by Ms. Dominga C. Gomez

1. NATIONAL STANDARDS IN
INFECTION CONTROL FOR
HEALTHCARE FACILITIES
Department of Health
Philippine Hospital Infection
Control Society
Philippine Hospital Infection
Control Nurses Association

2. Why is Infection Control
Important
1. Increasing incidence of healthcare
associated infection caused by
antibiotic resistant organisms.
2. More susceptible patients admitted in
HCF.
– Very old and very young
– Immunosuppressed
– Invasive diagnostic and therapeutic
procedures
– Chronic diseases

3. Why is Infection Control
Important
3. Emergence of life threatening
infection like SARS and other
emerging infections.
4. Threat of Pathogenic Avian Flu
pandemic and terrorism.

4. Cost of Health Care
Associated Infection
PERSONNEL
• Need for
hospitalization
• Income loss
• Pain and suffering
• Disfigurement/
Disability
• Death
INSTITUTIONS
• Loss of revenue
• Extra duty
• Liability insurance
• Malpractice
• Reputation

5. Cost of Health Care
Associated Infection
BSI Pneumonia UTI
Extra days
confinement
15 11 13
Added cost US$ 2,619 US$ 2,051 US$ 1,970
Rosenthal and Migone. Nosocomial Infections Costs And Extra Days In Intensive
Care Units In Argentina. Prospective Cohort Matched Cases.
IV Infections Control And Hospital Epidemiology
Pan American Congress. 2002, Cancun, Mexico.

6. ARE HEALTHCARE FACILITIES in
the PHILIPPINES PREPARED
TO RESPOND TO EMERGING and
RE-EMERGING INFECTIONS?

7. Country preparedness
means
Capability to prevent and control highly transmissible
infection
through
An Effective National Infection Control Program
with universally accepted standards
implemented by
All Healthcare Facilities
and
Coordinated by the
CHIEF OF HOSPITAL

8. Development of Standard in
Infection Control for Health Care
Facilities
Historical background:
1986 DOH Department order to create 3
important hospital committees.
1992 Philippine Hospital Infection
Control Society affiliate of
Philippine Hospital Association.
1996 DOH reiterated 1986 order but
with no implementing guidelines.

9. Development of Standards in
Infection Control for Health Care
Facilities
2000 *Need to have Standards of
Infection Control Programs.
2004 * Post SARS – Development of
Standard after collaboration with
DOH and NGO professional
societies (PHICS, PHICNA, PSMID)
- Technical Working Group created
to develop/formulate standards

10. National Policy on Infection
Prevention and Control in
Healthcare Facilities
• Draft/Proposals/ Presentations during
PHICS Conventions
• Sept 27, 2012- Creation of the National
Center for Health Facility Development
Technical Working Group for the
Development of the National Policy on
Infection Prevention and Control
• Finally signed January 8, 2016

16. • July 30 2008
• Administrative Order No 0023
• Subject: National Policy on Patient Safety
• Key Priority area…includes strengthening
of infection control standards,
maintenance of environment of care
• And waste management standards

17. Development of Standards in
Infection Control for Health Care
Facilities
2005 *Draft of Standards sent to
professional societies for
their comments/suggestions
- Final document – now in print.
- Updated- 2009

18. Standards in Infection
Control for Health Care
Facilities
Standards on:
I Management, Structure, Functions
and Responsibilities
II Policies, Guidelines and Procedures
III Microbiology Service
IV Surveillance
V Education and Training

19. I. Standard on Management
Structure and Functions
and Responsibilities

20. Management, Structure,
Function and
Responsibilities
Each health care facilities (HCF) shall have
a coordinated institutional program
provided with:
• Significant and adequate personnel with
clearly defined responsibilities,
commensurate authority, clear lines of
communication.

21. Management, Structure,
Function and
Responsibilities
Each health care facilities (HCF) shall have
a coordinated institutional program
provided with:
• Resources to facilitate effective
implementation of infection control
program.

22. The Infection Control Committee created
under the Chief of Hospital serves as the
management structure of the Health Care
Facilities.

23. The Infection Control Committee (ICC) has a
multidisciplinary membership composed of:
• Chief of Hospital or his designated
representative.
• Core Members
• Auxiliary members

24. The ICC Core Members
composed of:
• Administrative Officer or equivalent
• Representative from:
– Clinical Departments including Infectious
Disease Section
– Nursing Service
– Microbiology Laboratory
– Special & High Risk units
• Emergency Room
• Operating Room
• Dialysis Unit
• Intensive Care Unit
• Endoscopy Unit
• Transplant Unit

25. Auxiliary Members
Representative from:
• Employees Health Service
• maintenance or Engineering
Service
• Pharmacy
• Central Sterilization Unit
• Dietary Service
• Linen and Laundry Service

26. Auxiliary Members
Representative from:
• Purchasing and Supply
Department
• Housekeeping Department
• Linked healthcare facilities
• Clinical Laboratory
• Others as needed

27. ICC Function and
Responsibilities
1. Formulate/update infection control
policies, guidelines and procedures.
2. Ensure implementation of infection
control, guidelines and procedures.
3. Ensure availability of resources and
contingencies for infection control
program.

28. ICC Function and
Responsibilities
6. Disseminate the necessary information and
coordinate with medical, nursing, administration,
other hospital committees and other appropriate
government agencies.
7. Oversees the performance of the ICT
8. Approves the infection control training modules.
9. Conduct IC meetings regularly at least quarterly
and as needed.

29. There shall be a functional
Infection Control Team

30. The Infection Control
Team
The Infection Control Team shall
be responsible for the day-to-day
infection control activities.

31. There shall be at least 1 full time
Infection Control Nurse (ICN) a
registered nurse who has been trained
or is receiving training in infection
control provided by an accredited
training organizations like PHICS,
PHICNA, PSMID. The ICN coordinates
with the ICP as well as with other
senior hospital staff.

32. There shall be sufficient number of
trained ICNs to facilitate and ensure the
effective implementation of infection
control program in the healthcare
facility. The ICN may be augmented by
trained nurses (link nurses) in patient
care areas or at least in high-risk clinical
areas.

33. ICT Functions
1. Conducts and document surveillance activities.
2. Coordinates with the Infectious Disease Section,
Microbiology Laboratory and administration as
well as other departments about known or
suspected cases of notifiable/ reportable
infectious disease, food poisoning and other
significant infections such as Multi Drug
Resistance Organism (MDRO)

34. ICT Functions
3. Investigates and initiates appropriate
responses to incidents or outbreaks of
infections, assess risks of infection and
recommends allocation of resources for
investigation, management and control.
4. Responds to urgent problems of infection
control through a 24 hours emergency
referral system.

35. ICT Functions
5. Ensures adequate, accurate and timely
reporting and feedback of information to
concerned areas/unit.
6. Propose resource requirement for the
program and any contingencies.
7. Develops IC training modules, organizes
the relevant education and training
programs for all healthcare staff and
encourages reflexive practice of infection
control measures.

36. ICT Functions
8. Monitors compliance to infection control
policies, guidelines and procedures.
9. Gives advice on the procurement of medical
equipment, drugs/medicines and supplies.
10. Participates in the planning and design of
plant facilities critical to infection control, i.e.
renovations, repairs, relocation of critical areas.
11. Recommends/propose to ICC actions, which
may have implications for infection control in the
hospital.

37. II. Standards on
Policies, Guidelines
and Procedures

38. Standards on Guidelines,
Policies and Procedures
There are written guidelines, policies and
procedures that address infection
prevention and control detection in the
healthcare facility.

39. Standard 1
Each department or service has an updated
copy of the approved hospital guidelines,
policies and procedures pertinent to their
activities

40. Requirements:
Guidelines, Policies and Procedures
1. Patient admissions/referrals, isolation
and timely case reporting of highly
transmissible and notifiable/ reportable
infectious diseases.
2. General Infection Control Guidelines,
policies and procedures
3. Infection Control Guidelines, Policies
and Procedures on Prevention of
Healthcare Associated Infection.

41. 4. Infection Control Guidelines and
Policies on Housekeeping Procedures.
5. Infection Control Guidelines, policies
and Procedures for Specific Patient Care
Areas.
6. Infection Control Guidelines, Policies
and Procedures for Hospital Service
Department/ Units.
Con’t

42. 7. Guidelines, Policies and Procedures on
Outbreak Investigation.
8. Infection Control Guidelines and
Policies related to Purchasing of medical
equipment, drugs/medicines and
supplies.
Con’t

43. 9. Guidelines and Policies on Rational
Antibiotic Use of coordination with
Microbiology Laboratory and pharmacy
Therapeutic Committee.
10. Guidelines and Policies on Upholding
Patient Confidentiality (Patient’s Rights)
Con’t

44. General Infection Control
Guidelines, Policies and
Procedures on:
• Hand Hygiene
• Isolation Precaution
• Decontamination, Disinfection, Sterilization;
Disinfectants for specific medical equipment/items
and area.
• Environmental Care and Healthcare Waste
Management
• Protection of Healthcare workers

45. IC Guidelines, Policies and
Procedures on Prevention of
Healthcare-Associated Infection:
• Respiratory Care
• In-dwelling Intravascular device Care
• Urinary Catheter Care
• Wound Care

46. IC Guidelines, Policies on
Housekeeping Procedures for:
• Isolation Rooms
• Regular Rooms/Wards
• Special Areas and High Risk Units
• Out Patient Department

47. IC Guidelines, Policies and
Procedures for Specific Care
Areas:
• ICU/CCU
• OR, DR, Nursery
• Dialysis Unit
• Burn Unit, trauma
Ward
• Emergency Room
• Transplant Unit
• Dental Clinic
• Endoscopy Unit
• Oncology unit

48. IC Guidelines, Policies and
Procedures for Hospital Service
Departments / Units
• Laboratory
• Dietary
• Laundry
• Linen
• Pharmacy
• Sterile Service
• Engineering and
Building Service
• Patient transport
facilities
• maorgue

49. These guidelines, policies and
procedures are made known to all
personnel through an administrative
order/ memorandum disseminate
during orientation and regular in-service
training. A simple audit tool will be
utilized to monitor compliance.
Standard 2

50. III. Standards on
Microbiology
Services

51. Microbiology Services
There shall be access to a licensed
microbiology section in a DOH licensed
clinical laboratory that shall provide
quality diagnostic and clinical services
required for epidemiologic evaluation,
effective surveillance and infection
control.

52. Standard 1
For Healthcare Facilities with
Microbiology Laboratory
There is a document available to all users of
the laboratory, which describes the
organization, and scope of the laboratory
services and standard operating
procedures.

53. The document describes:
• Availability of services during regular
working hours, after office hours, public
holidays and emergencies.
• Proper collection, handling, transport,
processing and disposal of specimens.
– Instructions on the appropriate specimens
to be collected, the availability of request
forms, appropriate containers, swabs,
transport media etc.
Requirements:

54. The document describes:
– Method of labeling and details required to complete the
request form (e.g. Patient information data, relevant
clinical information, the type of specimen and the
examination required)
• Type and range of specimens routinely examined and
those examined by special arrangement
• Proper collection of appropriate specimen and isolation
and identification procedures of potentially pathogenic
microorganism to specie level.

55. The document describes:
• Interpretation of results and timely
dissemination of information to concerned
areas.
• Availability of reports, technical and clinical advice
and procedures to access services.
• Quality control procedures (internal and external).
• Information on national reference laboratory for
services not available within the microbiology
laboratory of the healthcare facility.

56. The document describes:
• Guidelines, Policies and Procedures to be
observed on safe handling, transport and disposal
of specimens.
– Biosafety and biohazard precautions.
– Disinfection and sterilization of laboratory facilities.
– Good microbiologic laboratory facilities.
– Personal protective equipment (PPE), vaccination and
the prophylaxis required for laboratory personnel.
– Safe waste management based on national guidelines
– Acceptable/recommended recycling methods for
laboratory supplies.

57. The document describes:
• Identification and antibiotic susceptibility
patterns of bacterial isolates to antimicrobial
agents based on international standards.
• Results of screening tests for hospital staff
and employees (e.g. Stool culture for
dietary staff).
• Monitoring of sterilization and disinfection
procedures.
• Technical assistance for environmental
sampling and cultures when indicated.

58. The document describes:
• Appropriate data storage, retrieval and
communication facilities for tracking of
specimen, tracing of report and preparation
of surveillance information directly relating
to infection control.

59. IV. Standard on
Surveillance

60. There is a defined program of surveillance
and reporting of healthcare associated and
community acquired infection including
the collection, analysis, dissemination,
feedback and storage of data.

61. Standard I.
There shall be a defined surveillance
program
Requirements:
• The Infection Control Committee (ICC) defines
goals, objectives and priorities for all
surveillance activities on healthcare-associated
infections, including time frame, areas, patient
population to be studied and method to be
used.
• The ICC shall adopt the universally accepted
definitions of healthcare-associated infections
to be used in all surveillance activities.

62. Requirements:
• The surveillance forms shall be adapted and
standardized.
• The ICT collects, analyzes and reports the data
to clinicians administrators and others who
could use them constructively as basis for
intervention.
• The ICT uses the surveillance data of
evaluation of the program, identifying
problems, as well as revision of guidelines.

63. Requirements:
• The ICT coordinates with the microbiology
laboratory in the development of a program for
the surveillance of microorganisms, antibiotic
resistance patterns as well as clustering of
patient groups within their hospital network.
• The ICT may compare data with benchmark set
by national/international bodies as well as with
other institution for collaborative activities.

64. There is an efficient mechanism of reporting
healthcare-associated and community
acquired notifiable/reportable infections
including significant outbreaks/potential
outbreaks to ICT, ICC and to the National
Epidemiology Center, Department of Health
(NEC-DOH).
Standard 2

65. Requirements
• There is an organized/systematic
method/procedure of reporting
Healthcare-Associated Infections (HAI)
and Community-Acquired infections (CAI)
with potential for outbreaks.
• The ICC regularly reports their semi-
annual infection rates, antibiotic resistance
pattern to the clinicians, and
administration.

66. Requirements
• The ICC immediately reports to NEC-DOH
through the Chief of Hospital any
suspicion of potential outbreaks for their
information and appropriate action
following the NEC-DOH reporting system.

67. V. Standards on
Education
and Training

68. All healthcare staff including
support services shall receive
appropriate education and training
on epidemiology, surveillance,
prevention and control of
healthcare-associated infections.

69. Standard 1
There are adequate resources available in
the hospital for the required education
and training activities.

70. Requirements:
• There are adequate resources for
education, skills building and training of
healthcare staff and support/auxiliary
services.
• There are available and accessible venues
for teaching and training.

71. Requirements:
• There is access to up-to-date tools like audio-
visual materials and/or relevant books and
journals in infection control and hospital
epidemiology at the infection control office.
• There is available budget to allow attendance
of ICC members to infection control training,
conference, production of educational materials
and related activities.

72. Requirements:
• There are continuing education
opportunities within and outside
healthcare facility.

73. Standard 2
There are infection control educational
programs for the healthcare staff and
support services focused on relevant
topics for specific clinical setting.

74. Requirements
• There are institutional materials available
for education and training which includes:
– Epidemiology of Healthcare-Associated
Infection
– Basic Principles in Prevention and Control:
hand Hygiene, Isolation Precaution,
decontamination, Disinfection & Sterilization,
Care of the Environment and Hospital Waste
Management

75. Requirements
– Infection Control During Routine Patient Care
– Infection Control in Special and High Risk
Area
– Infection Control in Hospital Ancillary Services
Healthcare worker: Infection Risks and
Prevention

76. Requirements
• There is involvement of the ICC/ICT in the
orientation and continuing education of
patients, students, trainees and other
healthcare staff and other healthcare
personnel.
– There is involvement of the ICC/ICT in the
course design and implementation of basic
level training and continuing education of
healthcare staff.

77. Requirements
– There is a basic course in infection control
conducted regularly, at least twice a year as
needed and records of the attendance of all
staff on these educational activities.
– There is a defined policy for teaching patients
and the appropriate members of their families
(e.g. Watchers class) about the precautions
relevant to the diagnosis of the
affected/infected patients.

78. Requirements
• There are mechanisms for information
dissemination and assessment of knowledge and
practices of healthcare staff on new guidelines and
written policies on infection control practices,
surveillance and observational studies.
• There are tools for knowledge assessment of
infection control practices, and procedures (e.g.
Equipment disinfection methods, when and how to
isolate patients, etc.)

79. Requirements
• The Infection Control Committee monitors
and conducts periodic assessment of
infection control practices.

80. Successful implementation of these Standards
needs
FULL COOPERATION and PARTICIPATION
of
Government and Non-Government Health
Care Facilities
and monitoring and evaluation by
the DOH and accrediting organizations

81. Mission/ Vision of HICU
• Mission
To be the instruments of change towards
improvement in processes and relationships
within the hospital in order that hospital
associated infection rates are decreased and
infectious diseases are managed in a timely and
effective manner; minimizing risks to other
patients and to staff.

82. Vision
A hospital of well-informed health-care
practitioners, while individually and
collectively providing excellent patient
care, are also working towards patient and
personnel safety; minimizing the risk for
adverse patient events such as nosocomial
infections.

83. Responsibilities of HICU
HICU is both policy-generating and policy-
implementing
1. Education on infection control of all PGH
employees abd house staff.
2. Targeted Surveillance of priority
infections in high risk areas
3. Control of antibiotic use and monitoring
of antimicrobial resistance

84. Cont…
• 4. Supervision and monitoring of
sterilization and disinfection of
equipment/instruments and hospital areas.
• 5. Waste management
• 6.. Prevention, management and
counseling of exposures of PGH
employees to infectious diseases.