container shall not be opened
for viewing or any other purpose prior to burial or cremation.
DOH ANTIMICROBIAL STEWARDSHIP PROGRAM IN
• Is the concerted implementation of systematic ,multidisciplinary ,
multi pronged interventions in both public and private hospitals
in the Philippines in order to improve appropriate use of
antimicrobials , which is essential for preventing the emergence
and spread of antimicrobial resistance (AMR).
Specifically the AMS Program aims to:
1.Promote rational and optimal antimicrobial therapy.
2. To improve patient outcomes and decrease healthcare
costs by reducing unnecessary antimicrobial use ,
adverse drug events, mortality and morbidity from infections
(including secondary infections caused by resistant pathogens.
3. to foster awareness on the global and country situation on the
threat of AMR and the compelling need to address it.
4. Effect positive behavior and or institutional changes through
educational and persuasive interventions towards improving the
use of antimicrobials by the prescribers, dispensers and other
health professionals and the patient.
CORE ELEMENTS OF AMS PROGRAM:
A dedicated multidisciplinary AMS committee and Team
supported by the hospital administration, shall be responsible to
successfully implement, perform and monitor the AMS Program in
2. POLICIES, GUIDELINES, CLINICAL PATHWAYS
Antibiotic policies and standardized clinical guidelines and
clinical pathways on the treatment and prophylaxis of infections
provide evidence –based guidance to clinicians and other
healthcare professionals on the management of infectious
diseases and in the selection of the most appropriate antimicrobial
3. SURVEILLANCE OF ANTIMICROBIAL UTILIZATION (AMU) AND
ANTIMICROBIAL RESISTANCE (AMR)
AMU & AMR are intricately related surveillance of AMU
provides important insights into prescribing patterns that may
explain for the evolution of AMR , and is useful in the development
and evaluation of AMS interventions. AMR surveillance allows for
the development of an antibiogram that informs empiric
antimicrobial choice, characterises the impact of AMS activities
on resistance and identification of specific AMR problem areas
that needs to be addressed notwithstanding infection control
The AMS Program employs a coordinated multi-pronged ,
multi-disciplinary approach to safeguad and optimize use of all
antimicrobials used within the hospital. Active interaction
between the AMS team and prescribers ( and other healthcare
professionals) is pivotal in encouraging compliance to AMS
interventions and being able to effectively persuade and influence
change in prescribing practices.
AMS- CORE ELEMENT
AMS practitioners need to gain COMPETENCY THROUGH COMPREHENSIVE
EDUCATION AND CLINICAL TRAINING TO EFFECTIVELY AND SAFELY PERFORM AMS
EDUCATION OF ALL HEALTHCARE PROFESSIONALS ON THE PRINCIPLES OF
JUDICIOUS USE OF ANTIMICROBIALS IS ALSO NECESSARY TO ENABLE POSITIVE
6. PERFORMANCE EVALUATION:
MEASURING PROCESS AND CLINICAL INDICATORS TPO ASSESS THE
OVERALL QUALITY MANAGEMENT IMPROVEMENT AND EFFECTIVENESS OF AMS
INTERVENTIONS IS FUNDAMENTAL IN GUIDING THE PROGRSSIVE
IMPLEMENTATION OF THE PROGRAM TOWARDS ACHIEVING THE GOAL TO COMBAT