General Directorate of Infection Prevention & Control

(GDIPC)
‫الدارة العامة لمكافحة عدوى المنشآت الصحية‬

INFECTION
PREVENTION &
CONTROL CORE
COMPONENTS
(IPCCC)

Guidelines for Practical

Implementation in Health
Care Facilities

Version 1: January 2021

In the name of ALLAH, Most
Gracious, Most Merciful
 MESSAGE

From the GENERAL DIRECTOR

It is with great pleasure and enthusiasm that we announce the release of first edition

of Infection Prevention & Control Core Components Practical Manual for implementation in
the healthcare facilities.

Health care-associated infections (HAI) are one of the most common adverse events in the
health care delivery with an impact on morbidity, mortality and quality of life. Moreover,
threats posed by epidemics, pandemics and antimicrobial resistance (AMR) have become
increasingly evident as ongoing universal challenges and are recognized as top priority by
Ministry of health for actions at all levels of which effective infection prevention and control
(IPC) is the cornerstone.

This manual will serve as a practical guide for Infection Preventionists (IPs) to ensure
effective implementation of core components of IPC programmes in their healthcare facilities
which will improve the quality and safety of health service delivery and the health outcomes of
the patients who access those services.

In conclusion, I pray to Almighty ALLAH to grant us strength & guidance to

accomplish all goals.

Dr Khalid H. Alanazi

General Director of Infection Prevention & Control (GDIPC)

Ministry of Health, Kingdom of Saudi Arabia

 FOREWORD

First & foremost, we express our deepest gratitude to ALLAH Almighty for
granting us guidance & help for successful completion of this manual.

Core Components of infection prevention & control (IPC) are a road map for how
the infection control best practices can prevent harm due to health care-associated infection
(HAI) and antimicrobial resistance (AMR).
This manual is based on the evidence-based recommendations on the core components of IPC
programmes that are required to be in place at the health care facility level. This will help to
strengthen IPC programmes & ensure practical implementation of infection prevention & control
standards within the healthcare facilities.
The consistent application of stringent infection control principles and practices in all healthcare
activities is necessary to achieve safety & best health outcomes for the patients, staff and
visitors.
The activities outlined in this manual require a broad range of skills, collaboration, cooperation
and engagement with a range of stakeholders; hospital leaders, quality improvement, patient
safety, occupational health, antimicrobial stewardship programmes, clinical microbiology and
environmental health etc.
It is important to note that implementation of infection prevention & control core components
is NOT the sole responsibility of the IC teams as core components of IC programmes are
interrelated in practice. In fact, it’s “everybody’s responsibility”

Good Luck!!!!

Dr Faiza Abdullah Al Fozan

Assistant General Director of Infection Prevention & Control (GDIPC)

Ministry of Health, Kingdom of Saudi Arabia

 PURPOSE OF THE MANUAL

This practical manual of infection prevention & Control (IPC) Core Components is designed to

support the hospitals to achieve effective implementation of their infection prevention and control
(IPC) programmes in accordance with international standards. This can be achieved by ensuring the
stepwise approach of training, monitoring & evaluation of infection prevention & control core
components, by adopting the World Health Organization (WHO) Guidelines for improving infection
prevention & control (IPC) at the healthcare facilities.

Infection prevention and control (IPC) is a universally relevant component of all health systems and
affects the health and safety of both people who use health services and those who provide them.
According to WHO, effective IPC is a key determinant of the quality of health service delivery to
achieve people-centred, integrated universal health coverage.

How to Use the Manual?

This manual is divided into 05 sections:

SECTION I: Introduction to “WHO” core components:

- Brief description of eight core elements & “WHO” multimodal strategy with examples.

SECTION II: Stepwise approach for effective implementation of Infection Control

Core Components (IPCCC) at the Hospital, Regional & GDIPC /MOH level:
- Explained following the WHAT, WHY, HOW. WHO, WHEN approach

SECTION III: IPCCC standards for each unit with explanation:

- Units have been subdivided according to type of services provided.
- Green text colour reflects the rationale and brief description of main standard.
- Black and Blue Text colour reflects brief explanation of each substandard.
- Common substandard in all units are not repeated in the main Manual but are added in the
toolkits designed for individual unit.
-
SECTION IV: TOOLS & RESOURCES:
- Various tools have been designed to facilitate the IPCCC implementation process & to
ensure uniformity and standardization.
- Tool can be used as such or could be adopted according to local needs.

SECTION V: REFERENCES:
- APIC, CDC & GCC Manual is the main referencing body for the all IPCCC standards
guidelines whereas WHO is the reference for development of practical implementation
steps.
 IPCCC Guidelines Team Work

Dr Faiza Rasheed
Prepared By: Dr Yousaf B Saad
Mr Ali Salman Asiri

Dr Abdulmajid M Almutairi
Ms Ghazail M Albeshi
Mr Yahya I Alnashbah
Mr Salem A Aldhubaib
Mr Riyadh S Alshehri
Mr Adel S Alanazi
Ms Wafa H Alshammari
Contributors: Ms Abrar S Mutlaq
Ms Imtithal J Alsaihati
Ms Ashwag S Alshwegi
Mr Rayed A Asiri
Ms Aisha M Al Shehri
Ms Arwa F Shesha
Ms Amal A Almedaini
Ms Amani S Samman

Approved By: Dr Khalid H. Alanazi

Director General, GDIPC

1 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Table of Contents
--------------------------------------------------------------------------------------------------------------------------------------

SECTION – I INTRODUCTION
WHO CORE COMPONENTS OF IPC PROGRAMMES 05
WHO MULTIMODEL IMPROVEMENT STRATEGY 08

SECTION – 2 STEPWISE APPROACH FOR PRACTICAL IMPLEMENTATION OF IPCCC

1. HOSPITAL LEVEL 10
2. REGIONAL LEVEL 15
3. GDIPC - MOH LEVEL 17

SECTION – 3 IPCCC STANDARDS

I: CRITICAL CARE UNITS 20
1. ADULT INTENSIVE CARE UNIT (ICU) 21
2. NEONATAL INTENSIVE CARE UNIT (NICU) 89
3. PEDIATRIC INTENSIVE CARE UNIT (PICU) 158
4. CORONARY CARE UNIT (CCU) 224
5. BURN UNIT 292

II: EMERGENCY & SPECIALIZED CARE UNITS 357

1. EMERGENCY ROOM (ER) 358
2. HAEMODIALYSIS UNIT (HDU) 436
3. OPERATION ROOM (OR) 534
4. ONCOLOGY UNIT 598

III: INPATIENT CARE UNITS 660

1. DELIVERY ROOM (DR) 661
2. INPATIENT UNITS / WARDS 715

IV: OUTPATIENT SERVICES 783

1. DENTAL SETTING 784
2. OUTPATIENT CLINICS 839

V: DIAGNOSTIC / INTERVENTIONAL SERVICES 890

1. CARDIAC CATHETERIZATION LABORATORY 891
2. RADIOLOGY SERVICES 949
3. ENDOSCOPY UNIT 991
4. BRONCHOSCOPY 1042
5. LABORATORY SERVICES 1100

2 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 VI: ALLIED HEALTH SERVICES 1135
1. PHYSIOTHERAPY 1136

VII: SUPPORT SERVICES 1180

1. CENTRAL STERILE SUPPLY DEPARTMENT (CSSD) 1181
2. PHARMACY SERVICES 1221
3. DIETARY SERVICES DEPARTMENT 1251
4. LAUNDRY SERVICES 1282
5. MORTUARY SERVICES 1316
6. INFECTIOUS MEDICAL WASTE ROOM 1346

VIII: OTHERS 1376

1. INFECTION CONTROL DEPARTMENT 1377

SECTION – 4 TOOLS & RESOURCES --------------------------------------------------------- 1470

1. IPCCC Checklists for Audit Rounds

2. Template of Letter from Administration to all units for implementation of IPCCC
3. Template for IPCCC Training Annual Plan (Excel)
4. Template for IPCCC Training & Competency Dashboard (Excel)
5. Template for IPCCC Evaluation / Audit Visits Schedule (Quarterly) (Excel)
6. Template for IPCCC Audit Feedback to Units (Quarterly)
7. Template for Proposed division of IC Practitioners Tasks (Excel)
8. Template of Regional IPCCC Training Plan (Excel)
9. Template for Certificate of Appreciation for Best Unit Performance in IPCCC (Quarterly)
10. Template for Certificate of Appreciation for Best Hospital Performance in IPCCC (Quarterly)
11. Template for Certification of Appreciation for Best Regional Performance in IPCCC (Quarterly)

SECTION – 5 REFERENCES --------------------------------------------------------------------- 1475

3 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
SECTION - I
I

INTRODUCTION

4 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
WHO’ CORE COMPONENTS OF INFECTION PREVENTION AND CONTROL (IPC)

Core Components of Infection Prevention and Control refers to essential activities required to prevent

health care-associated infections (HAIs) and manage antibiotic resistance at the health care facility.

Core components of IPC programmes form a key part of WHO strategies to prevent current and future threats,
strengthen health service resilience and help combat antimicrobial resistance. There are ’WHO’ ’eight core
components of Infection prevention & control:

Core Component 1. IPC Programmes

An IPC programme with a dedicated, trained IPC team should be in place in each acute health care
facility for the purpose of preventing HAI and combating AMR through implementing IPC
recommendations.
The programme should include clearly defined objectives and an annual work plan based on local
epidemiology and priorities according to risk assessments. The IPC programme needs to have a
dedicated budget and resources.
IPC objectives, measurable outcome indicators and targets should be set for critical health care facility
areas.

Core Component 2. IPC Guidelines

Evidence-based guidelines should be developed and implemented for the purpose of reducing HAI and
AMR. The education and training of relevant health care workers on the guideline recommendations and
the monitoring of adherence with guideline recommendations should be undertaken to achieve
successful implementation.

Core Component 3. IPC Education and Training

IPC education should be in place for all health care workers by utilizing team- and task-based strategies
that are participatory and include bedside and simulation training to reduce the risk of HAI and AMR.
Support of IPC education and training is a key function of IPC programmes with the ultimate aim of
developing a skilled and knowledgeable health workforce, including a frontline workforce with IPC basic
competencies, as well as providing continuous education for IPC specialists with advanced knowledge
and mentorship and implementation skills.
Health worker training has been found to be an essential component for effective IPC guideline
implementation, contributing to the ultimate prevention of HAIs and AMR and the provision of high
quality health service delivery.

5 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Core Component 4. HAI Surveillance
Facility-based HAI surveillance should be performed to identify the most frequent HAIs and detect HAI
outbreaks, including AMR surveillance. Timely feedback of results should be provided to health care
workers and managers, as well as through national networks, and should guide IPC interventions.
Surveillance should be an essential and well-defined component of the IPC programme.
Adequate microbiology laboratory capacity is needed to support surveillance.

Core component 5. Multimodal Strategies

IPC activities using multimodal strategies and a multidisciplinary team approach should be implemented
to improve practices and reduce HAI and AMR.
The use of multimodal strategies in IPC has been shown to be the best evidence-based approach to
achieve sustained behavioural change for the implementation of IPC interventions, with a large body of
evidence related to hand hygiene improvement.
The use of multimodal strategies supports all aspects of IPC implementation and underpins all of the
core component guideline recommendations.
Multimodal thinking means that IPC practitioners do not focus only on single strategies to change
practices (for example, training and education), but consider a range of strategies that target different
influencers of human behaviour, for example., monitoring and feedback, infrastructures or
organizational culture.

Core Component 6. Monitoring / Audit of IPC Practices and Feedback

Regular monitoring/audit and timely feedback of health care practices and other indicators according to
IPC standards should be performed to prevent and control HAI and AMR at the health care facility level.
Feedback should be provided to all audited persons and relevant staff.
The main purpose of monitoring / auditing practices and other indicators and feedback is to support the
achievement of behaviour or system change to improve practices and the quality of care with the goal
of reducing the risk of HAI and AMR spread as part of a multimodal approach.
It can include an assessment of the extent to which standards are being met, goals accomplished,
activities performed according to requirements, and aspects that may need improvement.

Core Component 7. Workload, Staffing and Bed Occupancy

Bed occupancy should not exceed the standard capacity of the facility (one patient per bed with
adequate spacing of >1 metre between patient beds).
In exceptional circumstances where bed capacity is exceeded, health care facility management should
act to ensure appropriate staffing levels that meet patient demand and an adequate distance between beds.
Health care worker staffing levels should be adequately assigned according to patient workload.

Core Component 8. Built Environment, Materials and Equipment for IPC

Patient care activities should be undertaken in a clean and/or hygienic environment that facilitates
practices related to the prevention and control of HAI, as well as AMR. This includes availability of
appropriate IPC materials and equipment, for example, alcohol-based hand rubs, soap and water,
personal protective equipment (PPE), urinary catheters, etc.
Materials and equipment to perform appropriate hand hygiene should be readily available at the point of care.

6 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Figure 1. Visual representation of how the IPC core
components interconnect

Ref: Interim practical manual supporting implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes

7 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Figure 2. FiVe eLeMeNTS OF ‘WHO’ MuLTiMOdaL iMprOVeMeNT STraTegy

Build it
(System
Change)

Live it Teach it
(Safety Climate (Training &
/ Culture of
safety) Education)
Multimodal
Improvement
Strategy

Sell it Check it
(Reminders & (Monitoring
Communication) & Feedback)

I. SYSTEM CHANGE – (BUILD IT)

• Consideration of procurement and accessibility of supplies, water availability and quality and ergonomic
factors including workflow.
• For example, the placement of a central venous catheter set and tray

II. TRAINING & EDUCATION – (TEACH IT)

• This involves written information and/or oral instruction and/ or e-learning and practical and interactive
training sessions, including simulation and/or bedside training.
• For example, the training of doctors and nurses in charge of the placement and maintenance of
central venous catheters on prevention of bloodstream infection (BSI), including critical best
practices in bundles.

III. MONITORING & FEEDBACK – (CHECK IT)

• This usually involves monitoring compliance with process and practice indicators, as well as monitoring
outcome indicators.
• For example, audits of catheter insertion and maintenance and the provision of timely and direct
feedback of results to doctors and nurses

IV. REMINDERS & COMMUNICATION – (SELL IT)

• Use of reminders, posters or other advocacy/awareness-raising tools to promote an intervention and
methods/initiatives to improve team communication across units and disciplines.
• For example, discussion of the strategy for the prevention of BSI during clinical meetings and the use
of promotional leaflets and posters to reinforce bundles of best practices.

V. SAFETY CLIMATE / CULTURE OF SAFETY – (LIVE IT)

• This is concerned with ensuring that senior managers/leaders show tangible support and act as
champions and role models, including making relevant decisions and promoting and strengthening a
culture that supports IPC, patient safety and quality. In addition, teams and individuals are empowered
so that they perceive ownership of the intervention.
• For example, discussion of BSI rates at the executive level facility meetings

8 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
SECTION - II

STEPWISE APPROACH FOR

PRACTICAL IMPLEMENTATION
OF IPCCC

9 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
‘STEPWISE APPROACH FOR IMPLEMENTATION OF IPCCC
(HOSPITAL LEVEL)
H

Education & Training (Train all HCWs on IPCCC standards)

Monitoring (Monitor & observe staff practices during routine IC rounds)

Evaluation (Evaluate / Assess the unit & staff perfromance using IPCCC Tool/ checklist)

Feedback (Provide formal feedback to all stakeholders unit / satff /administartion etc)

Report Submission (Send IPCCC report via online system to GDIPC)

I. EDUCATION & TRAINING:

WHAT?
Conduct education & training on infection control best practices
for all HCWs according to their area of work.
Provide continuous education and training to the health care
personnel as infection prevention & control is a discipline that
requires specific knowledge acquisition.
IPC education and training should be a part of an overall hospital education strategy, including new
employee orientation and the provision of continuous educational opportunities for existing staff,
regardless of level and position.

WHY?
Development and maintenance of a skilled, knowledgeable health workforce.
Educational interventions are crucial for IPC quality improvement elements.
Training & education is the key to ensure competency of healthcare providers during patient care
activities.

10 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HOW?

Send MEMO through administration to all units / Departments to start with education & training
phase of IPCCC quarterly activities. (Use attached template)
Obtain lists of all HCWs from relevant units, HR / Nursing Administration. (Doctors, Nurses ,
Housekeeping, RTs, Lab Technicians etc).
Divide each category of staff over four quarters (Jan – Dec) in order to achieve 100% coverage at
the end year (Use the attached official template)
Prepare training agenda / Annual training plan & schedule (Use the attached official template)
Send training schedule to all units with names of targeted HCWs intended to be trained in each
quarter.
Divide the units & tasks for IPCCC activities among all IC practitioners including infection control
directors.
Follow proposed division of task among ICPs to carry out hospital wide education & training
activities. (Use proposed division of task among ICPs template)
Each ICP should create WhatsApp group with each assigned unit for quick and effective follow up
of IPCCC activities.
Share the IPCCC departmental manual with each assigned unit.
Share the training material / checklists for preparation to relevant health care workers.
Use a blended approach for training including written information and/or oral instructions and/or
e-learning and interactive and practical sessions (including simulation and/or bedside training).
Train the same staff as per schedule following by evaluation in Month 3. (At least 2-3 from each
category depending on the number of staff belonging to different professional category in each
unit.
Document & keep track of the IPCCC training activities of each unit in order to achieve 100& staff
coverage at the end of year. (Use Training & Competency dashboard template)

Infection Control Teams training & education:

For IC team to have updated IC knowledge & to enhance IPCCC monitoring skills and knowledge, at
least biweekly IC departmental training activities must be conducted. (Use attached template)
Arrange regular education & training session for presentation by each ICP according to assigned
units / tasks.
Example: Week 1
ICP – XYZ:
Topic: IPCCC standards in hemodialysis unit (to be completed in multiple sessions)
Duration: 1 HOUR & according to suitable time to ensure attendance by all.

WHO?
IC department to provide continuous education & training to all health care workers according to
job category in all areas of hospital.

WHEN?
Dedicate first 02 months for IPCCC education & training activities followed by monitoring and
supervision.
Ensure to cover all targeted HCWs selected for training in each quarter as per schedule.

11 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
II. MONITORING:
WHAT?
Regular monitoring of health care practices based on IPCCC standards should be performed to
prevent and control HAI and AMR at the health care facility level.
Example hand hygiene compliance monitoring, monitoring of PPE practices while dealing with
isolated cases, monitoring of adherence to aseptic technique & monitoring of environmental
cleaning etc.
Observe the staff practices and behaviors and provide on-site feedback.

WHY?
The main purpose of monitoring is to improve practices and the quality of care with the goal of
reducing the risk of HAI and AMR spread as part of a multimodal approach.
To support the achievement of behavior or system change & to ensure implementation of
guidelines into practice.
Monitoring gives an estimate of the extent to which standards are being met & HCWs are
performing the activities according to requirements, goals accomplished, and aspects that may
need improvement.
Doing this helps to create a “monitoring and learning” culture to identify areas for improvement.

HOW?
ICPs must conduct regular rounds of assigned units / areas for IPCCC activities (Daily rounds, weekly
etc depending on the degree of associated risk in particular area).

Observe the staff practices & use authority to identify and rectify breach in practices.
Use the checklists / forms to ensure effective documentation of daily/ weekly IC rounds.

WHO?
All members of infection Control department. Infection Control directors would lead all IPCCC
activities.
IC director must ensure that all ICPs are well trained and have good knowledge & skills for
monitoring and observing staff practices.
Trained IC link nurses in different units could assist in the monitoring process, Hand hygiene
observations etc.

WHEN?
Monitoring and observation of IC practices is a continuous process to ensure strict adherence to IC
practices to ensure patients, staff & visitors safety.

12 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
III. EVALUATION / AUDIT:
WHAT?
Periodic evaluations / Audit / Assessment of both the effectiveness of training programmes
and assessment of staff knowledge will be undertaken using IPCCC checklist / Tool in each
quarter.

WHY?
Assessment of the extent to which standards are being met & goals are accomplished.
Calculate / estimate % percentage of compliance to all IPCCC standards in each unit to identify
areas of improvement.

HOW?
Prepare and send the schedule of internal audit visit for evaluation of IPCCC standards in all
hospital units. (Use the attached official template)
Send formal invitation along with IPCCC checklists in the particular quarter.
Evaluate the unit & performance of Health Care personnel using IPCCC checklist designed for
each unit.
Evaluate / Assess competency of the same staff who had received training in months 1& 2. (At
least 2-3 from each category depending on the number of staff belonging to different
professional category in each unit. (Competency Assessment).
Keep the evaluation form (hard version) in staff personal files as evidence of formal training &
competency assessment to be presented to external audit visits (MOH-CBAHI-JCI etc)
Based on results of evaluation / IPCCC score, acknowledge the performance of units & HCWs
by selecting the BEST UNITS & HCWs from each category in each quarter.
Use official certificates of appreciation for ‘’BEST UNIT PERFORMANCE’’ & “BEST STAFF
PERFORMANCE’’ in each quarter.

WHO?
All members of infection Control department to evaluate the assigned units for IPCCC activities as
per division of task.
Infection Control directors would lead all IPCCC activities & ensure all units are visited as per
schedule.

WHEN?
IPCCC audit / evaluation visit will be conducted for each unit in Month 3 of each quarter after
successful completion of IPCCC training & monitoring phase in Months 1 & 2.

13 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IV. FEEDBACK:

WHAT?
Provide formal / informal feedback of performance to the units & HCWs to work on the areas
of improvement and increase compliance to infection control measures.

WHY?
Performance feedback is an important and key factor in the quality improvement process.
Monitoring, audit and feedback are an important tool for convincing HCWs & other
stakeholders that there is a problem and that the solution chosen is the right one.
This should take place in a blame-free manner to promote a non-punitive culture within the
hospital setting.

HOW?
Send formal feedback to the units & HCWs evaluated in particular quarter. (Use official
template)
Share IPCCC score and result of competency with HCWs.
Consider retraining of staff if score is below the required. (At least 80%)
Recognize the BEST performance (Certificate of appreciation, 1 Day salary / days off etc
Post the certificates on IC bulletin boards to be easily seen by all.

WHO?
Infection control team will be responsible to prepare feedback document.
All certificates of appreciation MUST be signed by hospital director using official template.

WHEN?
At the end of each quarter after online submission of IPCCC report .

V. IPCCC ONLINE REPORT SUBMISSION:

Fill online report of IPCCC at the end of each quarter & submit to GDIPC.
Make sure all domains are complete.

14 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ‘STEPWISE APPROACH FOR IMPLEMENTATION OF IPCCC
(REGIONAL LEVEL)

Education & Training of ICPs

Monitoring of IPCCC Training activities

Tracking of IPCCC Evaluation / Audit

Tracking of online Report Submission

Data Validation & Feedback

I. EDUCATION & TRAINING:

Provide initial training & orientation to all hospitals to explain new steps of
IPCCC implementation process.
Conduct formal training of all hospitals on IPCCC standards at least once per year. (Online Training)
Use the official regional training template to plan for training activities to ensure 100% of hospitals have
received training on all IPCCC standards at the end of year.
Send evidence of training activities to GDIPC in each quarter (Training tracker)
Support the training activities of the hospitals in order to strengthen IPC programmers. (online
meetings with ICPs / email to hospital directors, IC directors etc)
Ensure 100% of planned training activities were conducted as per schedule in each quarter.
Submit quarterly & annual IPCCC training coverage to GDIPC.

II. MONITORING:
Monitor & track IPCCC training activities. (Month 1 & 2)
Review IPCCC training schedules and evidence of routine rounds.
Provide necessary feedback to the hospitals.

15 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
III. Tracking of IPCCC Evaluation / Audit:
Track the quarterly IPCCC formal evaluation process done by hospitals. (Month 3)
Ensure all visits were conducted as per schedule and evidence of visit provided by hospital.
Initiate visit tracker to ensure all 26 units / areas are evaluated in each quarter.
Follow up with hospitals who are lacking behind in visits.

IV. Tracking of online Report Submission:

Ensure timely submission of IPCCC reports via online system.
Follow up with hospitals who were delayed in report submission.

V. Data Validation & Feedback:

Download and review the IPCCC reports of each hospital.
Ensure the data is complete, valid & accurate,
Calculate the % of performance of each hospital and prepare hospital ranking. (Use automated scoring
from online system)
Acknowledge the performance of hospital with maximum scoring (Based on cumulative score of all
units in each Quarter)
Send certificate of Appreciation for ‘’BEST HOSPITAL PERFORMANCE IN IPCCC’’ (Use the official
template)

16 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ‘STEPWISE APPROACH FOR IMPLEMENTATION OF IPCCC
(GDIPC - MOH LEVEL)
H

Education & Training of Regional IPCCC Coordinators

Monitoring of IPCCC Regional Training activities

Follow up with Regions for IPCCC Audit Visit by Hospitals

Tracking of online Reports Submission

Data Validation & Feedback

I. EDUCATION & TRAINING:

To Provide initial training & orientation to all Regional IPCCC coordinators to explain new steps of
IPCCC implementation process.
To conduct formal training of all regions on IPCCC standards at least once per year. (Online
Training)
Generate training tracker to ensure 100% of regions have received training on all IPCCC standards
at least once per year.
To support the training activities of the regions in order to strengthen IPC programmes. (Online
Meetings with regional coordinators / MEMOs to hospital directors etc)

II. MONITORING:
Monitor the regional IPCCC training activities in each quarter.
Review the annual IPCCC training plan sent by regions for each quarter.
Follow up with regions to ensure all scheduled training activities are conducted on time in each
quarter.
Review the quarterly & annual IPCCC training activities / reports submitted by regions.

17 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
III. Follow up with Regions for IPCCC Audit Visit:
Follow up with regions to ensure all visits were conducted by ICPs as per schedule and evidence of visit
was sent to the regional directorates.
Follow up with regions who are lacking behind to ensure all visits were conducted on time in month 3 of
each quarter.

IV. Tracking of Online Reports Submission:

Track the online IPCCC reports submission via online system in each quarter.
Follow up with regions to ensure timely submission of IPCCC reports.
Follow up with regions who were delayed in report submission.

V. Data Validation & Feedback:

Randomly review at least 30% of reports submitted by hospitals to ensure the accuracy of data.
Calculate the % of performance of each region and prepare regional ranking. (Use automated scoring
from online system)
Acknowledge the performance of region with maximum scoring (Based on cumulative score of all
hospitals in each region in each Quarter)
Send certificate of Appreciation for ‘’BEST REGIONAL PERFORMANCE IN IPCCC’’.

18 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
SECTION - III

IPCCC - STANDARDS

19 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 CRITICAL CARE UNITS

# NAME OF UNIT PAGE #

01 ADULT INTENSIVE CARE UNIT (ICU) 21

02 NEONATAL INTENSIVE CARE UNIT (NICU) 89

03 PEDIATRIC INTENSIVE CARE UNIT (PICU) 158

04 CORONARY CARE UNIT (CCU) 224

05 BURN UNIT 291

20 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
INTENSIVE CARE unit (ICU)

Intensive Care Units are critical care areas that provide

intensive care to the critically ill patients. The intensive care units are capable of
providing services unique to its setting such as mechanical ventilation and invasive
cardiovascular monitoring. Patients admitted in the critical care units are at potential
risk of healthcare associated infections because of frequent need of invasive devices.
Hence, strict implementation of infection control procedures like bundles of care
including hand hygiene, wearing personal protective equipment (PPE) to prevent the
transmission of infection during patient care, practicing aseptic technique, isolation
precautions & environmental measures etc. would play a significant role in ensuring
patient & staff safety.

21 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN INTENSIVE
CARE unit (ICU)

POLICIES & PROCEDURES

INTENSIVE CARE UNIT

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

AIRNORNE INFECTION ISOLATION ROOMS (AIIRs)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

22 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 INTENSIVE CARE UNIT (ICU)
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them.
They guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff
safe. Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living,
breathing documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

23 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among
HCWs, patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided
with the required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide
the necessary resources for implementing trainings on infection control best practices & establishing auditing tools on
performance measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
Substandard # 2:1
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Healthcare Personnel
(HCP) receive Each HCPs must receive education & training on basic infection control skills from IC
orientation and department within 01 months of joining work. (BICSL)
training on Basic IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
Infection Control Skills joining work & issue a BICSL ID which should be renewed ever 02 years.
from IC department
Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
maximum within 1
hours as an evidence of basic infection control training to be presented to any external /internal
months of joining
audit visit for purpose of verification.
work & a BICSL card
is issued which is Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
renewed every 2 every 2 years by visiting infection control department.
years.

Components of BICSL includes:

- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

24 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on Isolation
Precautions by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
Substandard # 2:2 patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Healthcare Personnel knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
(HCP) receive job-
specific training on Infection Prevention & control department MUST provide education & training to all health care
infection prevention personnel on infection control best practices specific to their job as follows:
policies and
procedures upon Infection control Training specific to area of work must be provided initially upon hiring before
hiring and at least starting their duty.
once annually. Continuous education on relevant infection control policies and procedures must be conducted
at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

25 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters.

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

26 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control department MUST provide health education on infection control for families and
visitors.
Substandard # 2:4
IC team must ensure the availability of the following according to the specific unit / area:
Unit provides infection
control health Bilingual infection control health education & awareness material must be designed / formulated
education to the to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
patients, families & booklets, leaflets etc. containing information easy to understand with help of pictorial display.
Visitors. The general & specific health educational material must be posted and available in all patient
care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.

Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files.

Patients/Family members’ / care givers must be aware about importance of hand hygiene, care
of central line, identifying and notifying signs of inflammation etc.
Visitors are educated on precautions to be taken while being in the surrounding of the patient,
the importance of hand hygiene and the required isolation precautions etc education must be
provided on how to don / doff PPE and perform hand hygiene before entering isolation room.
Ensure strict adherence of visitors to the recommendations / instructions regarding infection
prevention requirements (e.g.PPE use, hand hygiene etc).

27 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to
treat. On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital
patients has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
patient's room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

28 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:2 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Health care Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
professionals (HCP) microorganisms without the need for an exogenous source of water and requiring no rinsing or
demonstrate drying with towels or other devices.
appropriate Indications:
technique for hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
rubbing and hand body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing. Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and
/or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced

29 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Substandard # 3:3
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Visual alerts are
posted at appropriate places.
available: WHO 5
moments, how to
- WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to
- How to hand wash poster beside ach hand washing sink
do hand wash.
- How to handrub poster beside each hand hygiene dispenser

WHO five moments of hand hygiene:

1: Before touching a patient:

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

30 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
31 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
32 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room
are available and readily but not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will
accessible to HCP. interfere with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Powered air purifying respirators (PAPRs) for bearded staff etc

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2 masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock
N - 95 respirators are available rooms.
in different types and sizes. Check if all types and sizes are available according to fit test result of each healthcare
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)

33 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding
using N-95 respirator according to fit test or follow alternate policy in case of non-
availability.
Substandard # 4:3
During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 to
(Countercheck / verify with their fit test ID).
be used based on the fit test.
Observe the practice of doctors with beards.

Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

❖ Air-purifying respirator means a respirator with an air-purifying filter, cartridge, or

canister that removes specific air contaminants by passing ambient air through the
air-purifying element.
Substandard # 4:4
❖ Powered air-purifying respirator (PAPR) means an air-purifying respirator that uses a
Alternative respirator, such as blower to force the ambient air through air-purifying elements to the inlet covering.
powered air-purifying respirator
(PAPR) is accessible for HCW ❖ Powered air purifying respirators offer protection against certain respiratory hazards
who failed in fit testing when with integrated head, eye and face protection that can help provide a more
dealing with patients under comfortable environment for the worker.
airborne isolation precautions. ❖ PAPR system uses a blower instead of lung power to draw air through the filter. This
lets HCWs to breathe more naturally while feeling a constant airflow in your while
dealing with patients.

❖ Ensure that powered air-purifying respirator (PAPRs) are available and accessible for
all HCWs who failed fit testing to N-95 mask of all types, brands & shapes.
❖ HCWs with beard must not use N-95 mask because of interference of facial hair in
ensuring perfect facial seal. Airborne particles are less than 5 microns in size which
can easily pass from beneath the mask if appropriately size is not used exposing staff
to risk of acquiring airborne infection.
❖ Bearded staff must only use powered air-purifying respirator (PAPR)while dealing
with patients under airborne infection isolation rooms.
❖ HCWs must also receive training on how to don the respirator and safely handle after
use.
Note:
If powered air-purifying respirator (PAPR)are not available, hospitals must have clearly
policy for bearded staff to strictly refrain from dealing with airborne cases and staff must
be well oriented about the policy in order to ensure safety of healthcare workers.

34 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.
Substandard # 4:5

Staff use personal protective

1: Appropriate PPE for Contact Isolation:
equipment appropriately (e.g. Before entering and leaving a patient’s room PPEs should be donned & doffed in this
donning and doffing) order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured
at neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
https://youtu.be/H4jQUBAlBrI
Don gloves. Extend gloves over isolation gown cuffs.
Watch Video How to safely put
on PPE Sequence of doffing PPEs before leaving the room:
Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.
NB: If goggles/face shield are worn:
• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand hygiene,
surgical mask and hand hygiene.

35 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

36 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
37 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
38 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
39 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

40 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:7 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

41 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

42 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

43 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

44 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:04
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 6:05 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 1. Disposable personal care items are discarded
worker, housekeeping 2. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 6:06 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

45 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:07 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

46 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

47 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:08 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:09
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

48 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Substandard # 6:11 Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
Housekeepers are well measures.
trained on hand hygiene, Routine practices related to environmental cleaning includes:
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals.
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

49 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
Substandard # 6:14 protocols.
Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping equipment is Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
kept clean and dry after use. buckets.
Mop heads must be sent to laundry unit after use.

50 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

51 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
52 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 7:01 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 7:02
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

53 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 7:03
in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of
to use large IV solution bottles for preparation & dilution of medications
medication is only done by
Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water
specified for preparation & dilution of medications.
ampoule.
Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 7:04
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 7:05
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

54 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 7:06 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient.
While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 7:07 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

55 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Maintaining the integrity of sterile equipment and solutions is extremely important to
Substandard # 7:08 prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
Sterile equipment and urinary catheter).
solutions are assembled - If the sterile items are assembled long before the procedure, there are chances of
immediately prior to use. contamination from environment such as dust etc.
- A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
the transfer of microorganisms and reduce the potential for infections.
- Principles of sterile technique help control and prevent infection, prevent the transmission
of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.
As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

56 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

Substandard # 7:09 A sterile object becomes non-sterile when touched by a non-sterile object.
Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
Sterile to sterile rule is transfer forceps.
applied during any aseptic Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
procedure. Non-sterile items should not cross over the sterile field. For example, a non-sterile person
should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

57 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 7:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 7:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

Substandard # 7:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

58 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 7:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
claim that each device is exclusively allocated only for one patient.
Substandard # 7:14
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
• Patient's name & medical record number to be used exclusively for one patient.
insulin pens) are used only
• Date of the first use to be discarded after expiration of the reuse life recommended
for single patient.
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 7:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.
Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
Substandard # 7:16
IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
IV solution bottles are only
than the self-sealed rubber cap.
accessed through the self-
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
sealed rubber cap.
Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

59 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 7:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7
days, but not more Following key points must be followed for replacement of IV sets in order to avoid risk of
frequently than 96-hour infection from frequent changing of IV sets:
intervals.
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 7:18
Rationale: Extending the duration of use permits considerable cost savings to hospitals
IV sets that are used to without significant increase in the risk of healthcare-associated BSI with peripheral IVs
administer blood, blood
products, lipid emulsions, or In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
dextrose/amino acid TPN acid TPN solutions, check that IV delivery systems are continuously connected and
solutions are replaced within changed within 24 hours of initiating the infusion.
24 hours of initiating the During daily rounds, observe that IV administration sets are labelled with dates & times of
infusion. initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
(hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 7:19 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

60 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide education & training to the healthcare personnel regarding the feeding systems & key
Substandard # 7:20 points that should be considered.
Observe the practices during routine monitoring rounds. Evaluate performance during IPCCC
Open feeding systems audit phase.
should be removed after 8
hours, whereas sterile Following MUST be implemented:
closed systems may remain
hanging for up to 24 to 48 If open feeding system are used, they should be removed after 8 hours.
hours or per manufacturer's If sterile closed feeding system are being used, they may remain hanging for upto 24 – 48
recommendation. Hours OR manufacturers instruction MUST be followed.

According to The Joint Commission, there are four chief aspects of the aseptic technique:
Substandard # 7:21 barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Maximum sterile barrier protect the patient from the transfer of pathogens from a healthcare worker, from the
precautions is applied environment, or from both. Some barriers used in aseptic technique include:
during any interventional - Sterile gloves
procedure, including cap, - Sterile gowns
mask, sterile gown, sterile - Masks for the patient and healthcare provider
gloves, and sterile full-body - Sterile drapes etc
drape. - Cap / Head Cover
Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
Substandard # 7:22
central line etc.
Traffic should be kept Traffic should be kept minimum once the sterile field has been established.
minimum once the sterile
Only necessary health personnel should be at the procedure. The more people present, the
field has been established.
more opportunities for harmful bacteria to cause contamination.
Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.
During the training phase of IPCCC, orient the staff regarding frequency of changing
Substandard 7:23 ventilation circuits.
Provide specific infection control policy for changing ventilation circuits in the ventilated
Change ventilation circuits patients. (Multidisciplinary policy approved from medical department, respiratory therapy
only when visibly soiled or department and nursing department)
mechanically
malfunctioning. During daily / weekly random select the ventilated patients & review files if policy is
implemented.
In order to avoid risk of acquiring risk of infection from frequent manipulations. Ventilation
circuits must only be changed only when:
- Visibly soiled
- Mechanically malfunctioning.
In the event of changing ventilation circuits for ventilated patients there must be clear
documentation with indications for replacement (Patient’s file, unit’s records or respiratory
therapist logs etc

61 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team must provide education & training to the ICU team for optimum site selection of site
for central venous access as part of CLABSI bundle:

Following MUST be considered:

Substandard 7:24 Femoral site:

- Greatest risk of infection in adults, especially in overweight patients,
Avoid using the femoral vein - Avoid using the femoral vein for central venous access in adult patients.
for central venous access in
adult patients. Subclavian site:
lower risk of CLABSI than the internal jugular vein:
- Preferred when infection is only consideration
- Higher risk of mechanical complications (Pneumothorax, subclavian artery
puncture, hemothorax, subclavian vein stenosis etc)

Physicians must weigh risk-benefit of site selection for individual patient

Substandard 7.:25 Haemodialysis Patients:

Avoid the subclavian site in Subclavian site must be avoided in haemodialysis patients and patients with advanced kidney
haemodialysis patients and disease to avoid stenosis of subclavian vein.
patients with advanced - Observe the staff practices during IC monitoring rounds.
kidney disease to avoid - Evaluate the performance during IPCCC audit phase.
subclavian vein stenosis. - Provide feedback and reconsider for training if needed.

Substandard 7:26 ❖ Educate healthcare personnel regarding the indications for intravascular catheter use,
proper procedures for the insertion and maintenance of intravascular catheters, and
Do not routinely replace appropriate infection control measures to prevent intravascular catheter-related infections.
CVCs, PICCs or pulmonary
artery catheters If there is ❖ Periodically assess knowledge of and adherence to guidelines for all personnel involved in
no evidence of infection. the insertion and maintenance of intravascular catheters. (at least once per year. Rotate
Replace them only when staff in each quarter in training phase of IPCCC in order to achieve 100% coverage at
there is a clinical indication. the end of each year.

62 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training must incorporate following key points:

- In order to prevent the risk of catheter related infections, central Venous Catheters
Substandard 7:27 (CVCs), peripherally inserted Central Catheters (PICCs) or pulmonary artery catheters
must not be frequently changed.
Remove the CVCs, PICCs or
pulmonary artery catheters - Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding
as soon as they are no the appropriateness of removing the catheter if infection is evidenced elsewhere or if a
longer needed. non-infectious cause of fever is suspected.

- Conduct daily review for line necessity and remove as soon as they are no longer
indicated. More the duration of invasive devices, risk of infection increases.

- 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 dressing should be
removed to allow thorough examination of the site

Infection control practitioner must provide education & training on the rules of aseptic
Substandard 7:28 technique:
Following must be considered:
If guidewire is used to
replace a malfunctioning - ICU doctors / staff must rule infection If guidewire is used to replace a malfunctioning
non-tunnelled catheter, non-tunnelled catheter.
infection should be ruled
out. - Observe the staff practices during IC monitoring rounds.
- Evaluate the performance during IPCCC audit phase.
- Provide feedback and reconsider for training if needed.

Recognized routes for contamination of catheters:

Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with
colonization of the catheter tip; this is the most common route of infection for short-term catheters
Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices.
Catheters might become hematogenously seeded from another focus of infection.
Infusate contamination might lead to CRBSI.

63 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 -

Train, monitor & audit on following key points for replacing dressings on short term CVCs &
Substandard # 7:29
implanted / implanted CVCs:
Replace dressings used on
Catheter Site Dressing Regimens:
short-term central venous
catheter (CVC) sites every 2
❖ Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the
days for gauze dressing.
catheter site
❖ Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.
❖ Gauze Dressings used on short-term central venous catheter (CVC) sites must be
Substandard # 7:30
replaced every 2 days for gauze dressing following aseptic technique.
❖ Transparent Dressings used on short-term central venous catheter (CVC) sites must be
Replace dressing used on
replaced every 7 days for gauze dressing following aseptic technique.
short-term CVC sites at
❖ Transparent Dressings used on tunnelled or implanted CVC sites must be replaced no
least every 7 days for
more than once per week (unless the dressing is soiled or loose), until the insertion site
transparent
has healed following aseptic technique.
dressing.

Additional points:
Substandard # 7:31
❖ Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis
Replace transparent catheters, because of their potential to promote fungal infections and antimicrobial
dressings used on tunnelled resistance.
or implanted CVC sites no ❖ Do not submerge the catheter or catheter site in water. Showering should be permitted if
more than once per week precautions can be taken to reduce the likelihood of introducing organisms into the
(unless the dressing is catheter (e.g., if the catheter and connecting device are protected with an impermeable
soiled or loose), until the cover during the shower)
insertion site has healed.
Reference: https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html

64 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 08 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention & control
strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with growth

and multiplication but without tissue invasion or damage.

A. The source of the infectious agent may be patients, personnel, or visitors

and may include persons with active infection, persons in the incubation
period of the disease, or persons who are colonized by the infectious
agent but have no apparent disease. Other sources of infection include
inanimate objects in the environment, such as equipment and
medications that have become contaminated.
B. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune system,
comorbidities, extremes of ages etc
C. The mode of transmission is the method by which the organism reaches
a susceptible host.

Three modes of transmission are of particular importance in the healthcare setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
i. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
ii. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments, dressings,
shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

65 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Rationale for admission screening:
- Rapid screening of all patients admitted or transferred from any other healthcare facility to
Substandard # 8:01 the critical care units must be conducted to identify those patients requiring isolation is of
significant importance in reducing or preventing the spread of infection to HCWs, patients
There is a screening and visitors.
policy for newly - In the absence of standard screening protocols, a substantial proportion of patients may
admitted or be silently colonized with MDROs that are not detected during their routine hospital stay.
transferred patients to - Furthermore, colonization by MDRO is known as a potential source of cross transmission and
all critical care units to a risk factor for the development of subsequent infection.
identify those who
- Colonized patient constitute the major reservoir for nosocomial transmission.
require isolation
precautions.
Develop and provide detailed screening policy & ensure during daily/weekly rounds that the
policy is fully implemented.

Randomly check files of newly admitted or transferred patients to verify if screening is done or
not.
Ask staff to provide results to confirm the negative status or appropriate isolation precautions
are initiated based on positive results findings.

Provide education to the staff regarding importance of isolation precautions during IPCCC training
Substandard # 8:02 activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis for
isolation precautions patients under isolation.
are available in the Use preferably isolation precautions signs provided by GDIPC.
unit & used Must be placed / posted on door only if occupied by patient.
appropriately. 02 types of isolation precaution signs must be available in the unit.
Isolation signs must - Isolation precaution signs for units to be posted on doors if the isolation room is
be : 1) Clear and occupied by patients with diseases transmitted either by contact, droplet or airborne
visible for HCWs and route.
visitors 2) Bilingual (in - Isolation Transportation cards for transportation of patients to other departments as
Arabic & English). 3) needed.
Color coded and
compatible with Contact isolation Precautions must be used together with standard precautions:
diagnosis (Examples:
contact: green, Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
airborne: blue, and infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
droplet: pink or red) The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

66 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Precautions must be used together with standard precautions. Droplet
Substandard # 8:03 Precautions are intended to reduce the risk of droplet transmission of infectious agents from close
contact (exposure to eyes, nose and mouth) with large-particle droplets
Appropriate isolation
transportation cards / Should be Initiated and maintained when there is suspected or confirmed diagnosis of an
sings are available in infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
the department & Use a single room. A negative air pressure room is not indicated.
used while Place a droplet sign on the door.
transporting patients Droplet isolation signage must be color coded (e.g., orange) and must be available in both
under transmission- English and Arabic languages.
based precautions to
other department as Airborne isolation precautions must be used together with standard precautions
needed. Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases that
are spread via the airborne route.
Transport Isolation Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
signs must be : 1) disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Clear and visible for Use a single room with a negative air pressure system (AIIR)
HCWs and visitors 2) Place the Airborne Isolation sign on the door.
Bilingual (in Arabic & Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English). 3) Color English and Arabic languages. b. Keep door closed at all times except when entering or
coded and compatible leaving the room.
with diagnosis
(Examples: contact: Patient Transportation:
green, airborne: blue,
and droplet: pink or Patient Transportation isolation signs must be used while transporting patients under
red) and selecting low transmission-based precautions to other department as needed.
traffic time & route.
Transport of isolated patients should be limited to essential purposes only, such as diagnostic
and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
should be worn to reduce potential contamination of the environment and the spread of
infection.
Isolation instructions must be clearly highlighted on the transmission-based precaution card
(isolation signs) while transporting patients under transmission-based precautions to other
department ( e.g radiology).

IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 8:04 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
Log book for exposure entry into isolation room for any task.
is available for any Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
potentially harmful Logbook must specify the name, designation / job category, Duration of exposure (Time in /
infectious exposures Time out) & type of PPE used.
as per exposure Appropriately used logbook will generate information needed in case of outbreaks etc
policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. before gaining entry into isolation room.
MERS-CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

67 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use items are those that are intended for single use only, on an individual patient for a
single procedure, and then should be discarded. It should not be reprocessed or reused again
Substandard # 8:05 even on the same patient.
Single use or
Provide training and orientation to staff regarding patient care equipment to be used for isolation
dedicated non-critical
rooms during daily/weekly rounds:
patient care equipment
(e.g., stethoscope,
Following instructions must be given:
pressure cuff, etc.) are
used for the isolation
If single use non critical items are used for isolation rooms, they must be immediately
room.
discarded after use. Single use items must never be kept to be reused for the same patient or
next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be disinfected
after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc

Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation room
is used for another isolation room or another area.

Transfer of patients under isolation precautions must be restricted to medically necessary

purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
Substandard # 8:06 procedures that cannot be performed in the patient’s room.

Facility limits Provide training and orientation to staff the transfer rules related to patient transportation under
movement of patients isolation precautions. Observe if unit is following the policy.
on isolation
Precautions outside of Following instructions must be given:
their room except for
medically necessary Receiving unit or facility is informed beforehand about the required isolation precautions to be
purposes. taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Substandard # 8:09 Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
unit etc.
If transfer of patient
under isolation is It is important that HCWs in the receiving unit have received prior training on how to safely
required, the receiving handle patients under isolation precautions and how to appropriately use PPE according to type
unit or facility is of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit tested
informed about the for N-95 mask and trained well on how to don & doff after use.
required isolation
precautions and Transferring the Patient to Another Facility:
availability of
appropriate PPE is Inform the receiving facility and the emergency vehicle personnel in advance about the type of
ensured. isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

68 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8:10 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation.
While transferring
patients under Key Points include:
droplet/airborne
isolation precaution, Explain to the patient the need for the protective apparel that he/she is required to wear.
patient should wear a Patient must wear mask during transportation (droplet & airborne isolation)
surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory Isolation instructions must highlight the transmission-based precaution card (isolation signs)
hygiene and cough needed while transporting patients under transmission-based precautions to other department (
etiquette. e.g radiology).
-

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or
Substandard # 8:11 more classes of antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to most
Contact isolation available antimicrobial agents.
precautions are
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci
initiated for patients
(VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
infected or colonized
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms.
Skin lesions and Proper attention & care to these pathogens is critical to curtail further emergence of these
infected or colonized highly resistant organisms.
areas of patient's body
Infection refers to the entry into and multiplication of an infectious agent in the tissues of the
should be contained
host and the tissue damage resulting in apparent or unapparent changes in the host.
and covered.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and covered
in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

69 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training to the staff for rules to be followed for patient transportation under contact isolation
Substandard # 8:12 precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

For transport patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin Leak-proof dressing should be used to reduce potential contamination of the environment and
lesions and infected or the spread of infection.
colonized areas of the Dress wounds with impervious dressings as required.
patient’s body with Dress the patient in a clean gown.
clean bandages and Cover the patient with a clean sheet.
clean linens. Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

In order to avoid potential risk of acquiring infection visitors should be strictly limited for
airborne isolation cases.
As per standards, some exemptions may be considered on a case to case basis i.e visitors may
be allowed to enter the isolation room if he / she fulfils the following criteria e.g mothers of
babies etc
Substandard 08:13
- Duration of stay will be minimum for few minutes only.
Visitors - Visitors must seek permission from nursing station.
should be strictly - Clear instructions must be provided to visitors in their language before entering into an isolation
limited for airborne room.
isolation cases. - Visitors must be fully compliant with the required PPE i.e visitors will wear same type of PPE
Exemptions may be and follows same protocols as any HCWs before entering isolation rooms.
considered on a case - Proper education, counselling, and monitoring should be provided to the visitors before
to case basis only for entering the airborne infection isolation room.
few minutes after - Nursing staff must keep records of visitor’s education & instructions as evidence to be
having permission presented to external auditors when requested.
from nursing station
and after receiving Educate the staff regarding visitor’s policy & ensure during daily/weekly rounds if its fully
proper instructions implemented:
before entering into an
isolation room and - Observe and ask staff about the visitors if isolation room occupied by patient.
within compliance with - Ask about the evidence of education & documentation in log book.
the required PPE. - Observe when possible any visitor entering or coming out of isolation room if compliant with
instructions.
- Sometimes visitors are not donning PPE appropriately. Gowns is not tied & masks is worn
inappropriately.
- It is also common observation to see visitors coming out of AIIR with all PPE and removing PPE
abruptly without practicing hand hygiene.
- Such practices would pose risk of acquiring infection. Nursing staff must be fulling adherent
with visitor’s policy for isolated patients.

Audit the unit performance during IPCCC audit phase and provide formal feedback.

70 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Airborne Infection Isolation Rooms (AIIRs)
Airborne Infection Isolation rooms (AIIRs), commonly called negative pressure rooms, are single-occupancy patient care spaces
designed to isolate patients with airborne pathogens to a safe containment area. AIIRs provide negative pressure in the room
(so that air flows under the gap into the room) with a pressure differential of >-2.5 Pa (Pascal) or >- 0.01” water gauge; an air
flow rate of >12 air changes per hour (ACH) and direct exhaust air from the room to the outside of the building; or recirculation
of air through a HEPA filter before returning to circulation.
AIIRs are designed in such a way so that no airborne particulates escape into other areas within the healthcare setting. Exhaust
from these rooms is not recirculated in the HVAC system. Instead, exhaust air typically moves in dedicated ductwork to
ventilation stacks on the rooftop, where atmospheric air provides sufficient dilution to make the resulting air safe.
For the safety of healthcare workers, patients, and visitors, negative pressure rooms occupied by patients requiring
airborne isolation must be checked daily.
Sub standards Explanation
According to Ministry of Health guidelines, there must be at least one Airborne Infection
Substandard 9.01
Isolation Room for every 8 beds. (e.g 1-8 beds 1 AIIRS, 16 beds 2 AIIRs, 24 beds 3
At least one AIIR for each 8 AIIRs & so on)
beds. . IPC team must send request to higher administration if there is no AIIRs in the unit to fulfil
the requirement.

Provide training and orientation to the staff regarding general specification to be met for
all negative pressure isolation rooms. Monitor different parameters during routine
infection control rounds and observe If within recommended ranges. Evaluate the
performance of unit during IPCCC audit phase & provide formal feedback.
Substandard 9.02 Nurse in charge must receive clear instructions to keep all necessary records in the unit
to be presented if requested from external auditors.
Central air condition or
separate concealed unit is This includes all routine maintenance records and actions taken in terms of deranged
the source of conditioned environmental control parameters or malfunctioning.
fresh air. Maintenance staff must be consulted to provide detailed evidence of all these
specifications and each unit & IC team must keep copy of records.
Units must hard to keep all parameters within normal range and well prepared to provide
documented evidence for any external audit visit.

Following specifications must be met for all AIIRs:

Substandard 9.03
- There must be 100% fresh air supply from central AC or concealed separate unit.
- Return of air is not permitted & source of conditioned fresh air must be only via these 02
Air exhausted from
sources. (Central air condition or separate concealed unit).
bathroom must be
-
exhausted 100% outside
through HEPA filter.
- Air from bathrooms must be exhausted 100 % outside through High‐Efficiency Particulate
Air (HEPA) filters.
- The exhaust air ducts MUST be independent of the building exhaust air system.
-

71 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - HEPA filter should be changed on regular basis and according to manufacturer’s
Substandard 9.04 instructions.
- Unit must keep records of all documents that prove the maintenance and changing of
HEPA filter is changed on
regular basis and according HEPA filter (as recommended)
to manufacturer's
recommendations.
Rationale:

High-efficiency particulate air (HEPA) filter is an air filter that removes >99.97% of particles
>0.3um at a specified flow rate of air. HEPA filters may be integrated into the central air
handling systems, installed at the point of use above the ceiling of a room, or used as
Substandard 9.05
[
portable units.
There is monitor for
continuous monitoring of During rounds ICPs must ensure that each AIIR is equipped with a fixed monitor for
pressure difference at continuous monitoring of environmental control parameters and are in functional condition.
negative pressure room
having audio visual alarming
system when the ventilation Monitor must exhibit following specifications and records following parameters:
system failed.

Negative pressure (-2.5 pascal or more)

Substandard 9.06
>12 air changes per hour.
Isolation Room is Has an audio-visual alarm system in case of ventilation system failure. There must be
maintained at negative
pressure (-2.5 pascal or Visible red flashing lights and audible sound comes from the monitor.
more) with respect to Fixed monitor must be installed outside each AIIRs in the corridor to monitor the pressure
corridors.
difference between the room and corridor.
Test the monitor to ensure that alarm is working or no, by keeping the door of AIIRs open
for few seconds. Hold the room door open. After the time delay, the audible and visual
Substandard 9.07
alarm should annunciate.
Isolation Room is
Verify that the monitor is correctly reading the pressure. While the door is held open, the
maintained with >12 air
changes per hour. pressure reading should be at or near 0" water gauge.
Use a manual device to monitor pressure differentials in rooms where no monitor is
installed.

72 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During daily / weekly rounds ICPs must ensure that policy for regular monitoring of negative
pressure difference is fully implemented. If any breaches unit head must be informed.
Monitor and evaluate unit performance in IPCCC audit phase using IPCCC tool.

Substandard 9.08
❖ Unit must keep record of all documents as evidence of regular monitoring of negative
pressure difference of AIIRs for at least last 3 months:
Records for routine
monitoring of pressure
gradients (daily if a patient ❖ Daily when in use (i.e., a patient is isolated inside) .
is isolated inside, weekly
❖ Weekly when not in use (i.e., no patient is isolated).
when not in use and
monthly by biomedical ❖ Monthly check by biomedical personals
department).
Responsibility of Nursing staff:

Negative pressure rooms in use:

Nursing staff must conduct visual checks for the direction of air flow (using flutter strips)
on all rooms where patients are in airborne isolation for query and confirmed airborne
transmissible diseases (e.g., Pulmonary Mycobacterium tuberculosis, measles, chicken
pox) when patients are in this room.
Prior to admitting patients needing airborne isolation, check and ensure that negative
pressure rooms are functioning well. For those designated isolation rooms without
monitor, call maintenance to check if the room is maintaining its negative pressure.
Follow the procedure of this policy in any room that fails inspection. d. All documentation
must be sent to the IP&C Department.

B. Negative Pressure Ventilation Failure:

Unit staff must respond to negative pressure failure.

Nursing staff will lace a surgical mask on the patient in airborne isolation.
Keep the door closed at all times.
Notify the Utilities & Maintenance (U&M) Department of the location and problem & IC
Department
If U&M declares the occupied room is no longer maintaining negative pressure, patient
must be transferred to another negative pressure room immediately.
Put a surgical mask on the patient before transporting.

73 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 An aerosol-generating procedure (AGP) is defined as any medical procedure that can induce
the production of aerosols of various sizes, including small (< 5 microns) Particles. AGPs
includes bronchoscopy, sputum induction, intubation and extubation,cardiopulmonary
Substandard 9.09 resuscitation, open suctioning of airways, Ambu bagging,nebulization therapy, high frequency
oscillation ventilation and Bilevel Positive Airway Pressure ventilation – BiPAP
Any aerosol generating
procedure (AGP) should be Precautions to be observed when performing aerosol- generating procedures, which may be
done in negative pressure associated with an increased risk of infection transmission:
room or single room with
portable HEPA filter using Perform procedures in a negative pressure room or single room with HEPA filter
appropriate PPE (N95 mask, Limit the number of persons present in the room to the absolute minimum required for the
eye protection, gloves & patient’s care and support.
gown) with possible minimal Wear N95 masks: Every healthcare worker should wear a fit-tested seal check N95 mask
number of staff. (or an alternative respirator if fit testing failed).
Wear eye protection (i.e. goggles or a face shield).
Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures require
sterile gloves
Wear an impermeable apron for some procedures with expected high fluid volumes that
might penetrate the gown.
Perform hand hygiene before and after contact with the patient and his or her surroundings
and after PPE removal.

Train & observe the following during daily/weekly rounds:

❖ HCWs performing any aerosol generating Procedure (AGPs) like CPR, intubation,
extubation, suctioning etc for any suspected or confirmed COVID – 19 or MERS- CoV
cases. (If possible to observe the real situation / scenario).
❖ Observe the type of PPE used by HCWs while preparing for AGPs.
❖ Observe if AGPs are performed in negative pressure room or single room with HEPA filter.
❖ Ask about the total number of staff to be present during procedure. Ensure minimum
number of staff are present who are absolutely necessary for specific procedure / task.

Evaluate the staff performance during IPCCC audit phase & provide formal feedback.

74 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 AIIRs MUST fulfill the following MOH specifications for standard isolation
rooms:
Substandard 9.10
FLOORS, WALLS & CEILING:
AIIRs fulfill all MOH
specifications for standard Minimal openings in the walls, floors and ceiling that are well sealed and airtight.
isolation rooms + windows Smooth, one piece without any cracks or decorative fine parts.
are sealed and fixed (i.e., They should be covered with such paints so as to withstand repeated cleaning
could not be opened/)
and disinfection by approved disinfectants.
openings in walls and
ceiling are sealed and DOORS:
airtight / doors are properly
designed and well-sealed. Doors are properly designed and well-sealed.
The door should open to the inside.
Extend completely to the floor
Substandard 9.11
Must have auto closure device / auto closure mechanism.
The door should open to the
WINDOWS:
inside, has auto closure
device, well-sealed and
Windows are sealed and fixed (i.e., could not be opened)
extend completely to the
This will ensure to maintain continuous negative pressure differentials inside
floor.
airborne infection isolation rooms.

CURTAINS:
Substandard 9.12
After discharge, transfer or death of patient under airborne precautions, curtains
Windows are completely must be changed after terminal cleaning of isolation rooms
sealed and fixed (i.e., could
not be opened). HAND HYGIENE FACILITY:

a) Hand Washing:
Substandard 9.13
Following are required inside patients’ room
Curtains must be changed Hand Washing Sink
between patients. Plain and antimicrobial soap
Paper towels
Available at easily accessible location
Substandard 9.14
b) Hand Rubbing:
Hand washing facilities and
supplies (sinks / plain and Alcohol - based hand rub dispensers
Available at easily accessible location for staff to practice 5 moments of hand hygiene & to
antimicrobial soap / paper
perform hand hygiene after doffing of PPE items.
towels, Alcohol - based
hand rub dispensers) are
available & easily PPE TROLLEY:
accessible.
Ensure availability of PPE trolley OUTSIDE AIIRs.
Well organized and well maintained.
Substandard 9.15: Appropriately cleaned external surfaces and internal surfaces of drawers ; free from
dust and any other visible contamination.
Trolley that contains the All required PPE items MUST available (Gowns, Gloves, N – 95 respirators. Face
proper PPEs is available. shields / goggles etc)
PPE items are organized in a way to facilitate staff while donning PPE.
PPE or any other medical supply must never be kept inside isolation rooms to avoid
risk of contamination.

75 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles
often contain large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not
transferred to patients or healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled
linens must follow Standard Precautions at all times. To reduce the possibility of occupational risks of infection transmission
and/or exposure, laundry workers should focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal
protective equipment (PPE). Removal of foreign objects from soiled linen. 4. To restore soiled linen to usable condition,
washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 10:01 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 10:02 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 10:03 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 10:04 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

76 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:05 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 10:06 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Substandard # 10:07 Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Linen carts are covered and Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
not overfilled. to 10 inches off the floor.
Linen from isolation rooms is considered regular soiled linen.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

77 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
Substandard # 11:01 - Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)
All types of waste
containers are Specification of Items:
available in sufficient
number and placed in Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
easily accessible sites. with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

78 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11:02 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 11:03
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 11:04 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 11:05 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

79 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 11:06 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 12 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 12:01
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 12:02 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to
Local records for corrective interventions which are taken if readings are not matching the
70%).
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.

80 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Each storage area is equipped with a fixed device for regular monitoring of temperature and
Substandard # 12:03 relative humidity:

Away from air vents and - Recommended temperature Range is: 22 - 24°C
well ventilated. - Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
Substandard # 12:04 documented evidence to be presented if requested by external auditors.

Storage shelves are 40

cm from the ceiling, 20 Infection control team must provide training and reorientation about all specifications to be
cm from the floor, and 5 followed for the maintenance of departmental medical stores.
cm from the outside wall.
Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.
Substandard # 12:05 Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Storage shelves made
from easily cleanable Specifications of Storage Shelves:
material (e.g., fenestrated
Storage shelves are made of easily cleanable material
stainless steel, Aluminium
or hard plastic) (e.g., fenestrated stainless steel, Aluminium or hard plastic).
Storage shelves are placed following these specifications.

Substandard # 12:06 - 40 cm from the ceiling

- 20 cm from the floor
Sterile and clean items - 5 cm from the wall
completely separated
from personal items & If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
foods and drinks. hard plastic).
Ensure that only sterile and clean items are allowed in the medical stores.
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 12:07 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
original cardboard shipping boxes.
Substandard # 12:08
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
inside sock room. (i.e., boxes made of thick cardboard for shipping.
Items not kept in original
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
cardboard shipping
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
boxes.
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

81 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
Substandard # 12:09 discarded)
If any stained item is found it would most likely reflect that item was restocked after being
No expired items, broken brought from patient care areas which is against the rules of aseptic technique. Such
packs or packs with practices must be strictly prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in
order to ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit
phase.
Provide formal feedback on unit & staff performance

Standard – 13 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of
coronavirus was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19
pandemic reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 13:01 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

82 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 13:02
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

83 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 13:03
prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers &
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
visitors strictly adhere
droplets can also be inhaled into the lungs.
to the principles of
Recent studies indicate that people who are infected but do not have symptoms likely also play a
social distancing,
role in the spread of COVID-19. Since people can spread the virus before they know they are
cough etiquette and
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
frequent hand hygiene
have any symptoms.
during duty hours /
visiting hospital.
Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

84 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 13:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc) HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, transportation of supply etc

85 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
86 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
87 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

88 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
NEONATAL INTENSIVE CARE unit
(NICU)

Neonates admitted in the neonatal intensive care units (NICUs), are

at risk for infection due to their immunocompromised status. Colonized neonates are
the major source of infection, and microorganisms are transmitted between neonates
on hands or equipment. Other sources include contaminated patient care supplies,
infected personnel, and visitors.
Hence, strict implementation of infection control procedures including hand hygiene,
wearing personal protective equipment (PPE) to prevent the transmission of infection
during patient care, practicing aseptic technique, isolation precautions & environmental
measures etc. would play a significant role in ensuring patient & staff safety.

89 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN NEONATAL
INTENSIVE CARE unit (NICU)

POLICIES & PROCEDURES

NEONATAL INTENSIVE CARE UNIT

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

INFANT FEEDING

AIRNORNE INFECTION ISOLATION ROOMS (AIIRs)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

90 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 NEONATAL INTENSIVE CARE UNIT (NICU)
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

91 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation
Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.

Each HCPs must receive education & training on basic infection control skills from IC
Substandard # 2:1 department within 01 months of joining work. (BICSL)
IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
joining work & issue a BICSL ID which should be renewed ever 02 years.
Healthcare Personnel
(HCP) receive Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
orientation and hours as an evidence of basic infection control training to be presented to any external /internal
training on Basic audit visit for purpose of verification.
Infection Control Skills Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
from IC department every 2 years by visiting infection control department.
maximum within 1
months of joining
work & a BICSL card
is issued which is Components of BICSL includes:
renewed every 2
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

92 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
Substandard # 2:2 patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Healthcare Personnel knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
(HCP) receive job-
specific training on Infection Prevention & control department MUST provide education & training to all health care
infection prevention personnel on infection control best practices specific to their job as follows:
policies and
procedures upon Infection control Training specific to area of work must be provided initially upon hiring before
hiring and at least starting their duty.
once annually. Continuous education on relevant infection control policies and procedures must be conducted
at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

93 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters.

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

94 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control department MUST provide health education on infection control for families and
visitors.
Substandard # 2:4
IC team must ensure the availability of the following according to the specific unit / area:
Unit provides infection
control health Bilingual infection control health education & awareness material must be designed / formulated
education to the to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
mothers / care givers. booklets, leaflets etc. containing information easy to understand with help of pictorial display.
The general & specific health educational material must be posted and available in all patient
care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.
Parents /Family members’ / care givers must be aware about importance of hand hygiene,
identifying and notifying signs of inflammation etc
Visitors are educated on precautions to be taken while being in the surrounding of the patient,
the importance of hand hygiene and the required isolation precautions etc education must be
provided on how to don / doff PPE and perform hand hygiene before entering isolation room.
Ensure strict adherence of visitors to the recommendations / instructions regarding infection
prevention requirements (e.g.PPE use, hand hygiene etc).

95 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to
treat. On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital
patients has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
patient's room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

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 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Substandard # 3:2 Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
Health care microorganisms without the need for an exogenous source of water and requiring no rinsing or
professionals (HCP) drying with towels or other devices.
demonstrate
appropriate Indications:
technique for hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
rubbing and hand body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing. Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and
/or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based hand rub into palm and
briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
97 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
Substandard # 3:3 incorporating the culture of best practices.

❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Visual alerts are posted at appropriate places.
available: WHO 5
moments, how to - WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to - How to hand wash poster beside ach hand washing sink
do hand wash. - How to handrub poster beside each hand hygiene dispenser
-
WHO five moments of hand hygiene :

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

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100 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room but
are available and readily not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will interfere
accessible to HCP. with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge, if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Powered air purifying respirators (PAPRs) for bearded staff etc

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2
masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock rooms.
N - 95 respirators are
Check if all types and sizes are available according to fit test result of each healthcare
available in different types and
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)
sizes.

101 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

Substandard # 4:4
❖ Contact: Appropriate PPE – Gown & Gloves
Staff use personal protective ❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
equipment appropriately (e.g. ❖ Airborne: N95 mask / respirator before entering the room.
donning and doffing) 1: Appropriate PPE for Contact Isolation:
Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

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 Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
https://youtu.be/H4jQUBAlBrI Remove surgical mask.
Watch Video How to safely put Perform hand hygiene.
on PPE
NB: If goggles/face shield are worn:
• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

103 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

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105 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
106 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

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Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:8 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

108 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Newborns are particularly susceptible to certain diseases, much more so than older children and
adults because their immune system is not adequately developed to fight the bacteria, viruses,
and parasites that cause these infections. It is of utmost importance to provide safe environment
for the neonates in order to avoid risk of acquiring infection.

During IPCCC training phase , provide training to the NICU staff regarding cleaning and
disinfection of incubators. Monitor practices during daily/ weekly rounds and evaluate the
performance in the IPCCC audit phase.
Substandard # 5:9 Key points:
Incubators should be
❖ Incubators must be cleaned and disinfected in between babies. i.e incubator must be
disinfected between
disinfected thoroughly after baby’s discharge before being used on next baby.
each baby. The
incubator is
❖ Following frequency must be followed:
disinfected after every
7 days of
a) Disinfection of incubator must be done after every 7 days of hospitalization if it is
hospitalization (every 5
still occupied (Neonates with birth weight > 1000 kgs)
days for babies less
b) Disinfection of incubator must be done after every 5 days of hospitalization if it is
than 1 kilogram).
still occupied (Neonates with birth weight < 1000 kgs)

Conduct routine inspection of the unit and ensure all points are well implemented. Countercheck by
gently wiping hard to reach surfaces.

Note: Do not use disinfectants to clean infant incubators while these items are occupied. If
disinfectants (e.g., phenolic) are used for the terminal cleaning of infant bassinets and
incubators, thoroughly rinse the surfaces of these items with water and dry them before these
items are reused. (CDC)

Substandard # 5:10 Cleaning & Disinfection of Incubators:

After use all NICU staff must be well familiarized with appropriate technique of cleaning and disinfection of
removable parts must incubators and other patient care equipment:
be washed and
thoroughly cleaned Provide training on following steps to be followed. Monitor & evaluate performance as part of
with detergent. Rinse IPCCC activities:
and dry thoroughly
using disposable Key points:
paper towels. The
incubator should also After discharge or transfer of baby remove all detachable parts from the incubator.
be cleaned and dried. Thoroughly wash with the approved detergent so that all surfaces are covered. Ensure all blood
Then all parts of the and other stains are being removed.
incubator should be Cleaning reduces the bioburden & removes foreign material e.g soil, organic material etc.
disinfected using Cleaning is accomplished with water and detergents. E.g enzymatic detergents etc). Also if the
chlorine (200-500 soiled material becomes dried on the parts, the removal becomes more difficult and disinfection
ppm) or isopropyl will be less effective. So care must be taken to clean all items thoroughly before being
alcohol (70%). disinfected,
Rinse thoroughly with water and dry using disposable paper towels.
Clean all internal and external surfaces of incubator and let it dry.
Substandard # 5:11 Disinfect incubator by using chlorine solution (200-500 ppm (parts per million) or isopropyl
alcohol (70%)
Aerate the incubator Incubator must be aerated well before reuse on the next neonate.
before re-use.

109 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide complete list of disinfectants and detergents specifically to be used for neonatal
intensive care areas.
Provide training and awareness to the staff regarding type of disinfectants to be used for specific
patient scare equipment.

❖ Phenolic compounds such as phenol, chlorophenol, biphenyl etc.) must not be used for
disinfection of incubators or other surfaces in direct contact with the new-borns because of risk
Substandard # 5:12 of development of Neonatal hyperbilirubinemia.

Phenolic compounds ❖ The use of phenolic in nurseries has been questioned because of hyperbilirubinemia in infants
should not be used on placed in bassinets where phenolic detergents were used. In addition, bilirubin levels were
incubators or other reported to increase in phenolic-exposed infants, compared with nonphenolic-exposed infants,
surfaces in direct when the phenolic was prepared according to the manufacturers' recommended dilution. If
contact with the new- phenolic are used to clean nursery floors, they must be diluted as recommended on the product
born. label.
❖ A report from the Center for Disease Control showed two outbreaks of idiopathic neonatal
hyperbilirubinemia associated with the use of a phenolic disinfectant detergent, when used in
higher than recommended concentrations.

Neonatal hyperbilirubinemia is a common clinical problem encountered during the neonatal period,
especially in the first week of life. It is a multifactorial disorder with many symptoms. Elevated
serum bilirubin concentration causes jaundice a yellow discoloration of the skin and eyes.

During visit to the neonatal intensive care units observe the staff practices:

Use of adhesive tape for sticking baby’s information label is strictly prohibited due to risk of
Substandard # 5:13 infection.
Adhesive tape is not
Adhesive injury is the most common source of skin breakdown in infants in the NICU, particularly in
used to stick a baby
premature skin, the layers of skin called the epidermis, outermost layer, and dermis, the next layer,
information's label.
are not as strongly bonded. Therefore, upon removal of adhesives these layers are pulled apart and
the epidermal layer is removed with the adhesive. This results in skin breakdown and increased risk
of infection, pain etc

HIGH TOUCH SURFACES

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 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

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 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

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 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:04
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 6:05 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 3. Disposable personal care items are discarded
worker, housekeeping 4. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 6:06 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

113 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:07 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

114 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

115 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:08 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:09
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

116 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Substandard # 6:11 Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
Housekeepers are well measures.
trained on hand hygiene, Routine practices related to environmental cleaning includes:
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals.
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

117 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

118 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

119 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
120 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 7:01 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 7:02
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

121 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 7:03
in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of
to use large IV solution bottles for preparation & dilution of medications
medication is only done by
Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water
specified for preparation & dilution of medications.
ampoule.
Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 7:04
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 7:05
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

122 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 7:06 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient.
While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 7:07 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

123 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Maintaining the integrity of sterile equipment and solutions is extremely important to
Substandard # 7:08 prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
Sterile equipment and urinary catheter).
solutions are assembled - If the sterile items are assembled long before the procedure, there are chances of
immediately prior to use. contamination from environment such as dust etc.
- A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
the transfer of microorganisms and reduce the potential for infections.
- Principles of sterile technique help control and prevent infection, prevent the transmission
of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.
As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

124 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

Substandard # 7:09 A sterile object becomes non-sterile when touched by a non-sterile object.
Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
Sterile to sterile rule is transfer forceps.
applied during any aseptic Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
procedure. Non-sterile items should not cross over the sterile field. For example, a non-sterile person
should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

125 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 7:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 7:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

Substandard # 7:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

126 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 7:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
claim that each device is exclusively allocated only for one patient.
Substandard # 7:14
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
• Patient's name & medical record number to be used exclusively for one patient.
insulin pens) are used only
• Date of the first use to be discarded after expiration of the reuse life recommended
for single patient.
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 7:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.
Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
Substandard # 7:16
IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
IV solution bottles are only
than the self-sealed rubber cap.
accessed through the self-
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
sealed rubber cap.
Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

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 Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 7:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7
days, but not more Following key points must be followed for replacement of IV sets in order to avoid risk of
frequently than 96-hour infection from frequent changing of IV sets:
intervals.
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 7:18
Rationale: Extending the duration of use permits considerable cost savings to hospitals
IV sets that are used to without significant increase in the risk of healthcare-associated BSI with peripheral IVs
administer blood, blood
products, lipid emulsions, or In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
dextrose/amino acid TPN acid TPN solutions, check that IV delivery systems are continuously connected and
solutions are replaced within changed within 24 hours of initiating the infusion.
24 hours of initiating the During daily rounds, observe that IV administration sets are labelled with dates & times of
infusion. initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
(hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 7:19 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

128 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide education & training to the healthcare personnel regarding the feeding systems & key
Substandard # 7:20 points that should be considered.
Observe the practices during routine monitoring rounds. Evaluate performance during IPCCC
Open feeding systems audit phase.
should be removed after 8
hours, whereas sterile Following MUST be implemented:
closed systems may remain
hanging for up to 24 to 48 If open feeding system are used, they should be removed after 8 hours.
hours or per manufacturer's If sterile closed feeding system are being used, they may remain hanging for upto 24 – 48
recommendation. Hours or manufacturers instruction MUST be followed.

According to The Joint Commission, there are four chief aspects of the aseptic technique:
Substandard # 7:21 barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Maximum sterile barrier protect the patient from the transfer of pathogens from a healthcare worker, from the
precautions is applied environment, or from both. Some barriers used in aseptic technique include:
during any interventional
procedure, including cap, - Sterile gloves
mask, sterile gown, sterile - Sterile gowns
gloves, and sterile full-body - Masks for the patient and healthcare provider
drape. - Sterile drapes etc

Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
Substandard # 7:22 environment requires keeping doors closed during an interventional procedure like insertion of
central line etc.
Traffic should be kept
minimum once the sterile Traffic should be kept minimum once the sterile field has been established.
field has been established.
Only necessary health personnel should be at the procedure. The more people present, the
more opportunities for harmful bacteria to cause contamination.

Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

129 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC, orient the staff regarding frequency of changing
Substandard 7.23:
ventilation circuits.
Provide specific infection control policy for changing ventilation circuits in the ventilated
Change ventilation circuits patients. (Multidisciplinary policy approved from medical department, respiratory therapy
only when visibly soiled or department and nursing department)
mechanically
malfunctioning. During daily / weekly random select the ventilated patients & review files if policy is
implemented.
In order to avoid risk of acquiring risk of infection from frequent manipulations. Ventilation
circuits must only be changed only when:

- Visibly soiled
- Mechanically malfunctioning.

In the event of changing ventilation circuits for ventilated patients there must be clear
documentation with indications for replacement (Patient’s file, unit’s records or respiratory
therapist logs etc)

Substandard 7.24: ❖ Educate healthcare personnel regarding the indications for intravascular catheter use,
proper procedures for the insertion and maintenance of intravascular catheters, and
Do not routinely replace appropriate infection control measures to prevent intravascular catheter-related infections.
CVCs, PICCs or pulmonary
artery catheters If there is ❖ Periodically assess knowledge of and adherence to guidelines for all personnel involved in
no evidence of infection. the insertion and maintenance of intravascular catheters. (at least once per year. Rotate
Replace them only when staff in each quarter in training phase of IPCCC in order to achieve 100% coverage at
there is a clinical indication. the end of each year.

Training must incorporate following key points:

- In order to prevent the risk of catheter related infections, central Venous Catheters
Substandard 7.25: (CVCs), peripherally inserted Central Catheters (PICCs) or pulmonary artery catheters
must not be frequently changed.
Remove the CVCs, PICCs or
pulmonary artery catheters - Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding
as soon as they are no the appropriateness of removing the catheter if infection is evidenced elsewhere or if a
longer needed. non-infectious cause of fever is suspected.

- Conduct daily review for line necessity and remove as soon as they are no longer
indicated. More the duration of invasive devices, risk of infection increases.

- 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 dressing should be
removed to allow thorough examination of the site

130 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 7.26: Infection control practitioner must provide education & training on the rules of aseptic
Remove and do not replace technique:
umbilical artery or venous
Following must be considered:
catheters if any signs of
Catheter-related - Remove and do not replace umbilical artery catheters if any signs of Catheter-related
bloodstream infection bloodstream infection (CRBSI) , vascular insufficiency in the lower extremities, or
(CRBSI), vascular thrombosis are present.
insufficiency in the lower - Neonatologists must rule infection If guidewire is used to replace a malfunctioning non-
extremities, or thrombosis tunnelled catheter,
are present.

Following key points MUST be considered during insertion to avoid risk of infection:
Substandard 7.27:
Cleanse the umbilical insertion site with an antiseptic before catheter insertion. Avoid
If guidewire is used to tincture of iodine because of the potential effect on the neonatal thyroid. Other iodine-
replace a malfunctioning containing products (e.g., povidone iodine) can be used.
non-tunnelled catheter, Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites
infection should be ruled because of the potential to promote fungal infections and antimicrobial resistance
out.

Recognized routes for contamination of catheters:

Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with
colonization of the catheter tip; this is the most common route of infection for short-term catheters
Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices.
Catheters might become hematogenously seeded from another focus of infection.
Infusate contamination might lead to CRBSI.

Train, monitor & audit on following key points for replacing dressings on short term CVCs &
Substandard # 7:28
implanted / implanted CVCs:
Replace dressings used on
Catheter Site Dressing Regimens:
short-term central venous
catheter (CVC) sites every 2
❖ Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the
days for gauze dressing.
catheter site
❖ Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.
❖ Gauze Dressings used on short-term central venous catheter (CVC) sites must be
Substandard # 7:29
replaced every 2 days for gauze dressing following aseptic technique.
❖ Transparent Dressings used on short-term central venous catheter (CVC) sites must be
Replace dressing used on
replaced every 7 days for gauze dressing following aseptic technique.
short-term CVC sites at
❖ Transparent Dressings used on tunnelled or implanted CVC sites must be replaced no
least every 7 days for
more than once per week (unless the dressing is soiled or loose), until the insertion site
transparent
has healed following aseptic technique.
dressing.

131 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Additional points:
Substandard # 7:30
❖ Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis
Replace transparent catheters, because of their potential to promote fungal infections and antimicrobial
dressings used on tunnelled resistance.
or implanted CVC sites no ❖ Do not submerge the catheter or catheter site in water. Showering should be permitted if
more than once per week precautions can be taken to reduce the likelihood of introducing organisms into the
(unless the dressing is catheter (e.g., if the catheter and connecting device are protected with an impermeable
soiled or loose), until the cover during the shower)
insertion site has healed.
Reference: https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html

132 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 08 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

D. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
E. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
F. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
iii. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
iv. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

133 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Rationale for admission screening:
- Rapid screening of all patients admitted or transferred from any other healthcare facility to
Substandard # 8:01 the critical care units must be conducted to identify those patients requiring isolation is of
significant importance in reducing or preventing the spread of infection to HCWs, patients
There is a screening and visitors.
policy for newly - In the absence of standard screening protocols, a substantial proportion of patients may
admitted or be silently colonized with MDROs that are not detected during their routine hospital stay.
transferred patients to - Furthermore, colonization by MDRO is known as a potential source of cross transmission and
all critical care units to a risk factor for the development of subsequent infection.
identify those who
- Colonized patient constitute the major reservoir for nosocomial transmission.
require isolation
precautions.
Develop and provide detailed screening policy & ensure during daily/weekly rounds that the
policy is fully implemented.

Randomly check files of newly admitted or transferred patients to verify if screening is done or
not.
Ask staff to provide results to confirm the negative status or appropriate isolation precautions
are initiated based on positive results findings.

Provide education to the staff regarding importance of isolation precautions during IPCCC training
Substandard # 8:02 activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis for
isolation precautions patients under isolation.
are available in the Use preferably isolation precautions signs provided by GDIPC.
unit & used Must be placed / posted on door only if occupied by patient.
appropriately. 02 types of isolation precaution signs must be available in the unit.
Isolation signs must - Isolation precaution signs for units to be posted on doors if the isolation room is
be : 1) Clear and occupied by patients with diseases transmitted either by contact, droplet or airborne
visible for HCWs and route.
visitors 2) Bilingual (in - Isolation Transportation cards for transportation of patients to other departments as
Arabic & English). 3) needed.
Color coded and
compatible with Contact isolation Precautions must be used together with standard precautions:
diagnosis (Examples:
contact: green, Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
airborne: blue, and infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
droplet: pink or red) The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

134 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Precautions must be used together with standard precautions. Droplet
Substandard # 8:03 Precautions are intended to reduce the risk of droplet transmission of infectious agents from close
contact (exposure to eyes, nose and mouth) with large-particle droplets
Appropriate isolation
transportation cards / Should be Initiated and maintained when there is suspected or confirmed diagnosis of an
sings are available in infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
the department & Use a single room. A negative air pressure room is not indicated.
used while Place a droplet sign on the door.
transporting patients Droplet isolation signage must be color coded (e.g., orange) and must be available in both
under transmission- English and Arabic languages.
based precautions to
other department as Airborne isolation precautions must be used together with standard precautions
needed. Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases that
are spread via the airborne route.
Transport Isolation Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
signs must be : 1) disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Clear and visible for Use a single room with a negative air pressure system (AIIR)
HCWs and visitors 2) Place the Airborne Isolation sign on the door.
Bilingual (in Arabic & Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English). 3) Color English and Arabic languages. b. Keep door closed at all times except when entering or
coded and compatible leaving the room.
with diagnosis
(Examples: contact: Patient Transportation:
green, airborne: blue,
and droplet: pink or Patient Transportation isolation signs must be used while transporting patients under
red) and selecting low transmission-based precautions to other department as needed.
traffic time & route.
Transport of isolated patients should be limited to essential purposes only, such as diagnostic
and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
should be worn to reduce potential contamination of the environment and the spread of
infection.
Isolation instructions must be clearly highlighted on the transmission-based precaution card
(isolation signs) while transporting patients under transmission-based precautions to other
department ( e.g radiology).

IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 8:04 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
Log book for exposure entry into isolation room for any task.
is available for any Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
potentially harmful Logbook must specify the name, designation / job category, Duration of exposure (Time in /
infectious exposures Time out) & type of PPE used.
as per exposure Appropriately used logbook will generate information needed in case of outbreaks etc
policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. before gaining entry into isolation room.
MERS-CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

135 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use items are those that are intended for single use only, on an individual patient for a
single procedure, and then should be discarded. It should not be reprocessed or reused again
Substandard # 8:05 even on the same patient.
Single use or
Provide training and orientation to staff regarding patient care equipment to be used for isolation
dedicated non-critical
rooms during daily/weekly rounds:
patient care equipment
(e.g., stethoscope,
Following instructions must be given:
pressure cuff, etc.) are
used for the isolation
If single use non critical items are used for isolation rooms, they must be immediately
room.
discarded after use. Single use items must never be kept to be reused for the same patient or
next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be disinfected
after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc

Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation room
is used for another isolation room or another area.

Transfer of patients under isolation precautions must be restricted to medically necessary

purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
Substandard # 8:06 procedures that cannot be performed in the patient’s room.

Facility limits Provide training and orientation to staff the transfer rules related to patient transportation under
movement of patients isolation precautions. Observe if unit is following the policy.
on isolation
Precautions outside of Following instructions must be given:
their room except for
medically necessary Receiving unit or facility is informed beforehand about the required isolation precautions to be
purposes. taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Substandard # 8:09 Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
unit etc.
If transfer of patient
under isolation is It is important that HCWs in the receiving unit have received prior training on how to safely
required, the receiving handle patients under isolation precautions and how to appropriately use PPE according to type
unit or facility is of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit tested
informed about the for N-95 mask and trained well on how to don & doff after use.
required isolation
precautions and Transferring the Patient to Another Facility:
availability of
appropriate PPE is Inform the receiving facility and the emergency vehicle personnel in advance about the type of
ensured. isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

136 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8:10 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation.
While transferring
patients under Key Points include:
droplet/airborne
isolation precaution, Explain to the patient the need for the protective apparel that he/she is required to wear.
patient should wear a Patient must wear mask during transportation (droplet & airborne isolation)
surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory Isolation instructions must highlight the transmission-based precaution card ( isolation signs)
hygiene and cough needed while transporting patients under transmission-based precautions to other department (
etiquette. e.g radiology).
-

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or
Substandard # 8:11 more classes of antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to
Contact isolation most available antimicrobial agents.
precautions are
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci
initiated for patients
(VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
infected or colonized
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms.
Skin lesions and Proper attention & care to these pathogens is critical to curtail further emergence of these
infected or colonized highly resistant organisms.
areas of patient's body
Infection refers to the entry into and multiplication of an infectious agent in the tissues of the
should be contained
host and the tissue damage resulting in apparent or unapparent changes in the host.
and covered.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and covered
in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

137 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training to the staff for rules to be followed for patient transportation under contact isolation
Substandard # 8:12 precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

For transport patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin Leak-proof dressing should be used to reduce potential contamination of the environment and
lesions and infected or the spread of infection.
colonized areas of the Dress wounds with impervious dressings as required.
patient’s body with Dress the patient in a clean gown.
clean bandages and Cover the patient with a clean sheet.
clean linens. Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

In order to avoid potential risk of acquiring infection visitors should be strictly limited for
airborne isolation cases.
As per standards, some exemptions may be considered on a case to case basis i.e visitors may
be allowed to enter the isolation room if he / she fulfils the following criteria e.g mothers of
babies etc
Substandard 08:13
- Duration of stay will be minimum for few minutes only.
Visitors - Visitors must seek permission from nursing station.
should be strictly - Clear instructions must be provided to visitors in their language before entering into an isolation
limited for airborne room.
isolation cases. - Visitors must be fully compliant with the required PPE i.e visitors will wear same type of PPE
Exemptions may be and follows same protocols as any HCWs before entering isolation rooms.
considered on a case - Proper education, counselling, and monitoring should be provided to the visitors before
to case basis only for entering the airborne infection isolation room.
few minutes after - Nursing staff must keep records of visitor’s education & instructions as evidence to be
having permission presented to external auditors when requested.
from nursing station
and after receiving Educate the staff regarding visitor’s policy & ensure during daily/weekly rounds if its fully
proper instructions implemented:
before entering into an
isolation room and - Observe and ask staff about the visitors if isolation room occupied by patient.
within compliance with - Ask about the evidence of education & documentation in log book.
the required PPE. - Observe when possible any visitor entering or coming out of isolation room if compliant with
instructions.
- Sometimes visitors are not donning PPE appropriately. Gowns is not tied & masks is worn
inappropriately.
- It is also common observation to see visitors coming out of AIIR with all PPE and removing PPE
abruptly without practicing hand hygiene.
- Such practices would pose risk of acquiring infection. Nursing staff must be fulling adherent
with visitor’s policy for isolated patients.

Audit the unit performance during IPCCC audit phase and provide formal feedback.

138 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Airborne Infection Isolation Rooms (AIIRs)
Airborne Infection Isolation rooms (AIIRs), commonly called negative pressure rooms, are single-occupancy patient care spaces
designed to isolate patients with airborne pathogens to a safe containment area. AIIRs provide negative pressure in the room (so
that air flows under the gap into the room) with a pressure differential of >-2.5 Pa (Pascal) or >- 0.01” water gauge; an air flow
rate of >12 air changes per hour (ACH) and direct exhaust air from the room to the outside of the building; or recirculation of air
through a HEPA filter before returning to circulation.
AIIRs are designed in such a way so that no airborne particulates escape into other areas within the healthcare setting. Exhaust
from these rooms is not recirculated in the HVAC system. Instead, exhaust air typically moves in dedicated ductwork to ventilation
stacks on the rooftop, where atmospheric air provides sufficient dilution to make the resulting air safe.
For the safety of healthcare workers, patients, and visitors, negative pressure rooms occupied by patients requiring airborne
isolation must be checked daily.
Sub standards Explanation
According to Ministry of Health guidelines, there must be at least one Airborne Infection
Substandard 8.01:
Isolation Room in the neonatal intensive care unit.
At least one AIIR for NICU. IPC team must send request to higher administration if there is no AIIRs in the unit to fulfil
the requirement.

Provide training and orientation to the staff regarding general specification to be met for
all negative pressure isolation rooms. Monitor different parameters during routine
infection control rounds and observe If within recommended ranges. Evaluate the
performance of unit during IPCCC audit phase & provide formal feedback.
Substandard 8.02 Nurse in charge must receive clear instructions to keep all necessary records in the unit
to be presented if requested from external auditors.
Central air condition or
separate concealed unit is This includes all routine maintenance records and actions taken in terms of deranged
the source of conditioned environmental control parameters or malfunctioning.
fresh air. Maintenance staff must be consulted to provide detailed evidence of all these
specifications and each unit & IC team must keep copy of records.
Units must hard to keep all parameters within normal range and well prepared to provide
documented evidence for any external audit visit.

Following specifications must be met for all AIIRs:

Substandard 8.03:
- There must be 100% fresh air supply from central AC or concealed separate unit.
- Return of air is not permitted & source of conditioned fresh air must be only via these 02
Air exhausted from
sources. (Central air condition or separate concealed unit).
bathroom must be
-
exhausted 100% outside
through HEPA filter.
- Air from bathrooms must be exhausted 100 % outside through High‐Efficiency Particulate
Air (HEPA) filters.
- The exhaust air ducts MUST be independent of the building exhaust air system.
-

139 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - HEPA filter should be changed on regular basis and according to manufacturer’s
Substandard 8.04: instructions.
- Unit must keep records of all documents that prove the maintenance and changing of
HEPA filter is changed on
regular basis and according HEPA filter (as recommended)
to manufacturer's
recommendations.
Rationale:

High-efficiency particulate air (HEPA) filter is an air filter that removes >99.97% of particles
>0.3um at a specified flow rate of air. HEPA filters may be integrated into the central air
handling systems, installed at the point of use above the ceiling of a room, or used as
Substandard 8.05:
[
portable units.
There is monitor for
continuous monitoring of During rounds ICPs must ensure that each AIIR is equipped with a fixed monitor for
pressure difference at continuous monitoring of environmental control parameters and are in functional condition.
negative pressure room
having audio visual alarming
system when the ventilation Monitor must exhibit following specifications and records following parameters:
system failed.

Negative pressure (-2.5 pascal or more)

Substandard 8.06:
>12 air changes per hour.
Isolation Room is Has an audio-visual alarm system in case of ventilation system failure. There must be
maintained at negative
pressure (-2.5 pascal or Visible red flashing lights and audible sound comes from the monitor.
more) with respect to Fixed monitor must be installed outside each AIIRs in the corridor to monitor the pressure
corridors.
difference between the room and corridor.
Test the monitor to ensure that alarm is working or no, by keeping the door of AIIRs open
for few seconds. Hold the room door open. After the time delay, the audible and visual
Substandard 8.07:
alarm should annunciate.
Isolation Room is
Verify that the monitor is correctly reading the pressure. While the door is held open, the
maintained with >12 air
changes per hour. pressure reading should be at or near 0" water gauge.
Use a manual device to monitor pressure differentials in rooms where no monitor is
installed.

140 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During daily / weekly rounds ICPs must ensure that policy for regular monitoring of negative
pressure difference is fully implemented. If any breaches unit head must be informed.
Monitor and evaluate unit performance in IPCCC audit phase using IPCCC tool.

❖ Unit must keep record of all documents as evidence of regular monitoring of negative
pressure difference of AIIRs for at least last 3 months:

❖ Daily when in use (i.e., a patient is isolated inside) .

Substandard 8.08: ❖ Weekly when not in use (i.e., no patient is isolated).
❖ Monthly check by biomedical personals

Records for routine

monitoring of pressure Responsibility of Nursing staff:
gradients (daily if a patient
is isolated inside, weekly
when not in use and Negative pressure rooms in use:
monthly by biomedical
department).
Nursing staff must conduct visual checks for the direction of air flow (using flutter strips)
on all rooms where patients are in airborne isolation for query and confirmed airborne
transmissible diseases (e.g., Pulmonary Mycobacterium tuberculosis, measles, chicken
pox) when patients are in this room.
Prior to admitting patients needing airborne isolation, check and ensure that negative
pressure rooms are functioning well. For those designated isolation rooms without
monitor, call maintenance to check if the room is maintaining its negative pressure.
Follow the procedure of this policy in any room that fails inspection. d. All documentation
must be sent to the IP&C Department.

B. Negative Pressure Ventilation Failure:

Unit staff must respond to negative pressure failure.

Nursing staff will lace a surgical mask on the patient in airborne isolation.
Keep the door closed at all times.
Notify the Utilities & Maintenance (U&M) Department of the location and problem & IC
Department
If U&M declares the occupied room is no longer maintaining negative pressure, patient
must be transferred to another negative pressure room immediately.
Put a surgical mask on the patient before transporting.

141 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 An aerosol-generating procedure (AGP) is defined as any medical procedure that can induce
the production of aerosols of various sizes, including small (< 5 microns) Particles. AGPs
includes bronchoscopy, sputum induction, intubation and extubation,cardiopulmonary
Substandard 8.09: resuscitation, open suctioning of airways, Ambu bagging,nebulization therapy, high frequency
oscillation ventilation and Bilevel Positive Airway Pressure ventilation – BiPAP
Any aerosol generating
procedure (AGP) should be Precautions to be observed when performing aerosol- generating procedures, which may be
done in negative pressure associated with an increased risk of infection transmission:
room or single room with
portable HEPA filter using Perform procedures in a negative pressure room or single room with HEPA filter
appropriate PPE (N95 mask, Limit the number of persons present in the room to the absolute minimum required for the
eye protection, gloves & patient’s care and support.
gown) with possible minimal Wear N95 masks: Every healthcare worker should wear a fit-tested seal check N95 mask
number of staff. (or an alternative respirator if fit testing failed).
Wear eye protection (i.e. goggles or a face shield).
Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures require
sterile gloves
Wear an impermeable apron for some procedures with expected high fluid volumes that
might penetrate the gown.
Perform hand hygiene before and after contact with the patient and his or her surroundings
and after PPE removal.

Train & observe the following during daily/weekly rounds:

❖ HCWs performing any aerosol generating Procedure (AGPs) like CPR, intubation,
extubation, suctioning etc for any suspected or confirmed COVID – 19 or MERS- CoV
cases. (If possible to observe the real situation / scenario).
❖ Observe the type of PPE used by HCWs while preparing for AGPs.
❖ Observe if AGPs are performed in negative pressure room or single room with HEPA filter.
❖ Ask about the total number of staff to be present during procedure. Ensure minimum
number of staff are present who are absolutely necessary for specific procedure / task.

Evaluate the staff performance during IPCCC audit phase & provide formal feedback.

142 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 AIIRs MUST fulfill the following MOH specifications for standard isolation
rooms:

FLOORS, WALLS & CEILING:

Substandard 8.10:
Minimal openings in the walls, floors and ceiling that are well sealed and airtight.
AIIRs fulfill all MOH Smooth, one piece without any cracks or decorative fine parts.
specifications for standard They should be covered with such paints so as to withstand repeated cleaning
isolation rooms + windows and disinfection by approved disinfectants.
are sealed and fixed (i.e.,
could not be opened/) DOORS:
openings in walls and
ceiling are sealed and Doors are properly designed and well-sealed.
airtight / doors are properly
The door should open to the inside.
designed and well-sealed.
Extend completely to the floor
Must have auto closure device / auto closure mechanism.
Substandard 8.11:
WINDOWS:
The door should open to the
inside, has auto closure
Windows are sealed and fixed (i.e., could not be opened)
device, well-sealed and
This will ensure to maintain continuous negative pressure differentials inside
extend completely to the
airborne infection isolation rooms.
floor.

HAND HYGIENE FACILITY:

Substandard 8.12:
c) Hand Washing:
Windows are completely Following are required inside patients’ room
sealed and fixed (i.e., could
not be opened). Hand Washing Sink
Plain and antimicrobial soap
Paper towels
Substandard 8.13: Available at easily accessible location

Hand washing facilities and d) Hand Rubbing:

supplies (sinks / plain and
Alcohol - based hand rub dispensers
antimicrobial soap / paper
Available at easily accessible location for staff to practice 5 moments of hand
towels, Alcohol - based
hygiene & to perform hand hygiene after doffing of PPE items.
hand rub dispensers) are
available & easily
accessible. PPE TROLLEY:

Ensure availability of PPE trolley OUTSIDE AIIRs.

Substandard 8.14:
Well organized and well maintained.
Trolley that contains the Appropriately cleaned external surfaces and internal surfaces of drawers ; free from
proper PPEs is available. dust and any other visible contamination.
All required PPE items MUST available (Gowns, Gloves, N – 95 respirators. Face
shields / goggles etc)
PPE items are organized in a way to facilitate staff while donning PPE.
PPE or any other medical supply must never be kept inside isolation rooms to avoid
risk of contamination.

143 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Infant Feeding
Breast milk provides immunological as well as nutritional benefits and has been reported to reduce the risk of sepsis in premature
infants. If expression of breast milk is necessary because the sick infant is unable to suck, measures should be taken to minimize
bacterial contamination. These include antiseptic hand hygiene and expression of milk into sterile containers. There is evidence
of Intrinsic contamination of commercial powdered infant formula.
Expressed breast milk & Formula feeds can become contaminated during preparation, collection, or handling. Infections have
been associated with contaminated blenders and breast milk pumps. Staff must adhere to strict infection control measures to
prevent the acquisition of infection from contaminated feedings.
Sub standards Explanation

Provide training to the NICU staff regarding the best practices to be adopted during
collection, handling, & storage of breast milk in order to reduce risk of acquiring infection
from contaminated infant feed. Monitor and evaluate performance during IPCCC audit
Substandard 10.01: phase.

Breast milk is collected and Following key points must be considered while collection & storage of breast milk.
stored aseptically. After
thawing, milk is used Aseptic technique including hand hygiene must be followed.
promptly or stored in a Expression of breast milk must be into sterile containers.
refrigerator for no longer Frozen breast milk may be thawed in the refrigerator or quickly under running water with
than 24 hours. care to avoid contamination from the water.
Once the milk is removed from the refrigerator, feeding should be completed within a
maximum of 4 hours.
Thawed milk can be stored in the refrigerator for maximum of 24 hours and after that all
left over milk must be discarded.

NICU staff must be well trained regarding the best practices to be adopted for using
readymade formula to avoid risk of acquiring infections.

Key points to observed during daily / weekly rounds.

Substandard 10.02:
If formula feeds are required and available, it must be a sterile commercial formula for
Ready-made formula is ready to feed.
available and labelled by There must be clear label specifying name of baby, date and time of opening.
date and time of opening to Once opened it must be used only within 4 hours of opening.
be used only within 4 hours
of opening. Commercial liquid concentrates are sterile while commercial powder formulas are not sterile
and must be considered only if there is no other option. Water used for dilution or
reconstitution should be sterile, and equipment should undergo sterilization or disinfection
before use.

144 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the staff practices during daily / weekly rounds if they area adherent to infection
Substandard 10.03:
control measures discussed in the IPCCC training phase.
If a breast pump is used, Observe how the staff will handle the breast pump after being used by mothers.
pump components are All components of breast pump that have come in contact with pump must be washed
washed with soapy water, thoroughly with hot soapy water.
rinsed off and sterilized after Must be rinsed off thoroughly with clean water.
use. All pump components must be sterilized before being used next time & stored in clean
place.

Standard – 11 Textile Management

Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often
contain large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred
to patients or healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must
follow Standard Precautions at all times. To reduce the possibility of occupational risks of infection transmission and/or exposure,
laundry workers should focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal protective equipment
(PPE). Removal of foreign objects from soiled linen. 4. To restore soiled linen to usable condition, washing, bleaching, rinsing,
and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 11:01 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 11:02 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 11:03 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

145 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 11:04 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

Substandard # 11:05 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
Place used linen in a laundry bag at the point of use.
functionally contain wet or
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing. textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 11:06 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Substandard # 11:07 Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Linen carts are covered and Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
not overfilled. to 10 inches off the floor.
Linen from isolation rooms is considered regular soiled linen.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

146 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
Substandard # 12:01 - Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)
All types of waste
containers are Specification of Items:
available in sufficient
number and placed in Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
easily accessible sites. with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

147 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 13:02 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 14:03
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 15:04 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 16:05 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

148 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 17:06 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 13 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the
integrity of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best
practices for safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 13:01
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 13:02 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to
Local records for corrective interventions which are taken if readings are not matching the
70%).
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.

149 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Each storage area is equipped with a fixed device for regular monitoring of temperature and
Substandard # 13:03 relative humidity:

Away from air vents and - Recommended temperature Range is: 22 - 24°C
well ventilated. - Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
Substandard # 13:04 documented evidence to be presented if requested by external auditors.

Storage shelves are 40

cm from the ceiling, 20 Infection control team must provide training and reorientation about all specifications to be
cm from the floor, and 5 followed for the maintenance of departmental medical stores.
cm from the outside wall.
Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.
Substandard # 13:05 Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Storage shelves made
from easily cleanable Specifications of Storage Shelves:
material (e.g., fenestrated
Storage shelves are made of easily cleanable material
stainless steel, Aluminium
or hard plastic) (e.g., fenestrated stainless steel, Aluminium or hard plastic).
Storage shelves are placed following these specifications.

Substandard # 13:06 - 40 cm from the ceiling

- 20 cm from the floor
Sterile and clean items - 5 cm from the wall
completely separated
from personal items & If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
foods and drinks. hard plastic).
Ensure that only sterile and clean items are allowed in the medical stores.
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 13:07 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
original cardboard shipping boxes.
Substandard # 13:08
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
inside sock room. (i.e., boxes made of thick cardboard for shipping.
Items not kept in original
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
cardboard shipping
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
boxes.
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

150 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
Substandard # 13:09 discarded)
If any stained item is found it would most likely reflect that item was restocked after being
No expired items, broken brought from patient care areas which is against the rules of aseptic technique. Such
packs or packs with practices must be strictly prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in
order to ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit
phase.
Provide formal feedback on unit & staff performance

Standard – 14 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 14:01 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

151 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 14:02
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

152 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 14:03
prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers &
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
visitors strictly adhere
droplets can also be inhaled into the lungs.
to the principles of
Recent studies indicate that people who are infected but do not have symptoms likely also play a
social distancing,
role in the spread of COVID-19. Since people can spread the virus before they know they are
cough etiquette and
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
frequent hand hygiene
have any symptoms.
during duty hours /
visiting hospital.
Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

153 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 14:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of HCWs is Following must be ensured:
strictly prohibited
unless necessary for Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
Infection Prevention & clinical staff) to avoid the unnecessary mobility in between the units.
control activities. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, mandatory inspection rounds, transportation of supply etc

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155 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
156 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

157 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
PEDIATRIC INTENSIVE CARE unit
(PICU)

Paediatric ICUs are critical care areas that provide intensive

care services to the critically ill children. These units are capable of providing services
unique to its setting such as mechanical ventilation and invasive cardiovascular
monitoring. Patients admitted in the critical care units are at potential risk of healthcare
associated infections because of frequent need of invasive devices.
Hence, strict implementation of infection control procedures like bundles of care
including hand hygiene, wearing personal protective equipment (PPE) to prevent the
transmission of infection during patient care, practicing aseptic technique, isolation
precautions & environmental measures etc. would play a significant role in ensuring
patient & staff safety.

158 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN paediatric
INTENSIVE CARE unit (pICU)

POLICIES & PROCEDURES

PEDIATRIC INTENSIVE CARE UNIT

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

AIRNORNE INFECTION ISOLATION ROOMS (AIIRs)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

159 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PEDIATRIC INTENSIVE CARE UNIT (PICU)
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

160 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among
HCWs, patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided
with the required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide
the necessary resources for implementing trainings on infection control best practices & establishing auditing tools on
performance measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation
Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.

Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Substandard # 2:1
IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
joining work & issue a BICSL ID which should be renewed ever 02 years.
Healthcare Personnel Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
(HCP) receive hours as an evidence of basic infection control training to be presented to any external /internal
orientation and audit visit for purpose of verification.
training on Basic
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
Infection Control Skills
every 2 years by visiting infection control department.
from IC department
maximum within 1
months of joining
work & a BICSL card
is issued which is Components of BICSL includes:
renewed every 2
years. - HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT, DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

161 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
Substandard # 2:2 patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Healthcare Personnel knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
(HCP) receive job-
specific training on Infection Prevention & control department MUST provide education & training to all health care
infection prevention personnel on infection control best practices specific to their job as follows:
policies and
procedures upon Infection control Training specific to area of work must be provided initially upon hiring before
hiring and at least starting their duty.
once annually. Continuous education on relevant infection control policies and procedures must be conducted
at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

162 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters.

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Infection Control department MUST provide health education on infection control for families and
visitors.
Substandard # 2:4 IC team must ensure the availability of the following according to the specific unit / area:
Bilingual infection control health education & awareness material must be designed / formulated
Unit provides infection to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
control health booklets, leaflets etc. containing information easy to understand with help of pictorial display.
education to the The general & specific health educational material must be posted and available in all patient
mothers / care givers. care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.
Parents /Family members’ / care givers must be aware about importance of hand hygiene,
identifying and notifying signs of inflammation etc
Visitors are educated on precautions to be taken while being in the surrounding of the patient,
the importance of hand hygiene and the required isolation precautions etc education must be
provided on how to don / doff PPE and perform hand hygiene before entering isolation room.
Ensure strict adherence of visitors to the recommendations / instructions regarding infection
prevention requirements (e.g.PPE use, hand hygiene etc).

163 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to
treat. On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital
patients has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
patient's room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

164 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:2 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Health care Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
professionals (HCP) microorganisms without the need for an exogenous source of water and requiring no rinsing or
demonstrate drying with towels or other devices.
appropriate Indications:
technique for hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
rubbing and hand body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing. Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and
/or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based hand rub into palm and
briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa, (to remove
debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

165 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
Substandard # 3:3 incorporating the culture of best practices.

Visual alerts are ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
available: WHO 5 posted at appropriate places.
moments, how to - WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to - How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispenser
do hand wash.
-
WHO five moments of hand hygiene :

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.
- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing
- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.
- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:
- When leaving the patients room / cubicle after touching any equipment or other items furniture etc
even without touching patient.
- After removing gloves.

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167 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
168 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment
may include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a
barrier between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier
has the potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes
properly removing and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room but
are available and readily not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will interfere
accessible to HCP. with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Powered air purifying respirators (PAPRs) for bearded staff etc

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2
masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock rooms.
N - 95 respirators are
Check if all types and sizes are available according to fit test result of each healthcare
available in different types and
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)
sizes.

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 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

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 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Substandard # 4:4
Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Staff use personal protective Sequence of donning PPEs before entering the room:
equipment appropriately (e.g.
donning and doffing) Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
https://youtu.be/H4jQUBAlBrI Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
Watch Video How to safely put nosepiece over nose bridge and secure head with ties or elastic.
on PPE Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

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 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

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173 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
174 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
175 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive
procedures involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk
of all such procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable
medical equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

176 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:8 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

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 HIGH TOUCH SURFACES

178 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

179 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

180 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:04
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 6:05 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 5. Disposable personal care items are discarded
worker, housekeeping 6. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 6:06 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

181 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:07 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

182 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

183 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:08 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:09
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

184 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Substandard # 6:11 Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
Housekeepers are well measures.
trained on hand hygiene, Routine practices related to environmental cleaning includes:
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals.
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

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 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

186 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

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188 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient
care across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 7:01 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 7:02
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

189 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 7:03
in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of
to use large IV solution bottles for preparation & dilution of medications
medication is only done by
Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water
specified for preparation & dilution of medications.
ampoule.
Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 7:04
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 7:05
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

190 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 7:06 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient.
While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 7:07 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

191 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Maintaining the integrity of sterile equipment and solutions is extremely important to
Substandard # 7:08 prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
Sterile equipment and urinary catheter).
solutions are assembled - If the sterile items are assembled long before the procedure, there are chances of
immediately prior to use. contamination from environment such as dust etc.
- A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
the transfer of microorganisms and reduce the potential for infections.
- Principles of sterile technique help control and prevent infection, prevent the transmission
of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.
As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

192 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

Substandard # 7:09 A sterile object becomes non-sterile when touched by a non-sterile object.
Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
Sterile to sterile rule is transfer forceps.
applied during any aseptic Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
procedure. Non-sterile items should not cross over the sterile field. For example, a non-sterile person
should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

193 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 7:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 7:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

Substandard # 7:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

194 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 7:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
claim that each device is exclusively allocated only for one patient.
Substandard # 7:14
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
• Patient's name & medical record number to be used exclusively for one patient.
insulin pens) are used only
• Date of the first use to be discarded after expiration of the reuse life recommended
for single patient.
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 7:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.
Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
Substandard # 7:16
IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
IV solution bottles are only
than the self-sealed rubber cap.
accessed through the self-
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
sealed rubber cap.
Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

195 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 7:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7
days, but not more Following key points must be followed for replacement of IV sets in order to avoid risk of
frequently than 96-hour infection from frequent changing of IV sets:
intervals.
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 7:18
Rationale: Extending the duration of use permits considerable cost savings to hospitals
IV sets that are used to without significant increase in the risk of healthcare-associated BSI with peripheral IVs
administer blood, blood
products, lipid emulsions, or In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
dextrose/amino acid TPN acid TPN solutions, check that IV delivery systems are continuously connected and
solutions are replaced within changed within 24 hours of initiating the infusion.
24 hours of initiating the During daily rounds, observe that IV administration sets are labelled with dates & times of
infusion. initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
(hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 7:19 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

196 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide education & training to the healthcare personnel regarding the feeding systems & key
Substandard # 7:20 points that should be considered.
Observe the practices during routine monitoring rounds. Evaluate performance during IPCCC
Open feeding systems audit phase.
should be removed after 8
hours, whereas sterile Following MUST be implemented:
closed systems may remain
hanging for up to 24 to 48 If open feeding system are used, they should be removed after 8 hours.
hours or per manufacturer's If sterile closed feeding system are being used, they may remain hanging for upto 24 – 48
recommendation. Hours or manufacturers instruction MUST be followed.

According to The Joint Commission, there are four chief aspects of the aseptic technique:
Substandard # 7:21 barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Maximum sterile barrier protect the patient from the transfer of pathogens from a healthcare worker, from the
precautions is applied environment, or from both. Some barriers used in aseptic technique include:
during any interventional - Sterile gloves
procedure, including cap, - Sterile gowns
mask, sterile gown, sterile - Masks for the patient and healthcare provider
gloves, and sterile full-body - Sterile drapes etc
drape. - Cap / Headcover
Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
Substandard # 7:22
central line etc.
Traffic should be kept Traffic should be kept minimum once the sterile field has been established.
minimum once the sterile
Only necessary health personnel should be at the procedure. The more people present, the
field has been established.
more opportunities for harmful bacteria to cause contamination.
Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.
During the training phase of IPCCC, orient the staff regarding frequency of changing
Substandard 7.23: ventilation circuits.
Provide specific infection control policy for changing ventilation circuits in the ventilated
Change ventilation circuits patients. (Multidisciplinary policy approved from medical department, respiratory therapy
only when visibly soiled or department and nursing department)
mechanically
malfunctioning. During daily / weekly random select the ventilated patients & review files if policy is
implemented.
In order to avoid risk of acquiring risk of infection from frequent manipulations. Ventilation
circuits must only be changed only when:
- Visibly soiled
- Mechanically malfunctioning.
In the event of changing ventilation circuits for ventilated patients there must be clear
documentation with indications for replacement (Patient’s file, unit’s records or respiratory
therapist logs etc

197 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 7.24: ❖ Educate healthcare personnel regarding the indications for intravascular catheter use,
proper procedures for the insertion and maintenance of intravascular catheters, and
Do not routinely replace appropriate infection control measures to prevent intravascular catheter-related infections.
CVCs, PICCs or pulmonary
artery catheters If there is ❖ Periodically assess knowledge of and adherence to guidelines for all personnel involved in
no evidence of infection. the insertion and maintenance of intravascular catheters. (at least once per year. Rotate
Replace them only when staff in each quarter in training phase of IPCCC in order to achieve 100% coverage at
there is a clinical indication. the end of each year.

Training must incorporate following key points:

- In order to prevent the risk of catheter related infections, central Venous Catheters
Substandard 7.25: (CVCs), peripherally inserted Central Catheters (PICCs) or pulmonary artery catheters
must not be frequently changed.
Remove the CVCs, PICCs or
pulmonary artery catheters - Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding
as soon as they are no the appropriateness of removing the catheter if infection is evidenced elsewhere or if a
longer needed. non-infectious cause of fever is suspected.

- Conduct daily review for line necessity and remove as soon as they are no longer
indicated. More the duration of invasive devices, risk of infection increases.

- 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 dressing should be
removed to allow thorough examination of the site

Infection control practitioner must provide education & training on the rules of aseptic
Substandard 7.26: technique:
Following must be considered:
If guidewire is used to
replace a malfunctioning - ICU doctors / staff must rule infection If guidewire is used to replace a malfunctioning
non-tunnelled catheter, non-tunnelled catheter.
infection should be ruled
out. Observe the staff practices during IC monitoring rounds.
Evaluate the performance during IPCCC audit phase.
Provide feedback and reconsider for training if needed.

Recognized routes for contamination of catheters:

Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with
colonization of the catheter tip; this is the most common route of infection for short-term catheters
Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices.
Catheters might become hematogenously seeded from another focus of infection.
Infusate contamination might lead to CRBSI.

198 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 -

Train, monitor & audit on following key points for replacing dressings on short term CVCs &
Substandard # 7:27
implanted / implanted CVCs:
Replace dressings used on
Catheter Site Dressing Regimens:
short-term central venous
catheter (CVC) sites every 2
❖ Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the
days for gauze dressing.
catheter site
❖ Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.
❖ Gauze Dressings used on short-term central venous catheter (CVC) sites must be
Substandard # 7:28
replaced every 2 days for gauze dressing following aseptic technique.
❖ Transparent Dressings used on short-term central venous catheter (CVC) sites must be
Replace dressing used on
replaced every 7 days for gauze dressing following aseptic technique.
short-term CVC sites at
❖ Transparent Dressings used on tunnelled or implanted CVC sites must be replaced no
least every 7 days for
more than once per week (unless the dressing is soiled or loose), until the insertion site
transparent
has healed following aseptic technique.
dressing.

Additional points:
Substandard # 7:29
❖ Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis
Replace transparent catheters, because of their potential to promote fungal infections and antimicrobial
dressings used on tunnelled resistance.
or implanted CVC sites no ❖ Do not submerge the catheter or catheter site in water. Showering should be permitted if
more than once per week precautions can be taken to reduce the likelihood of introducing organisms into the
(unless the dressing is catheter (e.g., if the catheter and connecting device are protected with an impermeable
soiled or loose), until the cover during the shower)
insertion site has healed.
Reference: https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html

199 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 08 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

G. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
H. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
I. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
v. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
vi. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

200 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Rationale for admission screening:
- Rapid screening of all patients admitted or transferred from any other healthcare facility to
Substandard # 8:01 the critical care units must be conducted to identify those patients requiring isolation is of
significant importance in reducing or preventing the spread of infection to HCWs, patients
There is a screening and visitors.
policy for newly - In the absence of standard screening protocols, a substantial proportion of patients may
admitted or be silently colonized with MDROs that are not detected during their routine hospital stay.
transferred patients to - Furthermore, colonization by MDRO is known as a potential source of cross transmission and
all critical care units to a risk factor for the development of subsequent infection.
identify those who
- Colonized patient constitute the major reservoir for nosocomial transmission.
require isolation
precautions.
Develop and provide detailed screening policy & ensure during daily/weekly rounds that the
policy is fully implemented.

Randomly check files of newly admitted or transferred patients to verify if screening is done or
not.
Ask staff to provide results to confirm the negative status or appropriate isolation precautions
are initiated based on positive results findings.

Provide education to the staff regarding importance of isolation precautions during IPCCC training
Substandard # 8:02 activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis for
isolation precautions patients under isolation.
are available in the Use preferably isolation precautions signs provided by GDIPC.
unit & used Must be placed / posted on door only if occupied by patient.
appropriately. 02 types of isolation precaution signs must be available in the unit.
Isolation signs must - Isolation precaution signs for units to be posted on doors if the isolation room is
be : 1) Clear and occupied by patients with diseases transmitted either by contact, droplet or airborne
visible for HCWs and route.
visitors 2) Bilingual (in - Isolation Transportation cards for transportation of patients to other departments as
Arabic & English). 3) needed.
Color coded and
compatible with Contact isolation Precautions must be used together with standard precautions:
diagnosis (Examples:
contact: green, Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
airborne: blue, and infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
droplet: pink or red) The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

201 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Precautions must be used together with standard precautions. Droplet
Substandard # 8:03 Precautions are intended to reduce the risk of droplet transmission of infectious agents from close
contact (exposure to eyes, nose and mouth) with large-particle droplets
Appropriate isolation
transportation cards / Should be Initiated and maintained when there is suspected or confirmed diagnosis of an
sings are available in infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
the department & Use a single room. A negative air pressure room is not indicated.
used while Place a droplet sign on the door.
transporting patients Droplet isolation signage must be color coded (e.g., orange) and must be available in both
under transmission- English and Arabic languages.
based precautions to
other department as Airborne isolation precautions must be used together with standard precautions
needed. Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases that
are spread via the airborne route.
Transport Isolation Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
signs must be : 1) disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Clear and visible for Use a single room with a negative air pressure system (AIIR)
HCWs and visitors 2) Place the Airborne Isolation sign on the door.
Bilingual (in Arabic & Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English). 3) Color English and Arabic languages. b. Keep door closed at all times except when entering or
coded and compatible leaving the room.
with diagnosis
(Examples: contact: Patient Transportation:
green, airborne: blue,
and droplet: pink or Patient Transportation isolation signs must be used while transporting patients under
red) and selecting low transmission-based precautions to other department as needed.
traffic time & route.
Transport of isolated patients should be limited to essential purposes only, such as diagnostic
and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
should be worn to reduce potential contamination of the environment and the spread of
infection.
Isolation instructions must be clearly highlighted on the transmission-based precaution card
(isolation signs) while transporting patients under transmission-based precautions to other
department ( e.g radiology).

IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 8:04 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
Log book for exposure entry into isolation room for any task.
is available for any Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
potentially harmful Logbook must specify the name, designation / job category, Duration of exposure (Time in /
infectious exposures Time out) & type of PPE used.
as per exposure Appropriately used logbook will generate information needed in case of outbreaks etc
policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. before gaining entry into isolation room.
MERS-CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

202 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use items are those that are intended for single use only, on an individual patient for a
single procedure, and then should be discarded. It should not be reprocessed or reused again
Substandard # 8:05 even on the same patient.
Single use or
Provide training and orientation to staff regarding patient care equipment to be used for isolation
dedicated non-critical
rooms during daily/weekly rounds:
patient care equipment
(e.g., stethoscope,
Following instructions must be given:
pressure cuff, etc.) are
used for the isolation
If single use non critical items are used for isolation rooms, they must be immediately
room.
discarded after use. Single use items must never be kept to be reused for the same patient or
next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be disinfected
after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc

Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation room
is used for another isolation room or another area.

Transfer of patients under isolation precautions must be restricted to medically necessary

purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
Substandard # 8:06 procedures that cannot be performed in the patient’s room.

Facility limits Provide training and orientation to staff the transfer rules related to patient transportation under
movement of patients isolation precautions. Observe if unit is following the policy.
on isolation
Precautions outside of Following instructions must be given:
their room except for
medically necessary Receiving unit or facility is informed beforehand about the required isolation precautions to be
purposes. taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Substandard # 8:09 Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
unit etc.
If transfer of patient
under isolation is It is important that HCWs in the receiving unit have received prior training on how to safely
required, the receiving handle patients under isolation precautions and how to appropriately use PPE according to type
unit or facility is of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit tested
informed about the for N-95 mask and trained well on how to don & doff after use.
required isolation
precautions and Transferring the Patient to Another Facility:
availability of
appropriate PPE is Inform the receiving facility and the emergency vehicle personnel in advance about the type of
ensured. isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

203 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8:10 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation.
While transferring
patients under Key Points include:
droplet/airborne
isolation precaution, Explain to the patient the need for the protective apparel that he/she is required to wear.
patient should wear a Patient must wear mask during transportation (droplet & airborne isolation)
surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory Isolation instructions must highlight the transmission-based precaution card ( isolation signs)
hygiene and cough needed while transporting patients under transmission-based precautions to other department (
etiquette. e.g radiology).
-

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or
Substandard # 8:11 more classes of antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to most
Contact isolation available antimicrobial agents.
precautions are
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci
initiated for patients
(VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
infected or colonized
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms.
Skin lesions and Proper attention & care to these pathogens is critical to curtail further emergence of these
infected or colonized highly resistant organisms.
areas of patient's body
Infection refers to the entry into and multiplication of an infectious agent in the tissues of the
should be contained
host and the tissue damage resulting in apparent or unapparent changes in the host.
and covered.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and covered
in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

204 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training to the staff for rules to be followed for patient transportation under contact isolation
Substandard # 8:12 precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

For transport patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin Leak-proof dressing should be used to reduce potential contamination of the environment and
lesions and infected or the spread of infection.
colonized areas of the Dress wounds with impervious dressings as required.
patient’s body with Dress the patient in a clean gown.
clean bandages and Cover the patient with a clean sheet.
clean linens. Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

In order to avoid potential risk of acquiring infection visitors should be strictly limited for
airborne isolation cases.
As per standards, some exemptions may be considered on a case to case basis i.e visitors may
be allowed to enter the isolation room if he / she fulfils the following criteria e.g mothers of
babies etc
Substandard 08:13
- Duration of stay will be minimum for few minutes only.
Visitors - Visitors must seek permission from nursing station.
should be strictly - Clear instructions must be provided to visitors in their language before entering into an isolation
limited for airborne room.
isolation cases. - Visitors must be fully compliant with the required PPE i.e visitors will wear same type of PPE
Exemptions may be and follows same protocols as any HCWs before entering isolation rooms.
considered on a case - Proper education, counselling, and monitoring should be provided to the visitors before
to case basis only for entering the airborne infection isolation room.
few minutes after - Nursing staff must keep records of visitor’s education & instructions as evidence to be
having permission presented to external auditors when requested.
from nursing station
and after receiving Educate the staff regarding visitor’s policy & ensure during daily/weekly rounds if its fully
proper instructions implemented:
before entering into an
isolation room and - Observe and ask staff about the visitors if isolation room occupied by patient.
within compliance with - Ask about the evidence of education & documentation in log book.
the required PPE. - Observe when possible any visitor entering or coming out of isolation room if compliant with
instructions.
- Sometimes visitors are not donning PPE appropriately. Gowns is not tied & masks is worn
inappropriately.
- It is also common observation to see visitors coming out of AIIR with all PPE and removing PPE
abruptly without practicing hand hygiene.
- Such practices would pose risk of acquiring infection. Nursing staff must be fulling adherent
with visitor’s policy for isolated patients.

Audit the unit performance during IPCCC audit phase and provide formal feedback.

205 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Airborne Infection Isolation Rooms (AIIRs)
Airborne Infection Isolation rooms (AIIRs), commonly called negative pressure rooms, are single-occupancy patient care spaces
designed to isolate patients with airborne pathogens to a safe containment area. AIIRs provide negative pressure in the room
(so that air flows under the gap into the room) with a pressure differential of >-2.5 Pa (Pascal) or >- 0.01” water gauge; an air
flow rate of >12 air changes per hour (ACH) and direct exhaust air from the room to the outside of the building; or recirculation
of air through a HEPA filter before returning to circulation.
AIIRs are designed in such a way so that no airborne particulates escape into other areas within the healthcare setting. Exhaust
from these rooms is not recirculated in the HVAC system. Instead, exhaust air typically moves in dedicated ductwork to
ventilation stacks on the rooftop, where atmospheric air provides sufficient dilution to make the resulting air safe.
For the safety of healthcare workers, patients, and visitors, negative pressure rooms occupied by patients requiring
airborne isolation must be checked daily.
Sub standards Explanation
According to Ministry of Health guidelines, there must be at least one Airborne Infection
Substandard 9.01:
Isolation Room for every 8 beds. (e.g 1-8 beds 1 AIIRS, 16 beds 2 AIIRs, 24 beds 3
At least one AIIR for each 8 AIIRs & so on)
beds. . IPC team must send request to higher administration if there is no AIIRs in the unit to fulfil
the requirement.

Provide training and orientation to the staff regarding general specification to be met for
all negative pressure isolation rooms. Monitor different parameters during routine
infection control rounds and observe If within recommended ranges. Evaluate the
performance of unit during IPCCC audit phase & provide formal feedback.
Substandard 9.02 Nurse in charge must receive clear instructions to keep all necessary records in the unit
to be presented if requested from external auditors.
Central air condition or
separate concealed unit is This includes all routine maintenance records and actions taken in terms of deranged
the source of conditioned environmental control parameters or malfunctioning.
fresh air. Maintenance staff must be consulted to provide detailed evidence of all these
specifications and each unit & IC team must keep copy of records.
Units must hard to keep all parameters within normal range and well prepared to provide
documented evidence for any external audit visit.

Following specifications must be met for all AIIRs:

Substandard 9.03:
- There must be 100% fresh air supply from central AC or concealed separate unit.
- Return of air is not permitted & source of conditioned fresh air must be only via these 02
Air exhausted from
sources. (Central air condition or separate concealed unit).
bathroom must be
exhausted 100% outside - Air from bathrooms must be exhausted 100 % outside through High‐Efficiency Particulate
through HEPA filter.
Air (HEPA) filters.
- The exhaust air ducts MUST be independent of the building exhaust air system.
- HEPA filter should be changed on regular basis and according to manufacturer’s
instructions.

206 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Unit must keep records of all documents that prove the maintenance and changing of
HEPA filter (as recommended)
Substandard 9.04:
Rationale:
HEPA filter is changed on
regular basis and according
to manufacturer's High-efficiency particulate air (HEPA) filter is an air filter that removes >99.97% of particles
recommendations. >0.3um at a specified flow rate of air. HEPA filters may be integrated into the central air
handling systems, installed at the point of use above the ceiling of a room, or used as
portable units.

During rounds ICPs must ensure that each AIIR is equipped with a fixed monitor for
continuous monitoring of environmental control parameters and are in functional condition.
Substandard 9.05:
[

There is monitor for Monitor must exhibit following specifications and records following parameters:
continuous monitoring of
pressure difference at
negative pressure room Negative pressure (-2.5 pascal or more)
having audio visual alarming
system when the ventilation >12 air changes per hour.
system failed. Has an audio-visual alarm system in case of ventilation system failure. There must be
Visible red flashing lights and audible sound comes from the monitor.
Substandard 9.06:
Fixed monitor must be installed outside each AIIRs in the corridor to monitor the pressure
Isolation Room is difference between the room and corridor.
maintained at negative
pressure (-2.5 pascal or Test the monitor to ensure that alarm is working or no, by keeping the door of AIIRs open
more) with respect to for few seconds. Hold the room door open. After the time delay, the audible and visual
corridors.
alarm should annunciate.
Verify that the monitor is correctly reading the pressure. While the door is held open, the
Substandard 9.07:
pressure reading should be at or near 0" water gauge.
Isolation Room is Use a manual device to monitor pressure differentials in rooms where no monitor is
maintained with >12 air
installed.
changes per hour.

207 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During daily / weekly rounds ICPs must ensure that policy for regular monitoring of negative
pressure difference is fully implemented. If any breaches unit head must be informed.
Monitor and evaluate unit performance in IPCCC audit phase using IPCCC tool.

❖ Unit must keep record of all documents as evidence of regular monitoring of negative
pressure difference of AIIRs for at least last 3 months:

❖ Daily when in use (i.e., a patient is isolated inside) .

Substandard 9.08: ❖ Weekly when not in use (i.e., no patient is isolated).
❖ Monthly check by biomedical personals

Records for routine

monitoring of pressure Responsibility of Nursing staff:
gradients (daily if a patient
is isolated inside, weekly
when not in use and Negative pressure rooms in use:
monthly by biomedical
department).
Nursing staff must conduct visual checks for the direction of air flow (using flutter strips)
on all rooms where patients are in airborne isolation for query and confirmed airborne
transmissible diseases (e.g., Pulmonary Mycobacterium tuberculosis, measles, chicken
pox) when patients are in this room.
Prior to admitting patients needing airborne isolation, check and ensure that negative
pressure rooms are functioning well. For those designated isolation rooms without
monitor, call maintenance to check if the room is maintaining its negative pressure.
Follow the procedure of this policy in any room that fails inspection. d. All documentation
must be sent to the IP&C Department.

B. Negative Pressure Ventilation Failure:

Unit staff must respond to negative pressure failure.

Nursing staff will lace a surgical mask on the patient in airborne isolation.
Keep the door closed at all times.
Notify the Utilities & Maintenance (U&M) Department of the location and problem & IC
Department
If U&M declares the occupied room is no longer maintaining negative pressure, patient
must be transferred to another negative pressure room immediately.
Put a surgical mask on the patient before transporting.

208 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 An aerosol-generating procedure (AGP) is defined as any medical procedure that can induce
the production of aerosols of various sizes, including small (< 5 microns) Particles. AGPs
includes bronchoscopy, sputum induction, intubation and extubation,cardiopulmonary
Substandard 9.09: resuscitation, open suctioning of airways, Ambu bagging,nebulization therapy, high frequency
oscillation ventilation and Bilevel Positive Airway Pressure ventilation – BiPAP
Any aerosol generating
procedure (AGP) should be Precautions to be observed when performing aerosol- generating procedures, which may be
done in negative pressure associated with an increased risk of infection transmission:
room or single room with
portable HEPA filter using Perform procedures in a negative pressure room or single room with HEPA filter
appropriate PPE (N95 mask, Limit the number of persons present in the room to the absolute minimum required for the
eye protection, gloves & patient’s care and support.
gown) with possible minimal Wear N95 masks: Every healthcare worker should wear a fit-tested seal check N95 mask
number of staff. (or an alternative respirator if fit testing failed).
Wear eye protection (i.e. goggles or a face shield).
Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures require
sterile gloves
Wear an impermeable apron for some procedures with expected high fluid volumes that
might penetrate the gown.
Perform hand hygiene before and after contact with the patient and his or her surroundings
and after PPE removal.

Train & observe the following during daily/weekly rounds:

❖ HCWs performing any aerosol generating Procedure (AGPs) like CPR, intubation,
extubation, suctioning etc for any suspected or confirmed COVID – 19 or MERS- CoV
cases. (If possible to observe the real situation / scenario).
❖ Observe the type of PPE used by HCWs while preparing for AGPs.
❖ Observe if AGPs are performed in negative pressure room or single room with HEPA filter.
❖ Ask about the total number of staff to be present during procedure. Ensure minimum
number of staff are present who are absolutely necessary for specific procedure / task.

Evaluate the staff performance during IPCCC audit phase & provide formal feedback.

209 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 AIIRs MUST fulfill the following MOH specifications for standard isolation
rooms:
Substandard 9.10:
FLOORS, WALLS & CEILING:
AIIRs fulfill all MOH
specifications for standard Minimal openings in the walls, floors and ceiling that are well sealed and airtight.
isolation rooms + windows Smooth, one piece without any cracks or decorative fine parts.
are sealed and fixed (i.e.,
They should be covered with such paints so as to withstand repeated cleaning
could not be opened/)
openings in walls and and disinfection by approved disinfectants.
ceiling are sealed and DOORS:
airtight / doors are properly
designed and well-sealed. Doors are properly designed and well-sealed.
The door should open to the inside.
Extend completely to the floor
Substandard 9.11:
Must have auto closure device / auto closure mechanism.
The door should open to the WINDOWS:
inside, has auto closure
device, well-sealed and Windows are sealed and fixed (i.e., could not be opened)
extend completely to the This will ensure to maintain continuous negative pressure differentials inside
floor. airborne infection isolation rooms.

CURTAINS:
Substandard 9.12:
After discharge, transfer or death of patient under airborne precautions, curtains
Windows are completely must be changed after terminal cleaning of isolation rooms
sealed and fixed (i.e., could
not be opened). HAND HYGIENE FACILITY:

e) Hand Washing:
Substandard 9.13:
Following are required inside patients’ room
Curtains must be changed Hand Washing Sink
between patients. Plain and antimicrobial soap
Paper towels
Available at easily accessible location
Substandard 9.14:
f) Hand Rubbing:
Hand washing facilities and
Alcohol - based hand rub dispensers
supplies (sinks / plain and
Available at easily accessible location for staff to practice 5 moments of hand hygiene & to
antimicrobial soap / paper
perform hand hygiene after doffing of PPE items.
towels, Alcohol - based
hand rub dispensers) are
available & easily PPE TROLLEY:
accessible.
Ensure availability of PPE trolley OUTSIDE AIIRs.
Well organized and well maintained.
Substandard 9.15: Appropriately cleaned external surfaces and internal surfaces of drawers ; free from
dust and any other visible contamination.
Trolley that contains the All required PPE items MUST available (Gowns, Gloves, N – 95 respirators. Face
proper PPEs is available. shields / goggles etc)
PPE items are organized in a way to facilitate staff while donning PPE.
PPE or any other medical supply must never be kept inside isolation rooms to avoid
risk of contamination.

210 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles
often contain large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not
transferred to patients or healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled
linens must follow Standard Precautions at all times. To reduce the possibility of occupational risks of infection transmission
and/or exposure, laundry workers should focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal
protective equipment (PPE). Removal of foreign objects from soiled linen. 4. To restore soiled linen to usable condition,
washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 10:01 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 10:02 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 10:03 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 10:04 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

211 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:05 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 10:06 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Substandard # 10:07 Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Linen carts are covered and Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
not overfilled. to 10 inches off the floor.
Linen from isolation rooms is considered regular soiled linen.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

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 Standard – 11 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly
managed and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful
handling, sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare
workers must be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated,
collected, transported and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should
be knowledgeable about the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
Substandard # 11:01 - Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)
All types of waste
containers are Specification of Items:
available in sufficient
number and placed in Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
easily accessible sites. with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

213 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11:02 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 11:03
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 11:04 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 11:05 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

214 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 11:06 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 12 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the
integrity of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best
practices for safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 12:01
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 12:02 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to
Local records for corrective interventions which are taken if readings are not matching the
70%).
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.

215 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:

Substandard # 12:03 - Recommended temperature Range is: 22 - 24°C

- Recommended relative Humidity is up to 70%.
Away from air vents and
well ventilated. Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

Substandard # 12:04
Infection control team must provide training and reorientation about all specifications to be
Storage shelves are 40 followed for the maintenance of departmental medical stores.
cm from the ceiling, 20
Train on following specifications / key points and observe in daily / weekly rounds if unit is
cm from the floor, and 5
adherent with recommendations or not.
cm from the outside wall.
Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Substandard # 12:05
Specifications of Storage Shelves:
Storage shelves made
Storage shelves are made of easily cleanable material
from easily cleanable
material (e.g., fenestrated (e.g., fenestrated stainless steel, Aluminium or hard plastic).
stainless steel, Aluminium Storage shelves are placed following these specifications.
or hard plastic)
- 40 cm from the ceiling
- 20 cm from the floor
Substandard # 12:06 - 5 cm from the wall

Sterile and clean items If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
completely separated hard plastic).
from personal items &
foods and drinks. Ensure that only sterile and clean items are allowed in the medical stores.
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 12:07 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
original cardboard shipping boxes.
Substandard # 12:08
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
inside sock room. (i.e., boxes made of thick cardboard for shipping.
Items not kept in original
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
cardboard shipping
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
boxes.
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

216 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
Substandard # 12:09 discarded)
If any stained item is found it would most likely reflect that item was restocked after being
No expired items, broken brought from patient care areas which is against the rules of aseptic technique. Such
packs or packs with practices must be strictly prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in
order to ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit
phase.
Provide formal feedback on unit & staff performance

Standard – 13 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 13:01 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

217 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 13:02
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

218 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 13:03
prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers &
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
visitors strictly adhere
droplets can also be inhaled into the lungs.
to the principles of
Recent studies indicate that people who are infected but do not have symptoms likely also play a
social distancing,
role in the spread of COVID-19. Since people can spread the virus before they know they are
cough etiquette and
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
frequent hand hygiene
have any symptoms.
during duty hours /
visiting hospital.
Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

219 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 13:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc) HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients etc

220 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
221 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
222 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

223 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
CORONARY CARE unit (CCU)

Coronary Care Unit provide care for patients with critical

cardiac conditions including acute myocardial infarction, acute cardiac failure or any
cardiac disease requiring critical care management.
Hence, strict implementation of infection control procedures including hand hygiene,
wearing personal protective equipment (PPE) to prevent the transmission of infection
during patient care, practicing aseptic technique, isolation precautions & environmental
measures etc. would play a significant role in ensuring patient & staff safety.

224 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN CORONARY CARE
unit (CCU)

POLICIES & PROCEDURES

CORONARY CARE UNIT

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

AIRNORNE INFECTION ISOLATION ROOMS (AIIRs)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

225 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 CORONARY CARE UNIT (CCU)
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them.
They guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff
safe. Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living,
breathing documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

226 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among
HCWs, patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided
with the required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide
the necessary resources for implementing trainings on infection control best practices & establishing auditing tools on
performance measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation
Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.

Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Substandard # 2:1
IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
joining work & issue a BICSL ID which should be renewed ever 02 years.
Healthcare Personnel Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
(HCP) receive hours as an evidence of basic infection control training to be presented to any external /internal
orientation and audit visit for purpose of verification.
training on Basic
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
Infection Control Skills
every 2 years by visiting infection control department.
from IC department
maximum within 1
months of joining
work & a BICSL card
is issued which is Components of BICSL includes:
renewed every 2
years. - HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

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 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on Isolation
Precautions by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
Substandard # 2:2 patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Healthcare Personnel knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
(HCP) receive job-
specific training on Infection Prevention & control department MUST provide education & training to all health care
infection prevention personnel on infection control best practices specific to their job as follows:
policies and
procedures upon Infection control Training specific to area of work must be provided initially upon hiring before
hiring and at least starting their duty.
once annually. Continuous education on relevant infection control policies and procedures must be conducted
at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

228 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters.

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Infection Control department provides MUST provide health education on infection control for
families and visitors.
IC team must ensure the availability of the following according to the specific unit / area:
Substandard # 2:4 Bilingual infection control health education & awareness material must be designed / formulated
to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
Unit provides infection booklets, leaflets etc. containing information easy to understand with help of pictorial display.
control health The general & specific health educational material must be posted and available in all patient
education to the care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
Patients, families & hygiene, cough etiquette, COVID 19 & MERS educational material, etc.
Visitors.
Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files.

Patients/Family members’ / care givers must be aware about importance of hand hygiene,
identifying and notifying signs of inflammation.

229 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Visitors are educated on precautions to be taken while being in the surrounding of the patient,
the importance of hand hygiene and the required isolation precautions etc education must be
provided on how to don / doff PPE and perform hand hygiene before entering isolation room.
Ensure strict adherence of visitors to the recommendations / instructions regarding infection
prevention requirements (e.g.PPE use, hand hygiene etc).

230 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
patient's room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

231 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:2 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Health care Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
professionals (HCP) microorganisms without the need for an exogenous source of water and requiring no rinsing or
demonstrate drying with towels or other devices.
appropriate Indications:
technique for hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
rubbing and hand body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing. Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and
/or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based hand rub into palm and
briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa, (to remove
debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

232 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
Substandard # 3:3 incorporating the culture of best practices.

Visual alerts are ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
available: WHO 5 posted at appropriate places.
moments, how to - WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to - How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispenser
do hand wash.
-
WHO five moments of hand hygiene :

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.
- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing
- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.
- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:
- When leaving the patients room / cubicle after touching any equipment or other items furniture etc
even without touching patient.
- After removing gloves.

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234 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
235 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room
are available and readily but not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will
accessible to HCP. interfere with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Powered air purifying respirators (PAPRs) for bearded staff etc

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2 masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock
N - 95 respirators are available rooms.
in different types and sizes. Check if all types and sizes are available according to fit test result of each healthcare
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)

236 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding
using N-95 respirator according to fit test or follow alternate policy in case of non-
availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 to (Countercheck / verify with their fit test ID).
be used based on the fit test. Observe the practice of doctors with beards.

Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

❖ Air-purifying respirator means a respirator with an air-purifying filter, cartridge, or canister that
removes specific air contaminants by passing ambient air through the air-purifying element.
Substandard # 4:4
❖ Powered air-purifying respirator (PAPR) means an air-purifying respirator that uses a blower to
force the ambient air through air-purifying elements to the inlet covering.
Alternative respirator, such as
powered air-purifying respirator ❖ Powered air purifying respirators offer protection against certain respiratory hazards with
integrated head, eye and face protection that can help provide a more comfortable environment for
(PAPR) is accessible for HCW
the worker.
who failed in fit testing when
dealing with patients under ❖ PAPR system uses a blower instead of lung power to draw air through the filter. This lets HCWs to
airborne isolation precautions. breathe more naturally while feeling a constant airflow in your while dealing with patients.

❖ Ensure that powered air-purifying respirator (PAPRs) are available and accessible for all HCWs who
failed fit testing to N-95 mask of all types, brands & shapes.
❖ HCWs with beard must not use N-95 mask because of interference of facial hair in ensuring perfect
facial seal. Airborne particles are less than 5 microns in size which can easily pass from beneath the
mask if appropriately size is not used exposing staff to risk of acquiring airborne infection.
❖ Bearded staff must only use powered air-purifying respirator (PAPR)while dealing with
patients under airborne infection isolation rooms.
❖ HCWs must also receive training on how to don the respirator and safely handle after use.
Note:
If powered air-purifying respirator (PAPR)are not available, hospitals must have clearly
policy for bearded staff to strictly refrain from dealing with airborne cases and staff
must be well oriente d about the policy in order to ensure safety of healthcare workers.

237 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.
Substandard # 4:5
All isolation precautions must be used together with Standard Precautions
Staff use personal protective
equipment appropriately (e.g. ❖ Contact: Appropriate PPE – Gown & Gloves
donning and doffing) ❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Before entering and leaving a patient’s room PPEs should be donned & doffed in this
order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured
at neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
https://youtu.be/H4jQUBAlBrI
out, fold into a bundle and discard.
Watch Video How to safely put
Perform hand hygiene.
on PPE
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.
238 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

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241 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
242 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive
procedures involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk
of all such procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable
medical equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

243 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

In Burn patients, disinfection and sterilization guidelines for patient care equipment must take into account the
presence of sometimes extensive, open wounds which is the major difference separating this population from
other patient populations. Following Spaulding’s scheme for categorizing patient care items and equipment, the
changes for the burn patient population involve what are considered “semicritical” and “noncritical” items. Many
items such as blood pressure cuffs, stethoscopes, bedpans, if used on areas without dry, occlusive dressings,
may need high-level disinfection as a semi critical item or may need to be restricted to an individual patient.

Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

244 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:7 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

HIGH TOUCH SURFACES

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 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

246 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

247 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:04
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 6:05 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 7. Disposable personal care items are discarded
worker, housekeeping 8. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 6:06 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

248 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:07 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

249 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

250 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:08 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:09
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

251 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Substandard # 6:11 Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
Housekeepers are well measures.
trained on hand hygiene, Routine practices related to environmental cleaning includes:
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals.
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

252 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

253 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

254 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
255 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 7:01 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 7:02
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

256 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 7:03
in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of
to use large IV solution bottles for preparation & dilution of medications
medication is only done by
Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water
specified for preparation & dilution of medications.
ampoule.
Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 7:04
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 7:05
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

257 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 7:06 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient.
While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 7:07 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

258 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Maintaining the integrity of sterile equipment and solutions is extremely important to
Substandard # 7:08 prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
Sterile equipment and urinary catheter).
solutions are assembled - If the sterile items are assembled long before the procedure, there are chances of
immediately prior to use. contamination from environment such as dust etc.
- A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
the transfer of microorganisms and reduce the potential for infections.
- Principles of sterile technique help control and prevent infection, prevent the transmission
of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.
As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

259 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

Substandard # 7:09 A sterile object becomes non-sterile when touched by a non-sterile object.
Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
Sterile to sterile rule is transfer forceps.
applied during any aseptic Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
procedure. Non-sterile items should not cross over the sterile field. For example, a non-sterile person
should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

260 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 7:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 7:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

Substandard # 7:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

261 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 7:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
claim that each device is exclusively allocated only for one patient.
Substandard # 7:14
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
• Patient's name & medical record number to be used exclusively for one patient.
insulin pens) are used only
• Date of the first use to be discarded after expiration of the reuse life recommended
for single patient.
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 7:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.
Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
Substandard # 7:16
IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
IV solution bottles are only
than the self-sealed rubber cap.
accessed through the self-
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
sealed rubber cap.
Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

262 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 7:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7
days, but not more Following key points must be followed for replacement of IV sets in order to avoid risk of
frequently than 96-hour infection from frequent changing of IV sets:
intervals.
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 7:18
Rationale: Extending the duration of use permits considerable cost savings to hospitals
IV sets that are used to without significant increase in the risk of healthcare-associated BSI with peripheral IVs
administer blood, blood
products, lipid emulsions, or In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
dextrose/amino acid TPN acid TPN solutions, check that IV delivery systems are continuously connected and
solutions are replaced within changed within 24 hours of initiating the infusion.
24 hours of initiating the During daily rounds, observe that IV administration sets are labelled with dates & times of
infusion. initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
(hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 7:19 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

263 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide education & training to the healthcare personnel regarding the feeding systems & key
Substandard # 7:20 points that should be considered.
Observe the practices during routine monitoring rounds. Evaluate performance during IPCCC
Open feeding systems audit phase.
should be removed after 8
hours, whereas sterile Following MUST be implemented:
closed systems may remain
hanging for up to 24 to 48 If open feeding system are used, they should be removed after 8 hours.
hours or per manufacturer's If sterile closed feeding system are being used, they may remain hanging for upto 24 – 48
recommendation. Hours OR manufacturers instruction MUST be followed.

According to The Joint Commission, there are four chief aspects of the aseptic technique:
Substandard # 7:21 barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Maximum sterile barrier protect the patient from the transfer of pathogens from a healthcare worker, from the
precautions is applied environment, or from both. Some barriers used in aseptic technique include:
during any interventional - Sterile gloves
procedure, including cap, - Sterile gowns
mask, sterile gown, sterile - Masks for the patient and healthcare provider
gloves, and sterile full-body - Sterile drapes etc
drape. - Cap / Head Cover
Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
Substandard # 7:22
central line etc.
Traffic should be kept Traffic should be kept minimum once the sterile field has been established.
minimum once the sterile
Only necessary health personnel should be at the procedure. The more people present, the
field has been established.
more opportunities for harmful bacteria to cause contamination.
Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.
During the training phase of IPCCC, orient the staff regarding frequency of changing
Substandard 7.23: ventilation circuits.
Provide specific infection control policy for changing ventilation circuits in the ventilated
Change ventilation circuits patients. (Multidisciplinary policy approved from medical department, respiratory therapy
only when visibly soiled or department and nursing department)
mechanically
malfunctioning. During daily / weekly random select the ventilated patients & review files if policy is
implemented.
In order to avoid risk of acquiring risk of infection from frequent manipulations. Ventilation
circuits must only be changed only when:
- Visibly soiled
- Mechanically malfunctioning.
In the event of changing ventilation circuits for ventilated patients there must be clear
documentation with indications for replacement (Patient’s file, unit’s records or respiratory
therapist logs etc

264 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team must provide education & training to the ICU team for optimum site selection of site
for central venous access as part of CLABSI bundle:

Following MUST be considered:

Substandard 7.24: Femoral site:

- Greatest risk of infection in adults, especially in overweight patients,
Avoid using the femoral vein - Avoid using the femoral vein for central venous access in adult patients.
for central venous access in
adult patients. Subclavian site:
lower risk of CLABSI than the internal jugular vein:
- Preferred when infection is only consideration
- Higher risk of mechanical complications (Pneumothorax, subclavian artery
puncture, hemothorax, subclavian vein stenosis etc)

Physicians must weigh risk-benefit of site selection for individual patient

Substandard 7.25: Haemodialysis Patients:

Avoid the subclavian site in Subclavian site must be avoided in haemodialysis patients and patients with advanced kidney
haemodialysis patients and disease to avoid stenosis of subclavian vein.
patients with advanced - Observe the staff practices during IC monitoring rounds.
kidney disease to avoid - Evaluate the performance during IPCCC audit phase.
subclavian vein stenosis. - Provide feedback and reconsider for training if needed.

Substandard 7.26: ❖ Educate healthcare personnel regarding the indications for intravascular catheter use,
proper procedures for the insertion and maintenance of intravascular catheters, and
Do not routinely replace appropriate infection control measures to prevent intravascular catheter-related infections.
CVCs, PICCs or pulmonary
artery catheters If there is ❖ Periodically assess knowledge of and adherence to guidelines for all personnel involved in
no evidence of infection. the insertion and maintenance of intravascular catheters. (at least once per year. Rotate
Replace them only when staff in each quarter in training phase of IPCCC in order to achieve 100% coverage at
there is a clinical indication. the end of each year.

265 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training must incorporate following key points:

- In order to prevent the risk of catheter related infections, central Venous Catheters
Substandard 7.27: (CVCs), peripherally inserted Central Catheters (PICCs) or pulmonary artery catheters
must not be frequently changed.
Remove the CVCs, PICCs or
pulmonary artery catheters - Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding
as soon as they are no the appropriateness of removing the catheter if infection is evidenced elsewhere or if a
longer needed. non-infectious cause of fever is suspected.

- Conduct daily review for line necessity and remove as soon as they are no longer
indicated. More the duration of invasive devices, risk of infection increases.

- 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 dressing should be
removed to allow thorough examination of the site

Infection control practitioner must provide education & training on the rules of aseptic
Substandard 7.28: technique:
Following must be considered:
If guidewire is used to
replace a malfunctioning - ICU doctors / staff must rule infection If guidewire is used to replace a malfunctioning
non-tunnelled catheter, non-tunnelled catheter.
infection should be ruled
out. Observe the staff practices during IC monitoring rounds.
Evaluate the performance during IPCCC audit phase.
Provide feedback and reconsider for training if needed.

Recognized routes for contamination of catheters:

Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with
colonization of the catheter tip; this is the most common route of infection for short-term catheters
Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices.
Catheters might become hematogenously seeded from another focus of infection.
Infusate contamination might lead to CRBSI.

266 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 -

Train, monitor & audit on following key points for replacing dressings on short term CVCs &
Substandard # 7:29
implanted / implanted CVCs:
Replace dressings used on
Catheter Site Dressing Regimens:
short-term central venous
catheter (CVC) sites every 2
❖ Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the
days for gauze dressing.
catheter site
❖ Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.
❖ Gauze Dressings used on short-term central venous catheter (CVC) sites must be
Substandard # 7:30
replaced every 2 days for gauze dressing following aseptic technique.
❖ Transparent Dressings used on short-term central venous catheter (CVC) sites must be
Replace dressing used on
replaced every 7 days for gauze dressing following aseptic technique.
short-term CVC sites at
❖ Transparent Dressings used on tunnelled or implanted CVC sites must be replaced no
least every 7 days for
more than once per week (unless the dressing is soiled or loose), until the insertion site
transparent
has healed following aseptic technique.
dressing.

Additional points:
Substandard # 7:31
❖ Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis
Replace transparent catheters, because of their potential to promote fungal infections and antimicrobial
dressings used on tunnelled resistance.
or implanted CVC sites no ❖ Do not submerge the catheter or catheter site in water. Showering should be permitted if
more than once per week precautions can be taken to reduce the likelihood of introducing organisms into the
(unless the dressing is catheter (e.g., if the catheter and connecting device are protected with an impermeable
soiled or loose), until the cover during the shower)
insertion site has healed.
Reference: https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html

267 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 08 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

J. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
K. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
L. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
vii. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
viii. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

268 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Rationale for admission screening:
- Rapid screening of all patients admitted or transferred from any other healthcare facility to
Substandard # 8:01 the critical care units must be conducted to identify those patients requiring isolation is of
significant importance in reducing or preventing the spread of infection to HCWs, patients
There is a screening and visitors.
policy for newly - In the absence of standard screening protocols, a substantial proportion of patients may
admitted or be silently colonized with MDROs that are not detected during their routine hospital stay.
transferred patients to - Furthermore, colonization by MDRO is known as a potential source of cross transmission and
all critical care units to a risk factor for the development of subsequent infection.
identify those who
- Colonized patient constitute the major reservoir for nosocomial transmission.
require isolation
precautions.
Develop and provide detailed screening policy & ensure during daily/weekly rounds that the
policy is fully implemented.

Randomly check files of newly admitted or transferred patients to verify if screening is done or
not.
Ask staff to provide results to confirm the negative status or appropriate isolation precautions
are initiated based on positive results findings.

Provide education to the staff regarding importance of isolation precautions during IPCCC training
Substandard # 8:02 activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis for
isolation precautions patients under isolation.
are available in the Use preferably isolation precautions signs provided by GDIPC.
unit & used Must be placed / posted on door only if occupied by patient.
appropriately. 02 types of isolation precaution signs must be available in the unit.
Isolation signs must - Isolation precaution signs for units to be posted on doors if the isolation room is
be : 1) Clear and occupied by patients with diseases transmitted either by contact, droplet or airborne
visible for HCWs and route.
visitors 2) Bilingual (in - Isolation Transportation cards for transportation of patients to other departments as
Arabic & English). 3) needed.
Color coded and
compatible with Contact isolation Precautions must be used together with standard precautions:
diagnosis (Examples:
contact: green, Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
airborne: blue, and infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
droplet: pink or red) The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

269 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Precautions must be used together with standard precautions. Droplet
Substandard # 8:03 Precautions are intended to reduce the risk of droplet transmission of infectious agents from close
contact (exposure to eyes, nose and mouth) with large-particle droplets
Appropriate isolation
transportation cards / Should be Initiated and maintained when there is suspected or confirmed diagnosis of an
sings are available in infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
the department & Use a single room. A negative air pressure room is not indicated.
used while Place a droplet sign on the door.
transporting patients Droplet isolation signage must be color coded (e.g., orange) and must be available in both
under transmission- English and Arabic languages.
based precautions to
other department as Airborne isolation precautions must be used together with standard precautions
needed. Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases that
are spread via the airborne route.
Transport Isolation Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
signs must be : 1) disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Clear and visible for Use a single room with a negative air pressure system (AIIR)
HCWs and visitors 2) Place the Airborne Isolation sign on the door.
Bilingual (in Arabic & Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English). 3) Color English and Arabic languages. b. Keep door closed at all times except when entering or
coded and compatible leaving the room.
with diagnosis
(Examples: contact: Patient Transportation:
green, airborne: blue,
and droplet: pink or Patient Transportation isolation signs must be used while transporting patients under
red) and selecting low transmission-based precautions to other department as needed.
traffic time & route.
Transport of isolated patients should be limited to essential purposes only, such as diagnostic
and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
should be worn to reduce potential contamination of the environment and the spread of
infection.
Isolation instructions must be clearly highlighted on the transmission-based precaution card
(isolation signs) while transporting patients under transmission-based precautions to other
department ( e.g radiology).

IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 8:04 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
Log book for exposure entry into isolation room for any task.
is available for any Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
potentially harmful Logbook must specify the name, designation / job category, Duration of exposure (Time in /
infectious exposures Time out) & type of PPE used.
as per exposure Appropriately used logbook will generate information needed in case of outbreaks etc
policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. before gaining entry into isolation room.
MERS-CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

270 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use items are those that are intended for single use only, on an individual patient for a
single procedure, and then should be discarded. It should not be reprocessed or reused again
Substandard # 8:05 even on the same patient.
Single use or
Provide training and orientation to staff regarding patient care equipment to be used for isolation
dedicated non-critical
rooms during daily/weekly rounds:
patient care equipment
(e.g., stethoscope,
Following instructions must be given:
pressure cuff, etc.) are
used for the isolation
If single use non critical items are used for isolation rooms, they must be immediately
room.
discarded after use. Single use items must never be kept to be reused for the same patient or
next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be disinfected
after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc

Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation room
is used for another isolation room or another area.

Transfer of patients under isolation precautions must be restricted to medically necessary

purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
Substandard # 8:06 procedures that cannot be performed in the patient’s room.

Facility limits Provide training and orientation to staff the transfer rules related to patient transportation under
movement of patients isolation precautions. Observe if unit is following the policy.
on isolation
Precautions outside of Following instructions must be given:
their room except for
medically necessary Receiving unit or facility is informed beforehand about the required isolation precautions to be
purposes. taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Substandard # 8:09 Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
unit etc.
If transfer of patient
under isolation is It is important that HCWs in the receiving unit have received prior training on how to safely
required, the receiving handle patients under isolation precautions and how to appropriately use PPE according to type
unit or facility is of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit tested
informed about the for N-95 mask and trained well on how to don & doff after use.
required isolation
precautions and Transferring the Patient to Another Facility:
availability of
appropriate PPE is Inform the receiving facility and the emergency vehicle personnel in advance about the type of
ensured. isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

271 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8:10 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation.
While transferring
patients under Key Points include:
droplet/airborne
isolation precaution, Explain to the patient the need for the protective apparel that he/she is required to wear.
patient should wear a Patient must wear mask during transportation (droplet & airborne isolation)
surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory Isolation instructions must highlight the transmission-based precaution card ( isolation signs)
hygiene and cough needed while transporting patients under transmission-based precautions to other department (
etiquette. e.g radiology).
-

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or
Substandard # 8:11 more classes of antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to
Contact isolation most available antimicrobial agents.
precautions are
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci
initiated for patients
(VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
infected or colonized
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms.
Skin lesions and Proper attention & care to these pathogens is critical to curtail further emergence of these
infected or colonized highly resistant organisms.
areas of patient's body
Infection refers to the entry into and multiplication of an infectious agent in the tissues of the
should be contained
host and the tissue damage resulting in apparent or unapparent changes in the host.
and covered.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and covered
in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

272 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training to the staff for rules to be followed for patient transportation under contact isolation
Substandard # 8:12 precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

For transport patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin Leak-proof dressing should be used to reduce potential contamination of the environment and
lesions and infected or the spread of infection.
colonized areas of the Dress wounds with impervious dressings as required.
patient’s body with Dress the patient in a clean gown.
clean bandages and Cover the patient with a clean sheet.
clean linens. Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

In order to avoid potential risk of acquiring infection visitors should be strictly limited for
airborne isolation cases.
As per standards, some exemptions may be considered on a case to case basis i.e visitors may
be allowed to enter the isolation room if he / she fulfils the following criteria e.g mothers of
babies etc
Substandard 08:13
- Duration of stay will be minimum for few minutes only.
Visitors - Visitors must seek permission from nursing station.
should be strictly - Clear instructions must be provided to visitors in their language before entering into an isolation
limited for airborne room.
isolation cases. - Visitors must be fully compliant with the required PPE i.e visitors will wear same type of PPE
Exemptions may be and follows same protocols as any HCWs before entering isolation rooms.
considered on a case - Proper education, counselling, and monitoring should be provided to the visitors before
to case basis only for entering the airborne infection isolation room.
few minutes after - Nursing staff must keep records of visitor’s education & instructions as evidence to be
having permission presented to external auditors when requested.
from nursing station
and after receiving Educate the staff regarding visitor’s policy & ensure during daily/weekly rounds if its fully
proper instructions implemented:
before entering into an
isolation room and - Observe and ask staff about the visitors if isolation room occupied by patient.
within compliance with - Ask about the evidence of education & documentation in log book.
the required PPE. - Observe when possible any visitor entering or coming out of isolation room if compliant with
instructions.
- Sometimes visitors are not donning PPE appropriately. Gowns is not tied & masks is worn
inappropriately.
- It is also common observation to see visitors coming out of AIIR with all PPE and removing PPE
abruptly without practicing hand hygiene.
- Such practices would pose risk of acquiring infection. Nursing staff must be fulling adherent
with visitor’s policy for isolated patients.

Audit the unit performance during IPCCC audit phase and provide formal feedback.

273 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Airborne Infection Isolation Rooms (AIIRs)
Airborne Infection Isolation rooms (AIIRs), commonly called negative pressure rooms, are single-occupancy patient care spaces
designed to isolate patients with airborne pathogens to a safe containment area. AIIRs provide negative pressure in the room
(so that air flows under the gap into the room) with a pressure differential of >-2.5 Pa (Pascal) or >- 0.01” water gauge; an air
flow rate of >12 air changes per hour (ACH) and direct exhaust air from the room to the outside of the building; or recirculation
of air through a HEPA filter before returning to circulation.
AIIRs are designed in such a way so that no airborne particulates escape into other areas within the healthcare setting. Exhaust
from these rooms is not recirculated in the HVAC system. Instead, exhaust air typically moves in dedicated ductwork to
ventilation stacks on the rooftop, where atmospheric air provides sufficient dilution to make the resulting air safe.
For the safety of healthcare workers, patients, and visitors, negative pressure rooms occupied by patients requiring
airborne isolation must be checked daily.
Sub standards Explanation
According to Ministry of Health guidelines, there must be at least one Airborne Infection
Substandard 9.01:
Isolation Room for every 8 beds. (e.g 1-8 beds 1 AIIRS, 16 beds 2 AIIRs, 24 beds 3
At least one AIIR for each 8 AIIRs & so on)
beds. . IPC team must send request to higher administration if there is no AIIRs in the unit to fulfil
the requirement.

Provide training and orientation to the staff regarding general specification to be met for
all negative pressure isolation rooms. Monitor different parameters during routine
infection control rounds and observe If within recommended ranges. Evaluate the
performance of unit during IPCCC audit phase & provide formal feedback.
Substandard 9.02 Nurse in charge must receive clear instructions to keep all necessary records in the unit
to be presented if requested from external auditors.
Central air condition or
separate concealed unit is This includes all routine maintenance records and actions taken in terms of deranged
the source of conditioned environmental control parameters or malfunctioning.
fresh air. Maintenance staff must be consulted to provide detailed evidence of all these
specifications and each unit & IC team must keep copy of records.
Units must hard to keep all parameters within normal range and well prepared to provide
documented evidence for any external audit visit.

Following specifications must be met for all AIIRs:

Substandard 9.03:
- There must be 100% fresh air supply from central AC or concealed separate unit.
- Return of air is not permitted & source of conditioned fresh air must be only via these 02
Air exhausted from
sources. (Central air condition or separate concealed unit).
bathroom must be
-
exhausted 100% outside
through HEPA filter.
- Air from bathrooms must be exhausted 100 % outside through High‐Efficiency Particulate
Air (HEPA) filters.
- The exhaust air ducts MUST be independent of the building exhaust air system.
-

274 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - HEPA filter should be changed on regular basis and according to manufacturer’s
Substandard 9.04: instructions.
- Unit must keep records of all documents that prove the maintenance and changing of
HEPA filter is changed on
regular basis and according HEPA filter (as recommended)
to manufacturer's
recommendations.
Rationale:

High-efficiency particulate air (HEPA) filter is an air filter that removes >99.97% of particles
>0.3um at a specified flow rate of air. HEPA filters may be integrated into the central air
handling systems, installed at the point of use above the ceiling of a room, or used as
Substandard 9.05:
[
portable units.
There is monitor for
continuous monitoring of During rounds ICPs must ensure that each AIIR is equipped with a fixed monitor for
pressure difference at continuous monitoring of environmental control parameters and are in functional condition.
negative pressure room
having audio visual alarming
system when the ventilation Monitor must exhibit following specifications and records following parameters:
system failed.

Negative pressure (-2.5 pascal or more)

Substandard 9.06:
>12 air changes per hour.
Isolation Room is Has an audio-visual alarm system in case of ventilation system failure. There must be
maintained at negative
pressure (-2.5 pascal or Visible red flashing lights and audible sound comes from the monitor.
more) with respect to Fixed monitor must be installed outside each AIIRs in the corridor to monitor the pressure
corridors.
difference between the room and corridor.
Test the monitor to ensure that alarm is working or no, by keeping the door of AIIRs open
for few seconds. Hold the room door open. After the time delay, the audible and visual
Substandard 9.07:
alarm should annunciate.
Isolation Room is
Verify that the monitor is correctly reading the pressure. While the door is held open, the
maintained with >12 air
changes per hour. pressure reading should be at or near 0" water gauge.
Use a manual device to monitor pressure differentials in rooms where no monitor is
installed.

275 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During daily / weekly rounds ICPs must ensure that policy for regular monitoring of negative
pressure difference is fully implemented. If any breaches unit head must be informed.
Monitor and evaluate unit performance in IPCCC audit phase using IPCCC tool.

❖ Unit must keep record of all documents as evidence of regular monitoring of negative
pressure difference of AIIRs for at least last 3 months:

❖ Daily when in use (i.e., a patient is isolated inside) .

Substandard 9.08: ❖ Weekly when not in use (i.e., no patient is isolated).
❖ Monthly check by biomedical personals

Records for routine

monitoring of pressure Responsibility of Nursing staff:
gradients (daily if a patient
is isolated inside, weekly
when not in use and Negative pressure rooms in use:
monthly by biomedical
department).
Nursing staff must conduct visual checks for the direction of air flow (using flutter strips)
on all rooms where patients are in airborne isolation for query and confirmed airborne
transmissible diseases (e.g., Pulmonary Mycobacterium tuberculosis, measles, chicken
pox) when patients are in this room.
Prior to admitting patients needing airborne isolation, check and ensure that negative
pressure rooms are functioning well. For those designated isolation rooms without
monitor, call maintenance to check if the room is maintaining its negative pressure.
Follow the procedure of this policy in any room that fails inspection. d. All documentation
must be sent to the IP&C Department.

B. Negative Pressure Ventilation Failure:

Unit staff must respond to negative pressure failure.

Nursing staff will lace a surgical mask on the patient in airborne isolation.
Keep the door closed at all times.
Notify the Utilities & Maintenance (U&M) Department of the location and problem & IC
Department
If U&M declares the occupied room is no longer maintaining negative pressure, patient
must be transferred to another negative pressure room immediately.
Put a surgical mask on the patient before transporting.

276 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 An aerosol-generating procedure (AGP) is defined as any medical procedure that can induce
the production of aerosols of various sizes, including small (< 5 microns) Particles. AGPs
includes bronchoscopy, sputum induction, intubation and extubation,cardiopulmonary
Substandard 9.09: resuscitation, open suctioning of airways, Ambu bagging,nebulization therapy, high frequency
oscillation ventilation and Bilevel Positive Airway Pressure ventilation – BiPAP
Any aerosol generating
procedure (AGP) should be Precautions to be observed when performing aerosol- generating procedures, which may be
done in negative pressure associated with an increased risk of infection transmission:
room or single room with
portable HEPA filter using Perform procedures in a negative pressure room or single room with HEPA filter
appropriate PPE (N95 mask, Limit the number of persons present in the room to the absolute minimum required for the
eye protection, gloves & patient’s care and support.
gown) with possible minimal Wear N95 masks: Every healthcare worker should wear a fit-tested seal check N95 mask
number of staff. (or an alternative respirator if fit testing failed).
Wear eye protection (i.e. goggles or a face shield).
Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures require
sterile gloves
Wear an impermeable apron for some procedures with expected high fluid volumes that
might penetrate the gown.
Perform hand hygiene before and after contact with the patient and his or her surroundings
and after PPE removal.

Train & observe the following during daily/weekly rounds:

❖ HCWs performing any aerosol generating Procedure (AGPs) like CPR, intubation,
extubation, suctioning etc for any suspected or confirmed COVID – 19 or MERS- CoV
cases. (If possible to observe the real situation / scenario).
❖ Observe the type of PPE used by HCWs while preparing for AGPs.
❖ Observe if AGPs are performed in negative pressure room or single room with HEPA filter.
❖ Ask about the total number of staff to be present during procedure. Ensure minimum
number of staff are present who are absolutely necessary for specific procedure / task.

Evaluate the staff performance during IPCCC audit phase & provide formal feedback.

277 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 AIIRs MUST fulfill the following MOH specifications for standard isolation
rooms:
Substandard 9.10:
FLOORS, WALLS & CEILING:
AIIRs fulfill all MOH
specifications for standard
Minimal openings in the walls, floors and ceiling that are well sealed and airtight.
isolation rooms + windows
are sealed and fixed (i.e., Smooth, one piece without any cracks or decorative fine parts.
could not be opened/) They should be covered with such paints so as to withstand repeated cleaning
openings in walls and and disinfection by approved disinfectants.
ceiling are sealed and
airtight / doors are properly DOORS:
designed and well-sealed.
Doors are properly designed and well-sealed.
Substandard 9.11: The door should open to the inside.
Extend completely to the floor
The door should open to the Must have auto closure device / auto closure mechanism.
inside, has auto closure
device, well-sealed and WINDOWS:
extend completely to the
floor. Windows are sealed and fixed (i.e., could not be opened)
This will ensure to maintain continuous negative pressure differentials inside
airborne infection isolation rooms.
Substandard 9.12:
CURTAINS:
Windows are completely
sealed and fixed (i.e., could After discharge, transfer or death of patient under airborne precautions, curtains
not be opened). must be changed after terminal cleaning of isolation rooms

HAND HYGIENE FACILITY:

Substandard 9.13:
g) Hand Washing:
Curtains must be changed Following are required inside patients’ room
between patients.
Hand Washing Sink
Plain and antimicrobial soap
Paper towels
Substandard 9.14:
Available at easily accessible location

Hand washing facilities and

h) Hand Rubbing:
supplies (sinks / plain and
antimicrobial soap / paper Alcohol - based hand rub dispensers
towels, Alcohol - based Available at easily accessible location for staff to practice 5 moments of hand hygiene & to
hand rub dispensers) are perform hand hygiene after doffing of PPE items.
available & easily
PPE TROLLEY:
accessible.
Ensure availability of PPE trolley OUTSIDE AIIRs.
Substandard 9.15: Well organized and well maintained.
Appropriately cleaned external surfaces and internal surfaces of drawers ; free from
Trolley that contains the dust and any other visible contamination.
proper PPEs is available. All required PPE items MUST available (Gowns, Gloves, N – 95 respirators. Face
shields / goggles etc)
PPE items are organized in a way to facilitate staff while donning PPE.
PPE or any other medical supply must never be kept inside isolation rooms to avoid
risk of contamination.

278 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often
contain large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred
to patients or healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must
follow Standard Precautions at all times. To reduce the possibility of occupational risks of infection transmission and/or exposure,
laundry workers should focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal protective equipment
(PPE). Removal of foreign objects from soiled linen. 4. To restore soiled linen to usable condition, washing, bleaching, rinsing,
and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 10:01 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 10:02 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 10:03 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 10:04 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

279 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:05 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 10:06 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Substandard # 10:07 Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Linen carts are covered and Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
not overfilled. to 10 inches off the floor.
Linen from isolation rooms is considered regular soiled linen.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

280 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
Substandard # 11:01 - Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)
All types of waste
containers are Specification of Items:
available in sufficient
number and placed in Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
easily accessible sites. with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

281 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11:02 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 11:03
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 11:04 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 11:05 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

282 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 11:06 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 12 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the
integrity of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best
practices for safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 12:01
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 12:02 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to
Local records for corrective interventions which are taken if readings are not matching the
70%).
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.

283 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
Substandard # 12:03
- Recommended temperature Range is: 22 - 24°C
Away from air vents and - Recommended relative Humidity is up to 70%.
well ventilated.
Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.
Substandard # 12:04

Storage shelves are 40 Infection control team must provide training and reorientation about all specifications to be
cm from the ceiling, 20 followed for the maintenance of departmental medical stores.
cm from the floor, and 5
Train on following specifications / key points and observe in daily / weekly rounds if unit is
cm from the outside wall.
adherent with recommendations or not.
Departmental medical stores must be well organized & well maintained.
Substandard # 12:05 Must be away from any contamination, direct sunlight and airs vents.

Storage shelves made Specifications of Storage Shelves:

from easily cleanable
Storage shelves are made of easily cleanable material
material (e.g., fenestrated
stainless steel, Aluminium (e.g., fenestrated stainless steel, Aluminium or hard plastic).
or hard plastic) Storage shelves are placed following these specifications.
- 40 cm from the ceiling
Substandard # 12:06 - 20 cm from the floor
- 5 cm from the wall
Sterile and clean items
completely separated If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
from personal items & hard plastic).
foods and drinks.
Ensure that only sterile and clean items are allowed in the medical stores.
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 12:07 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
original cardboard shipping boxes.
Substandard # 12:08 Visit the medical storage room during daily / weekly rounds to check if any shipment boxes
are placed inside sock room. (i.e., boxes made of thick cardboard for shipping.
Items not kept in original
cardboard shipping Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile
boxes. and clean supplies can be kept inside medical stores (e.g., small boxes of medical supplies:
clean gloves, surgical masks, syringes …etc.) but should be discarded immediately when
the box has been emptied.

284 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
Substandard # 12:09 discarded)
If any stained item is found it would most likely reflect that item was restocked after being
No expired items, broken brought from patient care areas which is against the rules of aseptic technique. Such
packs or packs with practices must be strictly prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in
order to ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit
phase.
Provide formal feedback on unit & staff performance

Standard – 13 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.

Following must be ensured:

Substandard # 13:01
- All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
Daily logbook is
book.
activated in the unit
- This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
for HCWs to record
symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
presence or absence
- Head nurse holds the key responsibility to ensure that log book is complete and signed by all
of fever, respiratory &
HCWs on daily basis.
GI symptoms etc.
- Head nurse must review to assess the need for any staff to be evaluated by occupational health
before starting work
clinic or need work restriction.
shift.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.

Use attached template.

285 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 13:02
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

286 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 13:03
prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers &
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
visitors strictly adhere
droplets can also be inhaled into the lungs.
to the principles of
Recent studies indicate that people who are infected but do not have symptoms likely also play a
social distancing,
role in the spread of COVID-19. Since people can spread the virus before they know they are
cough etiquette and
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
frequent hand hygiene
have any symptoms.
during duty hours /
visiting hospital.
Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

287 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 13:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc) HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, transportation of supply etc

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289 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
290 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

291 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Burn unit

Burn care is a high risk service that requires strict adherence to certain

requirements to be safe, efficient, and effective. When the hospital provides burn care, the unit should
be staffed with qualified individuals. Additionally, policies and procedures should guide staff for
appropriate burn care.

Burn patients have a higher incidence of sepsis compared to patients with other forms of trauma
because of extensive skin barrier disruption and an alternation in the cellular and humoral immune
responses.

The dysfunction of the immune system, a large cutaneous bacterial load, the possibility of gastro-
intestinal bacterial translocation, prolonged hospitalization and invasive diagnostic and therapeutic
procedures all contribute to sepsis. Therefore, infections in burn patients are a leading cause of
morbidity and mortality.

292 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Epidemiology of infection among Burn patients:

Burn wound infections are one of the most important and potentially serious complications that occur in the
acute period following injury.

Infection is the leading cause of mortality & morbidity despite improvements in care. Burns increase patient’s
susceptibility to infections by damaging both patients physical & immunological defences. The skin is the largest
organ of body and constitutes first defence against infection. The integrity of skin barrier is disrupted and
normally sterile sites becomes vulnerable to microbes.

Factors contributing to sepsis includes dysfunction of the immune system, skin bacterial load, the possibility of
gastro- intestinal bacterial translocation, prolonged hospitalization and invasive diagnostic and therapeutic
procedures.

Epidemiology of infection among burn patients, involves source of organisms, modes of transmission & a
susceptible host.

Reserviors / Source of Organisms

1. Surfaces of burn wounds in all burn patients
2. Hands of healthcare workers (HCWs)
3. inanimate environmental objects (hydrotherapy equipment
and associated plumbing, cooling blankets, mattresses, etc.)

Infections
in Burn
Patients
Modes of Transmission
Susceptable Host Factors
Direct or indirect contact via:
1: Burn wound size (the percentage of
TBSA burnt) 1. fomites such as bed rails, stethoscope,
ECG leads etc
2: Immunosuppression
2. Hydrotherapy equipments including
3: use of invasive devicesduration of water & Hands of Hydrotherapy & other
hospitalization personnel

Strict implementation of infection control procedures including hand hygiene, wearing personal protective
equipment (PPE) to prevent the transmission of infection during patient care, practicing aseptic technique,
isolation precautions & environmental measures etc. would play a significant role to ensure patient & staff safety.

293 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN Burn unit

POLICIES & PROCEDURES

EDUCATION & TRAINING

HAND HYGIENE
BURN UNIT

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19 Pandemic)

294 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 BURN UNIT
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them.
They guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff
safe. Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living,
breathing documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection Preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

295 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
(HCP) receive joining work & issue a BICSL ID which should be renewed ever 02 years.
orientation and Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
training on Basic hours as an evidence of basic infection control training to be presented to any external /internal
Infection Control Skills audit visit for purpose of verification.
from IC department
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
maximum within 1
every 2 years by visiting infection control department.
months of joining
work & a BICSL card
is issued which is Components of BICSL includes:
renewed every 2
years. - HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

296 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2:2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

297 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance.
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session will be considered.

Infection Control department provides MUST provide health education on infection control for
patients, families and visitors.
Tailored IPC education for patients or family members should be considered to minimize the
Substandard # 2:4
potential for HAI (for example, patients who are immunosuppressed or with invasive devices or
with multidrug resistant infections).
Burn unit provides
infection control health
education for patients, IC team must ensure the availability of the following according to the specific unit / area:
families & Visitors Bilingual infection control health education & awareness material must be designed / formulated
to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
booklets, leaflets etc. containing information easy to understand with help of pictorial display.
The educational material must be posted and available in all patient care areas, waiting areas at
the place easily seen and readable by patients, families and visitors. e,g hand hygiene, cough
etiquette, COVID 19 & MERS educational material, etc.

298 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files.
For example, Burn patients must receive education about personal hygiene, importance of
frequent hand hygiene, care of central venous catheter at home, how to take shower with intact
CVC etc
Family members’ / care givers must be aware about importance of hand hygiene, wound care at
home, precautions taken while changing dressing etc.
Visitors are educated on precautions to be taken while being in the surrounding of a patient, the
importance of hand hygiene and the isolation precautions required in case of isolated patients etc
education must be provided on how to don / doff PPE and perform hand hygiene before entering
isolation room.
Ensure availability of documented evidence of visitors education to be presented to external audit
visit teams.
Sitters / visitors must adhere to the burn unit personnel’s recommendations/instructions
regarding infection prevention requirements (e.g. PPE use, hand hygiene etc).

Visitors must be excluded from the patient care area during wound care. If a visitor is needed
during dressing (usually for small children), full protective equipment must be worn.

299 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way
to prevent infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are
becoming difficult to treat. On average, healthcare providers clean their hands less than half of the times they should. On any
given day, about one in 31 hospital patients has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
patient's room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

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 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Substandard # 3:2 Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
Health care microorganisms without the need for an exogenous source of water and requiring no rinsing or
professionals (HCP) drying with towels or other devices.
demonstrate
appropriate Indications:
technique for hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body fluid
rubbing and hand exposure risk, after touching a patient, after touching patient’s surroundings.
washing. Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in healthcare
settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or when
hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at high risk
areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:
- Wet hands with water
- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands and
fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa, (to
remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

301 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Substandard # 3:3
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Visual alerts are posted at appropriate places.
available: WHO 5
moments, how to - WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to - How to hand wash poster beside ach hand washing sink
do hand wash. - How to handrub poster beside each hand hygiene dispen
-
WHO five moments of hand hygiene in Burn Unit:

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

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304 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room but
are available and readily not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will interfere
accessible to HCP. with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Powered air purifying respirators (PAPRs) for bearded staff etc

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2
masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock rooms.
N - 95 respirators are
Check if all types and sizes are available according to fit test result of each healthcare
available in different types and
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)
sizes.

305 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

Substandard # 4:4 All isolation precautions must be used together with Standard Precautions

Staff use personal protective ❖ Contact: Appropriate PPE – Gown & Gloves
equipment appropriately (e.g. ❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
donning and doffing) ❖ Airborne: N95 mask / respirator before entering the room.
1: Appropriate PPE for Contact Isolation:
Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

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 Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
https://youtu.be/H4jQUBAlBrI Perform hand hygiene.
Watch Video How to safely put
NB: If goggles/face shield are worn:
on PPE
• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.
In case of combination of Contact and Airborne precautions with eye protection
(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.
❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

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309 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
310 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

In Burn patients, disinfection and sterilization guidelines for patient care equipment must take into account the
presence of sometimes extensive, open wounds which is the major difference separating this population from
other patient populations. Following Spaulding’s scheme for categorizing patient care items and equipment, the
changes for the burn patient population involve what are considered “semicritical” and “noncritical” items. Many
items such as blood pressure cuffs, stethoscopes, bedpans, if used on areas without dry, occlusive dressings,
may need high-level disinfection as a semi critical item or may need to be restricted to an individual patient.

311 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

312 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hydrotherapy involves the use of water for soothing pains and treating certain medical conditions.
Hydrotherapy equipment includes pools, hot tubs, and physiotherapy tanks. For the health and
safety of patients, it is vital to ensure that the water that is used in hydrotherapy is safe and clean.
Many of these patients have compromised immune systems due to current infections, and are
Substandard # 5:7 highly susceptible to new infections from contaminated water in hydrotherapy pools. Potential
routes of infection caused by contaminated water include accidental ingestion of the water,
Hydrotherapy breathing sprays and aerosols from the water, and allowing wounds to come in direct contact with
equipment must be the water.
cleaned and
disinfected between Provide training to the burn unit staff on appropriate cleaning and disinfection practices of the
patients and at the end hydrotherapy equipment.
of the day using a Hydrotherapy equipment MUST be cleaned and disinfected in between patients and at the end
hospital-approved of the day using a hospital-approved disinfectant as per the manufacturer’s instructions to
disinfectant as per the prevent infection transmission.
manufacturer’s Risks associated with care of the burn wound, such as hydrotherapy and common treatment
instructions. rooms, are related to the use of water sources that are frequently contaminated by gram-
negative organisms intrinsically, and may also be contaminated by organisms from other
patients.

https://www.cdc.gov/healthywater/other/medical/hydrotherapy.html

Substandard # 5:8 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

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 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

314 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

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 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:04
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 6:05 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 9. Disposable personal care items are discarded
worker, housekeeping 10. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 6:06 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

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 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:07 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

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 HIGH TOUCH SURFACES

318 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:08 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:09
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

319 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Substandard # 6:11 Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
Housekeepers are well measures.
trained on hand hygiene, Routine practices related to environmental cleaning includes:
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals.
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

320 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

321 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

322 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
323 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 7:01 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

324 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
Substandard # 7:02 importance in preventing sharp and needle stick injuries.

Sharp items (e.g., Observe the practices of staff during daily rounds regarding disposal of sharp items like
needles, scalpel needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
blades, broken metal All sharp items must be discarded in the specified sharp containers including the broken and
instruments and burs) unbroken glass vials.
are placed in an Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture any such situation inform the head nurse to monitor closely the staff practices.
resistant and leak- Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps collection staff / housekeeping staff.
container.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 7:03
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 7:04 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 7:05 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

325 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 7:06 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 8 Aseptic Technique

Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient
care across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 8:01 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 8:02
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

326 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 8:03 in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of to use large IV solution bottles for preparation & dilution of medications
medication is only done by Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water specified for preparation & dilution of medications.
ampoule. Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 8:04
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 8:05
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

327 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 8:06 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient. While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 8:07 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
wrapping. All reusable items are sent for reprocessing, even unused ones with intact original wrap.

Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

328 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Maintaining the integrity of sterile equipment and solutions is extremely important to
prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
urinary catheter).
- If the sterile items are assembled long before the procedure, there are chances of
contamination from environment such as dust etc.
Substandard # 8:08 - A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
Sterile equipment and the transfer of microorganisms and reduce the potential for infections.
solutions are assembled - Principles of sterile technique help control and prevent infection, prevent the transmission
immediately prior to use. of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.

As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.

Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
Substandard # 8:09 transfer forceps.
Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
Sterile to sterile rule is Non-sterile items should not cross over the sterile field. For example, a non-sterile person
applied during any aseptic should not reach over a sterile field.
procedure. Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.

329 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 8:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 8:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

330 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 8:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
claim that each device is exclusively allocated only for one patient.
Substandard # 8:14
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
• Patient's name & medical record number to be used exclusively for one patient.
insulin pens) are used only
• Date of the first use to be discarded after expiration of the reuse life recommended
for single patient.
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 8:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.

331 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
Substandard # 8:16 sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
IV solution bottles are only accessed through the self-sealed rubber cap. You may
IV solution bottles are only observe staff accessing the IV solution from the plastic body of IV solution bottle rather
accessed through the self- than the self-sealed rubber cap.
sealed rubber cap. You can check by pressing gently the IV solution bottle if any fluid leaks out or no.

Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 8:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7
days, but not more Following key points must be followed for replacement of IV sets in order to avoid risk of
frequently than 96-hour infection from frequent changing of IV sets:
intervals.
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 8:18
Rationale: Extending the duration of use permits considerable cost savings to hospitals
IV sets that are used to without significant increase in the risk of healthcare-associated BSI with peripheral IVs
administer blood, blood
products, lipid emulsions, or In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
dextrose/amino acid TPN acid TPN solutions, check that IV delivery systems are continuously connected and
solutions are replaced within changed within 24 hours of initiating the infusion.
24 hours of initiating the During daily rounds, observe that IV administration sets are labelled with dates & times of
infusion. initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
(hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

332 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 According to The Joint Commission, there are four chief aspects of the aseptic technique:
barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Substandard # 8:19 protect the patient from the transfer of pathogens from a healthcare worker, from the
environment, or from both. Some barriers used in aseptic technique include:
Maximum sterile barrier
precautions is applied - Sterile gloves
during any interventional - Sterile gowns
procedure, including cap, - Masks for the patient and healthcare provider
mask, sterile gown, sterile - Sterile drapes etc
gloves, and sterile full-body - Head Cover
drape.
Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
central line etc.
Only necessary health personnel should be at the procedure. The more people present, the
more opportunities for harmful bacteria to cause contamination.

Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 8:20 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

333 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 -

Train, monitor & audit on following key points for replacing dressings on short term CVCs &
Substandard # 8:21
implanted / implanted CVCs:
Replace dressings used on
Catheter Site Dressing Regimens:
short-term central venous
catheter (CVC) sites every 2
❖ Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the
days for gauze dressing.
catheter site
❖ Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.
❖ Gauze Dressings used on short-term central venous catheter (CVC) sites must be
Substandard # 8:22
replaced every 2 days for gauze dressing following aseptic technique.
❖ Transparent Dressings used on short-term central venous catheter (CVC) sites must be
Replace dressing used on
replaced every 7 days for gauze dressing following aseptic technique.
short-term CVC sites at
❖ Transparent Dressings used on tunnelled or implanted CVC sites must be replaced no
least every 7 days for
more than once per week (unless the dressing is soiled or loose), until the insertion site
transparent
has healed following aseptic technique.
dressing.
Additional points:

Substandard # 8:23 ❖ 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
Replace transparent resistance.
dressings used on tunnelled ❖ Do not submerge the catheter or catheter site in water. Showering should be permitted if
or implanted CVC sites no precautions can be taken to reduce the likelihood of introducing organisms into the
more than once per week catheter (e.g., if the catheter and connecting device are protected with an impermeable
(unless the dressing is cover during the shower)
soiled or loose), until the
insertion site has healed. Reference: https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html

334 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain large
numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or healthcare
workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must follow Standard Precautions at all times.
To reduce the possibility of occupational risks of infection transmission and/or exposure, laundry workers should focus on: a. Appropriate and
frequent hand hygiene. b. Appropriate use of personal protective equipment (PPE). Removal of foreign objects from soiled linen. 4. To restore
soiled linen to usable condition, washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 9:01 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 9:02 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 9:03 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 9:04 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

335 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9:05 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 9:06 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Substandard # 9:07 Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
to 10 inches off the floor.
Linen carts are covered and Linen from isolation rooms is considered regular soiled linen.
not overfilled. The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

336 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

M. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
N. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
O. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
ix. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
x. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

337 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Rationale for admission screening:
- Rapid screening of all patients admitted or transferred from any other healthcare facility to
Substandard # 10:01 the critical care units must be conducted to identify those patients requiring isolation is of
significant importance in reducing or preventing the spread of infection to HCWs, patients
There is a screening and visitors.
policy for newly - In the absence of standard screening protocols, a substantial proportion of patients may
admitted or be silently colonized with MDROs that are not detected during their routine hospital stay.
transferred patients to - Furthermore, colonization by MDRO is known as a potential source of cross transmission and
all critical care units to a risk factor for the development of subsequent infection.
identify those who
- Colonized patient constitute the major reservoir for nosocomial transmission.
require isolation
precautions.
Develop and provide detailed screening policy & ensure during daily/weekly rounds that the
policy is fully implemented.

Randomly check files of newly admitted or transferred patients to verify if screening is done or
not.
Ask staff to provide results to confirm the negative status or appropriate isolation precautions
are initiated based on positive results findings.

Provide education to the staff regarding importance of isolation precautions during IPCCC training
Substandard # 10:02 activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis for
isolation precautions patients under isolation.
are available in the Use preferably isolation precautions signs provided by GDIPC.
unit & used Must be placed / posted on door only if occupied by patient.
appropriately. 02 types of isolation precaution signs must be available in the unit.
Isolation signs must - Isolation precaution signs for units to be posted on doors if the isolation room is
be : 1) Clear and occupied by patients with diseases transmitted either by contact, droplet or airborne
visible for HCWs and route.
visitors 2) Bilingual (in - Isolation Transportation cards for transportation of patients to other departments as
Arabic & English). 3) needed.
Color coded and
compatible with Contact isolation Precautions must be used together with standard precautions:
diagnosis (Examples:
contact: green, Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
airborne: blue, and infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
droplet: pink or red) The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

338 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Precautions must be used together with standard precautions. Droplet
Substandard # 10:03 Precautions are intended to reduce the risk of droplet transmission of infectious agents from close
contact (exposure to eyes, nose and mouth) with large-particle droplets
Appropriate isolation
transportation cards / Should be Initiated and maintained when there is suspected or confirmed diagnosis of an
sings are available in infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
the department & Use a single room. A negative air pressure room is not indicated.
used while Place a droplet sign on the door.
transporting patients Droplet isolation signage must be color coded (e.g., orange) and must be available in both
under transmission- English and Arabic languages.
based precautions to
other department as Airborne isolation precautions must be used together with standard precautions
needed. Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases that
are spread via the airborne route.
Transport Isolation Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
signs must be : 1) disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Clear and visible for Use a single room with a negative air pressure system (AIIR)
HCWs and visitors 2) Place the Airborne Isolation sign on the door.
Bilingual (in Arabic & Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English). 3) Color English and Arabic languages. b. Keep door closed at all times except when entering or
coded and compatible leaving the room.
with diagnosis
(Examples: contact: Patient Transportation:
green, airborne: blue,
and droplet: pink or Patient Transportation isolation signs must be used while transporting patients under
red) and selecting low transmission-based precautions to other department as needed.
traffic time & route.
Transport of isolated patients should be limited to essential purposes only, such as diagnostic
and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
should be worn to reduce potential contamination of the environment and the spread of
infection.
Isolation instructions must be clearly highlighted on the transmission-based precaution card
(isolation signs) while transporting patients under transmission-based precautions to other
department ( e.g radiology).

IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 10:04 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
Log book for exposure entry into isolation room for any task.
is available for any Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
potentially harmful Logbook must specify the name, designation / job category, Duration of exposure (Time in /
infectious exposures Time out) & type of PPE used.
as per exposure Appropriately used logbook will generate information needed in case of outbreaks etc
policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. before gaining entry into isolation room.
MERS-CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

339 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Patients with greater than >25% total body surface area. (TBSA) burn injuries are more
immunocompromised, due to the larger size of their injury. This, in combination with their loss of
physical defences and need for invasive devices, significantly increases their risk of infection. These
patients also represent a significant risk for contamination of their surrounding environment with
organisms, which may then be spread to other patients in the unit.
Substandard # 10:05 Sources of organisms are found in the patient’s own endogenous (normal) flora, from exogenous
sources in the environment, and from healthcare personnel. Exogenous organisms from the hospital
Patients with larger environment are generally more resistant to antimicrobial agents than endogenous organisms.
burns (>25% total Organisms associated with infection in burn patients include gram-positive, gram-negative, and
body surface area) are yeast / fungal organisms.
placed in a single
room, when For these reasons, it is recommended that patients with larger burn injuries be isolated in
applicable, as an private rooms or other enclosed bed spaces to ensure physical separation from other patients
additional precaution. in the unit. Such isolation has been associated with a decrease in cross transmission of
organisms.
Educate staff about the importance of placing patients in single rooms in order to avoid cross
transmission of infection.
Encourage staff to adopt best practices for patient’s safety.
Audit unit performance to gauge if compliant with all IC protocols.

Single Use items are those that are intended for single use only, on an individual patient for a
single procedure, and then should be discarded. It should not be reprocessed or reused again
Substandard # 10:06 even on the same patient.
Single use or
Provide training and orientation to staff regarding patient care equipment to be used for isolation
dedicated non-critical
rooms during daily/weekly rounds:
patient care equipment
(e.g., stethoscope,
Following instructions must be given:
pressure cuff, etc.) are
used for the isolation
If single use non critical items are used for isolation rooms, they must be immediately
room.
discarded after use. Single use items must never be kept to be reused for the same patient or
next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be disinfected
after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc

Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation room
is used for another isolation room or another area.

340 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Transfer of patients under isolation precautions must be restricted to medically necessary
purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
Substandard # 10:07 procedures that cannot be performed in the patient’s room.

Facility limits Provide training and orientation to staff the transfer rules related to patient transportation under
movement of patients isolation precautions. Observe if unit is following the policy.
on isolation
Precautions outside of Following instructions must be given:
their room except for
medically necessary Receiving unit or facility is informed beforehand about the required isolation precautions to be
purposes. taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Substandard # 10:08 Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
unit etc.
If transfer of patient
under isolation is It is important that HCWs in the receiving unit have received prior training on how to safely
required, the receiving handle patients under isolation precautions and how to appropriately use PPE according to type
unit or facility is of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit tested
informed about the for N-95 mask and trained well on how to don & doff after use.
required isolation
precautions and Transferring the Patient to Another Facility:
availability of
appropriate PPE is Inform the receiving facility and the emergency vehicle personnel in advance about the type of
ensured. isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

Substandard # 10:09 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation.
While transferring
patients under Key Points include:
droplet/airborne
isolation precaution, Explain to the patient the need for the protective apparel that he/she is required to wear.
patient should wear a Patient must wear mask during transportation (droplet & airborne isolation)
surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory Isolation instructions must highlight the transmission-based precaution card ( isolation signs)
hygiene and cough needed while transporting patients under transmission-based precautions to other department (
etiquette. e.g radiology).
-

341 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or
Substandard # 10:10 more classes of antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to most
Contact isolation available antimicrobial agents.
precautions are
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci
initiated for patients
(VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
infected or colonized
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms.
Skin lesions and Proper attention & care to these pathogens is critical to curtail further emergence of these
infected or colonized highly resistant organisms.
areas of patient's body
Infection refers to the entry into and multiplication of an infectious agent in the tissues of the
should be contained
host and the tissue damage resulting in apparent or unapparent changes in the host.
and covered.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and covered
in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

Provide training to the staff for rules to be followed for patient transportation under contact isolation
Substandard # 10:11 precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

For transport patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin Leak-proof dressing should be used to reduce potential contamination of the environment and
lesions and infected or the spread of infection.
colonized areas of the Dress wounds with impervious dressings as required.
patient’s body with Dress the patient in a clean gown.
clean bandages and Cover the patient with a clean sheet.
clean linens. Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

342 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 In order to avoid potential risk of acquiring infection visitors should be strictly limited for
isolation cases.
As per standards, some exemptions may be considered on a case to case basis i.e visitors may
be allowed to enter the isolation room if he / she fulfils the following criteria e.g mothers of
babies etc
Substandard 10:12
- Duration of stay will be minimum for few minutes only.
Visitors - Visitors must seek permission from nursing station.
should be strictly - Clear instructions must be provided to visitors in their language before entering into an isolation
limited for isolation room.
cases. Exemptions - Visitors must be fully compliant with the required PPE i.e visitors will wear same type of PPE
may be considered on and follows same protocols as any HCWs before entering isolation rooms.
a case to case basis - Proper education, counselling, and monitoring should be provided to the visitors before
only for few minutes entering the airborne infection isolation room.
after having - Nursing staff must keep records of visitor’s education & instructions as evidence to be
permission from presented to external auditors when requested.
nursing station and
after receiving proper Educate the staff regarding visitor’s policy & ensure during daily/weekly rounds if its fully
instructions before implemented:
entering into an
isolation room and - Observe and ask staff about the visitors if isolation room occupied by patient.
within compliance with - Ask about the evidence of education & documentation in log book.
the required PPE. - Observe when possible any visitor entering or coming out of isolation room if compliant with
instructions.
- Sometimes visitors are not donning PPE appropriately. Gowns is not tied & masks is worn
inappropriately.
- It is also common observation to see visitors coming out of AIIR with all PPE and removing PPE
abruptly without practicing hand hygiene.
- Such practices would pose risk of acquiring infection. Nursing staff must be fulling adherent
with visitor’s policy for isolated patients.

Audit the unit performance during IPCCC audit phase and provide formal feedback.

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 Standard – 11 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the
integrity of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best
practices for safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 11:01
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 11:02 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to
Local records for corrective interventions which are taken if readings are not matching the
70%).
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

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Substandard # 11:03 Infection control team must provide training and reorientation about all specifications to be
followed for the maintenance of departmental medical stores.
Away from air vents and
well ventilated. Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.
Substandard # 11:04 Departmental medical stores must be well organized & well maintained.
Storage shelves are 40 Must be away from any contamination, direct sunlight and airs vents.
cm from the ceiling, 20 Specifications of Storage Shelves:
cm from the floor, and 5
cm from the outside wall. Storage shelves are made of easily cleanable material
(e.g., fenestrated stainless steel, Aluminium or hard plastic).
Substandard # 11:05
Storage shelves are placed following these specifications.
Storage shelves made
from easily cleanable - 40 cm from the ceiling
material (e.g., fenestrated - 20 cm from the floor
stainless steel, Aluminium - 5 cm from the wall
or hard plastic)
If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
Substandard # 11:06
hard plastic).
Sterile and clean items
completely separated Ensure that only sterile and clean items are allowed in the medical stores.
from personal items & Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
foods and drinks.
from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 11:07 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 11:08 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 11:09 Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
discarded)
No expired items, broken If any stained item is found it would most likely reflect that item was restocked after being brought
packs or packs with from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
prohibited.
stains are present.
Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

349 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 12:01 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.
Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
Substandard # 12:02 In health care settings, First and foremost, a mask is a core component of the personal protective
equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
All HCWs must abide in conjunction with gown, gloves, and eye protection.
by the policy of
universal masking i.e All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
wearing surgical face expected to wear surgical face masks, at all times, while in their respective clinical care settings.
mask at all times while This universal mask approach will serve to:
in their respective
Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
clinical setting. mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .
- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

350 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.
Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
Substandard # 12:03
arms’ length) from other healthcare workers during the duty hours.
Health Care workers,
visitors & Patients Why Practice Social Distancing?
strictly adhere to the
principles of social COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
distancing, cough prolonged period.
etiquette and frequent Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
hand hygiene during mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
duty hours / visiting droplets can also be inhaled into the lungs.
hospital. Recent studies indicate that people who are infected but do not have symptoms likely also play a
role in the spread of COVID-19. Since people can spread the virus before they know they are
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
have any symptoms.

Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

351 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 12:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc) HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, transportation of supply etc

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 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

356 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EMERGENCY & SPECIALIZED
CARE AREAS

# NAME OF UNIT PAGE #

01 EMERGENCY ROOM (ER) 358

02 HEMODIALYSIS UNIT (HDU) 436

03 OPERATION ROOM (OR) 534

04 ONCOLOGY UNIT 598

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EMERGENCY ROOM (ER)

Emergency Services are at the front line of

medical care, having high risk of exposure to patients with known or unknown
infectious diseases.
Emerging pathogens and antimicrobial-resistant strains are major problems facing all
healthcare providers.
Hence, strict implementation of infection control procedures including hand hygiene,
wearing personal protective equipment (PPE) to prevent the transmission of infection
during patient care, practicing aseptic technique, isolation precautions & environmental
measures etc. would play a significant role in ensuring patient & staff safety.

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 IPCCC - STANDARDS IN
EMERGENCY ROOM (ER)

POLICIES & PROCEDURES

EDUCATION & TRAINING

EMERGENCY ROOM (ER)

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

RESPIRATORY TRIAGE

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

AIRNORNE INFECTION ISOLATION ROOMS (AIIRs)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

EMERGENCY MEDICAL SERVICES

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

359 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EMERGENCY ROOM (ER)
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

360 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation
Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.

Each HCPs must receive education & training on basic infection control skills from IC
Substandard # 2:1
department within 01 months of joining work. (BICSL)
IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
Healthcare Personnel joining work & issue a BICSL ID which should be renewed ever 02 years.
(HCP) receive Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
orientation and hours as an evidence of basic infection control training to be presented to any external /internal
training on Basic audit visit for purpose of verification.
Infection Control Skills
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
from IC department
every 2 years by visiting infection control department.
maximum within 1
months of joining
work & a BICSL card Components of BICSL includes:
is issued which is
renewed every 2 - HAND HYGIENE
years. - PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

361 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year

b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.

Infection Prevention & control department MUST provide education & training to all health care
Substandard # 2:2 personnel on infection control best practices specific to their job as follows:

Healthcare Personnel Infection control Training specific to area of work must be provided initially upon hiring before
(HCP) receive job- starting their duty.
specific training on Continuous education on relevant infection control policies and procedures must be conducted
infection prevention at least once per year.
policies and Training will be conducted immediately without significant delay if there are new updates / new
procedures upon guidelines available.
hiring and at least EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:
once annually.
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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.

362 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters.

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Infection Control department MUST provide health education on infection control for families and
visitors.
Substandard # 2:4
IC team must ensure the availability of the following according to the specific unit / area:
Unit provides infection Bilingual infection control health education & awareness material must be designed / formulated
control health to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
education to the booklets, leaflets etc. containing information easy to understand with help of pictorial display.
Patients. families &
Visitors. The general & specific health educational material must be posted and available in all patient
care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.

Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files.

Patients/Family members’ / care givers must be aware about importance of hand hygiene, care
of central line, identifying and notifying signs of inflammation etc.
Visitors are educated on precautions to be taken while being in the surrounding of the patient,
the importance of hand hygiene and the required isolation precautions etc education must be
provided on how to don / doff PPE and perform hand hygiene before entering isolation room.
Ensure strict adherence of visitors to the recommendations / instructions regarding infection
prevention requirements (e.g.PPE use, hand hygiene etc).

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364 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
patient's room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

365 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Substandard # 3:2
Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
Health care
microorganisms without the need for an exogenous source of water and requiring no rinsing or
professionals (HCP)
drying with towels or other devices.
demonstrate
appropriate Indications:
technique for hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
rubbing and hand body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing. Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and
/or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
366 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
Substandard # 3:3 incorporating the culture of best practices.

❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Visual alerts are posted at appropriate places.
available: WHO 5
moments, how to - WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to - How to hand wash poster beside ach hand washing sink
do hand wash. - How to handrub poster beside each hand hygiene dispenser
-
WHO five moments of hand hygiene :

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

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369 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room
are available and readily but not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will
accessible to HCP. interfere with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Powered air purifying respirators (PAPRs) for bearded staff etc

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2 masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock
N - 95 respirators are available rooms.
in different types and sizes. Check if all types and sizes are available according to fit test result of each healthcare
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)

370 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding
using N-95 respirator according to fit test or follow alternate policy in case of non-
availability.
Substandard # 4:3
During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
Staff knows the suitable N95 to infections are using the correct size & type of N-95 mask according to fit test.
be used based on the fit test. (Countercheck / verify with their fit test ID).
Observe the practice of doctors with beards.

Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.
❖ Air-purifying respirator means a respirator with an air-purifying filter, cartridge, or
canister that removes specific air contaminants by passing ambient air through the
air-purifying element.
Substandard # 4:4 ❖ Powered air-purifying respirator (PAPR) means an air-purifying respirator that uses
a blower to force the ambient air through air-purifying elements to the inlet
Alternative respirator, such as covering.
powered air-purifying respirator
(PAPR) is accessible for HCW ❖ Powered air purifying respirators offer protection against certain respiratory hazards
with integrated head, eye and face protection that can help provide a more
who failed in fit testing when
comfortable environment for the worker.
dealing with patients under
airborne isolation precautions. ❖ PAPR system uses a blower instead of lung power to draw air through the filter. This
lets HCWs to breathe more naturally while feeling a constant airflow in your while
dealing with patients.
❖ Ensure that powered air-purifying respirator (PAPRs) are available and accessible for
all HCWs who failed fit testing to N-95 mask of all types, brands & shapes.
❖ HCWs with beard must not use N-95 mask because of interference of facial hair in
ensuring perfect facial seal. Airborne particles are less than 5 microns in size which
can easily pass from beneath the mask if appropriately size is not used exposing staff
to risk of acquiring airborne infection.
❖ Bearded staff must only use powered air-purifying respirator (PAPR)while dealing
with patients under airborne infection isolation rooms.
❖ HCWs must also receive training on how to don the respirator and safely handle after
use.
Note:
If powered air-purifying respirator (PAPR)are not available, hospitals must have clearly
policy for bearded staff to strictly refrain from dealing with airborne cases and staff
must be well oriente d about the policy in order to ensure safety of healthcare workers.

371 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.
Substandard # 4:5
All isolation precautions must be used together with Standard Precautions
Staff use personal protective
equipment appropriately (e.g. ❖ Contact: Appropriate PPE – Gown & Gloves
donning and doffing) ❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Before entering and leaving a patient’s room PPEs should be donned & doffed in this
order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured
at neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
https://youtu.be/H4jQUBAlBrI
out, fold into a bundle and discard.
Watch Video How to safely put
Perform hand hygiene.
on PPE
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.
372 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

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376 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 5 Respiratory Triage
Coronaviruses (CoV) are a large family of RNA viruses that cause illnesses ranging from the common cold to more severe diseases such as Middle East Respiratory
Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). ).
The new strain of coronavirus was identified in December 2019 in Wuhan city. The World Health Organization (WHO) has named the disease associated with SARS-
CoV-2 infections as Corona “COVID-19”. is a zoonotic pathogen with possible spillover directly from wildlife or via intermediate animal hosts or their products.
Sustained human-to-human transmission has been confirmed in China where numerous healthcare workers have been infected in clinical settings with overt clinical
illness and fatalities. However, there is not much information about SARS-CoV-2 to draw definitive conclusions about transmission mode, Transmission of the virus
mainly through droplets mode, less frequently through contact, it can be transmitted as well through aerosol in case of aerosol generated procedure and close contact
in indoor sitting. (Version: 2 - Nov 2020)
Middle East Respiratory Syndrome (MERS) is a viral respiratory disease caused by a novel coronavirus (Middle East Respiratory Syndrome Coronavirus, or MERS-CoV)
that was first identified in Saudi Arabia in 2012. Typical MERS-CoV symptoms include fever, cough and shortness of breath. Pneumonia is common, but not always
present. Approximately 35% of reported patients with MERS-CoV have died. (Version 5.1 - May 2018)

Sub standards Explanation

➢ Infection Control practitioners must ensure availability & strict adherence to MERS CoV & COVID – 19 protocols in ER.
➢ Provide training to all relevant health care personnel during training phase. Monitor staff practices and evaluate performance during IPCCC audit phase. 100% of
staff working in ER must receive training at least once per year and more frequently when new updates are available.
➢ Flowchart must be developed by the infection control including all protocols for MERS CoV & COVID – 19 based on latest released guidelines from MOH.
➢ Flow chart must delineate all steps and displayed at appropriate places to be easily seen by all relevant HCWs.

Example: Patient arrives at ER entrance

Substandard 5.1:
Respiratory Triage Station
There is a protocol for early (Nurse available 24/7 interview patients using predefined scoring criteria)
detection, management, and
transfer of respiratory
illness patients, “Flow Score 4 & above (≥ 4) Score less than 4 (<4)
Charts” for MERS - CoV &
COVID -19 must be
developed based on Respiratory Pathway / Triage Non - Respiratory Pathway
updated guidelines and (Common Triage)
present on well seen place (Dedicated
in the ER. waiting area if clinic
is occupied.)

Respiratory Triage Clinic / Assessment Room

Meets criteria for Does NOT meet

suspected case criteria for
Definition suspected case definition
(MERS / COVID - 19)

(Isolation Room (AIIR) / Single room with HEPA filter)

❖ Follow Algorithm for Managing suspected MERS-CoV Patients
(Appendix C - page # 26 Version 5.1 / 2018)
❖ Follow COVID - 19 Guidelines for managing suspected COVID -19 cases

- All HCWs dealing with respiratory illness patients must be well familiarized with respiratory
pathway based on the provided protocols as mentioned in flowchart in order to avoid confusions
and mismanagement of patients.
- Monitor activities during daily rounds that staff are strictly adhering to protocols.
- Evaluate the performance during IPCCC audit phase.

377 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ❖ To prevent the transmission of respiratory infections in the healthcare settings, all
Substandard 5.2: healthcare facilities should have designated triage area for suspected cases that is
physically separated from other areas.
There is a designated area ❖ All patients passing through emergency room must be triaged at the entrance using
for “ RESPIRATORY predefined scoring mechanism. (except those with immediately life-threatening
TRIAGE” facing ER entrance conditions)
for suspected MERS‐CoV &
COVID - 19 cases with ❖ Infection Control practitioners must ensure availability of designated triage area in th ER.
required equipment It must me at the entrance to facilitate early detection and segregation of patients from
(surgical facemask, hand initial checkpoint at entrance.
hygiene sanitizer etc.) ❖ IC team must seek administrative support in case of facing difficulties in implementing
the respiratory triage protocols.

Substandard 5.3: Following pathway must be established:

Respiratory triage for

MERS-Cov and COVID-19 is Visual Triage:
active 24/7 according to the
MOH MERS-CoV and ❖ Visual Triage must be available at the entry point of emergency room entrance for effective
COVID-19 guidelines capturing & early identification of all individuals passing through the entrance with ARI
symptoms.
Substandard 5.4: ❖ Required equipment at Visual triage includes respiratory scoring checklist. surgical mask,
hand hygiene sanitizer, posters etc.
Assigned and documental
❖ Must be activated 24/7 with an assigned trained staff.
trained HCW is available at
visual triage area who can Location of triage station:
communicate in arabic and
english to fill the form ❖ Location of triage station must be at place to facilitate effective capturing of all individuals
accurately. passing through ER entrance.
❖ Visual alert ATTENTION signage must be posted for reminding symptomatic patients to
Substandard 5.5: inform HCWs.
There is effective capturing
of all individuals passing Staff assigned at the visual triage station must be well trained on the triage process for both
through ER entrance & MERS –CoV & COVID – 19.
visual alert signage is
posted for reminding ❖ Obtain list of staff assigned for visual triage & conduct training according to the schedule.
symptomatic patients to Include all old & new staff as part of refresher IPCCC training activities.
inform HCWs. ❖ Staff assigned at the triage station must be well trained and have proficiency of both Arabic
& English languages.
Substandard 5.6:
❖ Monitor and observe the process during routine daily/ weekly rounds. Provide feedback
Respiratory triage scoring when needed.
form is available for MERS- ❖ Ensure no new staff is assigned at the visual triage station without prior infection control
CoV & COVID - 19 which is training & competency.
up-to-date, approved and
used. (electronic form on
Respiratory triage scoring form:
the system is preferable.

Substandard 5.7:
❖ Up to date & approved triage scoring form is available & used.
Patients who have scored ❖ Electronic scoring system is preferred over manual system in order to minimize the items,
≥4 in either MERS-CoV or avoid cross infection and to ensure efficient record keeping.
COVID-19 , are instructed to ❖ Staff must be capable of completing all items in the checklist in minimum possible time in
wear facemask and perform order to avoid overcrowding at the entrance.
hand hygiene.
❖

378 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Respiratory triage scoring mechanism & Pathway:

Substandard 5.8: ❖ Patients who have scored ≥4 in either MERS-CoV or COVID-19, are instructed to wear
facemask and perform hand hygiene.
If the patients score ≥4 in
❖ If the patients score ≥4 (4 & above) in either MERS-CoV or COVID-19, they are directed
either MERS-CoV or COVID-
19, they are directed safely safely to Respiratory Triage Clinic.
to Respiratory Triage Clinic ❖ If the respirator triage clinic is occupied patients must wait in the designated Respiratory
or Respiratory waiting area. waiting area.
❖ Patients with score 3 & less will follow the normal pathway / common triage.

- ICPs must conduct random inspection at different times to ensure respiratory triage is
active at all times.
- There must be back up if the assigned staff will be away from station during break hours
or any other urgent need etc.

Respiratory Triage Clinic / Respiratory Assessment room :

❖ IC team must ensure availability of designated respiratory Triage Clinic in the ER for clinical
assessment of patients identified from the visual triage station.
Substandard 5.9: ❖ Respiratory triage clinic must have minimal items to facilitate effective disinfection in
between patients.
Designated Respiratory
❖ ER physician must be available to apply the MERS – CoV & COVID – 19 case definitions.
Triage Clinic is available in
the Emergency Department. ❖ If the patients fulfil criteria for suspected MERS – CoV / COVID – 19, they should be
transferred to negative pressure room or single room with HEPA filter for further
management. (MERS – CoV / COVID 19 testing etc)

- IC Team must monitor during daily rounds to ensure all infection control standards are
being followed.
- Evaluate the unit performance during IPCCC audit phase.

Respiratory Waiting Area:

Substandard 5.10:
❖ There must be a dedicated respiratory waiting area with fixed chairs & spatial separation of
Respiratory waiting area is
at least 1.2 meter between each patient.
available with fixed chairs
❖ Respiratory waiting area must be clearly identified with appropriate signage to be used only
and distance at least 1.2
for ARI patients directed from the visual triage stations & awaiting clinical assessment by
meter with availability of
ER physicians.
hand sanitizer, paper tissues
❖ Respiratory waiting area must be equipped with hand rub sanitizer, paper tissues & waste
& foot operated waste
receptacle which is operated by foot. Open household waste receptacles must not be
container.
used in the healthcare setting.

379 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During IPCCC training activities provide training to the staff on the updated case definition of
Substandard 5.11: MERS – CoV & COVID – 19.
Reinforce during daily rounds and evaluate HCW during IPCCC audit phase & provide formal
Written reminders for case feedback on performance.
definition of MERS & COVID
19 are posted & staff are ❖ Ensure updated written case definition reminders are posted in Emergency department at
aware about the updated all appropriate places in ER as staff reminders (Nursing stations, respiratory clinics etc)
case definition and the ❖ Provide personal cards incorporating MERS & COVID - 19 Case definitions for quick
flowchart of MERS-CoV and reference of physicians to apply criteria for suspected case definitions for all patients
COVID-19 . directed from visual triage station with score 4 & above.

It is of utmost importance to ensure that all patients and visitors must practice hand hygiene
and cough etiquette within the hospital in order to ensure clean environment & prevent cross
infection transmission.
Substandard 5.12:
IC team must take responsibility to post appropriate visual alerts in both Arabic & English
Bilingual visual education languages at the entrance of healthcare facilities (emergency rooms, inpatients and
signs for patients and outpatient areas).
visitors on recommended
Hand Hygiene & Respiratory ❖ Posters, banners, electronic screens etc. containing information regarding hand hygiene &
Hygiene/Cough Etiquette Respiratory Hygiene/Cough Etiquette practices.
practices are posted in the ❖ Must be posted at all convenient locations where information can be easily seen and read
emergency department by the patients & visitors.
including respiratory & other
waiting areas. Messages in the visual alerts include the following:

❖ Cover your mouth and nose with a tissue when coughing or sneezing.
❖ Dispose of the tissue in the nearest waste receptacle immediately after use.
❖ Pictoral display on how to wear surgical mask & perform hand hygiene after having contact
with respiratory secretions and contaminated objects or materials

Substandard 5.13:
In order to increase awareness and education of patients and visitors regarding MERS – CoV
Bilingual health education & & COVID – 19, education material must be placed and posted in all patient care & waiting
awareness material for areas.
MERS - CoV & COVID -19 is
available & posted in all ❖ Education material can be in the form of posters, brochures, leaflets, booklets & pamphlets.
appropriate places for ❖ Messages must include clinical features, modes of transmission & prevention strategies to
patients and visitors (e.g be of COVID -19 & MERS – CoV .
Posters, brochures /leaflets,
booklets etc) See the figures posted below.

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 Health care workers in the hospitals are at significant risk of exposure to various types of
infections transmitted either by contact, droplet or airborne route. According to updated
guidelines from Ministry of health, all healthcare facilities should identify and trace all health
Substandard 5.14: care workers who had protected (proper use of PPE) or unprotected (without wearing PPE or
PPE used improperly) exposure to patients with confirmed MERS-CoV infection.
Hospital has log for HCWs
who contact with a ❖ Healthcare workers shall be assessed daily for 14 days post exposure for the development
confirmed case to record of symptoms through the activation of log.
the presence or absence of ❖ IC teams must provide logbook for the staff to be activated after exposure to confirmed
fever, symptoms of acute COVID 19 or MERS-CoV. Case.
respiratory illness, diarrhea, ❖ All HCWs who fulfilled exposure criteria according to infection control assessment must
vomiting or nausea before record presence or absence of fever symptoms of acute respiratory illness, diarrhea,
starting their shift. vomiting or nausea before starting their shift.
❖ Exclusion from work and nasopharyngeal swabbing will depend on the degree and duration
of exposure. (Refer to COVID & MERS guidelines)

An aerosol-generating procedure (AGP) is defined as any medical procedure that can induce
the production of aerosols of various sizes, including small (< 5 microns) particles. AGPs
includes bronchoscopy, sputum induction, intubation and extubation, cardiopulmonary
resuscitation, open suctioning of airways, Ambu bagging,
nebulization therapy etc

Substandard 5.15: As per MERS – CoV guidelines, Precautions to be observed when performing aerosol-
generating procedures, which may be associated with an increased risk of infection
Suspected cases are transmission:
transferred to airborne
isolation room for ❖ Perform procedures in a negative pressure room or single room with HEPA filter
nasopharyngeal swabbing. ❖ Limit the number of persons present in the room to the absolute minimum required
An aerosol generating for the patient’s care and support.
procedure (AGP) should be ❖ Every healthcare worker should wear a fit-tested seal check N95 mask (or an
done in negative pressure alternative respirator if fit testing failed).
room or single room with ❖ Wear eye protection (i.e. goggles or a face shield).
portable HEPA filter, using ❖ Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures
appropriate PPE (N95 mask, require sterile gloves
eye protection, gloves & ❖ Wear an impermeable apron for some procedures with expected high fluid volumes
gown) with minimal possible that might penetrate the gown.
number of staff. ❖ Perform hand hygiene before and after contact with the patient and his or her
surroundings and after PPE removal.

- IC Team must provide training to the relevant staff regarding all infection control
protocols to be followed during aerosol generating procedure (AGP).
- Monitor the practices during daily rounds and evaluate the performance during IPCCC
audit phase.
- Provide formal feedback to the staff & consider for retraining if needed.

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 ❖ In order to ensure the availability of skilled HCWs to be available 24/7 for taking
Substandard 5.16: nasopharyngeal swab of suspected patients or re-swabbing of the confirmed patients, IC
team must obtain the duty schedule of health care workers (Doctors, nurses etc) covering
Nasopharyngeal swabbing 24 hours period.
of suspected or re-swabbing
for confirmed patients is ❖ IC Team must ensure that all HCWs who are assigned to collect specimens should be
performed by trained HCW properly trained on the technique and wear PPE appropriate for aerosol generating
personnel, there must be procedures.
schedule for duty covering
24 hours for the trained ❖ Training must be documented and evidence must be kept in the staff personal files to be
assigned HCWs for presented to external MOH or CBAHI auditors when needed.
nasopharyngeal swabbing.
Refer to MOH COVID Guidelines:
Coronavirus Disease COVID-19 Guidelines, V 2.0 ;Page 18 – 19.

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 Standard – 6 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 6:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 6:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 6:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

390 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 6:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 6:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 6:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 6:7 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

391 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 7 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 7:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 7:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

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 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 7:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

393 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 7:04
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 7:05 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 11. Disposable personal care items are discarded
worker, housekeeping 12. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 7:06 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

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 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 7:07 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

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 HIGH TOUCH SURFACES

396 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 7:08 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 7:09
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

397 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 7:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Housekeeping staff must adhere to Standard Precautions and if required Expanded
Substandard # 7:11 Precautions when performing routine practices of cleaning and following infection control
measures.
Housekeepers are well Routine practices related to environmental cleaning includes:
trained on hand hygiene,
proper use of PPE, methods HAND HYGIENE:
of cleaning & proper & safe
mixing of chemicals. Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

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 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 7:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 7:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 7:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

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 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 7:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 7:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 7:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

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401 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 8:01 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 8:02
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 8:03
in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of
to use large IV solution bottles for preparation & dilution of medications
medication is only done by
Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water
specified for preparation & dilution of medications.
ampoule.
Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

402 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 8:04
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
Substandard # 8:05
future use even on the same patient.
While checking the medication refrigerator, you may find opened prefilled syringe labelled
Needles and syringes
with patient's name & medical record number. This means it is stored for future use on
including vacutainer holders
the same patient.
are used for only one
While checking the medication refrigerator, you find opened prefilled syringe without
patient.
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 8:06 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient.
While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

403 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

After completion of treatment session or any clinical procedure or patient discharge following
must be practiced:
Substandard # 8:07
All remaining single-use items are discarded, even unused ones with intact original wrap
All patient care supplies are (i.e., they cannot be used on other patients or returned to clean areas, such as medical
brought to patient area stores or medication preparation areas etc )
when needed with no
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
excess. Any remaining
items after patient discharge
Visit the medical store and check the stock by random selection. You may find an item with
are considered
contaminated even in their open cover or occasional blood or betadine stain. Such practices are strictly prohibited.
wrapping.
Audit the performance in IPCCC audit phase:
Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

- Maintaining the integrity of sterile equipment and solutions is extremely important to

Substandard # 8:08 prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
Sterile equipment and urinary catheter).
solutions are assembled - If the sterile items are assembled long before the procedure, there are chances of
immediately prior to use. contamination from environment such as dust etc.
- A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
the transfer of microorganisms and reduce the potential for infections.
- Principles of sterile technique help control and prevent infection, prevent the transmission
of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.
As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

404 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

Substandard # 8:09 A sterile object becomes non-sterile when touched by a non-sterile object.
Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
Sterile to sterile rule is transfer forceps.
applied during any aseptic Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
procedure. Non-sterile items should not cross over the sterile field. For example, a non-sterile person
should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

405 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 8:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 8:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

Substandard # 8:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

406 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 8:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
claim that each device is exclusively allocated only for one patient.
Substandard # 8:14
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
• Patient's name & medical record number to be used exclusively for one patient.
insulin pens) are used only
• Date of the first use to be discarded after expiration of the reuse life recommended
for single patient.
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 8:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.
Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
Substandard # 8:16
IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
IV solution bottles are only
than the self-sealed rubber cap.
accessed through the self-
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
sealed rubber cap.
Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

407 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 8:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7
days, but not more Following key points must be followed for replacement of IV sets in order to avoid risk of
frequently than 96-hour infection from frequent changing of IV sets:
intervals.
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 8:18
Rationale: Extending the duration of use permits considerable cost savings to hospitals
IV sets that are used to without significant increase in the risk of healthcare-associated BSI with peripheral IVs
administer blood, blood
products, lipid emulsions, or In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
dextrose/amino acid TPN acid TPN solutions, check that IV delivery systems are continuously connected and
solutions are replaced within changed within 24 hours of initiating the infusion.
24 hours of initiating the During daily rounds, observe that IV administration sets are labelled with dates & times of
infusion. initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
(hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 8:19 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

408 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 According to The Joint Commission, there are four chief aspects of the aseptic technique:
Substandard # 8:20 barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Maximum sterile barrier protect the patient from the transfer of pathogens from a healthcare worker, from the
precautions is applied environment, or from both. Some barriers used in aseptic technique include:
during any interventional
procedure, including cap, - Sterile gloves
mask, sterile gown, sterile - Sterile gowns
gloves, and sterile full-body - Masks for the patient and healthcare provider
drape. - Sterile drapes etc
Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
Substandard # 8:21 central line etc.
Traffic should be kept minimum once the sterile field has been established.
Traffic should be kept
minimum once the sterile Only necessary health personnel should be at the procedure. The more people present, the
field has been established. more opportunities for harmful bacteria to cause contamination.
Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

Recognized routes for contamination of catheters:

Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with
colonization of the catheter tip; this is the most common route of infection for short-term catheters
Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices.
Catheters might become hematogenously seeded from another focus of infection.
Infusate contamination might lead to CRBSI.

409 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 09 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

P. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
Q. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
R. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xi. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xii. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

410 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Provide education to the staff regarding importance of isolation precautions during IPCCC training
Substandard # 9:01 activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis for
isolation precautions patients under isolation.
are available in the Use preferably isolation precautions signs provided by GDIPC.
unit & used Must be placed / posted on door only if occupied by patient.
appropriately. 02 types of isolation precaution signs must be available in the unit.
Isolation signs must - Isolation precaution signs for units to be posted on doors if the isolation room is
be : 1) Clear and occupied by patients with diseases transmitted either by contact, droplet or airborne
visible for HCWs and route.
visitors 2) Bilingual (in - Isolation Transportation cards for transportation of patients to other departments as
Arabic & English). 3) needed.
Color coded and
compatible with Contact isolation Precautions must be used together with standard precautions:
diagnosis (Examples:
contact: green, Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
airborne: blue, and infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
droplet: pink or red) The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

411 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Precautions must be used together with standard precautions. Droplet
Substandard # 9:02 Precautions are intended to reduce the risk of droplet transmission of infectious agents from close
contact (exposure to eyes, nose and mouth) with large-particle droplets
Appropriate isolation
transportation cards / Should be Initiated and maintained when there is suspected or confirmed diagnosis of an
sings are available in infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
the department & Use a single room. A negative air pressure room is not indicated.
used while Place a droplet sign on the door.
transporting patients Droplet isolation signage must be color coded (e.g., orange) and must be available in both
under transmission- English and Arabic languages.
based precautions to
other department as Airborne isolation precautions must be used together with standard precautions
needed. Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases that
are spread via the airborne route.
Transport Isolation Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
signs must be : 1) disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Clear and visible for Use a single room with a negative air pressure system (AIIR)
HCWs and visitors 2) Place the Airborne Isolation sign on the door.
Bilingual (in Arabic & Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English). 3) Color English and Arabic languages. b. Keep door closed at all times except when entering or
coded and compatible leaving the room.
with diagnosis
(Examples: contact: Patient Transportation:
green, airborne: blue,
and droplet: pink or Patient Transportation isolation signs must be used while transporting patients under
red) and selecting low transmission-based precautions to other department as needed.
traffic time & route.
Transport of isolated patients should be limited to essential purposes only, such as diagnostic
and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
should be worn to reduce potential contamination of the environment and the spread of
infection.
Isolation instructions must be clearly highlighted on the transmission-based precaution card
(isolation signs) while transporting patients under transmission-based precautions to other
department ( e.g radiology).

IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 9:03 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
Log book for exposure entry into isolation room for any task.
is available for any Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
potentially harmful Logbook must specify the name, designation / job category, Duration of exposure (Time in /
infectious exposures Time out) & type of PPE used.
as per exposure Appropriately used logbook will generate information needed in case of outbreaks etc
policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. before gaining entry into isolation room.
MERS-CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

412 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use items are those that are intended for single use only, on an individual patient for a
single procedure, and then should be discarded. It should not be reprocessed or reused again
Substandard # 9:04 even on the same patient.
Single use or
Provide training and orientation to staff regarding patient care equipment to be used for isolation
dedicated non-critical
rooms during daily/weekly rounds:
patient care equipment
(e.g., stethoscope,
Following instructions must be given:
pressure cuff, etc.) are
used for the isolation
If single use non critical items are used for isolation rooms, they must be immediately
room.
discarded after use. Single use items must never be kept to be reused for the same patient or
next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be disinfected
after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc

Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation room
is used for another isolation room or another area.

Transfer of patients under isolation precautions must be restricted to medically necessary

purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
Substandard # 9:05
procedures that cannot be performed in the patient’s room.
Facility limits
Provide training and orientation to staff the transfer rules related to patient transportation under
movement of patients
isolation precautions. Observe if unit is following the policy.
on isolation
Precautions outside of
Following instructions must be given:
their room except for
medically necessary
Receiving unit or facility is informed beforehand about the required isolation precautions to be
purposes.
taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
Substandard # 9:06
unit etc.
If transfer of patient
It is important that HCWs in the receiving unit have received prior training on how to safely
under isolation is
handle patients under isolation precautions and how to appropriately use PPE according to type
required, the receiving
of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit tested
unit or facility is
for N-95 mask and trained well on how to don & doff after use.
informed about the
required isolation
Transferring the Patient to Another Facility:
precautions and
availability of
Inform the receiving facility and the emergency vehicle personnel in advance about the type of
appropriate PPE is
isolation and standard precautions (PPE) required.
ensured.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

413 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9:07 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation.
While transferring
patients under Key Points include:
droplet/airborne
isolation precaution, Explain to the patient the need for the protective apparel that he/she is required to wear.
patient should wear a Patient must wear mask during transportation (droplet & airborne isolation)
surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory Isolation instructions must highlight the transmission-based precaution card ( isolation signs)
hygiene and cough needed while transporting patients under transmission-based precautions to other department (
etiquette. e.g radiology).
-

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or
Substandard # 9:8 more classes of antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to
Contact isolation most available antimicrobial agents.
precautions are
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci
initiated for patients
(VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
infected or colonized
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms.
Skin lesions and Proper attention & care to these pathogens is critical to curtail further emergence of these
infected or colonized highly resistant organisms.
areas of patient's body
Infection refers to the entry into and multiplication of an infectious agent in the tissues of the
should be contained
host and the tissue damage resulting in apparent or unapparent changes in the host.
and covered.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and covered
in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

414 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training to the staff for rules to be followed for patient transportation under contact isolation
Substandard # 9:09 precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

For transport patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin Leak-proof dressing should be used to reduce potential contamination of the environment and
lesions and infected or the spread of infection.
colonized areas of the Dress wounds with impervious dressings as required.
patient’s body with Dress the patient in a clean gown.
clean bandages and Cover the patient with a clean sheet.
clean linens. Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

In order to avoid potential risk of acquiring infection visitors should be strictly limited for
airborne isolation cases.
As per standards, some exemptions may be considered on a case to case basis i.e visitors may
be allowed to enter the isolation room if he / she fulfils the following criteria e.g mothers of
babies etc
Substandard 09:10
- Duration of stay will be minimum for few minutes only.
Visitors - Visitors must seek permission from nursing station.
should be strictly - Clear instructions must be provided to visitors in their language before entering into an isolation
limited for airborne room.
isolation cases. - Visitors must be fully compliant with the required PPE i.e visitors will wear same type of PPE
Exemptions may be and follows same protocols as any HCWs before entering isolation rooms.
considered on a case - Proper education, counselling, and monitoring should be provided to the visitors before
to case basis only for entering the airborne infection isolation room.
few minutes after - Nursing staff must keep records of visitor’s education & instructions as evidence to be
having permission presented to external auditors when requested.
from nursing station
and after receiving Educate the staff regarding visitor’s policy & ensure during daily/weekly rounds if its fully
proper instructions implemented:
before entering into an
isolation room and - Observe and ask staff about the visitors if isolation room occupied by patient.
within compliance with - Ask about the evidence of education & documentation in log book.
the required PPE. - Observe when possible any visitor entering or coming out of isolation room if compliant with
instructions.
- Sometimes visitors are not donning PPE appropriately. Gowns is not tied & masks is worn
inappropriately.
- It is also common observation to see visitors coming out of AIIR with all PPE and removing PPE
abruptly without practicing hand hygiene.
- Such practices would pose risk of acquiring infection. Nursing staff must be fulling adherent
with visitor’s policy for isolated patients.

Audit the unit performance during IPCCC audit phase and provide formal feedback.

415 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Airborne Infection Isolation Rooms (AIIRs)
Airborne Infection Isolation rooms (AIIRs), commonly called negative pressure rooms, are single-occupancy patient care spaces
designed to isolate patients with airborne pathogens to a safe containment area. AIIRs provide negative pressure in the room (so
that air flows under the gap into the room) with a pressure differential of >-2.5 Pa (Pascal) or >- 0.01” water gauge; an air flow
rate of >12 air changes per hour (ACH) and direct exhaust air from the room to the outside of the building; or recirculation of air
through a HEPA filter before returning to circulation.
AIIRs are designed in such a way so that no airborne particulates escape into other areas within the healthcare setting. Exhaust
from these rooms is not recirculated in the HVAC system. Instead, exhaust air typically moves in dedicated ductwork to ventilation
stacks on the rooftop, where atmospheric air provides sufficient dilution to make the resulting air safe.
For the safety of healthcare workers, patients, and visitors, negative pressure rooms occupied by patients requiring airborne
isolation must be checked daily.
Sub standards Explanation
According to Ministry of Health guidelines, there must be at least one Airborne Infection
Substandard 10.01:
Isolation Room for every 8 beds. (e.g 1-8 beds 1 AIIRS, 16 beds 2 AIIRs, 24 beds 3
At least one AIIR for each 8 AIIRs & so on)
beds. . IPC team must send request to higher administration if there is no AIIRs in the unit to fulfil
the requirement.

Provide training and orientation to the staff regarding general specification to be met for
all negative pressure isolation rooms. Monitor different parameters during routine
infection control rounds and observe If within recommended ranges. Evaluate the
performance of unit during IPCCC audit phase & provide formal feedback.
Substandard 10.02 Nurse in charge must receive clear instructions to keep all necessary records in the unit
to be presented if requested from external auditors.
Central air condition or
separate concealed unit is This includes all routine maintenance records and actions taken in terms of deranged
the source of conditioned environmental control parameters or malfunctioning.
fresh air. Maintenance staff must be consulted to provide detailed evidence of all these
specifications and each unit & IC team must keep copy of records.
Units must hard to keep all parameters within normal range and well prepared to provide
documented evidence for any external audit visit.

Following specifications must be met for all AIIRs:

Substandard 10.03:
- There must be 100% fresh air supply from central AC or concealed separate unit.
- Return of air is not permitted & source of conditioned fresh air must be only via these 02
Air exhausted from
sources. (Central air condition or separate concealed unit).
bathroom must be
-
exhausted 100% outside
through HEPA filter.
- Air from bathrooms must be exhausted 100 % outside through High‐Efficiency Particulate
Air (HEPA) filters.
- The exhaust air ducts MUST be independent of the building exhaust air system.

416 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - HEPA filter should be changed on regular basis and according to manufacturer’s
instructions.
Substandard 10.04: - Unit must keep records of all documents that prove the maintenance and changing of
HEPA filter (as recommended)
HEPA filter is changed on
regular basis and according
to manufacturer's Rationale:
recommendations.

High-efficiency particulate air (HEPA) filter is an air filter that removes >99.97% of particles
>0.3um at a specified flow rate of air. HEPA filters may be integrated into the central air
handling systems, installed at the point of use above the ceiling of a room, or used as
portable units.
Substandard 10.05:
[

During rounds ICPs must ensure that each AIIR is equipped with a fixed monitor for
There is monitor for continuous monitoring of environmental control parameters and are in functional condition.
continuous monitoring of
pressure difference at
negative pressure room Monitor must exhibit following specifications and records following parameters:
having audio visual alarming
system when the ventilation
system failed. Negative pressure (-2.5 pascal or more)
>12 air changes per hour.
Substandard 10.06:
Has an audio-visual alarm system in case of ventilation system failure. There must be
Isolation Room is Visible red flashing lights and audible sound comes from the monitor.
maintained at negative
pressure (-2.5 pascal or Fixed monitor must be installed outside each AIIRs in the corridor to monitor the pressure
more) with respect to difference between the room and corridor.
corridors.
Test the monitor to ensure that alarm is working or no, by keeping the door of AIIRs open
for few seconds. Hold the room door open. After the time delay, the audible and visual
Substandard 10.07: alarm should annunciate.

Isolation Room is Verify that the monitor is correctly reading the pressure. While the door is held open, the
maintained with >12 air pressure reading should be at or near 0" water gauge.
changes per hour.
Use a manual device to monitor pressure differentials in rooms where no monitor is
installed.

417 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During daily / weekly rounds ICPs must ensure that policy for regular monitoring of negative
pressure difference is fully implemented. If any breaches unit head must be informed.
Monitor and evaluate unit performance in IPCCC audit phase using IPCCC tool.

❖ Unit must keep record of all documents as evidence of regular monitoring of negative
pressure difference of AIIRs for at least last 3 months:

❖ Daily when in use (i.e., a patient is isolated inside) .

Substandard 10.08: ❖ Weekly when not in use (i.e., no patient is isolated).
❖ Monthly check by biomedical personals

Records for routine

monitoring of pressure Responsibility of Nursing staff:
gradients (daily if a patient
is isolated inside, weekly
when not in use and Negative pressure rooms in use:
monthly by biomedical
department).
Nursing staff must conduct visual checks for the direction of air flow (using flutter strips)
on all rooms where patients are in airborne isolation for query and confirmed airborne
transmissible diseases (e.g., Pulmonary Mycobacterium tuberculosis, measles, chicken
pox) when patients are in this room.
Prior to admitting patients needing airborne isolation, check and ensure that negative
pressure rooms are functioning well. For those designated isolation rooms without
monitor, call maintenance to check if the room is maintaining its negative pressure.
Follow the procedure of this policy in any room that fails inspection. d. All documentation
must be sent to the IP&C Department.

B. Negative Pressure Ventilation Failure:

Unit staff must respond to negative pressure failure.

Nursing staff will lace a surgical mask on the patient in airborne isolation.
Keep the door closed at all times.
Notify the Utilities & Maintenance (U&M) Department of the location and problem & IC
Department
If U&M declares the occupied room is no longer maintaining negative pressure, patient
must be transferred to another negative pressure room immediately.
Put a surgical mask on the patient before transporting.

418 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 An aerosol-generating procedure (AGP) is defined as any medical procedure that can induce
the production of aerosols of various sizes, including small (< 5 microns) Particles. AGPs
includes bronchoscopy, sputum induction, intubation and extubation,cardiopulmonary
Substandard 10.09: resuscitation, open suctioning of airways, Ambu bagging,nebulization therapy, high frequency
oscillation ventilation and Bilevel Positive Airway Pressure ventilation – BiPAP
Any aerosol generating
procedure (AGP) should be Precautions to be observed when performing aerosol- generating procedures, which may be
done in negative pressure associated with an increased risk of infection transmission:
room or single room with
portable HEPA filter using Perform procedures in a negative pressure room or single room with HEPA filter
appropriate PPE (N95 mask, Limit the number of persons present in the room to the absolute minimum required for the
eye protection, gloves & patient’s care and support.
gown) with possible minimal Wear N95 masks: Every healthcare worker should wear a fit-tested seal check N95 mask
number of staff. (or an alternative respirator if fit testing failed).
Wear eye protection (i.e. goggles or a face shield).
Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures require
sterile gloves
Wear an impermeable apron for some procedures with expected high fluid volumes that
might penetrate the gown.
Perform hand hygiene before and after contact with the patient and his or her surroundings
and after PPE removal.

Train & observe the following during daily/weekly rounds:

❖ HCWs performing any aerosol generating Procedure (AGPs) like CPR, intubation,
extubation, suctioning etc for any suspected or confirmed COVID – 19 or MERS- CoV
cases. (If possible to observe the real situation / scenario).
❖ Observe the type of PPE used by HCWs while preparing for AGPs.
❖ Observe if AGPs are performed in negative pressure room or single room with HEPA filter.
❖ Ask about the total number of staff to be present during procedure. Ensure minimum
number of staff are present who are absolutely necessary for specific procedure / task.

Evaluate the staff performance during IPCCC audit phase & provide formal feedback.

419 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 AIIRs MUST fulfill the following MOH specifications for standard isolation
rooms:
Substandard 10.10:
FLOORS, WALLS & CEILING:
AIIRs fulfill all MOH
specifications for standard Minimal openings in the walls, floors and ceiling that are well sealed and airtight.
isolation rooms + windows Smooth, one piece without any cracks or decorative fine parts.
are sealed and fixed (i.e., They should be covered with such paints so as to withstand repeated cleaning
could not be opened/)
and disinfection by approved disinfectants.
openings in walls and
ceiling are sealed and
airtight / doors are properly DOORS:
designed and well-sealed.
Doors are properly designed and well-sealed.
The door should open to the inside.
Substandard 10.11:
Extend completely to the floor
Must have auto closure device / auto closure mechanism.
The door should open to the
inside, has auto closure
WINDOWS:
device, well-sealed and
extend completely to the
Windows are sealed and fixed (i.e., could not be opened)
floor.
This will ensure to maintain continuous negative pressure differentials inside
airborne infection isolation rooms.
Substandard 10.12:
CURTAINS:
Windows are completely After discharge, transfer or death of patient under airborne precautions, curtains
sealed and fixed (i.e., could must be changed after terminal cleaning of isolation rooms
not be opened).
HAND HYGIENE FACILITY:
Substandard 10.13:
i) Hand Washing:
Curtains must be changed Following are required inside patients’ room
between patients. Hand Washing Sink
Plain and antimicrobial soap
Paper towels
Substandard 10.14: Available at easily accessible location

Hand washing facilities and j) Hand Rubbing:

supplies (sinks / plain and
antimicrobial soap / paper Alcohol - based hand rub dispensers
Available at easily accessible location for staff to practice 5 moments of hand hygiene & to
towels, Alcohol - based
perform hand hygiene after doffing of PPE items.
hand rub dispensers) are
available & easily PPE TROLLEY:
accessible.
Ensure availability of PPE trolley OUTSIDE AIIRs.
Well organized and well maintained.
Substandard 10.15: Appropriately cleaned external surfaces and internal surfaces of drawers ; free from
dust and any other visible contamination.
Trolley that contains the All required PPE items MUST available (Gowns, Gloves, N – 95 respirators. Face
proper PPEs is available. shields / goggles etc)
PPE items are organized in a way to facilitate staff while donning PPE.
PPE or any other medical supply must never be kept inside isolation rooms to avoid
risk of contamination.

420 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often
contain large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred
to patients or healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must
follow Standard Precautions at all times. To reduce the possibility of occupational risks of infection transmission and/or exposure,
laundry workers should focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal protective equipment
(PPE). Removal of foreign objects from soiled linen. 4. To restore soiled linen to usable condition, washing, bleaching, rinsing,
and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 11:01 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 11:02 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 11:03 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 11:04 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

421 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11:05 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 11:06 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Substandard # 11:07 Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Linen carts are covered and Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
not overfilled. to 10 inches off the floor.
Linen from isolation rooms is considered regular soiled linen.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

422 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
Substandard # 12:01 - Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)
All types of waste
containers are Specification of Items:
available in sufficient
number and placed in Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
easily accessible sites. with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

423 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 12:02 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 12:03
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 12:04 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 12:05 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

424 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 12:06 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 13 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 13:01
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 13:02 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to
Local records for corrective interventions which are taken if readings are not matching the
70%).
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.

425 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
Substandard # 13:03
- Recommended temperature Range is: 22 - 24°C
Away from air vents and - Recommended relative Humidity is up to 70%.
well ventilated.
Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.
Substandard # 13:04
Infection control team must provide training and reorientation about all specifications to be
Storage shelves are 40 followed for the maintenance of departmental medical stores.
cm from the ceiling, 20
Train on following specifications / key points and observe in daily / weekly rounds if unit is
cm from the floor, and 5
adherent with recommendations or not.
cm from the outside wall.
Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Substandard # 13:05
Specifications of Storage Shelves:
Storage shelves made
Storage shelves are made of easily cleanable material
from easily cleanable
material (e.g., fenestrated (e.g., fenestrated stainless steel, Aluminium or hard plastic).
stainless steel, Aluminium Storage shelves are placed following these specifications.
or hard plastic)
- 40 cm from the ceiling
- 20 cm from the floor
Substandard # 13:06 - 5 cm from the wall

Sterile and clean items If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
completely separated hard plastic).
from personal items &
foods and drinks. Ensure that only sterile and clean items are allowed in the medical stores.
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 13:07 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
original cardboard shipping boxes.
Substandard # 13:08
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes
Items not kept in original are placed inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
boxes. Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile
and clean supplies can be kept inside medical stores (e.g., small boxes of medical supplies:
clean gloves, surgical masks, syringes …etc.) but should be discarded immediately when
the box has been emptied.

426 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
Substandard # 13:09 discarded)
If any stained item is found it would most likely reflect that item was restocked after being
No expired items, broken brought from patient care areas which is against the rules of aseptic technique. Such
packs or packs with practices must be strictly prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in
order to ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit
phase.
Provide formal feedback on unit & staff performance

Standard - 14 Emergency Medical Services (EMS) /Ambulance Services

Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that
provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care.
Ambulance service is also used for interhospital transportation of patients e.g COVID – 19 & MERS-CoV cases to the designated
hospitals etc and for other medical reasons.
Vehicular transportation of such patients pose risks including vehicle contamination and infection transmission. So appropriate
infection control protocols must be followed for ambulance staff & appropriate disinfection of vehicle must be ensured in order to
prevent risk of acquiring infection.
Emergency Medical Service (EMS) is at the front line of medical care, having high risk of exposure to patients with known or
unknown infectious diseases.
Emerging pathogens and antimicrobial-resistant strains are major problems facing all healthcare providers, including EMS
providers. 3. The ambulance is a mobile patient care environment. It is generally divided into two spaces: the driver area and the
patient care area. Patient care equipment are stored in enclosed compartments in the ambulance. Air circulation in the vehicle is
generally rapid, low-velocity airflow. Some ambulances have built-in high-efficiency particulate air (HEPA) filters which vary among
ambulance manufacturers. There is also an exhaust fan to assist in air exchange. These air handling systems basically place EMS
providers at low-risk for Mycobacterium Tuberculosis (MTB). The floor and walls of the ambulance are constructed for ease of
cleaning.

Sub standards Explanation

IC team must ensure that appropriate PPE supply & hand hygiene supply is available (Hand
sanitizers etc) available and readily accessible for the EMS/ambulance staff.

Substandard 14.1: For transportation of COVID – 19 or MERS CoV patients following key points must be
considered by IC team while conducting the training activities for Ambulance / EMS staff
Sufficient and appropriate based on updated MOH guidelines:
PPE are available and readily
accessible to HCPs.. - Ambulance staff providing care for or accompanying suspected or confirmed COVID-19
patients in the patient section of the ambulance should adhere to standard and
transmission-based precautions including required PPE.
Substandard 14.2: - EMS / ambulance staff must receive training on standard and transmission-based
precautions i.e airborne. Droplet, & contact etc
Hand hygiene supply is - In situations where personnel driving ambulances used to transport patients are involved in
available. moving patients onto stretchers or other forms of direct care, it is recommended that they
strictly use recommended PPE (including N95 mask and googles).
- IC must ensure that ambulance staff are also fit tested for N-95 mask and they are trained
on appropriate technique of donning & doffing of N-95 respirator and hand hygiene.

427 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - After patient transfer, appropriate cleaning and disinfection of ambulance must be
done.
- IC team must train the staff on the appropriate disinfection of the vehicle.

Following points must be emphasized:

Substandard 14.3:

There is a disinfection
❖ Prior to cleaning the ambulance, staff should don disposable gowns and gloves. Eye/face
activity log including all
protection PPE (goggles, face shields or facemasks) are recommended if the cleaning
items for disinfection in the
procedure will generate splashes or sprays.
ambulance.
❖ After the patient has left and prior to cleaning, exhaust the air within the patient care
compartment by opening the doors and windows of the vehicle while ventilation system
is running. This should be done outdoors and away from pedestrian traffic.

Substandard 14.4: ❖ Terminal cleaning should be done using manual method and /or hydrogen peroxide dry
mist or vapour.
Disinfection of all surfaces
is done after each use. ❖ Ambulance must be cleaned and disinfected in such a way to ensure that all contaminated
surfaces including stretcher, rails, control panels, floors, walls and work surfaces are
thoroughly cleansed with approved disinfectant and in accordance with manufacturer’s
instructions.
❖ IC team must provide a cleaning and disinfection checklist to the ambulance staff for
documentation of terminal cleaning process after each use.

❖ IC team must provide at least one spill kit to the ambulance staff for dealing with
Substandard 14.5: accidental spill of blood & body fluids.
❖ Staff must be well trained on how to use the spill kit in emergency situations.
There is at least one spill kit ❖ Explain its importance and hazards if not done according to recommendations. Video
available in the ambulance. demonstration would be more beneficial.
❖ Refer to substandard 6,3 --- for more details.

428 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 15 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 15:01 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

429 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 15:02
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

430 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 15:03
prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers &
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
visitors strictly adhere
droplets can also be inhaled into the lungs.
to the principles of
Recent studies indicate that people who are infected but do not have symptoms likely also play a
social distancing,
role in the spread of COVID-19. Since people can spread the virus before they know they are
cough etiquette and
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
frequent hand hygiene
have any symptoms.
during duty hours /
visiting hospital.
Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

431 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 15:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc). HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, transportation of supply etc

432 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
433 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
434 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

435 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
HAEMODIALYSIS UNIT (HDU)

Haemodialysis patients with end-stage renal failure are vulnerable

to infections for many reasons including the immunocompromised state intrinsic to

end- stage renal disease (ESRD), the high prevalence of diabetes, exposure to other
patients in the HD facility three times per week, frequent hospitalization, and the
invasiveness of the HD procedure.

Hence, strict implementation of infection control procedures including hand hygiene,

wearing personal protective equipment (PPE) to prevent the transmission of infection
during patient care, practicing aseptic technique, isolation precautions & environmental
measures etc. would play a significant role in ensuring patient & staff safety.

436 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IPCCC - STANDARDS IN
HAEMODIALYSIS UNIT (HDU)
POLICIES & PROCEDURES

EDUCATION & TRAINING

HAND HYGIENE
HEMODIALYSIS UNIT (HDU)

PERSONAL PROTECTIVE EQUIPMENT (PPE)

RESPIRATORY TRIAGE

UNIT DESIGN

HEMODIALYSIS PATIENTS & STAFF HEALTH

HEMODIALYSIS WATER QUALITY MONITORING

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

AIRNORNE INFECTION ISOLATION ROOMS (AIIRs)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLIES

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

437 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HAEMODIALYSIS UNIT (HDU)
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

438 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation
Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.

Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Substandard # 2:1
IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
joining work & issue a BICSL ID which should be renewed ever 02 years.
Healthcare Personnel Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
(HCP) receive hours as an evidence of basic infection control training to be presented to any external /internal
orientation and audit visit for purpose of verification.
training on Basic
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
Infection Control Skills
every 2 years by visiting infection control department.
from IC department
maximum within 1
months of joining
work & a BICSL card
is issued which is Components of BICSL includes:
renewed every 2
years. - HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

439 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.
Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
Substandard # 2:2 patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Healthcare Personnel knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
(HCP) receive job-
specific training on Infection Prevention & control department MUST provide education & training to all health care
infection prevention personnel on infection control best practices specific to their job as follows:
policies and
procedures upon Infection control Training specific to area of work must be provided initially upon hiring before
hiring and at least starting their duty.
once annually. Continuous education on relevant infection control policies and procedures must be conducted
at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

440 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters.

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

441 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Patients with end-stage renal failure on haemodialysis (HD) maintenance are vulnerable to infections for many
reasons including the immunosuppressed state intrinsic to end- stage renal disease (ESRD); the high
prevalence of diabetes; exposure to other patients in the HD facility three times per week; frequent
hospitalization; and, the invasiveness of the HD procedure.
Substandard # 2:4
Patients who undergo dialysis treatment have an increased risk for getting an infection because the process of
haemodialysis requires frequent use of catheters or insertion of needles to access the bloodstream.
Unit provides infection Haemodialysis patients have weakened immune systems, which increase their risk for infection, and they
control health require frequent hospitalizations and surgery where they might acquire an infection. Therefore, patient and
education to the family education is of utmost importance to ensure adherence to appropriate infection control precautions &
Patients. families & alert the staff if there are any signs of infections or any other unusual presentation.
Visitors.
IC team must develop the health education material in the form of brochures ,booklets etc in
Arabic & English highlighting important preventive measures to be taken at home. including
catheter site care, showering etc
Patient Health Education content may include basic infection control measure like importance
of hand hygiene, care of catheter site etc
Education imparted to the patients and visitors must be structured and documented in
patient’s files.

Areas for Patient Education:

Patients with catheters:

Hand hygiene
General access care at home (e.g., bathing with a catheter)
Signs and symptoms of infection (Redness Pus or unusual drainage Swelling
How to respond if problems with catheter develop outside of the dialysis center
Risks associated with catheters/importance of permanent access
Basic infection control practices during catheter accessing process (as a means to engage
patients)

Patients with other access types:

Hand hygiene
Washing the access site prior to treatment
General access care at home (e.g., don’t scratch or pick at the site
Signs and symptoms of infection
How to respond if problems with access develop outside of the dialysis center
Basic infection control practices during cannulation process (as a means to engage patients

Infection Control department MUST also provide infection control health education for common
health issues & risks to patients, families and visitors.

IC team must ensure the availability of the following according to the specific unit / area:

Bilingual infection control health education & awareness material must be designed / formulated
to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
booklets, leaflets etc. containing information easy to understand with help of pictorial display.
The educational material must be posted and available in all patient care areas, waiting areas at
the place easily seen and readable by families and visitors. e,g hand hygiene, cough etiquette,
COVID 19 & MERS educational material, etc.

442 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Patients, families & visitors must be well aware about importance of hand hygiene, identifying
and notifying disease symptoms to HCWs & social distancing in COVID era etc

Visitors are educated on precautions to be taken while being in the surrounding of patient , the
importance of hand hygiene and the required isolation precautions etc education must be
provided on how to don / doff PPE and perform hand hygiene before entering isolation room.
Sitters / visitors must adhere to the unit personnel’s recommendations / instructions regarding
infection prevention requirements (e.g.PPE use, hand hygiene, visiting timings).
Sitters / Families must receive instructions regarding the infection prevention measures & unit
staff must observe & rectify the practices.

443 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HEMODIALYSIS PATIENT & FAMILY EDUCATION

444 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, At least one handwashing sink MUST be available for every 4 chair/beds
(one for every 4 Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
chair/beds) and tap if hands free operation or open the tap to check for hot & cold water supply)
easily accessible. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying

Substandard # 3:2 Hand Rub Dispensers:

Alcohol - based - Check the availability of hand rub dispensers as per requirements:
hand rub dispensers One dispenser per patient's bed/ chair
are available in One at every nursing station
adequate numbers One any service areas e.g medication room, storage area etc
(one dispenser per
patient's bed/chair
one at every nursing - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
station and at any entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
service areas).
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

- At least one Alcohol - based hand rub dispensers are provided in the waiting areas.
Substandard # 3:3

Alcohol - based ❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
hand rub dispensers ❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.
are available in the
waiting areas.

445 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Substandard # 3:2
Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
Health care
microorganisms without the need for an exogenous source of water and requiring no rinsing or
professionals (HCP)
drying with towels or other devices.
demonstrate
appropriate Indications:
technique for hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
rubbing and hand body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing. Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and
/or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
446 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.

❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
posted at appropriate places.
Substandard # 3:3
- WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
Visual alerts are - How to hand wash poster beside ach hand washing sink
available: WHO 5 - How to handrub poster beside each hand hygiene dispenser
moments, how to -
do hand rub, how to WHO five moments of hand hygiene :
do hand wash.
1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

447 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
448 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
449 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room but
are available and readily not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will interfere
accessible to HCP. with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Powered air purifying respirators (PAPRs) for bearded staff etc

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2
masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock rooms.
N - 95 respirators are
Check if all types and sizes are available according to fit test result of each healthcare
available in different types and
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)
sizes.

450 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

451 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection prevention & control measures recommended for HDU aims to prevent patient to
patient transmission of infectious agents within the haemodialysis unit environment.
Substandard 4.4 Transmission of infection may occur directly or indirectly via contaminated devices,
equipment, supplies, environmental surfaces or hands of dialysis personnel. Times
Clean gown is worn during during which exposure is most likely to occur include initiation and termination of dialysis
splash producing procedures. and during reprocessing, cleaning, or disinfection procedures. So it is imperative to
e.g. connection and follow strict infection control standards while provide care to the patient.
disconnection
IC Team must provide education & training to the dialysis unit staff regarding
appropriate selection of PPE during different type of procedures including the
technique for donning & doffing the PPE. This will ensure staff safety and reduce
Substandard 4.5 misuse, overuse or underuse of personal protective equipment.

Sterile gloves are worn during Monitor the staff practices during daily / weekly rounds and provide feedback if any
connection and disconnection. breach of practice is being observed.
As part of IPCCC audit phase, assess competency assessment of staff and provide
formal feedback.
Consider for retraining if needed.

Substandard 4.6 Key components of training must include following:

Clean gloves are worn during ❖ Staff must don a clean gown during procedure with risk of splashes like connection &
contact with patient and disconnection of haemodialysis blood lines.
his/her surroundings. ❖ Sterile gloves are worn during connection and disconnection as an extra precaution to
avoid risk of infection.
❖ Clean gloves are worn during contact with patient and his/her surroundings.
❖ Gloves are removed immediately after use, and hand hygiene is performed immediately.
❖ All types of personal protective equipment are removed before leaving the patient area.
Substandard 4.7 Staff must not leave the patient station with PPE. This would result in contamination of
environment.
Gloves are removed
immediately after use, and
Appropriate PPE Personal Protective Equipment selection & use:
hand hygiene is performed
immediately.
Gloves are usually worn when caring for a patient or touching the patient's equipment

In general, gloves should be removed and hand hygiene performed when:

Substandard 4.8 - Leaving the immediate patient dialysis station

- In-between patients
All types of personal protective - Become soiled or torn
equipment are removed before - Become contaminated (i.e. having contact with biohazardous waste or
leaving the patient area. waste containers)

A fluid resistant gowns, masks and eye protection or face shields should be
worn when doing procedures with possibilities of blood or body fluid splash
or spatter:

- Initiation & termination of dialysis session

- Injection into bloodlines
- Troubleshooting the patient’s vascular access
- Removing disposable supplies and cleaning of the
- dialysis station

https://www.youtube.com/watch?v=ubxX9ZUJz68

452 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Substandard # 4:9 Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

Staff use personal protective
equipment appropriately (e.g.
❖ Contact: Appropriate PPE – Gown & Gloves
donning and doffing)
❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
https://youtu.be/H4jQUBAlBrI Perform hand hygiene.
Watch Video How to safely put Remove surgical mask.
on PPE Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

453 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

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455 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
456 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
457 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 5 Respiratory Triage

Coronaviruses (CoV) are a large family of RNA viruses that cause illnesses ranging from the common cold to more severe
diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). ).

The new strain of coronavirus was identified in December 2019 in Wuhan city. The World Health Organization (WHO) has named
the disease associated with SARS-CoV-2 infections as Corona “COVID-19”. is a zoonotic pathogen with possible spillover directly
from wildlife or via intermediate animal hosts or their products. Sustained human-to-human transmission has been confirmed in
China where numerous healthcare workers have been infected in clinical settings with overt clinical illness and fatalities.
However, there is not much information about SARS-CoV-2 to draw definitive conclusions about transmission mode,
Transmission of the virus mainly through droplets mode, less frequently through contact, it can be transmitted as well through
aerosol in case of aerosol generated procedure and close contact in indoor sitting. (Version: 2 - Nov 2020)

Middle East Respiratory Syndrome (MERS) is a viral respiratory disease caused by a novel coronavirus (Middle East Respiratory
Syndrome Coronavirus, or MERS-CoV) that was first identified in Saudi Arabia in 2012. Typical MERS-CoV symptoms include
fever, cough and shortness of breath. Pneumonia is common, but not always present. Approximately 35% of reported patients
with MERS-CoV have died. (Version 5.1 - May 2018)

Sub standards Explanation

➢ Infection Control practitioners must ensure availability & strict adherence to MERS CoV & COVID – 19 protocols in HDU.
➢ Provide training to all relevant health care personnel during training phase. Monitor staff practices and evaluate performance
during IPCCC audit phase. 100% of staff working in ER must receive training at least once per year and more frequently
when new updates are available.
➢ Flowchart must be developed by the infection control including all protocols for MERS CoV & COVID – 19 based on latest
MOH guidelines.
➢ Flow chart must delineate all steps and displayed at appropriate places to be easily seen by all relevant HCWs.

458 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Patient arrives at UNIT entrance for Dialysis session

Substandard 5.1
Respiratory Triage Station
(Nurse available at the start of each session to interview patients using predefined scoring criteria)
There is a protocol for
early detection,
management, and transfer Score 4 & above (≥ 4) Score less than 4 (<4)
of respiratory illness
patients, “Flow Charts” for
MERS - CoV & COVID -19
must be developed based Respiratory Pathway / Triage Dialysis station / area
on updated guidelines and
(Dedicated Respiratory
present on well seen place
waiting area if > 1 patient)
in the HDU.
Respiratory Triage Clinic / Assessment Room

Meets criteria for Does NOT meet

suspected case criteria for
Definition suspected case definition

(MERS / COVID - 19)

(Isolation Room (AIIR) / Single room with HEPA filter)

Follow Algorithm for Managing suspected MERS-CoV Patients
(Appendix C - page # 26 Version 5.1 / 2018)
Follow COVID - 19 Guidelines for managing suspected COVID -19 cases

❖ All HDU Staff dealing with respiratory illness patients must be well familiarized with
respiratory pathway based on the provided protocols as mentioned in flowchart in order to
avoid confusions and mismanagement of patients.
❖ Monitor activities during daily rounds that staff are strictly adhering to protocols.
❖ Evaluate the performance during IPCCC audit phase.
Note: Flow chart must be tailored according to each hospital situation following updated MERS & COVID -19
guidelines.

459 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ❖ To prevent the transmission of respiratory infections in the healthcare settings, all
Substandard 5.2 healthcare facilities should have designated triage area for suspected cases that is
physically separated from other areas.
Designated respiratory ❖ All patients passing through emergency room must be triaged at the entrance using
triage station is available at predefined scoring mechanism. (except those with immediately life-threatening
the unit entrance with conditions)
required equipment
(surgical facemask, hand
hygiene sanitizer, visual Infection Control practitioners must ensure availability of designated triage area in the
alerts ...etc.) HDU. It must me at the entrance to facilitate early detection and segregation of ARI
patients from initial checkpoint at entrance.
IC team must seek administrative support in case of facing difficulties in
Substandard 5.3
implementing the respiratory triage protocols.
Respiratory triage for
Following pathway must be established:
MERS-Cov and COVID-19
is active before start of
each shift.
Respiratory / Visual Triage :

Substandard 5.4 Visual Triage must be available at the entry point of entrance of unit for early
identification of all haemodialysis patients with ARI symptoms before starting dialysis
Assigned and documental session.
trained HCW is available at Required equipment at Visual triage includes respiratory scoring checklist. surgical
visual triage area who can mask, hand hygiene sanitizer, posters etc.
communicate in arabic and Must be activated before start of each shift with assigned trained staff.
english to fill the form
accurately.
Staff assigned at the visual triage station must be well trained on the triage process for both
MERS –CoV & COVID – 19.
Substandard 5.
Obtain list of staff assigned for visual triage & conduct training according to the
Respiratory triage scoring
schedule. Include all old & new staff as part of refresher IPCCC training activities.
form is available for MERS-
CoV & COVID - 19 which is Staff assigned at the triage station must be well trained and have proficiency of both
up-to-date, approved and Arabic & English languages.
used. (electronic form on Monitor and observe the process during routine daily/ weekly rounds. Provide feedback
the system is preferable. when needed.
Ensure no new staff is assigned at the visual triage station without prior infection control
Substandard 5.6 training & competency.

Patients who have scored Respiratory triage scoring form:

≥4 in either MERS-CoV or
COVID-19 , are instructed Up to date & approved triage scoring form is available & used.
to wear facemask and Electronic scoring system is preferred over manual system in order to minimize the items,
perform hand hygiene
avoid cross infection and to ensure efficient record keeping.
Staff must be capable of completing all items in the checklist in minimum possible time in
Substandard 5.7 order to avoid overcrowding at the entrance.

If the patients score ≥4 in Respiratory triage scoring mechanism & Pathway:

either MERS-CoV or
COVID-19, they are Patients who have scored ≥4 in either MERS-CoV or COVID-19, are instructed to wear
directed safely to facemask and perform hand hygiene.
Respiratory Triage Clinic or If the patients score ≥4 (4 & above) in either MERS-CoV or COVID-19, they are directed
Respiratory waiting area.
safely to Respiratory Triage Clinic.
460 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 If the respirator triage clinic is occupied patients must wait in the designated Respiratory
waiting area.
Patients with score 3 & less wil be allowed to enter the dialysis unit for regular dialysis
session.

- ICPs must conduct random inspection at different times to ensure respiratory triage is
active at all times.
- There must be back up if the assigned staff will be away from station during break hours
or any other urgent need etc.

Respiratory Triage Clinic / Respiratory Assessment room :

❖ IC team must ensure availability of designated respiratory Triage Clinic in the HDU for clinical
Substandard 5.8 assessment of patients identified from the visual triage station.
❖ Respiratory triage clinic must have minimal items to facilitate effective disinfection in
Designated Respiratory between patients.
Triage Clinic is available in
❖ Physician must be available to apply the MERS – CoV & COVID – 19 case definitions.
the Emergency
Department. ❖ If the patients fulfil criteria for suspected MERS – CoV / COVID – 19, they should be
transferred to negative pressure room or single room with HEPA filter for further
management. (MERS – CoV / COVID 19 testing etc)

- IC Team must monitor during daily rounds to ensure all infection control standards are
being followed.
- Evaluate the unit performance during IPCCC audit phase.

Substandard 5.9 Respiratory Waiting Area:

Respiratory waiting area is ❖ There must be a dedicated respiratory waiting area with fixed chairs & spatial separation of
available with fixed chairs at least 1.2 meter between each patient.
and distance at least 1.2 ❖ Respiratory waiting area must be clearly identified with appropriate signage to be used only
meter with availability of for hemodialysis patients with ARI symptoms.
hand sanitizer, paper ❖ Respiratory waiting area must be equipped with hand rub sanitizer, paper tissues & waste
tissues & foot operated receptacle which is operated by foot. Open household waste receptacles must not be used
waste container. in the healthcare setting.

During IPCCC training activities provide training to the staff on the updated case definition of
Substandard 5.10
MERS – CoV & COVID – 19.
Reinforce during daily rounds and evaluate HCW during IPCCC audit phase & provide formal
Written reminders for case
feedback on performance.
definition of MERS &
COVID 19 are posted &
❖ Ensure updated written case definition reminders are posted in the HDU at all appropriate
staff are aware about the
places as staff reminders (Nursing stations, respiratory clinic etc)
updated case definition
❖ Provide personal cards incorporating MERS & COVID - 19 Case definitions for quick
and the flowchart of
reference of physicians to apply criteria for suspected case definitions for all patients
MERS-CoV and COVID-19 .
directed from visual triage station with score 4 & above.

461 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 It is of utmost importance to ensure that all patients and visitors must practice hand hygiene
and cough etiquette within the hospital in order to ensure clean environment & prevent cross
infection transmission.
Substandard 5.11
IC team must take responsibility to post appropriate visual alerts in both Arabic & English
Bilingual visual education languages at the entrance of haemodialysis unit.
signs for patients and
visitors on recommended
Hand Hygiene & ❖ Posters, banners, electronic screens etc. containing information regarding hand hygiene &
Respiratory Hygiene/Cough Respiratory Hygiene/Cough Etiquette practices.
Etiquette practices are ❖ Must be posted at all convenient locations where information can be easily seen and read by
posted in the emergency the patients & visitors.
department including
respiratory & other waiting Messages in the visual alerts include the following:
areas.
❖ Cover your mouth and nose with a tissue when coughing or sneezing.
❖ Dispose of the tissue in the nearest waste receptacle immediately after use.
❖ Pictoral display on how to wear surgical mask & perform hand hygiene after having contact
with respiratory secretions and contaminated objects or materials

Substandard 5.12
In order to increase awareness and education of patients and visitors regarding MERS – CoV &
Bilingual health education COVID – 19, education material must be placed and posted in all patient care & waiting areas.
& awareness material for
MERS - CoV & COVID -19 ❖ Education material can be in the form of posters, brochures, leaflets, booklets & pamphlets.
is available & posted in all ❖ Messages must include clinical features, modes of transmission & prevention strategies to
appropriate places for be of COVID -19 & MERS – CoV .
patients and visitors (e.g
Posters, brochures See the figures posted below.
/leaflets, booklets etc)

Health care workers in the hospitals are at significant risk of exposure to various types of
infections transmitted either by contact, droplet or airborne route. According to updated
Substandard 5.13
guidelines from Ministry of health, all healthcare facilities should identify and trace all health
care workers who had protected (proper use of PPE) or unprotected (without wearing PPE or
Hospital has log for HCWs
PPE used improperly) exposure to patients with confirmed MERS-CoV infection.
who contact with a
confirmed case to record
❖ Healthcare workers shall be assessed daily for 14 days post exposure for the development
the presence or absence of
of symptoms through the activation of log.
fever, symptoms of acute
❖ IC teams must provide logbook for the staff to be activated after exposure to confirmed
respiratory illness,
COVID 19 or MERS-CoV. Case.
diarrhea, vomiting or
❖ All HCWs who fulfilled exposure criteria according to infection control assessment must
nausea before starting
record presence or absence of fever symptoms of acute respiratory illness, diarrhea,
their shift.
vomiting or nausea before starting their shift.
❖ Exclusion from work and nasopharyngeal swabbing will depend on the degree and duration
of exposure. (Refer to COVID & MERS guidelines)

462 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 An aerosol-generating procedure (AGP) is defined as any medical procedure that can induce
the production of aerosols of various sizes, including small (< 5 microns) particles. AGPs
includes bronchoscopy, sputum induction, intubation and extubation, cardiopulmonary
resuscitation, open suctioning of airways, Ambu bagging,
nebulization therapy etc

As per MERS – CoV guidelines, Precautions to be observed when performing aerosol-

Substandard 5.14 generating procedures, which may be associated with an increased risk of infection
transmission:
Aerosol generating
procedure (AGP) should be ❖ Perform procedures in a negative pressure room or single room with HEPA filter
done in negative pressure ❖ Limit the number of persons present in the room to the absolute minimum required for
room or single room with the patient’s care and support.
portable HEPA filter, using ❖ Every healthcare worker should wear a fit-tested seal check N95 mask (or an
appropriate PPE (N95 alternative respirator if fit testing failed).
mask, eye protection, ❖ Wear eye protection (i.e. goggles or a face shield).
gloves & gown) with ❖ Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures require
minimal possible number sterile gloves
of staff. ❖ Wear an impermeable apron for some procedures with expected high fluid volumes
that might penetrate the gown.
❖ Perform hand hygiene before and after contact with the patient and his or her
surroundings and after PPE removal.

- IC Team must provide training to the relevant staff regarding all infection control protocols
to be followed during aerosol generating procedure (AGP).
- Monitor the practices during daily rounds and evaluate the performance during IPCCC
audit phase.
- Provide formal feedback to the staff & consider for retraining if needed.

463 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
464 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
465 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
MERS - CoV

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469 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
470 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 UNIT DESIGN
Haemodialysis unit consist of patient’s treatment areas, triage areas & isolation rooms & water distribution and Storage Systems etc.
Dialysis or renal replacement therapies are procedures are performed that replace the normal functions of the kidney by removing metabolic
waste products through diffusion and hydraulic pressure gradients.
• Hemodialysis is performed using a machine that has internal fluid pathways that mix dialysate components (processed water, bicarbonate,
and acetate), passes them through the dialysate pathway of the hemodialyzer, and then discards them into a drain (single pass).
• The dialysate must also meet Association for the Advancement of Medical Instrumentation standards (AAMi)

. Blood and dialysate (a mixture of purified water, bicarbonate, and acetate) pass on opposite sides of the membrane but do not mix. Molecules
that can pass through the semipermeable membrane move from the area of higher concentration to that of lower concentration.
Haemodialysis removes toxins, electrolytes, and fluid by circulating the patient’s blood through a hemodialyzer. During intermittent or chronic
haemodialysis, patients are usually scheduled to receive haemodialysis treatments for 2 to 4 hours three times per week.

Haemodialysis Unit is so designed to maintain the appropriate distance in between patients in order to avoid risk of cross infection. Aim of water
distribution and storage Systems to provide highly purified water to be used for haemodialysis.

Sub standards Explanation

In order to prevent the overcrowding at the hemodialysis patients care areas following
Substandard 6.1
Space requirements for patients ‘treatment area must be met:
The minimal floor area of an
Area:
individual haemodialysis patient's
station is 80 feet (7.43m2) and
❖ individual patient area should have a minimum floor area of 80 feet (7.43 m2).
the distance separating space
between each adjacent dialysis
Clearance:
chairs/beds in not less than 1.2
meters.
❖ The distance between patients' beds/ chairs in hemodialysis units should be > 4
feet (1.2 meters) to reduce the risk of transmission between patients and to staff.
Substandard 6.2
❖ IC Team must ensure that above mentioned specification of distance are being
Aerosol generating procedure
followed.
(AGP) should be done in negative
❖ Evaluate the unit performance during IPCCC audit phase.
pressure room or single room
with portable HEPA filter, using
appropriate PPE (N95 mask, eye
❖ This will ensure sufficient space between stations to allow staff to move
protection, gloves & gown) with
freely.
minimal possible number of staff.
❖ Easy accessibility & space for adequate cleaning:
- Eliminate unneeded items
- Arrange required items in an orderly fashion
- Remove excess lengths of tubes, hoses, and wires from the floor

Substandard 6.3 IC Team must ensure availability of special room is available for HD catheter
insertion.
Special room is available for HD Room must be equipped with an appropriate hand washing facility and required PPE.
catheter insertion and it is Catheters should be inserted using maximal sterile Barrier Precautions: Special room
equipped with an appropriate for insertion equipped with hand washing facility, PPE (mask, sterile gloves, and
hand washing facility and required long-sleeve sterile gown), and large sterile sheet or drape.
PPE.

471 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must assess the specification of water distribution system along with HDU &
utility & maintenance responsible for maintenance of water distribution system.
Substandard 6.4
Following key points must be considered:
Water distribution system must
not be made up of metal. Water distribution system must not be made up of metal because of anticipated risk
of chemical contamination.
Water distribution systems are usually constructed of plastic pipes because use of
metal pipes could contaminate the treated water with elements such as copper,
Substandard 6.5 lead, or zinc.
Water distribution system should be configured as a continuous loop with no dead
Water distribution system should ends or unused branches to the piping system (as these stagnant areas may serve
be configured as a continuous
as a source of bacterial contamination for the rest of the water system.)
loop with no dead ends or unused
branches to the piping system. There should be a constant flow of water through all distribution piping.
The minimum number of elbows and T-joints should be used.
Outlets should be at the highest point of the system to allow adequate contact of all
parts of the distribution system with germicide during disinfection.

Refer to MOH haemodialysis guidelines for more details.

472 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Haemodialysis Patients and Staff Health
Haemodialysis patients & health care worker are exposed to risk of acquiring infection by several means. Dialysis patients may become infected
through the following means: lnternally through contaminated dialysis equipment (e.g., venous pressure gauges, isolators or filters). - Externally
through contaminated dialysis machines, including their surfaces, control knobs or intravenous poles. - lmproperly prepared or contaminated
injection site. - Through breaks in the skin or mucous membranes. - Contaminated items and surfaces such as clamps, scissors, telephones or
walls. - lmproper handling of multiple-dose medication vials and intravenous solutions. - The dialysis staff (contaminated hands, gloves and other
objects).
In order to ensure patient and staff safety it is extremely important to implement all required infection control standards like screening ,
immunization & vaccination etc for protection of patients and staff safety.
Most patients undergoing dialysis are already at risk for certain types of infections resulting from underlying diseases or conditions
(e.g., diabetes,…)
Dialysis also increases the patient's risk of infection because direct access into normally sterile areas, the circulatory system or
peritoneal cavity, is required.

Sub standards Explanation

Substandard 7.1 Adequate Staffing level is critical to providing quality care to the patients. Hence it is
imperative to ensure 1:1-2 staff ratio in HDU.
Appropriate staff to patient
ratio is applied according to
the updated MOH
recommendation.

IC team must ensure that all screening & immunization protocols are followed for
Substandard 7.2 haemodialysis patients & HCWs working in the haemodialysis unit.
Ensure appropriate medical records are maintained & updated frequently.
HCWs are tested for HBV, Electronic database / dashboards including all screening results with dates for tracking the
HCV and HIV upon hiring. patients’ health status is preferable. (See sample)
HBV vaccine is given for During routine daily / weekly rounds ICPs must review patient’s files at random & check if
those who are susceptible all relevant screening tests are done, results are documented, patients have received the
to hepatitis B. scheduled HBV vaccination dose etc.

Following guidelines for HDU staff are followed as part of occupational health program:
Substandard 7.3
❖ All HDU staff must have baseline screening for HBV, HCW, & HIV upon hiring.
Routine annual serologic
❖ Results must be reviewed promptly & HBV vaccine is given to all those who are
testing for haemodialysis
susceptible to hepatitis B infection.
staff for HBV, HCV, HIV is
❖ Routine annual testing of staff for HBV is no longer considered necessary as their risk
no longer recommended).
is not greater than that of other healthcare personnel.
❖ Routine testing of staff members for other bloodborne pathogens (HCV, HDV and HIV)
is also not recommended.

473 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 7.4 Serological markers for haemodialysis patients :
Following protocols must be followed for patients.
IC team must review random patients file during routine rounds to ensure patient’s screening is
Patient is tested for HBV done according to standards and appropriate vaccination schedule is followed for susceptible
markers on admission with patients.
vaccination of susceptible
one. Patient with negative Following guidelines for Routine Serologic Testing of Haemodialysis patients are followed:
results are periodically re-
tested with prompt review All HD patients are tested for HBV markers on admission with vaccination of susceptible one.
of results. Patient with negative results are periodically re-tested with prompt review of results.

Following serological markers are required to be tested UPON ADMISSION:

Substandard 7.5 Serologic testing for hepatitis B surface antigen (HBsAg)

Antibody to the core antigen (anti-HBc)

Patient is tested for HCV
markers on admission (ALT Antibody to hepatitis B surface antigen (anti-HBs)
and anti-HCV – ELISA).
Patient with negative results Antibody to hepatitis C virus (anti-HCV – ELISA)
are periodically re-tested
with prompt review of Alanine aminotransferase (ALT)
results.

Results of hepatitis B testing should be known before the patient begins dialysis. lf results
are not known, the patient should be treated as if he or she is HBsAg positive until the results
indicate otherwise.

RETESTING OF PATIENTS WITH NEGATIVE RESULTS:

➢ Patients who are anti-HBc and anti-HBs positive do not require further hepatitis B virus-
related testing.
➢ Patients who are only anti-HBs positive require annual anti-HBs testing and a booster if
anti-HBs declines to less than 1.0 mlU/mL.
➢ Patients susceptible to hepatitis B virus, including those with no response to the
vaccine, should be tested monthly for HBsAg.

HCV-Negative patients:

All anti-HCV negative patients should be tested for increased ALT at least monthly and anti-
HCV semi-annually.
Monthly ALT testing will facilitate the timely detection of new infections and provide a
pattern from which to determine when exposure or infection may have occurred.
ln the absence of unexplained ALT elevation, testing for anti-HCV (ELISA) every 5 months
should be sufficient to monitor the occurrence of new HCV infections.
lf unexplained ALT elevation is observed in patients who are anti-HCV negative, repeated
anti-HCV testing (ELISA) is necessary.
lf unexplained ALT elevation persists in patients who repeatedly test anti-HCV negative,
testing for HCV RNA (PCR) should be considered.

474 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Hepatitis B serologic testing involves measurement of several hepatitis B virus (HBV)-specific antigens and antibodies. Different serologic
“markers” or combinations of markers are used to identify different phases of HBV infection and to determine whether a patient has acute
or chronic HBV infection, is immune to HBV as a result of prior infection or vaccination, or is susceptible to infection.

Hepatitis B surface antigen (HBsAg): A protein on the surface of hepatitis B virus; it can be detected in high levels in serum during acute
or chronic hepatitis B virus infection. The presence of HBsAg indicates that the person is infectious. The body normally produces
antibodies to HBsAg as part of the normal immune response to infection. HBsAg is the antigen used to make hepatitis B vaccine

Hepatitis B surface antibody (anti-HBs): The presence of anti-HBs is generally interpreted as indicating recovery and immunity from
hepatitis B virus infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B.

Total hepatitis B core antibody (anti-HBc): Appears at the onset of symptoms in acute hepatitis B and persists for life. The presence of
anti-HBc indicates previous or ongoing infection with hepatitis B virus in an undefi ned time frame.

Antibody to hepatitis C virus (anti-HCV – ELISA): Presence of antibodies to HCV, using an Enzyme Linked Immunosorbent Assey (ELISA)

Alanine aminotransferase (ALT): Elevated serum alanine aminotransferase (ALT) & viral load In individuals with chronic hepatitis C may
have clinical relevance. When parenchymal liver cells are damaged, aminotransferases leak from the liver into the blood, resulting in
elevated levels of these enzymes in the bloodstream. For HCV – dialysis patients, monthly ALT testing will facilitate the timely detection of
new infections and provide a pattern from which to determine when exposure or infection may have occurred.

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476 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
477 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 The transmission of hepatitis B virus and hepatitis C virus in haemodialysis units has been
Substandard 7.6 documented. For this reason, infection prevention practices should be reviewed regularly
and rigorously followed. Hepatitis B vaccine is recommended for all susceptible
haemodialysis patients and staff. Segregation of hepatitis B patients and all patient care
HVB +ve patients are strictly items are the key measures to be considered for prevention of infection transmission.
segregated in a separate
room(s), treated by IC team must ensure strict implementation of infection control measure for hepatitis B
dedicated staff during positive dialysis patients.
dialysis sessions using Special measures are taken for HBV+ patients that includes:
designated machines,
equipment, instruments, ❖ Dedicated room equipped with dedicated machines to be used only for HBV+
supplies and medications patients.
which are used only for ❖ Dedicated staff must be assigned for HBV+ patients only. She must not be allowed to
them. handle any other patient during dialysis session.
❖ IC team must seek administrative support to ensure adequate staffing levels for
effective implementation of all infection control standards.
❖ Following must be ensured:
- Physically separated room(s) with accessible hand washing facilities within the
room(s).
- Dedicated HD machines
- Dedicate patient care equipment like stethsscope, BP cuff etc
- Dedicated instruments, medications & other patient care supplies.
- Special supplies kept in distinct store i.e Separate storage for medications,
instruments, supplies and other consumables (e.g.store or cabinet(s) away
from patients’ zones)

IC practitioners must conduct reorientation & training session for all HDU staff during
IPCCC training activities.
Observe practices in routine rounds. Conduct IPCCC audit & evaluate the unit & staff
performance.
Provide formal feedback & consider for retraining when needed.

Hepatitis B (HBV) infection

Mode of Transmission of Hepatitis B:
- Chronically infected patients are the primary source of transmission.
- HBV is considered to be a resistant virus, is relatively stable in the environment, and
remains viable for at least seven days on environmental surfaces at room temperature.
Dialysis staff members may acquire the infection
- Accidental needle puncture through intact skin.
- ii. Infected plasma, serum or contaminated environmental surfaces through breaks in
the skin such as abrasions, cuts, or scratches.
- ii. Introduction of infected serum or plasma into mucosal membranes (e.g., the
splashing of blood onto the mouth or eyes).
-
Dialysis patients may become infected through the following means:
- Internally through contaminated dialysis equipment (e.g., venous pressure gauges,
isolators or filters).
- Externally through contaminated dialysis machines, including their surfaces, control
knobs or intravenous poles.
- Improperly prepped or contaminated injection site.
- Through breaks in the skin or mucous membranes.
- Contaminated items and surfaces such as clamps, scissors, telephones or walls.
- Improper handling of multiple-dose medication vials and intravenous solutions.
- Contaminated hands & gloves of HCWs , gloves and other objects

478 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 The human immunodeficiency virus (HIV) targets the immune system and weakens people's
defence against many infections. As the virus destroys and impairs the function of immune
Substandard 7.7
cells, infected individuals gradually become immunodeficient that results in increased
Only patients with risk susceptibility to a wide range of infections, cancers and other diseases that people with
factors for HIV infection healthy immune systems can fight off. HIV can be transmitted via the exchange of a variety
(high-risk behaviors, e.g., of body fluids from infected people, such as blood, breast milk, semen and vaginal
repeated blood transfusions, secretions. HIV can also be transmitted from a mother to her child during pregnancy and
drug abuse …etc) are delivery.
tested for markers of HIV
infection As HIV infections is typically associated with certain risk behaviours so routine baseline
screening of all HD patients is not recommended.

Eligible patients for HIV infection screening includes HD patients with high risk behaviours
for HIV infection:

- Repeated blood transfusions

- Injecting drug abuse
- Sexual activity or tattoos

❖ Nephrologists must take detailed history of HIV infection risk behaviours from HD patients
upon new registration.
❖ Information must be clearly documented in patient files (Manual / electronic).
❖ HD team must take definitive decision for HIV screening of newly registered patients
based on the patient’s history.
❖ HD team must have clear evidence of screening or non-screening of HD patients for HIV.
Records must be well organized to be presented to external auditor during IC evaluation
rounds.

IC practitioners must review patient files at random & inquire about the screening status
of staff for HIV infection. HDU staff must have appropriate justification in either case

Substandard 7.8 IC practitioners must ensure availability of documents for HDU Documents for serological
testing of dialysis patients on admission & periodically (when indicated) with vaccination
of susceptible ones.
Previously HCV +ve patient Unit must keep a list of previously HCV +ve patients who were treated with DAAs (Direct
who was treated with DAAs Antiviral Agents) and achieved SVR (Sustained Virologic Response) (hard copy or soft
(Direct Antiviral Agents) and copy) apart from documentation in personal files.
achieved SVR (Sustained HCV-RNA (PCR) test must be conducted semi-annually to detect relapses.
Virologic Response) is
tested for HCV-RNA (PCR)
semi-annually to detect
relapse.

479 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Disinfection of Patient Care Equipment

Disinfection of patient care equipments is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.

The level of disinfection or sterilization is dependent on the intended use of the object: critical items (such as surgical instruments, which
contact sterile tissue) requires sterilization, semi critical items (such as endoscopes, which contact mucous membranes) requires high-level
disinfection, and noncritical items (such as stethoscopes, which contact only intact skin) require low-level disinfection,

Sub standards Explanation

❖ During daily / weekly IPCCC activities ensure all relevant disinfectants are available in
the unit for effective cleaning and disinfection practices.
❖ Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related
Substandard 8.1 documents which are essential for safe and effective use (Material Safety Data Sheet
(MSDS) – preparation & dilution – usage and contact time – precautions and required
Adequate supply of
PPE)
disinfectants is available.
❖ Verify if compatible with current scientific guidelines and recommended practices and
approved by MOH.

The manufacturer’s recommended procedures and chemicals for cleaning & disinfection
must be closely followed. Ignoring the manufacturer’s instructions and using
inappropriate cleaning agents may result in damage to the equipment and potential
injury. For example, alcohol is a superb cleaning agent but may blur the plastic viewing
window of monitors or remove labels surrounding knobs.

❖ After completing the training phase for the targeted staff, evaluate the staff performance
during the IPCCC evaluation process.
❖ Ask staff to differentiate between critical, non-critical and critical items and give specific
Substandard 8.2 task to perform. e.g disinfection of blood pressure cuff and observe selection of PPE ,
contact time is followed for disinfectant used and methodology i.e from less to more
Staff know the proper way of soiled and from up to down etc
disinfection for non-critical ❖ These items could potentially contribute to secondary transmission of microorganisms
medical care equipment. to healthcare workers’ hands; therefore, they require low level disinfection with hospital
approved disinfectant at the point of use.

480 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ICP must provide training to HD staff about appropriate cleaning and disinfection of
Substandard 8.3 patient care equipment.

All external surfaces and After each patient treatment session, all surfaces at the dialysis station (all surfaces
equipments in dialysis station in contact with the patient) should be mechanically cleaned and disinfected with
are disinfected by a MOH- MOH approved disinfectants.
approved disinfectant after
each HD session. - Outside of the dialysis machine (e.g., control panel; top, front and sides of the
Disinfection activity logbook machine).
including responsible HCW, - Bed (or chair) and
used agents, methods and - over-bed table.
surfaces (e.g. Haemodialysis - Touchscreens
machine external surface, bed, - Countertops
chair, BP cuff with its tubing, - BP cuffs and tubing.
TV remote control - TV control/ call light

Assigned IC practitioners must ensure the following:

Staff are aware about the correct dilution of the disinfectant agent.
HDU must establish written rules and use a practical checklist.
Identify responsible staff and ensure that they have been properly trained.
Determine required Personal Protective Equipment (PPE) based on risks and
disinfectant product labels.
Ensure provision of necessary supplies (this includes, but not limited to: gloves and
other PPE, MOH approved disinfectants, wipes, cloths, spray bottles and/or buckets,
…etc.)
Ensure procedure for disposable supplies brought to the patient’s station.
Establish procedure for reusable supplies (i.e., cleaning & disinfection after completion
of each treatment session.

Reusable medical devices are devices that health care providers can reprocess and reuse
on multiple patients. Examples of reusable medical devices include surgical forceps,
endoscopes and stethoscopes.
All reusable medical devices can be grouped into one of three categories according to the
degree of risk of infection associated with the use of the device:

• Non-critical devices, such as stethoscopes, come in contact with unbroken skin.

Substandard 8.4
• Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
Accessories to endoscopes, such as graspers and scissors etc
Reusable non critical medical
• Critical devices, such as surgical forceps, come in contact with blood or normally
care equipments are
sterile tissue.
disinfected properly after each
use before leaving patient
❖ Reusable items non-critical devices must be disinfected before leaving the patients
zone.
zone. e.g stethoscope. BP cuffs etc
❖ HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
❖ Observe the staff practices and provide guidance if not following the standard
recommendations.

481 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 8.5
❖ In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi
Well closed leak-proof critical items must be placed in the leak prof container immediately after use without
containers are available to any manipulation e.g Manual cleaning of blood / washing etc.
place reusable critical and ❖ Check for availability of closed leak proof container. (Ask staff to demonstrate handling
semi-critical items of any critical /semi critical item after procedure and observe practice.
immediately after use before
sending to CSSD without any All reusable critical and semi-critical items must be sent to CSSD. Staff are not allowed
interference from the staff. to handle any used item even away from patients zones.

High-touch surfaces are defined as surfaces, often in patient care areas, that are
frequently touched by healthcare workers and patients (e.g., bedrails, overbed table, IV
pole, door knobs, medication carts). These items need to be cleaned frequently because
of the high degree of handling and the high risk of cross transmission of infection
Substandard 8.6
The principal modes of transmission in HDU are via the hands of the personnel and
contact with inadequately decontaminated equipment or surfaces. The two areas most
Disinfection includes high likely to become contaminated when caring for the patient are the hands and apron area
touch surfaces in more of the person, as the surfaces (e.g., beds, side rails, tables, equipment) are often heavily
frequent times. contaminated with organisms from the patient. Likewise, all equipment used on the
patient (e.g., blood pressure cuffs, thermometers, wheelchairs, IV pumps) are also
heavily contaminated and may be transmitted to other patients if strict barriers are not
maintained and appropriate decontamination is not carried out.

Frequency of high touch surfaces Disinfection:

❖ Before and after (i.e., between) every procedure and twice daily and as needed
❖ At discharge / transfer (terminal cleaning)
❖ During the daily rounds check randomly the patient care equipment e.g. bedside
monitors by wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard 8.7 ❖ Provide disinfection activity log /cleaning checklist to the units which should include
name of staff responsible for disinfection, items present in the specified area intended
There is a disinfection activity to be cleaned.
log including responsible ❖ Name of disinfectants with dilutions and contact time.
HCW, used agents and items ❖ Randomly check during routine rounds if disinfection activities are done and
for disinfection in the unit. documented appropriately.

❖ Disinfection and cleaning of patient care equipment and surfaces is the sole
responsibility of clinical staff only as it requires more careful and meticulous cleaning.
(Nurses, doctors, RTs , X ray technicians etc
Substandard 8.
❖ (Housekeeping staff must not be allowed to handle any patient care equipment.
HCW are responsible for
cleaning and disinfecting of all
Adherence to these recommendations should improve disinfection and sterilization
patient care equipment and
practices in health care facilities, thereby reducing infections associated with
surfaces
contaminated patient-care items.

482 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 In order to ensure effective cleaning and disinfection of all surfaces within the dialysis
station, nursing staff must be well trained on basic infection control rules.

Following key points must be communicated:

Substandard 8.9 ❖ HD staff must not apply any plaster or paper label over the patient care equipment
or items in the immediate surroundings of the patients.
No plasters or paper labels ❖ Examples include equipment such as surfaces of dialysis machine, stethoscope,
over equipment requiring handles of dialysis chairs etc. This will result in inadequate disinfection and may
surface disinfection. contribute to infection transmission.

During routine rounds IC practitioners assigned for unit must closely observe and correct
such practices.
Evaluate the performance in IPCCC audit phase and provide formal feednback.

Disinfection of Dialysis Machines:

IC team has the responsibility to observe and monitor during routine rounds that all IC
protocols are strictly implemented in HDU.
Appropriate disinfection of dialysis machines must be done based on manufacturer
instruction for use. (IFU)
HD staff must be well trained on the entire disinfections process of internal fluid
pathways in order to ensure patient safety.

❖ Recirculating or recirculating single-pass dialysis machines should be

disinfected prior to first use of the day and after each use.
❖ For single-pass machines, the disinfection process should be performed
prior to first use of the day and at the frequency recommended by the
manufacturer.

Key Notes for ICPs:

Substandard 8.10
Dilaysis Machines: A blood pump, consisting of two or more rollers, is usually necessary
Haemodialysis machine is
to pump the patient's blood through tubing and the hemodialyzer at stable and accurate
disinfected after each
blood flow rates.
haemodialysis session
following an approved written
There are three types of fluid pathways in hemodialysis machines:
policy according to
manufacturer’s instructions.
Recirculating machines circulate dialysate repeatedly through the
hemodialyzer during dialysis
Recirculating single-pass machines have a reservoir that is partially
displaced by a constant flow of fresh dialysate
Single-pass machines discard all dialysate through the drain.

Recirculating systems permit nutrient-rich waste products from the patient

to be used as nutrients for microorganisms and therefore may result in
increased levels of bacteria during the dialysis treatment.
All internal fluid pathways of recirculating or recirculating single-pass
dialysis machines should be disinfected immediately prior to first use and
after each patient use.
If a blood leak occurs in a recirculating or recirculating single-pass
machine, the disinfection procedures used for the machine to control
bacterial infection are considered sufficient to reduce blood contamination
below infectious levels.

483 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team must ensure during routine rounds that appropriate cleaning and disinfection of water
treatment & distribution system is performed at least once weekly.
HD unit must keep records of cleaning an disinfection activities to be presented for any inspection
Substandard 8.11: visits.

Cleaning and disinfection of The purpose of the disinfection procedures for the dialysis system is not only to
the water treatment and prevent the multiplication of waterborne bacteria to a significant level but also to
distribution system is eliminate blood borne viruses.
performed at least once
weekly. Complete dialysis The routine disinfection of isolated components of a dialysis system is usually
system is considered during inadequate, and consequently, the complete dialysis system (water treatment
the disinfection procedure system, distribution system and dialysis machine) should be considered during
(water treatment system, the disinfection procedures.
distribution system and
dialysis machines). For the purpose of disinfecting dialysis systems, the manufacturer’s instructions
should be followed (water treatment system, distribution system, machines and
disinfectants).

484 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 9 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 9:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 9:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

485 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 9:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

486 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 9:04
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 9:05 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 13. Disposable personal care items are discarded
worker, housekeeping 14. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 9:06 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

487 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 9:07 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

488 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

489 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 9:08 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 9:09
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

490 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 9:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Substandard # 9:11 Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
Housekeepers are well measures.
trained on hand hygiene, Routine practices related to environmental cleaning includes:
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals.
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

491 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 9:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 9:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 9:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

492 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 9:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 9:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 9:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

493 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
494 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 10 Haemodialysis Product Water
The quality of water and associated dialysis solutions have been implicated in adverse patient outcomes and is therefore critical The quality of
dialysis water is of critical importance to patients, as it is an essential requirement of successful treatment. Dialysis patients may be exposed
to a large number of contaminants in the dialysis water if their quality is not taken care of.
The purity of water used for haemodialysis, reuse, or concentrate preparation is critical and of utmost importance in order to prevent adverse
outcomes in dialysis patients. Systems should be designed to remove the anticipated chemical and biologic impurities found in the potable
water in the location where they are installed. Most haemodialysis centres have water treatment systems that consist of a water softener,
carbon filters, particulate filters, reverse osmosis and/or deionizers, and filters and ultrafilters, with or without ultraviolet (UV) light.
Water is treated, purified, and transported through a distribution system within a dialysis center where it is used in the preparation of dialysate
concentrates, as well as for proportioning concentrates at the dialysis machine to produce the final dialysate bath. All of these steps provide an
opportunity for microbial growth or chemical exposure if the water is contaminated and not properly maintained.
Facility Utilities & Management (U&M) will maintain the reverse osmosis water treatment plants, conduct disinfection of water treatment and
distribution systems, do water sampling and testing, report the results, and take corrective actions as per related standard operating procedures
(SOPs) and guidelines. infection preventionists should be familiar with the purity of local potable water, the components of their facility's water
treatment system, and should understand potential problems.

Sub standards Explanation

Implications of inadequate Treatment or Distribution of Water:

Bacterial & Chemical and contamination of water used for dialysis has been associated with
Substandard # 10:01 severe illness and/or death.
There is a schedule for
Endotoxin:
microbiological & endotoxin
testing of water and
Endotoxin can acutely activate both humoral and cellular immune response, leading to fever,
dialysate testing covering all
shaking chills, hypotension, multisystem organ failure, and even death. Long-term exposure
HD machines at least once
may lead to a chronic inflammatory response.
annually (i.e. dialysate) with
product water from the
Gram-negative bacteria:
beginning and the end of
the water distribution
Gram-negative bacteria have been associated with pyrogenic reactions and bacteremia.
system monthly.
Symptoms include shaking chills, fever, hypotension, headaches, myalgia, nausea, and
vomiting.

Non-tuberculous Mycobacteria:

Non-tuberculous mycobacteria have been associated with disseminated disease, bacteremia,

localized abscess, and localized graft infection. Symptoms include fever, malaise, and
anorexia.

lP&C personnel are responsible of reviewing regularity of routine monitoring of treated

water for hemodialysis as per MOH guidelines (i.e., double-checking for frequency of
testing; testing methods; and corrective measures with abnormal results).
Infection Control team must ensure that the water quality is regular monitored to ensure it
maintains the standards.
HD staff must develop a schedule for microbiological testing of treated water & dialysate.
Microbiologic monitoring of treated water and dialysate (Bacterial counts and endotoxin
levels) should be performed at least monthly and more frequently if problems are identified
(i.e., weekly if not up to the standards).
HD staff should prepare schedule of all hemodialysis machines. Machines are rotated so
that all machines are tested at least once per year,.

495 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Samples should always be taken before disinfection or sanitization of the water system or
dialysis machines.
Minimum sites of sampling for testing:

a) Post RO membrane
Substandard # 10:02
b) First point of the water distribution loop (first outlet or first machine port)
c) End point of the water distribution loop (last outlet or last machine port)
Microbiological testing of
water and dialysate is
conducted before
Dialysate Samples for Bacterial Testing
disinfection of the system at
least monthly or even
Test at least 2 machines a month
weekly if standards are
Rotate so that each machine is tested at least once per year
exceeded. (Maximum
Obtain sample from the dialysate port of the dialyzer or a sampling port
acceptable levels is 100
Process immediately or refrigerate to retard growth
CFU/ml/ Action level is 50
CFU/ml) (AAMI Standard).
Limits and Action Level

Maximum Allowed
Sub Substandard # 10:3
❖ CFU level < 100 CFU/ml
❖ Endotoxin level < 0.25 EU/ml
Endotoxin testing of water
and dialysate is conducted
Action Level:
at least monthly, and if not
up to the standards, testing
The action level is the concentration at which corrective measures are to be immediately
is repeated weekly until the
conducted to reduce the bacteria and/or endotoxin levels, which are typically 50% of the
problem is resolved.
maximum allowable level.
(maximum acceptable level
in 0.25 EU/ml/ Action level is
❖ CFU level > 50 CFU/ml
0.125EU/ml)
❖ Endotoxin Level > 0.125EUlml

Note: lf Action Levels are observed, disinfection and retesting shall be done immediately to
restore the quality to an acceptable level.

Substandard # 10:04 During routine rounds ICPs must ensure to review the results of microbiological &
endotoxin testing of water.
Results must be reviewed by responsible nephrologist and actions are taken accordingly.
Results of microbiological
testing of water are available There must be documented evidence of reviewing chemical, microbiological and
and reviewed by responsible endotoxin testing results by responsible nephrologist and infection control practitioners
nephrologist and infection (signature and /or stamp).
control practitioners and HD staff must keep documented evidence of any corrective interventions if results were
actions are taken out of acceptable limits.
accordingly.

496 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
497 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).
An effective infection prevention and control program for HD units is comprised of multiple interventions which are designed to reduce the risk
of infection based on the unique characteristics of the HD patient population and environment.

Sub standards Explanation

Effective implementation of Infection prevention & control guidelines is extremely important

for the prevention of healthcare-associated infections among chronic dialysis patients. Good
vascular access is critical for haemodialysis patients. Types of vascular access in order of
Substandard # 11:01 preference for haemodialysis patients includes: Arteriovenous Fistula, Arteriovenous Graft &
central venous catheter (CVC).
Central Venous Catheter
(CVC) selection, insertion, ❖ Training & education of HD staff is the key to follow the best practices for the HD patients.
maintenance, dressing Training must be conducted during IPCCC training phase. Staff must be well oriented about the
change, connection and principles of aseptic technique during CVC insertion, maintenance, dressing change,
disconnection are done connection & disconnection of CVCs.
❖ Observe the staff practices during routine rounds and conduct competency assessment
according to CDC
during IPCCC evaluation phase.
guidelines.
❖ Provide onsite and formal feedback. Consider for retraining based on the staff performance
if needed.

Focus areas of training should be:

HD staff including doctors, nurses etc must be oriented about the vascular access
choices available for HD patients.
CVCs are associated with increased incidence of Infections, Inadequate flow (catheter
dysfunction) & Failure of vascular access
02 types are available :

- Short-term - Noncuffed catheters (NCCs)

- Long-term (TCCs) – Tunneled cuffed catheters

Noncuffed catheters (NCCs) is central venous catheter that travels directly from the skin entry site
to a vein and terminates close to the heart or one of the great vessels, typically intended for short term
use (e.g. triple lumen catheters).
Tunneled cuffed catheters is a central venous catheter that travels a distance under the skin i.e
tunnelled from the point of insertion before entering a vein, and terminates at or close to the heart or
one of the great vessels.
As CVCs are associated with risk of infections & complications they must be the least choice.

498 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Indications of CVCs:
- Acute kidney injury
- Fistula and graft are not possible
- Waiting for fistula or graft to be ready to use
- Waiting for a peritoneal dialysis catheter
- Waiting for a scheduled, live donor renal transplant
Substandard # 11:02
-
HDU Staff orientation must also include:
Central Venous Catheter
(CVC) selection, insertion,
How to properly select and insert Central Venous Catheter (CVC) and what are the
maintenance, dressing
required precautions (i.e., place, HH, PPE, supplies, technique …etc..) (Refer to
change, connection and
substandard 3 for details)
disconnection are done
How to safely maintain and perform dressing change and what are required precautions
according to CDC
(i.e., HH, PPE, supplies, technique …etc) (Refer to substandard for details)
guidelines.
How to properly handle Central Venous Catheter (CVC) during connection and
disconnection of patient to dialysis tubings /bloodlines and what are required precautions
(i.e., HH, PPE, supplies, technique …etc..)
CDC – GDIPC checklists must be followed during these procedures in order to ensure all
steps are followed as desired.
IC practitioners must ensure availability of adequate supplies required for applying these
precautions .
(e.g., PPE: gloves: clean/sterile – gowns: clean/sterile – mask – face shield or goggles /
sterile supplies: sterile drapes – sterile dressings / antiseptics: chlorhexidine gluconate
with alcohol (> 0.5%) – povidone-iodine)
Antiseptic of choice. Chlorhexidine gluconate CHG preparation with alcohol (> 0.5%)
Check the catheter compatibility
Use povidone-iodine ointment at the catheter exit site of hemodialysis patients.(Check
the catheter compatibility)

Strict adherence to best IC practices must be ensured during initiation & discontinuation of
treatment sessions:

Substandard # 11:03 Patients & staff should wear mask during initiation and termination of dialysis treatment if
vascular access is a catheter.
Patient and HCWs wear Catheter accessing / de-accessing:
masks for all central venous Perform hand hygiene2) Put on a new, clean pair of gloves*3) Employee and patient should
catheter access wear face mask to cover nose and mouth4) Remove old dressing5) Change gloves
connections.
Apply antiseptic to CVC exit site and allow it to dry7) Apply antimicrobial ointment or
chlorhexidine impregnated patch8) Apply new dressing to exit site9) Remove gloves and
perform hand hygiene.

499 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 According to The Joint Commission, there are four chief aspects of the aseptic technique:
barriers, patient equipment and preparation, environmental controls, and contact
guidelines. Each plays an important role in infection prevention during a medical procedure.
Barriers protect the patient from the transfer of pathogens from a healthcare worker, from
the environment, or from both. Some barriers used in aseptic technique include:
Substandard # 11:04
- Sterile gloves
Maximum sterile barrier - Sterile gowns
precautions are applied - Masks for the patient and healthcare provider
during central venous - Sterile drapes etc
catheter (CVC) insertion - Cap / Head Cover
including cap, mask, sterile
gown, sterile gloves, and Healthcare providers must use sterile barriers including sterile equipment and sterile
sterile full-body drape. instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
central line etc. Only necessary health personnel should be at the procedure. The more people
present, the more opportunities for harmful bacteria to cause contamination.

❖ Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
❖ Observe a central line procedure whenever applicable and provide needed feedback
❖ In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
❖ Provide formal feedback and schedule retraining if needed.

❖ In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 11:05
must be disinfected with appropriate antiseptic (alcohol swabs etc).
❖ Let it dry on skin before injection or IV cannulation.
The patient’s skin is
- During the training phase of IPCCC activities, educate clinical care staff about the
disinfected with an
importance of aseptic technique in order to ensure patient safety. Use the ppt & training
appropriate antiseptic
videos for better understanding.
before injection or
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
cannulation.
Evaluate their performance during IPCCC audit rounds.

The use of common medications, instruments or supplies is strictly prohibited.

Substandard # 11:06 If clean supplies are stored in a common cart
Mobile common medication
❖ Cart should be stationary, i.e., can not be moved from station to station
carts or trays are strictly
❖ Cart should be far enough away from stations to avoid splash
prohibited.
❖ If a tray is used to prepare or transport medications to a patient, it must be
cleaned and disinfected before being used for other patients.

500 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During IPCCC routine rounds ICPs must ensure the following:

❖ Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 11:07 in adequate amounts in the medical stores or not
❖ If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of to use large IV solution bottles for preparation & dilution of medications
medication is only done by ❖ Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water specified for preparation & dilution of medications.
ampoule. ❖ Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should not be used for preparation & dilution of medications even for
the same patient (whether labeled with patient’s name or not / whether labeled with date &
time of the first use or not)

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 11:08 reused again even on the same patient. - These device are packaged and marked as “single
use” or have the international sign for single use items.
No reuse of single use Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
items. (gowns, face shields) … etc..,

❖ Provide training and orientation about risks associated with reuse of single use items
during IPCCC training phase.
❖ Observe the staff practices during routine rounds and provide feedback. Evaluate the
performance in IPCCC audit.

❖ Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not? • Observe if these items are available in
adequate amounts (It is more likely to reuse these items if amounts are
Substandard # 11:09 inadequate/shortage of supplies)
❖ Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders future use even on the same patient.
are used for only one ❖ While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient. with patient's name & medical record number. This means it is stored for future use on
the same patient.
❖ While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles
of aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

501 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ❖ Observe if these items are kept with remaining doses (single-dose vial should not be kept
opened with any remaining dose whether labelled with any patient’s name or not to avoid
Substandard # 11:10 its reuse or storing for future use even on the same patient)

❖ While checking the medication refrigerator, you find opened single-use vial labelled with
Single dose medication patient's name & medical record number. This means it is stored for future use on the
vials, ampoules and bottles same patient.
of intravenous solution are
used for only one patient.
❖ While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
supplies brought to patient’s care areas ) in order to avoid risk of contamination.

After completion of treatment session, any clinical procedure or patient discharge observe and
Substandard # 11:11 train staff to practice the following:

All patient care supplies are • All remaining single-use items are discarded, even unused ones with intact original
brought to patient area wrap (i.e., they cannot be used on other patients or returned to clean areas, such as
when needed with no medical stores or medication preparation areas etc )
excess. Any remaining
items after patient discharge • All reusable items are sent for reprocessing, even unused ones with intact original
are considered wrap.
contaminated even in their
wrapping. Visit the medical store and check at random. You may find an item with open cover or
occasional blood or betadine stain. Such practices are strictly prohibited.

❖ Audit the performance in IPCCC audit phase:

❖ Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

502 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Maintaining the integrity of sterile equipment and solutions is extremely important to prevent
the associated risks of acquiring infection be it a surgical procedure or any bedside sterile
procedure like insertion of chest tube, central venous line, or indwelling urinary catheter). If
the sterile items are assembled long before the procedure, there are chances of contamination
from environment such as dust etc. A sterile field is a sterile surface on which to place sterile
equipment that is considered free from microorganisms. A sterile field is required for all
Substandard # 11:12 invasive procedures to prevent the transfer of microorganisms and reduce the potential for
infections. Sterile fields can be created in the OR using drapes, or at the bedside using a pre-
Sterile equipment and packaged set of supplies for a sterile procedure or wound care. Many sterile kits contain a
solutions are assembled waterproof inner drape that can be set up as part of the sterile field. Sterile items can be linen
immediately prior to use. wrapped or paper wrapped, depending on whether they are single- or multi-use. Principles of
sterile technique help control and prevent infection, prevent the transmission of all
microorganisms in a given area, and include all techniques that are practised to maintain
sterility.

❖ As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients. Staff must open
and assemble the required sterile items only immediately before the procedure. Staff must
set up sterile trays as close to the time of use as possible.
❖ During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.
Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

- A sterile object becomes non-sterile when touched by a non-sterile object.

Substandard # 11:13 - Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
transfer forceps.
Sterile to sterile rule is - Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
applied during any aseptic - Non-sterile items should not cross over the sterile field. For example, a non-sterile person
procedure. should not reach over a sterile field.
- Sterile area can only touch sterile area. Always Keep hands above waistline.
- All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
- Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
- Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
- Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
- Whenever the sterility of an object is questionable, consider it non-sterile.
- When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.

503 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Stay organized and complete procedures as soon as possible.
- Sterile objects can become non-sterile by prolonged exposure to environment.
- Movement around and in the sterile field must not compromise or contaminate the sterile
field.
- Do not sneeze, cough, laugh, or talk over the sterile field.

Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area. away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc

Substandard # 11:14 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

Proper infection control practices must be followed during the preparation and
administration of injected medications oOnly sterile devices and supplies are used for invasive
procedures, after patient’s skin antisepsis (e.g., sterile fistula needles, syringes, needles
Substandard # 11:15
& medications) Medications should not be prepared in the treatment areas
Intravenous medication vials labeled as single-dose or single-use vials should be used
All injectable medication
for a single procedure/injection
used in haemodialysis
Safe Injection Practices
should be in a single dose
Never administer medications from the same syringe to more than one patientoDo not
form. (whenever possible)
enter a medication vial, bag, or bottle with a used syringe or needleoNever use medications
packaged as single-dose or single-use for more than one procedure/injectionoAlways adhere
to aseptic technique when preparing and administering injections.

504 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 A multi-dose vial is a vial of liquid medication intended for parenteral administration (injection
or infusion) that contains more than one dose of medication. Multi-dose vials should be
dedicated to a single patient whenever possible. If multi-dose vials must be used for more than
Substandard # 11:16 one patient, they should only be kept and accessed in a dedicated clean medication
preparation area (e.g., nurses station), away from immediate patient treatment areas. This is to
If multi-dose vials must be prevent inadvertent contamination of the vial through direct or indirect contact with potentially
used, should be dedicated contaminated surfaces or equipment that could then lead to infections in subsequent patients.
for one patient only, dated If a multi-dose vial enters an immediate patient treatment area, it should be dedicated for
when accessed for the first single-patient use only.
time and discarded after 28
days unless the ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
manufacturer specifies a ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
different shorter or longer allocated only for one patient, observe to ensure that the following data are recorded on
period. used vials:

• Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’
treatment areas without patient's name & medical record number to avoid its
use for multiple patients)
• Date of the first use (when it has been accessed for the first time) must be
recorded on used vial. Must be discarded after 28 days unless the
manufacturer specifies a different shorter or a longer date (i.e., reuse life)

Substandard # 11:16 ❖ Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one ❖ Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should ❖ If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result contamination of vial in patient’s surroundings.
medication area and it must ❖ Such practices must be corrected by regular training sessions.
not enter the immediate ❖ Train, monitor and audit staff performance during IPCCC activities.
patient treatment area.

Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between the
injection materials and the non-sterile environment. Proper hand hygiene should be performed
Substandard # 11:17
before handling medications and the rubber septum should be disinfected with alcohol prior to
piercing it. It is NOT acceptable to leave a needle inserted in the septum of a medication vial
Multidose medication vials
for multiple medication draws.
(MDVs) are accessed with a
This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when
❖ Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses
additional doses from a multidose medication vials.
for the same patient.
❖ Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

505 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11:18 Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
The rubber self-sealed cap cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
on a medication vial is of antiseptic / wait the access site to dry before being penetrated with sterile device)
disinfected with alcohol Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
prior to piercing. being disinfected.

❖ Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
❖ Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
Substandard # 11:19
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
❖ IV solution bottles are only accessed through the self-sealed rubber cap. You may
IV solution bottles are only
observe staff accessing the IV solution from the sides of bottle rather than the self-sealed
accessed through the self-
rubber cap.
sealed rubber cap.
❖ You can check by pressing gently the IV solution bottle if any fluid leaks out or no. Staff
must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

❖ Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 11:20
aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used
❖ Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or
nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and
with sterile solutions is preferable).
changed between patients
❖ Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the
system are changed between patients and every 24 hours for the same patient.
same patient unless the
❖ Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made
time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies
sterile solution).
different dates.
❖ Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).
-
Substandard # 11:21 Train, monitor & audit on following key points for replacing dressings on short term CVCs &
implanted / implanted CVCs:
Replace dressings used on
short-term central venous Catheter Site Dressing Regimens:
catheter (CVC) sites every 2
days for gauze dressing. ❖ Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the
catheter site
❖ Transparent dressings are preferred over gauze dressings.
Substandard # 11:22 ❖ Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.
❖ Gauze Dressings used on short-term central venous catheter (CVC) sites must be
Replace dressing used on replaced every 2 days for gauze dressing following aseptic technique.
short-term CVC sites at ❖ Transparent Dressings used on short-term central venous catheter (CVC) sites must be
least every 7 days for replaced every 7 days for gauze dressing following aseptic technique.
transparent
dressing.

506 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ❖ Transparent Dressings used on tunnelled or implanted CVC sites must be replaced no
more than once per week (unless the dressing is soiled or loose), until the insertion site
has healed following aseptic technique.
Substandard # 11:23
Additional points:
Replace transparent
dressings used on tunnelled
❖ Do not submerge the catheter or catheter site in water. Showering should be permitted if
or implanted CVC sites no
precautions can be taken to reduce the likelihood of introducing organisms into the
more than once per week
catheter (e.g., if the catheter and connecting device are protected with an impermeable
(unless the dressing is
cover during the shower)
soiled or loose), until the
insertion site has healed.
Reference: https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html

507 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

S. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
T. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
U. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xiii. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xiv. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

508 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Provide education to the staff regarding importance of isolation precautions during IPCCC training
Substandard # 12:01 activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis for
isolation precautions patients under isolation.
are available in the Use preferably isolation precautions signs provided by GDIPC.
unit & used Must be placed / posted on door only if occupied by patient.
appropriately. 02 types of isolation precaution signs must be available in the unit.

- Isolation precaution signs for units to be posted on doors if the isolation room is
Isolation signs must occupied by patients with diseases transmitted either by contact, droplet or airborne
be : 1) Clear and route.
visible for HCWs and - Isolation Transportation cards for transportation of patients to other departments as
visitors 2) Bilingual (in needed.
Arabic & English). 3)
Color coded and Contact isolation Precautions must be used together with standard precautions:
compatible with
diagnosis (Examples: Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
contact: green, infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
airborne: blue, and The patient should be in a single room. A neutral pressure room is indicated.
droplet: pink or red) Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

509 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Precautions must be used together with standard precautions. Droplet
Precautions are intended to reduce the risk of droplet transmission of infectious agents from close
Substandard # 12:02 contact (exposure to eyes, nose and mouth) with large-particle droplets

Appropriate isolation Should be Initiated and maintained when there is suspected or confirmed diagnosis of an
transportation cards / infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
sings are available in Use a single room. A negative air pressure room is not indicated.
the department & Place a droplet sign on the door.
used while Droplet isolation signage must be color coded (e.g., orange) and must be available in both
transporting patients English and Arabic languages.
under transmission-
based precautions to Airborne isolation precautions must be used together with standard precautions
other department as Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases that
needed. are spread via the airborne route.
Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
Transport Isolation disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
signs must be : 1) Use a single room with a negative air pressure system (AIIR)
Clear and visible for Place the Airborne Isolation sign on the door.
HCWs and visitors 2) Airborne isolation signage must be color coded (e.g., blue) and must be available in both
Bilingual (in Arabic & English and Arabic languages. b. Keep door closed at all times except when entering or
English). 3) Color leaving the room.
coded and compatible
with diagnosis
Patient Transportation:
(Examples: contact:
green, airborne: blue,
and droplet: pink or Patient Transportation isolation signs must be used while transporting patients under
red) and selecting low transmission-based precautions to other department as needed.
traffic time & route.
Transport of isolated patients should be limited to essential purposes only, such as diagnostic
and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
should be worn to reduce potential contamination of the environment and the spread of
infection.
Isolation instructions must be clearly highlighted on the transmission-based precaution card
(isolation signs) while transporting patients under transmission-based precautions to other
department ( e.g radiology).

IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 12:03 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
Log book for exposure entry into isolation room for any task.
is available for any Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
potentially harmful Logbook must specify the name, designation / job category, Duration of exposure (Time in /
infectious exposures Time out) & type of PPE used.
as per exposure Appropriately used logbook will generate information needed in case of outbreaks etc
policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. before gaining entry into isolation room.
MERS-CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

510 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use items are those that are intended for single use only, on an individual patient for a
single procedure, and then should be discarded. It should not be reprocessed or reused again
Substandard # 12:04 even on the same patient.
Single use or
Provide training and orientation to staff regarding patient care equipment to be used for isolation
dedicated non-critical
rooms during daily/weekly rounds:
patient care equipment
(e.g., stethoscope,
Following instructions must be given:
pressure cuff, etc.) are
used for the isolation
If single use non critical items are used for isolation rooms, they must be immediately
room.
discarded after use. Single use items must never be kept to be reused for the same patient or
next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be disinfected
after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc

Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation room
is used for another isolation room or another area.

Transfer of patients under isolation precautions must be restricted to medically necessary

purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
procedures that cannot be performed in the patient’s room.

Provide training and orientation to staff the transfer rules related to patient transportation under
Substandard # 12:06 isolation precautions. Observe if unit is following the policy.

If transfer of patient Following instructions must be given:

under isolation is
required, the receiving Receiving unit or facility is informed beforehand about the required isolation precautions to be
unit or facility is taken. (Transfer could be internal to any unit inside facility or external to any other facility)
informed about the Clear instructions must be provided and documented in patient files before transfer.
required isolation Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
precautions and unit etc.
availability of
appropriate PPE is It is important that HCWs in the receiving unit have received prior training on how to safely
ensured. handle patients under isolation precautions and how to appropriately use PPE according to type
of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit tested
for N-95 mask and trained well on how to don & doff after use.

Transferring the Patient to Another Facility:

Inform the receiving facility and the emergency vehicle personnel in advance about the type of
isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

511 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 12:07 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation.
While transferring
patients under Key Points include:
droplet/airborne
isolation precaution, Explain to the patient the need for the protective apparel that he/she is required to wear.
patient should wear a Patient must wear mask during transportation (droplet & airborne isolation)
surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory Isolation instructions must highlight the transmission-based precaution card ( isolation signs)
hygiene and cough needed while transporting patients under transmission-based precautions to other department (
etiquette. e.g radiology).
-

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or
Substandard # 12:8 more classes of antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to
Contact isolation most available antimicrobial agents.
precautions are
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci
initiated for patients
(VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
infected or colonized
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms.
Skin lesions and Proper attention & care to these pathogens is critical to curtail further emergence of these
infected or colonized highly resistant organisms.
areas of patient's body
Infection refers to the entry into and multiplication of an infectious agent in the tissues of the
should be contained
host and the tissue damage resulting in apparent or unapparent changes in the host.
and covered.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and covered
in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

512 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training to the staff for rules to be followed for patient transportation under contact isolation
Substandard # 12:09 precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

For transport patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin Leak-proof dressing should be used to reduce potential contamination of the environment and
lesions and infected or the spread of infection.
colonized areas of the Dress wounds with impervious dressings as required.
patient’s body with Dress the patient in a clean gown.
clean bandages and Cover the patient with a clean sheet.
clean linens. Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

In order to avoid potential risk of acquiring infection visitors should be strictly limited for
airborne isolation cases.
As per standards, some exemptions may be considered on a case to case basis i.e visitors may
be allowed to enter the isolation room if he / she fulfils the following criteria e.g mothers of
babies etc
Substandard 12:10
- Duration of stay will be minimum for few minutes only.
Visitors - Visitors must seek permission from nursing station.
should be strictly - Clear instructions must be provided to visitors in their language before entering into an isolation
limited for airborne room.
isolation cases. - Visitors must be fully compliant with the required PPE i.e visitors will wear same type of PPE
Exemptions may be and follows same protocols as any HCWs before entering isolation rooms.
considered on a case - Proper education, counselling, and monitoring should be provided to the visitors before
to case basis only for entering the airborne infection isolation room.
few minutes after - Nursing staff must keep records of visitor’s education & instructions as evidence to be
having permission presented to external auditors when requested.
from nursing station
and after receiving Educate the staff regarding visitor’s policy & ensure during daily/weekly rounds if its fully
proper instructions implemented:
before entering into an
isolation room and - Observe and ask staff about the visitors if isolation room occupied by patient.
within compliance with - Ask about the evidence of education & documentation in log book.
the required PPE. - Observe when possible any visitor entering or coming out of isolation room if compliant with
instructions.
- Sometimes visitors are not donning PPE appropriately. Gowns is not tied & masks is worn
inappropriately.
- It is also common observation to see visitors coming out of AIIR with all PPE and removing PPE
abruptly without practicing hand hygiene.
- Such practices would pose risk of acquiring infection. Nursing staff must be fulling adherent
with visitor’s policy for isolated patients.

Audit the unit performance during IPCCC audit phase and provide formal feedback.

513 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 The transmission of hepatitis B virus and hepatitis C virus in haemodialysis units has been
documented. For this reason, infection prevention practices should be reviewed regularly and
rigorously followed. Hepatitis B vaccine is recommended for all susceptible haemodialysis
patients and staff. Segregation of hepatitis B patients and all patient care items are the key
measures to be considered for prevention of infection transmission.

IC team must ensure strict implementation of infection control measure for hepatitis B
positive dialysis patients.
Special measures are taken for HBV+ patients that includes:

❖ Dedicated room equipped with dedicated machines to be used only for HBV+ patients.
Substandard 12:11 ❖ Dedicated staff must be assigned for HBV+ patients only. She must not be allowed to
handle any other patient during dialysis session.
❖ IC team must seek administrative support to ensure adequate staffing levels for effective
HBV +ve patients are implementation of all infection control standards.
strictly segregated in a ❖ Following must be ensured:
separate room(s),
treated by dedicated - Physically separated room(s) with accessible hand washing facilities within the
staff during dialysis room(s).
session using - Dedicated HD machines
designated machines, - Dedicate patient care equipment like stethsscope, BP cuff etc
equipment, - Dedicated instruments, medications & other patient care supplies.
instruments, supplies - Special supplies kept in distinct store i.e Separate storage for medications,
and medications which instruments, supplies and other consumables (e.g.store or cabinet(s) away from
are used only for them patients’ zones)

IC practitioners must conduct reorientation & training session for all HDU staff during IPCCC
training activities.
Observe practices in routine rounds. Conduct IPCCC audit & evaluate the unit & staff
performance.
Provide formal feedback & consider for retraining when needed.

Hepatitis B (HBV) infection

Mode of Transmission of Hepatitis B:
- Chronically infected patients are the primary source of transmission.
- HBV is considered to be a resistant virus, is relatively stable in the environment, and remains
viable for at least seven days on environmental surfaces at room temperature.
Dialysis staff members may acquire the infection
- Accidental needle puncture through intact skin.
- ii. Infected plasma, serum or contaminated environmental surfaces through breaks in the skin
such as abrasions, cuts, or scratches.
- ii. Introduction of infected serum or plasma into mucosal membranes (e.g., the splashing of
blood onto the mouth or eyes).
-
Dialysis patients may become infected through the following means:
- Internally through contaminated dialysis equipment (e.g., venous pressure gauges, isolators
or filters).
- Externally through contaminated dialysis machines, including their surfaces, control knobs or
intravenous poles.
- Improperly prepped or contaminated injection site.
- Through breaks in the skin or mucous membranes.
- Contaminated items and surfaces such as clamps, scissors, telephones or walls.
- Improper handling of multiple-dose medication vials and intravenous solutions.
- Contaminated hands & gloves of HCWs , gloves and other objects

514 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 13 Airborne Infection Isolation Rooms (AIIRs)
Airborne Infection Isolation rooms (AIIRs), commonly called negative pressure rooms, are single-occupancy patient care spaces
designed to isolate patients with airborne pathogens to a safe containment area. AIIRs provide negative pressure in the room (so
that air flows under the gap into the room) with a pressure differential of >-2.5 Pa (Pascal) or >- 0.01” water gauge; an air flow
rate of >12 air changes per hour (ACH) and direct exhaust air from the room to the outside of the building; or recirculation of air
through a HEPA filter before returning to circulation.
AIIRs are designed in such a way so that no airborne particulates escape into other areas within the healthcare setting. Exhaust
from these rooms is not recirculated in the HVAC system. Instead, exhaust air typically moves in dedicated ductwork to ventilation
stacks on the rooftop, where atmospheric air provides sufficient dilution to make the resulting air safe.
For the safety of healthcare workers, patients, and visitors, negative pressure rooms occupied by patients requiring airborne
isolation must be checked daily.
Sub standards Explanation
IC Team MUST ensure the following related to Airborne Infection Isolation Room – AIIR
within the haemodialysis units.
Substandard 13.01
a) If Airborne Infection Isolation Room – AIIR is available within the unit, they MUST
Within the Hemodialysis fulfil specification of Airborne Infection Isolation Room – AIIR.
unit, there is an Airborne
Infection Isolation Room –
AIIR is available to provide b) AIIR is not available within the unit following MUST be ensured:
care for patients with
suspected MERS-CoV / Departmental polices should include written protocol for transferring dialysis patient
COVID – 19 infection, with suspected MERS-CoV infection to another healthcare facility, which has an AIIR
otherwise there is an to get their dialysis sessions while applying airborne infection isolation precautions.
applied written protocol to There must be evidence of applied protocol for transferring dialysis patient with
transfer them another
suspected MERS-CoV infection to another healthcare facility to get their dialysis
healthcare facility to get
sessions (e.g., forms used for contact and transfer)
their dialysis sessions while
applying airborne infection
isolation precautions) Flow chart for suspected MERS CoV / COVID 19 MUST clearly describe the pathway of
patients who need further assessment in Airborne Infection Isolation Room – AIIR (Will be
assessed inside Unit AIIR or will be transferred to other facility with Airborne infection
protocols for transfer)

Provide training and orientation to the staff regarding general specification to be met for
all negative pressure isolation rooms. Monitor different parameters during routine
infection control rounds and observe If within recommended ranges. Evaluate the
performance of unit during IPCCC audit phase & provide formal feedback.
Substandard 13.02 Nurse in charge must receive clear instructions to keep all necessary records in the unit
to be presented if requested from external auditors.
Central air condition or
separate concealed unit is This includes all routine maintenance records and actions taken in terms of deranged
the source of conditioned environmental control parameters or malfunctioning.
fresh air. Maintenance staff must be consulted to provide detailed evidence of all these
specifications and each unit & IC team must keep copy of records.
Units must hard to keep all parameters within normal range and well prepared to provide
documented evidence for any external audit visit.

515 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 13.03: Following specifications must be met for all AIIRs:

- There must be 100% fresh air supply from central AC or concealed separate unit.
Air exhausted from - Return of air is not permitted & source of conditioned fresh air must be only via these 02
bathroom must be sources. (Central air condition or separate concealed unit).
exhausted 100% outside
through HEPA filter.
- Air from bathrooms must be exhausted 100 % outside through High‐Efficiency Particulate
Air (HEPA) filters.
- The exhaust air ducts MUST be independent of the building exhaust air system
- HEPA filter should be changed on regular basis and according to manufacturer’s
instructions.
- Unit must keep records of all documents that prove the maintenance and changing of
HEPA filter (as recommended)
Substandard 13.04:

HEPA filter is changed on Rationale:

regular basis and according
to manufacturer's High-efficiency particulate air (HEPA) filter is an air filter that removes >99.97% of particles
recommendations. >0.3um at a specified flow rate of air. HEPA filters may be integrated into the central air
handling systems, installed at the point of use above the ceiling of a room, or used as
portable units.

During rounds ICPs must ensure that each AIIR is equipped with a fixed monitor for
continuous monitoring of environmental control parameters and are in functional condition.
Substandard 13.05:
[

There is monitor for

continuous monitoring of Monitor must exhibit following specifications and records following parameters:
pressure difference at
negative pressure room
having audio visual alarming Negative pressure (-2.5 pascal or more)
system when the ventilation >12 air changes per hour.
system failed.
Has an audio-visual alarm system in case of ventilation system failure. There must be
Visible red flashing lights and audible sound comes from the monitor.
Substandard 13.06:
Fixed monitor must be installed outside each AIIRs in the corridor to monitor the pressure
Isolation Room is difference between the room and corridor.
maintained at negative
pressure (-2.5 pascal or Test the monitor to ensure that alarm is working or no, by keeping the door of AIIRs open
more) with respect to for few seconds. Hold the room door open. After the time delay, the audible and visual
corridors.
alarm should annunciate.
Verify that the monitor is correctly reading the pressure. While the door is held open, the
Substandard 13.07:
pressure reading should be at or near 0" water gauge.
Isolation Room is Use a manual device to monitor pressure differentials in rooms where no monitor is
maintained with >12 air
changes per hour. installed.

516 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During daily / weekly rounds ICPs must ensure that policy for regular monitoring of negative
pressure difference is fully implemented. If any breaches unit head must be informed.
Monitor and evaluate unit performance in IPCCC audit phase using IPCCC tool.

❖ Unit must keep record of all documents as evidence of regular monitoring of negative
pressure difference of AIIRs for at least last 3 months:

❖ Daily when in use (i.e., a patient is isolated inside) .

Substandard 13.08:
❖ Weekly when not in use (i.e., no patient is isolated).
❖ Monthly check by biomedical personals
Records for routine
monitoring of pressure
gradients (daily if a patient Responsibility of Nursing staff:
is isolated inside, weekly
when not in use and
monthly by biomedical Negative pressure rooms in use:
department). Nursing staff must conduct visual checks for the direction of air flow (using flutter strips)
on all rooms where patients are in airborne isolation for query and confirmed airborne
transmissible diseases (e.g., Pulmonary Mycobacterium tuberculosis, measles, chicken
pox) when patients are in this room.
Prior to admitting patients needing airborne isolation, check and ensure that negative
pressure rooms are functioning well. For those designated isolation rooms without
monitor, call maintenance to check if the room is maintaining its negative pressure.
Follow the procedure of this policy in any room that fails inspection. d. All documentation
must be sent to the IP&C Department.

B. Negative Pressure Ventilation Failure:

Unit staff must respond to negative pressure failure.

Nursing staff will lace a surgical mask on the patient in airborne isolation.
Keep the door closed at all times.
Notify the Utilities & Maintenance (U&M) Department of the location and problem & IC
Department
If U&M declares the occupied room is no longer maintaining negative pressure, patient
must be transferred to another negative pressure room immediately.
Put a surgical mask on the patient before transporting.

517 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 An aerosol-generating procedure (AGP) is defined as any medical procedure that can induce
the production of aerosols of various sizes, including small (< 5 microns) Particles. AGPs
includes bronchoscopy, sputum induction, intubation and extubation,cardiopulmonary
Substandard 13.09: resuscitation, open suctioning of airways, Ambu bagging,nebulization therapy, high frequency
oscillation ventilation and Bilevel Positive Airway Pressure ventilation – BiPAP
Any aerosol generating
procedure (AGP) should be Precautions to be observed when performing aerosol- generating procedures, which may be
done in negative pressure associated with an increased risk of infection transmission:
room or single room with
portable HEPA filter using Perform procedures in a negative pressure room or single room with HEPA filter
appropriate PPE (N95 mask, Limit the number of persons present in the room to the absolute minimum required for the
eye protection, gloves & patient’s care and support.
gown) with possible minimal Wear N95 masks: Every healthcare worker should wear a fit-tested seal check N95 mask
number of staff. (or an alternative respirator if fit testing failed).
Wear eye protection (i.e. goggles or a face shield).
Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures require
sterile gloves
Wear an impermeable apron for some procedures with expected high fluid volumes that
might penetrate the gown.
Perform hand hygiene before and after contact with the patient and his or her surroundings
and after PPE removal.

Train & observe the following during daily/weekly rounds:

❖ HCWs performing any aerosol generating Procedure (AGPs) like CPR, intubation,
extubation, suctioning etc for any suspected or confirmed COVID – 19 or MERS- CoV
cases. (If possible to observe the real situation / scenario).
❖ Observe the type of PPE used by HCWs while preparing for AGPs.
❖ Observe if AGPs are performed in negative pressure room or single room with HEPA filter.
❖ Ask about the total number of staff to be present during procedure. Ensure minimum
number of staff are present who are absolutely necessary for specific procedure / task.

Evaluate the staff performance during IPCCC audit phase & provide formal feedback.

518 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 AIIRs MUST fulfill the following MOH specifications for standard isolation
rooms:
Substandard 13.10:
FLOORS, WALLS & CEILING:
AIIRs fulfill all MOH
specifications for standard Minimal openings in the walls, floors and ceiling that are well sealed and airtight.
isolation rooms + windows Smooth, one piece without any cracks or decorative fine parts.
are sealed and fixed (i.e., They should be covered with such paints so as to withstand repeated cleaning
could not be opened/)
and disinfection by approved disinfectants.
openings in walls and
ceiling are sealed and DOORS:
airtight / doors are properly
designed and well-sealed. Doors are properly designed and well-sealed.
The door should open to the inside.
Substandard 13.11: Extend completely to the floor
Must have auto closure device / auto closure mechanism.
The door should open to the
inside, has auto closure WINDOWS:
device, well-sealed and
extend completely to the Windows are sealed and fixed (i.e., could not be opened)
floor. This will ensure to maintain continuous negative pressure differentials inside
airborne infection isolation rooms.

Substandard 13.12: CURTAINS:

Windows are completely After discharge, transfer or death of patient under airborne precautions, curtains
sealed and fixed (i.e., could must be changed after terminal cleaning of isolation rooms
not be opened).
HAND HYGIENE FACILITY:

Substandard 10.13: k) Hand Washing:

Following are required inside patients’ room
Curtains must be changed
Hand Washing Sink
between patients.
Plain and antimicrobial soap
Paper towels
Available at easily accessible location
Substandard 13.14:
l) Hand Rubbing:
Hand washing facilities and
supplies (sinks / plain and Alcohol - based hand rub dispensers
antimicrobial soap / paper Available at easily accessible location for staff to practice 5 moments of hand hygiene & to
towels, Alcohol - based perform hand hygiene after doffing of PPE items.
hand rub dispensers) are
available & easily PPE TROLLEY:
accessible.
Ensure availability of PPE trolley OUTSIDE AIIRs.
Well organized and well maintained.
Substandard 13.15: Appropriately cleaned external surfaces and internal surfaces of drawers ; free from
dust and any other visible contamination.
Trolley that contains the All required PPE items MUST available (Gowns, Gloves, N – 95 respirators. Face
proper PPEs is available. shields / goggles etc)
PPE items are organized in a way to facilitate staff while donning PPE.
PPE or any other medical supply must never be kept inside isolation rooms to avoid
risk of contamination.

519 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 14 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often
contain large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred
to patients or healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must
follow Standard Precautions at all times. To reduce the possibility of occupational risks of infection transmission and/or exposure,
laundry workers should focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal protective equipment
(PPE). Removal of foreign objects from soiled linen. 4. To restore soiled linen to usable condition, washing, bleaching, rinsing,
and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 14:01 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 14:02 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 14:03 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 14:04 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

520 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 14:05 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 14:06 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Substandard # 14:07 Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Linen carts are covered and Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
not overfilled. to 10 inches off the floor.
Linen from isolation rooms is considered regular soiled linen.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

521 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 15 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
Substandard # 15:01 - Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)
All types of waste
containers are Specification of Items:
available in sufficient
number and placed in Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
easily accessible sites. with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

522 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 15:02 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 15:03
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 15:04 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 15:05 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

523 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 15:06 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 16 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 16:01
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 16:02 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to Local records for corrective interventions which are taken if readings are not matching the
70%). acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.

524 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
Substandard # 16:03
- Recommended temperature Range is: 22 - 24°C
Away from air vents and - Recommended relative Humidity is up to 70%.
well ventilated.
Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.
Substandard # 13:04

Storage shelves are 40 Infection control team must provide training and reorientation about all specifications to be
cm from the ceiling, 20 followed for the maintenance of departmental medical stores.
cm from the floor, and 5
Train on following specifications / key points and observe in daily / weekly rounds if unit is
cm from the outside wall.
adherent with recommendations or not.
Departmental medical stores must be well organized & well maintained.
Substandard # 16:05 Must be away from any contamination, direct sunlight and airs vents.

Storage shelves made Specifications of Storage Shelves:

from easily cleanable
Storage shelves are made of easily cleanable material
material (e.g., fenestrated
stainless steel, Aluminium (e.g., fenestrated stainless steel, Aluminium or hard plastic).
or hard plastic) Storage shelves are placed following these specifications.
- 40 cm from the ceiling
Substandard # 16:06 - 20 cm from the floor
- 5 cm from the wall
Sterile and clean items
completely separated If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
from personal items & hard plastic).
foods and drinks.
Ensure that only sterile and clean items are allowed in the medical stores.
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 16:07 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
original cardboard shipping boxes.
Substandard # 16:08
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
inside sock room. (i.e., boxes made of thick cardboard for shipping.
Items not kept in original
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
cardboard shipping
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
boxes.
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

525 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
Substandard # 16:09 discarded)
If any stained item is found it would most likely reflect that item was restocked after being
No expired items, broken brought from patient care areas which is against the rules of aseptic technique. Such
packs or packs with practices must be strictly prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in
order to ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit
phase.
Provide formal feedback on unit & staff performance

526 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 17 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 17:01 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.
Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
In health care settings, First and foremost, a mask is a core component of the personal protective
equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
Substandard # 17:02 in conjunction with gown, gloves, and eye protection.

All HCWs must abide All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
by the policy of expected to wear surgical face masks, at all times, while in their respective clinical care settings.
universal masking i.e
wearing surgical face
This universal mask approach will serve to:
mask at all times while
in their respective Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
clinical setting. mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

527 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

528 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 17:03
prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers &
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
visitors strictly adhere
droplets can also be inhaled into the lungs.
to the principles of
Recent studies indicate that people who are infected but do not have symptoms likely also play a
social distancing,
role in the spread of COVID-19. Since people can spread the virus before they know they are
cough etiquette and
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
frequent hand hygiene
have any symptoms.
during duty hours /
visiting hospital.
Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

529 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 17:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc) HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients etc

530 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
531 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
532 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

533 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
OPERATION ROOM (OR)

Operation room continue to be a high risk area where strict adherence to the

standards of care is essential for better patients’ safety. The quality and standard of surgical care in hospitals is
an important issue.

Strict implementation of infection control procedures including surgical hand antisepsis hand hygiene, practicing
aseptic technique, strict environmental measures, ensuring standard ventilation parameters etc. would play a
significant role in reducing risk of surgical site infections.

534 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN operation
room (or)

POLICIES & PROCEDURES

EDUCATION & TRAINING

OPERATION ROOM

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

THEATER DESIGN

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

535 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 OPERATION ROOM
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1.1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1.2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / dealing with
accessible for them. infectious cases etc. Ask verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

536 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2.1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
(HCP) receive joining work & issue a BICSL ID which should be renewed ever 02 years.
orientation and Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
training on Basic hours as an evidence of basic infection control training to be presented to any external /internal
Infection Control Skills audit visit for purpose of verification.
from IC department
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
maximum within 1
every 2 years by visiting infection control department.
months of joining
work & a BICSL card
is issued which is Components of BICSL includes:
renewed every 2
years. - HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

537 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2.2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

538 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2.3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

539 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way
to prevent infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are
becoming difficult to treat. On average, healthcare providers clean their hands less than half of the times they should. On any
given day, about one in 31 hospital patients has at least one healthcare-associated infection.
Sub standards Explanation

Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels
etc.) in all patient care areas, nursing stations and other appropriate places is crucial for effective
implementation of hand hygiene program.

Hand Washing Facilities:

Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities
are available that meet the needs of the unit and are clean and in good repair.
Observe availability of water supply (hot and cold) for hand washing (Place hands under the
water tap if hands free operation or open the tap to check for hot & cold water supply)
Substandard # 3.1 Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Hand Hygiene Supply
is available. Hand Rub Dispensers:

- Check the availability of hand rub dispensers as per requirements:

One dispenser per patient's bed,
One at every nursing station
One any service areas e.g medication room, storage area etc

- Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas
etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and
their ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and
switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

540 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3.2
Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand
Health care antisepsis
professionals (HCP) Hand washing – washing hands with plain or antimicrobial soap and water.
demonstrate Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
appropriate technique microorganisms without the need for an exogenous source of water and requiring no rinsing or
for hand rubbing and drying with towels or other devices.
hand washing.
Indications:
Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures,
after body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene
in healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile)
and /or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and
technique of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the
hands and fingers
541 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.

Substandard # 3.3 ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces
are posted at appropriate places.
Visual alerts are
available: WHO 5 - WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
moments, how to do - How to hand wash poster beside ach hand washing sink
hand rub, how to do - How to handrub poster beside each hand hygiene dispen
hand wash. -
WHO Five moments of hand hygiene:

1: Before touching a patient:

- Clean your hands before touching a patient when approaching him/her.

- This is to protect the patient against harmful germs carried on your hands.

2: Before aseptic procedures:

- Clean your hands immediately before performing a clean/aseptic procedure.

- This is to protect the patient against harmful germs, including the patient's own, from
entering his/her body
-
3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids & glove removal.
- This is to protect yourself and the health-care environment from harmful patient
germs.

4: After touching a patient:

- Clean your hands after touching a patient and her/his immediate surroundings, when
leaving the patient’s side.
- This is to protect yourself and the health-care environment from harmful patient
germs.

5. After touching patient surroundings:

- Clean your hands after touching any object or furniture in the patient’s immediate
surroundings, when leaving even if the patient has not been touched.
This is to protect yourself and the health-care environment from harmful patient germs.

542 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Surgical hand antisepsis is defined as an antiseptic hand wash or antiseptic hand rub performed
Substandard # 3.4 preoperative by surgical personnel to eliminate transient and reduce resident flora.

OR team strictly Bacteria on the hands of surgeons can cause wound infections if introduced into the operative field
adhere to the rules of during surgery. Rapid multiplication of bacteria occurs under surgical gloves if hands are washed with
a non-antimicrobial soap. Bacterial growth is slowed after preoperative scrubbing with an antiseptic
surgical hand
agent.
antisepsis before any
surgical procedure Reducing resident skin flora on the hands of the surgical team for the duration of a procedure reduces
following appropriate the risk of bacteria being released into the surgical field if gloves become punctured or torn during
technique & surgery / unnoticed puncture of the surgical glove releasing bacteria to the open wound.
recommended Therefore, strict adherence to surgical hand antisepsis is of utmost importance to protect the patients
duration. from acquiring surgical site infections.

IC MUST provide education & training to surgical team during IPCCC training phase followed by
monitoring and evaluation of practices. Practical training should be provided using videos etc

1. Surgical hand hygiene:

• Surgical hand scrub with antimicrobial soap

• Surgical hand rub with the hospital-approved alcohol-base preparation

2. Before starting surgical hand hygiene preparation (hand scrub or hand rub)
3.
4. 1. Remove all jewellery and wristwatches before entering the operating room (OR) suite.
5. 2. Wash hands and arms up to the elbows with an antimicrobial soap before entering the OR area.
6. 3. Use a nail cleaner for the first surgical hand scrub of the day.

Surgical hand scrub with antimicrobial soap:

- Start timing and then scrub each side of each finger, between the fingers and the back and
front of the hand for two minutes.
- Scrub the arms, keeping hands higher than the arms at all times.
- Wash each side of the arm from wrist to the elbow for one minute, repeating the process on
the other hand and arm.
- Rinse hands and arms by passing them through the water in one direction (from fingertip to
elbow), always keeping the hands above the elbows.
- Proceed to the OR holding hands above the elbows.
- Dry hands with a sterile towel and use aseptic technique to put on gloves.

NB: The duration of the procedure depends on the ingredients and the manufacturer’s instructions (can range from 3-5
minutes).

Surgical hand rub with the hospital-approved alcohol-base preparation:

- Start timing & apply sufficient product to keep hands and forearms wet with the hand rub
throughout the procedure.
- After application of the product, allow hands and forearms to dry before donning sterile
gloves.
- Proceed to the OR holding hands above the elbows.

NB: The duration of the procedure depends on the ingredients and the manufacturer’s instructions and should
last until hands are dry.

Use of brushes is discouraged as they may damage the skin and encourage shedding of cells.

543 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
544 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
545 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Surgical Hand Hygiene

546 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Surgical Hand Hygiene

547 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4.1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room but
are available and readily not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will interfere
accessible to HCP. with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2
masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock rooms.
N - 95 respirators are
Check if all types and sizes are available according to fit test result of each healthcare
available in different types and
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)
sizes.

548 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4.3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

549 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured at
Substandard # 4.4 neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.
Staff use personal protective
equipment appropriately (e.g. Sequence of doffing PPEs before leaving the room:
donning and doffing)
Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

https://youtu.be/H4jQUBAlBrI 2: Appropriate PPE for Droplet Isolation:

Watch Video How to safely put
on PPE Sequence of donning PPEs before entering the room:
Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

550 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

IC Team must ensure appropriate PPE to be used by staff in the delivery room due to
Substandard # 4.5 significant risk of exposure to blood and body fluids exposures.

Face shields / Goggles are Face shields or eye goggles MUST be available and used by staff in the delivery room
available to avoid splashes on along with gowns & gloves to avoid splashes to face & eyes.
face and eyes. Gown should Shoe covers must also be available and used to avoid splashes on feet.
be available. Wear shoe covers
to avoid splashes on feet. - Observe the staff practices during IC monitoring rounds
- Evaluate the performance during IPCCC audit phase.
- Provide feedback and reconsider for training if needed.

551 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
552 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
553 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
554 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5.1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5.2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5.3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

555 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5.4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5.5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5.6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5.7 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

556 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6.1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.
Substandard # 6.2
The spill kit must include the following:
There is at least one spill kit
available in the department. - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
- Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

557 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6.3 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

558 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
Substandard # 6.4 logs /checklists is extremely important to ensure effective implementation & to have the
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
Cleaning is done properly is done & documented appropriately as per schedule.
using checklist that include
cleaning frequency, Each unit must have the schedule for cleaning and disinfection activities.
responsible worker, used Schedule must include the frequency, the used disinfectant and the responsible staff.
agents, methods & Roles must be specified with clear instructions.
environmental surfaces
intended to be cleaned (e.g 1. Nursing staff for medical equipment
operating table, surgical 2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
lights, anaesthesia machine 3. Anaesthesia technician for anaesthesia machine etc
etc).
Assigned IC personnel must schedule frequent rounds for the OR. During routine rounds
ensure and observe the following:

There must be housekeeping schedule with cleaning / disinfection activities log that records :
Substandard # 6.5
- Responsible housekeeping staff (Only experienced staff are allowed. They should be well
OR environment is trained on hand hygiene, use of PPE, methods of cleaning, and proper and safe mixing of
maintained clean and there chemicals).
are clear procedures for - Methods of cleaning and used agents, materials and supplies (wet cleaning, MOH
routine cleaning and approved disinfectant/detergent, non-lining wipes …)
disinfection by allocated - Environmental surfaces intended to be cleaned & frequency (OR table, surgical lights,
housekeeping staff before anaesthesia machine etc.)
the first procedure, after - Clear procedures for cleaning / disinfection activities after each surgical procedure and at
each surgical procedure, least daily with practical updated detailed checklist.
after the last Procedure (i.e., - Clear procedures for cleaning and disinfecting anaesthesia machines by anaesthesia
terminal cleaning) and at technicians after each case and toward the end of working hours with practical detailed
least daily. checklist
- OR environment is clean (at all times) and free of contamination (no dirt or dust):
- You can wipe out the main operative light lamp, operative table, or other environmental
surfaces /
- Check & ensure if tools, agents & materials used for cleaning/disinfection activities are
available and matching MOH standards.

OR housekeeping schedule / nurse role & responsibility in cleaning/disinfection activities /

methods of cleaning / tools, agents & materials to be used / terminal cleaning checklists /
cleaning/disinfection activities after patients with infectious transmissible diseases /
handling body fluids spills.

In Charge nurse must supervise & document the terminal cleaning process after the surgical
procedure in following situations:
Substandard # 6.6
- If the procedure was performed for infectious diseases like Tuberculosis, COVID -19
Terminal cleaning must be & hepatitis B etc
supervised by the in-charge - This is to ensure meticulous environmental cleaning to avoid risk of infection
nurse if the procedure was considering the survival time of organisms on the environmental surfaces and
done on patients with patients care equipments.
infectious diseases e,g -
Tuberculosis, COVID -19, (All terminal cleaning checklist must be kept in the unit to be presented for review
Hepatitis B etc. during audit rounds by external inspection teams (MOH-CBAHI)

559 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6.7 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

560 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

561 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6.8 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
Substandard # 6.9 the hospital settings:
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

562 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6.10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team must train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Housekeeping staff must adhere to Standard Precautions and if required Expanded
Substandard # 6.11 Precautions when performing routine practices of cleaning and following infection control
measures.
Housekeepers are well Routine practices related to environmental cleaning includes:
trained on hand hygiene,
proper use of PPE, methods HAND HYGIENE:
of cleaning & proper & safe
mixing of chemicals. Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

563 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6.12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6.13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6.14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

564 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6.15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6.16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6.17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

565 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 7.1 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 7.2 in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of to use large IV solution bottles for preparation & dilution of medications
medication is only done by Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water specified for preparation & dilution of medications.
ampoule. Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 7.3
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

566 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 7.4
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 7.5 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient.
While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.
After completion of treatment session or any clinical procedure or patient discharge following
must be practiced:

Substandard # 7.6 All remaining single-use items are discarded, even unused ones with intact original wrap
(i.e., they cannot be used on other patients or returned to clean areas, such as medical
All patient care supplies are stores or medication preparation areas etc )
brought to patient area All reusable items are sent for reprocessing, even unused ones with intact original wrap.
when needed with no Visit the medical store and check the stock by random selection. You may find an item with
excess. Any remaining open cover or occasional blood or betadine stain. Such practices are strictly prohibited.
items after patient discharge
are considered Audit the performance in IPCCC audit phase:
contaminated even in their Observe a real treatment or procedure session or ask staff to simulate any procedures or
wrapping. treatment sessions (IV Cannulation or administration of multidose medications etc
• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)
Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

567 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Maintaining the integrity of sterile equipment and solutions is extremely important to
prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
urinary catheter).
- If the sterile items are assembled long before the procedure, there are chances of
contamination from environment such as dust etc.
Substandard # 7.7 - A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
Sterile equipment and the transfer of microorganisms and reduce the potential for infections.
solutions are assembled - Principles of sterile technique help control and prevent infection, prevent the transmission
immediately prior to use. of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.

As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.

Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Substandard # 7.8 Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
transfer forceps.
Sterile to sterile rule is Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
applied during any aseptic Non-sterile items should not cross over the sterile field. For example, a non-sterile person
procedure. should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.

568 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 7.9 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 7.10 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

569 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7.11 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 7.12 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
of antiseptic / wait the access site to dry before being penetrated with sterile device)
Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
being disinfected.

Substandard # 7.13 Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
The rubber self-sealed cap wipes).
on a medication vial is Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
disinfected with alcohol sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
prior to piercing. IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
than the self-sealed rubber cap.
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.

Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 7.14 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
IV solution bottles are only of antiseptic / wait the access site to dry before being penetrated with sterile device)
accessed through the self- Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
sealed rubber cap. being disinfected.

570 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
than the self-sealed rubber cap.
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
Substandard # 7.15 Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.
Maximum sterile barrier
According to The Joint Commission, there are four chief aspects of the aseptic technique:
precautions is applied
barriers, patient equipment and preparation, environmental controls, and contact guidelines.
during any interventional
Each plays an important role in infection prevention during a medical procedure. Barriers
procedure, including cap,
protect the patient from the transfer of pathogens from a healthcare worker, from the
mask, sterile gown, sterile
environment, or from both. Some barriers used in aseptic technique include:
gloves, and sterile full-body
drape. - Sterile gloves
- Sterile gowns
- Masks for the patient and healthcare provider
- Sterile drapes etc
Substandard # 7.16 - Head Covers
Healthcare providers must use sterile barriers including sterile equipment and sterile
Traffic should be kept instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
minimum once the sterile environment requires keeping doors closed during an interventional procedure like insertion of
field has been established. central line etc.
Only necessary health personnel should be at the procedure. The more people present, the
more opportunities for harmful bacteria to cause contamination.

Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
Substandard # 7.17 water / prefilled humidifiers with sterile solutions).
Check that only ready-made single-use bottles of sterile solutions are used to fill
Only sterile fluids are used nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
in nebulizers, humidifiers, or with sterile solutions is preferable).
any aerosol generator and Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
changed between patients system are changed between patients and every 24 hours for the same patient.
and every 24 hours for the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
same patient unless the time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
manufacturer of ready-made sterile solution).
sterile solutions specifies Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates. different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

571 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

V. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
W. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
X. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xv. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xvi. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

572 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation

IC Team must ensure availability of following documents in the OR for scheduling operations for
Substandard # 8.1 Patients with infectious diseases:

Patient with infectious OR Policy & Procedures:

disease having operation
are scheduled at the end - Policy MUST include handling patients with transmissible diseases (patient +ve for one of
of the day if possible. blood borne pathogens / patients under air-borne transmission-based precaution / patients
under contact and/or droplet transmission-based precaution)
- Scheduling cases with infected wounds (e.g., dirty wounds).
Substandard # 8.2
Operating lists:
For patients with active
infectious disease, only - OR must have evidence to review the last event for dealing with patients with transmissible
emergency procedures diseases or cases with infected wounds
are recommended.
Elective procedures Terminal Cleaning logs:
should be postponed until
the patient is no longer - OR staff must keep evidence of terminal cleaning/disinfection activities after patients with
infectious. infectious transmissible diseases or cases with infected wounds

Patients with active infectious diseases:

- For patients with active infectious disease, only emergency procedures are recommended.
- Elective procedures should be postponed until the patient is no longer infectious.
Provide education to the staff regarding importance of isolation precautions during IPCCC
training activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.

Contact isolation Signs: are used for patients with diseases transmitted by contact route.

Should be initiated and maintained when there is a suspected or confirmed diagnosis of an

infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies
etc
The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation
signage must be color coded (e.g., green) and must be available in both English and
Arabic languages.
Door must be kept closed at all times.

573 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Signs: are used for patients with diseases transmitted by droplet route.

Droplet Precautions are intended to reduce the risk of droplet transmission of infectious agents
from close contact (exposure to eyes, nose and mouth) with large-particle droplets

Should be Initiated and maintained when there is suspected or confirmed diagnosis of an

infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
Substandard # 8.3 Use a single room. A negative air pressure room is not indicated.
Place a droplet sign on the door.
Droplet isolation signage must be color coded (e.g., orange) and must be available in
Signs used to indicate both English and Arabic languages.
categories of isolation
precautions are available:
1) Clear and visible for
HCWs and visitors Airborne isolation Signs are used for patients with diseases transmitted by Airborne route.
2) Bilingual (in Arabic &
English). Airborne precautions is used when a patient is suspected or confirmed to have any of the
3) Color coded and diseases that are spread via the airborne route.
compatible with diagnosis Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an
(Examples: contact: infectious disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
green, airborne: blue, and Use a single room with a negative air pressure system (AIIR)
droplet: pink or red) Place the Airborne Isolation sign on the door.
Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English and Arabic languages. b. Keep door closed at all times except when entering or
leaving the room

Substandard # 8.4 Patient Transportation:

a Isolation transportation Patient Transportation isolation signs must be used while transporting patients under
cards must be used when transmission-based precautions to other department as needed.
transferring of patient
under isolation Transport of isolated patients should be limited to essential purposes only, such as
precautions and it must diagnostic and therapeutic procedures that cannot be performed in the patient’s room.
be consistent with the When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
patient diagnosis, color should be worn to reduce potential contamination of the environment and the spread of
coded, posted in Arabic infection.
and English, and Isolation instructions must be clearly highlighted on the transmission-based precaution
indicating the type of card (isolation signs) while transporting patients under transmission-based precautions to
precautions required for other department ( e.g radiology)
staff (it is preferable to
use the GDIPC approved
isolation transportation
cards), when transporting
the patient they should
select low traffic time &
route.

574 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 8.5 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc

Log book for exposure is Log book must be USED BY THE SURGICAL TEAM IF SURGERY IS scheduled for patients
available for any with potentially harmful infectious exposures as per exposure policies and procedures (e.g.
potentially harmful MERS-CoV).
infectious exposures as
per exposure policies and Logbook must specify the name, designation / job category, Duration of exposure (Time in /
procedures (e.g. MERS- Time out).
CoV).
OR Head Nurse must ensure all logsheets are filled appropriately with all needed
information.
Ensure by random check during IPCCC monitoring rounds if complaint.
Evaluate unit’s performance in IPCCC audit phase,

Substandard # 8.6 PPE use:

- IC Team must provide education & training to OR team on appropriate PPE use for
Proper PPE should be patients on isolation precautions.
used according to the - N – 95 mask must be donned alongwith standard precautions for diseases transmitted
type of isolation by airborne route,
precaution (e.g. N95 for
airborne isolation).

Transfer of patients under isolation precautions must be restricted to medically necessary

purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
procedures that cannot be performed in the patient’s room.

Provide training and orientation to staff the transfer rules related to patient transportation
under isolation precautions. Observe if unit is following the policy.

Following instructions must be given:

Substandard # 8.7 Receiving unit or facility is informed beforehand about the required isolation precautions to
be taken. (Transfer could be internal to any unit inside facility or external to any other
If transfer of patient facility)
under isolation is Clear instructions must be provided and documented in patient files before transfer.
required, the receiving Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
unit or facility is informed unit etc.
about the required
isolation precautions and It is important that HCWs in the receiving unit have received prior training on how to safely
availability of appropriate handle patients under isolation precautions and how to appropriately use PPE according to
PPE is ensured. type of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit
tested for N-95 mask and trained well on how to don & doff after use.

Transferring the Patient to Another Facility:

Inform the receiving facility and the emergency vehicle personnel in advance about the type
of isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

575 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
576 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
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578 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
579 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 THEATRE DESIGN
The operating room environment is a highly regulated patient service area that must be designed following the standard construction
protocols in order to ensure safe controlled environment for the patients undergoing surgical procedures. According to CDC, Surgical site
infection (SSI) remains the third most common healthcare-associated infection (HAI) and may affect the incision, deep soft tissues, or some
part of the anatomy (e.g., organs or spaces).
Most SSIs result from endogenous or exogenous microbial contamination of the wound during surgery. Surgical procedures carry the
potential for serious or catastrophic complications, including infection; therefore, patient care practices should use sound scientific data
to reduce the incidence of surgical site infections. There must be strict adherence to accepted practices and guidelines that address the
prevention of surgical site infections, hand hygiene in healthcare settings, and environmental infection control in healthcare facilities.
Sub standards Explanation

IC team must ensure that OR design and other environmental control parameters are in
accordance with the international standards.

OR suite that should be divided into three clearly demarcated zones*:

Unrestricted area: Area with limited public access that may include:
Central control point: it may be established to monitor the entrance of patients,
Substandard # 9.1
personnel, and materials from the unrestricted area into the semi-restricted area .
There is a clear demarcation Locker rooms: lead into semi-restricted area
between unrestricted, semi Pre-operative admission area.
Offices & waiting areas.
restricted and restricted
Post-anaesthesia care units (PACUs)
zones of OR with
restrictions and special Semi-restricted area: (Peripheral support areas of the surgical suite
precautions for movement Corridors leading from the unrestricted area to the restricted area of the surgical suite
between these zones. Storage areas for clean and sterile supplies

Restricted area:
A designated space with restricted access that can be reached only through a semi-
Substandard # 9.2 restricted area (this is primarily intended to support high level of asepsis control not
necessarily for security purposes
Washable floors, walls and Operating rooms
ceiling that can withstand Scrub stations (large scrub sink close to or at entry of operating room).
repeated cleaning and Areas for preparation of sterile surgical instruments and supplies (opening of sterile
disinfection by approved surgical sets & sterile field preparation), which directly leads to operating rooms
disinfectants.
❖ IC Team must provide refresher training & education during IPCCC training phase on the
infection control standards applicable to their area.
❖ Observe the staff practices, traffic control (movement of the patients, personnel,
instruments and materials) between different zones of the OR suite to ensure that
restrictions and special precautions for movement between different zones are strictly
applied
❖ Evaluate staff and unit performance during IPCCC audit phase.
❖ Provide formal feedback and consider for retraining if needed.

580 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Key points to consider / observe:
In Unrestricted area:
Ensure there is limited public access
Street clothes are permitted in this area
Patients are switched between units’ beds and OR trolleys or beds in this area.
Transport of patients inside semi restricted /restricted area on unit / ward beds is
strictly prohibited.
Semi-restricted area:
Limited access to authorized personnel and patients accompanied by authorized
personnel / Personnel in this area were wearing surgical attire, head covers & and
beard covers for facial hair
No units’ beds in this area (only OR trolleys or beds)
Restricted area:
Restricted access to authorized personnel and patients
Personnel in these areas are required to wear surgical attire head covers & and beard
covers
Masks are required where open sterile supplies or scrubbed persons may be located
+ appropriate use of sterile gowns and sterile gloves when indicated (operating room
scrub clothing).

Observe during routine rounds the internal finishing of the operating theatre (floors, walls
Substandard # 9.3
and ceilings) & any defects must be communicated to the OR supervisors for necessary
interventions.
Floors, walls, ceiling should
have no cracks or
Ensure they are formed of one piece without connections (if formed of separate units or
decorative fine parts , and
tiles, connections between units should be completely sealed)
be one piece without
No breaks, gaps, cracks or decorative parts are observed
connections and with
Only necessary openings (i.e., O2 supply ports, suction ports, electricity plugs …) that are
minimal openings that are
completely sealed to keep pressure differences intact.
completely sealed.
Made of suitable materials (easily cleanable / withstand repeated cleaning and disinfection

Assigned IC personnel must the Observe the scrubbing sink(s) of the operating theatre(s)
which should fulfil following specifications:

Substandard # 9.4 Large & deep and with hands free control
Close to or at the entry of each operating theatre.
At least one large scrubbing
sink is available at entry to D
Dedicated only for hand hygiene & surgical scrubbing
each operation theatre. Provided with dispenser of antiseptic hand soap for surgical hand hygiene (ideal to be
single use dispenser not refillable
One large scrubbing sink, which is shared between two adjacent operating theaters is an
acceptable option.

581 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Strict adherence to the IC measures inside the operation room is of utmost importance to
ensure provision of sterile environment to protect the patients from acquiring surgical site
infections. The basic principles of aseptic technique prevent contamination of the open wound,
isolate the operative site from the surrounding unsterile physical environment, and create and
maintain a sterile field in which surgery can be performed safely. Moreover limiting the
number of personnel & closure of doors will also keep environment safe for patients.
Substandard # 9.5
Traffic Control
Doors are kept closed and
only necessary personnel Only anaesthesia team + surgical team + unscrubbed assistant(s) + equipment
are allowed in the operation technician(s) if needed (as little as possible)
theatre & Only necessary Cleaning/maintenance activities should be avoided during the procedures
items are kept in the Doors are continuously kept closed during the procedures
restricted area of the OR.
Supplies

Unnecessary items are kept outside:

Only items prepared to be used with just one patient, and extra supplies, as little as
possible, may be also prepared to get ready for some emergency situations.
The use of storage cabinets in operating rooms should be minimized
Unnecessary personnel are excluded:

582 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Ventilation Parameters:

Following must be ensured:

- OR team must keep copies of the original charts or project scheme for ventilation system:
- Air supply from central AC through with at least 20 % fresh air.
- All re-circulated and fresh air is filtered through High-Efficiency Particulate Air (HEPA)
filters
- Air is introduced from the ceiling (or high air vents in the wall) and exhausted near the
Substandard # 9.6 floor.

All re-circulated or fresh air HEPA FILTERS:

is filtered through High-
Efficiency Particulate Air - HEPA filter should be changed on regular basis and according to manufacturer’s
(HEPA) filters that are instructions.
maintained and replaced as
per the manufacturer - Unit must keep records of all documents that prove the maintenance and changing of
instructions. HEPA filter (as recommended)

Substandard # 9.7 Rationale:

High-efficiency particulate air (HEPA) filter is an air filter that removes >99.97% of particles
Operation room is >0.3um at a specified flow rate of air. HEPA filters may be integrated into the central air
maintained at positive handling systems, installed at the point of use above the ceiling of a room.
pressure (at least +2.5
Pascal) with respect to
corridors. Positive pressure (at least +2.5 Pascals):

- Ensure operation room are under positive pressure of at least +2.5 Pascals.
Substandard # 9.8 - Fixed monitor must be installed outside each theatre to monitor the pressure

Operation room is difference between the room and corridor.

maintained at least with ≥
Temperature & Humidity:
20 air changes per hour
(ACH) with 20% fresh air. - Ensure Operation room temperature ranges from 21- 24 degree Celsius
- Ensure relative humidity from 20 - 60%
Substandard # 9.9
OR Team must keep following records:
Operation room temperature
Local records for regular monitoring (daily) of: positive pressure differences + temperatures and
ranges from 21- 24 degree
relative humidity ± air changes per hour (ACH) with corrective interventions if readings are not
Celsius and relative humidity matching the acceptable values.
from 20- 60%.
Copies of maintenance records for regular monitoring (every 3 months) of: positive pressure
differences + temperatures and relative humidity + air changes per hour (ACH) with corrective
interventions if readings are not matching the acceptable values.

Copies of records from the executing company (or maintenance records) for regular check-up and
replacement High-Efficiency Particulate Air (HEPA) filters as per the manufacturer recommendations

Copies of records from the executing company (or maintenance records) for regular calibration
(annually) of OR monitors.

583 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain
large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or
healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must follow Standard
Precautions at all times. To reduce the possibility of occupational risks of infection transmission and/or exposure, laundry workers should
focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal protective equipment (PPE). Removal of foreign objects
from soiled linen. 4. To restore soiled linen to usable condition, washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 10.1 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 10.2 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 10.3 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 10.4 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

584 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10.5 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 10.6 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Substandard # 10.7 Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
to 10 inches off the floor.
Linen carts are covered and Linen from isolation rooms is considered regular soiled linen.
not overfilled. The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

585 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 11.1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labelled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

586 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
Substandard # 11.2 importance in preventing sharp and needle stick injuries.

Sharp items (e.g., Observe the practices of staff during daily rounds regarding disposal of sharp items like
needles, scalpel needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
blades, broken metal All sharp items must be discarded in the specified sharp containers including the broken and
instruments and burs) unbroken glass vials.
are placed in an Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture any such situation inform the head nurse to monitor closely the staff practices.
resistant and leak- Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps collection staff / housekeeping staff.
container.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 11.3
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 11.4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 11.5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

587 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 11.6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 12 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

IC Team MUST ensure OR staff strictly adhere to infection control specification of clean and
Substandard # 12.1 sterile supply storage:
Clean and sterile supplies Clean and sterile supply must be kept in the specified storage rooms in the semi restricted
stored in semi restricted area.
area and never stored in In order to avoid risk of contamination unnecessary items should not be kept inside
restricted area restricted area in OR.
Only items prepared to be used with just one patient, and extra supplies, as little as possible,
may be also prepared to get ready for some emergency situations.
Substandard # 12.2 The use of storage cabinets in operating rooms should be minimized.
Only necessary items are Observe the practices during routine rounds and evaluate unit’s performance during IPCCC
kept in the restricted area audit phase.
of the OR.

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
Substandard # 12.3 IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Medical Storage are
clean, & dry with Following key points need to be followed:
adequate capacity and Medical storage areas. rooms must be clean without any contamination from dust etc
away from any form of There must be cleaning schedule with cleaning checklist including all items to be cleaned.
contamination and direct Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
sun light. disinfectants used and required PPE.

- Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

588 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 12.4 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to
Local records for corrective interventions which are taken if readings are not matching the
70%).
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

Infection control team must provide training and reorientation about all specifications to be
Substandard # 12.5 followed for the maintenance of departmental medical stores.

Away from air vents and Train on following specifications / key points and observe in daily / weekly rounds if unit is
well ventilated. adherent with recommendations or not.
Departmental medical stores must be well organized & well maintained.
Substandard # 12.6 Must be away from any contamination, direct sunlight and airs vents.

Storage shelves are 40 Specifications of Storage Shelves:

cm from the ceiling, 20
cm from the floor, and 5 Storage shelves are made of easily cleanable material
cm from the outside wall. (e.g., fenestrated stainless steel, Aluminium or hard plastic).
Storage shelves are placed following these specifications.
Substandard # 12.7
- 40 cm from the ceiling
Storage shelves made - 20 cm from the floor
from easily cleanable - 5 cm from the wall
material (e.g., fenestrated
stainless steel, Aluminium If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
or hard plastic)
hard plastic).
Substandard # 12.8 Ensure that only sterile and clean items are allowed in the medical stores.

Sterile and clean items Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
completely separated from cockroaches and other insects etc.
from personal items &
foods and drinks.

589 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 12.9 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 12.10 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 12.11 Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
discarded)
No expired items, broken If any stained item is found it would most likely reflect that item was restocked after being brought
packs or packs with from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
prohibited.
stains are present.
Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

590 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 13 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 13.1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.
Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
In health care settings, First and foremost, a mask is a core component of the personal protective
equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
Substandard # 13.2
in conjunction with gown, gloves, and eye protection.
All HCWs must abide
All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
by the policy of
expected to wear surgical face masks, at all times, while in their respective clinical care settings.
universal masking i.e
wearing surgical face
mask at all times while This universal mask approach will serve to:
in their respective Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
clinical setting. mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .
- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

591 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

Social distancing is a set of interventions or measures intended to prevent the spread of

a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Substandard # 13.3 Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
Health Care workers, arms’ length) from other healthcare workers during the duty hours.
visitors & Patients
strictly adhere to the
principles of social Why Practice Social Distancing?
distancing, cough COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
etiquette and frequent prolonged period.
hand hygiene during Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
duty hours / visiting mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
hospital. droplets can also be inhaled into the lungs.
Recent studies indicate that people who are infected but do not have symptoms likely also play a
role in the spread of COVID-19. Since people can spread the virus before they know they are
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
have any symptoms.

592 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
Substandard # 13.3
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).
Health Care workers,
visitors & Patients
Hand Hygiene:
strictly adhere to the
principles of social Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
distancing, cough COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
etiquette and frequent handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
hand hygiene during healthcare settings.
duty hours / visiting Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
hospital. transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 13.4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of HCWs is Following must be ensured:
strictly prohibited
unless necessary for Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
Infection Prevention & clinical staff) to avoid the unnecessary mobility in between the units.
control activities. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, mandatory inspection rounds, transportation of supply etc

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594 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
595 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
596 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:

□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms

□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

597 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
ONCOLOGY UNIT

Medical and RadiationOncology is a high risk service that requires

adherence to certain requirements to be safe, efficient, and effective.

Therefore, strict implementation of infection control procedures including hand
hygiene, wearing personal during patient care, practicing aseptic technique, protective
environment rooms, isolation precautions & strict environmental measures etc. would
play a significant role in ensuring patient & staff safety.

598 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN ONCOLOGY unit

POLICIES & PROCEDURES

EDUCATION & TRAINING

ONCOLOGY UNIT

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

PROTECTIVE ENVIRONMENT ROOM

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

599 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ONCOLOGY UNIT
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

600 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation
Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.

Each HCPs must receive education & training on basic infection control skills from IC
Substandard # 2:1 department within 01 months of joining work. (BICSL)
IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
joining work & issue a BICSL ID which should be renewed ever 02 years.
Healthcare Personnel
(HCP) receive Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
orientation and hours as an evidence of basic infection control training to be presented to any external /internal
training on Basic audit visit for purpose of verification.
Infection Control Skills Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
from IC department every 2 years by visiting infection control department.
maximum within 1
months of joining
work & a BICSL card Components of BICSL includes:
is issued which is
renewed every 2
- HAND HYGIENE
years.
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

601 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
Substandard # 2:2 patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Healthcare Personnel knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
(HCP) receive job-
specific training on Infection Prevention & control department MUST provide education & training to all health care
infection prevention personnel on infection control best practices specific to their job as follows:
policies and
procedures upon Infection control Training specific to area of work must be provided initially upon hiring before
hiring and at least starting their duty.
once annually. Continuous education on relevant infection control policies and procedures must be conducted
at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

602 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters.

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

603 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control department provides MUST provide health education on infection control for
families and visitors.
IC team must ensure the availability of the following according to the specific unit / area:
Substandard # 2:4
Bilingual infection control health education & awareness material must be designed / formulated
Unit provides infection to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
control health booklets, leaflets etc. containing information easy to understand with help of pictorial display.
education to the The general & specific health educational material must be posted and available in all patient
Patients, families & care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
visitors. hygiene, cough etiquette, COVID 19 & MERS educational material, etc.

Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files.

Patients/Family members’ / care givers must be aware about importance of hand hygiene, care
of central line, identifying and notifying signs of inflammation etc.
Visitors are educated on precautions to be taken while being in the surrounding of the patient,
the importance of hand hygiene and the required isolation precautions etc education must be
provided on how to don / doff PPE and perform hand hygiene before entering isolation room.
Ensure strict adherence of visitors to the recommendations / instructions regarding infection
prevention requirements (e.g.PPE use, hand hygiene etc).

604 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists (IPs) must ensure during daily/ weekly rounds that hand washing facilities
antimicrobial soap / are available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
patient's room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

605 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:2 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Health care Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
professionals (HCP) microorganisms without the need for an exogenous source of water and requiring no rinsing or
demonstrate drying with towels or other devices.
appropriate Indications:
technique for hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
rubbing and hand body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing. Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and
/or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced

606 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Substandard # 3:3
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Visual alerts are
posted at appropriate places.
available: WHO 5
moments, how to
- WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to
- How to hand wash poster beside ach hand washing sink
do hand wash.
- How to handrub poster beside each hand hygiene dispenser
-
WHO five moments of hand hygiene :

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

607 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
608 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
609 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room
are available and readily but not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will
accessible to HCP. interfere with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2 masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock
N - 95 respirators are available rooms.
in different types and sizes. Check if all types and sizes are available according to fit test result of each healthcare
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)

610 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding
using N-95 respirator according to fit test or follow alternate policy in case of non-
availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 to (Countercheck / verify with their fit test ID).
be used based on the fit test. Observe the practice of doctors with beards.

Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

611 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
Substandard # 4:4 ❖ Airborne: N95 mask / respirator before entering the room.

Staff use personal protective 1: Appropriate PPE for Contact Isolation:

equipment appropriately (e.g.
donning and doffing) Before entering and leaving a patient’s room PPEs should be donned & doffed in this
order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured
at neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
https://youtu.be/H4jQUBAlBrI Don gloves. Extend gloves over isolation gown cuffs.
Watch Video How to safely put
on PPE Sequence of doffing PPEs before leaving the room:
Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.
612 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

613 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
614 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
615 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
616 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

617 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:7 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

618 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

619 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

620 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

621 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:04
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 6:05 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 15. Disposable personal care items are discarded
worker, housekeeping 16. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 6:06 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

622 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:07 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

623 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

624 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:08 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:09
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

625 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Substandard # 6:11 Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
Housekeepers are well measures.
trained on hand hygiene, Routine practices related to environmental cleaning includes:
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals.
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

626 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

627 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

628 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
629 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 7:1 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 7:2
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

630 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 7:3
in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of
to use large IV solution bottles for preparation & dilution of medications
medication is only done by
Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water
specified for preparation & dilution of medications.
ampoule.
Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 7:4
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 7:5
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

631 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 7:6 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient.
While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 7:7 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

632 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Maintaining the integrity of sterile equipment and solutions is extremely important to
Substandard # 7:8 prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
Sterile equipment and urinary catheter).
solutions are assembled - If the sterile items are assembled long before the procedure, there are chances of
immediately prior to use. contamination from environment such as dust etc.
- A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
the transfer of microorganisms and reduce the potential for infections.
- Principles of sterile technique help control and prevent infection, prevent the transmission
of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.
As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.
Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
transfer forceps.
Substandard # 7:9
Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
Non-sterile items should not cross over the sterile field. For example, a non-sterile person
Sterile to sterile rule is
applied during any aseptic should not reach over a sterile field.
procedure. Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.

633 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 7:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 7:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

634 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 7:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
Substandard # 7:14 claim that each device is exclusively allocated only for one patient.
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
insulin pens) are used only • Patient's name & medical record number to be used exclusively for one patient.
for single patient. • Date of the first use to be discarded after expiration of the reuse life recommended
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 7:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.

635 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
Substandard # 7:16 sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
IV solution bottles are only accessed through the self-sealed rubber cap. You may
IV solution bottles are only observe staff accessing the IV solution from the plastic body of IV solution bottle rather
accessed through the self- than the self-sealed rubber cap.
sealed rubber cap. You can check by pressing gently the IV solution bottle if any fluid leaks out or no.

Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 7:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7
days, but not more Following key points must be followed for replacement of IV sets in order to avoid risk of
frequently than 96-hour infection from frequent changing of IV sets:
intervals.
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 7:18
Rationale: Extending the duration of use permits considerable cost savings to hospitals
IV sets that are used to without significant increase in the risk of healthcare-associated BSI with peripheral IVs
administer blood, blood
products, lipid emulsions, or In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
dextrose/amino acid TPN acid TPN solutions, check that IV delivery systems are continuously connected and
solutions are replaced within changed within 24 hours of initiating the infusion.
24 hours of initiating the During daily rounds, observe that IV administration sets are labelled with dates & times of
infusion. initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
(hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

636 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 7:19 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

Provide education & training to the healthcare personnel regarding the feeding systems & key
Substandard # 7:20 points that should be considered.
Observe the practices during routine monitoring rounds. Evaluate performance during IPCCC
Open feeding systems audit phase.
should be removed after 8
hours, whereas sterile Following MUST be implemented:
closed systems may remain
hanging for up to 24 to 48 If open feeding system are used, they should be removed after 8 hours.
hours or per manufacturer's If sterile closed feeding system are being used, they may remain hanging for upto 24 – 48
recommendation. Hours OR manufacturers instruction MUST be followed.

According to The Joint Commission, there are four chief aspects of the aseptic technique:
Substandard # 7:21 barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Maximum sterile barrier protect the patient from the transfer of pathogens from a healthcare worker, from the
precautions is applied environment, or from both. Some barriers used in aseptic technique include:
during any interventional
procedure, including cap, - Sterile gloves
mask, sterile gown, sterile - Sterile gowns
gloves, and sterile full-body - Masks for the patient and healthcare provider
drape. - Sterile drapes etc
Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
Substandard # 7:22 central line etc.
Traffic should be kept minimum once the sterile field has been established.
Traffic should be kept
minimum once the sterile Only necessary health personnel should be at the procedure. The more people present, the
field has been established. more opportunities for harmful bacteria to cause contamination.
Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

637 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Recognized routes for contamination of catheters:
Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with
colonization of the catheter tip; this is the most common route of infection for short-term catheters
Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices.
Catheters might become hematogenously seeded from another focus of infection.
Infusate contamination might lead to CRBSI.

638 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 08 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

Y. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
Z. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
AA. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xvii. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xviii. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

639 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Provide education to the staff regarding importance of isolation precautions during IPCCC training
Substandard # 8:1 activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis for
isolation precautions patients under isolation.
are available in the Use preferably isolation precautions signs provided by GDIPC.
unit & used Must be placed / posted on door only if occupied by patient.
appropriately. 02 types of isolation precaution signs must be available in the unit.
Isolation signs must - Isolation precaution signs for units to be posted on doors if the isolation room is
be : 1) Clear and occupied by patients with diseases transmitted either by contact, droplet or airborne
visible for HCWs and route.
visitors 2) Bilingual (in - Isolation Transportation cards for transportation of patients to other departments as
Arabic & English). 3) needed.
Color coded and
compatible with Contact isolation Precautions must be used together with standard precautions:
diagnosis (Examples:
contact: green, Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
airborne: blue, and infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
droplet: pink or red) The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

640 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Precautions must be used together with standard precautions. Droplet
Substandard # 8:2 Precautions are intended to reduce the risk of droplet transmission of infectious agents from close
contact (exposure to eyes, nose and mouth) with large-particle droplets
Appropriate isolation
transportation cards / Should be Initiated and maintained when there is suspected or confirmed diagnosis of an
sings are available in infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
the department & Use a single room. A negative air pressure room is not indicated.
used while Place a droplet sign on the door.
transporting patients Droplet isolation signage must be color coded (e.g., orange) and must be available in both
under transmission- English and Arabic languages.
based precautions to
other department as Airborne isolation precautions must be used together with standard precautions
needed. Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases that
are spread via the airborne route.
Transport Isolation Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
signs must be : 1) disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Clear and visible for Use a single room with a negative air pressure system (AIIR)
HCWs and visitors 2) Place the Airborne Isolation sign on the door.
Bilingual (in Arabic & Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English). 3) Color English and Arabic languages. b. Keep door closed at all times except when entering or
coded and compatible leaving the room.
with diagnosis
(Examples: contact: Patient Transportation:
green, airborne: blue,
and droplet: pink or Patient Transportation isolation signs must be used while transporting patients under
red) and selecting low transmission-based precautions to other department as needed.
traffic time & route.
Transport of isolated patients should be limited to essential purposes only, such as diagnostic
and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
should be worn to reduce potential contamination of the environment and the spread of
infection.
Isolation instructions must be clearly highlighted on the transmission-based precaution card
(isolation signs) while transporting patients under transmission-based precautions to other
department ( e.g radiology).

IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 8:3 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
Log book for exposure entry into isolation room for any task.
is available for any Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
potentially harmful Logbook must specify the name, designation / job category, Duration of exposure (Time in /
infectious exposures Time out) & type of PPE used.
as per exposure Appropriately used logbook will generate information needed in case of outbreaks etc
policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. before gaining entry into isolation room.
MERS-CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

641 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use items are those that are intended for single use only, on an individual patient for a
Substandard # 8:4 single procedure, and then should be discarded. It should not be reprocessed or reused again
even on the same patient.
Single use or
dedicated non-critical Provide training and orientation to staff regarding patient care equipment to be used for isolation
patient care equipment rooms during daily/weekly rounds:
(e.g., stethoscope,
pressure cuff, etc.) are Following instructions must be given:
used for the isolation
room. If single use non critical items are used for isolation rooms, they must be immediately
discarded after use. Single use items must never be kept to be reused for the same patient or
next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be disinfected
after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc

Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation room
is used for another isolation room or another area.

Transfer of patients under isolation precautions must be restricted to medically necessary

purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
Substandard # 8:5
procedures that cannot be performed in the patient’s room.
Facility limits
Provide training and orientation to staff the transfer rules related to patient transportation under
movement of patients
isolation precautions. Observe if unit is following the policy.
on isolation
Precautions outside of
Following instructions must be given:
their room except for
medically necessary
Receiving unit or facility is informed beforehand about the required isolation precautions to be
purposes.
taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
Substandard # 8:6
unit etc.
If transfer of patient
It is important that HCWs in the receiving unit have received prior training on how to safely
under isolation is
handle patients under isolation precautions and how to appropriately use PPE according to type
required, the receiving
of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit tested
unit or facility is
for N-95 mask and trained well on how to don & doff after use.
informed about the
required isolation
Transferring the Patient to Another Facility:
precautions and
availability of
Inform the receiving facility and the emergency vehicle personnel in advance about the type of
appropriate PPE is
isolation and standard precautions (PPE) required.
ensured.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

642 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8:7 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation.
While transferring
patients under Key Points include:
droplet/airborne
isolation precaution, Explain to the patient the need for the protective apparel that he/she is required to wear.
patient should wear a Patient must wear mask during transportation (droplet & airborne isolation)
surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory Isolation instructions must highlight the transmission-based precaution card ( isolation signs)
hygiene and cough needed while transporting patients under transmission-based precautions to other department (
etiquette. e.g radiology).
-

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or
Substandard # 8:8 more classes of antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to
Contact isolation most available antimicrobial agents.
precautions are
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci
initiated for patients
(VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
infected or colonized
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms.
Skin lesions and Proper attention & care to these pathogens is critical to curtail further emergence of these
infected or colonized highly resistant organisms.
areas of patient's body
Infection refers to the entry into and multiplication of an infectious agent in the tissues of the
should be contained
host and the tissue damage resulting in apparent or unapparent changes in the host.
and covered.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and covered
in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

643 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training to the staff for rules to be followed for patient transportation under contact isolation
Substandard # 8:9 precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

For transport patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin Leak-proof dressing should be used to reduce potential contamination of the environment and
lesions and infected or the spread of infection.
colonized areas of the Dress wounds with impervious dressings as required.
patient’s body with Dress the patient in a clean gown.
clean bandages and Cover the patient with a clean sheet.
clean linens. Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

In order to avoid potential risk of acquiring infection visitors should be strictly limited for
airborne isolation cases.
As per standards, some exemptions may be considered on a case to case basis i.e visitors may
be allowed to enter the isolation room if he / she fulfils the following criteria e.g mothers of
babies etc
Substandard 08:10
- Duration of stay will be minimum for few minutes only.
Visitors - Visitors must seek permission from nursing station.
should be strictly - Clear instructions must be provided to visitors in their language before entering into an isolation
limited for airborne room.
isolation cases. - Visitors must be fully compliant with the required PPE i.e visitors will wear same type of PPE
Exemptions may be and follows same protocols as any HCWs before entering isolation rooms.
considered on a case - Proper education, counselling, and monitoring should be provided to the visitors before
to case basis only for entering the airborne infection isolation room.
few minutes after - Nursing staff must keep records of visitor’s education & instructions as evidence to be
having permission presented to external auditors when requested.
from nursing station
and after receiving Educate the staff regarding visitor’s policy & ensure during daily/weekly rounds if its fully
proper instructions implemented:
before entering into an
isolation room and - Observe and ask staff about the visitors if isolation room occupied by patient.
within compliance with - Ask about the evidence of education & documentation in log book.
the required PPE. - Observe when possible any visitor entering or coming out of isolation room if compliant with
instructions.
- Sometimes visitors are not donning PPE appropriately. Gowns is not tied & masks is worn
inappropriately.
- It is also common observation to see visitors coming out of AIIR with all PPE and removing PPE
abruptly without practicing hand hygiene.
- Such practices would pose risk of acquiring infection. Nursing staff must be fulling adherent
with visitor’s policy for isolated patients.

Audit the unit performance during IPCCC audit phase and provide formal feedback.

644 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Protective Environment Room (PE)
Oncology patients and other immunocompromised populations are at increased risk of acquiring healthcare associated infection
because of their underlying disease process and /or treatment regimens that result in neutropenia and impaired immune response.
Treatment of infection is difficult in this population so prevention is the key.
A protective environment (including high-efficiency particulate air filtration of incoming air, >12 air exchanges, and with a pressure
differential of >2.5 Pa [0.01’ water gauge] positive pressure) is recommended for immunocompromised patients.
Immunocompromised patients can be cared for in the same environment as other patients. However, it is advisable to minimize
exposure to other patients with transmissible infections such as influenza and other respiratory viruses.
Patients with a neutrophil absolute count of <0.5 can be placed in a protective environment until their neutrophil counts have
recovered.
Key infection control measures include scrupulous attention to hand hygiene, care in the insertion and management of
intravascular catheters and other medical devices, environmental cleaning, and screening and regulation of visitors and personnel.
Sub standards Explanation

Infection control team MUST ensure the availability of protective environment rooms in the
oncology unit since these patients are highly prone to risk of acquiring infections.
Substandard # 9:01
Number of required positive pressure room would be based on the IC risk assessment.
There is number of positive
pressure rooms in oncology
unit depending on infection
Following specification must be ensured for protective Environment Rooms:
control risk assessment.
Patients are placed in a protective environment (PE) comprising positive room air pressure in
relation to the corridor (pressure differential of >2.5 Pa [0.01’ water gauge]) with ≥12 air
exchanges per hour and high-efficiency (>99%) particulate air (HEPA) filters capable of
removing particles >0.3 µm in diameter.

Substandard # 9:02
Infrastructure:
Central or point-of-use
HEPA filters are available for
supply (incoming) air.
Protective environment rooms should be well-sealed.
The air supply and exhaust grills should be located such that clean, filtered air enters from
Substandard # 03 one side of the room, flows across the patient’s bed, and exits on the opposite side of the
HEPA filter is changed on room.
regular basis and according
Self-closing doors should be placed at all room exits.
to manufacturer's
recommendations Floor, walls, ceiling should have no cracks or decorative fine parts and should be with
minimal openings that are completely sealed.
Covered with such paints and material that can withstand repeated cleaning and
disinfection by approved disinfectants.

645 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 04 Ventilation Parameters:

There is monitor for - Pressure Differentials:

continuous monitoring of
pressure difference at PE Ensure pressure differential of >2.5 Pa (0.01’ water gauge) inside room in relation to the
room having audio visual
corridor.
alarming system when the
There must be regular monitoring of protective pressure rooms that must be documented
ventilation system failed.
in log sheets.

- Air Changes per Hour:

Substandard # 05 Ensure ≥12 air exchanges per hour

Records for routine

- Fixed monitors with audio-visual alarm:
monitoring of pressure
gradients are done on daily There should be continuous monitoring of pressure differentials to ensure room is under
basis. positive pressure at all times in order to ensure patient safety.
Monitor must be equipped with an audio-visual alarm system to alert the nursing staff
when the ventilation system fails. (Alarm sound should be audible flashing lights are
Substandard # 06 generated from the monitor in case of failure). Nurses must take urgent measures to
protect the patients.
Maintain positive room air
pressure (≥2.5 Pa) in
relation to the corridor.
HEPA Filters:
Substandard # 07
High-efficiency (>99%) particulate air (HEPA) filters capable of removing particles >0.3 µm
Ventilate the room to in diameter MUST be installed for supply (incoming) air.
maintain ≥12 ACH.
Filters must be replaced regularly based on the manufacturer’s recommendations. Filtration
Substandard # 08
efficiency should be monitored frequently to best determine the appropriate time for
replacement when there is major construction in the facility,
Floor, walls, ceiling should Back-up ventilation equipment (e.g., portable units for fans or filters) for emergency
have no cracks or decorative provision of ventilation requirements for PE areas, and take immediate steps to restore
fine parts and should be non-functioning ventilation systems must be available.
with minimal openings that
are completely sealed. They
should be covered with
antimicrobial paint that can
withstand repeated cleaning
and disinfection by approved
disinfectants.

646 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often
contain large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred
to patients or healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must
follow Standard Precautions at all times. To reduce the possibility of occupational risks of infection transmission and/or exposure,
laundry workers should focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal protective equipment
(PPE). Removal of foreign objects from soiled linen. 4. To restore soiled linen to usable condition, washing, bleaching, rinsing,
and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 10:1 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 10:2 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 10:3 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 10:4 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

647 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:5 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 10:6 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Substandard # 10:7 Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Linen carts are covered and Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
not overfilled. to 10 inches off the floor.
Linen from isolation rooms is considered regular soiled linen.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

648 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
Substandard # 11:1 - Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)
All types of waste
containers are Specification of Items:
available in sufficient
number and placed in Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
easily accessible sites. with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

649 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11:2 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 11:3
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 11:4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 11:5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

650 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 11:6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 12 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 12:1
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 12:2 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to
Local records for corrective interventions which are taken if readings are not matching the
70%).
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.

651 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
Substandard # 12:3 - Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.
Away from air vents and
well ventilated.
Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.
Substandard # 12:4

Storage shelves are 40 Infection control team must provide training and reorientation about all specifications to be
cm from the ceiling, 20 followed for the maintenance of departmental medical stores.
cm from the floor, and 5 Train on following specifications / key points and observe in daily / weekly rounds if unit is
cm from the outside wall. adherent with recommendations or not.
Departmental medical stores must be well organized & well maintained.
Substandard # 12:5 Must be away from any contamination, direct sunlight and airs vents.
Specifications of Storage Shelves:
Storage shelves made
from easily cleanable Storage shelves are made of easily cleanable material
material (e.g., fenestrated (e.g., fenestrated stainless steel, Aluminium or hard plastic).
stainless steel, Aluminium
or hard plastic) Storage shelves are placed following these specifications.
- 40 cm from the ceiling
Substandard # 12:6 - 20 cm from the floor
- 5 cm from the wall
Sterile and clean items
completely separated If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
from personal items & hard plastic).
foods and drinks.
Ensure that only sterile and clean items are allowed in the medical stores.
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 12:7 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
original cardboard shipping boxes.
Substandard # 12:8
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
inside sock room. (i.e., boxes made of thick cardboard for shipping.
Items not kept in original
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
cardboard shipping
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
boxes.
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

652 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
Substandard # 12:9 discarded)
If any stained item is found it would most likely reflect that item was restocked after being
No expired items, broken brought from patient care areas which is against the rules of aseptic technique. Such
packs or packs with practices must be strictly prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in
order to ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit
phase.
Provide formal feedback on unit & staff performance

Standard – 13 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 13:1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

653 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 13:2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

654 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 13:3
prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers &
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
visitors strictly adhere
droplets can also be inhaled into the lungs.
to the principles of
Recent studies indicate that people who are infected but do not have symptoms likely also play a
social distancing,
role in the spread of COVID-19. Since people can spread the virus before they know they are
cough etiquette and
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
frequent hand hygiene
have any symptoms.
during duty hours /
visiting hospital.
Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

655 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 13:4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.

Interdepartmental Following must be ensured:

mobility of healthcare
workers is strictly Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
prohibited unless clinical staff) to avoid the unnecessary mobility in between the units.
necessary for medical Moving in between departments and eating together in pantries is strictly prohibited.
purposes (Patients HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation etc) transportation of patients, etc

656 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
657 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
658 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

659 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 INPATIENT CARE AREAS

# NAME OF UNIT PAGE #

01 DELIVERY ROOM (DR) 661

02 INPATIENT UNITS / WARDS 715

660 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
DELIVERY ROOM

Delivery Room provide services to the women to ensure entire

delivery process takes place in a clean & safe environment to avoid the risk of
acquiring infection to the mother & newborns.
Strict implementation of infection control procedures including hand hygiene, wearing
personal protective equipment (PPE) to prevent the transmission of infection during
patient care, practicing aseptic technique, & strict environmental measures etc. would
play a significant role to ensure patient & staff safety.

661 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN delivery room

POLICIES & PROCEDURES

EDUCATION & TRAINING

DELIVERY ROOM

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

662 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 DELIVERY ROOM
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

663 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
(HCP) receive joining work & issue a BICSL ID which should be renewed ever 02 years.
orientation and Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
training on Basic hours as an evidence of basic infection control training to be presented to any external /internal
Infection Control Skills audit visit for purpose of verification.
from IC department
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
maximum within 1
every 2 years by visiting infection control department.
months of joining
work & a BICSL card
is issued which is Components of BICSL includes:
renewed every 2
years. - HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

664 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2:2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

665 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

666 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control department provides MUST provide health education on infection control for
families and visitors.

Substandard # 2:4 IC team must ensure the availability of the following according to the specific unit / area:
Bilingual infection control health education & awareness material must be designed / formulated
to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
Unit provides infection booklets, leaflets etc. containing information easy to understand with help of pictorial display.
control health
education for patients The general & specific health educational material must be posted and available in all patient
families & Visitors. care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.

Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files e.g care of wound, hand & personal hygiene, importance of breast
feeding etc

Visitors are educated on precautions to be taken while being in the surrounding of the patient,
the importance of hand hygiene and the required isolation precautions etc education must be
provided on how to don / doff PPE and perform hand hygiene before entering isolation room.
Ensure strict adherence of visitors to the recommendations / instructions regarding infection
prevention requirements (e.g.PPE use, hand hygiene etc).

667 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way
to prevent infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are
becoming difficult to treat. On average, healthcare providers clean their hands less than half of the times they should. On any
given day, about one in 31 hospital patients has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
patient's room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

668 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:2
Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Health care Hand washing – washing hands with plain or antimicrobial soap and water.
professionals (HCP) Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
demonstrate microorganisms without the need for an exogenous source of water and requiring no rinsing or
appropriate drying with towels or other devices.
technique for hand
rubbing and hand Indications:
washing. Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and
/or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
669 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Substandard # 3:3
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Visual alerts are
posted at appropriate places.
available: WHO 5
moments, how to
- WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to
- How to hand wash poster beside ach hand washing sink
do hand wash.
- How to handrub poster beside each hand hygiene dispen
-
WHO five moments of hand hygiene in Burn Unit:

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

670 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
671 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
672 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room but
are available and readily not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will interfere
accessible to HCP. with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2
masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock rooms.
N - 95 respirators are
Check if all types and sizes are available according to fit test result of each healthcare
available in different types and
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)
sizes.

673 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

674 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Substandard # 4:4
Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Staff use personal protective Sequence of donning PPEs before entering the room:
equipment appropriately (e.g.
donning and doffing) Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
https://youtu.be/H4jQUBAlBrI Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
Watch Video How to safely put nosepiece over nose bridge and secure head with ties or elastic.
on PPE Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

675 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

IC Team must ensure appropriate PPE to be used by staff in the delivery room due to
Substandard # 4:5 significant risk of exposure to blood and body fluids exposures.

Face shields / Goggles are Face shields or eye goggles MUST be available and used by staff in the delivery room
available to avoid splashes on along with gowns & gloves to avoid splashes to face & eyes.
face and eyes. Gown should Shoe covers must also be available and used to avoid splashes on feet.
be available. Wear shoe covers
to avoid splashes on feet. - Observe the staff practices during IC monitoring rounds
- Evaluate the performance during IPCCC audit phase.
- Provide feedback and reconsider for training if needed.

676 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
677 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
678 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
679 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

680 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:7 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

681 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.
Substandard # 6:02
The spill kit must include the following:
There is at least one spill kit
available in the department. - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
- Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

682 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
clean-up as per policy.
During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

Substandard # 6:03 STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:
HCW knows how to use spill
kit properly. Control access to area:
Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

683 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
Substandard # 6:04 logs /checklists is extremely important to ensure effective implementation & to have the
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
Cleaning is done properly is done & documented appropriately as per schedule.
using checklist that include
cleaning frequency, Each unit must have the schedule for cleaning and disinfection activities.
responsible worker, Schedule must include the frequency, the used disinfectant and the responsible staff.
housekeeping surfaces (e.g., Roles must be specified with clear instructions.
floors and walls), used
agents, methods & 1. Nursing staff for medical equipment
environmental surfaces 2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
intended to be cleaned. 3. Radiology technicians for portable X-ray
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 6:05 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 17. Disposable personal care items are discarded
worker, housekeeping 18. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 6:06 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

684 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:07 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

685 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

686 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:08 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:09
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

687 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
measures.
Routine practices related to environmental cleaning includes:

Substandard # 6:11
HAND HYGIENE:
Housekeepers are well Hand hygiene as the most important and effective measure to prevent the spread of
trained on hand hygiene, healthcare associated infections. Hand hygiene must be practiced:
proper use of PPE, methods
of cleaning & proper & safe Before initial patient environment contact (e.g., before coming into the patient’s room
mixing of chemicals. or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

688 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

689 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

690 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
691 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 7:1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

692 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7:2 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
Observe the practices of staff during daily rounds regarding disposal of sharp items like
needles, scalpel
needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
blades, broken metal
All sharp items must be discarded in the specified sharp containers including the broken and
instruments and burs)
unbroken glass vials.
are placed in an
Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture
any such situation inform the head nurse to monitor closely the staff practices.
resistant and leak-
Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps
collection staff / housekeeping staff.
container.
Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 7:3 to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into patient care areas at appropriate locations.
sharp containers. Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.
Provide training to staff on infectious waste management protocols during IPCCC training
Substandard # 7:4 activities.
Following waste segregation rules must be followed:
No infectious medical
waste or sharps are ❖ Black: To dispose general waste
observed outside ❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
specific containers. ❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)
Observe if the healthcare workers are discarding the waste in specified containers or not.
Randomly open the containers to observe if discarded waste is appropriate for that receptacle.
Substandard # 7:5 You may observe the following:

Waste are properly ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
segregated (no receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
medical waste inside ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
the regular waste Such practices must be observed and monitored & corrected during routine daily rounds.
container or regular ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
regular waste in yellow PPE bulging out of containers.
medical waste ➢ Used syringe / needle on the medication trolley.
container)
Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.
Observe the following:
Substandard # 7:6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

693 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 8:1 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 8:2
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 8:3 in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of to use large IV solution bottles for preparation & dilution of medications
medication is only done by Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water specified for preparation & dilution of medications.
ampoule. Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

694 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 8:4
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 8:5
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 8:6 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient. While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

695 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 8:7 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

- Maintaining the integrity of sterile equipment and solutions is extremely important to

prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
urinary catheter).
- If the sterile items are assembled long before the procedure, there are chances of
contamination from environment such as dust etc.
Substandard # 8:8 - A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
Sterile equipment and the transfer of microorganisms and reduce the potential for infections.
solutions are assembled - Principles of sterile technique help control and prevent infection, prevent the transmission
immediately prior to use. of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.

As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

696 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Substandard # 8:9 Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
transfer forceps.
Sterile to sterile rule is Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
applied during any aseptic Non-sterile items should not cross over the sterile field. For example, a non-sterile person
procedure. should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

697 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 8:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 8:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

Substandard # 8:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

698 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 8:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
claim that each device is exclusively allocated only for one patient.
Substandard # 8:14
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
• Patient's name & medical record number to be used exclusively for one patient.
insulin pens) are used only
• Date of the first use to be discarded after expiration of the reuse life recommended
for single patient.
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 8:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.
Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
Substandard # 8:16
IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
IV solution bottles are only
than the self-sealed rubber cap.
accessed through the self-
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
sealed rubber cap.
Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

699 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 8:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7
days, but not more Following key points must be followed for replacement of IV sets in order to avoid risk of
frequently than 96-hour infection from frequent changing of IV sets:
intervals.
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 8:18
Rationale: Extending the duration of use permits considerable cost savings to hospitals
IV sets that are used to without significant increase in the risk of healthcare-associated BSI with peripheral IVs
administer blood, blood
products, lipid emulsions, or In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
dextrose/amino acid TPN acid TPN solutions, check that IV delivery systems are continuously connected and
solutions are replaced within changed within 24 hours of initiating the infusion.
24 hours of initiating the During daily rounds, observe that IV administration sets are labelled with dates & times of
infusion. initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
(hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

According to The Joint Commission, there are four chief aspects of the aseptic technique:
barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Substandard # 8:19 protect the patient from the transfer of pathogens from a healthcare worker, from the
environment, or from both. Some barriers used in aseptic technique include:
Maximum sterile barrier
precautions is applied - Sterile gloves
during any interventional - Sterile gowns
procedure, including cap, - Masks for the patient and healthcare provider
mask, sterile gown, sterile - Sterile drapes etc
gloves, and sterile full-body
drape. Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
central line etc.
Only necessary health personnel should be at the procedure. The more people present, the
more opportunities for harmful bacteria to cause contamination.

Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

700 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 8:20 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

Standard – 9 Textile Management

Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain large
numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or healthcare
workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must follow Standard Precautions at all times.
To reduce the possibility of occupational risks of infection transmission and/or exposure, laundry workers should focus on: a. Appropriate and
frequent hand hygiene. b. Appropriate use of personal protective equipment (PPE). Removal of foreign objects from soiled linen. 4. To restore
soiled linen to usable condition, washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 9:1 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 9:2 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 9:3 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

701 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 9:4 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

Substandard # 9:5 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
Place used linen in a laundry bag at the point of use.
functionally contain wet or
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing. textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 9:6 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Substandard # 9:7 Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
to 10 inches off the floor.
Linen carts are covered and Linen from isolation rooms is considered regular soiled linen.
not overfilled. The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

702 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

BB. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
CC. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
DD. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xix. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xx. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.
703 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation

Provide education to the staff regarding importance of isolation precautions during IPCCC
Substandard # 10:1 training activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
a: Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis
isolation precautions are for patients under isolation.
available in the unit & Use preferably isolation precautions signs provided by GDIPC.
used appropriately. Must be placed / posted on door only if occupied by patient.
02 types of isolation precaution signs must be available in the unit.

- Isolation precaution signs for units to be posted on doors if the isolation room is
occupied by patients with diseases transmitted either by contact, droplet or
airborne route.
- Isolation Transportation cards for transportation of patients to other departments as
needed.

b: Isolation signs must be Contact isolation Precautions must be used together with standard precautions:
: 1) Clear and visible for
HCWs and visitors 2) Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
Bilingual (in Arabic & infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies
English). 3) Color coded etc
and compatible with The patient should be in a single room. A neutral pressure room is indicated.
diagnosis (Examples: Put a contact isolation sign on the door and the patient’s curtain. Contact isolation
contact: green, airborne: signage must be color coded (e.g., green) and must be available in both English and
blue, and droplet: pink or Arabic languages.
red) Door must be kept closed at all times.

Droplet Isolation Precautions must be used together with standard precautions. Droplet
Precautions are intended to reduce the risk of droplet transmission of infectious agents from
close contact (exposure to eyes, nose and mouth) with large-particle droplets

Should be Initiated and maintained when there is suspected or confirmed diagnosis of an

infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
Use a single room. A negative air pressure room is not indicated.
Place a droplet sign on the door.
Droplet isolation signage must be color coded (e.g., orange) and must be available in
both English and Arabic languages.

Airborne isolation precautions must be used together with standard precautions

Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases
that are spread via the airborne route.
Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an
infectious disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Use a single room with a negative air pressure system (AIIR)
Place the Airborne Isolation sign on the door.
Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English and Arabic languages. b. Keep door closed at all times except when entering or
leaving the room.

704 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:2
Patient Transportation:
a:Appropriate isolation
transportation cards / Patient Transportation isolation signs must be used while transporting patients under
sings are available in the transmission-based precautions to other department as needed.
department & used while
transporting patients
under transmission-based Transport of isolated patients should be limited to essential purposes only, such as
precautions to other
department as needed. diagnostic and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
b:Transport Isolation signs
must be : 1) Clear and should be worn to reduce potential contamination of the environment and the spread of
visible for HCWs and
infection.
visitors 2) Bilingual (in
Arabic & English). 3) Color Isolation instructions must be clearly highlighted on the transmission-based precaution
coded and compatible with
diagnosis (Examples: card (isolation signs) while transporting patients under transmission-based precautions to
contact: green, airborne: other department ( e.g radiology)
blue, and droplet: pink or
red) and selecting low
traffic time & route.

IC Team must provide a log book to the units to be used for isolation rooms occupied by patients
Substandard # 10:3 with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
entry into isolation room for any task.
Log book for exposure is
Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
available for any
Logbook must specify the name, designation / job category, Duration of exposure (Time in /
potentially harmful
Time out) & type of PPE used.
infectious exposures as Appropriately used logbook will generate information needed in case of outbreaks etc
per exposure policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. MERS- before gaining entry into isolation room.
CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

705 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use items are those that are intended for single use only, on an individual patient for a
Substandard # 10:4 single procedure, and then should be discarded. It should not be reprocessed or reused again
even on the same patient.
Single use or dedicated
non-critical patient care Provide training and orientation to staff regarding patient care equipment to be used for
equipment (e.g., isolation rooms during daily/weekly rounds:
stethoscope, pressure
cuff, etc.) are used for the Following instructions must be given:
isolation room.
If single use non critical items are used for isolation rooms, they must be immediately
discarded after use. Single use items must never be kept to be reused for the same patient
or next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be
disinfected after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc
Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation
room is used for another isolation room or another area.

Substandard # 10:5 Transfer of patients under isolation precautions must be restricted to medically necessary
purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
Facility limits movement procedures that cannot be performed in the patient’s room.
of patients on isolation
Precautions outside of Provide training and orientation to staff the transfer rules related to patient transportation
their room except for under isolation precautions. Observe if unit is following the policy.
medically necessary
purposes. Following instructions must be given:

Receiving unit or facility is informed beforehand about the required isolation precautions to
Substandard # 10:6 be taken. (Transfer could be internal to any unit inside facility or external to any other
facility)
If transfer of patient Clear instructions must be provided and documented in patient files before transfer.
under isolation is Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
required, the receiving unit etc.
unit or facility is informed
about the required It is important that HCWs in the receiving unit have received prior training on how to safely
isolation precautions and handle patients under isolation precautions and how to appropriately use PPE according to
availability of appropriate type of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit
PPE is ensured. tested for N-95 mask and trained well on how to don & doff after use.

Transferring the Patient to Another Facility:

Inform the receiving facility and the emergency vehicle personnel in advance about the type
of isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

706 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff for patient transportation under isolation precautions. Explain the type of PPE
Substandard # 10:7 and precautions to be taken by the patient while transportation.

While transferring Key Points include:

patients under
droplet/airborne isolation Explain to the patient the need for the protective apparel that he/she is required to wear.
precaution, patient should Patient must wear mask during transportation (droplet & airborne isolation)
wear a surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory hygiene Isolation instructions must highlight the transmission-based precaution card ( isolation
and cough etiquette. signs) needed while transporting patients under transmission-based precautions to other
department ( e.g radiology).
-

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one
or more classes of antimicrobial agents. Although the names of certain MDROs describe
Substandard # 10:8 resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to
most available antimicrobial agents.
Contact isolation
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant
precautions are initiated
Enterococci (VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
for patients infected or
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
colonized with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms. Skin
lesions and infected or Proper attention & care to these pathogens is critical to curtail further emergence of these
colonized areas of highly resistant organisms.
patient's body should be
Infection refers to the entry into and multiplication of an infectious agent in the tissues of
contained and covered.
the host and the tissue damage resulting in apparent or unapparent changes in the host.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and
covered in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

707 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training to the staff for rules to be followed for patient transportation under contact
isolation precautions. Explain the type of PPE and precautions to be taken by the patient while
Substandard # 10:9 transportation.

Key Points for transfer of patients under contact isolation include:

For transporting patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin lesions Leak-proof dressing should be used to reduce potential contamination of the environment
and infected or colonized and the spread of infection.
areas of the patient’s Dress wounds with impervious dressings as required.
body with clean bandages Dress the patient in a clean gown.
and clean linens. Cover the patient with a clean sheet.
Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

Standard – 12 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 12:1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

708 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 12:2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

709 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 12:3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

710 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 12:4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of HCWs is Following must be ensured:
strictly prohibited
unless necessary for Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
Infection Prevention & clinical staff) to avoid the unnecessary mobility in between the units.
control activities. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, etc

711 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
712 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
713 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

714 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
INPATIENT CARE UNITS

Patients admitted in different in patient locations are at risk of

acquiring infections during provision of care if appropriate infection control measures

are not followed.
Strict implementation of infection control procedures including hand hygiene, wearing
personal protective equipment (PPE) to prevent the transmission of infection during
patient care, practicing aseptic technique, isolation precautions & environmental
measures etc. would play a significant role to ensure patient & staff safety.

715 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN INPATIENT UNITS

POLICIES & PROCEDURES

EDUCATION & TRAINING

INPATIENT UNITS

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

AIRBORNE INFECTION ISOLATION ROOMS (AIIRs)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

716 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 INPATIENT UNITS
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

717 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training

Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
(HCP) receive joining work & issue a BICSL ID which should be renewed ever 02 years.
orientation and Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
training on Basic hours as an evidence of basic infection control training to be presented to any external /internal
Infection Control Skills audit visit for purpose of verification.
from IC department
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
maximum within 1
every 2 years by visiting infection control department.
months of joining
work & a BICSL card
is issued which is Components of BICSL includes:
renewed every 2
years. - HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

718 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2:2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

719 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

720 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control department provides MUST provide health education on infection control for
patients, families and visitors.
Tailored IPC education for patients or family members should be considered to minimize the
potential for HAI (for example, patients who are immunosuppressed or with invasive devices or
with multidrug resistant infections).
Substandard # 2:4
IC team must ensure the availability of the following according to the specific unit / area:
Inpatient Units Bilingual infection control health education & awareness material must be designed / formulated
provides infection to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
control health booklets, leaflets etc. containing information easy to understand with help of pictorial display.
education for patients
and their families. The educational material must be posted and available in all patient care areas, waiting areas at
the place easily seen and readable by patients, families and visitors. e,g hand hygiene, cough
etiquette, wound care , care of CVCs , COVID 19 & MERS educational material, etc.
In the patient care areas/units, education provided to patients and visitors must be structured
and documented in patient’s files.
For example, Burn patients must receive education about personal hygiene, importance of
frequent hand hygiene, care of central venous catheter at home, how to take shower with intact
CVC etc
Family members’ / care givers must be aware about importance of hand hygiene, wound care at
home, precautions taken while changing dressing etc.
Visitors are educated on precautions to be taken while being in the surrounding of a patient, the
importance of hand hygiene and the isolation precautions required in case of isolated patients etc
education must be provided on how to don / doff PPE and perform hand hygiene before entering
isolation room.
Sitters/visitors must adhere to the burn unit personnel’s recommendations/instructions
regarding infection prevention requirements (e.g., visiting patients, PPE use, hand hygiene).
Visitors must be excluded from the patient care area during wound care. If a visitor is needed
during dressing (usually for small children), full protective equipment must be worn.

Patients / sitters / families must receive instructions regarding the infection prevention
measures & unit staff must observe the practices.

721 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way
to prevent infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are
becoming difficult to treat. On average, healthcare providers clean their hands less than half of the times they should. On any
given day, about one in 31 hospital patients has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
patient's room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

722 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:2
Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Health care Hand washing – washing hands with plain or antimicrobial soap and water.
professionals (HCP) Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
demonstrate microorganisms without the need for an exogenous source of water and requiring no rinsing or
appropriate drying with towels or other devices.
technique for hand
rubbing and hand Indications:
washing. Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and
/or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
723 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Substandard # 3:3
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Visual alerts are
posted at appropriate places.
available: WHO 5
moments, how to
- WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to
- How to hand wash poster beside ach hand washing sink
do hand wash.
- How to handrub poster beside each hand hygiene dispen
-
WHO five moments of hand hygiene:

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

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726 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room
are available and readily but not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will
accessible to HCP. interfere with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Powered air purifying respirators (PAPRs) for bearded staff etc

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4.2 masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock
N - 95 respirators are available rooms.
in different types and sizes. Check if all types and sizes are available according to fit test result of each healthcare
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)

727 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding
using N-95 respirator according to fit test or follow alternate policy in case of non-
availability.
Substandard # 4:3
During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
Staff knows the suitable N95 to infections are using the correct size & type of N-95 mask according to fit test.
be used based on the fit test. (Countercheck / verify with their fit test ID).
Observe the practice of doctors with beards.

Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.
❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.
❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.
[
❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

❖ Air-purifying respirator means a respirator with an air-purifying filter, cartridge, or

canister that removes specific air contaminants by passing ambient air through the
air-purifying element.
Substandard # 4:4
❖ Powered air-purifying respirator (PAPR) means an air-purifying respirator that uses
Alternative respirator, such as a blower to force the ambient air through air-purifying elements to the inlet
powered air-purifying respirator covering.
(PAPR) is accessible for HCW ❖ Powered air purifying respirators offer protection against certain respiratory hazards
who failed in fit testing when with integrated head, eye and face protection that can help provide a more
dealing with patients under comfortable environment for the worker.
airborne isolation precautions.
❖ PAPR system uses a blower instead of lung power to draw air through the filter. This
lets HCWs to breathe more naturally while feeling a constant airflow in your while
dealing with patients.
❖ Ensure that powered air-purifying respirator (PAPRs) are available and accessible for
all HCWs who failed fit testing to N-95 mask of all types, brands & shapes.
❖ HCWs with beard must not use N-95 mask because of interference of facial hair in
ensuring perfect facial seal. Airborne particles are less than 5 microns in size which
can easily pass from beneath the mask if appropriately size is not used exposing staff
to risk of acquiring airborne infection.
❖ Bearded staff must only use powered air-purifying respirator (PAPR)while dealing
with patients under airborne infection isolation rooms.
❖ HCWs must also receive training on how to don the respirator and safely handle after
use.
Note:
If powered air-purifying respirator (PAPR)are not available, hospitals must have clearly
policy for bearded staff to strictly refrain from dealing with airborne cases and staff
must be well oriente d about the policy in order to ensure safety of healthcare workers.

728 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Substandard # 4:5 Train and evaluate the same staff on PPE practice as described in the manual.
Staff use personal protective PPE is indicated to be used based on risk assessment as part of standard precautions &
equipment appropriately (e.g. Transmission based precautions.
donning and doffing)
All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Before entering and leaving a patient’s room PPEs should be donned & doffed in this
order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured
at neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.
729 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:
https://youtu.be/H4jQUBAlBrI Sequence of donning PPEs before entering the room:
Watch Video How to safely put
on PPE ❖ Perform hand hygiene.
❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

IC Team must ensure appropriate PPE to be used by staff in the delivery room due to
Substandard # 4:5 significant risk of exposure to blood and body fluids exposures.

Face shields / Goggles are Face shields or eye goggles MUST be available and used by staff in the delivery room
available to avoid splashes on along with gowns & gloves to avoid splashes to face & eyes.
face and eyes. Gown should be Shoe covers must also be available and used to avoid splashes on feet.
available. Wear shoe covers to
avoid splashes on feet. - Observe the staff practices during IC monitoring rounds
- Evaluate the performance during IPCCC audit phase.
- Provide feedback and reconsider for training if needed.

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732 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
733 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

734 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:7 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

735 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:2 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

736 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:3 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

737 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:4
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 6:5 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 19. Disposable personal care items are discarded
worker, housekeeping 20. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 6:6 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

738 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:7 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

739 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

740 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:8 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:9
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

741 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
measures.
Substandard # 6:11 Routine practices related to environmental cleaning includes:

Housekeepers are well

trained on hand hygiene, HAND HYGIENE:
proper use of PPE, methods Hand hygiene as the most important and effective measure to prevent the spread of
of cleaning & proper & safe healthcare associated infections. Hand hygiene must be practiced:
mixing of chemicals.
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

742 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

743 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odor & offensive etc

744 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
745 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 7:1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

746 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7:2 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
Substandard # 7:3 risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
Used needles are not syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
manipulated or Blades or needles should not be disassembled from the equipment.
recapped and are
promptly disposed into Observe during monitoring rounds availability of sharp containers & if mounted in different
sharp containers. patient care areas at appropriate locations.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.
Substandard # 7:4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical Following waste segregation rules must be followed:
waste or sharps are ❖ Black: To dispose general waste
observed outside ❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
specific containers. ❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)
Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 7:5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.
You may observe the following:
Waste are properly
segregated (no - Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste receptacle
medical waste inside and N – 95 masks & blood soaked gauzes discarded in general waste.
the regular waste - Sometimes you may observe a paper tissue & surgical mask discarded in sharp container. Such
container or regular practices must be observed and monitored & corrected during routine daily rounds.
regular waste in yellow - You may also find used gloves & masks beside the waste receptacle on the floor & some PPE
medical waste bulging out of containers.
container) - Used syringe / needle on the medication trolley.
Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

747 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:
Substandard # 7:6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 8 Aseptic Technique

Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 8:1 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 8:2
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

748 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 8:3 in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of to use large IV solution bottles for preparation & dilution of medications
medication is only done by Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water specified for preparation & dilution of medications.
ampoule. Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 8:4
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 8:5
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

749 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 8:6 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient. While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 8:7 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
wrapping. All reusable items are sent for reprocessing, even unused ones with intact original wrap.

Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

750 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Maintaining the integrity of sterile equipment and solutions is extremely important to
prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
urinary catheter).
- If the sterile items are assembled long before the procedure, there are chances of
contamination from environment such as dust etc.
Substandard # 8:8 - A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
Sterile equipment and the transfer of microorganisms and reduce the potential for infections.
solutions are assembled - Principles of sterile technique help control and prevent infection, prevent the transmission
immediately prior to use. of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.

As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.

Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Substandard # 8:9 Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
transfer forceps.
Sterile to sterile rule is Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
applied during any aseptic Non-sterile items should not cross over the sterile field. For example, a non-sterile person
procedure. should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.

751 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 8:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 8:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

752 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 8:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
claim that each device is exclusively allocated only for one patient.
Substandard # 8:14
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
• Patient's name & medical record number to be used exclusively for one patient.
insulin pens) are used only
• Date of the first use to be discarded after expiration of the reuse life recommended
for single patient.
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 8:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.

753 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
Substandard # 8:16 sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
IV solution bottles are only accessed through the self-sealed rubber cap. You may
IV solution bottles are only observe staff accessing the IV solution from the plastic body of IV solution bottle rather
accessed through the self- than the self-sealed rubber cap.
sealed rubber cap. You can check by pressing gently the IV solution bottle if any fluid leaks out or no.

Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 8:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7
days, but not more Following key points must be followed for replacement of IV sets in order to avoid risk of
frequently than 96-hour infection from frequent changing of IV sets:
intervals.
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 8:18
Rationale: Extending the duration of use permits considerable cost savings to hospitals
IV sets that are used to without significant increase in the risk of healthcare-associated BSI with peripheral IVs
administer blood, blood
products, lipid emulsions, or In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
dextrose/amino acid TPN acid TPN solutions, check that IV delivery systems are continuously connected and
solutions are replaced within changed within 24 hours of initiating the infusion.
24 hours of initiating the During daily rounds, observe that IV administration sets are labelled with dates & times of
infusion. initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
(hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

754 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 According to The Joint Commission, there are four chief aspects of the aseptic technique:
barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Substandard # 8:19 protect the patient from the transfer of pathogens from a healthcare worker, from the
environment, or from both. Some barriers used in aseptic technique include:
Maximum sterile barrier
precautions is applied - Sterile gloves
during any interventional - Sterile gowns
procedure, including cap, - Masks for the patient and healthcare provider
mask, sterile gown, sterile - Sterile drapes etc
gloves, and sterile full-body
drape. Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
central line etc.
Only necessary health personnel should be at the procedure. The more people present, the
more opportunities for harmful bacteria to cause contamination.

Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 8:20 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

Train, monitor & audit on following key points for replacing dressings on short term CVCs &
Substandard # 8:21 implanted / implanted CVCs:

Replace dressings used on Catheter Site Dressing Regimens:

short-term central venous
catheter (CVC) sites every 2 ❖ Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the
days for gauze dressing. catheter site
❖ Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.

755 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ❖ Gauze Dressings used on short-term central venous catheter (CVC) sites must be
Substandard # 8:22 replaced every 2 days for gauze dressing following aseptic technique.
❖ Transparent Dressings used on short-term central venous catheter (CVC) sites must be
Replace dressing used on replaced every 7 days for gauze dressing following aseptic technique.
short-term CVC sites at ❖ Transparent Dressings used on tunnelled or implanted CVC sites must be replaced no
least every 7 days for more than once per week (unless the dressing is soiled or loose), until the insertion site
transparent has healed following aseptic technique.
dressing.
Additional points:

Substandard # 8:23 ❖ 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
Replace transparent resistance.
dressings used on tunnelled ❖ Do not submerge the catheter or catheter site in water. Showering should be permitted if
or implanted CVC sites no precautions can be taken to reduce the likelihood of introducing organisms into the
more than once per week catheter (e.g., if the catheter and connecting device are protected with an impermeable
(unless the dressing is cover during the shower)
soiled or loose), until the
insertion site has healed. Reference: https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html

756 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain
large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or
healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must follow Standard
Precautions at all times. To reduce the possibility of occupational risks of infection transmission and/or exposure, laundry workers should
focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal protective equipment (PPE). Removal of foreign objects
from soiled linen. 4. To restore soiled linen to usable condition, washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 9:1 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 9:2 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 9:3 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 9:4 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

757 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9:5 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
The collection bags must
Contaminated linen should not be shaken / agitated when removing it from the bed.
functionally contain wet or
soiled textiles and prevent Place used linen in a laundry bag at the point of use.
contamination of the Do not place on chairs or other furniture.
environment during Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
collection, transportation, centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
and storage prior to of contamination and prevent leakage from soaking through.
processing. Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
Substandard # 9:6 - Items of this nature present the greatest risk to the HCW in acquiring blood-borne
infection.
The containers must not - Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
tear when loaded to
are not left in the linen
capacity, be leak-proof, and
be capable of being closed
securely to prevent textiles Soiled textiles are not sorted or rinsed in patient-care areas.
from falling out. Quality of the laundry bags or containers should be good in order to avoid any leakage.
The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Substandard # 9:7
Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
to 10 inches off the floor.
Linen carts are covered and
Linen from isolation rooms is considered regular soiled linen.
not overfilled.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

758 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

EE. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
FF. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
GG. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xxi. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xxii. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

759 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation

Provide education to the staff regarding importance of isolation precautions during IPCCC
Substandard # 10:1 training activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.
a: Isolation signs used to
indicate categories of Observe if appropriate isolation signs are available and used according to type of diagnosis
isolation precautions are for patients under isolation.
available in the unit & Use preferably isolation precautions signs provided by GDIPC.
used appropriately. Must be placed / posted on door only if occupied by patient.
02 types of isolation precaution signs must be available in the unit.

- Isolation precaution signs for units to be posted on doors if the isolation room is
occupied by patients with diseases transmitted either by contact, droplet or
airborne route.
- Isolation Transportation cards for transportation of patients to other departments as
needed.

b: Isolation signs must be Contact isolation Precautions must be used together with standard precautions:
: 1) Clear and visible for
HCWs and visitors 2) Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
Bilingual (in Arabic & infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies
English). 3) Color coded etc
and compatible with The patient should be in a single room. A neutral pressure room is indicated.
diagnosis (Examples: Put a contact isolation sign on the door and the patient’s curtain. Contact isolation
contact: green, airborne: signage must be color coded (e.g., green) and must be available in both English and
blue, and droplet: pink or Arabic languages.
red) Door must be kept closed at all times.

Droplet Isolation Precautions must be used together with standard precautions. Droplet
Precautions are intended to reduce the risk of droplet transmission of infectious agents from
close contact (exposure to eyes, nose and mouth) with large-particle droplets

Should be Initiated and maintained when there is suspected or confirmed diagnosis of an

infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
Use a single room. A negative air pressure room is not indicated.
Place a droplet sign on the door.
Droplet isolation signage must be color coded (e.g., orange) and must be available in
both English and Arabic languages.

Airborne isolation precautions must be used together with standard precautions

Airborne isolation is used when a patient is suspected or confirmed to have any of the diseases
that are spread via the airborne route.
Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an
infectious disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Use a single room with a negative air pressure system (AIIR)
Place the Airborne Isolation sign on the door.
Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English and Arabic languages. b. Keep door closed at all times except when entering or
leaving the room.

760 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:2
Patient Transportation:
a:Appropriate isolation
transportation cards / Patient Transportation isolation signs must be used while transporting patients under
sings are available in the transmission-based precautions to other department as needed.
department & used while
transporting patients
under transmission-based Transport of isolated patients should be limited to essential purposes only, such as
precautions to other
department as needed. diagnostic and therapeutic procedures that cannot be performed in the patient’s room.
When patient transport is necessary, appropriate barriers (e.g., masks, leak-proof dressing)
b:Transport Isolation signs
must be : 1) Clear and should be worn to reduce potential contamination of the environment and the spread of
visible for HCWs and
infection.
visitors 2) Bilingual (in
Arabic & English). 3) Color Isolation instructions must be clearly highlighted on the transmission-based precaution
coded and compatible with
diagnosis (Examples: card (isolation signs) while transporting patients under transmission-based precautions to
contact: green, airborne: other department ( e.g radiology)
blue, and droplet: pink or
red) and selecting low
traffic time & route.

IC Team must provide a log book to the units to be used for isolation rooms occupied by patients
Substandard # 10:3 with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
entry into isolation room for any task.
Log book for exposure is
Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
available for any
Logbook must specify the name, designation / job category, Duration of exposure (Time in /
potentially harmful
Time out) & type of PPE used.
infectious exposures as Appropriately used logbook will generate information needed in case of outbreaks etc
per exposure policies and Train & educate staff regarding the importance of documenting relevant information in logbook
procedures (e.g. MERS- before gaining entry into isolation room.
CoV). Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
Evaluate unit’s performance in IPCCC audit phase,

761 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Single Use items are those that are intended for single use only, on an individual patient for a
Substandard # 10:4 single procedure, and then should be discarded. It should not be reprocessed or reused again
even on the same patient.
Single use or dedicated
non-critical patient care Provide training and orientation to staff regarding patient care equipment to be used for
equipment (e.g., isolation rooms during daily/weekly rounds:
stethoscope, pressure
cuff, etc.) are used for the Following instructions must be given:
isolation room.
If single use non critical items are used for isolation rooms, they must be immediately
discarded after use. Single use items must never be kept to be reused for the same patient
or next patient.
If the equipment is dedicated to a single patient in a patient’s room, it has to be cleaned and
disinfected at the end of the day or shift, or whenever it is soiled and when the patient is
discharged.
If dedicated / designated non critical patient care equipment ae used, they must be
disinfected after each use with approved disinfectants and kept inside isolation room.
Doctors must be strictly prohibited to use personal stethoscopes for examination of patients
under isolation precautions.
Examples includes stethoscopes, BP cuffs etc
Monitor the staff practices and rectify if a patient care equipment dedicated for one isolation
room is used for another isolation room or another area.

Substandard # 10:5 Transfer of patients under isolation precautions must be restricted to medically necessary
purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
Facility limits movement procedures that cannot be performed in the patient’s room.
of patients on isolation
Precautions outside of Provide training and orientation to staff the transfer rules related to patient transportation
their room except for under isolation precautions. Observe if unit is following the policy.
medically necessary
purposes. Following instructions must be given:

Receiving unit or facility is informed beforehand about the required isolation precautions to
Substandard # 10:6 be taken. (Transfer could be internal to any unit inside facility or external to any other
facility)
If transfer of patient Clear instructions must be provided and documented in patient files before transfer.
under isolation is Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
required, the receiving unit etc.
unit or facility is informed
about the required It is important that HCWs in the receiving unit have received prior training on how to safely
isolation precautions and handle patients under isolation precautions and how to appropriately use PPE according to
availability of appropriate type of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit
PPE is ensured. tested for N-95 mask and trained well on how to don & doff after use.

Transferring the Patient to Another Facility:

Inform the receiving facility and the emergency vehicle personnel in advance about the type
of isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

762 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff for patient transportation under isolation precautions. Explain the type of PPE
Substandard # 10:7 and precautions to be taken by the patient while transportation.

While transferring Key Points include:

patients under
droplet/airborne isolation Explain to the patient the need for the protective apparel that he/she is required to wear.
precaution, patient should Patient must wear mask during transportation (droplet & airborne isolation)
wear a surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory hygiene Isolation instructions must highlight the transmission-based precaution card ( isolation
and cough etiquette. signs) needed while transporting patients under transmission-based precautions to other
department ( e.g radiology).
-

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one
or more classes of antimicrobial agents. Although the names of certain MDROs describe
Substandard # 10:8 resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to
most available antimicrobial agents.
Contact isolation
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant
precautions are initiated
Enterococci (VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
for patients infected or
Enterobacteraceae (CRE) etc are among primary resistant microorganisms of significant
colonized with multidrug-
concern in the healthcare setting and are encountered in many hospitals.
resistant organisms. Skin
lesions and infected or Proper attention & care to these pathogens is critical to curtail further emergence of these
colonized areas of highly resistant organisms.
patient's body should be
Infection refers to the entry into and multiplication of an infectious agent in the tissues of
contained and covered.
the host and the tissue damage resulting in apparent or unapparent changes in the host.
Colonization refers to the presence of microorganisms in or on a host with growth and
multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and
covered in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

763 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training to the staff for rules to be followed for patient transportation under contact
isolation precautions. Explain the type of PPE and precautions to be taken by the patient while
Substandard # 10:9 transportation.

Key Points for transfer of patients under contact isolation include:

For transporting patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin lesions Leak-proof dressing should be used to reduce potential contamination of the environment
and infected or colonized and the spread of infection.
areas of the patient’s Dress wounds with impervious dressings as required.
body with clean bandages Dress the patient in a clean gown.
and clean linens. Cover the patient with a clean sheet.
Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

In order to avoid potential risk of acquiring infection visitors should be strictly limited for
airborne isolation cases.
As per standards, some exemptions may be considered on a case to case basis i.e visitors
may be allowed to enter the isolation room if he / she fulfils the following criteria e.g
mothers of babies etc

Substandard 10:10 - Duration of stay will be minimum for few minutes only.
- Visitors must seek permission from nursing station.
Visitors - Clear instructions must be provided to visitors in their language before entering into an
should be strictly limited isolation room.
for airborne isolation - Visitors must be fully compliant with the required PPE i.e visitors will wear same type of PPE
cases. Exemptions may and follows same protocols as any HCWs before entering isolation rooms.
be considered on a case - Proper education, counselling, and monitoring should be provided to the visitors before
to case basis only for few entering the airborne infection isolation room.
minutes after having - Nursing staff must keep records of visitor’s education & instructions as evidence to be
permission from nursing presented to external auditors when requested.
station and after receiving
proper instructions before Educate the staff regarding visitor’s policy & ensure during daily/weekly rounds if its fully
entering into an isolation implemented:
room and within
compliance with the - Observe and ask staff about the visitors if isolation room occupied by patient.
required PPE. - Ask about the evidence of education & documentation in log book.
- Observe when possible any visitor entering or coming out of isolation room if compliant with
instructions.
- Sometimes visitors are not donning PPE appropriately. Gowns is not tied & masks is worn
inappropriately.
- It is also common observation to see visitors coming out of AIIR with all PPE and removing
PPE abruptly without practicing hand hygiene.
- Such practices would pose risk of acquiring infection. Nursing staff must be fulling adherent
with visitor’s policy for isolated patients.

Audit the unit performance during IPCCC audit phase and provide formal feedback.

764 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
765 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
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768 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Airborne Infection Isolation Rooms (AIIRs)
Airborne Infection Isolation rooms (AIIRs), commonly called negative pressure rooms, are single-occupancy patient care spaces
designed to isolate patients with airborne pathogens to a safe containment area. AIIRs provide negative pressure in the room (so
that air flows under the gap into the room) with a pressure differential of >-2.5 Pa (Pascal) or >- 0.01” water gauge; an air flow
rate of >12 air changes per hour (ACH) and direct exhaust air from the room to the outside of the building; or recirculation of air
through a HEPA filter before returning to circulation.
AIIRs are designed in such a way so that no airborne particulates escape into other areas within the healthcare setting. Exhaust
from these rooms is not recirculated in the HVAC system. Instead, exhaust air typically moves in dedicated ductwork to ventilation
stacks on the rooftop, where atmospheric air provides sufficient dilution to make the resulting air safe.
For the safety of healthcare workers, patients, and visitors, negative pressure rooms occupied by patients requiring airborne
isolation must be checked daily.
Sub standards Explanation
According to Ministry of Health guidelines, there must be at least one Airborne Infection
Substandard 11.1
Isolation Room for every 8 beds. (e.g 1-8 beds 1 AIIRS, 16 beds 2 AIIRs, 24 beds 3
At least one AIIR for each 8 AIIRs & so on)
beds. . IPC team must send request to higher administration if there is no AIIRs in the unit to fulfil
the requirement.

Provide training and orientation to the staff regarding general specification to be met for
all negative pressure isolation rooms. Monitor different parameters during routine
infection control rounds and observe If within recommended ranges. Evaluate the
performance of unit during IPCCC audit phase & provide formal feedback.
Substandard 11.2 Nurse in charge must receive clear instructions to keep all necessary records in the unit
to be presented if requested from external auditors.
Central air condition or
separate concealed unit is This includes all routine maintenance records and actions taken in terms of deranged
the source of conditioned environmental control parameters or malfunctioning.
fresh air. Maintenance staff must be consulted to provide detailed evidence of all these
specifications and each unit & IC team must keep copy of records.
Units must hard to keep all parameters within normal range and well prepared to provide
documented evidence for any external audit visit.

Substandard 11.3 Following specifications must be met for all AIIRs:

- There must be 100% fresh air supply from central AC or concealed separate unit.
Air exhausted from
- Return of air is not permitted & source of conditioned fresh air must be only via these 02
bathroom must be
exhausted 100% outside sources. (Central air condition or separate concealed unit).
through HEPA filter. - Air from bathrooms must be exhausted 100 % outside through High‐Efficiency Particulate
Air (HEPA) filters.
- The exhaust air ducts MUST be independent of the building exhaust air system.
- HEPA filter should be changed on regular basis and according to manufacturer’s
instructions.
- Unit must keep records of all documents that prove the maintenance and changing of
HEPA filter (as recommended)

769 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Rationale:
Substandard 11.04:
High-efficiency particulate air (HEPA) filter is an air filter that removes >99.97% of particles
HEPA filter is changed on >0.3um at a specified flow rate of air. HEPA filters may be integrated into the central air
regular basis and according handling systems, installed at the point of use above the ceiling of a room, or used as
to manufacturer's portable units.
recommendations.
During rounds ICPs must ensure that each AIIR is equipped with a fixed monitor for
continuous monitoring of environmental control parameters and are in functional condition.

Substandard 11.05: Monitor must exhibit following specifications and records following parameters:
[

There is monitor for

continuous monitoring of
pressure difference at Negative pressure (-2.5 pascal or more)
negative pressure room >12 air changes per hour.
having audio visual alarming
system when the ventilation Has an audio-visual alarm system in case of ventilation system failure. There must be
system failed. Visible red flashing lights and audible sound comes from the monitor.
Fixed monitor must be installed outside each AIIRs in the corridor to monitor the pressure
Substandard 11.06: difference between the room and corridor.

Isolation Room is Test the monitor to ensure that alarm is working or no, by keeping the door of AIIRs open
maintained at negative for few seconds. Hold the room door open. After the time delay, the audible and visual
pressure (-2.5 pascal or
more) with respect to alarm should annunciate.
corridors. Verify that the monitor is correctly reading the pressure. While the door is held open, the
pressure reading should be at or near 0" water gauge.
Substandard 11.07: Use a manual device to monitor pressure differentials in rooms where no monitor is

Isolation Room is installed.

maintained with >12 air
changes per hour.

770 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During daily / weekly rounds ICPs must ensure that policy for regular monitoring of negative
pressure difference is fully implemented. If any breaches unit head must be informed.
Monitor and evaluate unit performance in IPCCC audit phase using IPCCC tool.

❖ Unit must keep record of all documents as evidence of regular monitoring of negative
pressure difference of AIIRs for at least last 3 months:

❖ Daily when in use (i.e., a patient is isolated inside) .

Substandard 11.08: ❖ Weekly when not in use (i.e., no patient is isolated).
❖ Monthly check by biomedical personals

Records for routine

monitoring of pressure Responsibility of Nursing staff:
gradients (daily if a patient
is isolated inside, weekly
when not in use and Negative pressure rooms in use:
monthly by biomedical
department).
Nursing staff must conduct visual checks for the direction of air flow (using flutter strips)
on all rooms where patients are in airborne isolation for query and confirmed airborne
transmissible diseases (e.g., Pulmonary Mycobacterium tuberculosis, measles, chicken
pox) when patients are in this room.
Prior to admitting patients needing airborne isolation, check and ensure that negative
pressure rooms are functioning well. For those designated isolation rooms without
monitor, call maintenance to check if the room is maintaining its negative pressure.
Follow the procedure of this policy in any room that fails inspection. d. All documentation
must be sent to the IP&C Department.

B. Negative Pressure Ventilation Failure:

Unit staff must respond to negative pressure failure.

Nursing staff will lace a surgical mask on the patient in airborne isolation.
Keep the door closed at all times.
Notify the Utilities & Maintenance (U&M) Department of the location and problem & IC
Department
If U&M declares the occupied room is no longer maintaining negative pressure, patient
must be transferred to another negative pressure room immediately.
Put a surgical mask on the patient before transporting.

771 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 An aerosol-generating procedure (AGP) is defined as any medical procedure that can induce
the production of aerosols of various sizes, including small (< 5 microns) Particles. AGPs
includes bronchoscopy, sputum induction, intubation and extubation,cardiopulmonary
Substandard 11.09: resuscitation, open suctioning of airways, Ambu bagging,nebulization therapy, high frequency
oscillation ventilation and Bilevel Positive Airway Pressure ventilation – BiPAP
Any aerosol generating
procedure (AGP) should be Precautions to be observed when performing aerosol- generating procedures, which may be
done in negative pressure associated with an increased risk of infection transmission:
room or single room with
portable HEPA filter using Perform procedures in a negative pressure room or single room with HEPA filter
appropriate PPE (N95 mask, Limit the number of persons present in the room to the absolute minimum required for the
eye protection, gloves & patient’s care and support.
gown) with possible minimal Wear N95 masks: Every healthcare worker should wear a fit-tested seal check N95 mask
number of staff. (or an alternative respirator if fit testing failed).
Wear eye protection (i.e. goggles or a face shield).
Wear a clean, non-sterile, long-sleeved gown and gloves (some of procedures require
sterile gloves
Wear an impermeable apron for some procedures with expected high fluid volumes that
might penetrate the gown.
Perform hand hygiene before and after contact with the patient and his or her surroundings
and after PPE removal.

Train & observe the following during daily/weekly rounds:

❖ HCWs performing any aerosol generating Procedure (AGPs) like CPR, intubation,
extubation, suctioning etc for any suspected or confirmed COVID – 19 or MERS- CoV
cases. (If possible to observe the real situation / scenario).
❖ Observe the type of PPE used by HCWs while preparing for AGPs.
❖ Observe if AGPs are performed in negative pressure room or single room with HEPA filter.
❖ Ask about the total number of staff to be present during procedure. Ensure minimum
number of staff are present who are absolutely necessary for specific procedure / task.

Evaluate the staff performance during IPCCC audit phase & provide formal feedback.

772 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 AIIRs MUST fulfill the following MOH specifications for standard isolation
rooms:
Substandard 11.10:
FLOORS, WALLS & CEILING:
AIIRs fulfill all MOH
Minimal openings in the walls, floors and ceiling that are well sealed and airtight.
specifications for standard
isolation rooms + windows Smooth, one piece without any cracks or decorative fine parts.
are sealed and fixed (i.e., They should be covered with such paints so as to withstand repeated cleaning
could not be opened/) and disinfection by approved disinfectants.
openings in walls and
ceiling are sealed and DOORS:
airtight / doors are properly
designed and well-sealed. Doors are properly designed and well-sealed.
The door should open to the inside.
Substandard 8.11: Extend completely to the floor
Must have auto closure device / auto closure mechanism.
The door should open to the
inside, has auto closure WINDOWS:
device, well-sealed and
extend completely to the Windows are sealed and fixed (i.e., could not be opened)
floor. This will ensure to maintain continuous negative pressure differentials inside
airborne infection isolation rooms.
CURTAINS:
Substandard 11.12:
After discharge, transfer or death of patient under airborne precautions, curtains
Windows are completely must be changed after terminal cleaning of isolation rooms
sealed and fixed (i.e., could
not be opened). HAND HYGIENE FACILITY:

m) Hand Washing:
Substandard 11.13:
Following are required inside patients’ room
Curtains must be changed Hand Washing Sink
between patients. Plain and antimicrobial soap
Paper towels
Available at easily accessible location
Substandard 11.14:
n) Hand Rubbing:
Hand washing facilities and
Alcohol - based hand rub dispensers
supplies (sinks / plain and
Available at easily accessible location for staff to practice 5 moments of hand hygiene & to
antimicrobial soap / paper
perform hand hygiene after doffing of PPE items.
towels, Alcohol - based
hand rub dispensers) are
available & easily PPE TROLLEY:
accessible.
Ensure availability of PPE trolley OUTSIDE AIIRs.
Well organized and well maintained.
Substandard 11.15: Appropriately cleaned external surfaces and internal surfaces of drawers ; free from
dust and any other visible contamination.
Trolley that contains the All required PPE items MUST available (Gowns, Gloves, N – 95 respirators. Face
proper PPEs is available. shields / goggles etc)
PPE items are organized in a way to facilitate staff while donning PPE.
PPE or any other medical supply must never be kept inside isolation rooms to avoid
risk of contamination.

773 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 12:1
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 12:2 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to Local records for corrective interventions which are taken if readings are not matching the
70%). acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

774 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 12:3 Infection control team must provide training and reorientation about all specifications to be
followed for the maintenance of departmental medical stores.
Away from air vents and
well ventilated. Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.
Substandard # 12:4 Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Storage shelves are 40
cm from the ceiling, 20 Specifications of Storage Shelves:
cm from the floor, and 5
cm from the outside wall. Storage shelves are made of easily cleanable material
(e.g., fenestrated stainless steel, Aluminium or hard plastic).
Substandard # 12:5
Storage shelves are placed following these specifications.
Storage shelves made - 40 cm from the ceiling
from easily cleanable - 20 cm from the floor
material (e.g., fenestrated - 5 cm from the wall
stainless steel, Aluminium
or hard plastic) If containers are used inside medical stores, they are made of easily cleanable material (e.g.,

Substandard # 12:6 hard plastic).

Ensure that only sterile and clean items are allowed in the medical stores.
Sterile and clean items
completely separated Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from personal items & from cockroaches and other insects etc.
foods and drinks.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 12:7 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 12:8 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
Substandard # 12:9
discarded)
If any stained item is found it would most likely reflect that item was restocked after being brought
No expired items, broken from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
packs or packs with prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

775 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 13 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 13:1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

776 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 13:2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

777 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 13:3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

778 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 13:4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of HCWs is Following must be ensured:
strictly prohibited
unless necessary for Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
Infection Prevention & clinical staff) to avoid the unnecessary mobility in between the units.
control activities. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, mandatory inspection rounds, transportation of supply etc

779 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
780 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
781 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:

□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms

□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

782 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 OUTPATIENT CARE AREAS

# NAME OF UNIT PAGE #

01 DENTAL SETTING 784

02 OUTPATIENT CLINICS 839

783 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
DENTAL SETTING

Patients and Dental healthcare workers are

exposed to a variety of infectious viral, and bacterial agents in dental care

settings via blood and other oral / respiratory secretions. Multiple potential
sources for microbial cross-contamination and infection exist during
treatment and instrument reprocessing.

Hence, preventing transmission of infection in Dental Clinics is of significant

importance by ensuring strict implementation of infection control measures
including hand hygiene, wearing personal protective equipment (PPE) to prevent
the transmission of infection during provision of care, & strict environmental
measures etc. would play a significant role to ensure patient & staff safety.

784 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN DENTAL SETTING

POLICIES & PROCEDURES

DENTAL SETTING

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

ASEPTIC TECHNIQUE

WASTE MANAGEMENT

DENTAL LAB

DENTAL UNIT WATERLINES (DUWL) PROTOCOLS

INSTRUMNET PROCESSING

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

785 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 DENTAL UNIT
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for dental instruments processing / PPE
accessible for them. use / aseptic technique etc. verbally and then give task to demonstrate how to access this policy
via electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

786 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Dental Health Care
Personnel DHCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.

Each DHCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
joining work & issue a BICSL ID which should be renewed ever 02 years.
Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Substandard # 2:1
hours as an evidence of basic infection control training to be presented to any external /internal
audit visit for purpose of verification.
Healthcare Personnel Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
(HCP) receive every 2 years by visiting infection control department.
orientation and
training on Basic Components of BICSL includes:
Infection Control Skills - HAND HYGIENE
from IC department - PPE
maximum within 1 - ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
months of joining - N – 95 FIT TEST
work & a BICSL card - INFLUENZA VACCINATION
is issued which is - MENINGOCOCCAL MENINGITIS VACCINATION
renewed every 2
years. Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Dental Health Care Personnel HCPs (DHCPs) receive training & demonstrate competency on
HAND HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Dental Health Care Personnel HCPs (DHCPs) receive training & demonstrate competency on
donning and doffing of personal protective equipment (PPEs) by undertaking a practical test
under the supervision of an Infection Control Practitioner / trained observer..

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

787 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained DHCPs would have a positive impact on patient safety and prevent adverse
patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Substandard # 2:2 knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Infection Prevention & control department MUST provide education & training to all health care
Healthcare Personnel personnel on infection control best practices specific to their job as follows:
(HCP) receive job-
specific training on Infection control Training specific to area of work must be provided initially upon hiring before
infection prevention starting their duty.
policies and Continuous education on relevant infection control policies and procedures must be conducted
procedures upon at least once per year.
hiring and at least Training will be conducted immediately without significant delay if there are new updates / new
once annually. guidelines available.

EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

Educate healthcare personnel regarding standard & transmission based precautions,aseptic

technique, disinfection of dental unit waterlines etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standard.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist for dental settings in audit phase.

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained DHCPs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to DHCPs on performance.
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

788 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control department provides MUST provide health education on infection control for
patients & families.

Substandard # 2:4 IC team must ensure the availability of the following according to the specific unit / area:

Dental Unit provides Bilingual infection control health education & awareness material must be designed / formulated
infection control health to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
education for patients booklets, leaflets etc. containing information easy to understand with help of pictorial display.
and their families. The educational material must be posted and available in all patient care areas, waiting areas at
the places easily seen and readable by patients, families and visitors. e,g hand hygiene, cough
etiquette,, COVID 19 & MERS educational material, etc.
In the dental units, infection control health education provided to patients must be structured
and documented in patient’s files.
DHCPs Dental health education is the process of imparting information about the dental health which
helps an individual to keep the oral cavity healthy as good oral hygiene helps a person to
prevent oral disease such as periodontal diseases, bad breath and other dental problems.

DHCPs Training & Competency

789 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
paper towels. are Check the availability of hand washing facilities in the clinics.
available & easily Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
accessible, at least tap if hands free operation or open the tap to check for hot & cold water supply)
one per clinic. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying

Substandard # 3:2
Hand Rub Dispensers:
Alcohol - based
hand rub - Check the availability of hand rub dispensers as per requirements:
dispensers) are
available in One dispenser per dental clinic
adequate numbers One in dental Lab
(one dispenser per One at dental X-ray department
clinic, one at dental - Observe dispensers are conveniently mounted and accessible at the point of care.
lab, dental x-ray
department and at - Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
any service areas). ease of accessibility to staff.
& easily accessible

Hand Rub Dispensers in waiting areas:

Substandard # 3:3
- At least one Alcohol - based hand rub dispensers are provided in the waiting areas.

Alcohol - based
hand rub dispensers ❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
are available in the ❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.
waiting areas.

790 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Substandard # 3:4 Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
Health care without the need for an exogenous source of water and requiring no rinsing or drying with towels or
professionals (HCP) other devices.
demonstrate
Indications:
appropriate
technique for hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
rubbing and hand fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing. Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.
IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.
3: Hand washing technique:
Hand washing with plain or antimicrobial soap includes following steps:
- Wet hands with water
- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

791 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Substandard # 3:5
posted at appropriate places.
Visual alerts are - WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
available: WHO 5 - How to hand wash poster beside ach hand washing sink
moments, how to - How to handrub poster beside each hand hygiene dispen
do hand rub, how to -
do hand wash. WHO Five moments of hand hygiene:

1: Before touching a patient:

- Clean your hands before touching a patient when approaching him/her.

- This is to protect the patient against harmful germs carried on your hands.

2: Before aseptic procedures:

- Clean your hands immediately before performing a clean/aseptic procedure.

- This is to protect the patient against harmful germs, including the patient's own, from
entering his/her body
-
3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids & glove removal.
- This is to protect yourself and the health-care environment from harmful patient germs.

4: After touching a patient:

- Clean your hands after touching a patient and her/his immediate surroundings, when
leaving the patient’s side.
- This is to protect yourself and the health-care environment from harmful patient germs.

5. After touching patient surroundings:

- Clean your hands after touching any object or furniture in the patient’s immediate
surroundings, when leaving even if the patient has not been touched.
- This is to protect yourself and the health-care environment from harmful patient germs.

792 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
793 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment
may include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a
barrier between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier
has the potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes
properly removing and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
Substandard # 4:1 in coordination with infection control department.

Sufficient and appropriate PPE During routine daily / weekly monitoring rounds, observe the availability of PPE by
are easily accessible and randomly checking the PPE trolleys / stock rooms.
available in adequate amount, PPE must be available at the point of use, which will interfere with effective use of PPE
types,and sizes with proper as per requirement.
qualities. Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

794 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

795 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Substandard # 4:4 Transmission based precautions.

Staff use personal protective All isolation precautions must be used together with Standard Precautions
equipment appropriately (e.g.
donning and doffing) ❖ Contact: Appropriate PPE – Gown & Gloves
❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE use for Dental Staff:

Sequence of donning PPEs :

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical facemask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don goggles/face shield.
Don gloves. Extend gloves over yellow gown cuffs.

Sequence of doffing PPEs:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
https://youtu.be/H4jQUBAlBrI
fold into a bundle and discard.
Watch Video How to safely put Perform hand hygiene.
on PPE Remove goggles/face shield
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

796 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control Team MUST provide training and education to the dental Health Care
personnel (DHCPs) regarding importance of PPE & associated risks if not used as per
recommendations.
Observe the DHCPs practices during routine monitoring rounds.
Evaluate the performance during IPCCC audit phase & provide feedback.

Following key points must be considered:

PPE must be changed:

Substandard # 4:5
- In between patients i.e a new set of PPE must be donned after completion of
PPE is changed between procedure on one patient.
patients or when it is visibly - When it is visibly soiled with blood & body fluids
soiled or penetrated by blood - When penetrated by blood or other potentially infectious fluids due to tear or low
or other potentially infectious quality PPE
fluids, all types of personal
protective equipment are PPE Doffing:
removed before leaving the - All types of personal protective equipment must be removed before leaving the
work area. work area.
- Dental Health Care personnel (DHCPs) should not move with gloved hands or other
PPE within the unit during procedure.
- Never use computer or add notes in patients file with gloved hands in to avoid risk
of contamination.
- Upon completion of any dental procedure all PPE should be removed at the work
area followed by hand hygiene.

797 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
798 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
799 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
800 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 05 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive
procedures involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk
of all such procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable
medical equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
Substandard # 5:3
stethoscopes.
All reusable medical devices can be grouped into one of three categories according to the degree
Reusable non critical
of risk of infection associated with the use of the device:
medical care
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

801 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 IC team must provide education & training to all dental healthcare personnel regarding

All reusable items importance of sterilization of critical and semi-critical instruments for patient safety & provision
used in the mouth of quality health care.
must be sent to CSSD.
No reprocessing of Moreover DHCPs must be well oriented & trained to send all critical and semi-critical
critical and semi- instruments for reprocessing inside CSSD to avoid risk of exposure from handling contaminated
critical instruments
inside the dental instruments within the unit.
laboratory or dental Reprocessing of critical and semi-critical instruments should NOT be done inside the dental
unit.
laboratory or dental unit.
Substandard # 5:5 Monitor the staff practices during routine rounds & evaluate performance in IPCCC audit phase.

Reusable autoclavable
film-holding and Film-holding and Positioning devices:
positioning devices
used whenever It is recommended that film-holding and positioning devices should be autoclaved & resued
possible. reusable whenever possible.

Substandard # 5:6 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:7 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist to
the units which should include name of staff responsible for disinfection, items present in the
There is a disinfection specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to external
unit. auditors for verification purposes.

802 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, IV pole, door knobs, medication carts etc).
Substandard # 5:8 The principal modes of transmission are via the hands of the personnel and contact with
inadequately decontaminated equipment or surfaces. Likewise, all equipment used on the patient
High touch surfaces (e.g., blood pressure cuffs, thermometers, wheelchairs, IV pumps) are also heavily contaminated
should be disinfected and may be transmitted to other patients if strict barriers are not maintained and appropriate
more frequently. decontamination is not carried out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:9 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors,
HCW are responsible Physiotherapists etc)
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

IC team must provide education & training to all dental healthcare personnel to ensure full
Substandard # 5:10
understanding on the best practice of environmental infection control in dental settings.
Clinical contact All healthcare workers must take the responsibility to conform and respect all aspects of IC
surfaces (e.g., light standards related to disinfection protocols.
handles, bracket trays, Unit heads have a key responsibility to ensure their department functions within the parameters
switches on dental of the IC policy and that staff are trained and assessed in these issues.
units, hoses to the air-
water syringe and Surface barrier: material that prevents the penetration of microorganisms, particulates, and fluids.
hand pieces, dental Disinfection: Destruction of pathogenic and other kinds of microorganisms by physical or chemical
radiograph equipment, means.
computer equipment)
are either barrier
protected or cleaned Based on the potential risk of contamination, the various environmental surfaces can be divided
and disinfected with a into clinical contact surfaces and housekeeping surfaces. These two types of surfaces require
hospital disinfectant different types of cleaning/disinfecting agents and protocols
after each patient.
Clinical Contact Surfaces:

Clinical contact surfaces are those surfaces which are potential risk of contamination with aerosols
and spatter or touched with contaminated gloves during any dental procedure.
- Dental chair
- light handles.
- Switches
- dental radiograph equipment
- dental chair-side computers
- reusable containers of dental materials
- drawer handles
- sinks and faucet handles used for processing contaminated items, countertops, pens,
telephones, and doorknobs.

803 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team must provide training and education to all DHCW on principles of cleaning & disinfection
protocols.
Provide training & monitor the practices during routine rounds.
Substandard # 5:11 Evaluate the unit & staff performance in IPCCC audit phase and provide formal feedback.
Key points must include the following:
Clinical contact
surfaces (e.g., light The spread of microorganism from these surfaces can be minimized by following means:
handles, bracket trays, Using impervious barriers to cover the surfaces during treatment
switches on dental Cleaning and disinfecting such surfaces after patient treatment.
units, hoses to the air-
water syringe and Using Barriers:
hand pieces, dental
radiograph equipment, All clinical contact surfaces must be covered with an impervious barrier is the preferred method
computer equipment) of preventing cross-contamination from clinical contact surfaces. Using barriers alone will not
are either barrier exclude the need for cleaning and disinfection after each session.
protected or cleaned
and disinfected with a So, even if barriers are used, general cleaning and disinfection of clinical contact surfaces,
hospital disinfectant dental unit surfaces, and countertops is required at the end of the work session.
after each patient.
When barriers are used to prevent cross-contamination, they must be removed between
patients. A new set of barriers should be placed with each patient. Barriers should never be
used for more than one patient.

After removal of the barrier, the surface should be examined. If the surface is found to have
been inadvertently soiled, then it should be cleaned and disinfected before placement of clean
barriers for the next patient.

Suitable materials for use as barriers include clear plastic wrap, bags, sheets, tubing, and
plastic-backed paper or other materials impervious to moisture.

IC Team must ensure availability of these items to ensure effective implementation.

Cleaning and Disinfection:

Cleaning is using detergents or surface active agents to remove organic matter (e.g. saliva and
blood), salts, and visible soils.
Cleaning must always be preceded by disinfection because if a surface is not cleaned first, the
disinfection process may be ineffective because organic matter interferes with the action of
some disinfectants. (depending on the type of disinfectant)
Removal of all visible blood and inorganic and organic matter is critical as the germicidal activity
of the disinfecting agent. Even if barriers are used, general cleaning and disinfection of
clinical contact surfaces, dental unit surfaces, and countertops is required at the end of the
work session.

804 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces require more frequent and rigorous environmental cleaning than low-touch
surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

805 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. (Housekeeping, During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
Dental staff etc) management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

806 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
Substandard # 6:04 logs /checklists is extremely important to ensure effective implementation & to have the
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
Cleaning is done properly is done & documented appropriately as per schedule.
using checklist that include
cleaning frequency, Each dental clinic must have the schedule for cleaning and disinfection activities.
responsible worker, Schedule must include the frequency, the used disinfectant and the responsible staff.
housekeeping surfaces (e.g., Roles must be specified with clear instructions.
floors and walls), used
agents, methods & 1. Dental staff for equipments
environmental surfaces 2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, sinks etc)
intended to be cleaned.

High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:05
Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more
Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light
Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap
During IPCCC audit visit, assess and interview same staff who had received training
water handles).
previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spills occur.

807 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:06 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:07
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

808 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
Substandard # 6:08
Best practices for environmental cleaning of general patient area floors:
The mop and solution must
be changed frequently &
Mop heads and cleaning and disinfectant solutions must be changed as often as needed
after being used to clean any
(e.g., when visibly soiled, after every isolation room, every third patient room or every
potentially infectious
1 hour) & at the end of each cleaning session.
materials.
IC Team must train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
Substandard # 6:09 educated on the cleaning agents, disinfectants, proper dilution and contact time.

Housekeepers are well Training must include following key parameters:

trained on hand hygiene,
proper use of PPE, methods Housekeeping staff must adhere to Standard Precautions and if required Expanded
of cleaning & proper & safe Precautions when performing routine practices of cleaning and following infection control
mixing of chemicals. measures. Routine practices related to environmental cleaning include:

HAND HYGIENE:
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before entering the clinic).
After potential body fluid exposure (e.g., after cleaning process or waste collection
etc).
After patient environment contact (e.g., after cleaning dental clinic.
After changing mop heads, cleaning solutions etc

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

809 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods

Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:10 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, far to reach surfaces etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:11 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use or discarded if single use.

810 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 6:12 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

811 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient
care across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

Substandard # 7:01 Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
in adequate amounts in the unit.
Preparation and dilution of Provide training to staff on importance of aseptic technique, monitor and evaluate
medication is only done by
practices.
ready-made sterile water
ampoule.

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 7:02
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples:, Intravenous sets, needles & syringes, PPE (gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
All single use items must be discarded after being used on patients.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes are used only for a single procedure
Substandard # 7:03
/ injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Needles and syringes are
items if amounts are inadequate/shortage of supplies)
used for only one patient.
Observe if these items are kept sterile and with their original intact wrap (they should not
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
future use even on the same patient.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

812 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7:04 Observe if these items are kept with remaining doses (Single dose medication vials,
ampoules and bottles of intravenous solution etc)
Single dose medication (single-dose vial should not be kept opened with any remaining dose whether labelled
vials, ampoules and bottles with any patient’s name or not to avoid its reuse or storing for future use even on the
of intravenous solution are same patient)
used for only one patient.

Observe the staff practices about the supplies and single-use medications that are taken to
Substandard # 7:05 patient’s care areas (i.e., for any procedure, only the required or necessary amount of
supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.
All patient care supplies are
brought to patient area After completion of treatment session /dental procedure following must be practiced
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge
are considered (i.e., they cannot be used on other patients or returned to clean areas for restocking
contaminated even in their All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.

- Maintaining the integrity of sterile equipment and solutions is extremely important to

prevent the associated risks of acquiring infection be it a surgical procedure or any other
sterile procedure
- If the sterile items are assembled long before the procedure, there are chances of
contamination from environment such as dust etc.
- A sterile field is a sterile surface on which to place sterile equipment that is considered
Substandard # 7:06 free from microorganisms. A sterile field is required for all invasive procedures to prevent
the transfer of microorganisms and reduce the potential for infections.
Sterile equipment and - Principles of sterile technique help control and prevent infection, prevent the transmission
solutions are assembled of all microorganisms in a given area, and include all techniques that are practised to
immediately prior to use. maintain sterility.

As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the start
of dental procedure. Staff must set up sterile trays as close to the time of use as
possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

813 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including dental assistants who assist the dentists should be fully aware
of the importance of sterile techniques. Breaks in the technique can lead to infections in the
patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Substandard # 7:07 Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
transfer forceps.
Sterile to sterile rule is Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
applied during any aseptic Non-sterile items should not cross over the sterile field. For example, a non-sterile person
procedure. should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
Substandard # 7:08 preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
Separate clean area is of contamination, including sinks or other water sources etc.
available for preparing
medications. • During daily / weekly rounds observe if dedicated medication preparation area is
available in dental clinic.
• To ensure best hand hygiene practices prior to preparation alcohol based hand rub
sanitizer & Hand washing facility must be available as close to work area.

814 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 7:09 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is
disinfected with alcohol Observe for availability of supplies required for disinfecting self-sealed rubber caps of
prior to piercing.
medication vials prior to access (e.g., approved antiseptic alcohol wipes).

Infection Control Team MUST provide training and education to the dental Health Care
personnel (DHCPs) regarding safety precautions to be taken during the procedures in
order to avoid risk of needle stick injuries.
Observe the DHCPs practices during routine monitoring rounds.
Evaluate the performance during IPCCC audit phase & provide feedback.

Substandard # 7:10 Following key points to be considered:

If needles with self- For procedures involving multiple injections with a single needle, the practitioner
sheathing mechanism and should recap the needle between injections by using a one handed recapping (scoop
recapping devices are not technique) if no engineering controls like needles with self-sheathing mechanism and
available, dental care recapping devices are not available are available for reheating the needle or holding
personnel use one-handed the needle cover.
recapping (scoop technique)
for recapping needles. Steps of One-handed recapping (scoop technique):

Safe way to recap needles in the absence of safety devices.

Place the cap on the tabletop and hold the syringe in one hand.
Keep the other hand by your side.
With one hand hold the syringe and use needle to ‘’SCOOP UP’’ the cap.
When cap covers the needles completely use the other hand to secure the cap on
needle hub.

815 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
816 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Waste Management
Dental facilities routinely generate a variety of waste materials, which may range from non infectious to infectious, hazardous, or toxic. The
implementation and application of logical procedures in safely handling, storing, and disposing of waste items further minimize occupational
risks to HCWs, reduce exposure to the public and protect the environment.
Infectious Medical waste is sufficiently capable of causing infection during handling and disposal (e.g., blood- or saliva-soaked cotton rolls,
extracted teeth, sharp items such as needles and endodontic files, and surgically removed hard and soft tissues) to merit special handling
and disposal.
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed and
disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling, sorting, and
appropriate disposal of waste from is important to prevent transmission of infection. Therefore healthcare workers must be well trained on
safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported and stored in a safe and
systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about the risks and safety operating
procedures of the waste they are handling.

Sub standards Explanation

❖ During routine daily / weekly rounds ensure all different sizes and types of waste containers
are available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)

Specification of Items:
Substandard 8.1:
Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
All types of waste
with a hermetical seal with an opening aperture which allows insertion of sharp items
containers are
(e.g., needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which
available in sufficient
must be printed in both Arabic and English. etc.
number and placed in
easily accessible sites
Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl
and away from traffic.
Chloride (PVC). - Thickness must not be less than 70 microns thick. - All designated
infectious waste containers should have a biohazard symbol or labelled with the word
“Infectious” both in Arabic and English or be color-coded (i.e., yellow bags), rendering
them identifiable by hospital staff.

➢ Observe availability of different sizes of color-coded waste bags.

➢ Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
➢ Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

- Sometimes sharp containers are mounted behind the patient bed at far location from
staff
- You may observe sharp containers placed directly on floor, mounted very high above the
eye level & at locations inaccessible for the healthcare workers.
Provide corrections and guidance to staff and audit unit performance for adherence to instruction
during IPCCC evaluation phase.

817 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 8.2: Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an
unbroken glass vials.
appropriate puncture
resistant and leak- Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
proof sharps container any such situation inform the head nurse to monitor closely the staff practices.
that are wall mounted Sharp item disposed off in infectious or general waste poses a significant risk of injury to waste
or placed on a stand at collection staff / housekeeping staff.
points of production.

Bending needles or any other manipulation in the dental healthcare exposes the dentals staff to
Substandard 8.3: significant risk of acquiring Needle stick Injuries from accidental exposure to sharps.
Sharp containers are used to dispose all used and unused sharps (e.g., Hypodermic, intravenous or
Used needles are not other needles, auto-disable syringes, syringes with attached needles, scalpels, glass pipettes,
manipulated and are knives, blades, broken glass)..
promptly disposed into
sharp containers. ❖ Observe during IPCCC sharp containers mounted in different patient care areas.
❖ Open lid of sharp containers at random and check if any broken, bent, or separated needles are
present.
❖ Such practices must be notified to the unit head.

Substandard 8.4: ❖ Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not. ❖
Substandard 8.5: Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp
waste in yellow container. Such practices must be observed and monitored & corrected during routine
medical waste daily rounds.
container) ➢ Used gloves & masks beside the waste receptacle on the floor & some PPE bulging out
of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase. Closely Monitor
the staff practices & evaluate staff and unit’s performance during IPCCC audit phase.

818 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:
Substandard 8.6:
Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags
If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are
temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4
Observe the label of infectious waste bags with the following information: a. Generating
filled)
department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Dental amalgam is a dental filling material used to fill cavities caused by tooth decay. Dental
amalgam is a mixture of metals, consisting of liquid (elemental) mercury and a powdered alloy
Substandard 8.7: composed of silver, tin, and copper. Approximately half (50%) of dental amalgam is elemental
mercury by weight. The chemical properties of elemental mercury allow it to react with and bind
Extracted teeth that together the silver/copper/tin alloy particles to form an amalgam. (FDA)
do not contain
amalgam are disposed Infection control Team must provide training & education to the dental staff regarding safe
of as regulated handling & management of infectious waste.
medical waste unless Observe the practices during routine rounds & audit staff and unit performance during IPCCC
returned to the patient. evaluation phase.
Training must incorporate all aspects of waste management including safe handling of
Substandard 8.8: sharps, extracted teeth & amalgam waste.

Dental amalgam is not Key Points for training best management practices for amalgam waste:
placed in biohazard
containers, infectious - Amalgam waste, amalgam capsules and extracted teeth that contain amalgam restorations
waste containers or should NOT be placed in biohazard containers, infectious waste containers or regular
regular garbage. They garbage.
should not be flushed - Amalgam waste should be stored in a labelled wide-mouthed, covered, rigid plastic
down the drain or container.
toilet. - After mixing amalgam, the empty capsules should be placed in a wide-mouthed, container
that is marked “Amalgam Capsule Waste for Recycling.” The container lid should be well
Substandard 8.9: sealed. When the container is full, it should be sent to a recycler. (Refer to MOH dental
guidelines for details)
Amalgam waste - Amalgam waste should not be flushed down the drain or toilet.
should be stored in a - Devices containing amalgam should NOT be rinsed under running water over drains or
labelled wide- sinks as this could introduce dental amalgam into the waste stream.
mouthed, covered, - Precapsulated alloys and a variety of capsule sizes should be used to minimize the amount
rigid plastic container. of amalgam waste generated. Bulk mercury should not be used.
- Extracted teeth that do not contain amalgam are disposed of as regulated medical waste
unless returned to the patient.

819 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 8.10: Dental healthcare personnel MUST ensure full understanding on the best practice of managing
extracted teeth and other tissues in dental practice. This is important to prevent / minimize the
Extracted teeth risk of infection in dental settings & to promote awareness for each dental personnel in the
collected for importance of managing extracted teeth and other tissues.
educational training
are cleansed of visible Extracted teeth are occasionally collected and used for preclinical or postgraduate educational
blood and gross training.
debris, maintained in a Extracted teeth collected for educational training must undergo processing as follows:
hydrated state (stored
in sodium hypochlorite All visible contamination i.e visible blood & gross debris etc must be removed from the
diluted 1:10 with tap extracted teeth.
water) and placed in a Must be maintained in a hydrated state i.e it must be kept /stored in the chlorine solution
well-constructed (Sodium hypochlorite diluted 1:10 with tap water).
container with a Extracted teeth must be placed in a an appropriately designed container that is secured with a
secure lid. lid.

820 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 9 Dental Lab
Dental laboratory is a place to manufacture or customize a variety of products to assist in the provision of oral healthcare by a dentist. All
dental lab personnel must ensure full understanding on the best practice of infection control in dental lab. Aim is to prevent/minimize the
risk of infection in dental settings & to promote awareness for each dental personnel in the importance of infection control in dental lab.
Sub standards Explanation
Infection control team must ensure that the design of dental lab is so designed in order to
prevent cross infection and environmental contamination. Lab personnel must be well
trained about the principles of infection control while handling with dental items to prevent
risk of acquiring infections.

Substandard 9.1: The design of a dental laboratory should include the following areas:

There is a complete 1. Receiving area. 2. Production area. 3. Shipping area.

separation between the
receiving area and the Receiving Area:
production area.
The receiving area should be separate from the production area.
Persons working in the receiving area should wear a clean uniform or laboratory coat, a
face mask, protective eyewear, and disposable gloves.
Personnel working in the receiving area should remove their PPE before moving to an
uncontaminated area of the lab.
Receiving area must be equipped with running water and hand-washing facilities.

Production Area:

Separate areas should be designated for new work and repairs inside the production area.
If this area is separated adequately and all incoming cases are known to have been
disinfected, DHCP can handle new cases as non-infectious once they have been
decontaminated.
Full PPE should be used when handling these items and every effort should be made to
avoid cross-contamination from such items.

Shipping Area:

This area is designed for final inspection, cleaning and disinfection of prostheses and
appliances.
The disinfected devices should be shipped in a labelled and sealed plastic bag (information
such as type of disinfectant used, disinfection method, and duration should all be
mentioned).

821 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During IPCCC training phase, assigned infection control practitioner must provide training
to the lab staff on the Use of Proper Method and Materials for Decontaminating Soiled
Items.
Lab personnel must be well oriented about the items that need to be sterilized before
being uses on another patient.

Steam Sterilization (Autoclave):

Substandard 9.2: Heat tolerant items used in the mouth and on contaminated laboratory items and materials
should be cleaned and sterilized before being used for another patient or another laboratory
Reusable heat-resistant case.
items used in the mouth Examples of such items are:
(e.g., metal impression trays Metal impression trays
and face-bow forks) are Burs & Laboratory knives
cleaned and heat-sterilized. Facebow forks
Handpieces and instruments
Orthodontic pliers & Impression guns etc

❖ Observe the practices in routine rounds.

❖ Randomly ask or pick any item from abovementioned list and ask if it was handled
after
❖ All above items must be cleaned and heat sterilized in the CSSD.

Evidence of cleaning and disinfection activities is of utmost importance in the healthcare

setting. IC team must provide relevant cleaning and disinfection activity logs and ensure all
cleaning activities are documented in between cases.
Substandard 9.3:
❖ IC team must ensure during routine rounds that appropriate cleaning is done in between
There is a documented cases.
cleaning of working surfaces ❖ Randomly wipe any surface to rule out presence of dust / soil or debris etc.
in the lab between the ❖ Review the cleaning log and ensure cleaning activities are documented according to the
cases. specified cleaning frequency.
❖ Verify the number of cases received from dental clinic the previous day and match with
frequency of cleaning in the cleaning log.
❖ Intermediate-level disinfectant with a “hospital-approved disinfectant” that is labeled
“tuberculocidal” to disinfect laboratory materials must be used.

822 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 DHCP must receive training from IC team on the safe handling, cleaning and
disinfection of dental prostheses and prosthodontics materials before being transported
to dental lab for further manipulations & work up.
Monitor the practices during routine rounds and provide necessary feedback. It’s the
key responsibility of dental staff & unit head and to ensure that appropriate IC
measures are followed at all times.
Evaluate unit performance during IPCCC audit phase and provide formal feedback.

Training must incorporate following key items:

Substandard 9.4:
❖ Disinfection of Dental Impressions:
Before handling dental
prostheses and Dental Impressions must be cleaned and disinfected immediately after their removal
prosthodontics materials in from the mouth.
the dental lab (e.g., Chair-side rinsing of impressions is the first step in successful infection control in
impressions, bite the laboratory.
registrations, and occlusal Impressions should be rinsed under running water after being removed from the
rims), they are cleaned and mouth to visibly eliminate saliva and blood.
disinfected according to Prostheses or appliances that have been worn by patients and require repair should
manufacturer’s instructions. be handled as contaminated (even after disinfection) and cleaned thoroughly before
disinfection by scrubbing with a brush and an antiseptic hand wash chairside or by
cleaning in an ultrasonic unit.
Impression materials marketed as containing a disinfectant still need to be rinsed
and disinfected after removal from the oral cavity.
The best time to clean and disinfect prostheses, or appliances is as soon as possible
after removal from the patient’s mouth before drying of blood or other bioburden
can occur.

Interpersonal communication & Transfer of items:

The dental practitioner should communicate with the dental laboratory regarding
infection control procedures used in the dental clinic.
When a case is transported from and to the dental clinic or dental laboratory, DHCP
should provide written information regarding the methods (e.g., type of disinfectant
and exposure time) used to clean and disinfect the material (e.g., impression, stone
model, or appliance); otherwise, the laboratory or dental clinic should assume that
the case is contaminated and disinfect as appropriate.
If during manipulation of a material or appliance a previously undetected area of
blood or bioburden becomes apparent, cleaning and disinfection procedures should
be repeated.
Transportation of contaminated items should be in a closed, leak proof container
which is either colored or identified with a biohazard label.

823 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 10 Dental Unit Water Lines (DUWL) protocols
Dental unit water lines: Small-bore tubing, usually plastic, used to deliver dental treatment water through a dental unit.
dental unit water systems (DUWS) have been known to be contaminated by non pathogenic and pathogenic organisms. The DUWS are
contaminated by organisms that colonize the system and water lines and soon after form biofilms inside the lumens of the water. Although the
water coming into the system from an external source is of potable quality.
All dental healthcare personnel to ensure full understanding on the best practice of treatment of dental unit waterlines. Dental units have
dental waterlines supplying several instrument hoses, three-in-one air/water syringes, patient cup-filler and cuspidor bowl rinse outlets. All
these waterlines are interconnected.
Sub standards Explanation

Substandard 10.1: Oral surgical procedures:

involve the incision, excision, or reflection of tissue that exposes the normally sterile areas of the oral
Only sterile water is used as cavity. Examples include biopsy, periodontal surgery, apical surgery, implant surgery, and surgical
a coolant/ irrigate for extractions of teeth (e.g., removal of tooth requiring elevation of mucoperiosteal flap, removal of bone
irrigating is used when or section of tooth, and suturing if needed).
performing oral surgical
procedures using an Sterile water:
water that is sterilized and contains no antimicrobial agents.
appropriate delivery device.
Provide training to DHCP on the importance of aseptic technique i.e using sterile water during oral
Substandard 10.2: surgical procedures in order to prevent risk of acquiring infections.
Observe during routine rounds the availability of supplies of sterile solutions that are used in dental
Dedicate sterile irrigating surgical procedures and check for opened sterile solution bottle(s) that is (are) not discarded after
solutions for one patient being used for one patient (e.g. sterile saline, sterile water).
ONLY and dispose of them Sterile irrigating solutions used during surgical procedures must be dedicated to one patient only
appropriately. Do not date or and leftover must be discarded after procedure.
save for later use, even on Opened sterile solution must never be kept to be used for next patient or the same patient.
the same patient.

Bacterial count:
A method of estimating the number of bacteria per unit sample. The term also refers to the estimated
number of bacteria per unit sample, usually expressed as colony forming units (CFUs) per square
centimeter (cm2) per milliliter (mL).
Biofilm:
An aggregate of microorganisms in which cells adhere to each other on a surface.
Substandard 10.3:
Colony forming unit (CFU):
For non-surgical dental Minimum number of separable cells on the surface of or in semi-solid agar medium which gives rise to
a visible colony of progeny is on the order of tens of millions.
treatment, Water that meets
environmental protection Independent water reservoir:
agency regulatory standards Container used to hold water or other solutions and supply it to handpieces and air/water syringes
for drinking water (i.e., ≤500 attached to a dental unit.
colony forming units
IC team must ensure high quality water to be used for non-surgical procedures.
(CFU)/mL of heterotrophic Ensure that DHCP are strictly adhering to the protocols of water quality & must follow the
water bacteria) should be process to monitor the quality of waterlines regularly.
used.
❖ For non-surgical procedures, regardless of the source water, the number of bacterial counts of
non-pathogenic bacteria in the water exiting the device into the oral cavity be as low as reasonably
achievable without exceeding 500 cfu/ml.

❖ Ensure all records / results of water quality monitoring are kept in the unit to be presented to the
external auditors for the purpose of verification.
❖ Available results from lab must be quantitative. Results mentioned as No growth must not be
accepted and returned to the lab for appropriate interpretation.

824 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 10.4: The safety and water quality for clinical use is of critical importance in dental practice. The
microbiological quality of water is a serious ecological problem for public health and for
In the absence of medical devices. Microbiological quality of water used in dental units is crucial for the safety of
manufacturer dental personnel and the requirements of dental patients and may relate to cross - infection
recommendations, water during the treatment particularly in immune suppressed patients. The fungi, Mycobacterium
should be tested monthly tuberculosis, Pseudomonas aeruginosa, Legionella species, Staphylococcus, Streptococcus
for three months when are considered opportunistic pathogens in dentistry. The presence of bacterial and water
beginning to use a new contamination is an important cause of cross - infection and cross – contamination.
product. If the unit meets
standards (i.e., ≤ 500 IC team must ensure manufacturer’s instructions are followed for water quality testing.
CFU/mL) during this period, If the manufacturer’s instructions are not available following protocols must be
then monitor the water from followed:
the dental unit at least
biannually and the records - Water should be tested monthly for three months when beginning to use a new product.
are maintained for at least - If the unit meets standards (i.e., ≤ 500 CFU/mL) during this period, then monitor the
(2) years. water from the dental unit at least biannually and the records are maintained for at least
(2) years.
Substandard 10.5: - Dental staff must keep records of water quality monitoring (Manual or electronic).

Water and air are

discharged for a minimum IC team must conduct training & education for the DHCP regarding infection control measures
of 20-30 seconds after each to be taken before starting the day, in between patients and at the end of day. Dental waterlines
patient, from any device must be flushed at the beginning of the clinic day to reduce the microbial load.
connected to the dental Patient material (e.g., oral microorganisms, blood, and saliva) can enter the dental water
water system that enters the system during patient treatment. Dental devices that are connected to the dental water
patient's mouth (e.g., hand- system and that enter the patient's mouth (e.g., hand pieces, ultrasonic scalers, or air/water
pieces, ultrasonic scalers, syringes) should be operated to discharge water and air for a minimum of 20--30 seconds
and air/water syringes). after each patient
Dental unit water that remains untreated or unfiltered is unlikely to meet drinking water
Substandard 10.6 standards, <500 CFU/mL, therefore, one or more commercial devices and procedures designed
to improve the quality of water should be employed. At the present time, commercially available
Each morning, remove hand options for improving dental unit water quality include the use of:
pieces and allow water lines
to run and discharge water Independent water reservoirs
for several minutes.
Chemical treatment regimens
Source water treatment systems
Daily draining and air purging regimens
Point-of-use filters
Following recommendations must be followed & adopted as part of daily
routine:

Flushing for 2 minutes in the morning and for 20–30 seconds after each patient should be
considered the norm for dental procedures, and longer flushing is suggested after weekends.
Flushing at the beginning of the day should be performed without hand pieces connected to
the waterlines.
Remove hand pieces and allow water lines to run and discharge water for several minutes to
reduce overnight microbial accumulation at the beginning of each clinic day.
If possible, use an enclosed container or high-velocity evacuation during discharge procedures
to minimize the spread of spray, spatter, and aerosols.
At the end of each working day, the water supply should be disconnected and the water lines
purged with air

825 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 10.7: IC team must ensure manufacturer’s instructions are followed for water quality testing.
If the manufacturer’s instructions are not available MOH approved solutions & instruction mustbe
The products and protocols used.
recommended by dental unit
manufacturer to maintain Following protocols must be followed:
water quality are followed.
Daily & Weekly disinfection of dental unit water lines (DUWL):
(if the manufacture
recommendations are not
Biofilm re-growth in DUWLs usually occurs within a week following disinfection/cleaning
available, water lines are
and so DUWLs need be treated regularly
disinfected daily/weekly with
Adherence to maintenance protocols is necessary as non-compliance has been associated
an approved MOH solution
with persistence of contamination of the water.
and as per the
manufacturer’s The following approaches are acceptable methods for reduction of the number of
recommendations). microorganisms and bacterial endotoxins exiting the waterlines:

Use of single-use disposable or sterilisable tubing

Elimination of the biofilm
Use of microfiltration devices placed inside DUWLs to treat water exiting the
waterlines.
Combined approach.

a) Use of single-use disposable or sterilisable tubing:

Whenever possible, single-use disposable or sterilizable tubes which allow the cleaning
and removal of the organic matrix of the biofilm from their lumens, are the preferred
method of controlling the microbial population within DUWLs.

b) Use of single-use disposable or sterilisable tubing

When using non-detachable tubings, management of waterline contamination should
aim at elimination of the biofilm.
Attempting to eliminate the resident bacteria without removal of the biofilm is an
inadequate approach to DUWL treatment which may increase the hazards of
contaminated water.
Biofilm re-growth in DUWLs usually occurs within a week following disinfection/cleaning
and so DUWLs need be treated regularly.
Elimination of the biofilm can be achieved through the use of a variety of chemical
products as per manufacturers instructions.

Introduction of the chemical agent into the waterlines may be either intermittent or
continuous.

The intermittent method of waterline treatment:

This method involves placement of the chemical agent in a self-contained water reservoir
(the source bottle) and flushing the water lines to allow the chemical to fill all the tubings.
The chemical is, then, left in contact with the tubings for the appropriate contact time
advised by the chemical’s manufacturer.
The continuous method of waterline treatment:
This method involves mixing low concentrations of the chemical agent with the dental
treatment water
This may be achieved either through mixing the chemical agent with the source water in a
self-contained system or through placement of the agent in a reservoir inside the dental
unit which provides for measured, continuous release into the water passing through the
tubings.

826 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 c) Microfiltration - Use of microfiltration devices placed inside DUWLs to treat water
Substandard 10.8: exiting the waterlines:
Public water system must not be delivered to the patient through the dental operative unit,
Water reservoir for the clinic
ultrasonic scaler, or other dental equipment.
is separated from the
Do not use water from the public water system for dental treatment, patient rinsing, or
municipal water supply, use
hand washing.
filters that will keep
Water reservoir for the clinic must be separated from the municipal water supply.
microorganisms out of the
There must be an alternate water supply that bypasses community water systems and
water, the water filters
DUWL by providing sterile or distilled water directly into water line attachments (i.e.,
should be changed
separate reservoir) combined with chemical treatment.
according to manufacturer
Filtration involving in-line filters to remove bacteria immediately before dental unit water
instruction.
enters instrument attachment i.e use of microfiltration devices placed inside DUWLs to
treat water exiting the waterlines.
Microfilters placed near the exit of waterlines reduce the number of bacteria in dental
treatment water.
Sediment filters commonly found in dental unit water regulators have pore sizes of 20-90
μm and do not function as microbiological filters.
Microfiltration occurs at a filter pore size of 0.03-10 μm.
The nearer the filters are placed to the exit of the tubings, the lower the bacterial counts
achieved.
Filters are not sufficient to manage the water-line problem alone, but they may be used in
conjunction with other water-line treatment methods to improve the quality of outgoing
water.

d) Combined Approach:
An ideal water-line treatment regimen would be filters combined with treatment of the
water-lines to remove the biofilm.

During routine infection control rounds IC Team must emphasize that all policies and
procedures are implemented for treatment of dental unit waterlines to ensure high
Substandard 10.9: quality water to be used for patients.
DHCP ensure regular maintenance of dental units by facility maintenance staff and /or
Regular maintenance of the manufacturer. It’s the key responsibility of unit head & IC team to ensure appropriate
dental units is done and all measures are taken.
the filters in the unit is All filters installed in the dental unit must be changed as per frequency specified by the
changed according to the manufacturer because filters may become contaminated & dysfunctional over time. Left
manufacturer instruction. unchecked, the debris collected in these filters builds up and can cause suction problems.
So it is important to conduct regular maintenance of the unit to ensure patient and staff
safety,

827 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Instrument Processing
Dental healthcare personnel must ensure full understanding on the best practice of Sterilization and Disinfection of Patient-Care Items. All
healthcare workers have responsibility to conform and respect all aspects of infection control policies and procedures, Moreover, unit heads
have a key responsibility to ensure their department functions within the parameters of the policy and that staff are trained and assessed in
these issues.

Sub standards Explanation

Substandard 11.01: Provide training to all dental healthcare personnel (DHCP) during IPCCC training regarding all
steps of instrument processing.
If the sterilization Ensure availability of all needed supply to ensure effective implementation of all IC standards.
process will be applied Monitor the staff practices during routine rounds.
after 2 hours or more, Evaluate performance of staff during IPCCC audit phase and provide formal feedback.
instruments inside
transferring containers IC education for instruments processing must be based on following recommendations:
are sprayed with
transportation No reprocessing of dental instruments should be carried inside the clinics. All the instruments
gel/spray. should be sent to the central sterilization department.
The critical and semi critical items must not be reprocessed in dental unit.

Preparation of dirty equipment before being sent to CSSD:

- Collection of used equipment in closed, sealed, and puncture resistant containers.

- Spraying of Pre Klenz spray or any other surfactant-based gel with corrosion inhibitors if
Substandard 11.02: transportation is not expected within two hours according to the hospital policy.
- No handling of instruments should be carried out inside the clinic. Manual cleaning before
All heat tolerant dental processing is strictly prohibited.
instruments are - Transfer of contaminated dental instruments to the central sterilization department in a
replaced between closed, sealable and puncture resistant container that is identified with a biohazard label.
patients and sent to
central sterilization. Heat tolerant dental instruments:

- All heat tolerant dental instruments are replaced between patients and sent to central
sterilization.
- Examples include ; surgical instruments, periodontal scalers ,hand pieces etc

Substandard 11.03: Specification of container used for transportation of contaminated items to the CSSD includes as
follows:
Contaminated dental
instruments are Must be rigid & puncture resistant
transferred to the Closed and sealable i.e it must be fully closed to avoid displacement or falling out of items that
central sterilization would result in contamination of environment and/or transportation carts.
department in a Container must be identified with a biohazard label.
closed, sealable and Container must meet the above specifications in order to ensure safe transportation of items to
puncture resistant CSSD for central processing.
container that is
identified with a
biohazard label.

828 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 11.04:
Transfer of instruments to and from the CSSD must be done following the infection control
Containers used for guidelines.
transferring
contaminated Containers used for transportation must be separate for contaminated and clean - processed
instruments is instruments identified with a clear label.
different than the one
used for transferring
clean instruments.

All dental healthcare personnel must ensure full understanding of the best practice of single-
use (disposable) devices in dental practice.

Single-use disposable item:

Substandard 11.05:
- A device intended to be used on one patient and then discarded appropriately; these items are
Single-use devices
not intended to be reprocessed (cleaned, disinfected, or sterilized) and used on another
(eg.,endodontic
patient.
broaches ,saliva
- Single-use devices MUST be used for one patient only and disposed of appropriately
ejectors, anesthesia
- Single-use devices include needles, prophylaxis cups and brushes, and plastic orthodontic
carpule…etc.) are
brackets etc are not heat-tolerant and cannot be reliably cleaned so they must be immediately
discarded after one
discarded after use on single patient.
use and not used for
- Certain items (e.g., prophylaxis angles, saliva ejectors, high-volume evacuator tips, and
more than one patient.
air/water syringe tips) are commonly available in a disposable form and should be disposed of
appropriately after each use.
- Any single-use device or item (e.g., cotton rolls, gauze, and irrigating syringes) used during
oral surgical procedures should be sterile at the time of use.

Substandard 11.06:
All sterilized dental instruments must be inspected before being used on the patients.
The sterilized dental Look for any stain or rust present on the instrument which reflects improper sterilization.
instruments should be Such instruments must not be used on patients and returned to CSSD for reprocessing.
checked for being IC team must be informed in such situation for necessary follow up in CSSD.
clean and rust free.

Internal Chemical Indicators:

Internal chemical indicators are placed with the items to be sterilized within the packs and are also
Substandard 11.07: called integrating indicators or slow-change indicators.
Internal chemical indicators should be placed inside every single instrument pack to ensure the
In each pack chemical steam has penetrated the packaging material and actually reached the instruments inside.
indicator should be
present. During routine rounds check at random the availability of chemical indicator inside each pack.
DHCP must be instructed to return any pack without chemical indicator and torn / opened
packs must be sent back to CSSD for reprocessing.

829 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the
integrity of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best
practices for safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 12:01
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
Substandard # 12:02 control parameters such as temperature, humidity etc are being monitored in the area or
not.
Medical store area has Ideally a fixed monitor should be installed for continuous monitoring of humidity &
controlled ventilation with temperatures.
adjusted temperature and
humidity (temperature Unit must have local records for regular monitoring (daily) of temperatures and relative
ranges from 22-24 humidity during the last month.
degree Celsius and Local records for corrective interventions which are taken if readings are not matching the
relative humidity up to acceptable values.
70%).
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

830 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection control team must provide training and reorientation about all specifications to be
Substandard # 12:03 followed for the maintenance of departmental medical stores.

Away from air vents and Train on following specifications / key points and observe in daily / weekly rounds if unit is
well ventilated. adherent with recommendations or not.
Departmental medical stores must be well organized & well maintained.
Substandard # 12:04 Must be away from any contamination, direct sunlight and airs vents.

Storage shelves are 40 Specifications of Storage Shelves:

cm from the ceiling, 20
cm from the floor, and 5 Storage shelves are made of easily cleanable material
cm from the outside wall. (e.g., fenestrated stainless steel, Aluminium or hard plastic).
Storage shelves are placed following these specifications.
Substandard # 12:05
- 40 cm from the ceiling
Storage shelves made - 20 cm from the floor
from easily cleanable - 5 cm from the wall
material (e.g., fenestrated
stainless steel, Aluminium If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
or hard plastic)
hard plastic).
Substandard # 12:06 Ensure that only sterile and clean items are allowed in the medical stores.

Sterile and clean items Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
completely separated from cockroaches and other insects etc.
from personal items &
foods and drinks.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 12:07 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 12:08 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 12:09
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
discarded)
No expired items, broken If any stained item is found it would most likely reflect that item was restocked after being brought
packs or packs with from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
stains are present. prohibited.
Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

831 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 13 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of
coronavirus was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19
pandemic reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.

Following must be ensured:

Substandard # 13:01
- All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
Daily logbook is book.
activated in the unit - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
for HCWs to record symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
presence or absence - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
of fever, respiratory & HCWs on daily basis.
GI symptoms etc. - Head nurse must review to assess the need for any staff to be evaluated by occupational health
before starting work clinic or need work restriction.
shift. - Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

Universal Masking in Hospitals in the Covid-19 Era:

Substandard # 13:02
According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
All HCWs must abide and health care workers from the virus MUST be intensified. These should include universal use of
by the policy of masks by all health care workers.
universal masking i.e In health care settings, First and foremost, a mask is a core component of the personal protective
wearing surgical face equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
mask at all times while in conjunction with gown, gloves, and eye protection.
in their respective
clinical setting. All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
expected to wear surgical face masks, at all times, while in their respective clinical care settings.

832 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 This universal mask approach will serve to:
Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

833 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.
Substandard # 13:03 Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
Health Care workers,
arms’ length) from other healthcare workers during the duty hours.
visitors & Patients
strictly adhere to the
principles of social Why Practice Social Distancing?
distancing, cough
COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
etiquette and frequent
prolonged period.
hand hygiene during
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
duty hours / visiting
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
hospital.
droplets can also be inhaled into the lungs.
Recent studies indicate that people who are infected but do not have symptoms likely also play a
role in the spread of COVID-19. Since people can spread the virus before they know they are
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
have any symptoms.

Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

834 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 13:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of DHCPs is Following must be ensured:
strictly prohibited
unless necessary for Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
Infection Prevention & clinical staff) to avoid the unnecessary mobility in between the units.
control activities. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of equipment for reprocessing etc

835 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
836 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
837 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:

□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms

□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

838 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
OUTPATIENT CLINICS

Preventing the transmission of infection in Outpatient Clinics

is an integral part of medical practice in all healthcare settings. All healthcare
providers should be adequately educated in the transmission, prevention, and
control of infectious diseases and understand their responsibilities.

Important measures to reduce the risk of transmission of infection include trying to

avoid crowding in waiting areas and scheduling patients with known or suspected
communicable diseases when the waiting area is least busy.

Standard infection prevention precautions are to be used with all patients, at all
times, in all healthcare settings, regardless of presumed infectious status or
diagnosis of the patient, and are determined by the circumstances of the patient,
the environment, and the task to be performed.

Strict implementation of infection control measures including hand hygiene, wearing

personal protective equipment (PPE) to prevent the transmission of infection during
provision of care, isolation precautions & environmental measures etc. would play
a significant role.

839 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN OUTPATIENT CLINICS

POLICIES & PROCEDURES

OUTPATIENT CLINICS

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

ISOLATION PRECAUTIONS

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

840 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 OUTPATIENT CLINICS

Standard – 1 Policies & Procedures

Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
Substandard # 1:2 access and refer to specific infection control policy & procedures.
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies &
procedures and is Interview the staff involved in patient care if they are well oriented about the policy content and
accessible for them. how to access the specific policy. e.g. (Ask about policy for isolation precautions/ PPE use etc.
verbally and then give task to demonstrate how to access this policy via electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

841 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST / PAPR
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

842 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Substandard # 2:2 knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel Infection Prevention & control department MUST provide education & training to all health care
(HCP) receive job- personnel on infection control best practices specific to their job as follows:
specific training on
infection prevention Infection control Training specific to area of work must be provided initially upon hiring before
policies and starting their duty.
procedures upon Continuous education on relevant infection control policies and procedures must be conducted
hiring and at least at least once per year.
once annually. Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

Educate healthcare personnel regarding standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standard.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.

843 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Infection Control department provides MUST provide health education on infection control for
Substandard # 2:4 patients & families.

Outpatient Clinic
IC team must ensure the availability of the following according to the specific unit / area:
provides infection
control health Bilingual infection control health education & awareness material must be designed / formulated
education for patients to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
and their families. booklets, leaflets etc. containing information easy to understand with help of pictorial display.
The educational material must be posted and available in all patient care areas, waiting areas at
the place easily seen and readable by patients, families and visitors. e,g hand hygiene, cough
etiquette,, COVID 19 & MERS educational material, etc.
In the OUTPATINET units, education provided to patients must be structured and documented
in patient’s files.

844 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
paper towels. are Check the availability of hand washing facilities in the clinics.
available & easily Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
accessible, at least tap if hands free operation or open the tap to check for hot & cold water supply)
one per clinic. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Substandard # 3:2

Alcohol - based Hand Rub Dispensers:

hand rub
dispensers) are - Check the availability of hand rub dispensers as per requirements:
available in One dispenser per clinic
adequate numbers One at every nursing station
(one dispenser per Ot any service areas
clinic, one at every
nursing station and - Observe dispensers are conveniently mounted and accessible at the point of care.
at any service - Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
areas). & easily ease of accessibility to staff.
accessible

Hand Rub Dispensers in waiting areas:

Substandard # 3:3
- At least one Alcohol - based hand rub dispensers are provided in the waiting areas.

Alcohol - based
hand rub dispensers ❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
are available in the ❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.
waiting areas.

845 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Substandard # 3:4 Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
Health care without the need for an exogenous source of water and requiring no rinsing or drying with towels or
professionals (HCP) other devices.
demonstrate Indications:
appropriate
Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
technique for hand
fluid exposure risk, after touching a patient, after touching patient’s surroundings.
rubbing and hand
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
washing.
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or
when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca

846 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Substandard # 3:5
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Visual alerts are
posted at appropriate places.
available: WHO 5
moments, how to
- WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to
- How to hand wash poster beside ach hand washing sink
do hand wash.
- How to handrub poster beside each hand hygiene dispen
-
WHO five moments of hand hygiene:

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before cannulation or accessing catheter.
- Before performing catheter site care.
- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

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848 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
849 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
Substandard # 4:1 in coordination with infection control department.

Sufficient and appropriate PPE During routine daily / weekly monitoring rounds, observe the availability of PPE by
are available in adequate randomly checking the PPE trolleys / stock rooms.
amount, types & sizes with PPE must be available at the point of use, which will interfere with effective use of PPE
proper qualities and readily as per requirement.
accessible to HCP. Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

850 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

851 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

Substandard # 4:4 1: Appropriate PPE for Contact Isolation:

Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Staff use personal protective
equipment appropriately (e.g. Sequence of donning PPEs before entering the room:
donning and doffing)
Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:
Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
https://youtu.be/H4jQUBAlBrI Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
Watch Video How to safely put nosepiece over nose bridge and secure head with ties or elastic.
on PPE Don gloves. Extend gloves over isolation gown cuffs.
Sequence of doffing PPEs before leaving the room:
Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

852 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

853 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
854 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
855 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
856 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
Substandard # 5:3
stethoscopes.
All reusable medical devices can be grouped into one of three categories according to the degree
Reusable non critical
of risk of infection associated with the use of the device:
medical care
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

857 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training pahse.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist to
the units which should include name of staff responsible for disinfection, items present in the
There is a disinfection specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to external
unit. auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, IV pole, door knobs, medication carts etc).
Substandard # 5:6 The principal modes of transmission are via the hands of the personnel and contact with
inadequately decontaminated equipment or surfaces. Likewise, all equipment used on the patient
High touch surfaces (e.g., blood pressure cuffs, thermometers, wheelchairs, IV pumps) are also heavily contaminated
should be disinfected and may be transmitted to other patients if strict barriers are not maintained and appropriate
more frequently. decontamination is not carried out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:7 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors,
HCW are responsible Physiotherapists etc)
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

858 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:2 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

859 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:3 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

860 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:4
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:5
Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more
Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light
Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap
During IPCCC audit visit, assess and interview same staff who had received training
water handles).
previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spills occur.

861 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:8 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:7
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

862 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
Substandard # 6:8
Best practices for environmental cleaning of general patient area floors:
The mop and solution must
be changed frequently &
Mop heads and cleaning and disinfectant solutions must be changed as often as needed
after being used to clean any
(e.g., when visibly soiled, after every isolation room, every third patient room or every
potentially infectious
1 hour) & at the end of each cleaning session.
materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.
Substandard # 6:9
Training must include following key parameters:
Housekeepers are well
trained on hand hygiene, Housekeeping staff must adhere to Standard Precautions and if required Expanded
proper use of PPE, methods Precautions when performing routine practices of cleaning and following infection control
of cleaning & proper & safe measures. Routine practices related to environmental cleaning include:
mixing of chemicals.
HAND HYGIENE:
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

863 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:10 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:11 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:12 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

864 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 6:13 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

HIGH TOUCH SURFACES

865 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
866 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 7:1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

867 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
Substandard # 7:2 importance in preventing sharp and needle stick injuries.

Sharp items (e.g., Observe the practices of staff during daily rounds regarding disposal of sharp items like
needles, scalpel needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
blades, broken metal All sharp items must be discarded in the specified sharp containers including the broken and
instruments and burs) unbroken glass vials.
are placed in an Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture any such situation inform the head nurse to monitor closely the staff practices.
resistant and leak- Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps collection staff / housekeeping staff.
container.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 7:3
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 7:4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 7:5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

868 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 7:6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

869 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 8:1 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 8:2 in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of to use large IV solution bottles for preparation & dilution of medications
medication is only done by Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water specified for preparation & dilution of medications.
ampoule. Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 8:3
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

870 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 8:4
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 8:5 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient. While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

871 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 8:6 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

- Maintaining the integrity of sterile equipment and solutions is extremely important to

prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
urinary catheter).
- If the sterile items are assembled long before the procedure, there are chances of
contamination from environment such as dust etc.
Substandard # 8:7 - A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
Sterile equipment and the transfer of microorganisms and reduce the potential for infections.
solutions are assembled - Principles of sterile technique help control and prevent infection, prevent the transmission
immediately prior to use. of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.

As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

872 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Substandard # 8:8 Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
transfer forceps.
Sterile to sterile rule is Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
applied during any aseptic Non-sterile items should not cross over the sterile field. For example, a non-sterile person
procedure. should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

873 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 8:9 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 8:10 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

Substandard # 8:11 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

874 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 8:12 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
claim that each device is exclusively allocated only for one patient.
Substandard # 8:13
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
• Patient's name & medical record number to be used exclusively for one patient.
insulin pens) are used only
• Date of the first use to be discarded after expiration of the reuse life recommended
for single patient.
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Substandard # 8:14 Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
The rubber self-sealed cap cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
on a medication vial is of antiseptic / wait the access site to dry before being penetrated with sterile device)
disinfected with alcohol Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
prior to piercing. being disinfected.

Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Substandard # 8:15
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
IV solution bottles are only
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
accessed through the self-
sealed rubber cap.

875 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 According to The Joint Commission, there are four chief aspects of the aseptic technique:
barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Substandard # 8:16 protect the patient from the transfer of pathogens from a healthcare worker, from the
environment, or from both. Some barriers used in aseptic technique include:
Maximum sterile barrier
precautions is applied - Sterile gloves
during any interventional - Sterile gowns
procedure, including cap, - Masks for the patient and healthcare provider
mask, sterile gown, sterile - Sterile drapes etc
gloves, and sterile full-body
drape. Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
central line etc.
Only necessary health personnel should be at the procedure. The more people present, the
more opportunities for harmful bacteria to cause contamination.

Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 8:17 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

876 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain large
numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or healthcare
workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must follow Standard Precautions at all times.
To reduce the possibility of occupational risks of infection transmission and/or exposure, laundry workers should focus on: a. Appropriate and
frequent hand hygiene. b. Appropriate use of personal protective equipment (PPE). Removal of foreign objects from soiled linen. 4. To restore
soiled linen to usable condition, washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 9:1 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 9:2 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 9:3 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 9:4 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

877 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9:5 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 9:6 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Substandard # 9:7 Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
to 10 inches off the floor.
Linen carts are covered and Linen from isolation rooms is considered regular soiled linen.
not overfilled. The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

878 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

HH. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
II. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
JJ. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xxiii. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xxiv. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

879 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Provide education to the staff regarding importance of isolation precautions & appropriate isolation
signs to be used during IPCCC training activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.

Observe if appropriate isolation signs are available and used according to type of diagnosis for
patients under isolation.
Use preferably isolation precautions signs provided by GDIPC.
Must be placed / posted on door only if occupied by patient.
Substandard # 10:1 02 types of isolation precaution signs must be available in the unit.
- Isolation precaution signs for units to be posted on doors if the isolation room is occupied
Staff are aware about by patients with diseases transmitted either by contact, droplet or airborne route.
the isolation signs and - Isolation Transportation cards for transportation of patients to other departments as
their color codes needed.

Examples: contact: Contact isolation Signs: are used for patients with diseases transmitted by contact route.
green, airborne: blue,
and droplet: pink or Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
red) infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

Droplet Isolation Signs: are used for patients with diseases transmitted by droplet route.

Droplet Precautions are intended to reduce the risk of droplet transmission of infectious agents from
close contact (exposure to eyes, nose and mouth) with large-particle droplets

Should be Initiated and maintained when there is suspected or confirmed diagnosis of an

infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
Use a single room. A negative air pressure room is not indicated.
Place a droplet sign on the door.
Droplet isolation signage must be color coded (e.g., orange) and must be available in both
English and Arabic languages.

Airborne isolation Signs are used for patients with diseases transmitted by Airborne route.

Airborne precautions is used when a patient is suspected or confirmed to have any of the diseases
that are spread via the airborne route.
Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Use a single room with a negative air pressure system (AIIR)
Place the Airborne Isolation sign on the door.
Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English and Arabic languages. b. Keep door closed at all times except when entering or
leaving the room.

880 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:2 IC Team must provide a log book to the units to be used for potentially harmful infectious
patient exposures such as MERS-CoV & COVID – 19 etc
Log book for exposure Logbook must specify the name, designation / job category, Duration of exposure (Time in /
is available for any Time out) & type of PPE used.
potentially harmful Appropriately used logbook will generate information needed in case of outbreaks etc
infectious exposures Train & educate staff regarding the importance of documenting relevant information in logbook
as per exposure before gaining entry into isolation room.
policies and Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
procedures (e.g. Evaluate unit’s performance in IPCCC audit phase.
MERS-CoV).
IC team must ensure the following in order avoid risk of exposure to staff and patients’ in the
Substandard # 10:3
outpatient clinics.
All appointments for All clinical appointments for patients with potentially infectious cases must be postponed till
patients with patients are fully recovered unless it is absolutely necessary for medical reasons.
potentially infectious Staff MUST take full necessary precautions in case if the appointments are scheduled for
cases should be patients with infectious diseases.
postponed until
recovery unless Educate the staff about the potential risks associated with exposure to infectious cases.
absolutely necessary. Observe the practices in the routine rounds to ensure implementation of policy.

Patient Transportation:
Patient Transportation isolation signs must be used while transporting patients under
transmission-based precautions to other department as needed.

Transfer of patients under isolation precautions must be restricted to medically necessary

purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
procedures that cannot be performed in the patient’s room.

Provide training and orientation to staff the transfer rules related to patient transportation under
Substandard # 10:4
isolation precautions. Observe if unit is following the policy.
If transfer of patient
Following instructions must be given:
under isolation is
required, the receiving
Receiving unit or facility is informed beforehand about the required isolation precautions to be
unit or facility is
informed about the taken. (Transfer could be internal to any unit inside facility or external to any other facility)
required isolation Clear instructions must be provided and documented in patient files before transfer.
precautions and Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
availability of unit etc.
appropriate PPE is
ensured. It is important that HCWs in the receiving unit have received prior training on how to safely
handle patients under isolation precautions and how to appropriately use PPE according to type
of isolation. e.g. For handling patients under airborne isolation, radiology staff must be fit tested
for N-95 mask and trained well on how to don & doff after use.

Transferring the Patient to Another Facility:

Inform the receiving facility and the emergency vehicle personnel in advance about the type of
isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

881 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 11:1
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 11:2 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to Local records for corrective interventions which are taken if readings are not matching the
70%). acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

882 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11:3 Infection control team must provide training and reorientation about all specifications to be
followed for the maintenance of departmental medical stores.
Away from air vents and
well ventilated. Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.
Substandard # 11:4 Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Storage shelves are 40
cm from the ceiling, 20 Specifications of Storage Shelves:
cm from the floor, and 5
cm from the outside wall. Storage shelves are made of easily cleanable material
(e.g., fenestrated stainless steel, Aluminium or hard plastic).
Substandard # 11:5
Storage shelves are placed following these specifications.
Storage shelves made - 40 cm from the ceiling
from easily cleanable - 20 cm from the floor
material (e.g., fenestrated - 5 cm from the wall
stainless steel, Aluminium
or hard plastic) If containers are used inside medical stores, they are made of easily cleanable material (e.g.,

Substandard # 11:6 hard plastic).

Ensure that only sterile and clean items are allowed in the medical stores.
Sterile and clean items
completely separated Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from personal items & from cockroaches and other insects etc.
foods and drinks.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 11:7 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 11:8 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 11:9 Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
discarded)
No expired items, broken If any stained item is found it would most likely reflect that item was restocked after being brought
packs or packs with from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
prohibited.
stains are present.
Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

883 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.

Following must be ensured:

Substandard # 12:1
- All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
Daily logbook is book.
activated in the unit - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
for HCWs to record symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
presence or absence - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
of fever, respiratory & HCWs on daily basis.
GI symptoms etc. - Head nurse must review to assess the need for any staff to be evaluated by occupational health
before starting work clinic or need work restriction.
shift. - Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

Universal Masking in Hospitals in the Covid-19 Era:

Substandard # 11:2
According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
All HCWs must abide and health care workers from the virus MUST be intensified. These should include universal use of
by the policy of masks by all health care workers.
universal masking i.e In health care settings, First and foremost, a mask is a core component of the personal protective
wearing surgical face equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
mask at all times while in conjunction with gown, gloves, and eye protection.
in their respective
clinical setting. All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
expected to wear surgical face masks, at all times, while in their respective clinical care settings.

884 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 This universal mask approach will serve to:
Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

885 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.
Substandard # 11:3 Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
Health Care workers,
arms’ length) from other healthcare workers during the duty hours.
visitors & Patients
strictly adhere to the
principles of social Why Practice Social Distancing?
distancing, cough
COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
etiquette and frequent
prolonged period.
hand hygiene during
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
duty hours / visiting
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
hospital.
droplets can also be inhaled into the lungs.
Recent studies indicate that people who are infected but do not have symptoms likely also play a
role in the spread of COVID-19. Since people can spread the virus before they know they are
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
have any symptoms.

Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

886 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 11:4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc) HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients etc

887 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
888 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
889 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 DIAGNOSTIC &
INTERVENTIONAL SERVICES

# NAME OF UNIT PAGE #

01 CARDIAC CATHETERIZATION LABORATORY 891

02 RADIOLOGY DERVICES 949

03 ENDOSCOPY UNIT 991

04 BRONCHOSCOPY 1042

05 LABORATORY SERVICES 1100

890 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
CARDIAC CATHETERIZATION
laboratory

Cardiac Catheterization and associated

diagnostic or therapeutic procedures bypass natural host defences and thereby

introduce the risk of infection. Early onset infections resulting from these procedures
can be related to bacterial entry into the host via the bloodstream.
Therefore, sterile preparation for vascular access is very important in all vascular
access procedures. Especially worrisome are the late onset infections that can occur
with implantable devices that are left in place (e.g., pacemakers, stents).
Hence, Sterile preparation of the patient and sterile surgical technique are vital to
reduce the risk of infection associated with these devices.
Strict implementation of infection control procedures including hand hygiene, wearing
personal protective equipment (PPE) to prevent the transmission of infection during
patient care, practicing aseptic technique, isolation precautions & environmental
measures etc. would play a significant role in ensuring patient & staff safety.

891 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN CARDIAc
CAthETERIZATION Lab

POLICIES & PROCEDURES

CARDIAC CATHETERIZATION LAB

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

CATH LAB DESIGN

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

892 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 CARDIAC CATHETERIZATION (CATH LAB)
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for aseptic technique / isolation
accessible for them. precautions etc. verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

893 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation
Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.

Each HCPs must receive education & training on basic infection control skills from IC
Substandard # 2:1 department within 01 months of joining work. (BICSL)
IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
joining work & issue a BICSL ID which should be renewed ever 02 years.
Healthcare Personnel
(HCP) receive Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
orientation and hours as an evidence of basic infection control training to be presented to any external /internal
training on Basic audit visit for purpose of verification.
Infection Control Skills Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
from IC department every 2 years by visiting infection control department.
maximum within 1
months of joining
work & a BICSL card Components of BICSL includes:
is issued which is
renewed every 2
- HAND HYGIENE
years.
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

894 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_title

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
Substandard # 2:2 patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Healthcare Personnel knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
(HCP) receive job-
specific training on Infection Prevention & control department MUST provide education & training to all health care
infection prevention personnel on infection control best practices specific to their job as follows:
policies and
procedures upon Infection control Training specific to area of work must be provided initially upon hiring before
hiring and at least starting their duty.
once annually. Continuous education on relevant infection control policies and procedures must be conducted
at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

895 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

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, implementation of
Care bundles, standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standards
specific for each unit.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.
Example: Assess knowledge of and adherence to guidelines for all personnel involved in the
insertion and maintenance of intravascular catheters.

Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Infection Control department provides MUST provide health education on infection control for
patients & families.
Substandard # 2:4
Tailored IPC education for patients or family members should be considered to minimize the
potential for HAI (for example, patients who are immunosuppressed or with invasive devices or
Unit provides infection
with multidrug resistant infections).
control health
education for patients
IC team must ensure the availability of the following according to the specific unit / area:
& families.
Bilingual infection control health education & awareness material must be designed / formulated
to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
booklets, leaflets etc. containing information easy to understand with help of pictorial display.
The general & specific health educational material must be posted and available in all patient
care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.

Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files.

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897 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
towels) are available Check the availability of hand washing facilities in patients’ rooms.
& easily accessible, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
at least one per tap if hands free operation or open the tap to check for hot & cold water supply)
procedure room. Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
soap 3: Paper Towels for drying
Alcohol - based
hand rub dispensers Hand Rub Dispensers:
are available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
(one dispenser per One dispenser per patient's bed,
patient's bed, one at One at every nursing station
every nursing One any service areas e.g medication room, storage area etc
station and at any
service areas). - Observe dispensers are conveniently mounted and accessible at the point of care: a. At the
entrance to each patient room. b. Examination room c. Treatment rooms, and similar areas etc.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
Substandard # 3:2 ease of accessibility to staff.

Alcohol - based Hand Rub Dispensers in waiting areas:

hand rub dispensers
are available in the - At least one Alcohol - based hand rub dispensers are provided in the waiting areas.
waiting areas.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

898 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:3 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Health care Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of
professionals (HCP) microorganisms without the need for an exogenous source of water and requiring no rinsing or
demonstrate drying with towels or other devices.
appropriate
technique for hand Indications:
rubbing and hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
washing. body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile)
and /or when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients
at high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking different categories of staff to
demonstrate hand hygiene. (Nurses, doctors, RT, Housekeeping etc)

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
899 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
Substandard # 3:4
incorporating the culture of best practices.
Visual alerts are
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
available: WHO 5
posted at appropriate places.
moments, how to
do hand rub, how to
- WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand wash.
- How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispenser
-
WHO five moments of hand hygiene :

1: Before touching a patient :

- Before entering the room / cubicle to provide care to a patient.

- Before contact with vascular access site.
- Before adjusting or removing cannulas.

2: Before aseptic procedures:

- Before changing or applying dressing

- Before parenteral medication preparation.
- Before administering infusions or lV medications

3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids.

- After performing wound care or dressing changes.

4: After touching a patient:

- When leaving the patients room/ cubicle after performing patient care.
- After removing gloves.
-
5. After touching patient surroundings:

- When leaving the patients room / cubicle after touching any equipment or other items
furniture etc even without touching patient.
- After removing gloves.

900 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
901 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
902 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.

Substandard # 4:1 During routine daily / weekly monitoring rounds, observe the availability of PPE by
randomly checking the PPE trolleys / stock rooms.
Sufficient and appropriate PPE PPE must be available at the point of use. Sometimes PPE is available in stock room but
are available and readily not in the PPE trolley / shelves e.g. eye goggles, N-95 masks etc which will interfere
accessible to HCP. with effective use of PPE as per requirement.
Simultaneously ask the nurse in charge, if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles, face shields)
- Different sizes and type of N - 95 masks

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Review the PPE checklist to ensure the availability of all PPE items including N-95
Substandard # 4:2
masks.
Check availability of N-95 masks in PPE trolleys outside isolation rooms & stock rooms.
N - 95 respirators are
Check if all types and sizes are available according to fit test result of each healthcare
available in different types and
worker. (Doctors, Nurses, RTs, Housekeeping staff etc)
sizes.

903 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

Substandard # 4:4 ❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
Staff use personal protective ❖ Airborne: N95 mask / respirator before entering the room.
equipment appropriately (e.g.
donning and doffing)
1: Appropriate PPE for Contact Isolation:
Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

904 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

3: Appropriate PPE for Airborne Isolation:

https://youtu.be/H4jQUBAlBrI Sequence of donning PPEs before entering the room:

Watch Video How to safely put
on PPE ❖ Perform hand hygiene.
❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.
❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

905 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
906 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
907 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
908 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
Substandard # 5:3 multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
stethoscopes.
Reusable non critical All reusable medical devices can be grouped into one of three categories according to the degree
medical care of risk of infection associated with the use of the device:
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

909 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 In order to avoid staff exposure to risk of acquiring infection, reusable critical and semi critical
items must be placed in the leak prof container immediately after use without any manipulation
Well closed leak-proof e.g Manual cleaning of blood / debris in the sinks etc.
containers are Check for availability of a well closed leak proof container.
available to place Provide education & training about associated risks during IPCCC training phase.
reusable critical and Ask staff to demonstrate handling of any critical /semi critical item after procedure and observe
semi-critical items practice.
immediately after use Provide on-site feedback on performance and correct practices if needed.
before sending to
CSSD without any - All reusable critical and semi-critical items must be sent to CSSD.
interference from the - Staff are not allowed to handle any used critical & semi critical item even away from
staff. patient’s zones within the unit.

Substandard # 5:5 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist
to the units which should include name of staff responsible for disinfection, items present
There is a disinfection in the specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to
unit. external auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, overbed table, IV pole, door knobs, medication
carts etc).
The principal modes of transmission in burn units are via the hands of the personnel and contact
Substandard # 5:6 with inadequately decontaminated equipment or surfaces. The two areas most likely to become
contaminated when caring for the burn patient are the hands and apron area of the person, as the
High touch surfaces surfaces (e.g., beds, side rails, tables, equipment) are often heavily contaminated with organisms
should be disinfected from the patient. Likewise, all equipment used on the patient (e.g., blood pressure cuffs,
more frequently. thermometers, wheelchairs, IV pumps) are also heavily contaminated and may be transmitted to
other patients if strict barriers are not maintained and appropriate decontamination is not carried
out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
At discharge / transfer (terminal cleaning)
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:7 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, Respiratory
HCW are responsible Therapists (RTs), X ray technicians etc
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

910 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:2 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

911 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:3 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same using / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

912 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:4
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

Terminal cleaning of inpatient areas after the patient is discharged/transferred, aims to remove
Substandard # 6:5 organic material and significantly reduce and eliminate microbial contamination to ensure that
there is no transfer of microorganisms to the next patient.
Terminal cleaning is done Terminal cleaning requires collaboration between cleaning, clinical &Infection control staff, to
properly using checklist delineate responsibility for every surface and item, including ensuring that:
including responsible 21. Disposable personal care items are discarded
worker, housekeeping 22. Patient care equipment are removed for reprocessing
surfaces, used agents, It is important that the staff responsible for these tasks are identified in checklists and SOPs to
methods & environmental ensure that items are not overlooked because of confusion in responsibility.
surfaces intended to be
cleaned. Terminal cleaning checklist must include all the items present in the assigned area.
Terminal cleaning checklist must specify responsible staff (Nusre. Housekeeping, RT etc)
for intended item /area to be disinfected.
Substandard # 6:6 Terminal cleaning checklist must specify all surfaces and areas to be disinfected in the
isolation rooms.
Terminal cleaning after Type of disinfectant to be used with correct dilution and contact time, method (Clean
discontinuation of isolation only, clean & disinfect etc).
is supervised by the in- Terminal cleaning process must be supervised by nurse – in charge, countercheck all
charge nurse, and in case of items and surfaces at random and sign the checklist.
outbreak by infection control Infection Control team must supervise the terminal cleaning process in case of outbreak
practitioner. in particular unit. Unit must call the ICP after completion of terminal cleaning process to
countercheck and document in cleaning checklist.
(All terminal cleaning checklist must be kept in the unit to be reviewed during audit
rounds by external auditors

913 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:7 Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap During IPCCC audit visit, assess and interview same staff who had received training
water handles). previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spill occur.

914 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

915 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:8 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:9
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

916 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 6:10 contaminated unless changed.

The mop and solution must Best practices for environmental cleaning of general patient area floors:
be changed frequently (e.g.,
every third patient room or Mop heads and cleaning and disinfectant solutions must be changed as often as needed
hourly) and after being used (e.g., when visibly soiled, after every isolation room, every third patient room or every
to clean any potentially 1 hour) & at the end of each cleaning session.
infectious materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Housekeeping staff must adhere to Standard Precautions and if required Expanded
Substandard # 6:11 Precautions when performing routine practices of cleaning and following infection control
measures.
Housekeepers are well Routine practices related to environmental cleaning includes:
trained on hand hygiene,
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals. Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:

Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

917 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 6:12 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:13 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:14 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

918 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Cleaning and disinfection of isolation rooms requires special attention and training since
Substandard # 6:15 there would be more risk of exposure to infectious material in the environment.

Environmental cleaning and There must be dedicated cleaning and disinfection equipment (Trolley with dedicated
disinfection equipment (i.e. mops, buckets, microfiber cloths etc)
mops and buckets) Train the staff to be used exclusively for isolation rooms and never to be used for regular
dedicated for isolation room rooms.
only and never being used Monitor staff during routine rounds and evaluate the performance of staff in IPCCC
for another area. rounds in each quarter.

Bedside or privacy curtains are considered high touch items.

IC team MUST provide and ensure implementation of policies and procedure for curtain
changing including frequency according to unit/area. Etc
When patients are NOT on Isolation Precaution:
Substandard # 6:16 Curtains should be changed and cleaned on a routine schedule and whenever visibly
soiled.
Bedside curtains are clean,
free from stains and When patients are UNDER Isolation Precaution:
changed regularly & when If the patient is on Contact Precautions for C. difficile, MRSA, VRE, MDRO, ESBL, or
visibly contaminated. KPC, droplet isolation or airborne isolation, it is recommended that they should be
changed after the patient is discharged, transferred, or taken out of isolation.

IC team must observe the implementation of policy during routine IC rounds.

Observe for any visible contamination such as blood stains. & any other splashes -
stains etc.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
Substandard # 6:17
Infection control must develop a schedule for pest control in different units.
There is a regular schedule Schedule must include frequency of pesticide spraying, date & time of spraying.
for pest control including the Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
frequency, date, time & to GCC manual for list of banned pesticides. . (ICM - X- 08 Pest Control Pg 377)
approved pesticides being
used. Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.
For critical areas like burn unit, oncology units consideration must be given to selection of
pesticides with less odour & offensive etc

919 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
920 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defence
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 7:1 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Frequent manipulations and replacements of peripheral catheters without indication can lead to
Substandard # 7:2
development of infections & phlebitis by introduction of microorganisms into blood stream.
Therefore, PVCs must be replaced only when indicated.
There is no need to replace
peripheral catheters more
During routine rounds, verify if policy is implemented. Peripheral venous catheters must
frequently than every 72–96
be fixed properly (preferably with transparent sterile dressings)
hours to reduce risk of
Data of insertion is clearly written (date, time and responsible HCW)
infection and phlebitis in
Peripheral catheters MUST not be replaced more frequently than every 72–96 hours.
adults.
Counter check by reviewing patient files about the patient encounters & interviewing
responsible staff about the insertion time of peripheral venous catheter to ensure that
HCWs strictly follow the peripheral venous catheter related policy.
Any peripheral venous catheter that is conflicting with the recommended duration for the
replacement of PVCs, issue must be discussed with nursing staff to comply with
guidelines.
Peripheral venous catheter’s insertion site is inspected each shift to be removed if signs
of inflammation, infiltration, extravasation, signs of infection, occlusion or blockage are
present, or if the PVC is no longer needed for therapy.

921 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 7:3
in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of
to use large IV solution bottles for preparation & dilution of medications
medication is only done by
Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water
specified for preparation & dilution of medications.
ampoule.
Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 7:4
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 7:5
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

922 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 7:6 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient.
While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 7:7 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

923 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Maintaining the integrity of sterile equipment and solutions is extremely important to
Substandard # 7:8 prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
Sterile equipment and urinary catheter).
solutions are assembled - If the sterile items are assembled long before the procedure, there are chances of
immediately prior to use. contamination from environment such as dust etc.
- A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
the transfer of microorganisms and reduce the potential for infections.
- Principles of sterile technique help control and prevent infection, prevent the transmission
of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.
As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.
Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
Substandard # 7:9 transfer forceps.
Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
Sterile to sterile rule is Non-sterile items should not cross over the sterile field. For example, a non-sterile person
applied during any aseptic should not reach over a sterile field.
procedure. Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.

924 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 7:10 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 7:11 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

925 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7:12 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 7:13 performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials a medication vial for multiple medication draws.
(MDVs) are accessed with a This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses additional doses from a multidose medication vials.
for the same patient. Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).

Check and observe during daily/ weekly rounds if cartridge devices such as insulin pens
are used or not (e.g., presence of insulin pens in the medication refrigerator)
Check the refrigerator, if cartridge devices such as insulin pens are present, and HCWs
Substandard # 7:14 claim that each device is exclusively allocated only for one patient.
In such situation, cartridge device must be labelled with following data:
Cartridge devices (e.g.
insulin pens) are used only • Patient's name & medical record number to be used exclusively for one patient.
for single patient. • Date of the first use to be discarded after expiration of the reuse life recommended
by the manufacturer.
• Check the refrigerator, if you find used cartridge device such as insulin pen without
patient's name or medical record number, this means it is used for multiple
patients.

❖ Train and observe staff practices if following recommendations.

Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 7:15 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.

926 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
Substandard # 7:16
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
IV solution bottles are only accessed through the self-sealed rubber cap. You may
IV solution bottles are only
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
accessed through the self-
than the self-sealed rubber cap.
sealed rubber cap.
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

Crystalloid solutions, which contain water-soluble electrolytes including sodium and chloride,
Substandard # 7:17 lack proteins and insoluble molecules. They are classified by tonicity as:
Isotonic crystalloids contain the same amount of electrolytes as the plasma.
IV sets (including secondary Hypertonic and hypotonic crystalloids respectively contain more and less electrolytes than the
sets and add-on devices) plasma. Examples includes Normal Saline, Ringers Lactate, dextrose 5% in Water
that are continuously used
to infuse crystalloid Provide retraining & orientation to staff during IPCCC training phase regarding frequency
solutions (hypotonic, of changing the IV sets used for administration of crystalloid solutions, blood products, &
isotonic, or hypertonic), are lipid emulsions.
replaced at least every 7 Following key points must be followed for replacement of IV sets in order to avoid risk of
days, but not more infection from frequent changing of IV sets:
frequently than 96-hour
IV sets used to infuse crystalloid solutions (hypotonic, isotonic, or hypertonic), are
intervals.
replaced at least every 7 days, but not more frequently than 96-hour intervals. This
means that IV sets must not be replaced before 96 hours unless there is an indication
for replacement / removal.
Substandard # 7:18 Rationale: Extending the duration of use permits considerable cost savings to hospitals
without significant increase in the risk of healthcare-associated BSI with peripheral IVs
IV sets that are used to
administer blood, blood In patients who are receiving blood, blood products, lipid emulsions, or dextrose/amino
products, lipid emulsions, or acid TPN solutions, check that IV delivery systems are continuously connected and
dextrose/amino acid TPN changed within 24 hours of initiating the infusion.
solutions are replaced within During daily rounds, observe that IV administration sets are labelled with dates & times of
24 hours of initiating the initiating treatment (e.g., dates & times of initiating infusion of crystalloid solutions
infusion. (hypotonic, isotonic, or hypertonic solutions) or administration of blood, blood
products, lipid emulsions or TPN solutions).

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 7:19 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

927 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide education & training to the healthcare personnel regarding the feeding systems & key
Substandard # 7:20 points that should be considered.
Observe the practices during routine monitoring rounds. Evaluate performance during IPCCC
Open feeding systems audit phase.
should be removed after 8
hours, whereas sterile Following MUST be implemented:
closed systems may remain
hanging for up to 24 to 48 If open feeding system are used, they should be removed after 8 hours.
hours or per manufacturer's If sterile closed feeding system are being used, they may remain hanging for upto 24 – 48
recommendation. Hours OR manufacturers instruction MUST be followed.

According to The Joint Commission, there are four chief aspects of the aseptic technique:
Substandard # 7:21 barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Maximum sterile barrier protect the patient from the transfer of pathogens from a healthcare worker, from the
precautions is applied environment, or from both. Some barriers used in aseptic technique include:
during any interventional
procedure, including cap, - Sterile gloves
mask, sterile gown, sterile - Sterile gowns
gloves, and sterile full-body - Masks for the patient and healthcare provider
drape. - Sterile drapes etc
Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
Substandard # 7:22 central line etc.
Traffic should be kept minimum once the sterile field has been established.
Traffic should be kept
minimum once the sterile Only necessary health personnel should be at the procedure. The more people present, the
field has been established. more opportunities for harmful bacteria to cause contamination.
Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

Recognized routes for contamination of catheters:

Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with
colonization of the catheter tip; this is the most common route of infection for short-term catheters
Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices.
Catheters might become hematogenous seeded from another focus of infection.
Infuscate contamination might lead to CRBSI.

928 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

KK. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
LL. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
MM. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xxv. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xxvi. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

929 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation

Substandard # 8:1 Cardiac catheter-associated procedures introduce the risk of infection. These procedures range from
minimally invasive procedures to surgical procedures. The risk of infection following these
Patient with infectious procedures can be minimized if good procedural technique and good infection prevention processes
disease requiring are followed. For staff and patient protection, standard precautions that minimize exposure to blood
intervention are and body fluids must be followed.
scheduled at the end
of the day if possible. IC must provide education & training to the staff regarding the infection control risks associated
with cardiac catheterization.

Following MUST be considered while scheduling patient appointments and preparing list for daily
procedures:
Substandard # 8:2
Patient with infectious disease requiring intervention are scheduled at the end of the day if
Patient with infectious
-

possible to avoid risk of infection transmission

disease requiring
- Patient with infectious disease requiring operation are scheduled at the end of the day if
operation are
possible.
scheduled at the end
- These includes coronary angiography. Hemodynamic testing. Percutaneous coronary
of the day if possible.
interventions. Trasnseptal catheterization etc

Provide education to the staff regarding importance of isolation precautions & appropriate isolation
signs to be used during IPCCC training activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.

Observe if appropriate isolation signs are available and used according to type of diagnosis for
patients under isolation.
Use preferably isolation precautions signs provided by GDIPC.
Substandard # 8:3
Must be placed / posted on door only if occupied by patient.
02 types of isolation precaution signs must be available in the unit.
Cath Lab Staff are
aware about the - Isolation precaution signs for units to be posted on doors if the isolation room is occupied
isolation signs and by patients with diseases transmitted either by contact, droplet or airborne route.
their color codes - Isolation Transportation cards for transportation of patients to other departments as
needed.
Examples: contact:
green, airborne: blue, Contact isolation Signs: are used for patients with diseases transmitted by contact route.
and droplet: pink or
red) Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

930 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Droplet Isolation Signs: are used for patients with diseases transmitted by droplet route.

Droplet Precautions are intended to reduce the risk of droplet transmission of infectious agents from
close contact (exposure to eyes, nose and mouth) with large-particle droplets

Should be Initiated and maintained when there is suspected or confirmed diagnosis of an

infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
Use a single room. A negative air pressure room is not indicated.
Place a droplet sign on the door.
Droplet isolation signage must be color coded (e.g., orange) and must be available in both
English and Arabic languages.
Substandard # 8.4
Airborne isolation Signs are used for patients with diseases transmitted by Airborne route.
Contact isolation
precautions are
Airborne precautions is used when a patient is suspected or confirmed to have any of the diseases
initiated for patients
that are spread via the airborne route.
infected or colonized
Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
with multidrug-
disease that is transmitted by the airborne route. e,g tuberculosis, chickenpox etc
resistant organisms.
Use a single room with a negative air pressure system (AIIR)
Skin lesions and
Place the Airborne Isolation sign on the door.
infected or colonized
Airborne isolation signage must be color coded (e.g., blue) and must be available in both
areas of patient's body
English and Arabic languages. b. Keep door closed at all times except when entering or
should be contained
leaving the room
and covered.
MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or
more classes of antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently resistant to
most available antimicrobial agents.
Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci
(VRE) Extended Spectrum Beta-lactamases (ESBLs) & Carbapenem-Resistant
Enterobacteriaceae (CRE) etc are among primary resistant microorganisms of significant
concern in the healthcare setting and are encountered in many hospitals.
Proper attention & care to these pathogens is critical to curtail further emergence of these
highly resistant organisms.
Infection refers to the entry into and multiplication of an infectious agent in the tissues of the
host and the tissue damage resulting in apparent or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with growth and

multiplication but without tissue invasion or damage.

ICPs must emphasize on the following key points during training phase of IPCCC:

- Contact isolation should be initiated and maintained for patients infected or colonized with
multidrug-resistant organisms.
- Skin lesions and infected or colonized areas of patient's body should be contained and covered
in order to avoid cross transmission of infection to immediate patient surroundings.

Monitor & evaluate unit performance during audit phase of IPCCC activities and provide formal
feedback.

931 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8:5 Infection control team must provide training & education to Cath lab staff to ensure strict
implementation of following IC precautions if a patient with active tuberculosis requires operation:
For patient with active
TB requiring operation, HCW should wear N95 masks throughout the procedure.
HCW should wear N95 Bacterial filter is placed on the patient’s endotracheal tube.
masks throughout the Attempts should be made to perform the procedure at a time when other patients are not
procedure and a present in the operative suite and when the minimum number of personnel are present
bacterial filter is (e.g., at the end of the day)
placed on the patient’s
endotracheal tube.

IC Team must provide a log book to the units to be used for isolation rooms occupied by
Substandard # 8:6 patients with potentially harmful infectious exposures such as MERS-CoV & COVID – 19 etc
Log book must be placed outside isolation room to be filled by any healthcare provider gaining
Log book for exposure entry into isolation room for any task.
is available for any Doctors, nurses, respiratory therapist. X-ray technician. Housekeeping staff or any visitor etc
potentially harmful Logbook must specify the name, designation / job category, Duration of exposure (Time in /
infectious exposures Time out) & type of PPE used.
as per exposure Appropriately used logbook will generate information needed in case of outbreaks etc
policies and Train & educate staff regarding the importance of documenting relevant information in logbook.
procedures (e.g. Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
MERS-CoV). Evaluate unit’s performance in IPCCC audit phase,

Substandard # 8:7 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation.
While transferring
patients under Key Points include:
droplet/airborne
isolation precaution, Explain to the patient the need for the protective apparel that he/she is required to wear.
patient should wear a Patient must wear mask during transportation (droplet & airborne isolation)
surgical mask and Encourage the patient to observe the respiratory hygiene and cough etiquette.
follow respiratory Isolation instructions must highlight the transmission-based precaution card ( isolation signs)
hygiene and cough needed while transporting patients under transmission-based precautions to other department (
etiquette. e.g radiology).
-

Provide training to the staff for rules to be followed for patient transportation under contact isolation
Substandard # 8:8 precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

For transport patient
under contact isolation Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
precautions: • Contain clean bandages and clean linens.
and cover all skin Leak-proof dressing should be used to reduce potential contamination of the environment and
lesions and infected or the spread of infection.
colonized areas of the Dress wounds with impervious dressings as required.
patient’s body with Dress the patient in a clean gown.
clean bandages and Cover the patient with a clean sheet.
clean linens. Return the patient to the isolation room as soon as circumstances allow.
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.

932 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Provide training and orientation to staff the transfer rules related to patient transportation under
isolation precautions. Observe if unit is following the policy.

Following instructions must be given:

Substandard # 8.9 Receiving unit or facility is informed beforehand about the required isolation precautions to be
taken. (Transfer could be internal to any unit inside facility or external to any other facility)
If transfer of patient Clear instructions must be provided and documented in patient files before transfer.
under isolation is Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
required, the receiving unit etc.
unit or facility is
informed about the It is important that HCWs in the receiving unit have received prior training on how to safely
required isolation handle patients under isolation precautions and how to appropriately use PPE according to type
precautions and of isolation. e.g For handling patients under airborne isolation, radiology staff must be fit tested
availability of for N-95 mask and trained well on how to don & doff after use.
appropriate PPE is
ensured. Transferring the Patient to Another Facility:

Inform the receiving facility and the emergency vehicle personnel in advance about the type of
isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

933 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 CATH LAB DESIGN
Cardiac Catheterization Procedures performed in the cardiac catheterization laboratory offer information about the heart, the
coronary arteries on the heart’s surface, and the aorta. During the procedure, a physician inserts a catheter into a patient’s blood
vessel (usually in the groin) and explores the arteries leading to the heart muscle to identify problems (blockages, narrowing,
etc.). The procedure can help a physician to (1) identify narrowed or clogged arteries, (2) evaluate the heart’s four valves, (3)
assess myocardial structure and function, and (4) assess for any congenital heart defects.
Therapeutic procedures may be done during procedures in the cardiac catheterization laboratory to open blocked arteries. If the
coronary arteries have localized narrowing, PTCA, a minimally invasive procedure to open up blocked coronary arteries, may be
the chosen course of treatment.
Hence , the design of cardiac catheterization laboratory must be such to ensure strict implementation of Infection Control
measures to prevent procedure related risk of acquiring infections.
Sub standards Explanation

Substandard # 9.1 IC team must ensure that Cath lab design for cardiac procedures and other environmental control
parameters are in accordance with the international standards.
Traffic pattern is
controlled by a clear OR suite that should be divided into three clearly demarcated zones*:
demarcation between
unrestricted, semi Unrestricted area: Area with limited public access that may include:
restricted and Central control point: it may be established to monitor the entrance of patients, personnel,
restricted zones of and materials from the unrestricted area into the semi-restricted area .
cath- lab with Locker rooms: lead into semi-restricted area
restrictions and Post-anaesthesia care units (PACUs)
special precautions
from movement Semi-restricted area:
between these zones. Corridors leading from the unrestricted area to the restricted area of the surgical suite
Storage areas for clean and sterile supplies

Restricted area:
A designated space with restricted access that can be reached only through a semi-
restricted area
Procedure, operating rooms
Scrub stations (large scrub sink close to or at entry of procedure room).

934 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9.2 Other Specification include:

Scrub sinks operate Scrub sinks:

with hand free control,
adjacent to and - Scrub sinks MUST be available that operate with hand free control with all requires supply
outside procedure needed for surgical hand antisepsis.
room.
- Located adjacent to and outside procedure room.

Substandard # 9.3 Floors, Walls & Ceiling:

Washable floors, walls - Floors, walls and ceiling are washable with made of materials that can withstand repeated
and ceiling that can cleaning and disinfection by approved disinfectants.
withstand repeated
cleaning and - Free from any cracks, decorative fine parts , and be one piece without connections and
disinfection by with minimal openings that are completely sealed
approved
disinfectants. Traffic Control:

- Number of personnel should be kept to minimum once sterile field is established.

Substandard # 9.4 - Doors are kept closed with restriction of staff mobility once procedure has started.

Floors, walls, ceiling

should have no ❖ IC Team must provide refresher training & education during IPCCC training phase on the
cracks, decorative fine infection control standards applicable to their area.
parts , and be one ❖ Observe the staff practices, traffic control (movement of the patients, personnel, instruments
piece without
and materials) between different zones of the Cath lab to ensure that restrictions and special
connections and with
minimal openings that precautions for movement between different zones are strictly applied
are completely sealed. ❖ Evaluate staff and unit performance during IPCCC audit phase.
❖ Provide formal feedback and consider for retraining if needed.
Substandard # 9.5

Doors are kept closed

after procedure
started.

935 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often
contain large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred
to patients or healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must
follow Standard Precautions at all times. To reduce the possibility of occupational risks of infection transmission and/or exposure,
laundry workers should focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal protective equipment
(PPE). Removal of foreign objects from soiled linen. 4. To restore soiled linen to usable condition, washing, bleaching, rinsing,
and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 10:1 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 10:2 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 10:3 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 10:4 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

936 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:5 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
The collection bags must
Contaminated linen should not be shaken / agitated when removing it from the bed.
functionally contain wet or
soiled textiles and prevent Place used linen in a laundry bag at the point of use.
contamination of the Do not place on chairs or other furniture.
environment during Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
collection, transportation, centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
and storage prior to of contamination and prevent leakage from soaking through.
processing. Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
Substandard # 10:6 - Items of this nature present the greatest risk to the HCW in acquiring blood-borne
infection.
The containers must not - Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
tear when loaded to
are not left in the linen
capacity, be leak-proof, and
be capable of being closed
securely to prevent textiles Soiled textiles are not sorted or rinsed in patient-care areas.
from falling out. Quality of the laundry bags or containers should be good in order to avoid any leakage.
The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Substandard # 10:7
Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Linen carts are covered and
Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
not overfilled.
to 10 inches off the floor.
Linen from isolation rooms is considered regular soiled linen.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

937 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
Substandard # 11:1 - Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)
All types of waste
containers are Specification of Items:
available in sufficient
number and placed in Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
easily accessible sites. with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labelled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

938 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11:2 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 11:3
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 11:4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 11:5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

939 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 11:6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard – 12 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 12:1
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 12:2 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to Local records for corrective interventions which are taken if readings are not matching the
70%). acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.

940 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Each storage area is equipped with a fixed device for regular monitoring of temperature and
Substandard # 12:3 relative humidity:
- Recommended temperature Range is: 22 - 24°C
Away from air vents and
- Recommended relative Humidity is up to 70%.
well ventilated.
Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.
Substandard # 12:4

Storage shelves are 40

cm from the ceiling, 20 Infection control team must provide training and reorientation about all specifications to be
cm from the floor, and 5 followed for the maintenance of departmental medical stores.
cm from the outside wall. Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.

Substandard # 12:5 Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Storage shelves made
Specifications of Storage Shelves:
from easily cleanable
material (e.g., fenestrated Storage shelves are made of easily cleanable material
stainless steel, Aluminium (e.g., fenestrated stainless steel, Aluminium or hard plastic).
or hard plastic)
Storage shelves are placed following these specifications.
- 40 cm from the ceiling
Substandard # 12:6
- 20 cm from the floor
Sterile and clean items - 5 cm from the wall
completely separated
from personal items & If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
foods and drinks. hard plastic).
Ensure that only sterile and clean items are allowed in the medical stores.
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 12:7 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
original cardboard shipping boxes.
Substandard # 12:8
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
inside sock room. (i.e., boxes made of thick cardboard for shipping.
Items not kept in original
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
cardboard shipping
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
boxes.
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

941 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
Substandard # 12:9 discarded)
If any stained item is found it would most likely reflect that item was restocked after being
No expired items, broken brought from patient care areas which is against the rules of aseptic technique. Such
packs or packs with practices must be strictly prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in
order to ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit
phase.
Provide formal feedback on unit & staff performance

Standard – 13 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 13:1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

942 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 13:2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

943 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 13:3
prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers &
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
visitors strictly adhere
droplets can also be inhaled into the lungs.
to the principles of
Recent studies indicate that people who are infected but do not have symptoms likely also play a
social distancing,
role in the spread of COVID-19. Since people can spread the virus before they know they are
cough etiquette and
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
frequent hand hygiene
have any symptoms.
during duty hours /
visiting hospital.
Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

944 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 13:4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc) HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients etc

945 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
946 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
947 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

948 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
RADIOLOGY SERVICES

Radiology services in hospitals are meant to help advance the practice of

radiology and improve the quality of service to patients. They promote the safe and effective
use of diagnostic and therapeutic radiology by describing specific standards of staffing,
qualifications, training, skills and techniques.
Radiology staff are exposed to risk of acquiring infections while rendering care to the variety
of patients. Therefore, strict implementation of infection control measures including hand
hygiene, wearing personal protective equipment (PPE) to prevent the transmission of
infection during provision of care, isolation precautions & environmental measures etc. would
play a significant role in ensuring patient & staff safety.

949 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN RADIOLOGY

POLICIES & PROCEDURES

RADIOLOGY SERVCIES

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

ISOLATION PRECAUTIONS

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

950 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 RADIOLOGY SERVICES

Standard – 1 Policies & Procedures

Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
Substandard # 1:2 access and refer to specific infection control policy & procedures.
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies &
procedures and is Interview the staff involved in patient care if they are well oriented about the policy content and
accessible for them. how to access the specific policy. e.g. (Ask about policy for isolation precautions/ PPE use etc.
verbally and then give task to demonstrate how to access this policy via electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

951 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

952 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Substandard # 2:2 knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel Infection Prevention & control department MUST provide education & training to all health care
(HCP) receive job- personnel on infection control best practices specific to their job as follows:
specific training on
infection prevention Infection control Training specific to area of work must be provided initially upon hiring before
policies and starting their duty.
procedures upon Continuous education on relevant infection control policies and procedures must be conducted
hiring and at least at least once per year.
once annually. Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

Educate healthcare personnel regarding standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standard.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.

953 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3
during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
professional Training & education activities must be followed by assessing the competency of each
competency in healthcare personnel.
infection control best IP&C Department must train and validate the competence of trained HCWs every year and a
practices validated by certificate must be provided which should be kept in staff personal files.
infection control This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
department every audit phase.
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Infection Control department provides MUST provide health education on infection control for
patients & families.
Substandard # 2:4
IC team must ensure the availability of the following according to the specific unit / area:
Radiology department
Bilingual infection control health education & awareness material must be designed / formulated
provides infection
to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
control health
booklets, leaflets etc. containing information easy to understand with help of pictorial display.
education for patients
and their families. The general & specific health educational material must be posted and available in all patient
care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.
Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files.

954 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
paper towels, Check the availability of hand washing facilities in the clinics.
Alcohol - based Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
hand rub tap if hands free operation or open the tap to check for hot & cold water supply)
dispensers) are Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
available in soap 3: Paper Towels for drying
adequate numbers
(one per clinic & Hand Rub Dispensers:
easily accessible)
- Check the availability of hand rub dispensers as per requirements:
One dispenser per clinic
Substandard # 3:2 One at any service area

- Observe dispensers are conveniently mounted and accessible at the point of care.
Alcohol - based - Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
hand rub dispensers ease of accessibility to staff.
are available in the
waiting areas. - At least one Alcohol - based hand rub dispensers are provided in the waiting areas.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

955 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:3 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Health care Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
professionals (HCP) without the need for an exogenous source of water and requiring no rinsing or drying with towels or
demonstrate other devices.
appropriate
technique for hand Indications:
rubbing and hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
washing. fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or
when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
956 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.

Substandard # 3:3 ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
posted at appropriate places.
Visual alerts are
available: WHO 5 - WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
moments, how to - How to hand wash poster beside ach hand washing sink
do hand rub, how to - How to handrub poster beside each hand hygiene dispen
do hand wash. -
WHO Five moments of hand hygiene:

1: Before touching a patient:

- Clean your hands before touching a patient when approaching him/her.

- This is to protect the patient against harmful germs carried on your hands.

2: Before aseptic procedures:

- Clean your hands immediately before performing a clean/aseptic procedure.

- This is to protect the patient against harmful germs, including the patient's own, from
entering his/her body
-
3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids & glove removal.
- This is to protect yourself and the health-care environment from harmful patient germs.

4: After touching a patient:

- Clean your hands after touching a patient and her/his immediate surroundings, when
leaving the patient’s side.
- This is to protect yourself and the health-care environment from harmful patient germs.

5. After touching patient surroundings:

- Clean your hands after touching any object or furniture in the patient’s immediate
surroundings, when leaving even if the patient has not been touched.
- This is to protect yourself and the health-care environment from harmful patient germs.

957 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
958 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
959 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
Substandard # 4:1 in coordination with infection control department.

Sufficient and appropriate PPE During routine monitoring rounds, observe the availability of PPE by randomly checking
are available in adequate the PPE trolleys / stock rooms.
amount, types & sizes with PPE must be available at the point of use, which will interfere with effective use of PPE
proper qualities and readily as per requirement.
accessible to HCP. Simultaneously ask the staff in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Different sizes and type of N - 95 masks

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

960 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During monitoring rounds, ask and assess if the HCWs dealing with airborne infections
are using the correct size & type of N-95 mask according to fit test. (Countercheck /
Staff knows the suitable N95 verify with their fit test ID).
to be used based on the fit Observe the practice of doctors / X-Ray technicians with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

Substandard # 4:4
❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
Staff use personal protective ❖ Airborne: N95 mask / respirator before entering the room.
equipment appropriately (e.g.
donning and doffing)
1: Appropriate PPE for Contact Isolation:
Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

961 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:
Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.
Sequence of doffing PPEs before leaving the room:
Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

https://youtu.be/H4jQUBAlBrI
Watch Video How to safely put ❖ Perform hand hygiene.
on PPE ❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

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963 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
964 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
965 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 05 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

NN. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
OO. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
PP. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xxvii. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xxviii. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

966 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Provide education to the staff regarding importance of isolation precautions & appropriate isolation
signs to be used during IPCCC training activities.
Observe the practices in routine rounds and audit staff performance in IPCCC audit phase.

Observe if appropriate isolation signs are available and used according to type of diagnosis for
patients under isolation.
Substandard # 5:1 Use preferably isolation precautions signs provided by GDIPC.
Must be placed / posted on door only if occupied by patient.
Radiology staff are 02 types of isolation precaution signs must be available in the unit.
aware about the
- Isolation precaution signs for units to be posted on doors if the isolation room is occupied
isolation signs and
by patients with diseases transmitted either by contact, droplet or airborne route.
their color codes
- Isolation Transportation cards for transportation of patients to other departments as
needed.
Examples: contact:
green, airborne: blue,
Contact isolation Signs: are used for patients with diseases transmitted by contact route.
and droplet: pink or
red)
Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

Droplet Isolation Signs: are used for patients with diseases transmitted by droplet route.

Droplet Precautions are intended to reduce the risk of droplet transmission of infectious agents from
close contact (exposure to eyes, nose and mouth) with large-particle droplets

Should be Initiated and maintained when there is suspected or confirmed diagnosis of an

infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
Use a single room. A negative air pressure room is not indicated.
Place a droplet sign on the door.
Droplet isolation signage must be color coded (e.g., orange) and must be available in both
English and Arabic languages.

Airborne isolation Signs are used for patients with diseases transmitted by Airborne route.

Airborne precautions is used when a patient is suspected or confirmed to have any of the diseases
that are spread via the airborne route.
Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Use a single room with a negative air pressure system (AIIR)
Place the Airborne Isolation sign on the door.
Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English and Arabic languages. b. Keep door closed at all times except when entering or
leaving the room.

967 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:2 IC Team must provide a log book to the units to be used for potentially harmful infectious
patient exposures such as MERS-CoV & COVID – 19 etc
Log book for exposure Logbook must specify the name, designation / job category, Duration of exposure (Time in /
is available for any Time out) & type of PPE used.
potentially harmful Appropriately used logbook will generate information needed in case of outbreaks etc
infectious exposures Train & educate staff regarding the importance of documenting relevant information in logbook
as per exposure before gaining entry into isolation room.
policies and Nurses in charge must ensure that X- ray Technicians sign in exposure log sheet while
procedures (e.g. performing portable x ray for isolated cases & ensure all logbooks are filled appropriately with
MERS-CoV). all needed information.
Evaluate unit’s performance in IPCCC audit phase.

IC team must ensure the availability of Portable X - ray machine in order avoid risk of exposure to
Substandard # 5:3
staff and visitors from unnecessary movement of patients to the radiology department. etc
Portable x-ray
Number of portable x ray machines /equipment will be need based according to
machine is available
requirement of the units.
for usage in isolation
Units requiring frequent radiological assessment, may have a dedicated portable x ray
room when needed.
machines in the units e.g ICUs, COVID wards etc

Substandard # 5:4
Infection Control department must educate & orient the radiology staff regarding the following
protocols:
If the radiological test
is required to be taken
If the patient under isolation precautions need to be transported to radiology department for any
in radiology
radiological test Ultrasound. CT scan. MRI etc following must be ensured:
department, the
radiology department
- Written & verbal communication with radiological department before patient transfer.
must be informed
about the precautions - Patients isolation status must be described and all needed precautions to be taken by unit
needed and the patient staff based on diagnosis.
must not be shifted - Units must coordinate and confirm acceptance from radiology department before
until acceptance from transferring patients & ensuring all needed precautions have been taken.
radiology department - Appropriate transportation isolation signs must be used during patient transportation.
after taking all
precautions.

Substandard # 5:5 Infection Control Team MUST educate & train the staff regarding necessary precautions to be taken
while dealing with patients under airborne isolation.
If transport to the
radiology department Ensure following measures to be taken by radiology staff; If it was necessary to transport the patient
is necessary for any with suspected airborne disease to the radiology department:
suspected airborne
Radiology staff while dealing with patient should wear N – 95.
disease, the unit
Staff must don the N – 95 mask according to the fit testing to avoid risk of exposure to
should be cleared
airborne organisms if their imperfect facial fit. So staff MUST use N -95 mask only
from any visitor and
according to his size & brand.
the staff should wear
Ensure there is no overcrowding & visitors must be cleared from area/unit after informing
N95 according to the
them about the risk of exposure.
fit testing.

968 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff for patient transportation under isolation precautions. Explain the type of PPE and
precautions to be taken by the patient while transportation & importance of communication with
radiology department before transfer.
Substandard # 5.6
Key Points include:
While transferring
patients under
Explain to the patient the need for the protective apparel that he/she is required to wear.
droplet/airborne
Patient must wear mask during transportation (droplet & airborne isolation)
isolation precaution,
Encourage the patient to observe the respiratory hygiene and cough etiquette.
patient should wear a
Isolation instructions must be highlighted in the transmission-based precaution card ( isolation
surgical mask and
signs) that are needed while transporting patients under transmission-based precautions to
follow respiratory
other department ( e.g radiology).
hygiene and cough
etiquette.
Radiology department MUST ensure all necessary precautions were taken by unit staff before
transporting patient on AIRBORNE & DROPLET precautions.
Any breach of practice MUST be noted and communicated to Infection Control Department.
-

Provide training to the staff for rules to be followed for patient transportation under contact isolation
precautions. Explain the type of PPE and precautions to be taken by the patient while transportation.

Key Points for transfer of patients under contact isolation include:

Substandard # 5.7
Contain and cover all skin lesions and infected or colonized areas of the patient’s body with
clean bandages and clean linens.
For transport patient
Leak-proof dressing should be used to reduce potential contamination of the environment and
under contact isolation
the spread of infection.
precautions: • Contain
Dress wounds with impervious dressings as required.
and cover all skin
Dress the patient in a clean gown.
lesions and infected or
Cover the patient with a clean sheet.
colonized areas of the
Return the patient to the isolation room as soon as circumstances allow.
patient’s body with
Clean and disinfect the wheelchair or stretcher with the hospital-approved disinfectant.
clean bandages and
clean linens.
Radiology department MUST ensure all necessary precautions were taken by unit staff before
transporting patient on CONTACT precautions.
Any breach of practice MUST be noted and communicated to Infection Control Department.

969 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 6 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 6:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 6:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Substandard # 6:3 Infection control Practitioners MUST Provide education & training to the x - ray technicians
about the cleaning & disinfection protocols of portable x ray machine.
Portable X-ray Observe the practices during routine monitoring rounds.
machine should be Evaluate the performance / assess competence of X ray technician during IPCCC audit phase.
disinfected before
leaving isolation room F Following key points must be included in training:
& returning back to
the radiology - Importance of disinfection of portable x – ray machine at the point of use before taking it out of
department. isolation rooms.
- As there is significant risk of equipment contamination, therefore appropriate disinfection MUST
be ensured.
- X - ray technician must be educated about the type of dinfectant used, contact time & method
of cleaning.
- Importance of documentation of disinfection activity in the disinfection log sheet after each use.
- Disinfection log must be available in the unit to be presented to external audit teams for the
purpose of verification. (MOH – CBAHI)

970 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 6.4: Infection Control Team must ensure provision of disinfection activity log /cleaning checklist to
the units which should include name of staff responsible for disinfection, items present in the
There is a disinfection specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to external
unit. auditors for verification purposes.

Substandard # 6:5 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors, X ra etc)
HCW are responsible Housekeeping staff must not be allowed to handle any patient care equipment.
for cleaning and
disinfecting of all Adherence to these recommendations should improve disinfection and sterilization practices in
patient care health care facilities, thereby reducing infections associated with contaminated patient-care
equipment. items.

Standard - 7 Housekeeping & Unit Environment

Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 7:1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

971 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
Substandard # 7:2 spills.

There is at least one spill kit The spill kit must include the following:
available in the department. - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
- Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.
Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
clean-up as per policy.
During audit phase of IPCCC, ask the same Nursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Substandard # 7:3 Provide feedback on performance and correct the mistakes. (If any)

HCW knows how to use spill STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
kit properly. infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other potentially
infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp objects
from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the manufacturer’s
recommended contact time. Allow the spill to solidify before removing.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e. paper
towel) on top of the spill and apply the appropriate disinfectant. To avoid creating aerosols, never
spray disinfectant directly onto the spilled material. Instead, gently pour disinfectant on top of paper
towels covering the spill or gently flood the affected area, first around the perimeter of the spill,
then working slowly toward the spilled material. If sodium hypochlorite solution (5.25% household
chlorine bleach) is used, prepare a fresh solution on a daily basis. Leave for the recommended
contact time.

972 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 7:4
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 7:5
Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more
Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light
Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap
During IPCCC audit visit, assess and interview same staff who had received training
water handles).
previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spills occur.

973 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 7:6 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 7:7
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

974 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
Substandard # 7:8
Best practices for environmental cleaning of general patient area floors:
The mop and solution must
be changed frequently &
Mop heads and cleaning and disinfectant solutions must be changed as often as needed
after being used to clean any
(e.g., when visibly soiled, after every isolation room, every third patient room or every
potentially infectious
1 hour) & at the end of each cleaning session.
materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

975 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must conduct training of housekeeping staff in coordination with environmental
Substandard # 7:9 services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Housekeepers are well Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
trained on hand hygiene, educated on the cleaning agents, disinfectants, proper dilution and contact time.
proper use of PPE, methods Training must include following key parameters:
of cleaning & proper & safe
mixing of chemicals. Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
measures. Routine practices related to environmental cleaning include:

HAND HYGIENE:
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.
It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

976 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Emphasize during training and monitoring phase on appropriate cleaning practices.
Substandard # 7:10 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 7:11 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
Substandard # 7:12 protocols.
Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping equipment is Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
kept clean and dry after use. buckets.
Mop heads must be sent to laundry unit after use.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 7:13 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

977 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 8:1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

978 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
Substandard # 8:2 importance in preventing sharp and needle stick injuries.

Sharp items (e.g., Observe the practices of staff during daily rounds regarding disposal of sharp items like
needles, scalpel needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
blades, broken metal All sharp items must be discarded in the specified sharp containers including the broken and
instruments and burs) unbroken glass vials.
are placed in an Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture any such situation inform the head nurse to monitor closely the staff practices.
resistant and leak- Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps collection staff / housekeeping staff.
container.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 8:3
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 8:4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 8:5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

979 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 8:6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

980 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain large
numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or healthcare
workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must follow Standard Precautions at all times.
To reduce the possibility of occupational risks of infection transmission and/or exposure, laundry workers should focus on: a. Appropriate and
frequent hand hygiene. b. Appropriate use of personal protective equipment (PPE). Removal of foreign objects from soiled linen. 4. To restore
soiled linen to usable condition, washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 9:1 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 9:2 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 9:3 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 9:4 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

981 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9:5 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 9:6 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Substandard # 9:7 Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
to 10 inches off the floor.
Linen carts are covered and Linen from isolation rooms is considered regular soiled linen.
not overfilled. The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

982 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 10:1
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 10:2 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to Local records for corrective interventions which are taken if readings are not matching the
70%). acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

983 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:3 Infection control team must provide training and reorientation about all specifications to be
followed for the maintenance of departmental medical stores.
Away from air vents and
Train on following specifications / key points and observe in daily / weekly rounds if unit is
well ventilated.
adherent with recommendations or not.
Substandard # 10:4 Departmental medical stores must be well organized & well maintained.
Storage shelves are 40 Must be away from any contamination, direct sunlight and airs vents.
cm from the ceiling, 20 Specifications of Storage Shelves:
cm from the floor, and 5
cm from the outside wall. Storage shelves are made of easily cleanable material
(e.g., fenestrated stainless steel, Aluminium or hard plastic).
Substandard # 10:5
Storage shelves are placed following these specifications.
Storage shelves made
from easily cleanable - 40 cm from the ceiling
material (e.g., fenestrated - 20 cm from the floor
stainless steel, Aluminium - 5 cm from the wall
or hard plastic)
If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
Substandard # 10:6
hard plastic).
Sterile and clean items Ensure that only sterile and clean items are allowed in the medical stores.
completely separated
from personal items & Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
foods and drinks. from cockroaches and other insects etc.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 10:7 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 10:8 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 10:9 Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
discarded)
No expired items, broken If any stained item is found it would most likely reflect that item was restocked after being brought
packs or packs with from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
prohibited.
stains are present.
Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

984 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 11:1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

985 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 11:2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

986 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 11:3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

987 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 11:4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc) HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients etc

988 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
989 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
990 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ENDOSCOPY UNIT

Flexible Endoscopy
is an invaluable diagnostic and therapeutic tool.

There are associated risks of infection with endoscopic equipment, accessories,

and automated endoscope reprocesses but are preventable.
Appropriate cleaning followed by disinfection and/or sterilization is critical to ensure
patient safety.
Healthcare personnel (HCP) responsible for reprocessing endoscopic equipment
should receive education and demonstrate competency prior to assuming
responsibility for cleaning, disinfection, and/or sterilization.

These fundamentals are integrated into the quality assurance program. HCP should
use hand hygiene together with task-specific and appropriate personal protective
equipment (PPE) etc to prevent the transmission of microorganisms.

991 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN ENDOSCOPY

POLICIES & PROCEDURES

EDUCATION & TRAINING

ENDOSCOPY UNIT

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

UNIT DESIGN

REPROCESSING OF BRONCHOSCOPES & ACCESSORIES

HOUSEKEEPING & UNIT ENVIRONMENT

WASTE MANAGEMENT

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

TRACKING & TRACING SYSTEM

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

992 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ENDOSCOPY UNIT
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for reprocessing soiled endoscopes ,PPE
accessible for them. use etc. Ask verbally and then give task to demonstrate how to access this policy via electronic
system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

993 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

994 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer..

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Substandard # 2:2 knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel Infection Prevention & control department MUST provide education & training to all health care
(HCP) receive job- personnel on infection control best practices specific to their job as follows:
specific training on
infection prevention Infection control Training specific to area of work must be provided initially upon hiring before
policies and starting their duty.
procedures upon Continuous education on relevant infection control policies and procedures must be conducted
hiring and at least at least once per year.
once annually. Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

Educate healthcare personnel regarding standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standard.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.

995 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Infection Control department provides MUST provide health education on infection control for
patients & families.

Substandard # 2:4 IC team must ensure the availability of the following according to the specific unit / area:

Bilingual infection control health education & awareness material must be designed / formulated
Unit provides infection to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
control health booklets, leaflets etc. containing information easy to understand with help of pictorial display.
education for patients
and their families. The general & specific health educational material must be posted and available in all patient
care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.
Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files.

996 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
paper towels, Check the availability of hand washing facilities in the clinics.
Alcohol - based Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
hand rub tap if hands free operation or open the tap to check for hot & cold water supply)
dispensers) are Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
available in soap 3: Paper Towels for drying
adequate numbers
(one dispenser per Hand Rub Dispensers:
clinic, one at every
nursing station and - Check the availability of hand rub dispensers as per requirements:
at any service One dispenser per clinic
areas). easily One at nursing station
accessible One at any service area like medication preparations, store room etc

Substandard # 3:2 - Observe dispensers are conveniently mounted and accessible at the point of care.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.
Alcohol - based
hand rub dispensers - At least one Alcohol - based hand rub dispensers are provided in the waiting areas.
are available in the
waiting areas.
❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

997 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Substandard # 3:3 Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
Health care without the need for an exogenous source of water and requiring no rinsing or drying with towels or
professionals (HCP) other devices.
demonstrate
appropriate Indications:
technique for hand
Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
rubbing and hand
fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or
when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
-
998 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Substandard # 3:4
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
Visual alerts are
posted at appropriate places.
available: WHO 5
moments, how to
- WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand rub, how to
- How to hand wash poster beside ach hand washing sink
do hand wash.
- How to handrub poster beside each hand hygiene dispen
-
WHO five moments of hand hygiene:

WHO Five moments of hand hygiene:

1: Before touching a patient:

- Clean your hands before touching a patient when approaching him/her.

- This is to protect the patient against harmful germs carried on your hands.

2: Before aseptic procedures:

- Clean your hands immediately before performing a clean/aseptic procedure.

- This is to protect the patient against harmful germs, including the patient's own, from
entering his/her body
-
3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids & glove removal.
- This is to protect yourself and the health-care environment from harmful patient germs.

4: After touching a patient:

- Clean your hands after touching a patient and her/his immediate surroundings, when
leaving the patient’s side.
- This is to protect yourself and the health-care environment from harmful patient germs.

5. After touching patient surroundings:

- Clean your hands after touching any object or furniture in the patient’s immediate
surroundings, when leaving even if the patient has not been touched.
- This is to protect yourself and the health-care environment from harmful patient germs..

999 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1000 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1001 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
Substandard # 4:1 in coordination with infection control department.

Sufficient and appropriate PPE During routine daily / weekly monitoring rounds, observe the availability of PPE by
are available in adequate randomly checking the PPE trolleys / stock rooms.
amount, types & sizes with PPE must be available at the point of use, which will interfere with effective use of PPE
proper qualities and readily as per requirement.
accessible to HCP. Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Substandard 4.2 Review the PPE checklist to ensure the availability of all PPE items including N-95 masks.
Check availability in PPE trolleys outside isolation rooms & stock rooms.
N - 95 respirators are available Check if all types and sizes are available according to fit test result of each healthcare
in different types and sizes. worker. (Doctors, Nurses, RTs, Housekeeping staff etc)

1002 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding
using N-95 respirator according to fit test or follow alternate policy in case of non-
availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 to (Countercheck / verify with their fit test ID).
be used based on the fit test. Observe the practice of doctors with beards.

Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

1003 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Substandard # 4:4 Train and evaluate the same staff on PPE practice as described in the manual.

Staff use personal protective PPE is indicated to be used based on risk assessment as part of standard precautions &
equipment appropriately (e.g. Transmission based precautions.
donning and doffing)
All isolation precautions must be used together with Standard Precautions
❖ Contact: Appropriate PPE – Gown & Gloves
❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Before entering and leaving a patient’s room PPEs should be donned & doffed in this
order.
Sequence of donning PPEs before entering the room:
Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured
at neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.
https://youtu.be/H4jQUBAlBrI NB: If goggles/face shield are worn:
Watch Video How to safely put • Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
on PPE gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

1004 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

1005 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1006 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 UNIT DESIGN
The endoscopy unit should have enough space to accommodate people, activities, and growth mainly composed of with Endoscope The design
of the endoscope reprocessing area should facilitate both infection prevention and control, as well as, patient and employee safety. When
designing an endoscope reprocessing area, considerations must be taken to ensure unidirectional workflow from the decontaminated area to
the clean area and then to the storage area.

Sub standards Explanation

IC team must ensure that design of unit such so as to allow unidirectional flow of work and
Substandard 5.1 to minimize risk of staff exposure to potentially infectious organisms during procedure and
reprocessing of soiled scoped.
The procedure room(s) and
the decontamination area are Following Unit design must be ensured:
physically separated and
access allowed for authorized Physical Separation:
personnel only.
- There should be complete physical separation between the procedure room(s) and the
decontamination area are physically separated.
Substandard 5.2 - Access should be for authorized personnel only. Appropriate restriction signage must
be posted at the entrance doors of rooms.
Workflow in the - The processing area should be physically separated from the patient procedure rooms.
decontamination / - The processing area should be defined for endoscope / bronchoscope reprocessing
reprocessing area should be only and designed to allow for unidirectional flow of devices from the receipt of new
unidirectional from dirty to and/or used endoscopes to storage prior to next patient use.
the clean area and then to the
storage area in order to Work Flow:
minimize opportunity for
cross contamination. - Workflow should be unidirectional from the decontaminated area to the clean area
and then to the storage area.
- Workflow patterns should be designed to contain contaminants, prevent damage to
Substandard 5.3 endoscopes, and minimize employee exposure to blood-borne and other disease
producing organisms.
Procedure room should have - Work area design should allow adequate space for all functions and should promote
a separate, dedicated hand- efficiency by minimizing distances between related areas.
washing sink with hand free - Adequate space should be provided to allow for manual cleaning and rinsing of
controls. devices during decontamination.
- An area should be defined for disinfection/sterilization that is separate from the
manual cleaning/reprocessing area.
- A separate area should also be defined and controlled for the storage of devices,
either temporarily or longer-term, before patient use.

Hand Washing Sink:

- Hand hygiene facilities should be conveniently located and designed to allow good
hand hygiene practices.
- Procedure room should have a separate, dedicated hand- washing sink with hand
free controls.
- During monitoring rounds place hand under the water tap to check if its functional or
not.

1007 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Reprocessing of Endoscopes and Accessories
Healthcare facilities should have a reliable, high-quality system for endoscope reprocessing which minimizes infection risks. Flexible endoscopy
is an invaluable diagnostic and therapeutic tool. Flexible endoscope used for diagnostic and therapeutic procedures always have intrinsic and
extrinsic risks of complications including infections. To minimize the risk of infection, healthcare providers must ensure that equipment is designed
& maintained properly and that guidelines for reprocessing are strictly followed. Reprocessing requires meticulous cleaning and high-level
disinfection or sterilization of internal channels, external surfaces, openings, valves and caps. Accessory equipment used to biopsy, brush, or cut
tissue must be cleaned and sterilized or discarded if it is disposable.
Healthcare personnel (HCP) responsible for reprocessing endoscopic equipment should receive education and demonstrate competency prior to
assuming responsibility for cleaning, disinfection, and/or sterilization.
HCP should use hand hygiene together with task-specific and appropriate personal protective equipment (PPE) to prevent the transmission of
microorganisms. Appropriate cleaning followed by disinfection and/or sterilization is critical to ensure patient safety.

Sub standards Explanation

Substandard 6.1 Infection control team must provide intensive training and education to the staff handling
with the soiled bronchoscopes. Appropriate infection control measures must be followed
Reprocessing of contaminated in order to ensure effective disinfection to be safe for use on next patient. Moreover, staff
equipment should be performed must be fully protected while handling soiled scopes in order to avoid risk of acquiring
in a separate area or room, not in infection.
the bronchoscopy procedure
room. Provide training on the below mentioned steps. Monitor staff practices in routine
rounds. Audit performance in the IPCCC audit phase.
Substandard 6.2

Reprocessing area with negative

Reprocessing room Specifications:
pressure and good ventilation.
The procedure room(s) and the decontamination area are physically separated and
Substandard 6.3 access allowed for authorized personnel only.

Reprocessing areas should be After completion of procedure, all contaminated equipment must be reprocessed in
provided with a separate hand separate room /area away from the procedure room.
washing station.
Reprocessing area is well ventilated and under negative pressure.
Decontamination room should have a separate, dedicated hand washing sink with
Substandard 6.4
hand free controls.
Appropriate personal protective
equipment (respirator, gloves:
nitrile or butyl rubber, goggles Health care workers safety:
and gowns) are used.
In order to ensure staff safety, provision of following is crucial in the reprocessing area:
Provide appropriate personal protective equipment (respirator, gloves: nitrile or butyl
Substandard 6.5 rubber, goggles and gowns etc
In case of accidental exposure , emergency eyewash safety station is available in
Emergency eyewash safety
station is available in decontamination area and accessible within 30 meters or 10 seconds of potential
decontamination area and
chemical exposure.
accessible within 30 meters or 10
seconds of potential chemical
exposure.

1008 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 6.6 Handling of soiled Endoscopes:
In order to prevent development of biofilms, and drying of secretions; pre-cleaning
Single use endoscope
accessories should be discarded should take place at the point of use immediately following the procedure.
immediately after use. All channels of endoscope are flushed & external surfaces are wiped with a detergent
solution immediately at the point of use.
Soiled endoscopes are transported safely in a suitable closed container to the
Substandard 6.7 reprocessing area with biohazard label.
Leak testing is performed according to manufacturer’s requirements before manual
Soiled Bronchoscope should be
cleaning and the result is documented.
transported to the reprocessing
area in a closed container. Single use endoscope accessories should be discarded immediately after use.
Soiled endoscopes are transported safely in a suitable closed container to the
reprocessing area with biohazard label.
Substandard 6.8 Perform leak testing after each use according to the manufacturer’s guidelines.
Leak testing should be performed ▪ Observe the instrument carefully for continuous bubbling. If continuous
according to manufacturer’s bubbling is observed from a given area, this indicates a leak. Remove the
requirements.
instrument from the water immediately after the leak test cycle. Do not use the
instrument.
Substandard 6.9 ▪ Dry and clean the instrument, place it in a plastic bag and pack it into the
transport case.
All detachable components ▪ Contact the appropriate department for repairs.
should be cleaned individually ▪ Document outcome of leak testing.
using enzymatic solution.
Manual Cleaning:
Substandard 6.10
Manual cleaning starts after confirming that the endoscope does not have any leaks and
Reusable instruments and should be conducted as soon as possible after use to prevent soil from drying on the
accessories that break the device.
mucosa are sterilized after use.
Endoscopes are manually cleaned (brushed and flushed) with detergent solution.
Substandard 6.11
Fresh low-foaming cleaning solution must be prepared for each endoscope. The
Clean external ports, surfaces, temperature of the cleaning solution should be monitored and documented.
and internal channels Place the endoscope in the solution, keeping it below the fluid’s surface level at all
mechanically with water and an times.
enzymatic detergent prior to Clean the endoscope’s exterior surfaces with a single-use lint free cloth or sponge.
processing. Disposable single use brushes should be used, if not available, reusable brushes that
are sterilized after every use are considered as acceptable alternative.
Substandard 6.12
Bronchoscope accessories:
If an automated disinfector is not
used to process the endoscope, Reusable heat-stable accessories that break the mucosa (e.g., biopsy forceps) are
allow disinfectant solution to cleaned mechanically and sterilized after each use.
perfuse through all channels as All detachable components should be cleaned individually using enzymatic solution
instructed by the High- Level External ports, surfaces, and internal channels must be clean mechanically with water
Disinfection solution
and an enzymatic detergent before processing.
manufacturer, following time and
temperature recommendations.

1009 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 6.13
High- Level Disinfection:
High level disinfectant should be
routinely tested to ensure
minimum effective concentration If an automated disinfector is NOT used to process the endoscope, allow disinfectant
of the active ingredient as per
manufacturer recommendation. solution to perfuse through all channels as instructed by the High- Level Disinfection
solution manufacturer, following time and temperature recommendations.
Substandard 6.14
Flush all channels according to the endoscope manufacturer’s written IFU
The endoscope and inner (Instructions for use) and rinse exterior surfaces with potable water until all cleaning
channels should be washed with
sterile water or, if this is not solution is visibly removed
practical, then clean tap water
followed by an alcohol rinse. Manual Rinsing:
After cleaning the endoscope, removed components and accessories should be

Substandard 6.15 thoroughly rinsed with copious amount of potable water to help ensure all cleaning
solutions and loosened debris are removed.
Single brush use for manual
cleaning. High level disinfectant used should be approved by MOH and routinely tested to
ensure Minimum Effective Concentration MEC of the active ingredient (test strips are

Substandard 6.16 used and results recorded)

Manual drying:
The bronchoscope and inner
channels are completely dried Effective drying can reduce the risk of microbial contamination following high level
using clean, forced air.
disinfection.
▪ Drying can be achieved by flowing air through all endoscopes channels for a
Substandard 6.17
specified period of time.
When storing the endoscopes, it ▪ Drying maybe facilitated by using 70-80% ethyl or isopropyl
should be hanged in a vertical
position to facilitate drying (with
caps, valves, and other Storage of reprocessed endoscopes:
detachable components removed
as per manufacturer instructions).
The endoscope should be hung vertically with the distal tip hanging freely in a well-
ventilated, clean area to facilitate drying. caps, valves, and other detachable
Substandard 6.18 components removed as per manufacturer instructions). To keep the parts together
with the scope, a small bag or similar device can be used to attach the parts to the
Endoscope are stored uncoiled, scope.
hanging vertically in a clean, dry, Endoscopes can be stored in a closed cabinet with vent that allows air circulation
ventilated storage cabinet with around the endoscopes and with adequate height to allow endoscopes to hang
logbook.
without touching the bottom of the cabinet.
There should be sufficient space between and around scopes to prevent hitting into
one another which can cause damage to the scopes.
Each scope should be identified with a tag or other means so that when it is pulled
from storage, the user is able to verify that the scope has been processed and is
ready for use

1010 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 7 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 7:1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 7:2 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

1011 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 7:3 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

1012 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
Substandard # 7:4 logs /checklists is extremely important to ensure effective implementation & to have the
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
Cleaning is done properly is done & documented appropriately as per schedule.
using checklist that include
cleaning frequency, Each unit must have the schedule for cleaning and disinfection activities.
responsible worker, Schedule must include the frequency, the used disinfectant and the responsible staff.
housekeeping surfaces (e.g., Roles must be specified with clear instructions.
floors and walls), used
agents, methods & 1. Nursing staff for medical equipment
environmental surfaces 2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
intended to be cleaned.

High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 7:5
Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more
Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light
Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap
During IPCCC audit visit, assess and interview same staff who had received training
water handles).
previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spills occur.

1013 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 7:6 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 7:7
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

1014 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
Substandard # 7:8
Best practices for environmental cleaning of general patient area floors:
The mop and solution must
be changed frequently &
Mop heads and cleaning and disinfectant solutions must be changed as often as needed
after being used to clean any
(e.g., when visibly soiled, after every isolation room, every third patient room or every
potentially infectious
1 hour) & at the end of each cleaning session.
materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Housekeeping staff must adhere to Standard Precautions and if required Expanded

Substandard # 7:9 Precautions when performing routine practices of cleaning and following infection control
measures. Routine practices related to environmental cleaning include:
Housekeepers are well
trained on hand hygiene, HAND HYGIENE:
proper use of PPE, methods Hand hygiene as the most important and effective measure to prevent the spread of
of cleaning & proper & safe healthcare associated infections. Hand hygiene must be practiced:
mixing of chemicals. Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

1015 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 7:10 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 7:11 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 7:12 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

1016 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 7:13 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

HIGH TOUCH SURFACES

1017 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1018 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 8:1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

1019 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
Substandard # 8:2 importance in preventing sharp and needle stick injuries.

Sharp items (e.g., Observe the practices of staff during daily rounds regarding disposal of sharp items like
needles, scalpel needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
blades, broken metal All sharp items must be discarded in the specified sharp containers including the broken and
instruments and burs) unbroken glass vials.
are placed in an Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture any such situation inform the head nurse to monitor closely the staff practices.
resistant and leak- Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps collection staff / housekeeping staff.
container.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 8:3
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 8:4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 8:5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

1020 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 8:6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

1021 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient
care across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defense
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 9.1 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 9.2 in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of to use large IV solution bottles for preparation & dilution of medications
medication is only done by Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water specified for preparation & dilution of medications.
ampoule. Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 9.3
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

1022 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 9.4
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 9.5 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient. While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

1023 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 9.6 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

- Maintaining the integrity of sterile equipment and solutions is extremely important to

prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
urinary catheter).
- If the sterile items are assembled long before the procedure, there are chances of
contamination from environment such as dust etc.
Substandard # 9.7 - A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
Sterile equipment and the transfer of microorganisms and reduce the potential for infections.
solutions are assembled - Principles of sterile technique help control and prevent infection, prevent the transmission
immediately prior to use. of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.

As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

1024 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Substandard # 9.8 Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
transfer forceps.
Sterile to sterile rule is Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
applied during any aseptic Non-sterile items should not cross over the sterile field. For example, a non-sterile person
procedure. should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

1025 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 9.9 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 9.10 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

Substandard # 9.11 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

1026 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 9.12
performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials
a medication vial for multiple medication draws.
(MDVs) are accessed with a
This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when
Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses
additional doses from a multidose medication vials.
for the same patient.
Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).
Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 9.13 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.
Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
Substandard # 9.14
IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
IV solution bottles are only
than the self-sealed rubber cap.
accessed through the self-
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
sealed rubber cap.
Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 9.15 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

1027 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 According to The Joint Commission, there are four chief aspects of the aseptic technique:
Substandard # 9.16 barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Maximum sterile barrier protect the patient from the transfer of pathogens from a healthcare worker, from the
precautions is applied environment, or from both. Some barriers used in aseptic technique include:
during any interventional
procedure, including cap, - Sterile gloves
mask, sterile gown, sterile - Sterile gowns
gloves, and sterile full-body - Masks for the patient and healthcare provider
drape. - Sterile drapes etc
- Cap / Head cover

Substandard # 9.17 Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
Traffic should be kept to a central line etc.
minimum once the sterile Only necessary health personnel should be at the procedure. The more people present, the
field has been established. more opportunities for harmful bacteria to cause contamination.

Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

1028 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

QQ. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
RR. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
SS. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xxix. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xxx. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

1029 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation

Provide education to the staff regarding importance of isolation precautions & appropriate isolation
signs to be used during IPCCC training activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.

Observe if appropriate isolation signs are available and used according to type of diagnosis for
patients under isolation.
Use preferably isolation precautions signs provided by GDIPC.
Substandard # 10.1 Must be placed / posted on door only if occupied by patient.
02 types of isolation precaution signs must be available in the unit.
Staff are aware about - Isolation precaution signs for units to be posted on doors if the isolation room is occupied
the isolation signs and by patients with diseases transmitted either by contact, droplet or airborne route.
their color codes - Isolation Transportation cards for transportation of patients to other departments as
needed.
Examples: contact:
green, airborne: blue, Contact isolation Signs: are used for patients with diseases transmitted by contact route.
and droplet: pink or
red) Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

Droplet Isolation Signs: are used for patients with diseases transmitted by droplet route.

Droplet Precautions are intended to reduce the risk of droplet transmission of infectious agents from
close contact (exposure to eyes, nose and mouth) with large-particle droplets

Should be Initiated and maintained when there is suspected or confirmed diagnosis of an

infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
Use a single room. A negative air pressure room is not indicated.
Place a droplet sign on the door.
Droplet isolation signage must be color coded (e.g., orange) and must be available in both
English and Arabic languages.

Airborne isolation Signs are used for patients with diseases transmitted by Airborne route.

Airborne precautions is used when a patient is suspected or confirmed to have any of the diseases
that are spread via the airborne route.
Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Use a single room with a negative air pressure system (AIIR)
Place the Airborne Isolation sign on the door.
Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English and Arabic languages. b. Keep door closed at all times except when entering or
leaving the room.

1030 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10.2 IC Team must provide a log book to the units to be used for potentially harmful infectious
patient exposures such as MERS-CoV & COVID – 19 etc
Log book for exposure Logbook must specify the name, designation / job category, Duration of exposure (Time in /
is available for any Time out) & type of PPE used.
potentially harmful Appropriately used logbook will generate information needed in case of outbreaks etc
infectious exposures Train & educate staff regarding the importance of documenting relevant information in logbook
as per exposure before gaining entry into isolation room.
policies and Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
procedures (e.g. Evaluate unit’s performance in IPCCC audit phase.
MERS-CoV).

IC team must ensure the following in order avoid risk of exposure to staff and patients’ in the
Substandard # 10.3
outpatient clinics.
All appointments for All clinical appointments for patients with potentially infectious cases must be postponed till
patients with patients are fully recovered unless it is absolutely necessary for medical reasons.
potentially infectious Staff MUST take full necessary precautions in case if the appointments are scheduled for
cases should be patients with infectious diseases.
postponed until
recovery unless Educate the staff about the potential risks associated with exposure to infectious cases.
absolutely necessary. Observe the practices in the routine rounds to ensure implementation of policy.

Patient Transportation:

Patient Transportation isolation signs must be used while transporting patients under
transmission-based precautions to other department as needed.
Substandard # 10.4
Transfer of patients under isolation precautions must be restricted to medically necessary
If transfer of patient purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
under isolation is procedures that cannot be performed in the patient’s room.
required, the receiving
unit or facility is Provide training and orientation to staff the transfer rules related to patient transportation under
informed about the isolation precautions. Observe if unit is following the policy.
required isolation
precautions and Following instructions must be given:
availability of
appropriate PPE is Receiving unit or facility is informed beforehand about the required isolation precautions to be
ensured. taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
unit etc.

It is important that HCWs in the receiving unit have received prior training on how to safely
handle patients under isolation precautions and how to appropriately use PPE according to type
of isolation. e.g. For handling patients under airborne isolation, radiology staff must be fit tested
for N-95 mask and trained well on how to don & doff after use.

Transferring the Patient to Another Facility:

Inform the receiving facility and the emergency vehicle personnel in advance about the type of
isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

1031 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Tracking & Tracing System
Documentation is essential for quality assurance purposes and for patient tracing in the event a look back is necessary.
Maintain documentation of adherence to these essential steps each time an endoscope is reprocessed. For all methods of
reprocessing using High Level Disinfection or sterilization, document endoscope and patient identifiers. Tracking is essential in
the event of a disinfection failure and for responding to device or product recalls.
Sub standards Explanation
Infection Control Team MUST provide training to staff regarding importance of
Substandard # 11.1 documentation of all stages of endoscopes / bronchoscopes reprocessing.
During routine monitoring rounds ensure that appropriate record keeping is done.
There is a tracking and Randomly review content for the procedures done in the previous days.
tracing system that records Evaluate the unit performance during IPCCC audit phase.
different stages of
decontamination, the Following must be part of efficient record keeping:
persons involved, storage &
subsequent patient use. a) Unit must have well established & efficient tracking and tracing system that records
different stages of decontamination, the persons involved, storage & subsequent patient
use. (Manual / Computerized)
b) Following must be documented:

Substandard # 11.2 - Patient name,

- Medical record number,
Records should include - Date and time of the clinical procedure
patient name, medical - Identification number and type of bronchoscope
record number, date and - Manual High level disinfection was done or Automated Endoscope Reprocessor
time of the clinical (AER) was used.
procedure, identification - Results of inspection and leak test and name of the person reprocessing the
number and type of bronchoscopes.
bronchoscope and AER,
results of inspection and Unit must ensure completeness and accuracy of all records in order to be presented to any
leak test and name of the external or internal inspection visit teams for the purpose of verification.
person reprocessing the
bronchoscopes.

1032 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 12.1
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 12.2 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to Local records for corrective interventions which are taken if readings are not matching the
70%). acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

1033 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 12.3 Infection control team must provide training and reorientation about all specifications to be
followed for the maintenance of departmental medical stores.
Away from air vents and
well ventilated. Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.
Substandard # 12.4 Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Storage shelves are 40
cm from the ceiling, 20 Specifications of Storage Shelves:
cm from the floor, and 5
cm from the outside wall. Storage shelves are made of easily cleanable material
(e.g., fenestrated stainless steel, Aluminium or hard plastic).
Substandard # 12.5
Storage shelves are placed following these specifications.
Storage shelves made - 40 cm from the ceiling
from easily cleanable - 20 cm from the floor
material (e.g., fenestrated - 5 cm from the wall
stainless steel, Aluminium
or hard plastic) If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
hard plastic).
Substandard # 12.6
Ensure that only sterile and clean items are allowed in the medical stores.
Sterile and clean items
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
completely separated
from personal items & from cockroaches and other insects etc.
foods and drinks.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 12.7 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 12.8 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 12.9 Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
discarded)
No expired items, broken If any stained item is found it would most likely reflect that item was restocked after being brought
packs or packs with from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
prohibited.
stains are present.
Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

1034 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 13 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 13.1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

1035 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 13.2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

1036 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 13.3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1037 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 13.4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes (Patients Moving in between departments and eating together in pantries is strictly prohibited.
transportation etc) HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, etc

1038 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1039 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1040 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE
WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

1041 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 BRONCHOSCOPY

Bronchoscopy is an endoscopic technique of visualizing the inside

of the airways for diagnostic and therapeutic purposes.

This procedure poses infection risk therefore strict implementation of infection control
measures including hand hygiene, wearing appropriate personal protective equipment (PPE)
to prevent the transmission of infection during provision of care, isolation precautions &
environmental measures etc. would play a significant role to ensure patient & staff safety.

1042 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN BRONCHOSCOPY

POLICIES & PROCEDURES

EDUCATION & TRAINING

BRONCHOSCOPY

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

IC PRECAUTIONS FOR POTENTIALLY INFECTIOUS CASES

REPROCESSING OF BRONCHOSCOPES & ACCESSORIES

UNIT DESIGN

HOSUEKEEPING & UNIT ENVIRONMENT

WASTE MANAGEMENT

ASEPTIC TECHNIQUE

ISOLATION PRECAUTIONS

TRACKING & TRACING SYSTEM

STORAGE OF PATIENT CARE SUPPLIES

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1043 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 BRONCHOSCOPY
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
Substandard # 1:2 access and refer to specific infection control policy & procedures.
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies &
procedures and is Interview the staff involved in patient care if they are well oriented about the policy content and
accessible for them. how to access the specific policy. e.g. (Ask about policy for isolation precautions/ PPE use etc.
verbally and then give task to demonstrate how to access this policy via electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

1044 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

1045 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Substandard # 2:2 knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel Infection Prevention & control department MUST provide education & training to all health care
(HCP) receive job- personnel on infection control best practices specific to their job as follows:
specific training on
infection prevention Infection control Training specific to area of work must be provided initially upon hiring before
policies and starting their duty.
procedures upon Continuous education on relevant infection control policies and procedures must be conducted
hiring and at least at least once per year.
once annually. Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

Educate healthcare personnel regarding standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standard.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.

1046 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Infection Control department provides MUST provide health education on infection control for
patients & families.

Substandard # 2:4
IC team must ensure the availability of the following according to the specific unit / area:
Unit provides infection Bilingual infection control health education & awareness material must be designed / formulated
control health to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
education for patients booklets, leaflets etc. containing information easy to understand with help of pictorial display.
and their families.
The educational material must be posted and available in all patient care areas, waiting areas at
the place easily seen and readable by patients, families and visitors. e,g hand hygiene, cough
etiquette, COVID 19 & MERS educational material, etc.
Education provided to patients must be structured and documented in patient’s files.

1047 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
paper towels, Check the availability of hand washing facilities in the clinics.
Alcohol - based Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
hand rub tap if hands free operation or open the tap to check for hot & cold water supply)
dispensers) are Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
available in soap 3: Paper Towels for drying
adequate numbers
(one dispenser per Hand Rub Dispensers:
clinic, one at every
nursing station and - Check the availability of hand rub dispensers as per requirements:
at any service One dispenser per clinic
areas). easily One at nursing station
accessible One at any service area like medication preparations, store room etc

Substandard # 3:2 - Observe dispensers are conveniently mounted and accessible at the point of care.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.
Alcohol - based
hand rub dispensers - At least one Alcohol - based hand rub dispensers are provided in the waiting areas.
are available in the
waiting areas.
❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

1048 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:3
Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Health care Hand washing – washing hands with plain or antimicrobial soap and water.
professionals (HCP) Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
demonstrate without the need for an exogenous source of water and requiring no rinsing or drying with towels or
appropriate other devices.
technique for hand
rubbing and hand Indications:
washing. Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or
when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
1049 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Substandard # 3:4
❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
posted at appropriate places.
Visual alerts are
available: WHO 5
- WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
moments, how to
- How to hand wash poster beside ach hand washing sink
do hand rub, how to
- How to handrub poster beside each hand hygiene dispen
do hand wash.
-
WHO five moments of hand hygiene in Burn Unit:

WHO Five moments of hand hygiene:

1: Before touching a patient:

- Clean your hands before touching a patient when approaching him/her.

- This is to protect the patient against harmful germs carried on your hands.

2: Before aseptic procedures:

- Clean your hands immediately before performing a clean/aseptic procedure.

- This is to protect the patient against harmful germs, including the patient's own, from
entering his/her body
-
3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids & glove removal.
- This is to protect yourself and the health-care environment from harmful patient germs.

4: After touching a patient:

- Clean your hands after touching a patient and her/his immediate surroundings, when
leaving the patient’s side.
- This is to protect yourself and the health-care environment from harmful patient germs.

5. After touching patient surroundings:

- Clean your hands after touching any object or furniture in the patient’s immediate
surroundings, when leaving even if the patient has not been touched.
- This is to protect yourself and the health-care environment from harmful patient germs..

1050 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1051 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1052 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
Substandard # 4:1 in coordination with infection control department.

Sufficient and appropriate PPE During routine daily / weekly monitoring rounds, observe the availability of PPE by
are available in adequate randomly checking the PPE trolleys / stock rooms.
amount, types & sizes with PPE must be available at the point of use, which will interfere with effective use of PPE
proper qualities and readily as per requirement.
accessible to HCP. Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Different sizes and type of N - 95 masks
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring
infections.

Substandard 4.2 Review the PPE checklist to ensure the availability of all PPE items including N-95 masks.
Check availability in PPE trolleys outside isolation rooms & stock rooms.
N - 95 respirators are available Check if all types and sizes are available according to fit test result of each healthcare
in different types and sizes. worker. (Doctors, Nurses, RTs, Housekeeping staff etc)

1053 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding
using N-95 respirator according to fit test or follow alternate policy in case of non-
availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 to (Countercheck / verify with their fit test ID).
be used based on the fit test. Observe the practice of doctors with beards.

Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

❖ Air-purifying respirator means a respirator with an air-purifying filter, cartridge, or canister that
removes specific air contaminants by passing ambient air through the air-purifying element.
Substandard # 4:4
❖ Powered air-purifying respirator (PAPR) means an air-purifying respirator that uses a blower to
force the ambient air through air-purifying elements to the inlet covering.
Alternative respirator, such as
powered air-purifying respirator ❖ Powered air purifying respirators offer protection against certain respiratory hazards with
integrated head, eye and face protection that can help provide a more comfortable environment for
(PAPR) is accessible for HCW
the worker.
who failed in fit testing when
dealing with patients under ❖ PAPR system uses a blower instead of lung power to draw air through the filter. This lets HCWs to
airborne isolation precautions. breathe more naturally while feeling a constant airflow in your while dealing with patients.

❖ Ensure that powered air-purifying respirator (PAPRs) are available and accessible for all HCWs who
failed fit testing to N-95 mask of all types, brands & shapes.
❖ HCWs with beard must not use N-95 mask because of interference of facial hair in ensuring perfect
facial seal. Airborne particles are less than 5 microns in size which can easily pass from beneath the
mask if appropriately size is not used exposing staff to risk of acquiring airborne infection.
❖ Bearded staff must only use powered air-purifying respirator (PAPR)while dealing with
patients under airborne infection isolation rooms.
❖ HCWs must also receive training on how to don the respirator and safely handle after use.
Note:
If powered air-purifying respirator (PAPR)are not available, hospitals must have clearly
policy for bearded staff to strictly refrain from dealing with airborne cases and staff
must be well oriented d about the policy in order to ensure safety of healthcare workers.

1054 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Substandard # 4:5 Train and evaluate the same staff on PPE practice as described in the manual.

Staff use personal protective PPE is indicated to be used based on risk assessment as part of standard precautions &
equipment appropriately (e.g. Transmission based precautions.
donning and doffing)
All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Before entering and leaving a patient’s room PPEs should be donned & doffed in this
order.
Sequence of donning PPEs before entering the room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured
at neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside
out, fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
https://youtu.be/H4jQUBAlBrI Perform hand hygiene.
Watch Video How to safely put
on PPE NB: If goggles/face shield are worn:
• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.
1055 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

1056 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1057 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1058 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1059 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 5 Infection Control Precautions during bronchoscopy for potentially infectious cases
Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. Bronchoscopy is a
procedure to look directly at the airways in the lungs using a thin, lighted tube (bronchoscope). The bronchoscope is put in the nose or mouth.
It is moved down the throat and windpipe (trachea), and into the airways. A healthcare provider can then see the voice box (larynx), trachea,
large airways to the lungs (bronchi), and smaller branches of the bronchi (bronchioles).During performance of the procedure, host defences
are bypassed routinely as, most often, the bronchoscope is passed through the upper airways, which are invariably colonized by a myriad of
potential pathogens. The patient’s cough and other protective reflexes are attenuated purposefully with a variety of medications, ensuring
aspiration of microbes, and these and other solutions are instilled routinely into progressively more distal airways, potentially soiling peripheral
lung parenchyma. Normal mucosal barriers to infection are disrupted during lung biopsies and an increasing array of interventional procedures.
With the latter, lengthier procedure times may increase opportunities for hematogenous as well as local infections. miniaturization of
bronchoscopes and accessories introduces potential difficulties in effective cleaning and disinfection of these structurally complex instruments
Endoscope refers to a flexible device used to visualize the interior of a hollow organ.

Sub standards Explanation

Infection control must provide training to the staff in the bronchoscopy unit regarding IC
precautions to be taken while performing Aerosol generating procedure such as
Substandard # 5:1
bronchoscopy.
All patients should be
screened for symptoms Following protocols must be followed:
suggestive of tuberculosis
Screening policy must be implemented for all patients before undergoing bronchoscopy.
or other infections
Patients must be screened to rule out evidence of tuberculosis and other infections
transmitted by airborne
transmitted by airborne route.
route.
If patients are suspected of having these conditions, the following measures should be
Substandard # 5:2 implemented:
Bronchoscopy should not be performed unless absolutely necessary
All potentially infectious
If medically necessary, bronchoscopy should only be performed in a room that meets the
cases should be postponed
ventilation requirements for an airborne infection isolation room (negative directional air
unless absolutely
flow, a minimum of 12 air exchanges per hour and direct exhaust to the outside more than
necessary.
25 feet from an air intake or discharged through a high efficiency particulate air filtration
system).

❖ Infection control must provide training to the staff in the bronchoscopy unit regarding the
type of PPE to worn during the procedure.
❖ As bronchoscopy is an aerosol generating procedure so airborne precautions will be
Substandard # 5:3 followed.
❖ PPE must include gown, gloves, face shield /eye protection & N -95 respirator.
HCP should wear ❖ Each staff must be fit tested for specific type & brand of N – 95 mask.
appropriate personal ❖ IC team must provide fit test ID to all relevant HCWs in the unit after qualifying fit test.
protective equipment ❖ Those HCWs who failed to pass fit test due to any reason or males staff with beard must be
including a fit-tested strictly prohibited from using N-95 mask.
respirator or power air- ❖ Alternately a power air-purifying respirator (PAPR) must be used instead.
purifying respirator. ❖ If PAPRs are not available there must be a clear policy for bearded staff.

Train, monitor practices during daily/weekly rounds and audit staff and unit performance
during IPCCC audit phase.

1060 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Reuse of single use items is strictly prohibited. The re-use of Single Use Device has legal
Substandard # 5:4 implications. Anyone who reprocesses or re-uses device intended for use on one occasion by the
manufacturer, bears full responsibility for its safety and effectiveness.
Disposable biopsy caps or Single Use Device: a medical device that is intended for single use only, on an individual patient
valves should be discarded for a single procedure, and then should be discarded. It should not be reprocessed or reused again
after every procedure and even on the same patient.
not reused.
IC teams must provide clear instructions to nursing staff on policy for single use.
Disposable items like biopsy caps or valves etc must never be reprocessed or disinfected
after procedure.
All disposable items must be immediately discarded after the procedure.

Substandard # 5:5 Strict infection control measures should be implemented to prevent transmission of M.
tuberculosis or other organisms potentially transmitted via airborne droplet nuclei During &
Airborne Precautions after procedure.
should be continued after
procedure as patients may Post Procedure Precautions:
continue to cough and
pose additional risk. After the procedure patients may continue to cough and pose additional risk; therefore,
airborne precautions should be maintained & expose staff to infection risk.

In order to ensure safety of patients, the bronchoscopy procedure room should not be
Substandard 5.6 used for another patient until adequate time has elapsed for potential airborne
contaminants to be removed and after thorough disinfection.
The room should not be
used for another patient All potentially contaminated surfaces must be thoroughly cleaned and disinfected with an
until adequate time has
approved disinfectant in order to make it safe for next patient use.
elapsed for potential
airborne contaminants to
be removed and after
thorough disinfection.

1061 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Reprocessing of Bronchoscopes and Accessories
Healthcare facilities should have a reliable, high-quality system for endoscope reprocessing which minimizes infection risks. Flexible endoscopy
is an invaluable diagnostic and therapeutic tool. Flexible endoscope used for diagnostic and therapeutic procedures always have intrinsic and
extrinsic risks of complications including infections. To minimize the risk of infection, healthcare providers must ensure that equipment is designed
& maintained properly and that guidelines for reprocessing are strictly followed. Reprocessing requires meticulous cleaning and high-level
disinfection or sterilization of internal channels, external surfaces, openings, valves and caps. Accessory equipment used to biopsy, brush, or cut
tissue must be cleaned and sterilized or discarded if it is disposable.
Healthcare personnel (HCP) responsible for reprocessing endoscopic equipment should receive education and demonstrate competency prior to
assuming responsibility for cleaning, disinfection, and/or sterilization.
HCP should use hand hygiene together with task-specific and appropriate personal protective equipment (PPE) to prevent the transmission of
microorganisms. Appropriate cleaning followed by disinfection and/or sterilization is critical to ensure patient safety.

Sub standards Explanation

Substandard 6.1: Infection control team must provide intensive training and education to the staff
handling with the soiled bronchoscopes. Appropriate infection control measures must
Reprocessing of contaminated be followed in order to ensure effective disinfection to be safe for use on next patient.
equipment should be performed Moreover, staff must be fully protected while handling soiled scopes in order to avoid
in a separate area or room, not in risk of acquiring infection.
the bronchoscopy procedure
room. Provide training on the below mentioned steps. Monitor staff practices in routine
rounds. Audit performance in the IPCCC audit phase.
Substandard 6.2

Reprocessing area with negative

Reprocessing room Specifications:
pressure and good ventilation.
The procedure room(s) and the decontamination area are physically separated and
Substandard 6.3 access allowed for authorized personnel only.

Reprocessing areas should be After completion of procedure, all contaminated equipment must be reprocessed in
provided with a separate hand separate room /area away from the procedure room.
washing station.
Reprocessing area is well ventilated and under negative pressure.
Decontamination room should have a separate, dedicated hand washing sink with
Substandard 6.4
hand free controls.
Appropriate personal protective
equipment (respirator, gloves:
nitrile or butyl rubber, goggles Health care workers safety:
and gowns) are used.
In order to ensure staff safety, provision of following is crucial in the reprocessing area:
Provide appropriate personal protective equipment (respirator, gloves: nitrile or butyl
Substandard 6.5 rubber, goggles and gowns etc
In case of accidental exposure , emergency eyewash safety station is available in
Emergency eyewash safety
station is available in decontamination area and accessible within 30 meters or 10 seconds of potential
decontamination area and
chemical exposure.
accessible within 30 meters or 10
seconds of potential chemical
exposure.

1062 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 .
Substandard 6.6 Handling of soiled Bronchoscopes:
In order to prevent development of biofilms, and drying of secretions; pre-cleaning
Single use bronchoscope
accessories should be discarded should take place at the point of use immediately following the procedure.
immediately after use. All channels of endoscope are flushed & external surfaces are wiped with a detergent
solution immediately at the point of use.
Soiled endoscopes are transported safely in a suitable closed container to the
Substandard 6.7 reprocessing area with biohazard label.
Leak testing is performed according to manufacturer’s requirements before manual
Soiled Bronchoscope should be
cleaning and the result is documented.
transported to the reprocessing
area in a closed container. Single use bronchcopic accessories should be discarded immediately after use.
Soiled endoscopes are transported safely in a suitable closed container to the
reprocessing area with biohazard label.
Substandard 6.8 Perform leak testing after each use according to the manufacturer’s guidelines.
Leak testing should be performed ▪ Observe the instrument carefully for continuous bubbling. If continuous
according to manufacturer’s bubbling is observed from a given area, this indicates a leak. Remove the
requirements.
instrument from the water immediately after the leak test cycle. Do not use the
instrument.
Substandard 6.9 ▪ Dry and clean the instrument, place it in a plastic bag and pack it into the
transport case.
All detachable components ▪ Contact the appropriate department for repairs.
should be cleaned individually ▪ Document outcome of leak testing.
using enzymatic solution.

Substandard 6.10 Manual Cleaning:

Reusable instruments and Manual cleaning starts after confirming that the endoscope does not have any leaks and
accessories that break the should be conducted as soon as possible after use to prevent soil from drying on the
mucosa are sterilized after use. device.

Substandard 6.11
Endoscopes are manually cleaned (brushed and flushed) with detergent solution.
Clean external ports, surfaces, Fresh low-foaming cleaning solution must be prepared for each endoscope. The
and internal channels temperature of the cleaning solution should be monitored and documented.
mechanically with water and an Place the endoscope in the solution, keeping it below the fluid’s surface level at all
enzymatic detergent prior to times.
processing. Clean the endoscope’s exterior surfaces with a single-use lint free cloth or sponge.
Disposable single use brushes should be used, if not available, reusable brushes that
are sterilized after every use are considered as acceptable alternative.
Substandard 6.12
Bronchoscope accessories:
If an automated disinfector is not
used to process the Reusable heat-stable accessories that break the mucosa (e.g., biopsy forceps) are
Bronchoscope, allow disinfectant cleaned mechanically and sterilized after each use.
solution to perfuse through all All detachable components should be cleaned individually using enzymatic solution
channels as instructed by the
External ports, surfaces, and internal channels must be clean mechanically with water
High- Level Disinfection solution
manufacturer, following time and and an enzymatic detergent before processing.
temperature recommendations.

1063 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High- Level Disinfection:

Substandard 6.13 If an automated disinfector is NOT used to process the bronchoscope, allow
disinfectant solution to perfuse through all channels as instructed by the High- Level
High level disinfectant should be
routinely tested to ensure Disinfection solution manufacturer, following time and temperature
minimum effective concentration recommendations.
of the active ingredient as per
manufacturer recommendation. Flush all channels according to the bronchoscope manufacturer’s written IFU
(Instructions for use) and rinse exterior surfaces with potable water until all cleaning
Substandard 6.14
solution is visibly removed
The bronchoscope and inner
channels should be washed with Manual Rinsing:
sterile water or, if this is not After cleaning the endoscope, removed components and accessories should be
practical, then clean tap water
thoroughly rinsed with copious amount of potable water to help ensure all cleaning
followed by an alcohol rinse.
solutions and loosened debris are removed.
High level disinfectant used should be approved by MOH and routinely tested to
Substandard 6.15
ensure Minimum Effective Concentration MEC of the active ingredient (test strips are
Single brush use for manual
used and results recorded)
cleaning.
Manual drying:
Substandard 6.16 Effective drying can reduce the risk of microbial contamination following high level

The bronchoscope and inner disinfection.

channels are completely dried ▪ Drying can be achieved by flowing air through all endoscopes channels for a
using clean, forced air. specified period of time.
▪ Drying maybe facilitated by using 70-80% ethyl or isopropyl
Substandard 6.17
Storage of reprocessed endoscopes:
When storing the bronchoscope,
it should be hanged in a vertical The endoscope should be hung vertically with the distal tip hanging freely in a well-
position to facilitate drying (with
ventilated, clean area to facilitate drying. caps, valves, and other detachable
caps, valves, and other
detachable components removed components removed as per manufacturer instructions). To keep the parts together
as per manufacturer instructions). with the scope, a small bag or similar device can be used to attach the parts to the
scope.
Substandard 6.18 Endoscopes can be stored in a closed cabinet with vent that allows air circulation
around the endoscopes and with adequate height to allow endoscopes to hang
Bronchoscopes are stored without touching the bottom of the cabinet.
uncoiled, hanging vertically in a
There should be sufficient space between and around scopes to prevent hitting into
clean, dry, ventilated storage
cabinet with logbook. one another which can cause damage to the scopes.
Each scope should be identified with a tag or other means so that when it is pulled
from storage, the user is able to verify that the scope has been processed and is
ready for use

1064 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 UNIT DESIGN
The endoscopy unit should have enough space to accommodate people, activities, and growth mainly composed of with Endoscope The design
of the endoscope reprocessing area should facilitate both infection prevention and control, as well as, patient and employee safety. When
designing an endoscope reprocessing area, considerations must be taken to ensure unidirectional workflow from the decontaminated area to
the clean area and then to the storage area.

Sub standards Explanation

IC team must ensure that design of unit such so as to allow unidirectional flow of work and
to minimize risk of staff exposure to potentially infectious organisms during procedure and
Substandard 7.1 reprocessing of soiled scoped.

Following Unit design must be ensured:

The procedure room(s) and
the decontamination area are Physical Separation:
physically separated and
access allowed for authorized - There should be complete physical separation between the procedure room(s) and the
personnel only. decontamination area are physically separated.
- Access should be for authorized personnel only. Appropriate restriction signage must
be posted at the entrance doors of rooms.
Substandard 7.2 - The processing area should be physically separated from the patient procedure rooms.
- The processing area should be defined for endoscope / bronchoscope reprocessing
Workflow in the only and designed to allow for unidirectional flow of devices from the receipt of new
decontamination / and/or used endoscopes to storage prior to next patient use.
reprocessing area should be
unidirectional from dirty to Work Flow:
the clean area and then to the
storage area in order to
- Workflow should be unidirectional from the decontaminated area to the clean area
minimize opportunity for
and then to the storage area.
cross contamination.
- Workflow patterns should be designed to contain contaminants, prevent damage to
endoscopes, and minimize employee exposure to blood-borne and other disease
producing organisms.
Substandard 7.3
- Work area design should allow adequate space for all functions and should promote
efficiency by minimizing distances between related areas.
Procedure room should have
- Adequate space should be provided to allow for manual cleaning and rinsing of
a separate, dedicated hand-
devices during decontamination.
washing sink with hand free
- An area should be defined for disinfection/sterilization that is separate from the
controls.
manual cleaning/reprocessing area.
- A separate area should also be defined and controlled for the storage of devices,
either temporarily or longer-term, before patient use.

Hand Washing Sink:

- Hand hygiene facilities should be conveniently located and designed to allow good
hand hygiene practices.
- Procedure room should have a separate, dedicated hand- washing sink with hand
free controls.
- During monitoring rounds place hand under the water tap to check if its functional or
not.

1065 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 7.4 Bronchoscopy is an Aerosol generating procedure (AGP) so it must be performed in a
negative pressure isolation room fulfilling the following specifications of an airborne infection
Bronchoscopy should be isolation room .
performed in a room that
meets the ventilation Specifications includes as follows:
requirements for an airborne
infection isolation room ❖ Negative pressure differentials 2.5 Pascal’s
(negative directional air flow,
a minimum of 12 air ❖ Air changes 12 per hour
exchanges per hour and ❖ Direct exhaust to the outside more than 25 feet from an air intake or discharged
direct exhaust to the outside
more than 25 feet from an air through a high-efficiency particulate air filtration system).
intake or discharged through
a high efficiency particulate
air filtration system.

1066 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 8:1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 8:2 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

1067 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 8:3 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

1068 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 8:4
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 8:5
Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more
Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light
Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap
During IPCCC audit visit, assess and interview same staff who had received training
water handles).
previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spills occur.

1069 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 8:6 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 8:7
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

1070 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
Substandard # 8:8
Best practices for environmental cleaning of general patient area floors:
The mop and solution must
be changed frequently &
Mop heads and cleaning and disinfectant solutions must be changed as often as needed
after being used to clean any
(e.g., when visibly soiled, after every isolation room, every third patient room or every
potentially infectious
1 hour) & at the end of each cleaning session.
materials.
IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

1071 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must conduct training of housekeeping staff in coordination with environmental
services supervisor followed by monitoring & auditing the staff practices.
Substandard # 8:9 All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
Housekeepers are well educated on the cleaning agents, disinfectants, proper dilution and contact time.
trained on hand hygiene,
proper use of PPE, methods Training must include following key parameters:
of cleaning & proper & safe
mixing of chemicals. Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
measures. Routine practices related to environmental cleaning include:

HAND HYGIENE:
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.
It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

1072 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Emphasize during training and monitoring phase on appropriate cleaning practices.
Substandard # 8:10 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 8:11 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 8:12 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 8:13 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

1073 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 HIGH TOUCH SURFACES

1074 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1075 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 9:1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

1076 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
Substandard # 9:2 importance in preventing sharp and needle stick injuries.

Sharp items (e.g., Observe the practices of staff during daily rounds regarding disposal of sharp items like
needles, scalpel needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
blades, broken metal All sharp items must be discarded in the specified sharp containers including the broken and
instruments and burs) unbroken glass vials.
are placed in an Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture any such situation inform the head nurse to monitor closely the staff practices.
resistant and leak- Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps collection staff / housekeeping staff.
container.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 9:3
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 9:4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 9:5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

1077 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 9:6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

1078 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Aseptic Technique
Aseptic technique means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to
minimize the risk of infection. Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care
across all settings where healthcare is delivered.
Asepsis or aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease. Healthcare
professionals use aseptic technique to protect patients from infection. Aseptic technique is a standard healthcare practice that helps prevent
the transfer of germs to or from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first line of defence
against germs. A person is vulnerable to infection as soon as there is a break in their skin, regardless of whether it occurs as a result of an
accidental injury or a surgical incision unless the rules of aseptic technique are in place that helps prevent healthcare-associated infections
(HCAIs).

Sub standards Explanation

In order to avoid risk of acquiring infection from patients own skin flora, patients skin
Substandard # 10:1 must be disinfected with appropriate antiseptic (alcohol swabs etc).
Let it dry on skin before injection or IV cannulation.
The patient’s skin is
disinfected with an - During the training phase of IPCCC activities, educate clinical care staff about the
appropriate antiseptic before importance of aseptic technique in order to ensure patient safety. Use the training videos
injection or cannulation. for better understanding.
- Observe if the staff are following rules of aseptic technique during daily / weekly rounds.
- Evaluate their performance during IPCCC audit Phase.

Check if ready-made single-dose sterile solutions’ bottles of appropriate sizes are available
Substandard # 10:2 in adequate amounts in the medical stores or not?
If amounts of these items are inadequate or there is shortage of supplies, it is more likely
Preparation and dilution of to use large IV solution bottles for preparation & dilution of medications
medication is only done by Check if there is an opened large IV solution bottle in any medication preparation area
ready-made sterile water specified for preparation & dilution of medications.
ampoule. Provide training to staff, monitor and evaluate practices.

Best Practices:

Large IV solution bottle should NOT be used for preparation & dilution of medications even for
the same patient (even if labelled with patient’s name & date & time of the first use )

Single Use Device: A medical device that is intended for single use only, on an individual
patient for a single procedure, and then should be discarded. It should not be reprocessed or
Substandard # 10:3
reused again even on the same patient. –
These devices are packaged and marked as “single use” or have the international sign for
No reuse of single use
single use items.
items.
Examples: airway circuits, suction catheters, Intravenous sets, needles & syringes, PPE
(gowns, face shields) … etc.,

Provide training and orientation to the staff about risks associated with reuse of single use
items during IPCCC training phase.
Observe the staff practices during routine rounds and provide feedback.
Evaluate the performance in IPCCC audit.

1079 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Check if needles, syringes including prefilled syringes, and vacutainer holders are used
only for a single procedure / injection or not?
Observe if these items are available in adequate amounts (It is more likely to reuse these
Substandard # 10:4
items if amounts are inadequate/shortage of supplies)
Observe if these items are kept sterile and with their original intact wrap (they should not
Needles and syringes
be kept opened or labelled with any patient’s name to avoid their reuse or storing for
including vacutainer holders
future use even on the same patient.
are used for only one
While checking the medication refrigerator, you may find opened prefilled syringe labelled
patient.
with patient's name & medical record number. This means it is stored for future use on
the same patient.
While checking the medication refrigerator, you find opened prefilled syringe without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

During IPCCC training phase, provide retraining and orientation to staff about the principles of
aseptic technique in order to ensure patient safety.
Monitor, audit staff performance & provide feedback to staff for improvement.

Observe if these items are kept with remaining doses (single-dose vial should not be kept
Substandard # 10:5 opened with any remaining dose whether labelled with any patient’s name or not to avoid
its reuse or storing for future use even on the same patient)
Single dose medication While checking the medication refrigerator, you find opened single-use vial labelled with
vials, ampoules and bottles patient's name & medical record number. This means it is stored for future use on the
of intravenous solution are same patient.
used for only one patient. While checking the medication refrigerator, you find opened single-use vial without
patient's name or medical record number. This means it is more likely to be reused by
multiple patients.

1080 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the staff practices about the supplies and single-use medications that are taken to
patient’s care areas (i.e., for any procedure, only the required or necessary amount of
Substandard # 10:6 supplies should be brought to patient’s care areas ) in order to avoid risk of contamination.

All patient care supplies are After completion of treatment session or any clinical procedure or patient discharge following
brought to patient area must be practiced:
when needed with no
excess. Any remaining All remaining single-use items are discarded, even unused ones with intact original wrap
items after patient discharge (i.e., they cannot be used on other patients or returned to clean areas, such as medical
are considered stores or medication preparation areas etc )
contaminated even in their
All reusable items are sent for reprocessing, even unused ones with intact original wrap.
wrapping.
Visit the medical store and check the stock by random selection. You may find an item with
open cover or occasional blood or betadine stain. Such practices are strictly prohibited.

Audit the performance in IPCCC audit phase:

Observe a real treatment or procedure session or ask staff to simulate any procedures or
treatment sessions (IV Cannulation or administration of multidose medications etc

• Observe If he/she is taking needed supplies that are only required for the procedure
or extra supplies are taken there?
• If there were extra supplies, what was their practice towards all unused single items
(Both single use & reusable items)

Best Practice:
All single use items must be discarded and reusable items must be sent to CSSD for
reprocessing (Even items with original intact pack)

- Maintaining the integrity of sterile equipment and solutions is extremely important to

prevent the associated risks of acquiring infection be it a surgical procedure or any
bedside sterile procedure like insertion of chest tube, central venous line, or indwelling
urinary catheter).
- If the sterile items are assembled long before the procedure, there are chances of
contamination from environment such as dust etc.
Substandard # 10:7 - A sterile field is a sterile surface on which to place sterile equipment that is considered
free from microorganisms. A sterile field is required for all invasive procedures to prevent
Sterile equipment and the transfer of microorganisms and reduce the potential for infections.
solutions are assembled - Principles of sterile technique help control and prevent infection, prevent the transmission
immediately prior to use. of all microorganisms in a given area, and include all techniques that are practised to
maintain sterility.

As part of IPCCC training phase, train staff on the importance of aseptic technique in
terms of maintaining the integrity of sterile items prior to use on patients.
Staff must open and assemble the required sterile items only immediately before the
procedure. Staff must set up sterile trays as close to the time of use as possible.
During daily rounds observe the staff practices and evaluate performance during IPCCC
audit phase.

1081 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Breaks in aseptic techniques or contamination of sterile field or supplies cause complications.
Using a sterile technique reduces the microbial count by creating a sterile field and prevents
infection.
All healthcare workers including nurses who assist physicians and surgeons should be fully
aware of the importance of sterile techniques. Breaks in the technique can lead to infections in
the patient, which leads to higher costs of healthcare. It is important to routinely audit all
physicians and nurses involved in sterile procedures to ensure proper protocol is followed.

Train, monitor & audit on following key points for sterile to sterile rule:

A sterile object becomes non-sterile when touched by a non-sterile object.

Substandard # 10:8 Sterile objects must only be touched by sterile gloves or sterile equipment such as sterile
transfer forceps.
Sterile to sterile rule is Sterile technique may include the use of sterile equipment, sterile gowns, and gloves etc.
applied during any aseptic Non-sterile items should not cross over the sterile field. For example, a non-sterile person
procedure. should not reach over a sterile field.
Sterile area can only touch sterile area. Always Keep hands above waistline.
All objects used in a sterile field must be sterile. Check packages for sterility by assessing
intactness, dryness, and expiry date prior to use.
Any torn, previously opened, or wet packaging, or packaging that has been dropped on
the floor, is considered non-sterile and may not be used in the sterile field.
Sterile items that are below the waist level are considered to be non-sterile. Keep all
sterile equipment above waist level.
Sterile fields must always be kept in sight to be considered sterile. Never turn your back
on the sterile field as sterility cannot be guaranteed.
Whenever the sterility of an object is questionable, consider it non-sterile.
When opening sterile equipment and adding supplies to a sterile field, take care to avoid
contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to environment.
Stay organized and complete procedures as soon as possible.
Movement around and in the sterile field must not compromise or contaminate the sterile
field.
Do not sneeze, cough, laugh, or talk over the sterile field.

Sterile fields can be created at the bedside using a pre-packaged set of supplies for a sterile
procedure or wound care.
Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile
field.

1082 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Medication preparation area is the used for preparation of medications. From an infection
control perspective, all medication preparation should occur in a dedicated clean medication
preparation area away from immediate patient treatment areas. Medications should be drawn
up in a designated clean medication preparation area that is not adjacent to potential sources
of contamination, including sinks or other water sources etc.

Substandard # 10:9 During daily / weekly rounds observe medication preparation area (s) which should be
provided with:
Separate clean area is
available for preparing ❖ Controlled ventilation with monitor for recording the temperature and humidity
medications. (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)
❖ At least, one hand washing sink that is equipped with hot & cold water / plain and
antimicrobial soap / towels
❖ At least, one alcohol based hand rub dispenser.
❖ If no physically separated room, a specified area away from patient care areas must be
dedicated for preparation of medications.
❖ Train & audit staff about the rules followed during preparing medications (e.g. getting a
dose from multi-dose vials and preparing supplies for dressing change)

A multi-dose vial is a vial of liquid medication intended for parenteral administration

(injection or infusion) that contains more than one dose of medication. Multi-dose vials
should be dedicated to a single patient whenever possible.
If multi-dose vials must be used for more than one patient, they should only be kept and
Substandard # 10:10 accessed in a dedicated clean medication preparation area away from immediate patient
treatment areas.
If multi-dose vials must be This is to prevent inadvertent contamination of the vial through direct or indirect contact
used, should be dedicated with potentially contaminated surfaces or equipment that could then lead to infections in
for one patient only, dated subsequent patients.
when accessed for the first
time and discarded after 28 ❖ Observe the staff practices regarding multi-dose vials e.g heparin, insulin etc
days unless the ❖ If multi-dose vials are present, and HCWs claim that each multi-dose vial is exclusively
manufacturer specifies a allocated only for one patient, observe to ensure that the following data are recorded on
different shorter or longer used vials:
period.
Patient's name & medical record number is recorded on used vial to be used
exclusively for only this patient (i.e., multi-dose vial is never kept in patients’ treatment
areas without patient's name & medical record number to avoid its use for multiple
patients)
Date of the first use (when it has been accessed for the first time) must be recorded on
used vial. Must be discarded after 28 days unless the manufacturer specifies a different
shorter or a longer date (i.e., reuse life)

Substandard # 10:11 Multi-dose vials used for more than one patient are exclusively kept and accessed in the
medications preparation areas (i.e., multi-dose vials used for more than one patient are
If multidose medication is never taken to patients’ treatment areas)
used for more than one Check if multi-dose vials are present in patients’ care areas. If so it must be dedicated to
patient, the dose should be that patient ONLY with appropriate label as stated above.
prepared and the vial should If Multi-dose vials is present in the patient care area without any label, it means it will be
be kept in a separate used for multiple patients that would result in contamination of vial in patient’s
medication area and it must surroundings.
not enter the immediate Such practices must be corrected by regular training sessions.
patient treatment area. Train, monitor and audit staff performance during IPCCC activities.

1083 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Parenteral medications should be accessed in an aseptic manner. This includes using a new
sterile syringe and sterile needle to draw up medications while preventing contact between
the injection materials and the non-sterile environment. Proper hand hygiene should be
Substandard # 10:12
performed before handling medications and the rubber septum should be disinfected with
alcohol prior to piercing it. It is NOT acceptable to leave a needle inserted in the septum of
Multidose medication vials
a medication vial for multiple medication draws.
(MDVs) are accessed with a
This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
new needle and a new
syringe, even when
Provide training to staff, monitor and audit if they are following the protocols of obtaining
obtaining additional doses
additional doses from a multidose medication vials.
for the same patient.
Nurses must always use new needle and syringe even for obtaining additional doses for
same patient in order to avoid potential risks of contamination of Multidose medication
vials (MDVs).
Prior to any access to a medication vial or an IV solution bottle, its self-sealed rubber cap is
Substandard # 10:13 disinfected with approved alcohol antiseptic wipe (i.e., vigorously scrub the self-sealed rubber
cap with antiseptic wipe for 10 – 15 seconds / never touch the access site after the application
The rubber self-sealed cap of antiseptic / wait the access site to dry before being penetrated with sterile device)
on a medication vial is Exclusively, IV solution bottles should be accessed through their self-sealed rubber caps after
disinfected with alcohol being disinfected.
prior to piercing.
Observe for availability of supplies required for disinfecting self-sealed rubber caps of
medication vials or IV solution bottles prior to access (e.g., approved antiseptic alcohol
wipes).
Observe to ensure that prior to any access to medication vial or IV solution bottle, its self-
sealed rubber cap is disinfected with approved alcohol antiseptic wipes.
Substandard # 10:14
IV solution bottles are only accessed through the self-sealed rubber cap. You may
observe staff accessing the IV solution from the plastic body of IV solution bottle rather
IV solution bottles are only
than the self-sealed rubber cap.
accessed through the self-
You can check by pressing gently the IV solution bottle if any fluid leaks out or no.
sealed rubber cap.
Staff must be taught of contamination risk of IV solutions if not accessed via self-sealed
rubber cap after appropriate disinfection with alcohol antiseptic wipes before piercing.

Observe for availability of supplies required for filling nebulizers, humidifiers, and any
Substandard # 10:15 aerosol generating system (e.g., ready-made single use bottles of sterile saline or sterile
water / prefilled humidifiers with sterile solutions).
Only sterile fluids are used Check that only ready-made single-use bottles of sterile solutions are used to fill
in nebulizers, humidifiers, or nebulizers, humidifiers, and any aerosol generating system (Use of prefilled humidifiers
any aerosol generator and with sterile solutions is preferable).
changed between patients Notice if sterile solutions used in nebulizers, humidifiers, and any aerosol generating
and every 24 hours for the system are changed between patients and every 24 hours for the same patient.
same patient unless the Observe to ensure that when humidifier or nebulizer is in use, it is labelled with date &
manufacturer of ready-made time of initiating treatment (e.g., date & time of filling the humidifier or nebulizer with
sterile solutions specifies sterile solution).
different dates. Manufacturer’s instructions of the ready-made sterile solutions must be followed when
different dates for change are specified (e.g., the use of some prefilled humidifiers may
extend for 1 month).

1084 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 According to The Joint Commission, there are four chief aspects of the aseptic technique:
Substandard # 10:16 barriers, patient equipment and preparation, environmental controls, and contact guidelines.
Each plays an important role in infection prevention during a medical procedure. Barriers
Maximum sterile barrier protect the patient from the transfer of pathogens from a healthcare worker, from the
precautions is applied environment, or from both. Some barriers used in aseptic technique include:
during any interventional
procedure, including cap, - Sterile gloves
mask, sterile gown, sterile - Sterile gowns
gloves, and sterile full-body - Masks for the patient and healthcare provider
drape. - Sterile drapes etc
- Head cover

Substandard # 10:17 Healthcare providers must use sterile barriers including sterile equipment and sterile
instruments to protect the patient from acquiring infection. In addition, maintaining a sterile
environment requires keeping doors closed during an interventional procedure like insertion of
Traffic should be kept to a central line etc.
minimum once the sterile Only necessary health personnel should be at the procedure. The more people present, the
field has been established. more opportunities for harmful bacteria to cause contamination.

Train the healthcare worker during IPCCC training activities and monitor the activities
during routine rounds.
Observe a central line procedure whenever applicable and provide needed feedback
In IPCCC audit phase, evaluate the performance by asking staff to simulate the entire
procedure.
Provide formal feedback and schedule retraining if needed.

1085 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

TT. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
UU. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
VV. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xxxi. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xxxii. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

1086 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Provide education to the staff regarding importance of isolation precautions & appropriate isolation
signs to be used during IPCCC training activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.

Observe if appropriate isolation signs are available and used according to type of diagnosis for
patients under isolation.
Use preferably isolation precautions signs provided by GDIPC.
Must be placed / posted on door only if occupied by patient.
Substandard # 11:1 02 types of isolation precaution signs must be available in the unit.
- Isolation precaution signs for units to be posted on doors if the isolation room is occupied
Staff are aware about by patients with diseases transmitted either by contact, droplet or airborne route.
the isolation signs and - Isolation Transportation cards for transportation of patients to other departments as
their color codes needed.

Examples: contact: Contact isolation Signs: are used for patients with diseases transmitted by contact route.
green, airborne: blue,
and droplet: pink or Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
red) infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

Droplet Isolation Signs: are used for patients with diseases transmitted by droplet route.

Droplet Precautions are intended to reduce the risk of droplet transmission of infectious agents from
close contact (exposure to eyes, nose and mouth) with large-particle droplets

Should be Initiated and maintained when there is suspected or confirmed diagnosis of an

infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
Use a single room. A negative air pressure room is not indicated.
Place a droplet sign on the door.
Droplet isolation signage must be color coded (e.g., orange) and must be available in both
English and Arabic languages.

Airborne isolation Signs are used for patients with diseases transmitted by Airborne route.

Airborne precautions is used when a patient is suspected or confirmed to have any of the diseases
that are spread via the airborne route.
Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Use a single room with a negative air pressure system (AIIR)
Place the Airborne Isolation sign on the door.
Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English and Arabic languages. b. Keep door closed at all times except when entering or
leaving the room.

1087 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11:2 IC Team must provide a log book to the units to be used for potentially harmful infectious
patient exposures such as MERS-CoV & COVID – 19 etc
Log book for exposure Logbook must specify the name, designation / job category, Duration of exposure (Time in /
is available for any Time out) & type of PPE used.
potentially harmful Appropriately used logbook will generate information needed in case of outbreaks etc
infectious exposures Train & educate staff regarding the importance of documenting relevant information in logbook
as per exposure before gaining entry into isolation room.
policies and Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
procedures (e.g. Evaluate unit’s performance in IPCCC audit phase.
MERS-CoV).

IC team must ensure the following in order avoid risk of exposure to staff and patients’ in the
Substandard # 11:3
outpatient clinics.
All appointments for All clinical appointments for patients with potentially infectious cases must be postponed till
patients with patients are fully recovered unless it is absolutely necessary for medical reasons.
potentially infectious Staff MUST take full necessary precautions in case if the appointments are scheduled for
cases should be patients with infectious diseases.
postponed until
recovery unless Educate the staff about the potential risks associated with exposure to infectious cases.
absolutely necessary. Observe the practices in the routine rounds to ensure implementation of policy.

1088 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Patient Transportation:
.
Patient Transportation isolation signs must be used while transporting patients under
Substandard # 11:4 transmission-based precautions to other department as needed.
If transfer of patient Transfer of patients under isolation precautions must be restricted to medically necessary
under isolation is purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
required, the receiving procedures that cannot be performed in the patient’s room.
unit or facility is
informed about the Provide training and orientation to staff the transfer rules related to patient transportation under
required isolation isolation precautions. Observe if unit is following the policy.
precautions and
availability of Following instructions must be given:
appropriate PPE is
ensured. Receiving unit or facility is informed beforehand about the required isolation precautions to be
taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
unit etc.

It is important that HCWs in the receiving unit have received prior training on how to safely
handle patients under isolation precautions and how to appropriately use PPE according to type
of isolation. e.g. For handling patients under airborne isolation, radiology staff must be fit tested
for N-95 mask and trained well on how to don & doff after use.

Transferring the Patient to Another Facility:

Inform the receiving facility and the emergency vehicle personnel in advance about the type of
isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

1089 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Tracking & Tracing System
Documentation is essential for quality assurance purposes and for patient tracing in the event a look back is necessary.
Maintain documentation of adherence to these essential steps each time an endoscope is reprocessed. For all methods of
reprocessing using High Level Disinfection or sterilization, document endoscope and patient identifiers. Tracking is essential in
the event of a disinfection failure and for responding to device or product recalls.
Sub standards Explanation
Infection Control Team MUST provide training to staff regarding importance of
documentation of all stages of endoscopes / bronchoscopes reprocessing.
Substandard # 12:1 During routine monitoring rounds ensure that appropriate record keeping is done.
Randomly review content for the procedures done in the previous days.
There is a tracking and Evaluate the unit performance during IPCCC audit phase.
tracing system that records
different stages of Following must be part of efficient record keeping:
decontamination, the
persons involved, storage & c) Unit must have well established & efficient tracking and tracing system that records
subsequent patient use. different stages of decontamination, the persons involved, storage & subsequent patient
use. (Manual / Computerized)
d) Following must be documented:

- Patient name,
Substandard # 12:2 - Medical record number,
- Date and time of the clinical procedure
Records should include - Identification number and type of bronchoscope
patient name, medical - Manual High level disinfection was done or Automated Endoscope Reprocessor
record number, date and (AER) was used.
time of the clinical - Results of inspection and leak test and name of the person reprocessing the
procedure, identification bronchoscopes.
number and type of
bronchoscope and AER, Unit must ensure completeness and accuracy of all records in order to be presented to any
results of inspection and external or internal inspection visit teams for the purpose of verification.
leak test and name of the
person reprocessing the
bronchoscopes.

1090 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 13 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 13:1
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 13:2 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to Local records for corrective interventions which are taken if readings are not matching the
70%). acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

1091 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 13:3 Infection control team must provide training and reorientation about all specifications to be
followed for the maintenance of departmental medical stores.
Away from air vents and
well ventilated. Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.
Substandard # 13:4 Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Storage shelves are 40
cm from the ceiling, 20 Specifications of Storage Shelves:
cm from the floor, and 5
cm from the outside wall. Storage shelves are made of easily cleanable material
(e.g., fenestrated stainless steel, Aluminium or hard plastic).
Substandard # 13:5
Storage shelves are placed following these specifications.
Storage shelves made - 40 cm from the ceiling
from easily cleanable - 20 cm from the floor
material (e.g., fenestrated - 5 cm from the wall
stainless steel, Aluminium
or hard plastic) If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
hard plastic).
Substandard # 13:6
Ensure that only sterile and clean items are allowed in the medical stores.
Sterile and clean items
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
completely separated
from personal items & from cockroaches and other insects etc.
foods and drinks.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 13:7 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 13:8 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 13:9 Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
discarded)
No expired items, broken If any stained item is found it would most likely reflect that item was restocked after being brought
packs or packs with from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
prohibited.
stains are present.
Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

1092 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 14 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 14:1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

1093 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 14:2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

1094 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 14:3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1095 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 14:4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of HCWs is Following must be ensured:
strictly prohibited
unless necessary for Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
Infection Prevention & clinical staff) to avoid the unnecessary mobility in between the units.
control activities. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, etc

1096 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1097 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1098 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE
WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:

□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms

□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

1099 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
LABORATORY SERVICES

Laboratory is a unique work environment that may pose

infectious disease threats to those who work there.

Laboratorians are at high risk of occupational infections, and there must be specific
policies and procedures in place to protect them from organisms in their unique
environment. Second, the laboratory is an essential partner of infection preventionists
in assisting in the detection and characterization of pathogens, not only for healthcare-
associated infections, but also for organisms associated with community.

Biosafety levels must be established to ensure that the laboratory environment is

adequately equipped with measures to ensure the safety of those working in them or
the surrounding environment. Special Infection control procedures are used to ensure
the safe handling and transport of biohazardous materials.

1100 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN LABORATORY

POLICIES & PROCEDURES

LABORATORY SERVCIES

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

HOSUEKEEPING & UNIT ENVIRONMENT

WASTE MANAGEMENT

WORKING AREA SPECIFICATIONS

LABORATORY SAFETY PARAMETERS

LAB STORAGE AREA

SPECIMEN COLLECTION AREA / PHLEBOTOMY

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1101 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 LABORATORY SERVICES

Standard – 1 Policies & Procedures

Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1.1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
Substandard # 1.2 access and refer to specific infection control policy & procedures.
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies &
procedures and is Interview the staff involved in patient care if they are well oriented about the policy content and
accessible for them. how to access the specific policy. e.g. (Ask about policy for safe handling of culture plates etc.
Ask verbally and then give task to demonstrate how to access this policy via electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

1102 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2.1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT, DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

1103 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2.2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

1104 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2.3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Standard – 3 Hand Hygiene

Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3.1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
paper towels, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
tap if hands free operation or open the tap to check for hot & cold water supply)
Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
Substandard # 3.2 soap 3: Paper Towels for drying

Alcohol - based Hand Rub Dispensers:

hand rub
dispensers) are - Check the availability of hand rub dispensers as per requirements:
available in One dispenser per work area
adequate numbers One at any service area

- Observe dispensers are conveniently mounted and accessible at the point of care.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

1105 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Substandard # 3.3 Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
Health care without the need for an exogenous source of water and requiring no rinsing or drying with towels or
professionals (HCP) other devices.
demonstrate
appropriate Indications:
technique for hand
Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
rubbing and hand
fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or
when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa

1106 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
Substandard # 3.3 hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Visual alerts are
available: ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
how to do hand rub, posted at appropriate places.
how to do hand
wash. - How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispen

1107 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
Substandard # 4.1 staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.
Sufficient and appropriate PPE
are available in adequate During routine monitoring rounds, observe the availability of PPE in the pharmacy.
amount, types & sizes with PPE must be available at the point of use which will interfere with effective use of PPE
proper qualities and readily as per requirement.
accessible to HCP. Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- N-95 Masks

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

1108 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

Substandard # 4.2
1: Appropriate PPE use :
Staff use personal protective
equipment appropriately (e.g. Sequence of donning PPEs
donning and doffing)
Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical facemask. Place surgical mask over nose, mouth and chin then fit flexible
https://youtu.be/H4jQUBAlBrI nosepiece over nose bridge and secure head with ties or elastic.
Watch Video How to safely put Don goggles/face shield.
on PPE Don gloves. Extend gloves over yellow gown cuffs.

Sequence of doffing PPEs

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove goggles/face shield
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

1109 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1110 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 5.1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
Substandard # 5.2 spills.

There is at least one spill kit The spill kit must include the following:
available in the department. - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
- Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids in order to avoid risk of contamination & infection
transmission.
Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

1111 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
clean-up as per policy.
During audit phase of IPCCC, ask the same Nursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Substandard # 5.3 Provide feedback on performance and correct the mistakes. (If any)

HCW knows how to use spill STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
kit properly. infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other potentially
infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp objects
from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the manufacturer’s
recommended contact time. Allow the spill to solidify before removing.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e. paper
towel) on top of the spill and apply the appropriate disinfectant. To avoid creating aerosols, never
spray disinfectant directly onto the spilled material. Instead, gently pour disinfectant on top of paper
towels covering the spill or gently flood the affected area, first around the perimeter of the spill,
then working slowly toward the spilled material. If sodium hypochlorite solution (5.25% household
chlorine bleach) is used, prepare a fresh solution on a daily basis. Leave for the recommended
contact time.

Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning

Substandard # 5.4 logs /checklists is extremely important to ensure effective implementation & to have the
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
Cleaning is done properly is done & documented appropriately as per schedule.
using checklist that include
cleaning frequency, Each unit must have the schedule for cleaning and disinfection activities.
responsible worker, Schedule must include the frequency, the used disinfectant and the responsible staff.
housekeeping surfaces (e.g., Roles must be specified with clear instructions.
floors and walls), used
agents, methods & 1. Laboratory staff for medical equipment
environmental surfaces 2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
intended to be cleaned.

1112 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors may require, more frequent cleaning, depending on the risk-level

Provide training to the selected staff during IPCCC training phase in each quarter with
Substandard # 5.5 help of cleaning supervisor to explain the right process and technique of cleaning and
disinfection of floors using double/ or triple bucket technique or scrubbing machines.
Floors are cleaned or
disinfected using double/ or Double bucket Technique:
triple bucket technique or This consist of 02 different buckets One with disinfection solution & other with water.
scrubbing machines. Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 5.6
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

1113 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
Substandard # 5.7 avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
The mop and solution must
be changed frequently & Best practices for environmental cleaning of general patient area floors:
after being used to clean any
potentially infectious Mop heads and cleaning and disinfectant solutions must be changed as often as needed
materials. IC Team must train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

1114 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must conduct training of housekeeping staff in coordination with environmental
services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.
Training must include following key parameters:
Substandard # 5.8
Housekeeping staff must adhere to Standard Precautions and if required Expanded
Housekeepers are well Precautions when performing routine practices of cleaning and following infection control
measures. Routine practices related to environmental cleaning include:
trained on hand hygiene,
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals. Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.
It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:
Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

1115 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Emphasize during training and monitoring phase on appropriate cleaning practices.
Substandard # 5.9 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 5.10 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 5.11 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

1116 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 6 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 6.1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labelled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

1117 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
Substandard # 6.2 importance in preventing sharp and needle stick injuries.

Sharp items (e.g., Observe the practices of staff during daily rounds regarding disposal of sharp items like
needles, scalpel needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
blades, broken metal All sharp items must be discarded in the specified sharp containers including the broken and
instruments and burs) unbroken glass vials.
are placed in an Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture any such situation inform the head nurse to monitor closely the staff practices.
resistant and leak- Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps collection staff / housekeeping staff.
container.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 6.3
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 6.4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 6.5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

1118 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 6.6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Infection Control Team must provide training to the lab staff for safe handling of culture plates.

Following must available:

Substandard # 6.7 Log book for the autoclave that must be have the loads number and date.
Quality performance tests for the autoclave operation (results of physical indicators (bowie
Culture plates are dick), chemical indicators and biological indicators).
autoclaved in Infection control list of highly infectious microorganisms that their cultures must be autoclaved
appropriate autoclave in the laboratory department before being disposed as infectious medical waste.
bags and then Ensure availability of working autoclave in a dedicated well ventilated place that is physically
contained inside separated from other areas in the department.
yellow coloured bags
Autoclavable bags must be that are used to sterilize the culture plates to avoid adherence of the
with a biohazard
load in the autoclave chamber.
symbol before
disposal as infectious Availability of physical indicator (bowie dick), chemical indicator strips and biological indicator.
medical waste.
After autoclaving in appropriate autoclave bags, culture plates are contained inside yellow
coloured bags with a biohazard symbol before disposal as infectious medical waste.

1119 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 7 Working Area Specifications
The laboratory plays an integral role in the clinical setting by providing valuable information to clinicians. Because of its specialized
setting, the laboratory and laboratory workers may be at increased risk of contamination/infection. The laboratory is a unique work
environment that may pose infectious disease threats to those who work there. Working areas in the laboratory must be completely
separated. Laboratorians are at high risk of occupational infections, and there must be specific policies and procedures in place
to protect them from organisms in their unique environment.

Sub standards Explanation

Substandard # 7.1
IC Team must ensure lab personnel strict adherence to infection control measures in their
Separation of the work
specified work areas.
areas with no overlapping of
items. Provide training & observe the practices during routine rounds.
Evaluate performance in IPCCC audit phase & Provide necessary feedback
Substandard # 7.2
Work areas must be completely separated from each other & there should be no
overlapping between items in order to avoid risk of contamination as there is frequent
Any remaining open vials
are thrown after the end of handling with chemicals, blood and urine specimens etc.
the work.
Assigned IC must ensure that any remaining open vials must be discarded / thrown after
Substandard # 7.3 the end of the work.
All Laboratory specimens must be transported in clean, closed containers in order to
Laboratory specimens are
transported in clean, closed avoid exposure and environmental contamination form accidental spillage etc
containers.

Substandard # 7.4 Lab staff must adhere to the policy of storing potentially infectious materials in the lab
freezers and refrigerators.
Refrigerators and freezers
used to store potentially All Refrigerators and freezers that are used to store potentially infectious materials must
infectious materials labelled be labelled with the universal biohazard symbol to alert the lab personnel.
with the universal biohazard
symbol. Temperature logs:

IC team must ensure that temperature parameters are appropriately recorded in daily log
Substandard # 7.5 sheets for all refrigerators and fridges.

Temperature logs for There must be documented evidence of action taken if temperature readings were out of
refrigerators are complete range.
and action is taken when
temperature is out of range. These records must be kept inside the unit to be presented as evidence of regular
monitoring to the external inspection teams. (MOH, CBAHI etc)

1120 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Lab personnel must receive periodic infection control training on appropriate cleaning
Substandard # 7.6 and disinfection practices including type of disinfectants, contact time, frequency &
cleaning methods etc.
Working surfaces and Training must emphasize on decontamination of work surfaces after completion of work
equipment are regularly and after any spill or splash of potentially infectious material with appropriate disinfectant.
cleaned and disinfected. During visit randomly wipe any working surface and equipment to rule out presence of
dust.

Standard - Lab Safety Parameters

Lab safety is one of the important domain that would assist in minimizing or preventing the transmission of infectious agents in the laboratory.
The laboratory is a unique work environment that may pose infectious disease threats to those who work there. Biosafety levels were
established to ensure that the laboratory environment is adequately equipped with measures to ensure safety of those working in them or the
surrounding environment. Laboratorians should be an integral part of an infection prevention program. The microbiology laboratory helps
detect and identify microorganisms so that the infection control team can monitor, prevent, and control infection transmission.
Sub standards Explanation

Substandard # 8.1 IC team must provide training & education to the lab personnel as part of IPCCC training activities
regarding infection control measures in the lab settings including safety parameters.
Monitor practices during routine rounds and evaluate the staff and unit performance during IPCCC
Restrict access to the
audit phase.
laboratory with a sign
Provide formal feedback and reconsider for training if needed.
incorporating the universal
biohazard symbol, it must Ensure availability of the following:
be posted at the entrance to
the laboratory. - There is a sign that indicates “Restricted area – Authorized Personnel ONLY” posted on
the entrance door of the laboratory.
- Signage must be clear to be easily seen by the visitors.
Substandard # 8.2 - There is a universal bio-hazard sign posted at the entrance.
- Lab staff must be strictly prohibited from eating, drinking, smoking, handling contact lenses,
Eating, drinking, smoking, and storing food for human consumption in laboratory areas.
handling contact lenses, and - Food must be stored outside the laboratory area in cabinets or refrigerators designated and
storing food for human used for this purpose.
consumption must not be
permitted in laboratory
areas.

1121 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Biological Safety Cabinet:
Substandard # 8.3 Biosafety Cabinet: Biosafety cabinet is primary containment device designed to draw air inward by
mechanical means in order to contain infectious splashes or aerosols generated during certain
All manipulation of laboratory procedures. There are three types of biosafety cabinets, class I, II and class III. Most
infectious materials that laboratories use class I and class II cabinets.
may generate aerosols
should be conducted in a Aerosol generating procedures in lab include blowing out pipettes, shaking or vortexing tubes,
biological safety cabinet stirring, opening snap top tubes, breakage of culture containers, flaming loops or slides, pulling
(BSC - class II-B). needles out of septa, filling a syringe, pouring liquids, centrifugation steps such as filling centrifuge
tubes, removing plugs or caps from tubes after centrifugation, removing supernatant, breakage of
tubes during centrifugation, and centrifugation itself
Substandard # 8.4 IC team must ensure the availability of biological safety Cabinets (BSC - class II-B).
If biological safety cabinet (BSC) is available, determine its class: it should be class IIB (exhaust air
Biological safety cabinets from BSC discharged to outside through HEPA filters)
(class BII) is (BSC - class II-
B) dedicated for aerosols
generating procedures are Maintenance of Biological Safety Cabinet (BSC);
well maintained, tested and
certified at least annually. IC team must ensure availability of copy of maintenance records inside the unit
(PPM and Quality control records for the last 2 years) to be presented to external auditors during
evaluation phase.
There must be a valid annual certificate from authorized company.

Biosafety Level III Laboratory (BSL-3 laboratory):

Class III BSCs – are totally enclosed, ventilated cabinets of gas-tight construction that offer the
highest degree of protection from infectious aerosols. They also protect research materials from
biological contamination. Class III BSCs are most suitable to work with hazardous agents that
require containment at BL-3 or BL-4.
All operations in the work area of the cabinet are performed through attached rubber gloves. The
Substandard # 8.5 cabinets are operated under negative pressure.
Supply air if HEPA filtered, and the cabinet exhaust air is filtered by two HEPA filters in series or
Mycobacteriology HEPA filtration followed by incineration before discharge outside of the facility .
Laboratory that manipulates
cultures suspected or
confirmed to contain Ensure availability of Biosafety Level III lab for the Mycobacteriology Laboratory that manipulates
Mycobacterium tuberculosis cultures suspected or confirmed to contain Mycobacterium tuberculosis complex
complex is at least Biosafety (BSL-3 laboratory).
Level III Laboratory (BSL-3 There must be Preventative Maintenance (PPM) schedule for Biological Safety Cabinet - BSC with
laboratory). copies from PPM records for regular maintenance in the last 2 years (regular checkup with
replacement of filters as per the manufacturer recommendations - corrective interventions when
indicated).
Valid annual certificate from authorized company.
The laboratory supervisor must ensure that laboratory personnel demonstrate proficiency in
standard and special microbiological practices before working with BSL-2 agents.

Substandard # 8.6
Whenever possible, plastic tubes must be replaced with the glass ones to avoid sharp injuries.
Plastic tubes replace the Train the staff during IPCCC training phase.
Monitor the practices of lab personnel during routine rounds.
glass ones to avoid sharp
Evaluate performance and provide feedback.
injuries.

1122 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8.7
Eye wash station must be available for immediate action after exposure.
Eye wash station must be
available for immediate Eye wash station must be located at convenient place to be easily accessible for emergency in
action after exposure. case of accidental exposure to blood and body fluids.

Substandard # 8.8 Tissues, organs, other body parts, specimens of body fluids and their containers (stored
in lab for burial) must be disposed of in the Red Bags.
Histopathology specimens /
fatal parts should be
disposed of in red bags.

Substandard # 8.9 IC team must provide periodic training & education to lab personnel on the basics of infection
control in order to avoid environmental contamination & risk of cross infection.
Lab personnel must be well trained on how to use PPE appropriately.
Staff working in a section of
PPE must be discarded immediately before leaving the work station followed by hand hygiene.
lab should not visit other
Movement of staff with PPE in between different areas/ sections within the lab is strictly prohibited.
sections with used PPEs. Lab supervisor holds the key responsibility to ensure appropriate infection control measures are
They should discard PPEs being implemented.
before leaving their area.

Steam autoclave is the method of choice for decontaminating discarded cultures. If laboratory wastes
must be stored before disposal, storage should be as brief as possible. The site must be properly
identified with a biohazard label, have restricted access, and be located near the site of generation.
Clean the areas thoroughly each time it is emptied of waste contents.
Ensure availability of autoclaves used for autoclaving of microbiological cultures within the
laboratory.
There must be a log book for the autoclave that must be have the loads number and date.
Substandard # 8.10 Location of autoclave & other items:

Autoclaves are placed in Presence of working autoclave in a dedicated well ventilated place that is physically separated from
appropriate location and other areas in the department.
fulfils quality control Presence of the autoclavable bags that are used to sterilize the culture plates to avoid adherence of
parameters. the load in the autoclave chamber.
Availability of physical indicator (bowie dick), chemical indicator strips and biological indicator

Quality control parameters.

Quality performance tests for the autoclave operation (results of physical indicators (bowie dick),
chemical indicators and biological indicators).
Infection control list of highly infectious microorganisms that their cultures must be autoclaved in
the laboratory department before being disposed as infectious medical waste.

1123 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 09 STORAGE AREAS

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the
integrity of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best
practices for safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.

Substandard # 9.1 Following key points need to be followed:

Medical storage areas. rooms must be clean without any contamination from dust etc
Storage rooms are clean, There must be cleaning schedule with cleaning checklist including all items to be cleaned.
& dry with adequate Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
capacity and away from disinfectants used and required PPE.
any form of contamination
and direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
Substandard # 9.2 control parameters such as temperature, humidity etc are being monitored in the area or
There is controlled not.
ventilation with adjusted Ideally a fixed monitor should be installed for continuous monitoring of humidity &
temperature and humidity temperatures.
(temperature ranges from
22-24 degree Celsius and Unit must have local records for regular monitoring (daily) of temperatures and relative
relative humidity up to humidity during the last month.
70%). Local records for corrective interventions which are taken if readings are not matching the
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

1124 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection control team must provide training and reorientation about all specifications to be
Substandard # 9.3 followed for the maintenance of departmental medical stores.

Away from air vents and Train on following specifications / key points and observe in daily / weekly rounds if unit is
well ventilated. adherent with recommendations or not.
Departmental medical stores must be well organized & well maintained.
Substandard # 9.4 Must be away from any contamination, direct sunlight and airs vents.

Storage shelves are 40 Specifications of Storage Shelves:

cm from the ceiling, 20
cm from the floor, and 5 Storage shelves are made of easily cleanable material
cm from the outside wall. (e.g., fenestrated stainless steel, Aluminium or hard plastic).
Storage shelves are placed following these specifications.
Substandard # 9.5
- 40 cm from the ceiling
Storage shelves made - 20 cm from the floor
from easily cleanable - 5 cm from the wall
material (e.g., fenestrated
stainless steel, Aluminium If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
or hard plastic)
hard plastic).
Substandard # 9.6 Ensure that only sterile and clean items are allowed in the medical stores.
Sterile and clean items
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
completely separated
from personal items & from cockroaches and other insects etc.
foods and drinks.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 9.7 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the storage room during daily/ weekly rounds and randomly pick up item from container
as to avoid the use of placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 9.8 original cardboard shipping boxes.
Visit the storage room during daily / weekly rounds to check if any shipment boxes are placed inside
Items not kept in original
sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 9.9
Expired, broken or soiled items/packs are not allowed inside stores (i.e., it should be discarded)
If any stained item is found it would most likely reflect that item was restocked after being brought
No expired items, broken from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
packs or packs with prohibited.
stains are present. Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

1125 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Specimen Collection Area / Phlebotomy
Laboratory is responsible for most phlebotomy procedures in the hospital. Given that it is almost impossible to identify what might be infectious
without testing, all patients and their bodily fluids should be handled using standard precautions. Handle all body fluids using standard precautions.
a. Wear gloves when performing venepuncture. b. Wear other protective equipment such as goggles, mask or lab coat for a procedure based on
the risk of exposure (i.e., arterial punctures). c. Use safe needles at all times. d. Use only single-use disposable tube holders. e. Dispose all
phlebotomy needles promptly in a puncture-resistant container to prevent their reuse or accidental injury to a handler.
Sub standards Explanation

Substandard # 10.1 IC team must ensure strict adherence to infection control standards during blood sample collection/
phlebotomy procedures.
Provide training to the lab personnel / phlebotomist about IC measures to be taken during blood
Dedicated room for
sample collection.
specimen collection away
Observe practices in routine IC rounds and evaluate staff performance during IPCCC audit phase.
from the working area
Following must be ensured:
Substandard # 10.2
- Availability of dedicated room for blood sample collection which is away from other working areas.
No excess items in the - Minimize the items at the blood sample collection point in order to minimize risk of contamination.
blood sample collection Huge supply of collection tubes, syringes, PPE items near the collection point etc is strictly prohibited.
point.

Substandard # 10.3 - Sharp containers must be mounted at the suitable level near the point of use in order to avoid risk of
needle and sharp injuries.
- Other specification of sharp containers must be followed. It must be replaced when filled to 3/4 th of
Sharp container is mounted
capacity.
in suitable level near the
point of use.

Hand hygiene is the single most effective means to prevent transmission of infection & to
Substandard # 10.4 protect the patient from colonization or infection after phlebotomy along with other
aseptic measures.
Hand washing supply and all - Ensure availability of easily accessible hand washing facilities and supplies (sinks with hot & cold
required PPEs are is water / plain soap / paper towels) and other waterless hand hygiene facilities (alcohol - based hand
available inside the room. rub dispensers).
- Ensure availability of all PPEs in the area. PPE must be of good quality & amount to avoid shortage.
(Gloves, gowns, facemasks, goggles / face shields, etc)

1126 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Phlebotomist may be one of the first HCWs contact with a new patient within a healthcare
facility, so standard precautions must be applied for all the patients based on risk
assessment.

Lab personnel must be properly trained on appropriate selection and technique of PPE
Use & other IC measures during sample collection.

Following MUST be included:

Substandard # 10.5
Wear gloves when performing venipuncture. (OSHAs Bloodborne Pathogen Standard)
PPEs are appropriately used Wear other protective equipment such as goggles, mask or lab coat for a procedure
during sample collection. based on the risk of exposure (i.e., arterial punctures).

Best Practices:
Use safe needles at all times.
Use only single-use disposable tube holders.
Dispose all phlebotomy needles promptly in a puncture-resistant container to prevent their
reuse or accidental injury to a handler.

- Hand hygiene is the single most effective means to prevent transmission of infection.
- To protect the patient from colonization or infection after phlebotomy, the following
measures should be employed:
Tourniquets should be one time use or one patient use only
Skin should be antiseptically prepared before phlebotomy with either a 70%
isopropyl alcohol prep or, in the case of blood cultures, 10% povidone iodine
solution or chlorhexidine gluconate
Clean gauze pad, cotton ball, or bandage should be placed over the puncture site
to stop bleeding if necessary.

To protect the phlebotomist from infection and reduce the risk of infection to others,
isolation precautions should be followed.

1127 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.

Following must be ensured:

- All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
Substandard # 11.1
book.
Daily logbook is - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
activated in the unit
symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
for HCWs to record
presence or absence - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
of fever, respiratory &
HCWs on daily basis.
GI symptoms etc.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift.
clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.

Use attached template.

1128 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 11.2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

1129 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 11.3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1130 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 8:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
necessary for medical clinical staff) to avoid the unnecessary mobility in between the units.
purposes. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary for medical purposes.

1131 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1132 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1133 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE
WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:

□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms

□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

1134 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ALLIED HEALTH
SERVICES

# NAME OF UNIT PAGE #

01 PHYSIOTHERAPY 1136

1135 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
PHYSIOTHERAPY SERVICES

Physiotherapy services refers to the provision of care by a skilled

healthcare professional – Physiotherapist who uses physical therapeutic means and

exercises to ensure maximum recovery and early independence of patients. The
treatment of the patients is usually prescribed to relieve pain, restore normal
function and strength, prevent further injury and promote healthy living and
lifestyles.
Strict implementation of infection control measures including hand hygiene, wearing personal
protective equipment (PPE) to prevent the transmission of infection during provision of care,
isolation precautions & environmental measures etc. would play a significant role in ensuring
patient & staff safety.

1136 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN PHYSIOTHERAPY

POLICIES & PROCEDURES

PHYSIOTHERAPY SERVCIES

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

DISINFECTION OF PATIENT CARE EQUIPMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE MANAGEMENT

WASTE MANAGEMENT

ISOLATION PRECAUTIONS

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1137 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PHYSIOTHERAPY SERVICES
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for transportation of patient on contact
accessible for them. isolation etc. Ask verbally and then give task to demonstrate how to access this policy via
electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

1138 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT , DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

1139 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Aim of such training activities and courses is to have significant impact on employees’
Substandard # 2:2 knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel Infection Prevention & control department MUST provide education & training to all health care
(HCP) receive job- personnel on infection control best practices specific to their job as follows:
specific training on
infection prevention Infection control Training specific to area of work must be provided initially upon hiring before
policies and starting their duty.
procedures upon Continuous education on relevant infection control policies and procedures must be conducted
hiring and at least at least once per year.
once annually. Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

EXAMPLE OF JOB SPECIFIC IC - TRAINING ACTIVITY:

Educate healthcare personnel regarding standard & transmission based precautions etc
Education & training MUST be conducted as part of IPCCC training on all IPCCC standard.
Monitor & observe staff practices during routine daily/Weekly rounds and provide needed
feedback.
Estimate if the education imparted was well taken by staff and is reflected in his / her daily
practice.
Evaluate the staff performance using IPCCC checklist.

1140 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Infection Control department provides MUST provide health education on infection control for
patients & families.

Substandard # 2:4 IC team must ensure the availability of the following according to the specific unit / area:

Bilingual infection control health education & awareness material must be designed / formulated
Physiotherapy unit to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
provides infection booklets, leaflets etc. containing information easy to understand with help of pictorial display.
control health
education for patients The general & specific health educational material must be posted and available in all patient
and their families. care areas, waiting areas at the place easily seen and readable by families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.
Specific Infection Control Health Education provided to patients must be structured and
documented in patient’s files.

1141 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Substandard # 3:1 Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Hand washing implementation of hand hygiene program.
facilities and
supplies (sinks with Hand Washing Facilities:
hot & cold water /
plain and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
antimicrobial soap / available that meet the needs of the unit and are clean and in good repair.
paper towels, Check the availability of hand washing facilities in the clinics.
Alcohol - based Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
hand rub tap if hands free operation or open the tap to check for hot & cold water supply)
dispensers) are Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
available in soap 3: Paper Towels for drying
adequate numbers
(one per clinic & Hand Rub Dispensers:
easily accessible)
- Check the availability of hand rub dispensers as per requirements:
One dispenser per clinic
Substandard # 3:2
- Observe dispensers are conveniently mounted and accessible at the point of care.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
Alcohol - based ease of accessibility to staff.
hand rub dispensers
are available in the - At least one Alcohol - based hand rub dispensers are provided in the waiting areas.
waiting areas.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

1142 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:3
Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Health care Hand washing – washing hands with plain or antimicrobial soap and water.
professionals (HCP) Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
demonstrate without the need for an exogenous source of water and requiring no rinsing or drying with towels or
appropriate other devices.
technique for hand
rubbing and hand Indications:
washing. Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or
when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
1143 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
Substandard # 3:3 incorporating the culture of best practices.

Visual alerts are ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
available: WHO 5 posted at appropriate places.
moments, how to
do hand rub, how to - WHO 5 moments for hand hygiene at (nursing stations, procedure rooms etc
do hand wash. - How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispen
-
-
WHO Five moments of hand hygiene:

1: Before touching a patient:

- Clean your hands before touching a patient when approaching him/her.

- This is to protect the patient against harmful germs carried on your hands.

2: Before aseptic procedures:

- Clean your hands immediately before performing a clean/aseptic procedure.

- This is to protect the patient against harmful germs, including the patient's own, from
entering his/her body
-
3: Following body fluid exposure risk:

- Following exposure to any blood or contaminated body fluids & glove removal.
- This is to protect yourself and the health-care environment from harmful patient germs.

4: After touching a patient:

- Clean your hands after touching a patient and her/his immediate surroundings, when
leaving the patient’s side.
- This is to protect yourself and the health-care environment from harmful patient germs.

5. After touching patient surroundings:

- Clean your hands after touching any object or furniture in the patient’s immediate
surroundings, when leaving even if the patient has not been touched.
- This is to protect yourself and the health-care environment from harmful patient germs.

1144 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1145 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1146 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
Substandard # 4:1 in coordination with infection control department.

Sufficient and appropriate PPE During routine daily / weekly monitoring rounds, observe the availability of PPE by
are available in adequate randomly checking the PPE trolleys / stock rooms.
amount, types & sizes with PPE must be available at the point of use, which will interfere with effective use of PPE
proper qualities and readily as per requirement.
accessible to HCP. Simultaneously ask the nurse in charge , if all relevant PPE is available in the unit for
HCPs according to their sizes and needs.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)
- Different sizes and type of N - 95 masks (need based)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc

Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

1147 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 N-95 mask must always be worn according to the fit test ID provided after qualifying the
fit test for specific size, brand and type of N-95 mask. . Wearing N – 95 mask of
inappropriate size or with facial hair will not provide the protection against airborne
particles which are less than 5 microns in size. It will give a sense of false protection
exposing staff to risk of acquiring infections. So HCWs must be educated regarding using
N-95 respirator according to fit test or follow alternate policy in case of non-availability.

Substandard # 4:3 During daily / weekly rounds, ask and assess if the HCWs dealing with airborne
infections are using the correct size & type of N-95 mask according to fit test.
Staff knows the suitable N95 (Countercheck / verify with their fit test ID).
to be used based on the fit Observe the practice of doctors with beards.
test.
Key points:

❖ Healthcare workers are required to have a respirator fit test at least once every 2 years
and if weight fluctuates or facial/dental alterations occur.

❖ A fit test only qualifies the specific brand/make/model of a respirator with which an
acceptable fit testing result was achieved and therefore users should only wear the
specific brand, model, and size he or she wore during a successful fit test.

❖ Each time a respirator is donned, a seal check must be performed using the procedures
recommended by the manufacturer of the respirator.

❖ For healthcare workers who have facial hair that comes between the sealing surface of
the face piece and the face of the wearer a Powered Air Purifying Respirator (PAPR)
should be used instead.

1148 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

PPE is indicated to be used based on risk assessment as part of standard precautions &
Transmission based precautions.

All isolation precautions must be used together with Standard Precautions

❖ Contact: Appropriate PPE – Gown & Gloves

❖ Droplet: Appropriate PPE - Surgical mask, Gloves, and Gown
❖ Airborne: N95 mask / respirator before entering the room.

1: Appropriate PPE for Contact Isolation:

Substandard # 4:4
Before entering and leaving a patient’s room PPEs should be donned & doffed in this order.
Staff use personal protective Sequence of donning PPEs before entering the room:
equipment appropriately (e.g.
donning and doffing) Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene. Use soap and water when dealing with a patient with spore-
forming bacteria (e.g., Clostridium difficile) or if hands are visibly soiled.

2: Appropriate PPE for Droplet Isolation:

Sequence of donning PPEs before entering the room:

Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
https://youtu.be/H4jQUBAlBrI Don surgical mask. Place surgical mask over nose, mouth and chin then fit flexible
Watch Video How to safely put nosepiece over nose bridge and secure head with ties or elastic.
on PPE Don gloves. Extend gloves over isolation gown cuffs.

Sequence of doffing PPEs before leaving the room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

NB: If goggles/face shield are worn:

• Don PPEs in this order: Hand hygiene, gown, surgical mask, goggles/face shield and
gloves.
• Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene, surgical mask and hand hygiene.

1149 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 3: Appropriate PPE for Airborne Isolation:

Sequence of donning PPEs before entering the room:

❖ Perform hand hygiene.

❖ Don N95 mask or respirator. Place over nose, mouth and chin then fit flexible
nosepiece over nose bridge, secure on the head with ties or elastic. Perform fit check.

Sequence of doffing PPEs before leaving the room:

❖ Perform hand hygiene.

❖ Outside the room, remove your N95 mask (in the anteroom if available) iii. Perform
hand hygiene.

In case of combination of Contact and Airborne precautions with eye protection

(goggles/ace shield):

❖ Put on PPEs in this order: Hand hygiene, gown, N95 mask, goggles/face shield and
gloves.

❖ Remove PPEs in this order: Gloves, hand hygiene, goggles/face shield, gown, hand
hygiene (inside the room), and remove N95 mask (outside the room) and perform
hand hygiene.

1150 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1151 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1152 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1153 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Disinfection of Patient Care Equipment
Disinfection of patient care equipment is of utmost importance in providing safe and quality health care to the patients, All invasive procedures
involve contact between a medical device or surgical instrument and a patient's sterile tissue or mucous membranes. A major risk of all such
procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical
equipment carries a risk associated with breach of the host barriers.
The level of disinfection or sterilization is dependent on the intended use of the object:
Critical items such as surgical instruments, which contact sterile tissue) requires sterilization.
Semi critical items such as endoscopes, which contact mucous membranes) requires high-level disinfection
Non critical items such as stethoscopes, which contact only intact skin) require low-level disinfection.

Sub standards Explanation

During daily / weekly IPCCC activities, ensure all relevant disinfectants are available in the unit
Substandard # 5:1
for effective cleaning and disinfection practices.
Provide List of antiseptics, disinfectants and detergent/disinfectants’ with related documents
Adequate supply of
which are essential for safe and effective use (Material Safety Data Sheet (MSDS) – preparation
disinfectants is
& dilution – usage and contact time – precautions and required PPE)
available.
Verify if disinfectants recommended practices and approved by MOH.

After completing the training phase for the targeted staff, evaluate the staff performance during
the IPCCC evaluation process.
Substandard # 5:2 Ask staff to differentiate between critical, non-critical and critical items and give specific task to
perform. e.g disinfection of blood pressure cuff and observe selection of PPE , contact time is
Staff know the proper followed for disinfectant used and methodology i.e from less to more soiled and from up to
way of disinfection for down etc
non-critical medical These items could potentially contribute to secondary transmission of microorganisms to
care equipment. healthcare workers’ hands; therefore, they require low level disinfection with hospital approved
disinfectant at the point of use.

Reusable medical devices are devices that health care providers can reprocess and reuse on
multiple patients. Examples of reusable medical devices include surgical forceps, endoscopes and
Substandard # 5:3
stethoscopes.
All reusable medical devices can be grouped into one of three categories according to the degree
Reusable non critical
of risk of infection associated with the use of the device:
medical care
equipment are
disinfected properly • Non-critical devices, such as stethoscopes, come in contact with unbroken skin.
after each use before • Semi-critical devices, such as endoscopes, come in contact with mucus membranes,
leaving patient zone. accessories to endoscopes, such as graspers and scissors etc
• Critical devices, such as surgical forceps, come in contact with blood or normally sterile
tissue.

Reusable items non-critical devices must be disinfected before leaving the patients zone.
e.g stethoscope. BP cuffs etc
HCWs are not permitted to use personal stethoscopes in between patients or take the
items to nursing stations or offices.
Train & observe the staff practices and provide guidance if not following the standard
recommendations.

1154 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5:4 Infection Control Team must ensure provision of disinfection activity log /cleaning checklist to
the units which should include name of staff responsible for disinfection, items present in the
There is a disinfection specified area intended to be cleaned.
activity log including Name of disinfectants with dilutions and contact time.
responsible HCW, Randomly check during routine rounds if disinfection activities are done and documented
used agents and items appropriately.
for disinfection in the Evidence of cleaning / disinfection activities must be kept in the unit to be presented to external
unit. auditors for verification purposes.

High-touch surfaces are defined as surfaces, often in patient care areas, that are frequently touched
by healthcare workers and patients (e.g., bedrails, IV pole, door knobs, medication carts etc).
Substandard # 5:5 The principal modes of transmission are via the hands of the personnel and contact with
inadequately decontaminated equipment or surfaces. Likewise, all equipment used on the patient
High touch surfaces (e.g., blood pressure cuffs, thermometers, wheelchairs, IV pumps) are also heavily contaminated
should be disinfected and may be transmitted to other patients if strict barriers are not maintained and appropriate
more frequently. decontamination is not carried out.

Frequency of high touch surfaces Disinfection:

Before and after (i.e., between) every procedure and twice daily and as needed
During the daily rounds check randomly the patient care equipment e.g. bedside monitors by
wiping over hard to reach surfaces and rule out presence of dust etc.

Substandard # 5:6 Disinfection and cleaning of patient care equipment and surfaces is the sole responsibility of
clinical staff as it requires more careful and meticulous cleaning. (Nurses, doctors,
HCW are responsible Physiotherapists etc)
for cleaning and Housekeeping staff must not be allowed to handle any patient care equipment.
disinfecting of all
patient care equipment Adherence to these recommendations should improve disinfection and sterilization practices in
and surfaces health care facilities, thereby reducing infections associated with contaminated patient-care
items.

1155 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:01
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.

Substandard # 6:02 The spill kit must include the following:

There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.

Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

1156 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Substandard # 6:03 Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
HCW knows how to use spill clean-up as per policy.
kit properly. During audit phase of IPCCC, ask the same ursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other
potentially infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp
objects from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before removing.
Remove the solidified waste material using the scoop and scraper and carefully dispose
all contaminated materials into the infectious waste bag.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e.
paper towel) on top of the spill and apply the appropriate disinfectant. To avoid creating
aerosols, never spray disinfectant directly onto the spilled material. Instead, gently pour
disinfectant on top of paper towels covering the spill or gently flood the affected area,
first around the perimeter of the spill, then working slowly toward the spilled material. If
sodium hypochlorite solution (5.25% household chlorine bleach) is used, prepare a fresh
solution on a daily basis. Leave for the recommended contact time
Pick up all absorbent material and carefully place in the infectious yellow bag for disposal.
Remove PPEs and place in a yellow bag for disposal.
Seal the yellow bag.
Wash hands thoroughly with soap and water.
Contact housekeeping to clean the affected area with hospital-approved disinfectant.

1157 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Substandard # 6:04
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
is done & documented appropriately as per schedule.
Cleaning is done properly
using checklist that include
Each unit must have the schedule for cleaning and disinfection activities.
cleaning frequency,
Schedule must include the frequency, the used disinfectant and the responsible staff.
responsible worker,
Roles must be specified with clear instructions.
housekeeping surfaces (e.g.,
floors and walls), used
1. Nursing staff for medical equipment
agents, methods &
2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
environmental surfaces
3. Radiology technicians for portable X-ray
intended to be cleaned.
4. Respiratory therapist for respiratory therapy equipment. etc.

High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Substandard # 6:05
Common high-touch surfaces related to housekeeping activities includes doorknobs, light
switches & tap water handles etc
High touch surfaces should
be disinfected more
Explain staff about the importance of cleaning the high touch surfaces.
frequently (e.g., light
Monitor the activities during routine rounds and provide needed feedback.
switches, door knobs, tap
During IPCCC audit visit, assess and interview same staff who had received training
water handles).
previously.

High touch – are those that have frequent contact with hands. Examples include door- knobs,
elevator buttons, telephones, call bells, bedrails, light switches, computer keyboards,
monitoring equipment, wall areas around toilet and edges of privacy curtains.
High touch surfaces in care areas require more frequent cleaning and disinfection than
minimal contact surfaces. Cleaning and disinfection is usually done at least daily or per shift
and more frequently if the risk of environmental contamination is higher (e.g., intensive care
units).
Low touch – are those that have minimal contact with hands. Examples include floors, walls,
mirrors and window sills. Low-touch surfaces require cleaning at least on a daily basis or
whenever soiling or spills occur.

1158 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6:06 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:07
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

1159 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
Substandard # 6:08
Best practices for environmental cleaning of general patient area floors:
The mop and solution must
be changed frequently &
Mop heads and cleaning and disinfectant solutions must be changed as often as needed
after being used to clean any
(e.g., when visibly soiled, after every isolation room, every third patient room or every
potentially infectious
1 hour) & at the end of each cleaning session.
materials.
IC Team must train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

1160 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must conduct training of housekeeping staff in coordination with environmental
services supervisor followed by monitoring & auditing the staff practices.
Substandard # 6:09 All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
Housekeepers are well educated on the cleaning agents, disinfectants, proper dilution and contact time.
trained on hand hygiene,
proper use of PPE, methods Training must include following key parameters:
of cleaning & proper & safe
mixing of chemicals. Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
measures. Routine practices related to environmental cleaning include:

HAND HYGIENE:
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.
It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

1161 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Emphasize during training and monitoring phase on appropriate cleaning practices.
Substandard # 6:10 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:11 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:12 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 6:13 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

1162 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 7:01 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labeled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Key points for observation:

Sometimes sharp containers are mounted behind the patient bed at far location from staff
You may observe sharp containers placed directly on floor, mounted very high above the eye
level & at locations inaccessible for the healthcare workers.
Provide corrective solutions and guidance to staff during monitoring rounds & ensure
adherence to instructions.
Audit unit performance during IPCCC evaluation phase.

1163 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
Substandard # 7:02 importance in preventing sharp and needle stick injuries.

Sharp items (e.g., Observe the practices of staff during daily rounds regarding disposal of sharp items like
needles, scalpel needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
blades, broken metal All sharp items must be discarded in the specified sharp containers including the broken and
instruments and burs) unbroken glass vials.
are placed in an Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture any such situation inform the head nurse to monitor closely the staff practices.
resistant and leak- Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps collection staff / housekeeping staff.
container.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Substandard # 7:03
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
Used needles are not
Blades or needles should not be disassembled from the equipment.
manipulated or
recapped and are
Observe during monitoring rounds availability of sharp containers & if mounted in different
promptly disposed into
patient care areas at appropriate locations.
sharp containers.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.

Substandard # 7:04 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 7:05 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside ➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste receptacle and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular ➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
regular waste in yellow Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste ➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container) PPE bulging out of containers.
➢ Used syringe / needle on the medication trolley.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

1164 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 7:06 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

1165 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain large
numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or healthcare
workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must follow Standard Precautions at all times.
To reduce the possibility of occupational risks of infection transmission and/or exposure, laundry workers should focus on: a. Appropriate and
frequent hand hygiene. b. Appropriate use of personal protective equipment (PPE). Removal of foreign objects from soiled linen. 4. To restore
soiled linen to usable condition, washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 8:01 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Health care personnel must practice the hand hygiene before handling any clean linens in
Substandard # 8:02 order to avoid contamination of linen.
Ensure adequate hand washing facilities equipped with all required supplies & alcohol
Personnel must wash their Based Hand Rub (ABHR) dispensers in all patient care areas.
hands before handling clean HCWs must be oriented about handling the clean linen without risk of contamination.
linen. Monitor / observe staff practices during rounds.

Substandard # 8:03 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled textiles should be There should be schedule for daily collection of soiled linen from the units.
transported to the laundry
Visit the dirty utility room & verify if soiled linen is transported regularly as per
facility on a regular
schedule (e.g., daily). schedule.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 8:04 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

1166 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8:05 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
functionally contain wet or Place used linen in a laundry bag at the point of use.
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing.
textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.
- Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 8:06 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
the dirty utility room or a designated area for pickup by laundry staff.
Substandard # 8:07 Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
to 10 inches off the floor.
Linen carts are covered and Linen from isolation rooms is considered regular soiled linen.
not overfilled. The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

1167 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 09 Isolation Precautions
The spread of infection within the hospital requires three essential elements: a source of infectious agents, a susceptible host, and a mode of
transmission which can be linked in a chain. In order to prevent the transmission of infectious agents, stringent infection prevention &
control strategies implemented together can break chain of infection within the healthcare settings.

Infection refers to the entry and multiplication of an infectious agent in the tissues of the host causing tissue damage that results in apparent
or unapparent changes in the host.

Colonization refers to the presence of microorganisms in or on a host with

growth and multiplication but without tissue invasion or damage.

WW. The source of the infectious agent may be patients, personnel, or

visitors and may include persons with active infection, persons in the
incubation period of the disease, or persons who are colonized by the
infectious agent but have no apparent disease. Other sources of
infection include inanimate objects in the environment, such as
equipment and medications that have become contaminated.
XX. The susceptible host are vulnerable to developing infection when their
bodies are invaded by germs. e.g those with weakened immune
system, comorbidities, extremes of ages etc
YY. The mode of transmission is the method by which the organism
reaches a susceptible host.

Three modes of transmission are of particular importance in the healthcare

setting:

1. Contact Transmission is the most important and frequent mode of transmission in nosocomial infections. This transmission type is further
divided into two sub-groups:
xxxiii. Direct Contact:
Involves direct physical contact between a susceptible host and an infected or colonized person, e.g., nurse-patient contact during
routine care, patient-patient contact or patient-visitor contact. Such contact can cause direct transfer of microorganisms from one
person to another.
xxxiv. ii. Indirect Contact:
Involves the physical contact of a susceptible host with a contaminated intermediate object such as bed linen, instruments,
dressings, shared equipment or healthcare environmental surface

b. Droplet Transmission: involves the transmission of microorganisms in droplets generated from an infected or colonized person during
talking, sneezing or coughing or generated during certain procedures such as suctioning and bronchoscopy. Microorganisms are aerosolized
and deposited on the host’s conjunctiva, nasal mucosa and/or mouth.

c. Airborne Transmission involves the dissemination of droplet nuclei or dust particles containing the infectious agent in the air. Organisms
carried in this manner can be widely dispersed by air currents before being inhaled.

Isolation precautions contain two tiers: Standard Precautions and Transmission-based Precautions:

a. Standard precautions

These are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in
hospitals. Standard precautions apply to blood, all body fluids (secretions and excretions except sweat regardless of whether they contain
blood), non-intact skin and mucous membranes.

b. Transmission-based precaution

These are designed for patients documented to be or suspected to be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions beyond Standard Precautions are required. i. There are three types of isolation
precautions: Airborne, Droplet and Contact Precautions. ii. These precautions may be combined for diseases that have multiple routes of
transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

1168 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Sub standards Explanation
Provide education to the staff regarding importance of isolation precautions & appropriate isolation
signs to be used during IPCCC training activities.
Observe the practices in daily rounds and audit staff performance in IPCCC audit phase.

Observe if appropriate isolation signs are available and used according to type of diagnosis for
patients under isolation.
Use preferably isolation precautions signs provided by GDIPC.
Must be placed / posted on door only if occupied by patient.
Substandard # 09:01 02 types of isolation precaution signs must be available in the unit.
- Isolation precaution signs for units to be posted on doors if the isolation room is occupied
Staff are aware about by patients with diseases transmitted either by contact, droplet or airborne route.
the isolation signs and - Isolation Transportation cards for transportation of patients to other departments as
their color codes needed.

Examples: contact: Contact isolation Signs: are used for patients with diseases transmitted by contact route.
green, airborne: blue,
and droplet: pink or Should be initiated and maintained when there is a suspected or confirmed diagnosis of an
red) infectious disease that is transmitted by the contact route e.g Clostridium difficile, Scabies etc
The patient should be in a single room. A neutral pressure room is indicated.
Put a contact isolation sign on the door and the patient’s curtain. Contact isolation signage
must be color coded (e.g., green) and must be available in both English and Arabic
languages.
Door must be kept closed at all times.

Droplet Isolation Signs: are used for patients with diseases transmitted by droplet route.

Droplet Precautions are intended to reduce the risk of droplet transmission of infectious agents from
close contact (exposure to eyes, nose and mouth) with large-particle droplets

Should be Initiated and maintained when there is suspected or confirmed diagnosis of an

infectious disease that is transmitted by the droplet route. E.g influenza, MERS etc
Use a single room. A negative air pressure room is not indicated.
Place a droplet sign on the door.
Droplet isolation signage must be color coded (e.g., orange) and must be available in both
English and Arabic languages.

Airborne isolation Signs are used for patients with diseases transmitted by Airborne route.

Airborne precautions is used when a patient is suspected or confirmed to have any of the diseases
that are spread via the airborne route.
Initiate and maintain isolation when there is suspicion or confirmed diagnosis of an infectious
disease that is transmitted by the airborne route. E,g tuberculosis, chickenpox etc
Use a single room with a negative air pressure system (AIIR)
Place the Airborne Isolation sign on the door.
Airborne isolation signage must be color coded (e.g., blue) and must be available in both
English and Arabic languages. b. Keep door closed at all times except when entering or
leaving the room.

1169 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9:02 IC Team must provide a log book to the units to be used for potentially harmful infectious
patient exposures such as MERS-CoV & COVID – 19 etc
Log book for exposure Logbook must specify the name, designation / job category, Duration of exposure (Time in /
is available for any Time out) & type of PPE used.
potentially harmful Appropriately used logbook will generate information needed in case of outbreaks etc
infectious exposures Train & educate staff regarding the importance of documenting relevant information in logbook
as per exposure before gaining entry into isolation room.
policies and Nurses in charge must ensure all logbooks are filled appropriately with all needed information.
procedures (e.g. Evaluate unit’s performance in IPCCC audit phase.
MERS-CoV).

IC team must ensure the following in order avoid risk of exposure to staff and patients’ in the
Substandard # 9:03
outpatient clinics.
All appointments for All clinical appointments for patients with potentially infectious cases must be postponed till
patients with patients are fully recovered unless it is absolutely necessary for medical reasons.
potentially infectious Staff MUST take full necessary precautions in case if the appointments are scheduled for
cases should be patients with infectious diseases.
postponed until
recovery unless Educate the staff about the potential risks associated with exposure to infectious cases.
absolutely necessary. Observe the practices in the routine rounds to ensure implementation of policy.

Patient Transportation:
.
Patient Transportation isolation signs must be used while transporting patients under
Substandard # 9:04 transmission-based precautions to other department as needed.
If transfer of patient Transfer of patients under isolation precautions must be restricted to medically necessary
under isolation is purposes in order to avoid risk of infection transmission such as diagnostic and therapeutic
required, the receiving procedures that cannot be performed in the patient’s room.
unit or facility is
informed about the Provide training and orientation to staff the transfer rules related to patient transportation under
required isolation isolation precautions. Observe if unit is following the policy.
precautions and
availability of Following instructions must be given:
appropriate PPE is
ensured. Receiving unit or facility is informed beforehand about the required isolation precautions to be
taken. (Transfer could be internal to any unit inside facility or external to any other facility)
Clear instructions must be provided and documented in patient files before transfer.
Ensure all PPE relevant for type of isolation is available in the unit e.g. Radiology, endoscopy
unit etc.

It is important that HCWs in the receiving unit have received prior training on how to safely
handle patients under isolation precautions and how to appropriately use PPE according to type
of isolation. e.g. For handling patients under airborne isolation, radiology staff must be fit tested
for N-95 mask and trained well on how to don & doff after use.

Transferring the Patient to Another Facility:

Inform the receiving facility and the emergency vehicle personnel in advance about the type of
isolation and standard precautions (PPE) required.
Provide complete information on the infectious status of the patient to the receiving facility.
Inform receiving hospital and document the presence of a MDRO and specify whether it is a
colonization or an infection.

1170 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 10:01
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 10:02 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to Local records for corrective interventions which are taken if readings are not matching the
70%). acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

1171 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10:03 Infection control team must provide training and reorientation about all specifications to be
followed for the maintenance of departmental medical stores.
Away from air vents and
well ventilated. Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.
Substandard # 10:04 Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Storage shelves are 40
cm from the ceiling, 20 Specifications of Storage Shelves:
cm from the floor, and 5
cm from the outside wall. Storage shelves are made of easily cleanable material
(e.g., fenestrated stainless steel, Aluminium or hard plastic).
Substandard # 10:05
Storage shelves are placed following these specifications.
Storage shelves made - 40 cm from the ceiling
from easily cleanable - 20 cm from the floor
material (e.g., fenestrated - 5 cm from the wall
stainless steel, Aluminium
or hard plastic) If containers are used inside medical stores, they are made of easily cleanable material (e.g.,

Substandard # 10:06 hard plastic).

Ensure that only sterile and clean items are allowed in the medical stores.
Sterile and clean items
completely separated Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
from personal items & from cockroaches and other insects etc.
foods and drinks.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 10:07 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 10:08 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 10:09 Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
discarded)
No expired items, broken If any stained item is found it would most likely reflect that item was restocked after being brought
packs or packs with from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
prohibited.
stains are present.
Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

1172 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 11:01 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

1173 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 11:02
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

1174 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 11:03
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1175 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 11:04 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.

Interdepartmental Following must be ensured:

mobility of healthcare
workers is strictly Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
prohibited unless clinical staff) to avoid the unnecessary mobility in between the units.
necessary for medical Moving in between departments and eating together in pantries is strictly prohibited.
purposes (Patients HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation etc) transportation of patients, etc

1176 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1177 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1178 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE
WORKERS

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:

□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms

□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

1179 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 SUPPORT SERVICES

# NAME OF UNIT PAGE #

01 CENTRAL STERILE SUPPLY DEPARTMENT (CSSD) 1181

02 PHARMACY SERVICES 1221

03 DIETARY SERVICES DEPARTMENT 1251

04 LAUNDRY SERVICES 1282

05 MORTUARY SERVICES 1316

06 INFECTIOUS MEDICAL WASTE ROOM 1346

1180 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
CENTRAL STERILE SUPPLY
DEPARTMENT (CSSD)

Central Sterile supply department provides services for the

reprocessing of reusable items, proper storage, and event-related shelf life of all
sterile items and equipment.
All invasive procedures involve contact by a medical device or surgical instrument with
a patient’s sterile tissue or mucous membranes. A major risk of all such procedures is
the introduction of pathogenic microbes leading to infection. Failure to properly
disinfect or sterilize reusable medical equipment carries a risk associated with breach
of the host barriers.

Strict adherence to infection control procedures during all stages of instruments

processing is critical to ensure high quality sterile equipment for patient’s use.

1181 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IPCCC - STANDARDS IN CSSD

POLICIES & PROCEDURES

EDUCATION & TRAINING

CENTRAL STERILIE SUPPLY

HAND HYGIENE
DEPARTMENT (CSSD)

PERSONAL PROTECTIVE EQUIPMENT (PPE)

CSSD STAFF QUALIFICATIONS

HOSUEKEEPING & UNIT ENVIRONMENT

WASTE MANAGEMENT

TRANSPORTAATION & DECONTAMINATION

UNIT DESIGN

INSPECTION, ASSEMBLING & PACKING (IAP) AREA

STERILE STORAGE

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1182 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 CENTRAL STERILE SUPPLY DEPARTMENT (CSSD)

Standard – 1 Policies & Procedures

Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1.1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1.2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for quality control/ recall of equipment
accessible for them. etc. Ask verbally and then give task to demonstrate how to access this policy via electronic
system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

1183 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2.1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT, DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

1184 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2.2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

1185 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2.3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Standard – 3 Hand Hygiene

Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
implementation of hand hygiene program.
Substandard # 3.1
Hand Washing Facilities:
Hand washing
facilities and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
supplies (sinks with available that meet the needs of the unit and are clean and in good repair.
hot & cold water / Check the availability of hand washing facilities in the clinics.
plain and Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
antimicrobial soap / tap if hands free operation or open the tap to check for hot & cold water supply)
paper towels, Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
Alcohol - based soap 3: Paper Towels for drying
hand rub
dispensers) are Hand Rub Dispensers:
available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
One dispenser per work area
One at any service area

- Observe dispensers are conveniently mounted and accessible at the point of care.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

1186 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3.2 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Health care Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
professionals (HCP) without the need for an exogenous source of water and requiring no rinsing or drying with towels or
demonstrate other devices.
appropriate Indications:
technique for hand
Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
rubbing and hand
fluid exposure risk, after touching a patient, after touching patient’s surroundings.
washing.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or
when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:
- Wet hands with water
- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa

1187 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
Substandard # 3.3 hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Visual alerts are
available: ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
how to do hand rub, posted at appropriate places.
how to do hand
wash. - How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispen

1188 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
Substandard # 4.1 staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.
Sufficient and appropriate PPE
are available in adequate During routine monitoring rounds, observe the availability of PPE in the pharmacy.
amount, types & sizes with PPE must be available at the point of use which will interfere with effective use of PPE
proper qualities and readily as per requirement.
accessible to HCP. Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves including heavy duty gloves

- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles, face shields)
- N – 95 masks

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

1189 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.
Substandard # 4.2
1: Appropriate PPE use for CSSD Staff:
Staff use personal protective
equipment appropriately (e.g. Sequence of donning PPEs :
donning and doffing)
Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical facemask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
https://youtu.be/H4jQUBAlBrI Don goggles/face shield.
Watch Video How to safely put Don gloves. Extend gloves over yellow gown cuffs.
on PPE
Sequence of doffing PPEs:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove goggles/face shield
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

1190 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1191 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 CSSD STAFF QUALIFICATION
Qualification & professional development of CSSD staff is critical for practicing the standards of care. Certification is the pinnacle of practice
and serves as one measure of validation of CSSD staff expertise. Central Sterile processing is the department most often responsible for
reprocessing and sterilizing instrumentation and other reusable medical devices involving carious steps. The goal is to provide safe, functional,
and sterile instruments and medical devices to reduce the transmission of pathogenic organisms from patient to patient and to reduce the risk
for surgical site infection.
Hence availability of competent CSSD staff is of utmost importance in ensuring quality of sterile processing at all steps for provide quality
services to the patients.
Sub standards Explanation
CSSD personnel must be efficient & well trained who are competent to perform the function of CSSD
Substandard # 5.1 with the knowledge of the department’s reporting structure.
IC Team must ensure that job description of all CSSD personnel including manager, supervisor,
Job Description of the
technicians & other relevant staff must be available as per assigned task in the unit.
manager, supervisor,
CSSD team are well aware about the roles of responsibilities as per assigned area of work according
Technicians and other staff to the job description document.
is available (the job Implementation of all IC measures is individual responsibility so staff must clearly understand the
description per each area). tasks and roles as explained in job description in order to avoid confusion and negligence.

Work activities include transporting, sorting, disassembling, cleaning, disinfecting, inspecting, packaging,
sterilizing, storing, and distributing reprocessed items.
During these activities, it is important for the central sterile processing staff to be familiar with the
principles of disinfection and sterilization, as well as the equipment manufacturers’ written instructions
Substandard # 5.2 for use of reprocessing equipment, and the chemicals being used.

Qualified, trained, CSSD staff must have professional qualifications like diploma, certification etc.
immunized staff and able to All CSSD must be fully immunized against the infectious disease like hepatitis B because of risk of
apply correct practice for all exposure during decontamination phase.
procedures. Immunization records must be kept inside staff personal files.
IC teams has the key responsibility to ensure all CSSD staff are well trained on the protocols of
sterile processing.
CSSD staff must also attend periodic training course to ensure professional development and
knowledge update in order to ensure effective implementation of all IC standards to produce quality
product for end users.

1192 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails, IV Poles, door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6.1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.
Substandard # 6.2
The spill kit must include the following:
There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads.
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.
Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

1193 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
clean-up as per policy.
During audit phase of IPCCC, ask the same Nursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Substandard # 6.3 Provide feedback on performance and correct the mistakes. (If any)

HCW knows how to use spill STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
kit properly. infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other potentially
infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp objects
from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the manufacturer’s
recommended contact time. Allow the spill to solidify before removing.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e. paper
towel) on top of the spill and apply the appropriate disinfectant. To avoid creating aerosols, never
spray disinfectant directly onto the spilled material. Instead, gently pour disinfectant on top of paper
towels covering the spill or gently flood the affected area, first around the perimeter of the spill,
then working slowly toward the spilled material. If sodium hypochlorite solution (5.25% household
chlorine bleach) is used, prepare a fresh solution on a daily basis. Leave for the recommended
contact time.

Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning

Substandard # 6.4 logs /checklists is extremely important to ensure effective implementation & to have the
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
Cleaning is done properly is done & documented appropriately as per schedule.
using checklist that include
cleaning frequency, Each unit must have the schedule for cleaning and disinfection activities.
responsible worker, Schedule must include the frequency, the used disinfectant and the responsible staff.
housekeeping surfaces (e.g., Roles must be specified with clear instructions.
floors and walls), used
agents, methods & 1. CSSD staff for machines etc
environmental surfaces 2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
intended to be cleaned.

1194 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
Substandard # 6.5
prerequisite to the development of cleaning procedures.
High touch surfaces should
Common high-touch surfaces related to housekeeping activities includes doorknobs, light
be disinfected more
switches & tap water handles etc
frequently (e.g., light
switches, table tops. door
Explain staff about the importance of cleaning the high touch surfaces.
knobs, tap water handles).
Monitor the activities during routine rounds and provide needed feedback.
During IPCCC audit visit, assess and interview same staff who had received training
previously.

1195 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors in general inpatient and outpatient areas must always be cleaned last after other
environmental surfaces at least daily. Floors may require, more frequent cleaning, depending
on the risk-level in a specific patient care area.

Substandard # 6.6 Provide training to the selected staff during IPCCC training phase in each quarter with
help of cleaning supervisor to explain the right process and technique of cleaning and
Floors are cleaned or disinfection of floors using double/ or triple bucket technique or scrubbing machines.
disinfected using double/ or
triple bucket technique or Double bucket Technique:
scrubbing machines. This consist of 02 different buckets One with disinfection solution & other with water.
Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6.7
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

1196 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
Substandard # 6.8
Best practices for environmental cleaning of general patient area floors:
The mop and solution must
be changed frequently &
Mop heads and cleaning and disinfectant solutions must be changed as often as needed
after being used to clean any
(e.g., when visibly soiled, after every isolation room, every third patient room or every
potentially infectious
1 hour) & at the end of each cleaning session.
materials.
IC Team must train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

1197 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must conduct training of housekeeping staff in coordination with environmental
services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Substandard # 6.9 Training must include following key parameters:

Housekeeping staff must adhere to Standard Precautions and if required Expanded
Housekeepers are well Precautions when performing routine practices of cleaning and following infection control
trained on hand hygiene, measures. Routine practices related to environmental cleaning include:
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals.
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.
It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:
Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed

1198 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Emphasize during training and monitoring phase on appropriate cleaning practices.
Substandard # 6.10 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6.11 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6.12 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use or discarded if single use.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 6.13 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

1199 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Waste Management

Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 7.1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labelled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Monitor the staff practices during routine rounds.

Evaluate unit & staff performance during IPCCC evaluation phase.

1200 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7.2 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the head nurse to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
Substandard # 7.3 risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
Used needles are not syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
manipulated or Blades or needles should not be disassembled from the equipment.
recapped and are
promptly disposed into Observe during monitoring rounds availability of sharp containers & if mounted in different
sharp containers. patient care areas at appropriate locations.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit.

Substandard # 7.4 Provide training to staff on infectious waste management protocols during IPCCC training
activities.
No infectious medical
waste or sharps are Following waste segregation rules must be followed:
observed outside
specific containers. ❖ Black: To dispose general waste
❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)

Observe if the CSSD staff are discarding the waste in specified containers or not.
Substandard # 7.5
Randomly open the containers to observe if discarded waste is appropriate for that receptacle.
Waste are properly
You may observe the following:
segregated (no
medical waste inside
➢ Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste
the regular waste
receptacle.
container or regular
➢ Sometimes you may observe a paper tissue & surgical mask discarded in sharp container.
waste in yellow
Such practices must be observed and monitored & corrected during routine daily rounds.
medical waste
➢ You may also find used gloves & masks beside the waste receptacle on the floor & some
container)
PPE bulging out of containers.

Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

1201 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Observe the following:

Substandard # 7.6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

Standard - 8 TRANSPORTATION & DECONTAMINATION

Reprocessing of instruments and other patient care items involves transporting, sorting, disassembling, cleaning, disinfecting inspecting,
packaging, sterilizing, storing, and distributing reprocessed items. Appropriate IC measures must be followed at each step for quality
assurance of processed item. Aim should be to protect workers from contamination with possible infectious materials. Flowing key
parameters to be considered. 1: Ensure that gloves and gowns appropriately protect staff from contact with contaminated fluids, 2.Ensure
that personal protective equipment prevents contaminated materials from entering the eyes or mouth. 3. Reduction of the bioburden and
microbes to a level safe for use or further reprocessing. 4. Ensure that decontamination chemical detergents are appropriate, are within
effective concentrations, and are not expired 5. Ensure that the decontamination process used for each device is in accordance with its IFU.

Sub standards Explanation

During IPCCC training phase IC team must provide retraining and orientation to staff in
various department on appropriate handling of all semi critical and critical care items
before transportation to the CSSD.
Observe the staff practices during routine rounds and evaluate performance in IPCCC
audit phase.

Substandard # 8.1 Following key points must be incorporated in the training session:

Gross soil is removed from Transportation gel must be applied to all contaminated instruments in order to prevent
contaminated instruments drying of blood and other secretions which will be difficult to clean. So all gross soiling
with transportation gel at must be removed at the point of use by spraying with appropriate transportation gel.
the point of use.
At the earliest stage possible, following a procedure staff must ensure to prevent organic
matter from drying on instruments and microorganisms from growing on devices. Keep
instrumentation moist so that bioburden is not dried onto the device.

Contain contaminated devices in a closed container or yellow bag to prevent accidental

exposure to staff and patients

1202 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Transportation of Contaminated items:
Substandard # 8.2
IC team must ensure that each unit has a schedule for the transportation of contaminated
Transportation of items to the CSSD based on scope of services.
contaminated items to the All contaminated items must be kept in the closed containers or yellow bags.
CSSD is done in a rotational Transportation carts must be available and used for the transportation of contaminated
schedule using closed items to the CSSD in order to prevent accidental spillage and environmental contamination
containers or yellow bags and cross infection transmission.
that are kept inside closed IC team must observe the practices and any breach of practice must be communicated to
transportation carts in such relevant unit head.
a way that prevents spillage End users MUST spray all reusable devices immediately after use with a hospital-
and spread of infection as approved transport gel or wiped with wet cloth at the point of use.
well as to protect the Place used devices in a covered receptacle in the soiled utility room.
instrument.

Specification of Transportation Carts:

Substandard # 8.3
Carts used for transportation of contaminated items to CSSD must exhibit following
Transportation carts mandatory features:
includes mandatory features
such as correct size, rigid - Size: Transportation carts must be of appropriate size to accommodate all containers
material, secured to prevent with instruments & other items to be processed at one time.
spill, washable with smooth - Material: Rigid, hard material able to resist punctures having smooth wheels.
wheels & identified with a - Secured: Must be well secured from all sides in order to prevent spill.
clearly visible biohazard - Cleanable: i.e easily washable including the wheels based on specified cleaning and
label. disinfection frequency.
- Biohazard Label: Clearly visible biohazard label must be posted on the cart to alert
the bystanders.

Cleaning & Disinfection of Transportation Carts:

Substandard # 8.4
- Transportation carts must be cleaned and disinfected after each use with hospital
The transportation carts are approved disinfectant.
cleaned and disinfected after - IC team must provide training along with environmental services supervisor on the
each use.(all parts including cleaning process, use of disinfectants with dilutions & contact time etc.
the cart wheels) - Cleaning process must include the cart wheels in order to avoid environmental
contamination from inappropriate cleaning practices.
- IC team must train, observe and evaluate the performance of responsible staff as part
of IPCCC activities.

1203 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8.5 Environmental Control Parameters:

Environmental control log Assigned ICP must ensure during routine rounds that all environmental control parameters are
within specified range and appropriately documented in environmental control logbook.
book includes details of
Environmental control parameters that must be continuously monitored via fixed monitors include
humidity, pressure, following:
temperature, and air- 1. Humidity range = 30%-60%,
exchange records i.e 2. Temperature range = 16-18 c⁰
humidity range = 30%-60%, 3. Negative pressure
temperature range = 16-18 4. Air-exchange = 10 times/hour
c⁰, negative pressure and
air-exchange = 10 All records must be kept inside unit for the purpose of verification and to be presented during
times/hour. external audit rounds.
There must be at least quarterly report checked by the utility & maintenance department.

Staff assigned in the receiving area must ensure effective documentation of all items
received from specific area for the purpose of verification and to have documented
Substandard # 8.6
proof / evidence of items sent and received.

Following must be documented in the receiving items logbook:

Receiving items log book
must record date,
- Date
Sets/devices name, quantity,
- Name of sets/ devices
departments, sender ID, and
- Quantity
receiver ID.
- Department/ OR name
- Sender ID (ID of staff who have sent the items)
- Receiver ID (ID of staff who have received the items)

IC team must ensure availability of all supply required for effective cleaning and
disinfection process.
Substandard # 8.7 All Detergents and cleaning supplies used in CSSD must be approved from MOH and
staff are trained on how to use.
Detergents and cleaning
supplies are available These Items includes:
(brushes with different
shapes & sizes, enzymatic - Brushes of various sizes and shapes
and cleaning detergent, - Enzymatic detergents, Alkaline solutions
sponges, PPE, cleaning - Sponges
trays etc). - Appropriate PPE
- Cleaning Trays etc
- Verification tests (sono check-protein test -water PH and hardness test)

1204 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must be well familiarized with all protocols of instruments decontamination
cycle in the CSSD for effective monitoring and evaluation.
CSSD staff must receive periodic training to ensure strict adherence to infection control
Substandard # 8.8 measures during instrument processing in each zone:

Manual cleaning for all Procedures to be followed in decontamination area:

instruments must be
performed before loading it Key domains of training should include:
in washer disinfector,
Ultrasonic washer or Manual Manual cleaning:
disinfection.
The cleaning process is the most critical step in the sterilization process. Blood, body fluids,
Substandard # 8.9 and other organic and inorganic soil remaining on medical devices interfere with the
sterilization process, and, if they are not removed, the item(s) cannot be considered sterilized.
For manual cleaning at least Instruments with removable parts should be disassembled and cleaned. All lumens should be
two deep sinks are available brushed and flushed.
with measured indicator.
Items are submerged and Before loading to washer disinfector, manual cleaning of all instruments must be
cleaned under water level to performed. Correct dilution for the cleaning detergents must be followed as directed
prevent aerosolization. it in the detergent's IFU, a final rinse with treated water is required.
Instruments are
disassembled as per At least two deep sinks are available with measured indicator which will guide for
manufacturer's maximum water level to be achieved.
recommendations.
Instruments are disassembled as per manufacturer's recommendations.
Substandard # 8.10
Items should be submerged should be cleaned under water level to prevent
All manual and mechanical aerosolization based on manufactures' instructions for use.
test result are recorded in a
logbook (Ultrasonic check, Ensure that tools and supplies used to remove bioburden are clean and its compatible
protein check, chemical to the standards.
strips)
Ensure that all cleaning detergents are approved and diluted as per the detergents''
Substandard # 8.11 manufactures (correct concentration)

Detergents should be In order to ensure the cleaning efficacy of processed instruments all manual and
changed whenever visibly mechanical test results must be recorded in the logbook. e.g., ultrasonic check,
soiled. Strainers and spray protein residue checks etc.
arm should be checked
daily. Solutions of detergents should be changed whenever visibly soiled.

In order to ensure maintenance and functionality of washer disinfector; strainers and spray
arms must be checked daily.

An emergency eyewash stations are essential equipment for every CSSD unit that
Substandard # 8.12
uses chemicals and hazardous substances. Emergency eyewash stations serve the purpose of
reducing workplace injury and keeping workers away from various dangers.
Emergency eyewash safety
station is available in
IC team must ensure availability of Emergency eyewash safety station in decontamination
decontamination area and
area.
accessible within 30 meters
Eye wash station must be installed at appropriate location and operate without any
or 10 seconds of potential
obstacle to reach it.
chemical exposure.
Must be accessible within 30 meters or 10 seconds of potential chemical exposure.

1205 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 9 UNIT DESIGN
The Central Sterile Supply Department must be physically separated into three zones to minimize the risk of cross-contamination. The
environmental conditions are monitoring under negative pressure in Decontamination area and under positive pressure in the Inspection,
Assembly and Packaging area, and Sterile Storage area. The work flow inside each area must be from dirtiest to cleanliest point
(unidirectional way)
Sub standards Explanation
IC team must ensure that unit design is according to specifications & there is complete separation
between 3 zones in CSSD.
Central Sterile Services Department is physically divided into following 3 zones:

❖ Decontamination Area
❖ Inspection - Assembling - Packaging Area
❖ Sterile Storage Area

1: Decontamination Area Design:

There must be a physical barrier between the decontamination area and the other
Substandard # 9.1 work areas.
Must have Negative pressure ventilation. The ventilation of the area should have
CSSD unit is physically negative air pressure (pulls air into the work area)
separated into 3 areas Floor, walls, ceilings & working surfaces are so designed to withstand frequent
(Decontamination Area, cleaning & disinfection.
Inspection - Assembling - Easily accessible handwashing facilities
Packaging Area & Sterile Eye wash station & material safety Data sheet for each chemical.
Storage Area). Clearly Each area should have a clear signage posted outside specifying particular area
visible demarcation signs (Decontamination Area, Inspection - Assembling - Packaging Area & Sterile Storage Area).
are posted for each area Restricted sign must also be posted on the main entrances
with restriction sign on the (AUTHORIZED PERSONNEL ONLY)
main entrances.
2: Inspection, Assembly, Packaging Area Design:

The Inspection, Assembly, Packaging Area design area should be physically separated
from the decontamination area.
Beyond the decontamination area, central services require positive airflow i.e. air is
pushed out of the work area into adjacent areas or hallways.

3: Sterilization Area Design:

Sterilizers are usually located along the processing pathway adjacent to where sets are
prepared and package, on the “clean” side.
Positive pressure Ventilation must be maintained and recorded daily

The delivery of sterile healthcare products for use in patient care depends not only on the
Substandard # 9.2 efficacy of the sterilization itself but also on the factors like efficient facility design in terms of
Work flow is in functional, controlled, one-way traffic flow with defined work zones.
unidirectional way from dirty
to clean areas with traffic Flow of work MUST be in one direction from dirty to clean areas in order to avoid risk
control signs. of cross contamination.
There MUST be clearly visible traffic control signs posted in appropriate places.

1206 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 10 Inspection , Assembling and Packing (IAP) Area
Aim of ensure that pack preparation promotes adequate sterilant penetration so that sterilant reaches all surfaces holding microorganisms
Ensure that instruments are free of debris and in good working order Disassemble or position instruments for maximum penetration of sterilant
Ensure that any packaged accessories are appropriate for use inside instrument trays Prepare instrument sets to obtain sterilant contact.

Sub standards Explanation

Substandard # 10.1 IC team must conduct training & education session with CSSD team to ensure strict
adherence to all IC protocols.
After unloading, the items Monitor the practices during routine rounds & provide necessary feedback.
are checked for Cleanliness: Evaluate the unit performance & provide formal feedback.
(inspection of items by
magnifying lenses to be Following key items must be incorporated in training:
rejected returned back to
decontamination area if After the cleaning process all items must be checked to ensure cleaning process was efficiently
soiled• Function and lack for removed all visible soiling blood, stains, any other debris etc
defects (to be maintained or
replaced if not functioning Inspection:
well) completeness (count
the items in each tray When cleaning and disinfecting have been completed and devices are safe for handling,
following the instruments reprocessed items need to be inspected.
checklist). Rusted
instruments should be Lighted magnifying glasses should be available at work stations to assist with detailed
replaced out of the set. inspections. Magnifying glass must be used to verify the level of cleanliness of all items
processed in the decontamination area.
Items must be returned to decontamination area for reprocessing if there is any visible
soiling still present on the items.
Integrity, correct functioning, defects, and the need to replace instruments should be
Substandard # 10.2
applied at this point. The sharpness of cutting surfaces should be checked.
Such items with defects or loss of function e,g scissors, forceps etc must be replaced or
repaired.
Defects, missing, and
Ensure completeness of all items in the specified trays. Items must be counted and
damage of the instruments
checked according to the instruments checklist.
is recorded in separate log
Instruments that have been rusted must be removed out of sets and should never be used.
book for tracking the
Lubrication is performed after cleaning as final steps in mechanical washer, or it can be
instrument inventory.
applied manually in the clean area using a spray bottle.
Lubrication is performed
after cleaning as final steps
in mechanical washer, or it
can be applied manually in
Items logbook:
the clean area using a spray
bottle. IC team must ensure availability of logbook for all documents if any defected, missed or
damaged items were found. This is important to track the items / instruments inventory.

1207 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Environmental Control Parameters:

Inspection , Assembling and Packing (IAP) Area must be under positive pressure
Substandard # 10.3
ventilation & all environmental control parameters must be documented in the
environmental control logbook.
Environmental control log
Assigned ICP must ensure during routine rounds that all environmental control
book includes details of
parameters are within specified range and appropriately documented in environmental
humidity, pressure,
control logbook.
temperature, and air-
Environmental control parameters that must be continuously monitored via fixed monitors
exchange records i.e
include following:
humidity range = 30%-60%,
I. Humidity range = 30%-60%,
temperature range = 20-23
II. Temperature range = 20-23 c⁰
c⁰, positive pressure and
III. Positive pressure
air-exchange = 10
IV. Air-exchange = 10 times/hour
times/hour.
All records must be kept inside unit for the purpose of verification and to be presented
during external audit rounds.
There must be at least quarterly report checked by the utility & maintenance department.

IC team must coordinate with CSSD supervisor for effective documentation of all processes
Substandard # 10.4 for the purpose of verification & evidence /proof that all items underwent all steps following
best practices.
Wrapped or Pouched items
are labelled with sterilization Labelling of wrapped /pouched items:
date, Name of department/ ❖ Appropriate labelling of wrapped and pouched items must be ensured.
unit, set name, technician ❖ Label the pouch on the plastic side, label wrapped items on tape.
initial with consideration of
either the expiry date or Following must be documented:
negative impact on
packaging (rupture, dust or Date of Sterilization
wet pack) Department / Unit Name
Name of sets
Initials of CSSD technicians

Sterilizer load logbook:

For each sterilization load, the following information is documented in case of recall
Substandard # 10.5 incident.

Sterilizer loading logbook Date and time

include information to refer Load contents
to in case of recall incident: lot control number
date a, type of sterilizer , Sterilizer used, cycle type,
cycle number, load contents Critical parameters for the chosen sterilization method
, lot control number, ,and Operator's name
operator's name. and results of BI, if indicated.

CSSD team must strictly adhere to written policy and procedure to address who, when, and
how to recall reprocessed items. Evidence of sterilization failures (e.g., positive biological
indicators) is the most common reason for a recall.

1208 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Quality Control / Quality Assurance Testing:

❖ IC team must ensure during routine rounds all quality control parameters are being
implemented.
❖ Evaluate unit performance on adherence to quality parameters and provide formal feedback.

CSSD team must perform quality assurance testing of reprocessed items on an ongoing basis.
Following must be adhered to:

Substandard # 10.6 Sterilization parameters that effect the efficacy of sterilization process includes temperature,
exposure times, pressure, vacuum levels, moisture conditions or relative humidity, chemical
Bowie-Dick test must be concentrations and adequate air removal. Each load parameters must be recorded and
applied daily in first empty documented.
load, placed over the drain.
Bowie-Dick test:

❖ Bowie dick test must be performed each day before the first processed load in each
dynamic air removal steam sterilizer.
❖ Test is done to detect any air leaks, inadequate air removal, inadequate steam penetration
Substandard # 10.7 etc
❖ Sterilizer should not be used if Bowie Dick test did not pass. This indicate the machine
Chemical Indicator (CI) are malfunction. It must be removed from service and repaired.
available, class 6 are placed
in each set or pack and Chemical Indicator (CI) , Pack & Load control monitoring:
placed in each layer of
multi-layered sets. - A chemical indicator is a device used for monitoring of one or more predefined process
parameters required for effective sterilization process.
- The device is designed to respond with chemical or physical change to one or more of the
physical parameters within the sterilizing chamber.
- Chemical indicators are intended to detect potential sterilization failures that could result
from incorrect configurations of packaging, incorrect cycle of the sterilizer, or
malfunctions of the sterilizer.
- Class 6 chemical indicators are placed in each set or pack and placed in each layer of
multi-layered sets to ensure the adequate sterilization process.
- External tape place on the top and around the wrapped items and avoid excessive tape
that may prevent steam penetrations.
- If the indicator is only inside the pack, it should be visible in the peel pouches to the user
examining the package.
- Chemical indicators are used to verify the penetration of the sterilization process inside
the pack or set

1209 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10.8 Biological Indicator (BI) for Load control monitoring:

BI process done daily or at - BI is a vial used to monitor sterilization process. The device contains a viable population
least weekly and BI result of highly resistant bacterial spores that are resistant to the type or method of sterilization
recorded with each implant being monitored.
devices, and after any - BI process done daily or at least weekly and BI result recorded with each implant devices,
mechanical maintenance. and after any mechanical maintenance.
- Each load of implants must be monitored with BI and load must be quarantined unless
results of biological indictor is available.
Substandard # 10.9 - Monitoring of each load and quarantining loads unless results are available is a method to
reduce risk and cost of healthcare associated infections.
Biological Indicator (BI) record are available for one year, details include:
Biological Indicator (BI)
-

record are available for one

year, details include ❖ Operator's name
operator's name, date, ❖ Date,
sterilizer number, cycle ❖ Sterilizer number,
❖ Cycle number,
number, BI result.
❖ BI result.

Sterilization Monitoring Records:

Substandard # 10.10
Sterilization monitoring record for every load must be documented and a copy of load print out
Sterilization physical must be kept.
parameters (print out from
sterilizer / manual Records of sterilization monitoring includes:
documentation of
sterilization parameters by Sterilization physical parameters (print out from sterilizer or manual documentation of
the operator) sterilization parameters by the operator.

IC Team must ensure implementation of infection control policies and procedures during
routine IPCCC rounds.
Substandard # 10.11
Recall refers to action taken when BIs, CIs or physical indictors shows failure.
There is a documentation Policy and procedure MUST address who, when, and how to recall reprocessed items.
logbook or incident Report Evidence of sterilization failures (e.g., positive biological indicators) is the most common
implemented policies & reason for a recall.
procedures for recall of The recall process is often for instruments unless the items are used on the patients in
unsterilized items in case of which case there is patient recall.
positive BI or fail CI results. The recall process is often collaborative and may include the infection preventions, risk
manager, surgical services manager, and the surgeon or the attending physician for the
involved patients.

Loading the Sterilizer:

Substandard # 10.12
For sterilizer loading it is important to follow steriliser, instrument and packages
The Instruments pouches, manufacturer instructions for use (IFUs)
rigid containers, and For sterilizer loading it is important to apply sterilizer configuration with lighter packs on
wrapped pack are arranged the top of the rack and heavier on bottom to ensure steam penetration, air removal. &
properly in the steriliser condensate drainage etc.
rack.

1210 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Inventory Tracking System:
Substandard # 10.13 An essential component of the reprocessing items is the inventory of medical devices. This
involves a manual stock count or a computer-assisted system. This is important to track items
There is a tracking system in sets, track items in stock supply, track items out for repair.
(manual or computerized) in
place and is used properly. IC team must ensure the unit has a system for tracking all items. (Manual or electronic)

- IC team must train & observe the staff practices during routine IC rounds.
- Assess the staff and unit performance during IPCCC audit phase.
- Provide formal feedback & consider for retraining based on performance.

Standard – 11 STERILE STORAGE

Appropriate storage of items prevents microbial contamination of sterilized items. It must be ensured that sterilized items are
not exposed to extreme temperature differences that result in condensation and contamination. In order to ensure that all
storage or transport units do not damage the packaging. Store the sterile supplies in a way that sterility will not be
compromised. Maintain a clean and dry storage area with low traffic volume.

Sub standards Explanation

Environmental Control Parameters:

Sterile storage area must be under positive pressure ventilation & all environmental
control parameters must be documented in the environmental control logbook.
Substandard # 11.1
Assigned ICP must ensure during routine rounds that all environmental control
The sterile storage area is parameters are within specified range and appropriately documented in environmental
maintained at positive control logbook.
pressure with 4 air changes Environmental control parameters that must be continuously monitored via fixed monitors
per hour at least, include following:
temperature ranges from 22
to 24 and relative humidity - Humidity range = Should not exceed 70%,
with limit of 70% (checked - Temperature range = 20-23 c⁰
with the utility & - Positive pressure Ventilation
maintenance department). - Air-exchange = at least 4 times/hour

All records must be kept inside unit for the purpose of verification and to be presented
during external audit rounds.
There must be at least quarterly report checked by the utility & maintenance department.

1211 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11.2 Unloading of sterilizer:

To avoid wet packs after Cool down the load at room temperature to avoid wet packs.
unloading of sterilizers, The load should remain on the carts /racks until items are adequately cooled to prevent
items are placed in a low contamination by minimizing handling.
traffic area, away from
Check the printout to ensure that all physical parameters are met.
vents, doors, windows,
drafts, and not touched until Check the integrity of packaging (rupture, puncture, tears etc)
the load cool down at room
temperature.

Sterile Storage Specifications:

Substandard # 11.3
IC team must ensure all specifications are followed for sterile storage areas in CSSD.
Storage Shelves are 20cm
from floor, 40cm from Following key parameters must be fulfilled:
ceiling and 5cm away from
wall. Arrangement of storage shelves must be 20cm from floor, 40cm from ceiling and 5cm
away from wall.
Storage shelves must be movable, clearly labelled and easily washable.
Substandard # 11.4 They must be away from sprinklers and air vents; and temperature and humidity must be
monitored.
Shelves and bins are free of
Inspect all sterile items for package integrity and/or expiration dates or negative impact on
dust, away from sprinklers
and air vents. packaging.
Avoid overstock packaging on shelves.
Minimize the handling of sterile items to reduce and prevent the risk of packages from
Substandard # 11.5 being crushed, bent, compressed or punctured.

Items distributing / Items distributing / dispatching:

dispatching is done with
respect to First in First out Follow First in, first out principle for distributing/ dispatching items.
principle (FIFO) Items stocked first must be dispatched first.

Labelling:
Substandard # 11.6
Storage shelves must be clearly labelled with name and type of sets being placed, Name
The sterile store shelves are
clearly labelled. of Unit /department etc
This will ensure easy identification of items for distribution.

1212 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Dispatching items log book:

Recordkeeping is an essential and important component to have the documented evidence of

Substandard # 11.7
all processes and steps are followed based on the standards from receiving till final dispatch.
Dispatching items log book
Logbook must be available to record the following:
records: Date, time, devices
name, quantity,
Date & Time of Item distribution / dispatch.
departments, Dispatcher ID,
Name/s of devices – sets
and recover ID.
Department Name
ID of dispatcher
ID of receiving personnel

During IPCCC training activities orient staff regarding the associated risks with presence of
original cardboard shipping boxes.

Substandard # 11.8 - Visit the sterile storage area during routine rounds to check if any shipment boxes
are placed (i.e., boxes made of thick cardboard for shipping.
No Items are kept in their
original cardboard shipping
boxes. - Internal shipping boxes (made of thin smooth glazed cardboard used to dispense
sterile and clean supplies can be kept inside medical stores (e.g., small boxes of
medical supplies: clean gloves, surgical masks, syringes …etc.) but should be
discarded immediately when the box has been emptied.

1213 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Infection Control Precautions in Special Situations (e.g. COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.

Substandard # 12.1 Following must be ensured:

- All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
Daily logbook is
book.
activated in the unit
- This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
for HCWs to record
symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
presence or absence
- Head nurse holds the key responsibility to ensure that log book is complete and signed by all
of fever, respiratory &
HCWs on daily basis.
GI symptoms etc.
- Head nurse must review to assess the need for any staff to be evaluated by occupational health
before starting work
clinic or need work restriction.
shift.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

1214 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 12.2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

1215 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 12.3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1216 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 12.4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
related to work clinical staff) to avoid the unnecessary mobility in between the units.
(Instrument collection Moving in between departments and eating together in pantries is strictly prohibited.
/transportation etc) HCWs must limit the movement unless absolutely necessary like Instrument collection
/transportation etc

1217 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1218 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1219 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE
WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

1220 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
PHARMACY SERVICES

Pharmacy is one of the allied healthcare professions responsible for

the preparation and storage of compounded sterile and nonsterile preparations.

Pharmacy compounding is the process of combining drug ingredients to prepare
medications that are not commercially available or to alter commercially available
medications to meet specific patient needs, such as dye-free or liquid formulations.
Failure to follow proper aseptic techniques may lead to intrinsic (i.e., contamination
during the manufacturing process or transport to the healthcare facility) or extrinsic
(i.e., contamination during preparation, storage, or administration within the healthcare
facility) contamination, which may lead to colonization or infection in the patient.

1221 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN pharmacy
PHARMACY SERVCIES

POLICIES & PROCEDURES

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

COMPOUND STERILE PREPARATION (CSP)

HOSUEKEEPING & UNIT ENVIRONMENT

STORAGE OF PATIENT CARE SUPPLEIS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1222 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PHARMACY SERVICES
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
Substandard # 1:2 access and refer to specific infection control policy & procedures.
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies &
procedures and is Interview the staff involved in patient care if they are well oriented about the policy content and
accessible for them. how to access the specific policy. e.g. (Ask about policy for PPE use during sterile compounding
etc. verbally and then give task to demonstrate how to access this policy via electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

1223 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT, DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

1224 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2:2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

1225 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Standard – 3 Hand Hygiene

Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
implementation of hand hygiene program.
Substandard # 3:1
Hand Washing Facilities:
Hand washing
facilities and Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
supplies (sinks with available that meet the needs of the unit and are clean and in good repair.
hot & cold water / Check the availability of hand washing facilities e.g CSP room
plain and Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
antimicrobial soap / tap if hands free operation or open the tap to check for hot & cold water supply)
paper towels, Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
Alcohol - based soap 3: Paper Towels for drying
hand rub
dispensers) are Hand Rub Dispensers:
available in
adequate numbers - Check the availability of hand rub dispensers as per requirements:
One dispenser per work area
One at any service area

- Observe dispensers are conveniently mounted and accessible at the point of care.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

1226 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:2 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Health care Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
professionals (HCP) without the need for an exogenous source of water and requiring no rinsing or drying with towels or
demonstrate other devices.
appropriate
technique for hand Indications:
rubbing and hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
washing. fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc

Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or
when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
1227 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing of left thumb clasped in right palm and vice verca
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
Substandard # 3:3 hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Visual alerts are
available: ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
how to do hand rub, posted at appropriate places.
how to do hand
wash. - How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispen

1228 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1229 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
Substandard # 4:1 staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.
Sufficient and appropriate PPE
are available in adequate During routine monitoring rounds, observe the availability of PPE in the pharmacy.
amount, types & sizes with PPE must be available at the point of use which will interfere with effective use of PPE
proper qualities and readily as per requirement, such as outside compound sterile preparation room (CSP),
accessible to HCP. Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

1230 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.
Substandard # 4:2

Staff use personal protective 1: Appropriate PPE use for Pahrmacy Staff:
equipment appropriately (e.g.
donning and doffing) Sequence of donning PPEs before entering the CSP room:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
https://youtu.be/H4jQUBAlBrI Don surgical facemask. Place surgical mask over nose, mouth and chin then fit flexible
Watch Video How to safely put nosepiece over nose bridge and secure head with ties or elastic.
on PPE Don goggles/face shield.
Don gloves. Extend gloves over yellow gown cuffs.

Sequence of doffing PPEs before leaving the CSP room:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove goggles/face shield
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

1231 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1232 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 5 Compound Sterile Preparation (CSP)
Pharmacy is responsible for preparing & storing most sterile medications. A CSP is a sterile drug that is prepared by compounding or underwent
other handling or manipulation prior to administration. Compounding is the process of combining drug ingredients to prepare medications that
are not commercially available or to alter commercially available medications to meet specific patient needs such as dye-free or liquid
formulations. Patient morbidity and mortality can result from contaminated pharmaceutical items. Infection control breaches that may lead to
contamination includes: (CDC) - Failure to follow aseptic practices (Lack of proper hand hygiene) In - Lack of trained / qualified personnel
performing sterile compounding - Sterile compounding occurring in absence of proper controls - Sterile compounding hood adjacent to open
window - Compounding hood disinfected with alcohol of insufficient strength - Improper storage of sterile medication vials etc . Understanding
the risks inherent in sterile compounding and incorporating established standards are essential for patient safety. Pharmacy staff must receive
comprehensive training on the principles of asepsis during compound sterile preparations.
Sub standards Explanation

Infection control team must provide continuous education and training to the
Substandard # 5:1 pharmaceutical staff about the rules of aseptic technique, appropriate use of PPE etc.
ICPs must ensure that CSP is restricted to the competent and well trained staff who are
Compound Sterile knowledgeable and well familiarized with infection control protocols during compounding
Preparation (CSP) is with exception of emergency situations.
restricted to competent Provide training and observe practices during routine IC rounds:
pharmaceutical staff (except
during emergency ❖ Observe staff working in Compound sterile preparation (CSP), how the personnel are
situations), who are familiar entering in the CSP i.e. presence of biometric /coded entrance for the personnel
with aseptic techniques and working in CSP.
proper use of appropriate ❖ Clear Signage ‘’Restricted Access’’ must be posted on the door.
PPE. ❖ Observe if staff are compliant with appropriate PPE use. Notice if PPE is donned
appropriately. Observe for any breach in practice (e.g. staff moving in out with same set
of PPE & frequently touching the surfaces with gloved hands etc.)
❖ Observe if authorized personnel working in CSP are familiarized with rules of aseptic
technique and adhering strictly to it. (e.g. Hand hygiene, Use a sterile device (e.g., a
needle) each time a vial is accessed and avoid touch contamination of sterile supplies,
Disinfect the rubber stoppers of containers and the diaphragms of vials with 70%
alcohol wipe prior to use. etc.)
❖ Failure to follow sterile compounding standards and proper aseptic technique could lead
to intrinsic and extrinsic contamination

Authorized Personnel for CSP:

Pharmacist and pharmacy technicians are the professionals responsible for the
preparation and storage of compound sterile and non-sterile products.
This must be clearly stated in the policy and there must be documented evidence of
Compounding personnel privileges and authorization to work in CSP;
There must be a clear emergency / contingency plan regarding the alternate staff who
will be assigned to work in CSP during such unforeseen situations.

1233 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - During the IPCCC training phase, CSP personnel must receive comprehensive training
Substandard # 5:2
on aseptic technique , PPE use and other IC measures etc
- Monitor the staff practices and evaluate performance during IPCCC audit phase.
Compound Sterile
Preparation (CSP) is
Education & training sessions must incorporate following key points.
restricted to competent
pharmaceutical staff (except
Aseptic technique during CSPs:
during emergency
situations), who are familiar
Practice aseptic technique to prevent contamination of pharmaceuticals
with aseptic techniques and
Remove any hand / wrist jewellery and perform hand scrubbing before each procedure.
proper use of appropriate
Scrub nails, hands, and forearms with antimicrobial soap before handling sterile
PPE.
products.
Wear a gown, a facemask, shoe covers, hair covers etc upon entering the preparation
area.
Wear sterile gloves before preparing intravenous (IV) admixtures.
Gloves should be removed when exiting the preparation area.
Gloved personnel should not touch any surface outside of the hood. Etc.

The location of Compound sterile preparation (CSP) room/area should be with complete
physically separation from other areas of pharmacy.
Substandard 5.3 CSP must be under positive pressure. Ensure availability of pressure gauge / fixed
monitor for continuous monitoring of positive pressure differentials.
Compound Sterile Monitor must have inbuilt audiovisual alarm system to alert staff in case of deranged
Preparation (CSP) room/area pressure gradients.
is a functionally separated CSP personnel must keep records of positive pressure differentials (at least one month)
facility which is under of +2.5 pascals (Log sheets must be kept in the unit to be presented to external MOH or
positive pressure. CBAHI auditors.
Observe if there are any deranged values in the past and evidence / document for
necessary action taken by CSP personnel to address the issue (If any)

Substandard 5.4 Doors of The doors of the Compound Sterile Preparation (CSP) room/area must be
equipped with an auto-closure mechanism.
The doors of the Compound Self-closing doors / doors with auto closure mechanism will ensure pressure control
Sterile Preparation (CSP) inside the CSP room and suitable protective environment necessary for sterile
room/area are equipped with compounding.
an auto-closure mechanism. Seek administrative support if not equipped with auto closure mechanism.

1234 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Laminar Flow Cabinets create particle-free working environments by projecting air through
a filtration system and exhausting it across a work surface in a laminar or uni-directional
air stream. They provide an excellent clean air environment.
Laminar airflow is defined as air moving at the same speed and in the same direction, with
Substandard 5.5
no or minimal cross-over of air streams (or “lamina”).
Mixing IV medications must
Engineering Controls in CSP:
be in the middle of laminar
flow hood or safety cabinet
IC team must ensure following records related to safety hood are available in the unit.
with air supplied through
High-Efficacy Particulate Air
Manufacturer’s manual of laminar air flow hood or safety cabinet must be available in the
(HEPA) filter.
unit. (Laminar air flow hood or safety cabinet is designed to generate laminar air flow
and supplied air is through HEPA Filter installed in the opening channel of hood /
biosafety cabinet )

Document stating date when HEPA Filter was being changed. (PPM for the safety
cabinet/hood, quality monitoring and inspection of safety cabinet/hood).

CSP must be trained that all mixing of IV medication must be done inside the laminar
flow safety cabinet / hood.

IC team must provide training to the CSP on appropriate technique of disinfection

process and type of disinfectants to be used.
Choice of disinfectant must be compatible with the surface of safety hood.
Frequency of cleaning must be followed as per cleaning schedule and all activities
Substandard 5.6 must be documented in daily cleaning logs.

Working Surface of work Observe the staff practices during daily rounds:
(under the laminar air flow
hood) is regularly disinfected ❖ Observe how the compounding personnel are disinfecting the working surface under the
by an approved disinfectant laminar air flow hood.
using non linting wipes. ❖ Observe technique & type of disinfectant being used (if possible to observe real situation
or ask to demonstrate
❖ Ensure availability of disinfectants & non lining wipes in the unit.

A lint free cloth is a special type of cleaning cloth that does not give up any fluff / fibers
when used and less likely to generate electrostatic charges.

Substandard 5.7 IC Team must ensure availability of cleaning and disinfection schedule of the compound
sterile preparation (CSP) room / area.
Compound sterile preparation Roles and responsibilities of CSP personnel & housekeeping during cleaning process
(CSP) room/area is cleaned must be specified.
and disinfected with an (Authorized and trained housekeeping must be dedicated for housekeeping surfaces
approved ONLY i.e. Floors, walls, ceilings, HW sinks, emptying trash receptacles etc.)
detergent/disinfectant and Check for MSDS of disinfectant used in CSP.
assigned staffs are well Type of detergent/disinfectant are being used (Check for active ingredients and expire
trained on cleaning / dates) & verify if approved by MOH.
disinfection process. How the process of cleaning and disinfection is being carried out inside the CSP room.
(Technique i.e. from inside to outside, from top to down etc.).
If floor and other areas are kept clean and tidy. (Randomly wipe any surface to confirm.)
Place where cleaning equipment and detergent / disinfectants are being kept.
Ask if they have dedicated mops for CSP and how mop heads are processed after use.

1235 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team must ensure that all supplies and containers being used in CSP are sterile.
Observe if supply is stored at appropriate storage areas. (Sometimes huge amount of
sterile supply is kept in the anteroom with increased risk of contamination) (Example of
Substandard 5.8 sterile supply : Sterile gloves , gowns, syringes, single use containers like ampules,
single dose vials, IV bags, irrigation bottles etc. and multidose vials MDV.
All supplies and containers
used in CSPs preparations - Pharmaceutical container is a device in which drug is enclosed & is in direct contact
must be sterile. with drug. (e.g. single dose containers, multidose containers. light resistant
containers, aerosol containers etc.
- Ensuring sterility of all supply during compounding is of utmost important in order to
avoid contamination & subsequent infection risk to patients.

Substandard 5.9 Ensure availability of sharp containers of appropriate size for discarding various types of
sharps. Vials needles, syringes etc
Sharp and medical waste
containers are available and Appropriate medical waste receptacles are available & used.
used in Compound sterile
preparation room.

Substandard 5.10 IC Team must incorporate training and education on safe handing of sharps during the
IPCCC training phase.
Used needles are not In order to avoid the risk of acquiring needlestick and sharp injury, used needles must
manipulated or recapped and never be recapped or manipulated.
are promptly disposed into All sharps must be disposed off in the specified sharp container
sharps containers.

Quality control records & Periodic Preventive Maintenance (PPM) records of hoods and
safety cabinets MUST be available in the unit.

(Ensure certification of the Laminar Airflow hood (LAFH) annually, or more frequently as
Substandard 5.11 needed, and maintain certification records.)

Maintenance records for During routine IC rounds ensure the following:

hoods and safety cabinets
are available. Check for validity of LAFH certificate / PPM. - Maintenance records should include
functionality, HEPA filter change etc.)
All maintenance records must be kept in the CSP, documentation only with maintenance
department isn’t enough.

1236 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 6:1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
Substandard # 6:2 spills.

There is at least one spill kit The spill kit must include the following:
available in the department. - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
- Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.
Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

1237 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
clean-up as per policy.
During audit phase of IPCCC, ask the same Nursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Substandard # 6:3 Provide feedback on performance and correct the mistakes. (If any)

HCW knows how to use spill STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
kit properly. infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other potentially
infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp objects
from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the manufacturer’s
recommended contact time. Allow the spill to solidify before removing.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e. paper
towel) on top of the spill and apply the appropriate disinfectant. To avoid creating aerosols, never
spray disinfectant directly onto the spilled material. Instead, gently pour disinfectant on top of paper
towels covering the spill or gently flood the affected area, first around the perimeter of the spill,
then working slowly toward the spilled material. If sodium hypochlorite solution (5.25% household
chlorine bleach) is used, prepare a fresh solution on a daily basis. Leave for the recommended
contact time.

Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning

Substandard # 6:4 logs /checklists is extremely important to ensure effective implementation & to have the
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
Cleaning is done properly is done & documented appropriately as per schedule.
using checklist that include
cleaning frequency, Each unit must have the schedule for cleaning and disinfection activities.
responsible worker, Schedule must include the frequency, the used disinfectant and the responsible staff.
housekeeping surfaces (e.g., Roles must be specified with clear instructions.
floors and walls), used
agents, methods & 1. Pharmacy staff for medical equipment
environmental surfaces 2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
intended to be cleaned.

1238 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 High-touch surfaces are recognized as a possible reservoir of infectious agents and their
contamination can pose a risk also for the spread of multi-resistant organisms, hence they are
recommended to be cleaned and disinfected on a more frequent schedule than minimal touch
surfaces.
The identification of high-touch surfaces and items in each patient care area is a necessary
prerequisite to the development of cleaning procedures.
Common high-touch surfaces related to housekeeping activities includes doorknobs, light
Substandard # 6:5 switches & tap water handles etc
High touch surfaces should Explain staff about the importance of cleaning the high touch surfaces.
be disinfected more Monitor the activities during routine rounds and provide needed feedback.
frequently (e.g., light During IPCCC audit visit, assess and interview same staff who had received training
switches, door knobs, tap previously.
water handles)

Floors must always be cleaned last after other environmental surfaces at least daily

Provide training to the selected staff during IPCCC training phase in each quarter with
Substandard # 6:6 help of cleaning supervisor to explain the right process and technique of cleaning and
disinfection of floors using double/ or triple bucket technique or scrubbing machines.
Floors are cleaned or
disinfected using double/ or Double bucket Technique:
triple bucket technique or This consist of 02 different buckets One with disinfection solution & other with water.
scrubbing machines. Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

1239 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 6:7
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

Train the staff on importance of changing the cleaning solutions and mop heads in order to
Substandard # 6:8 avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
The mop and solution must
be changed frequently & Best practices for environmental cleaning of general patient area floors:
after being used to clean any
potentially infectious Mop heads and cleaning and disinfectant solutions must be changed as often as needed
materials. IC Team msut train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be sent to the laundry on a daily basis.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

1240 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must conduct training of housekeeping staff in coordination with environmental
services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Substandard # 6:9
Housekeeping staff must adhere to Standard Precautions and if required Expanded
Housekeepers are well Precautions when performing routine practices of cleaning and following infection control
trained on hand hygiene, measures. Routine practices related to environmental cleaning include:
proper use of PPE, methods
of cleaning & proper & safe HAND HYGIENE:
mixing of chemicals.
Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.
It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.
1241 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Emphasize during training and monitoring phase on appropriate cleaning practices.
Substandard # 6:10 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Top of cabinets, back of monitors etc
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Substandard # 6:11 Designated / labelled room for clean and dirty utility equipment/materials.
Rooms must be dedicated only for its usage.
Separate clean and dirty During routine rounds randomly visit the clean and dirty utility rooms & observe the
utility room should be
practices.
available.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 6:12 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 6:13 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

1242 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 07 Storage of Patient Care Supplies

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the integrity
of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best practices for
safety of patients.

Sub standards Explanation

Train & orient the nursing staff regarding appropriate storage of Patient Care Supplies & all
specifications and protocols to be followed for the medical departmental stores during
IPCCC training activities.
Observe during daily/ weekly rounds and audit unit performance during IPCCC audit phase.
Substandard # 7:1
Following key points need to be followed:
Medical departmental Medical storage areas. rooms must be clean without any contamination from dust etc
stores are clean, & dry There must be cleaning schedule with cleaning checklist including all items to be cleaned.
with adequate capacity Staff responsible for cleaning must be well aware about the frequency of cleaning, type of
and away from any form disinfectants used and required PPE.
of contamination and
direct sun light. - Storage area must have adequate space in order to ensure effective ventilation by avoiding
overcrowding of items.
- It must not be directly exposed to sunlight or source of potential contamination.

❖ Visit the medical storage rooms and randomly wipe over surfaces to ensure if cleaned
appropriately.
❖ Wipe the inside of plastic containers to rule out presence of dust, soil etc

Substandard # 7:2 Visit the medical storage rooms during daily/ weekly rounds and observe if environmental
control parameters such as temperature, humidity etc are being monitored in the area or
Medical store area has not.
controlled ventilation with Ideally a fixed monitor should be installed for continuous monitoring of humidity &
adjusted temperature and temperatures.
humidity (temperature
ranges from 22-24 Unit must have local records for regular monitoring (daily) of temperatures and relative
degree Celsius and humidity during the last month.
relative humidity up to
Local records for corrective interventions which are taken if readings are not matching the
70%).
acceptable values.
Storage area(s) is (are) centrally air conditioned with adjusted temperature and relative
humidity.
Each storage area is equipped with a fixed device for regular monitoring of temperature and
relative humidity:
- Recommended temperature Range is: 22 - 24°C
- Recommended relative Humidity is up to 70%.

Units must keep maintenance record in case of any deranged values / fluctuations in the past as
documented evidence to be presented if requested by external auditors.

1243 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7:3 Infection control team must provide training and reorientation about all specifications to be
followed for the maintenance of departmental medical stores.
Away from air vents and
well ventilated. Train on following specifications / key points and observe in daily / weekly rounds if unit is
adherent with recommendations or not.
Substandard # 7:4 Departmental medical stores must be well organized & well maintained.
Must be away from any contamination, direct sunlight and airs vents.
Storage shelves are 40
cm from the ceiling, 20 Specifications of Storage Shelves:
cm from the floor, and 5
cm from the outside wall. Storage shelves are made of easily cleanable material
(e.g., fenestrated stainless steel, Aluminium or hard plastic).
Substandard # 7:5
Storage shelves are placed following these specifications.
Storage shelves made - 40 cm from the ceiling
from easily cleanable - 20 cm from the floor
material (e.g., fenestrated - 5 cm from the wall
stainless steel, Aluminium
or hard plastic) If containers are used inside medical stores, they are made of easily cleanable material (e.g.,
hard plastic).
Substandard # 7:6
Ensure that only sterile and clean items are allowed in the medical stores.
Sterile and clean items
Personal items, foods and drinks are not allowed to be kept in the medical storage to protect
completely separated
from personal items & from cockroaches and other insects etc.
foods and drinks.

FIFO (First In First Out): is an inventory management and evaluation method in which items
Substandard # 7:7 stocked first are used first. Hence the first item in the shelf / container is the first item out of
the shelf / container). This is to ensure that expired items are not used.
Rotate supplies on a
first-in-first-out basis so Visit the medical storage room during daily/ weekly rounds and randomly pick up item from
as to avoid the use of container placed far from reach.
expired items. Check the date of expiry and assess if items are stocked following First in / First out rule.

During IPCCC training activities orient staff regarding the associated risks with presence of
Substandard # 7:8 original cardboard shipping boxes.
Visit the medical storage room during daily / weekly rounds to check if any shipment boxes are placed
Items not kept in original
inside sock room. (i.e., boxes made of thick cardboard for shipping.
cardboard shipping
Internal shipping boxes ( made of thin smooth glazed cardboard used to dispense sterile and clean
boxes.
supplies can be kept inside medical stores (e.g., small boxes of medical supplies: clean gloves,
surgical masks, syringes …etc.) but should be discarded immediately when the box has been
emptied.

During visit of medical storage room inside unit, inspect the items at random to rule out
presence of any expired, broken packs or stained item.
Key points:
Substandard # 7:9 Expired, broken or soiled items/packs are not allowed inside medical stores (i.e., it should be
discarded)
No expired items, broken If any stained item is found it would most likely reflect that item was restocked after being brought
packs or packs with from patient care areas which is against the rules of aseptic technique. Such practices must be strictly
prohibited.
stains are present.
Staff must be educated about the importance of following the established best practices in order to
ensure patient safety.
Monitor the practices in daily rounds and evaluate the unit & staff practices during audit phase.
Provide formal feedback on unit & staff performance

1244 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 08 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 8:1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

1245 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 8:2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

1246 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 8:3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1247 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 8:4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of staff is Following must be ensured:
strictly prohibited
unless necessary for Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
Infection Prevention & clinical staff) to avoid the unnecessary mobility in between the units.
control activities. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary for medical reasons e.g
transportation of patients, transportation of supply, mandatory inspection rounds, etc.

1248 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1249 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1250 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE
WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:

□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms

□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____ □ Diarrhea _____
times/day times/day times/day times/day times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others_________ □ Others_________ □ Others_________ □ Others_________ □ Others_________

1251 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
DIETARY SERVICES

Dietary services department has the key responsibility in preventing

foodborne diseases and food poisoning by applying strict infection control measures.
Standards of safety for sanitation of food, equipment, cleaning supplies, and personnel
must be applied to reduce risk infection risk of patients & employees.

1252 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN dietary
services

POLICIES & PROCEDURES

EDUCATION & TRAINING

DIETARY SERVCIES

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

UNIT DESIGN

OCCUPATIONAL HEALTH

FOOD HANDLING

CLEANING AND SANITIZATION OF UTENSILS

HOUSEKEEPING & UNIT ENVIRONMENT

STORAGE

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1253 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 DIETARY SERVICES
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1.1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
Substandard # 1.2 access and refer to specific infection control policy & procedures.
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies &
procedures and is Interview the staff involved in patient care if they are well oriented about the policy content and
accessible for them. how to access the specific policy. e.g. (Ask about policy for isolation precautions/ PPE use etc.
verbally and then give task to demonstrate how to access this policy via electronic system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

1254 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2.1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT, DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

1255 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2.2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

1256 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Standard – 3 Hand Hygiene

Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
implementation of hand hygiene program.

Hand Washing Facilities:

Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
available that meet the needs of the unit and are clean and in good repair.
Check the availability of hand washing facilities in different zones.
Substandard # 3.1 Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
tap if hands free operation or open the tap to check for hot & cold water supply)
Hand washing sink Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
with all hand soap 3: Paper Towels for drying
hygiene supplies
must be available in Hand Rub Dispensers:
suitable places and
in sufficient - Check the availability of hand rub dispensers as per requirements:
quantity. One dispenser per work area
One at any service area

- Observe dispensers are conveniently mounted and accessible at the point of care.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

1257 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Substandard # 3.2 Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
Food services without the need for an exogenous source of water and requiring no rinsing or drying with towels or
employees shall other devices.
wash their hands
thoroughly in the IC Team must ensure training on hand hygiene practices during IPCCC training phase:
following situations:
• Before starting - Each healthcare personnel must be well trained on how and when to perform hand hygiene with
work. appropriate technique and recommended duration.
• After using the
toilet. Food services employees shall wash their hands thoroughly in the following situations:
• After touching
their ears, nose, a) Before starting work.
mouth, or hair. b) After using the toilet.
• After handling c) After touching their ears, nose, mouth, or hair.
food. d) After handling food.
• After handling any e) After handling any food waste.
food waste. f) Before and after any cleaning procedures or after handling soiled articles or trash.
• Before and after g) After handling raw food.
any cleaning h) Before moving from a raw food preparation area to cook foods.
procedures or after i) After removing gloves.
handling soiled
articles or trash. - During routine monitoring rounds, observe the practice of staff, whether they are compliant with
• After handling raw hand hygiene or not. Assess if they are following the recommended duration, steps and technique
food. of hand rubbing & hand washing.
• Before moving - Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.
from a raw food
preparation area to 2: Hand rub technique:
cook foods.
• After removing Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
gloves. hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
Substandard # 3.3 versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.
Kitchen staff
demonstrate 3: Hand washing technique:
appropriate
techniques for hand Hand washing with plain or antimicrobial soap includes following steps:
washing and hand
rubbing. - Wet hands with water
- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
1258 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
Substandard # 3.4 hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Visual alerts are
available: ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
how to do hand rub, posted at appropriate places.
how to do hand - How to hand wash poster beside ach hand washing sink
wash. - How to handrub poster beside each hand hygiene dispen

1259 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
Substandard # 4.1 staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.
Sufficient and appropriate PPE
are available and readily During routine monitoring rounds, observe the availability of PPE in the pharmacy.
accessible to HCP. PPE must be available at the point of use which will interfere with effective use of PPE
as per requirement, such as outside compound sterile preparation room (CSP),
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Gloves
- Surgical masks
- Gowns / Aprons
- Head Cover etc

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

1260 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.
Substandard # 4.2
Follow proper and frequent hand hygiene and personal hygiene practices
Staff use personal protective
equipment appropriately. o Fingernails: Keep fingernails trimmed and filed; do not apply finger nail polish
Kitchen staff are or artificial fingernails. B
fully compliant with use of head o Jewellery: Do not wear jewellery on the arms and hands while preparing food
covers and gloves during food to allow for proper hand hygiene.
preparation and handling.
IC team must provide training to the kitchen staff about the importance of using head
covers and gloves during food preparation and handling.
Monitor staff practices in routine rounds.
Audit performance in the IPCCC audit phase.

Food handlers must adhere to the following:

Wear and maintain proper clean attire during food handling

Clean uniform, apron, hair and beard restraint, clean gloves when needed).
Do not wear street clothes in food service areas.

Do not eat, drink or smoke while preparing or handling food.

Do not go to the washroom with masks or gloves on.
Do not leave the work area with mask or gloves on.

1261 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 5 UNIT DESIGN

Design and workflow in the kitchen must be such in order to avoid food contamination staff with infection control and environmental
health guidelines and standards to prevent food borne diseases and food poisoning.

Sub standards Explanation

Infection control team must ensure all IC standards are met in the dietary services
department.
IC Team must inspect and review the unit design is fulfilling the requirement as per
standards.
Provide intensive training and education to the food services staff regarding
appropriate infection control measures to be followed in order to ensure food safety.
Substandard 5.1
Following specification must be met:
Kitchen is designed as
physically separated areas - Different areas in the kitchen must be physically separated from each other with no
with specified equipment & overlapping of items.
supplies (e.g., Mixers, - Each area must have specified equipment & supplies (e.g., Mixers, juicers, boards,
juicers, boards, plates, plates, knives … etc.) for different types of food.
knives … etc.) for different - There is orderly sequential handling of the product from the receiving area storage
types of food. area preparation area processing area packaging area
distribution area

Following are different areas in the kitchen:

- Dry storage area

- Storage for meat, poultry & fish (i.e., freezers)
- Storage for vegetables and fruits (i.e., refrigerators)
- Vegetable and salad cutting area & washing area for vegetables and fruits
- Meat cutting area: specified equipment & supplies e.g. cutting boards and knives should be
color coded and separate for poultry, meat and fish & vegetables. Sawing machines can be
same but proper cleaning is required before processing different type of meat.
- Food cooking/preparation areas & packaging area
- Food distribution area etc

IC team must ensure availability of adequate number of hand hygiene facilities in the
kitchen.

Hand washing sinks must be equipped with all required supplies and Alcohol Based Hand
Substandard 5.2 Rub (ABHR) dispensers.
Ensure hand washing sink are in good working condition with provision o f hot & cold
Adequate number of hand water & paper towels.
washing facilities are
Adequate refers to presence of hand hygiene facility within the working area (i.e.,
available.
personnel does not need to leave his working area to reach a hand hygiene facility of
another area OR presence of DEDICATED hand washing facility with proper supplies apart
from sinks used for any other working purposes (i.e., sinks used for washing vegetables
and fruits are not acceptable)

1262 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard 5.3
Infrastructure:
Surfaces, walls and floors
are made of material that is - Design of kitchen should be such that all surfaces, walls and floors are made of material
easily cleaned, and prevent that is easily cleaned, and prevent stagnation of water.
stagnation of water. - Stagnant water would increase the risk for accumulation of flies, mosquitos etc

Substandard 5.4 Openings:

All outer openings shall be - All outer openings shall be kept closed at all times to minimize entrance of flies, rodents.
kept closed at all times to
minimize entrance of flies,
rodents. Waste Storage Area:

- All garbage must be stored inside garbage containers either outdoors or above a smooth
Substandard 5.5 surface of non-absorbent material.
Garbage storage room shall - Garbage storage room shall not be located inside the food facility.
not be located inside the food
- Wash containers and sanitize them routinely in an area provided with a floor drain
facility.
connected to a sanitary sewer.

1263 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 6 Occupational Health
Food services managers assures that food handlers are monitored appropriately for illnesses. All food handlers must receive a
valid medical examination certificate indicating that they are free from infectious diseases and fit to work as a food handler, this
certificate must be issued by the Infection Prevention & Control Department and will be valid for one year, renewable yearly after
an assessment of the food handler.

Sub standards Explanation

Infection control team holds the responsibility to ensure that food handlers working in the food
Substandard 6.1 services department are free from any illness through periodic health checks. Valid health
cards of all kitchen staff must be kept in the unit & employee health clinic in staff files.
Stool tests and cultures are
performed routinely upon IC team must ensure that flowing medical tests and examinations are completed for staff
hiring, every 6 months and upon hiring, every 6 months and upon returning from long vacations.
after returning from long
vacation. Results are In addition to the hospital pre-employment screening requirements, food handlers complete a
reviewed by the employee’s screening process involving the following:
health clinic and the IC
team. Clinical examination (evaluation of the chest and abdomen, as well as, possible skin
diseases and other communicable diseases).
Chest X-ray to rule out pulmonary tuberculosis.
Stool analysis for ova and parasites
Stool culture for Salmonella, Shigella and Vibrio cholera

Key points:

- All results must be reviewed by employee health clinic & IC team to certify that staff
is free from infection and fit to join.
- Staff returning form long vacations will not be allowed to return to work unless stool
tests are done, results are available, reviewed and cleared by employee health clinic &
IC department.
- Ensure all results are signed by both IC & EHC team before keeping in staff health
files as an evidence to be presented to external audit / Inspection teams during the
visit.
- Staff health records must be kept both inside the unit & employee health clinic
(Manual or electronic)

IC team must ensure during routine rounds that work restriction policy is strictly
implemented in the kitchen.
Substandard 6.2
For safety of the patients & employees it is important that Kitchen staff with respiratory
Kitchen staff with respiratory
infections, gastroenteritis, diarrhea or hand infections or wounds must be restricted from
infections, gastroenteritis,
handling food.
diarrhea or hand infections or
IC team must ensure and observe following:
wounds are restricted from
handling food. - Daily monitoring of food handlers for respiratory & gastrointestinal and hand
infections through activation of logbook.
- Staff must log in / document signs & symptoms each day before starting work to rule
out presence or absence of these infections.

1264 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Staff with any evidence of infection must be restricted from work, evaluated by EHC &
given sick leave until cleared by EHC & IC.

Visual Alerts:
- IC teams to provide the visual alerts for the food handlers that must be posted in
various locations as staff reminders.
- Instructions must be clearly written in English, Arabic and their local language that
staff with abovementioned infections are prohibited from work / food handling.
- Must inform supervisor for further evaluation in EHC.

IC team MUST ensure and track the Vaccination / immunization schedule with employee
health clinic team.
Substandard 6.4
Following are mandatory vaccinations for
All of the kitchen staff receive
vaccines against hepatitis-A, Vaccination for Hepatitis A (Annual)
typhoid and meningococcal Vaccination for meningococcal disease, with a booster every 5 years.
meningitis. Vaccination for typhoid fever, with a booster every 5 years.
Receive a valid medical examination certificate indicating that they are free from
infectious diseases and fit to work as a food handler.

1265 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 FOOD HANDLING
Safe preparation, handling and storage of food is of utmost importance to minimize contamination of food by microorganisms and
chemicals. The department must also be familiar with the activities that may influence the infection risk of patients, employees,
and their customers. Extrinsic contamination may result from contamination introduced during food preparation. 3,6,7,18 It can
occur indirectly from one food source to another or from personnel. Foods that receive extensive handling or are mixed or
reconstituted during preparation have a higher risk of contamination if appropriate practices are not employed.
An improper storage or holding temperature is the most common practice associated with foodborne disease. 8 Organisms that
are naturally present in food or have been introduced during processing or handling can thrive and proliferate under improper
storage conditions, such as leaving foods at room temperature when they should be kept either cold or hot. Foodborne bacteria
can replicate and may produce food-related infections or intoxication. 1,6,10,12,25 Key factors leading to foodborne contamination
and disease include failure to use food within an appropriate amount of time after preparation; failure to maintain or store food at
appropriate temperatures; or unsanitary methods of displaying and serving food

Sub standards Explanation

Infection control team must educate and assuring competency of FOOD handlers in order
to avoid risk of contamination.
Observe the staff practices during routine rounds.
Evaluate performance during IPCCC audit phase and provide formal feedback. Training &
competency records must be well maintained in staff personal files and electronic training
& competency database must be regularly updated.
Substandard 7.1
Training & education regarding food handling must incorporate the following important
Separate boards are used to standards:
cut meat, poultry and
chicken from vegetables - Cutting boards are well known to be a potential source of contamination. Boards should be
and fruits and immediately non absorbent. The preferred materials for cutting boards include plastic blocks, hard
washed after use. rubber, and non absorbent wood

Cutting boards shall be

washed and sanitized - Boards and knives which are used to cut meat, poultry, fish or vegetables are identifiably
properly after each use. separated (color - coded) and immediately washed after use.
- There must be signboard for color-codes of boards and knives posted in all relevant areas
that displays colors to be used for different purposes (e.g., cutting meat, poultry, fish or
vegetables) to alert the food handing staff to select the right color according to category of
food item.

- Old cutting boards must be discarded if there are signs of over usage. (e.g., cutting boards
are not cracked or having deep cuts) which will interfere with effective cleaning process.

Thorough washing & disinfection of fruits & vegetables is extremely important to remove
visible contamination from the external peelings. Fruits and vegetable are washed and
Substandard 7.2 disinfected thoroughly.

Fruits and vegetable are ICP must observe the staff practices during routine rounds if they are following the right
washed and disinfected procedures for washing & disinfection of fruits & vegetables.
thoroughly. Ensure availability of disinfection tablets in the kitchen.
Food handlers must be taught about the right dilution & contact time of the disinfectant
i.e duration of time vegetables and fruits must be immersed in solution to ensure
effective disinfection.

1266 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Area for washing fruits & vegetables to be equipped with two dedicated deep
stainless steel sinks one for washing and the second for disinfection.

One deep container can also be used in absence of double sinks (i.e., used for
vegetables and fruits immersion for disinfection)

Observe the type of disinfectant being used and ensure that an appropriate
concentration, contact time is being followed

Check the presence of measuring device(s) for measurement the amount of liquids.

ICP must ensure that all items in the storage area are well organized & containers are
appropriately labelled with expiry date noted. Expiry dates of food stuffs are checked before
Substandard 7.3 use.

Food containers are Visit the dry storage area & observe the following:
properly labelled and expiry
dates noted. Expiry dates of All food containers are clearly identified with properly label & clearly written/ printed expiry
food stuffs are checked dates.
before use. Check all supplies of same kind are stocked together (for example stock of salt, tea, jam
etc.., that have the same lot numbers and expiry dates).
Storage logs / inventory (either electronic or manual system) can be checked to
demonstrate expiry dates of all products with recognition of near to expiry foods

Substandard 7.4 In order to facilitate the process of cleaning to ensure that cleaning is done as required,
appropriate equipment use must be ensured.
Usage of appropriate Food preparations need the right equipment and tools.
equipment that have no These items must be routinely inspected to assure that they are in proper working
hidden places, cracks, condition.
scratches and easy to clean. All equipment should be easy to disassemble and to clean, without cracks or crevices that
can provide reservoirs for microbial growth.

Equipment used for cooking, storage etc must be smooth without any cracks, scratches
or hidden points that can interfere with the cleaning process must not be used. All old
Substandard 7.5 equipment must be discarded to be replaced with new ones.
Usage of appropriate equipment that have no hidden places, cracks, scratches and easy to
Food is packed and clean.
protected from environment Food is packed and protected from environment during storage, preparation, display, and
during storage, preparation, transportation.
display, and transportation. Extreme care must be taken to ensure there is no contamination of food (Cooked
/uncooked) during all phases of food processing from reception till transportation.

Substandard 7.6 Food services manager & Infection Control team must ensure that the water used for cooking
is supplied by commercially approved companies or hospital water that is tested at least
monthly to ensure that its quality meets regulatory standards for potable water.
Water used for cooking is
supplied by commercially Review and ensure all results of water quality are maintained in files in the unit.
approved companies or
hospital water that is tested Water is subjected to microbiological and chemical testing each month to ensure meet the
at least monthly to ensure regulatory standards of potable water.
that its quality meets Records for maintenance & interventions (as per hospital policy) if the water testing
regulatory standards for results don’t match the acceptable standards for potable water.
potable water.

1267 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Ensure valid contract with commercially approved company for supplying water, if the
kitchen is using ready-made water for cooking (i.e., no need for testing water
microbiologically & chemically BUT the supply chain of the water must be checked)
IC team must ensure that those responsible for collection water sample are trained & their
role should be clearly communicated.
Records must be reviewed promptly and appropriate action must be taken if water quality
is not meeting the standards,

Key factors leading to foodborne contamination and disease include failure to use food within
an appropriate amount of time after preparation, failure to maintain or store food at appropriate
temperatures, or unsanitary methods of displaying and serving food.
Substandard 7.7
In order to serve freshly prepared food to the patient’s food should not be prepared way
Food should not be
in advance of the intended service time.
prepared way in advance of
No precooking and holding meats for final cooking.
the intended service time.
IC team to observe the practice of food handlers during IC rounds. Any breach of practice must
be communicated to the food services manager / administration for corrective intervention to
ensure the high quality & freshly prepared food is served to the patients,

Substandard 7.8 For transportation of food to the inpatient areas following key points need to be considered:

Temperature controlled Food is transported to different areas while protected in temperature-controlled carts.
vehicle to maintain Establish safe times for food items to be stored in inpatient care areas.
temperature of food during Protect food on display from contamination during transportation.
transportation. Maintain food on display at the proper temperature, whether hot or cold.
Interventions records for atypical temperatures and failure situations

1268 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Cleaning & Sanitization of Utensils
Cleaning and sanitizing are the basic components of good food safety techniques. If cleaning and sanitizing don’t happen correctly,
patients’ health could be at risk.
Comprehensive cleaning schedules must be established for all utensils & equipment / fixtures. There should be monitoring of
dishwasher washing and rinsing temperature to achieve proper sanitation and cleaning of food utensils. The most commonly used
sanitizers are chemicals and heat. It is important to select appropriate disinfectants, sanitizers, and detergents as an intervention
in preventing foodborne illness.
All work surfaces, utensils, and equipment should be cleansed thoroughly, rinsed, and sanitized after each period of use. Specific
cleaning procedures should include when, how, and with what each item or groups of equipment are cleaned. Hence continuous
education and assuring competency of workers are important parts of prevention strategies.
Sub standards Explanation

Substandard 8.1 For effective cleaning and sanitization of utensils following standards must be followed:

Utensils shall be All utensils should be disassembled before cleaning in order to ensure full penetration of
disassembled before steam and chemicals for effective cleaning & sanitization.
cleaning.
Dishwashers:

Substandard 8.2 The water temperature in dishwashing machines should be checked prior to use to ensure
that it is sufficient to clean and sanitize.
Cleaning utensils using a Cleaning utensils using a dishwasher should maintain the wash/rinse cycle temperature at
dishwasher should maintain 74ºC and the sanitization temperature at 82º
the wash/rinse cycle
temperature at 74ºC and the Manual Washing:
sanitization temperature at
82º Cleaning consists of removing food and soil from working surfaces, utensils, and
equipment.

Substandard 8.3 It must be noted that sanitizing agent (e.g., chlorine) cannot work unless the equipment is
cleaned first. Rinsing with clean, potable water to remove organic matter and then washing
Manual washing should be with detergent should precede sanitizing.
done in a four-compartment
sink. The sanitization phase Manual washing should be done in a four-compartment sink.
can be done by using hot
water (70ºC) or the use of Step One: Scrape
sanitizer (sodium Step Two: Wash
hypochlorite) with the Step Three: Rinse
appropriate concentration and Step Four: Sanitize
exposure time. Step Five: Air Dry

Scrape – Pre wash:

Substandard 8.4
This means removing significant food residue and food particles from dishware to prepare
Manual dishwasher shall be them for the cleaning or wash.
designed into scrape, wash, Food particles must be scraped or flush out large food particles before washing.
rinse and sanitize
compartments with splash Wash:
guard installed on both sides
of the four-compartment sink. Wash with warm water and detergent solution capable of removing grease.

1269 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 WASH in 2nd compartment with hot water at 110F - 120 F using a good washing
detergent, brush & physical scrubbing.
Washing detergent does not sanitize dishware and utensils.

Rinse:

Rinse dishware and utensils in 3rd compartment by immersion in clean hot water.
In the rinse step, the washing detergent is rinsed off.
Substandard 8.5 Change the rinse water frequently. DO NOT rinse dishware and utensils in dirty water.

Al cleaned and sanitized Sanitize:

equipment shall be allowed to
air dry or drained (bottoms- Sanitize dishware and utensils in the 4th compartment by hot water or chemicals.
up) on racks in a separate
area. • Sanitize with clean warm water.
Towel drying is prohibited. • Soak for at least 45 seconds in one of the following:
o 24°C (75°F) water with 100ppm chlorine.
o 24°C (75°F) water with 200ppm quaternary ammonium.
o 24°C (75°F) water with 25ppm iodine.
• Use test papers to check your sanitizer solution strength.
• Use a thermometer to check the temperature.

Air Dry & Drain:

Utensils must be air dried /drain on a drainboard on your sink.

DO NOT towel dry. Towel drying decontaminates dishware and utensils.

Substandard 8.6 IC team provides training to the food handling staff regarding importance of monitoring
temperatures of refrigerators, dishwashing machines, & hot holding cabinets etc
Refrigerators, dishwashing
machines, and hot holding There must be daily monitoring of refrigerators, dishwashing machines, and hot holding
cabinets will be monitored cabinets for correct temperature assurance.
daily for correct temperatures Temperature logs must be used to record temperature & records must be kept in the unit
and temperature logs shall be to be presented to any external audit visit teams.
kept. Appropriate corrective actions must be taken in case of any deranged reading and evidence
must be present in the files (Manual/ electronic)

Substandard 8.7 Appropriate cleaning & sanitization of refrigerators, hot holding cabinets, and ice chests
should be must be done when visibly dirty and weekly.
Refrigerators, hot holding
cabinets, and ice chests will Schedule must be present and cleaning activities must be documented
be cleaned and sanitized
when visibly dirty and weekly.

1270 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 9 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient
care environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure
to comply with environmental cleaning protocols would result in infection transmission within the healthcare settings.
Sub standards Explanation
Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard 9.1
Review the availability of disinfectants & insecticides in daily/weekly rounds. Ask the head
nurse to provide checklist to ensure availability and adequacy of different variety of
Adequate MOH approved
disinfectants.
disinfectants & insecticides
are available in the Ensure disinfectant / insecticides are MOH approved & appropriate for the area / surface
department. to be disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning

Substandard 9.2 logs /checklists is extremely important to ensure effective implementation & to have the
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
Cleaning is done properly is done & documented appropriately as per schedule.
using checklist that include
cleaning frequency, Each unit must have the schedule for cleaning and disinfection activities.
responsible worker, Schedule must include the frequency, the used disinfectant and the responsible staff.
housekeeping surfaces (e.g., Roles must be specified with clear instructions.
floors and walls), used
agents, methods & 1. Kitchen staff for cleaning utensils & machines etc
environmental surfaces 2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, etc)
intended to be cleaned.

1271 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must coordinate with food services manager to ensure availability of insect and
rodent control plan in the unit & its implemented strictly.

Following documents must be available:

Substandard 9.3
Insect and rodent control plan and the applied schedule (e.g., spraying chemicals and
There is an Insect and pesticides is done as per hospital’s policy: a frequent routine task + when a threshold is
rodent control plan that is reached
strictly implemented. Valid contract with a commercially approved company
Check which chemicals and pesticides are used (check safety of the chemicals and
pesticides used in kitchen / Instruct manager to keep MSDS for these chemicals and
pesticides)
Written protocol for spraying chemicals and pesticides with precautions to be taken
before, during and after it
Checklists for routine inspection and monitoring of incoming deliveries, storage & other
areas for roaches / rodents or their traces.

Following must be ensured for implementation of Plan:

Devices for insect and rodent control are available, e.g., sticky fly traps, ultrasonic pest
repeller …etc.
All windows that open to the outside have screens that are kept in good repair
All areas are kept clean, sanitized and in good repair
All openings and defects with risk of infestations are sealed (e.g., cracks, tears in windows’
screens … etc..)

Substandard 9.4 There should be regular cleaning & disinfection activities in the kitchen and dining areas

Tabletops in the dining halls Following cleaning frequency must be followed in the dining areas:
should be cleaned using a
MOH-approved disinfectant Tabletops in the dining halls should be cleaned using a MOH-approved disinfectant:
when soiled and after every
clearance of meal trays or - When soiled and after and after every clearance of meal trays or dishes.
dishes.
Floors must be cleaned with wet mops after each meal service.
This is no ensure all kitchen areas are meticulously clean at all time to prevent
Substandard 9.5 accumulation of floes, ants or other insects from leftover foods.
Floors should be wet-
mopped after each meal
service.

1272 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
contaminated unless changed.
Substandard 9.6
Best practices for environmental cleaning:
The mop and solution must
be changed frequently. Mop heads and cleaning and disinfectant solutions must be changed as often as needed
IC Team must train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads should be reprocessed appropriately.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard 9.7 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach (Table tops, food preparation area etc)
dust. Open refrigerators to check for cleanliness from inside. In stock room check for dust
inside containers & shelves.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
Substandard 9.8
protocols.
Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping equipment is
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
kept clean and dry after use.
buckets.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard 9.9 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in the units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcides were used.

1273 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Storage
Improper storage or environmental sanitation may introduce contamination or allow low microbial load to proliferate if not kept at
appropriate temperatures. Food storage must be done in a systematic manner to assure that all food safety requirements are
met. Food shall be protected from cross-contamination by separating raw animal foods during storage, preparation, holding, and
display from raw ready-to-eat food, including fruits and vegetables, as well as cooked ready-to-eat foods.

Sub standards Explanation

IC team & Food services manager must ensure that all storage specifications are met.
Provide education & training to the concerned kitchen staff about the requirement of
storage of all kinds of food items including the prepared food.

Following key points must be emphasized:

Substandard 10.1 Refrigerators and deep freezers temperatures are checked daily and documented.
Following is recommended temperature range:
Refrigerators and deep
freezers temperatures are a. Fruit and vegetables (except those in dry storage): 40ºF to 45ºF (4ºC to 7ºC).
checked daily and b. Dairy products, eggs, meats, poultry, fish, and shellfish: 32ºF to 40ºF (0 ºC to 4ºC).
documented. c. Frozen foods: -10 ºF to 0ºF (-23ºC to -10ºC).

IC team must ensure that all temperature logs of all storage areas are kept inside the unit ,
if a problem occurs, correct it and record the methods used to correct it; date, sign, and
file.
Planned Preventive Maintenance (PPM) and Quality check for freezers, refrigerators,
transport trolleys (if applicable) and temperature display monitors

Other storage requirements:

Substandard 10.2
No refreezing of food products after being defrosted
No refreezing of food
products after being Assigned Infection control practitioner for food services department must provide training &
defrosted. orientation regarding all aspects of infection control measure during different phases of food
processing from receiving till distribution.

Substandard 10.3 1. Provide instructions on the key points pertaining to appropriate storage conditions.
2. Monitor staff practices & audit the unit performance during IPCCC audit phase if all
Store non-perishable food in storage requirements are met.
clean, dry and properly 3. Provide formal feedback to the food services manager to work on identified
ventilated areas. deficiencies if needed.

Following food storage requirement must be met.

Substandard 10.4
Processed or packaged food i.e. non-perishable food that can withstand prolonged storage
Store food in designated without being subjected to rapid deterioration or decay if all storage requirements are met.
areas. Do not store in
housekeeping and Non-perishable food MUST be in clean, dry and properly ventilated areas.
dishwashing areas or near Food must always be stored food in designated areas. Do not store in housekeeping and
any sources of potential dishwashing areas or near any sources of potential contamination.
contamination.
Food products must be stored in a way to avoid cross-contamination between cooked and
raw foods and between washed and non-washed food.

1274 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ICP must randomly visit these areas during routine rounds to observe the practices of kitchen
Substandard 10.5
staff towards food storage. Any breach must be communicated to immediate supervisor for
necessary action.
Store food products in a way
that avoids cross-
Other Storage Requirements:
contamination between
cooked and raw foods and
Toxic materials used for cleaning and sanitation MUST never be stored in food storage
between washed and non-
area. Label and store in a locked area away from food and paper goods.
washed food.
Storage areas and vehicles that transport food must be kept clean. The area must have
variable lighting, ventilation, and air circulation. A temperature range for dry storage is
50ºF to 70ºF (10ºC to 21ºC).
All corrugated cardboard MUST BE REMOVED as soon as possible, because these boxes
may deteriorate or damage the product, the product may leak, or water damage may be
present; any moisture rots the boxes, and these conditions allow for pest infestation and
possible damage to the product.

Storage Shelves:
Substandard 10.6
IPC Team must ensure that storage shelves are being used based on approved guidleines as
Store food at least 6 inches below: recommended,
above the floor level and
away from walls to facilitate Food must be stored in the shelves at least 6-inches above the floor level on clean
cleaning and pest control racks with slatted shelves or racks that prevent cross-contamination and proper air
measures. circulation. (i.e shelves made up of long thin strip of metal
Never cover the slats with foil or other materials as this prevents flow of air; and,
keep away from walls to facilitate cleaning and allow for pest control measure
Shelving must allow for cleaning under the bottom of the shelf or flushing of the
floor; away from walls to facilitate cleaning; and reduce infestation of pests.
Substandard 10.7
Storage shelves should be at least 2 inches from outside walls that may sweat
Rotate food stocks to avoid because of differences between inside and outside temperatures.
using expired food. Use the first in first out (FIFO) procedure to rotate stock. Items must be stocked in a
manner to keep the items with long expiry date at the end of shelve and items with
nearest expiry date to be kept at front and used early.
Periodically check the expiration dates on all food and supplies.

Substandard 10.8 IC & food managers must ensure that all protocols for storage conditions must be followed.
Store food must be appropriately covered and labelled at the proper temperature:
Store food covered and
labelled at the proper 1. Freezing storage, less than - 18◦C
temperature (freezing 2. Refrigeration 2 to 7◦C
storage, less than - 18◦C; 3. Hot storage above 60◦C)
refrigeration 2 to 7◦C; hot
storage above 60◦C).
Substandard 10.9
Food Sample:
Food samples of all prepared
and distributed meals should Food samples of all prepared and distributed meals should be properly labelled when
be properly labelled when stored in the refrigerator for a maximum of twenty four (24) hours only.
stored in the refrigerator for a This is important to ensure quality in food service.
maximum of twenty-four (24)
hours only.

1275 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard 11.1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
In health care settings, First and foremost, a mask is a core component of the personal protective
Substandard 11.2 equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
in conjunction with gown, gloves, and eye protection.
All HCWs must abide
by the policy of All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
universal masking i.e expected to wear surgical face masks, at all times, while in their respective clinical care settings.
wearing surgical face
mask at all times while This universal mask approach will serve to:
in their respective
Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
clinical setting.
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

1276 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

Social distancing is a set of interventions or measures intended to prevent the spread of

a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.
Substandard 11.3

Health Care workers, Why Practice Social Distancing?

visitors & Patients
COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
strictly adhere to the
prolonged period.
principles of social
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
distancing, cough
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
etiquette and frequent
droplets can also be inhaled into the lungs.
hand hygiene during
Recent studies indicate that people who are infected but do not have symptoms likely also play a
duty hours / visiting
role in the spread of COVID-19. Since people can spread the virus before they know they are
hospital.
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
have any symptoms.

Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

1277 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard 11.4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
related to work (Food clinical staff) to avoid the unnecessary mobility in between the units.
Distribution etc) Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary (Food Distribution etc)

1278 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1279 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1280 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1281 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE
WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Kingdom of Saudi Arabia

Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

1282 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
LAUNDRY SERVICES

Laundry services play a critical role in a healthcare facility’s

infection prevention and control program. Contaminated textiles often contain large
numbers of microorganisms from body substances, thus it is important to ensure that
pathogens are not transferred to patients or healthcare workers.
Efforts to reduce the occupational risk of infection associated with handling
contaminated patient care and/or surgical textiles should primarily focus on the
appropriate use of hand hygiene, protective barriers, and removal of foreign objects
from the contaminated textiles.
Strict adherence to infection control standards must be ensured during entire
laundering process to render textiles safe and suitable for reuse.

1283 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN LAUNDRY

POLICIES & PROCEDURES

LAUNDRY SERVCIES

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

DESIGN OF LAUNDRY & FLOW OF WORK

OCCUPATIONAL HEALTH

WASTE MANAGEMENT

HOSUEKEEPING & UNIT ENVIRONMENT

TEXTILE DISINFECTION

TRANSPORTATION OF LINEN

STORAGE OF CLEAN LINEN

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1284 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 LAUNDRY SERVICES
Standard – 1 Policies & Procedures
Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
Substandard # 1:2 access and refer to specific infection control policy & procedures.
Staff are aware Observe the staff practices during monitoring rounds if staff are aware and all policies and
about the policies & procedures are applied.
procedures and is Interview the staff involved in patient care if they are well oriented about the policy content and
accessible for them. how to access the specific policy. e.g. (Ask about policy for handling contaminated linen etc
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

1285 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT, DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

1286 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2:2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

1287 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Standard – 3 Hand Hygiene

Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
in all patient care areas, nursing stations and other appropriate places is crucial for effective
Substandard # 3:1
implementation of hand hygiene program.
Hand hygiene
Hand Washing Facilities:
facilities and
supplies (sinks with
Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
hot & cold water /
available that meet the needs of the unit and are clean and in good repair.
plain liquid soap/
Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
paper towels,
tap if hands free operation or open the tap to check for hot & cold water supply)
Alcohol - based
Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
hand rub
soap 3: Paper Towels for drying
dispensers) are
available & easily
Hand Rub Dispensers:
accessible in work
areas. Hand
- Check the availability of hand rub dispensers as per requirements:
washing sink must
be present at soiled One dispenser per work area
area. One at any service area

- Observe dispensers are conveniently mounted and accessible at the point of care.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

1288 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 3:2 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Health care Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
professionals (HCP) without the need for an exogenous source of water and requiring no rinsing or drying with towels or
demonstrate other devices.
appropriate
technique for hand Indications:
rubbing and hand Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after body
washing. fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore forming
organism (Clostridium difficile, Bacillus anthracis), before eating and after using a restroom etc
Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in
healthcare settings, unless hands are visibly soiled.
Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile) and /or
when hands are visibly soiled.
Artificial fingernails or nail extenders are prohibited for those having direct contact with patients at
high risk areas.

IC Team must ensure training on hand hygiene practices during IPCCC training phase:

- Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water
- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
-
1289 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
Substandard # 3:3 hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Visual alerts are
available: ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
how to do hand rub, posted at appropriate places.
how to do hand
wash. - How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispen

1290 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment
may include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a
barrier between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier
has the potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes
properly removing and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
Substandard # 4:1 staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.
Sufficient and appropriate PPE
are available in adequate During routine monitoring rounds, observe the availability of PPE in the pharmacy.
amount, types & sizes with PPE must be available at the point of use which will interfere with effective use of PPE
proper qualities and readily as per requirement, such as outside compound sterile preparation room (CSP),
accessible to HCP. Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

1291 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

Substandard # 4:2
1: Appropriate PPE use :
Staff use personal protective
equipment appropriately (e.g. Sequence of donning PPEs:
donning and doffing)
Perform hand hygiene
Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical facemask. Place surgical mask over nose, mouth and chin then fit flexible
https://youtu.be/H4jQUBAlBrI nosepiece over nose bridge and secure head with ties or elastic.
Watch Video How to safely put Don goggles/face shield.
on PPE Don gloves. Extend gloves over yellow gown cuffs.

Sequence of doffing PPEs:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove goggles/face shield
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

1292 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1293 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Unit Design & Flow of Work

Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain large
numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or healthcare
workers.

Sub standards Explanation

Substandard # 5.1 Design of the laundry unit must be such to allow unidirectional flow of traffic from soiled to the
clean area.
There is a complete In order to separate the clean and soiled linen & there must be complete physical separation
physical separation between 2 zones & appropriate ventilations must be ensured.
between soiled area Separate the areas for sorting and processing soiled linens from the areas for ironing, folding, and
and clean area. storing clean linen in order to avoid cross contamination.
Flow of Work:

Flow of work must be unidirectional flow of traffic from solid area to clean areas.
Work flow should be unidirectional from soiled areas to clean areas (Receiving & Sorting
Washing & Extraction Condition/Drying & Folding Storage & Distribution )
Substandard # 5.2 Soiled areas should be physically separated from clean areas (complete physical separation is
required, i.e., using double doors washing machines or installing walls or partitions)
There is a
unidirectional flow Laundry unit must be divided into following areas:
of traffic from solid
area to clean areas. Receiving area:
- An area where soiled textiles are sorted, usually by textile category and sometimes by degree of
soiling or color.
- Alert signs about the presence of contaminated textiles & to follow to follow standard precautions
must be posted in this area
Washing (Processing) area:

An area where soiled textiles are washed and in which such equipment as washers, extractors,
washer-extractors, continuous-batch washers and/or continuous processing systems is located.
Extraction area:

An area where excess water is removed from textiles after laundering, but before conditioning or
drying.

Condition/Drying area:

An area where, after extraction, textiles are either conditioned (partly dried) or fully dried in a
dryer or tumbler.

Folding area:

An area where textiles are folded.

Storage & Staging area:

An area for temporary storing and preparing textiles for delivery and having them wrapped and ready
for transport to patient treatment units

1294 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5.3
To ensure safety of laundry personnel. Emergency eyewash/shower equipment is available with
Emergency
eyewash/shower unobstructed access in the soiled area.
equipment is This will protect the staff from accidental exposure to different type of chemicals used during the
available with washing cycle.
unobstructed
access.

Substandard # 5.4 Negative pressure ventilation must be ensured in the soiled area to avoid contamination of
environment.
Negative pressure is In the laundry facility, negative pressure should be maintained in the area where contaminated
maintained in the textiles are received compared with the clean areas of the unit.
soiled area.

1295 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 6 OCCUPATIONAL HEALTH
Infection control practices for the hospital laundry to protect workers from exposure to potentially infectious materials during the collection,
handling and sorting of soiled linen, which may be contaminated with blood and body fluids or other infectious material.
Efforts to reduce the occupational risk of infection associated with handling contaminated patient care and/or surgical textiles should primarily
focus on the appropriate use of hand hygiene, protective barriers, and removal of foreign objects from the contaminated textile product stream.

Sub standards Explanation

IC team holds the key responsivity to ensure all laundry staff are vaccinated against blood borne
pathogens i.e Hepatitis B vaccination etc & influenza vaccine.
Laundry staff personal files are maintained in the employee health clinic.
Substandard # 6.1
Vaccination for Hepatitis B
Laundry staff are
Vaccination for Influenza
vaccinated against
hepatitis B virus and
Medical records:
received influenza
During visit of Employee health clinic (EHC) review by random selection medical records of
vaccine .
laundry personnel & check if they have received vaccination against Hepatitis B.
Verify if they have completed the required dosing schedule.
Vaccination status of laundry personnel must be tracked and records are completed even if it
done outside of hospital.

Substandard # 6.2 Laundry staff are exposed to needle & sharp injuries during course of work if accidentally needle or
broken vial was left in the linen & not discarded appropriately. Laundry staff must follow the same
Laundry workers protocols for post exposure follow up & management as other HCWs.
report needle stick
and sharp injuries to IC team must ensure that waste workers are well oriented about the post exposure management
occupational health steps if they experience accidental needle stick injuries.
department. They must be trained on steps to be followed. A schematic flow chart describing steps of post
exposure management & follow up would serve as an effective reminder.

Substandard # 6.3 Steps include:

Post exposure First Aid:

follow up - Wash needle sticks and cuts with soap and water
procedures are - Then apply isopropyl alcohol 70%
clear and applicable - Bandage appropriately
for exposed - Reporting the injury to immediate his supervisor
workers. - Fill & submit and complete a reporting form (OVR : Occurrence Variance report)
- The report should include:
o Staff Information
o The date and time of the incident
Substandard # 6.4 o The location where the incident occurred
o Details of exposure type
For the staff with
skin lesion, area is Laundry personnel who have any skin lesion must apply water proof plaster to protect the
covered by water- affected area from exposure to water and other chemicals.
proof plasters.

1296 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 6.4 In order to ensure safety of laundry staff and to avoid risk of infection from handling contaminate
textiles visual alerts/ warning signs must be posted in the soiled /contaminated zone to alert the
Warning signs about staff about the contaminated textiles.
the presence of Visual education reminders must also be posted to alert staff to follow standard precautions at all
contaminated times. i.e hand hygiene, appropriate PPE use etc safe linen handling, needle and shary safety safe
textiles and they waste disposal etc
need to follow
Universal
Precautions, must
be posted in work
areas

Standard – 7 Waste Management

Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
Substandard # 7.1 - Sharp containers of different sizes for discarding needles, sharp , broken vials etc
- Waste receptacles of different sizes
All types of waste - Color coded waste bags (yellow, red , black)
containers are
available in sufficient Specification of Items:
number and placed in
easily accessible sites. Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labelled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste
generated.
Check If the number of sharp containers are available in soiled area to discard accidental sharps
found from linen.

Observe staff during monitoring rounds & ensure adherence to instructions.

Audit unit performance during IPCCC evaluation phase.

1297 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7.2 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during daily rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades, broken metal instruments and burs, guidewires, broken vials etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers including the broken and
are placed in an unbroken glass vials.
appropriate puncture Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
resistant and leak- any such situation inform the laundry supervisor to monitor closely the staff practices.
proof sharps Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
container. collection staff / housekeeping staff.

Substandard # 7.3 Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
Used needles are not to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
manipulated or syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
recapped and are Blades or needles should not be disassembled from the equipment.
promptly disposed into Observe during monitoring rounds availability of sharp container & if mounted in different at
sharp containers. appropriate location.
Open lid of sharp container at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the the laundry supervisor

Substandard # 7.4
Provide training to staff on infectious waste management protocols during IPCCC training
No infectious medical activities.
waste or sharps are Following waste segregation rules must be followed:
observed outside ❖ Black: To dispose general waste
specific containers. ❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.

Substandard # 7.5 Observe if the healthcare workers are discarding the waste in specified containers or not.
Randomly open the containers to observe if discarded waste is appropriate for that receptacle.
Waste are properly You may observe the following:
segregated (no
medical waste inside - Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste receptacle
the regular waste and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular - Sometimes you may observe a paper tissue & surgical mask discarded in sharp container. Such
regular waste in yellow practices must be observed and monitored & corrected during routine daily rounds.
medical waste - You may also find used gloves & masks beside the waste receptacle on the floor & some PPE
container) bulging out of containers.
Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

Observe the following:

Substandard # 7.6
Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
Medical waste bags overfilled beyond 3/4th capacity.
and sharp boxes are Waste bags should be well secured & tied with a self-lock plastic tie/
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

1298 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces door knobs etc.) require more frequent and rigorous environmental cleaning
than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 8.1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
Substandard # 8.2 spills.

There is at least one spill kit The spill kit must include the following:
available in the department. - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
- Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood from contaminate linen in order to avoid risk of contamination &
infection transmission.
Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

1299 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
During audit phase of IPCCC, ask the same Nursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)
Substandard # 8.3
STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
HCW knows how to use spill infectious materials:
kit properly.
Control access to area:
Prevent people from walking through affected area and spreading the blood or other potentially
infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp objects
from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the manufacturer’s
recommended contact time. Allow the spill to solidify before removing.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e. paper
towel) on top of the spill and apply the appropriate disinfectant. To avoid creating aerosols, never
spray disinfectant directly onto the spilled material. Instead, gently pour disinfectant on top of paper
towels covering the spill or gently flood the affected area, first around the perimeter of the spill,
then working slowly toward the spilled material. If sodium hypochlorite solution (5.25% household
chlorine bleach) is used, prepare a fresh solution on a daily basis. Leave for the recommended
contact time.

Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning

Substandard # 8.4 logs /checklists is extremely important to ensure effective implementation & to have the
documented evidence of regular cleaning process. Head nurse must ensure cleaning process
Cleaning is done properly is done & documented appropriately as per schedule.
using checklist that include
cleaning frequency, Each unit must have the schedule for cleaning and disinfection activities.
responsible worker, Schedule must include the frequency, the used disinfectant and the responsible staff.
housekeeping surfaces (e.g., Roles must be specified with clear instructions.
floors and walls), used
agents, methods & 1. Laundry staff for machines etc
environmental surfaces 2. Housekeeper for other environmental surfaces (Floors, walls, ceiling, toilets etc)
intended to be cleaned.

1300 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors may require, more frequent cleaning, depending on the risk-level

Provide training to the selected staff during IPCCC training phase in each quarter with
Substandard # 8.5 help of cleaning supervisor to explain the right process and technique of cleaning and
disinfection of floors using double/ or triple bucket technique or scrubbing machines.
Floors are cleaned or
disinfected using double/ or Double bucket Technique:
triple bucket technique or This consist of 02 different buckets One with disinfection solution & other with water.
scrubbing machines. Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

Housekeeping staff must be well trained on basic protocols and rules of cleaning process.
Household brooms or such cleaning tools are prohibited which may facilitate following in
the hospital settings:
Substandard # 8.6
Turbulence: (violent or unsteady movement of air or water)
Cleaning activities and tools Aerosolization of dust particles (Aerosols are fine solid particles or liquid droplets which
are used to ensure a remain suspended in air for certain period pf time e.g dust, fog ,mist etc)
minimal turbulence and
aerosolization of dust. Train the staff with involvement of environmental services supervisor & monitor activities
during daily / weekly rounds
Evaluate the performance during IPCCC audit rounds in each quarter and provide
feedback.

1301 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Train the staff on importance of changing the cleaning solutions and mop heads in order to
avoid risk of contamination to ensure effective cleaning. Cleaning solution become frequently
Substandard # 8.7
contaminated unless changed.
The mop and solution must
Best practices for environmental cleaning of general patient area floors:
be changed frequently &
after being used to clean any
Mop heads and cleaning and disinfectant solutions must be changed as often as needed.
potentially infectious
materials. IC Team must train & monitor if proper procedure for effective use of mops, cloths, and
solution are followed:
- Prepare cleaning solution daily, or as needed and replace with fresh solution as
needed.
- Use clean mops and cloths every time a bucket of cleaning solution is emptied
and replenished with clean, fresh solution.
- Used mop heads must be laundered after use.

- Train & monitor the staff practices during rounds and provide needed guidance.
- Evaluate the performance in IPCCC audit phase.

IC Team must conduct training of housekeeping staff in coordination with environmental

services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.

Training must include following key parameters:

Housekeeping staff must adhere to Standard Precautions and if required Expanded

Substandard # 8.8 Precautions when performing routine practices of cleaning and following infection control
measures. Routine practices related to environmental cleaning include:
Housekeepers are well
trained on hand hygiene, HAND HYGIENE:
proper use of PPE, methods
of cleaning & proper & safe Hand hygiene as the most important and effective measure to prevent the spread of
mixing of chemicals. healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.

It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

1302 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 PERSONAL PROTECTIVE EQUIPMENT (PPE):
Cleaning staff should wear and use Personal Protective Equipment (PPEs):
Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.
METHODS OF CLEANING:
Provide training on proper use of dusting methods
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

Emphasize during training and monitoring phase on appropriate cleaning practices.

Substandard # 8.9 Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
Observe presence of dirty / dusty surfaces.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean ( machines & table tops etc )
dust. Open lockers or cabinets and check for its cleanliness from inside. In stock rooms check
for dust inside containers which are placed close to wall.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
Substandard # 8.10 protocols.
Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping equipment is Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
kept clean and dry after use. buckets.
Mop heads must be sent to laundry unit after use.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 8.11 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

1303 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 TEXTILE DISINFECTION
The laundering process is designed to remove organic soil and render the linen clean. The correct amount of each chemical (at an adequate
dilution), the mechanical action of the equipment, the water flow, the water temperature, the timing (cycles), and drying must be optimized as
part of the process in order to ensure high level of linen cleaning.
Cleaning: A process that uses a cleaning agent and physical action, such as scrubbing or wiping, to remove visible soil, organic matter, and
bioburden from a surface or object. This renders the surface of object safe to handle. The cleaning agent may be a wet or dry chemical. The
specifics of a cleaning process are affected by factors associated with the item to be cleaned, e.g., chemical compatibility, wetness tolerance,
surface topography and complexity etc
Decontamination: The use of physical or chemical means to remove, inactivate, or destroy blood borne pathogens on a surface or disinfecting
the item to the point where it is no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use,
or disposal.
Contaminated: The presence of blood or Other Potentially Infectious Material (OPIM) on an item or surface.
Contaminated laundry: According to the Occupational Safety and Health Administration (OSHA), laundry that has been soiled with blood or
Other Potentially Infectious Material (OPIM), or may contain sharps.
Soiled textile: a textile product that has been used or worn and soiled by perspiration, body oils, or one of the many other items to which it
may have been exposed.

Sub standards Explanation

IC Team must ensure that the laundry supervisor is well trained and has
knowledge and experience in the linen management.
IC team must ensure that laundry personnel are well trained on the processing of
soiled / contaminated linen and risk associated with improper handling.

All personnel involved in the sorting and washing of contaminated healthcare linen
should:

▪ Be appropriately trained.
Substandard # 9.1
▪ Oriented about different steps of linen processing & IC parameters to be
followed.
The supervisor of the laundry has
▪ Appropriate technique of hand hygiene and have adequate access to hand
experience, and knowledge in linen
hygiene facilities.
management and rest of the staff is
▪ Use PPE (overalls, mask, head cover, heavy duty gloves, and boots).
able to explain different steps and
▪ Oriented about different steps of linen processing & IC parameters to be
main parameters to be followed
followed.
(steps and types of washing cycles,
▪ Type of disinfectants to be used
PPE to be used and concentration of
▪ Concentration of disinfectants to be used for chemical disinfection
disinfectants to be used for chemical
disinfection).
Training should include information on the proper use of PPE (when and
how to don, when and how to remove) and the location of containers where
items are to be placed for either disposal or laundering
All staff must be trained in proper hand hygiene techniques.
Procedures for identifying, bagging, handling, and transporting contaminated
laundry.
How to handle and dispose of sharps and other biohazardous materials that
might have inadvertently been left in the textiles while being collected. Not to
be overlooked is the need for

1304 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Infection control team must educate and assure competency of laundry
personnel regarding all steps of safe processing of contaminated / soiled linen
in order to produce an end product that is safe to be used for the patients.
- Observe the staff practices during routine rounds.
- Evaluate performance during IPCCC audit phase and provide formal feedback.
- Training & competency records must be well maintained in staff personal files
and electronic training & competency database must be regularly updated.

Training & education regarding safe linen handling and processing must incorporate
the following important standards:

Substandard # 9.2 Laundering has been defined as a method of restoring soiled textile articles to usable
condition, with operations that include washing, bleaching, rinsing, and removal of
the load size (weight) for each water.
classification of soil shall be
established by the facility and There are six components in the laundering process, and these determine the quality
recorded for each load processed. of the product the system produces.
Mechanical action in the equipment
Dilution and size of the load
Water flow
Water temperature
Time
Chemicals used

❖ Staff working in the soiled area must be well familiarized with all requirements of
the the reprocessing cycle.
❖ IC team must ensure that weight of linen (Load Size) must be in accordance with
the manufacturer’s instructions.

1305 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9.3 When textiles are laundered using proper amounts of each chemical and subjected to
adequate dilution, mechanical action, and water temperatures, the patient is ensured
During high temperature washing of being provided items that are “hygienically clean.
cycle, water temperature is at a
minimum of 71◦C for 25 minutes High temperature washing cycle: (Heat Disinfection).
(heat disinfection).
IC team must train & observe the practices during routine rounds to assure that all
Substandard # 9.4 recommendations are being followed.

During low temperature washing Observe and review the records during routine rounds:
cycle (22◦C - 50◦C), sodium
hypochlorite is added as a High temperature: A temperature of at least 71ºC (160ºF) for a minimum of 25
disinfectant during bleach wash cycle minutes is normally recommended for the hot water wash cycle
(chemical disinfection: residual
bleach is 50 - 150 ppm, this is Ensure availability of records of high temperature washing cycles including
monitored and controlled. monitoring and control of washing cycles (i.e., recording processed loads /
selected washing cycles / temperatures and times) –
Substandard # 9.5
Low temperature washing cycle: (Chemical Disinfection):
If sodium hypochlorite is not
appropriate for the fabrics or not Low temperature: A lower temperature of 22ºC-25ºC (71ºF-77ºF) can
recommended by manufacturer’s, satisfactorily reduce microbial contamination in the washer.
Chlorine alternatives (e.g., activated Sodium hypochlorite is added as a disinfectant during bleach wash cycle
oxygen-based detergents) may be (chemical disinfection: residual bleach is 50 - 150 ppm, this is monitored and
used to ensure adequate disinfection controlled.
of laundry during low temperature
washing cycle. Ensure availability of records of low temperature washing cycles including
monitoring and control of used chemicals (i.e., chemical types / preparations
Substandard # 9.6 method / effective concentrations and contact times)
Soap is never being mixed with Soap is never being mixed with chlorine compounds or any other chemicals.
chlorine compounds or any other
chemical.
Residual Chlorine:

Substandard # 9.7 The washing cycles (one for bleach wash), series of rinses, and the last rinse will
neutralize any residual chemicals.
Washing process is documented The amount of residual chlorine (bleach) should be between 50 and 150 ppm and
including type of disinfection and must be monitored and controlled
category for each washing cycle.

Substandard # 9.8
Other precautions for quality processing of linen:
Clean healthcare textiles shall be
After the washing cycles are completed, clean healthcare textiles shall be
extracted or dried in a manner that
extracted or dried in a manner that minimizes microbial growth after washing.
minimizes microbial growth after
Damp textiles shall not be left in machines overnight
washing. Damp textiles shall not be
After extraction, the linen can be dried by either ironing (flatwork or mangle iron)
left in machines overnight.
or by tumble drying.

1306 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9.9 In order to produce the hygienically safe product meeting the expectations and needs
of the end user, following must be ensured:
The processed textiles should
meet the needs and expectations Routine inspection is conducted after washing and linen with blood or/and body fluid
of the user. Routine inspection is stains is washed again.
conducted after washing and If there are persistent blood stains after repeated washing, such linen must be
linen with blood or/and body fluid discarded and never be transported for patient use.
stains is washed again.

Substandard # 9.10 Planned Preventive Maintenance (PPM) for washing machines with Quality check for
different parameters of washing cycles
All laundry equipment are well
maintained with PPM records for Appropriate Interventions / corrective action s must be records for abnormal
washing machines - Equipment temperatures and failure situations must be
& supply problems are
immediately reported to the
laundry manager.

1307 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 TRANSPORTATION OF LINEN

Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain
large numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or
healthcare workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must follow Standard
Precautions at all times. To reduce the possibility of occupational risks of infection transmission and/or exposure, laundry workers should
focus on: a. Appropriate and frequent hand hygiene. b. Appropriate use of personal protective equipment (PPE). Removal of foreign objects
from soiled linen. 4. To restore soiled linen to usable condition, washing, bleaching, rinsing, and drying are necessary.

Sub standards Explanation

Infection Control Team MUST ensure during routine monitoring rounds the specification
Substandard # 10.1 related to linen collection & transportation are met.

Linen carts are covered and In the units laundry bags should not be filled more than ¾ full. Once full, tie off soiled
not overfilled. linen bags in the dirty utility room or a designated area for pickup by laundry staff.
Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
to 10 inches off the floor.
The laundry collection staff must ensure that linen carts must not be overfilled & must
be covered appropriately.

- Train. Monitor & evaluate the staff practices.

- Provide formal feedback.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 10.2 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles hand hygiene, appropriate PPE etc.
must follow standard ❖ Laundry staff should wear appropriate personal protective equipment when handling used
Precautions at all times. or contaminated linen.

Substandard # 10.3 ❖ Dirty linen should be separated from clean linen during collection & transport (i.e., the
laundry staff maintain functional separation of soiled from clean textiles in carts and/or
Clean and dirty linen are vehicles at all times during the collection and transportation)
separated during transport, ❖ Carts used for collection & transport of dirty linen are clearly identified from those used of
linen carts used for clean clean linen.
and dirty linen are clearly ❖ Linen carts must be washed with an approved disinfectant on regular basis.
identified and they should ❖ During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
be routinely washed. soiled and clean linen are separated at the place of production.

1308 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control Team MUST provide training & ensure during routine monitoring rounds
that specification related to linen collection bags & their transportation are met.
Substandard # 10.4

The collection bags must Quality of the laundry bags or containers should be good in order to avoid any leakage.
functionally contain wet or
soiled textiles and prevent The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
contamination of the can be closed securely to prevent textiles from falling out
environment during
collection, transportation, laundry bags or containers functionally contain wet or soiled textiles and prevent
and storage prior to contamination of the environment during collection, transportation and storage before
processing. being processed.

Environmental contamination would increase risk of cross transmission of infection so

strict rules must be followed during collection, transportation & storage.

Standard – 11 Storage of Clean Linen

Appropriate storage of all medical supply based on the infection control standards is extremely important in ensuring the
integrity of items and prevention of contamination. It’s the patient right to receive the high quality care based on the best
practices for safety of patients.

Sub standards Explanation

Train & orient the laundry staff during IPCCC training activities regarding appropriate storage of
Substandard # 11.1
clean processed textile & all specifications and protocols to be followed for the storage of clean
textiles. Observe during daily/ weekly rounds and audit unit performance during IPCCC audit
Clean linen is stored and
phase.
covered in a clean dry
area and separated from
Following key points need to be followed:
potential sources of
contamination..
Storage areas must be clean & dry without any contamination from dust etc
There must be cleaning schedule with cleaning checklist including all items to be cleaned.
Substandard # 11.2 Laundry Staff must ensure regular cleaning is done as scheduled and storage is away from
Clean linen is packed in sources of contamination.
bags which are securely
fastened ready for Packing of Clean Linen:
delivery on clean trolleys
After completion of all phases of laundry processing, linen must be safely packed in order
to avoid risk of contamination from dust & debris etc
Substandard # 11.3
Appropriate bags must be available & used to securely fasten & pack the clean linen for
The door should be transportation to the units in clean trolleys
always closed with good
ventilation to prevent - Door of the storage room always be closed to avoid dust accumulation.
accumulation of dust. - Must have adequate space in order to ensure good ventilation.

1309 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11.4 Specifications of Storage Shelves:

Storage shelves are 25 Storage shelves are made of easily cleanable material
cm from the ceiling, 20 (e.g., fenestrated stainless steel).
cm from the floor, and 5
Storage shelves are placed following these specifications.
cm from the outside wall.
- 25 cm from the ceiling
- 20 cm from the floor
- 05 cm from the wall

❖ Assigned IC team member inspect the clean linen storage area and randomly wipe over
storage shelves to ensure if cleaned appropriately.
❖ Wipe over packed linen bag to rule out presence of dust, soil etc

Standard – 12 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 12.1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

1310 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 12.2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

1311 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 12.3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1312 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 12.4 measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of healthcare Following must be ensured:
workers is strictly
prohibited unless Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
related to work (Linen clinical staff) to avoid the unnecessary mobility in between the units.
collection Moving in between departments and eating together in pantries is strictly prohibited.
/transportation etc) HCWs must limit the movement unless absolutely necessary e.g Linen collection /transportation
etc)

1313 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1314 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1315 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE
WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

1316 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
MORTUARY SERVICES

Preparing the deceased for the Morgue always involves

the handling of blood, body fluids, and biological agents and may also involve
exposure to life-threatening biologicals, chemicals, radiation, or electrical current.
Appropriate infection control measures must be taken for care of body following death
to protect healthcare workers (HCWs), morgue staff and families from potential
infectious exposures.

1317 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN mortuary
services
MORTUARY SERVCIES

POLICIES & PROCEDURES

EDUCATION & TRAINING

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

HOSUEKEEPING & UNIT ENVIRONMENT

WASTE MANAGEMENT

TEXTILES MANAGEMENT

OCCUPATIONAL SAFETY & STAFF QUALIFFICATIONS

WORKING AREA SPECIFICATIONS

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1318 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 MORTUARY SERVICES

Standard – 1 Policies & Procedures

Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
access and refer to specific infection control policy & procedures.
Substandard # 1:2
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware procedures are applied.
about the policies & Interview the staff involved in patient care if they are well oriented about the policy content and
procedures and is how to access the specific policy. e.g. (Ask about policy for isolation precautions while dealing
accessible for them. with infectious dead bodies / PPE use etc. Ask verbally and then give task to demonstrate how to
access this policy via electronic or manual system.)
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

1319 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external /internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT, DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

1320 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2:2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

1321 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
audit phase.
department every
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

Standard – 3 Hand Hygiene

Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to treat.
On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital patients
has at least one healthcare-associated infection.
Sub standards Explanation

Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
at appropriate places is crucial for effective implementation of hand hygiene program.

Hand Washing Facilities:

Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
Substandard # 3:1 available that meet the needs of the unit and are clean and in good repair.
Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
Hand washing tap if hands free operation or open the tap to check for hot & cold water supply)
facilities and Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap 2: Antimicrobial
supplies (sinks with soap 3: Paper Towels for drying
hot & cold water /
plain liquid soap / Hand Rub Dispensers:
paper towels,
Alcohol - based - Check the availability of hand rub dispensers as per requirements:
hand rub
dispensers) are One dispenser per work area
available in One at any service area
adequate numbers
- Observe dispensers are conveniently mounted and accessible at the point of care.
& easily accessible.
- Observe whether hand washing facilities & Hand rub dispensers are conveniently placed and their
ease of accessibility to staff.

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open any dispenser to check if hand sanitizer is available & not expired.

1322 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
Substandard # 3:2
without the need for an exogenous source of water and requiring no rinsing or drying with towels or
other devices.
HCP demonstrates
appropriate
techniques for hand IC Team must ensure training on hand hygiene practices during IPCCC training phase:
washing and hand
rubbing . - Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.
Substandard # 3:3
3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

1323 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
Substandard # 3:3 hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Visual alerts are
available: ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
how to do hand rub, posted at appropriate places.
how to do hand
wash. - How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispen

1324 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
Substandard # 4:1 staff must follow the supply chain rules to ensure sufficient stock is available at all times
in coordination with infection control department.
Sufficient and appropriate PPE
are available and readily During routine monitoring rounds, observe the availability of PPE in the pharmacy.
accessible to HCP. PPE must be available at the point of use.
Review PPE checklist for the unit to ensure amount is adequate.
PPE checklist should include minimal quantity of each type of PPE with daily stock
consumption monitoring.

Check Availability of various types of PPE in all patient care areas:

- Different sizes & types of gloves

- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc

Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

1325 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
Substandard # 4:2 staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.
Staff use personal protective
equipment appropriately. 1: Appropriate PPE use:

Sequence of donning PPEs:

Perform hand hygiene

Don gown. Gown should cover the body from neck to knees and should be secured at
neck and waist.
Don surgical facemask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don goggles/face shield.
Don gloves. Extend gloves over yellow gown cuffs.
https://youtu.be/H4jQUBAlBrI
Watch Video How to safely put Sequence of doffing PPEs:
on PPE
Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove goggles/face shield
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

1326 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1327 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 5 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 5.1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
spills.
Substandard # 5.2
The spill kit must include the following:
There is at least one spill kit - Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
available in the department. - Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.

IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids in order to avoid risk of contamination & infection
transmission.
Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

1328 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
During audit phase of IPCCC, ask the same Nursing / housekeeping staff to demonstrate
management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)

Substandard # 5.3 STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:
HCW knows how to use spill
kit properly. Control access to area:
Prevent people from walking through affected area and spreading the blood or other potentially
infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp objects
from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the manufacturer’s
recommended contact time. Allow the spill to solidify before removing.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e. paper
towel) on top of the spill and apply the appropriate disinfectant. To avoid creating aerosols, never
spray disinfectant directly onto the spilled material. Instead, gently pour disinfectant on top of paper
towels covering the spill or gently flood the affected area, first around the perimeter of the spill,
then working slowly toward the spilled material. If sodium hypochlorite solution (5.25% household
chlorine bleach) is used, prepare a fresh solution on a daily basis. Leave for the recommended
contact time.

Substandard # 5.4 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Cleaning is done properly documented evidence of regular cleaning process. Head nurse must ensure cleaning process
using checklist that include is done & documented appropriately as per schedule.
cleaning frequency,
responsible worker, Each unit must have the schedule for cleaning and disinfection activities.
housekeeping surfaces (e.g., Schedule must include the frequency, the used disinfectant and the responsible staff.
floors and walls), used Roles must be specified with clear instructions.
agents, methods &
environmental surfaces
intended to be cleaned.

1329 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Floors may require, more frequent cleaning, depending on the risk-level

Provide training to the selected staff during IPCCC training phase in each quarter with
Substandard # 5.4 help of cleaning supervisor to explain the right process and technique of cleaning and
disinfection of floors using double/ or triple bucket technique or scrubbing machines.
Floors are cleaned or
disinfected using double/ or Double bucket Technique:
triple bucket technique or This consist of 02 different buckets One with disinfection solution & other with water.
scrubbing machines. Steps:
- Dip the mop in the disinfectant solution
- Mop the floor for specified square meters
- Dip the mop in the bucket of water.
- Rinse the excess water off the mop head in the bucket of water this is to prevent
carrying too much water back into disinfectant solution and making it diluted.
- Dip the mop in disinfectant & repeat.

Three bucket technique:

The three-bucket technique consists of 03 buckets - clean solution bucket, waste bucket &
a rinse bucket.

- Wet mop from clean disinfectant solution bucket

- Remove excess solution in the waste bucket.
- Perform mopping process for about 1 square meter.
- Remove contaminated solution into waste bucket.
- Dip mop into rinse bucket.
- Remove excess water into waste bucket.
- Reapply disinfectant solution from clean bucket.
- Remove excess water into waste bucket.

This is important to control the spread of infection.

Repeat the steps 1-8 until cleaning process is complete or mop solution needs to be changed.
Mop solution must be changed immediately when there are signs of visible contamination.

Observe the staff practices during routine monitoring rounds.

Evaluate the performance in IPCCC audit phase.

A floor scrubber is a floor cleaning device. It can be a simple tool such as a floor mop or floor
brush, or in the form of a walk-behind or a ride-on machine to clean larger areas by injecting
water with cleaning solution, scrubbing, and lifting the residue off the floor.

1330 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must conduct training of housekeeping staff in coordination with environmental
services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.
Training must include following key parameters:
Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
measures. Routine practices related to environmental cleaning include:

HAND HYGIENE:
Hand hygiene as the most important and effective measure to prevent the spread of
Substandard # 5.4 healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
Housekeepers are well linen, equipment or waste).
trained on hand hygiene, After patient environment contact (e.g., after cleaning client/patient/resident room;
proper use of PPE, methods after cleaning equipment such as stretchers; after changing mop heads).
of cleaning, and proper and After using the toilet.
safe mixing of chemicals. It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

1331 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 5.7 Emphasize during training and monitoring phase on appropriate cleaning practices.
Evaluate the cleanliness of environmental surfaces during IPCCC rounds of each unit.
The mortuary is generally Observe presence of dirty / dusty surfaces.
clean, well-organized, and In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
adequately ventilated. not clean.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
protocols.
Substandard # 5.8 Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
Housekeeping equipment is buckets.
kept clean and dry after use. Mop heads must be sent to laundry unit after use.

Substandard # 5.9 IC team must ensure that table tops , stretchers & body boards are made of washable
materials in order to with stand repeated cleaning and disinfection.
All tabletops, stretchers, and
Ensure availability in coordination with morgue supervisor.
body boards are made of
washable materials.
Evaluate the unit performance during IPCCC audit phase in each quarter and provide feedback.

1332 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 6 Waste Management
Infectious waste has been specifically defined as any waste capable of causing infection. If Medical waste is not properly managed
and disposed of, it can result in injury by contaminated sharps and infection with Blood borne pathogens. Careful handling,
sorting, and appropriate disposal of waste is important to prevent transmission of infection. Therefore, healthcare workers must
be well trained on safe handling of infectious medical waste. Infectious waste should always be segregated, collected, transported
and stored in a safe and systematic manner in accordance with the policies and procedures. Staff should be knowledgeable about
the risks and safety operating procedures of the waste they are handling.

Sub standards Explanation

During routine daily / weekly rounds ensure all different sizes and types of waste containers are
available in sufficient amounts and appropriate locations:
- Sharp containers of different sizes for discarding needles, sharp , broken vials etc
Substandard # 6.1 - Waste receptacles of different sizes
- Color coded waste bags (yellow, red , black)
All types of waste
containers are Specification of Items:
available in sufficient
number and placed in Sharps containers: - Must be rigid, puncture-proof, leak-proof and closable. - Equipped
easily accessible sites. with a hermetical seal with an opening aperture which allows insertion of sharp items (e.g.,
needles and lancets). - Has a biohazard logo and labelled as “Sharp Items” which must be
printed in both Arabic and English. etc.

Plastic bags - Should be tear-resistant and leak proof - Must not contain Polyvinyl Chloride
(PVC). - Thickness must not be less than 70 microns thick. - All designated infectious
waste containers should have a biohazard symbol or labelled with the word “Infectious”
both in Arabic and English or be color-coded (i.e., yellow bags), rendering them identifiable
by hospital staff.

Observe availability of different sizes of color-coded waste bags.

Check If the number of waste receptacles are adequate according to amount of waste generated
in specific unit.
Check If the number of sharp containers are adequate in number & appropriate sizes. 4. Waste
receptacles. Sharp containers and color coded bags must meet the regulations of Ministry of
Health.

Substandard # 6.2 Appropriate disposal of all types of sharps safely in the specified containers is of utmost
importance in preventing sharp and needle stick injuries.
Sharp items (e.g.,
needles, scalpel Observe the practices of staff during routine rounds regarding disposal of sharp items like
blades, broken metal needles, scalpel blades etc)
instruments and burs) All sharp items must be discarded in the specified sharp containers.
are placed in an Randomly open the waste receptacles (Yellow & Black) to verify if any sharp item is present. In
appropriate puncture any such situation inform the morgue supervisor to monitor closely the staff practices.
resistant and leak- Sharp item disposed of in infectious or general waste poses a significant risk of injury to waste
proof sharps collection staff / housekeeping staff.
container.

1333 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Recapping, bending needles or any other manipulation exposes the healthcare workers to significant
Substandard # 6.3 risk of acquiring Needle stick Injuries from accidental exposure to sharps. Sharp containers are used
to dispose all used and unused sharps (e.g., Hypodermic, intravenous or other needles, auto-disable
Used needles are not syringes, syringes with attached needles, scalpels, glass pipettes, knives, blades, broken glass). -
manipulated or Blades or needles should not be disassembled from the equipment.
recapped and are
promptly disposed into Observe during monitoring rounds availability of sharp containers & if mounted appropriate
sharp containers. location.
Open lid of sharp containers at random and check if any broken, bent, recapped or separated
needles are present.
Any such breach of practice must be noted and communicated to the unit head / nurse in
charge.
Substandard # 6.4
Provide training to staff on infectious waste management protocols during IPCCC training
No infectious medical activities.
waste or sharps are Following waste segregation rules must be followed:
observed outside ❖ Black: To dispose general waste
specific containers. ❖ Yellow: To dispose infectious waste, soaked items with blood or body fluid
❖ Red: To dispose body parts and organs
❖ Sharp Containers: To dispose all kinds of sharps (needles, broken/ glass, syringes with
attached needles, blades; etc.)
Observe if the healthcare workers are discarding the waste in specified containers or not.
Substandard # 6.5 Randomly open the containers to observe if discarded waste is appropriate for that receptacle.

Waste are properly You may observe the following:

segregated (no
medical waste inside - Card boxes, Papers & plastic wrappers & sharp object discarded in infectious waste receptacle
the regular waste and N – 95 masks & blood soaked gauzes discarded in general waste.
container or regular - Sometimes you may observe a paper tissue & surgical mask discarded in sharp container. Such
regular waste in yellow practices must be observed and monitored & corrected during routine daily rounds.
medical waste - You may also find used gloves & masks beside the waste receptacle on the floor & some PPE
container) bulging out of containers.
- Used syringe / needle on the medication trolley.
Staff must be retrained on waste disposal protocols during IPCCC training phase.
Closely Monitor the staff practices & evaluate staff and unit’s performance during IPCCC audit
phase.

Observe the following:

Substandard # 6.6 Medical waste bags & sharp containers in the temporary holding areas which shouldn’t be
overfilled beyond 3/4th capacity.
Medical waste bags If waste bags are well secured & tied with a self-lock plastic tie before placing them in a
and sharp boxes are temporary holding area such as a dirty utility room.
not over filled (i.e. 3/4 Observe the label of infectious waste bags with the following information: a. Generating
filled) department b. Date collected c. Time etc.
Train, monitor and evaluate the unit’s performance in IPCCC audit rounds.

1334 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Textile Management
Laundry services play a critical role in a healthcare facility’s infection prevention and control program. Contaminated textiles often contain large
numbers of microorganisms from body substances, thus it is important to ensure that pathogens are not transferred to patients or healthcare
workers. Soiled linens must be assumed to be contaminated; personnel who handle soiled linens must follow Standard Precautions at all times.
To reduce the possibility of occupational risks of infection transmission and/or exposure, laundry workers should focus on: a. Appropriate and
frequent hand hygiene. b. Appropriate use of personal protective equipment (PPE). Removal of foreign objects from soiled linen. 4. To restore
soiled linen to usable condition, washing, bleaching, rinsing, and drying are necessary.
Sub standards Explanation

Dirty linen should be separated from clean linen during collection & transport (i.e., the
Substandard # 7.1 laundry staff maintain functional separation of soiled from clean textiles in carts and/or
vehicles at all times during the collection and transportation)
Clean and soiled linen are Carts used for collection & transport of dirty linen are clearly identified from those used of
stored and handled clean linen.
separately. During daily / weekly rounds visit the clean and dirty utility rooms to make sure that the
soiled and clean linen are separated at the place of production.

Substandard # 7.2 In order to avoid risk of contamination soiled linen / textiles must be transported to
laundry for processing on regular scheduled basis.
Soiled / Contaminated There should be schedule for daily collection of soiled linen from the units.
textiles after handling the
Visit the dirty utility room & verify if soiled linen is transported regularly as per
cadavers should be
transported to the laundry schedule.
when applicable.

Educate health care personnel regarding safe handling of contaminated linen and
Substandard # 7.3 associated risks, monitor & audit the performance in IPCCC audit phase.

Soiled healthcare textiles Focus on following key points:

must be assumed to be
contaminated; personnel ❖ Personnel who handle soiled healthcare textiles apply standard precautions at all times like
who handle soiled textiles
hand hygiene, appropriate PPE etc.
must follow standard
Precautions at all times. ❖ Nursing staff should wear appropriate personal protective equipment when handling used
or contaminated linen. Following must be practiced:

Substandard # 7.4 Contaminated linen should be bagged at the site of generation in a manner that minimizes
agitation and prevents contamination of the environment and personnel.
Contaminated linen should not be shaken / agitated when removing it from the bed.
The collection bags must
Place used linen in a laundry bag at the point of use.
functionally contain wet or
soiled textiles and prevent Do not place on chairs or other furniture.
contamination of the Collect soiled linen in such a fashion as to keep the heavily soiled portion contained in the
environment during centre by folding or rolling the soiled spot into the centre. This action will reduce the risk
collection, transportation, of contamination and prevent leakage from soaking through.
and storage prior to Care should be taken before placing soiled linen in a laundry bag to ensure that all non-
processing. textile items, including instruments, needles, or plastic single-use under pads, are
removed. These items can cause extensive damage to laundry equipment.

1335 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Items of this nature present the greatest risk to the HCW in acquiring blood-borne
Substandard # 7.5 infection.
- Ensure that the patient’s personal items (e.g., dentures, eyeglasses, and hearing aids)
The containers must not
are not left in the linen
tear when loaded to
capacity, be leak-proof, and
be capable of being closed Soiled textiles are not sorted or rinsed in patient-care areas.
securely to prevent textiles Quality of the laundry bags or containers should be good in order to avoid any leakage.
from falling out. The laundry bags or containers must be leak-proof, not torn when loaded to capacity and
can be closed securely to prevent textiles from falling out (i.e., laundry bags or containers
functionally contain wet or soiled textiles and prevent contamination of the environment
during collection, transportation and temporary storage before being processed in the
laundry).
Laundry bags should not be filled more than ¾ full. Once full, tie off soiled linen bags in
Substandard # 7.6 the dirty utility room or a designated area for pickup by laundry staff.
Linen bags must not be placed directly on the floor. Use a bin or rack to keep the bags 8
Linen carts are covered and to 10 inches off the floor.
not overfilled. Linen from isolation rooms is considered regular soiled linen.
The laundry provider must maintain functional separation of clean from soiled linens in
carts and/or vehicles at all times during the collection and transportation of soiled linens.
Care should be taken when removing laundry bags from these areas.
Linen carts must not be overfilled & must be covered appropriately.

1336 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Occupational Safety & Staff Qualifications
Preparing the deceased for the morgue always involves the handling of blood, body fluids, and biological agents and may also involve
exposure to life-threatening biologicals, chemicals, radiation, or electrical current. Infection control standards and guidelines must be
followed on appropriate care of the body following death to protect healthcare workers (HCWs), morgue staff and families from potential
infectious exposures.
Sub standards Explanation

Substandard # 8.1 For safety of morgue staff, IC team must ensure annual medical evaluation of morgue
personnel in the employee health clinic.
All morgue staff are Morgue staff must be trained on the post exposure management and follow up protocols
evaluated annually for after any accidental blood and body fluid exposure.
medical check-ups and at All medical records must be kept in the staff health files.
any other time when
necessary (such as after
exposure to blood and body
fluid).

Substandard # 8.2 Eating & drinking must be strictly prohibited in the mortuary in order to avoid risk of
contamination.
No drinking or eating inside
the morgue.

Substandard # 8.3 IC team must ensure that personnel working in the morgue who are dealing with cadavers
are experienced and have appropriate qualification to deal with the dead bodies i.e
Only experienced personnel specialists in the filed or technicians.
(specialists and/or IC team must ensure periodic training and education of morgue staff on appropriate
technicians) are dealing with infection control measures to be taken while handling cadavers,
cadavers, they should be
fully aware about handling IC training should include but not limited to:
deceased patients due to
infectious diseases or died - Hand washing / hand rubbing
while under isolation - Appropriate use of PPE
precautions according to the - Modes of disease transmission
relevant approved hospital - Type of isolation precautions etc
policy.

1337 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Working Area Specifications

Dead bodies could pose a significant health risk if appropriate infection control measures are not followed during handling of cadavers.
Moreover certain specifications must be met in order to ensure the best provision of mortuary care.

Sub standards Explanation

IC team must ensure during routine IC rounds that all IC supply is available in the unit.
Substandard # 9.1
Provide training & orientation to morgue staff about the infection control measures
pertaining to mortuary care.
Different sizes of the body
Evaluate unit performance & performance of morgue staff during IPCCC audit phase and
bags are available & used
provide formal feedback.
especially with deceased
Consider for retraining if needed.
patients under isolation
precautions and cadavers
Following must be fulfilled:
with open wounds or oozing
body fluids.
Cadaver Bags:

a) Ensure availability of different sizes of the body bags. (Adult / paediatric) & used.
b) Morgue staff must use the body bags especially with deceased patients who were under
Substandard # 9.2
isolation precautions. (Droplet, contact, airborne)
c) Body bags must be used cadavers with open wounds or oozing body fluids.
Death log book is available
d) Ensure that the body bags (which are plastic) are appropriately disposed of when the
in morgue.
body is removed (in a yellow bag).
e) Ensure availability of death log book in the morgue to fulfil all legal requiremnts.

Substandard # 9.3 Ventilation Parameters:

Temperature log book a) Environmental control parameters must be recorded through availabity of fixed monitors.
should be maintained for the b) Monitor the temperature of the refrigerators (4°C) and record the temperature on the
refrigerators & any temperature chart on a daily basis.
temperature failure must be c) Any temperature failure (temperature out of range) must be reported to the Utilities and
reported to the Utilities and Maintenance (U&M) Department.
Maintenance (U&M)
Department.

Cleaning & Disinfection:

Substandard # 9.4
IC team must ensure that appropriate cleaning & disinfection protocols are followed after
After the transfer of the the transfer of dead bodies.
cadaver , make sure the Ensure availability of MOH approved disinfectants and cleaning agents.
area is disinfected with MOH Housekeeping must receive refresher training on appropriate methods of cleaning, dilution
approved disinfectant. of disinfectant & contact time etc
All cleaning activities must be documented in the cleaning checklists & records kept in the
unit.

1338 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Nursing staff must follow protocols of transfer of dead bodies under isolation precautions.
Transportation card must be attached to the body bags of deceased with infectious
Substandard # 9.5
diseases to identify type of infection control precautions required.
The nurse in charge or dedicated personnel must inform the morgue supervisor if the
Transportation card is
deceased was known to harbour an infectious agent. (This information will also be
attached to dead bodies
confirmed in writing on the identification tag attached to the body bag.)
cadavers with infectious
Morgue staff must be well familiarized with the types of isolation precautions &
diseases to identify type of
appropriate PPE to be used to avoid risk of acquiring infection.
infection control precautions
required.
Body Parts & Placenta:
Substandard # 9.6
IC team must provide training to the relevant staff in labor & delivery, OR etc for protocols
of handling & transportation of body parts, placentas, stillborns, products of miscarriage
Body parts (including
etc to the morgue.
placentas, stillborn,
Following key points must be ensured:
products of miscarriage,
etc.) are received in a red
a) All Body parts (including placentas, stillborn, products of miscarriage, etc.) must be
bag, clearly labelled, and
placed in a red bag.
stored in the refrigerator for
b) Complete information must be written on the label including type of organ/part, unit, date
temporary storage until
etc
burial.
c) Must be kept in the refrigerator until delivery to morgue.
d) Morgue staff must ensure that received items are in red bag with clearly identified label.
e) Must be kept in MORGUE refrigerator until collected by municipality for burial.

1339 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 10.1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

1340 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 10.2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

1341 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
prolonged period.
Substandard # 10.3
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
Health Care workers,
droplets can also be inhaled into the lungs.
visitors & Patients
Recent studies indicate that people who are infected but do not have symptoms likely also play a
strictly adhere to the
role in the spread of COVID-19. Since people can spread the virus before they know they are
principles of social
sick, it is important to stay at least 6 feet away from others when possible, even if they do not
distancing, cough
have any symptoms.
etiquette and frequent
hand hygiene during
duty hours / visiting Cough Etiquette:
hospital. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1342 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
Substandard # 10.4 another patient, HCWs to patients & in between HCWs.

Interdepartmental Following must be ensured:

mobility of healthcare
workers is strictly Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
prohibited unless clinical staff) to avoid the unnecessary mobility in between the units.
related to work. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary.

1343 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1344 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1345 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

1346 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
INFECTIOUS WASTE ROOM

Infectious Waste should always be segregated, collected,

transported and stored in a safe manner with consideration of the risk, occupational
safety rules and should be in accordance with local regulations.
Waste collection staff should be knowledgeable about the risks and safety operating
procedures of the waste they are handling.

1347 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN INFECTIOUS
WASTE ROOM
INFECTIOUS WASTE ROOM

POLICIES & PROCEDURES

EDUCATION & TRAINING

OCCUPATIONAL HEALTH

WASTE MANAGEMENT SUPPLY

MEDICAL WASTE COLLECTION

PERSONAL PROTECTIVE EQUIPMENT (PPE)

HAND HYGIENE

MEDICAL WASTE STORE SPECIFICATIONS

HOUSEKEEPING &UNIT ENVIRONMENT

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1348 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 INFECTIOUS WASTE ROOM

Standard – 1 Policies & Procedures

Policies and procedures are an incredibly important part of making sure that health care professionals know how to care for
patients and to perform their jobs based on the evidence based guidelines. Policies provide the foundation for operational
excellence and good patient care. Even the best policies won’t do much good if the staff are not well familiarized with them. They
guide day-to-day activities, helping promote consistency in best practices, reduce mistakes, and keep patients and staff safe.
Healthcare regulations and standards are constantly changing so policies and procedures in healthcare should be living, breathing
documents that grow and change within the healthcare setting.

Sub standards Explanation

Infection Control team members holds the key responsibility to ensure the following related to polices
Substandard # 1:1 & procedures in each unit.
Updated infection Infection preventionists (IPs) must develop, update and distribute the policies & procedures
control policies & relevant for the unit.
procedures are Policies needs to be updated every 2 - 3 years and when new updates are available.
available in the unit. Distribute all relevant policies & procedures in the unit. (electronic and / or printed version)

During routine rounds / monitoring activities, Infection Control team members MUST ensure:

Policies & procedures are easily accessible to the staff whenever needed.
During the training phase of IPCCC activities, provide training & orientation to the staff on how to
Substandard # 1:2 access and refer to specific infection control policy & procedures.
Observe the staff practices during monitoring rounds if staff are aware and all policies and
Staff are aware
procedures are applied.
about the policies &
procedures and is Interview the staff involved if they are well oriented about the policy content and how to access
accessible for them. the specific policy. e.g. (Ask about policy for disinfection of waste collection trolleys & PPE use
etc. Ask verbally and then give task to demonstrate how to access this policy.
Evaluate the staff performance / assess competence during IPCCC audit phase. Assess the same
staff who had received prior training in each quarter.
Provide feedback (formal / informal) on performance & consider for retraining if needed.

1349 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.

Sub standards Explanation

Training is an essential part of implementing policies and procedures that helps Health Care
Personnel HCPs to know how policies apply to them & how to properly follow procedures.
IC Team must ensure implementation of policy for orientation & education of newly hired HCWs on
basics of infection control skills before they can commence work in their respective clinical areas.
Substandard # 2:1
Each HCPs must receive education & training on basic infection control skills from IC
department within 01 months of joining work. (BICSL)
Healthcare Personnel
(HCP) receive IC team MUST conduct BICSL training for all newly hired staff within maximum 01 month of
orientation and joining work & issue a BICSL ID which should be renewed ever 02 years.
training on Basic Health Care Personnel HCPs (HCPs) must keep BICSL ID with them at all times during duty
Infection Control Skills hours as an evidence of basic infection control training to be presented to any external / internal
from IC department audit visit for purpose of verification.
maximum within 1
Health Care Personnel HCPs must be aware and hold responsibility to renew the BICSL card
months of joining
every 2 years by visiting infection control department.
work & a BICSL card
is issued which is
renewed every 2 Components of BICSL includes:
years.
- HAND HYGIENE
- PPE
- ISOLATION PRECAUTIONS (CONTACT, DROPLET & AIRBORNE PRECAUTIONS)
- N – 95 FIT TEST
- INFLUENZA VACCINATION
- MENINGOCOCCAL MENINGITIS VACCINATION

1350 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training should be completed within the first month of employment in the hospital for those newly-
hired clinical staff.

Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on HAND
HYGIENE by undertaking a practical test under the supervision of an Infection Control
Practitioner / trained observer
Health Care Personnel HCPs (HCPs) receive training & demonstrate competency on donning
and doffing of personal protective equipment (PPEs) by undertaking a practical test under the
supervision of an Infection Control Practitioner / trained observer.

Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
Purifying Respirator (PAPR) testing .

Validity of N-95 fit test is for maximum period of 2 years or as per hospital policy.

Complete mandatory vaccination Meningococcal & influenza vaccination.

a. Influenza vaccination every year
b. Meningococcal Meningitis Vaccination every 3 years

On completion of training and orientation BICSL card must be issued for a period of 02 years.
For renewal of employment, BICSL status must be valid.

Watch Basic Infection Control Skills License BICSL training module @ https://www.youtube.com/watch?v=-
XtSE7rHF3Q&feature=emb_titl

Skilled & trained HCP would have a positive impact on patient safety and prevent adverse
patient outcomes.
Substandard # 2:2 Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.
Healthcare Personnel
(HCP) receive job- Infection Prevention & control department MUST provide education & training to all health care
specific training on personnel on infection control best practices specific to their job as follows:
infection prevention
policies and Infection control Training specific to area of work must be provided initially upon hiring before
procedures upon starting their duty.
hiring and at least Continuous education on relevant infection control policies and procedures must be conducted
once annually. at least once per year.
Training will be conducted immediately without significant delay if there are new updates / new
guidelines available.

1351 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Competence implies the ability to apply learned knowledge in the number of clinical situations
Substandard # 2:3 during routine patient care activities, so the healthcare personnel must be competent to apply
knowledge & skills in to practice.
Healthcare personnel
(HCP) exhibit
Training & education activities must be followed by assessing the competency of each
professional
healthcare personnel.
competency in
IP&C Department must train and validate the competence of trained HCWs every year and a
infection control best
certificate must be provided which should be kept in staff personal files.
practices validated by
This can be correlated with the staff formal evaluation / assessment during IPCCC evaluation /
infection control
department every audit phase.
year. (Competency Provide formal feedback to HCWs on performance/
Assessment) If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational & training session must be considered.

1352 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 OCCUPATIONAL HEALTH
In order to ensure safety of waste collection staff, Infectious waste should always be segregated, collected, transported and
stored in a safe manner with consideration of the risk, occupational safety rules and should be in accordance with local
regulations. Staff should be knowledgeable about the risks and safety operating procedures of the waste they are handling.
If Medical waste is not properly managed and disposed of, it can result in injury by contaminated sharps and infection with Blood
borne pathogens.
Sub standards Explanation

IC team holds the key responsivity to ensure all allocated infectious waste workers are
vaccinated against blood borne pathogens i.e Hepatitis B vaccination etc
Infectious waste worker’s personal files are maintained in the employee health clinic. In
situation where waste workers are being immunized from the concerned company, copy
of all vaccination records must be kept in staff health files.

Medical records:
During visit of Employee health clinic (EHC) review by random selection medical records
of infectious waste workers & check if they have received vaccination against Hepatitis B.
Substandard # 3.1 Verify if they have completed the required dosing schedule.
Vaccination status of infectious waste worker must be tracked and records are completed
Allocated infectious waste even if it done outside of hospital.
workers are vaccinated
against blood borne Training & Education:
pathogens and trained on
safe handling of waste. IC team must conduct refresher training session for all infectious waste collection staff.
Provide training during IPCCC training phase.
Observe the practices during routine daily/ weekly rounds and provide corrective action
measure if needed.
Evaluate staff performance in the audit phase.

Key points for training include but not limited to: -

Safe handling of infectious waste & other waste management protocols during collection,
transportation, storage etc
Hand hygiene & PPE training
Appropriate Labelling / coding that designates an item as infectious waste
Sharp injuries & post exposure protocols etc
Cleaning & disinfection procedures

1353 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infectious waste workers are exposed to needle & sharp injuries during course of work if not
managed appropriately.
Infectious waste workers must follow the same protocols for post exposure follow up &
management as other HCWs.

IC team must ensure that waste workers are well oriented about the post exposure
management steps if they experience accidental needle stick injuries.
Substandard # 3.2 They must be trained on steps to be followed. A schematic flow chart describing steps of
post exposure management & follow up would serve as an effective reminder.
Post exposure follow up
procedures are clear and Steps include:
applicable for exposed
medical waste workers. First Aid:
- Wash needle sticks and cuts with soap and water
- Then apply isopropyl alcohol 70%
- Bandage appropriately
- Reporting the injury to immediate his supervisor
- Fill & submit and complete a reporting form (OVR : Occurrence Variance report)
- The report should include:
o Staff Information
o The date and time of the incident
o The location where the incident occurred
o Details of exposure type

1354 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 WASTE MANAGEMENT SUPPLY
Availability of waste management supply is crucial for the effective implementation of waste management plan. This includes waste collection
bags of different colors & sizes, autoclave bags, sharp containers of different sizes, liquid waste containers, waste collection & storage
trolleys, Personal protective gears , hand hygiene & disinfectant supply etc. Administration must ensure availability of all supply for
handling, transporting, and disposing infectious waste to ensure cost reduction and the safety of healthcare workers (HCWs), sanitation
workers, and the general public.
Infectious waste is categorized as:
Blood and blood products: Bulk blood, blood-tinged suctioned fluids, excretions, secretions are considered infectious waste.
Pathology waste: includes human or animal tissues such as placenta, uteruses, organs, and body parts collected at autopsy or during surgery
Microbiological cultures, stocks and microbiological waste: items containing blood or other potentially infectious materials, as well as, discarded
live and attenuated vaccines.
Sharps: used or unused sharps (e.g., hypodermic, intravenous or other needles; auto disposable syringes; syringes with attached needles;
infusion sets; scalpels; pipettes; knives; blades; broken glass). etc

Sub standards Explanation

Substandard # 4.1 Four (4) methods of waste segregation must be followed at the point of generation (i.e., by the
end user):
Waste collection yellow and - Black bags: Used to dispose of general hospital waste.
red bags match the required - Yellow bags: Used to dispose of infectious waste. Refer to categories of infectious
thickness and should be waste
tear resistant with bio- - Red Bags Use to transport body parts, organs, or fetuses for burial.
hazard logo. - Sharp Containers Used to dispose all used and unused sharps (e.g., Hypodermic,
intravenous or other needles, auto-disable syringes, syringes with attached needles,
scalpels, glass pipettes, knives, blades, broken glass).

A) Specifications of waste containers. (1)

Plastic Waste bags

Substandard # 4.2
- Should be tear-resistant and leak proof
Sharps are placed in a rigid
- Must not contain Polyvinyl Chloride (PVC).
puncture-proof and leak-
- Thickness must not be less than 70 microns thick.
proof containers with bio-
- All designated infectious waste containers should have a biohazard symbol or
hazard logo. They are
labelled with the word “Infectious” both in Arabic and English or be color-
available in sufficient
coded (i.e., yellow bags), rendering them identifiable by hospital staff.
numbers.
Sharps containers:

- Must be rigid, puncture-proof, leak-proof and closable.

- Equipped with a hermetical seal with an opening aperture which allows
insertion of sharp items (e.g., needles and lancets).
- Has a biohazard logo and labelled as “Sharp Items” which must be printed in
both Arabic and English. etc
- Ensure different sizes of sharp containers are available according to the
amount and type of sharp waste produced.

1355 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 4.3 Autoclavable bags:
Autoclavable bags for
- IC team must ensure availability of autoclavable bags for selected pathogens
selected pathogens
microbial cultures waste are available in microbiology laboratory and used.
microbial cultures waste are
- Culture plates of specified pathogens as per approved MOH list must never
available in microbiology
discarded directly into yellow waste receptacle without prior treatment in the
laboratory and used.
autoclave.

Substandard # 4.4 Yellow Liquid waste containers:

Yellow Liquid waste Ensure availability of yellow liquid waste containers for all liquid waste generated from
containers with biohazard laboratories etc
logo and tight lid prevents Must have a clear biohazard logo.
leakage are available Must have a tight well sealed lid to prevent accidental leakage /spillage etc

Substandard # 4.5 Self-lock plastic ties:

Self-lock plastic ties are Self-lock plastic ties must be available to tie the waste bags at the point of collection to be
available to tie the waste kept in temporary storage area,
bags. This will ensure that waste bags are well secured in order to prevent contamination of
environment during transportation.

Labelling:

Appropriate label must be available & used.

Each medical waste bag , sharp & liquid waste container must have a clear label posted
Substandard # 4.6 with following information:
Labels indicating the
a. Generating department
department, date and
b. Date & Time of collection
signature of the department
c. Signature of supervisor
supervisor are available and
used.
❖ IC Team holds key responsibility to ensure all required supply is available in the units.
❖ Observe the staff practices and take necessary action if any breach of practice is
observed.
❖ Periodic training & staff orientation on proper disposal and handling of waste must be
conducted.

1356 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 MEDICAL WASTE COLLECTION

Sub standards Explanation

Substandard # 5.1 Specification of Waste collection trolleys / carts: :

Medical Waste are collected Carts / Trolleys used for transportation of Infectious medical waste meet the following
from departments by a specifications.
suitable size leak-proof
containers with bio-hazard - Closed & Impervious
logo and with tightly close - Leak proof & readily cleanable
lid. - Tightly closed lid
- Clearly visible Biohazard Signage

IC Team must ensure the following during routine daily / weekly rounds:

Each unit has a schedule of waste collection within the units with specified frequency of
waste collection according to estimated amount of waste generated each day.
(Frequency of waste collection should be clearly specified in the schedule / log sheet
that must be at fixed intervals. (Every 2 hours, once per shift etc)

Substandard # 5.2 Any evidence that waste collection protocols are being followed. e.g. (In case of increased
demand etc) contact numbers to call the medical waste staff are available
Collection from departments
done at fixed time without Assigned ICPs for each unit must observe the waste receptacles to rule out if full. Bulging
delay with availability of out.
rapid response when
needed Visit the temporary holding areas i.e. dirty utility rooms etc if collection frequency is
matching with what is specified in schedule. (You may observe large number of waste
bags and sharp containers not collected as per schedule)

(PPE must be changed frequently when moving from one station to another station. Staff
must perform hand hygiene after removing PPE. This has been observed that waste
collection staff use on set of PPE throughout the hospital and use elevators with same
gloved hands contributing / posing to infection risk)

1357 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 6 Personal Protective Equipment (PPE)
Personal protective equipment, commonly referred to as "PPE", is equipment worn to protect the health care workers from acquiring infections
and other hazards. Health care personnel are exposed to multiple health risks according to nature of their work. HCPs may be exposed to
infectious agents, chemical agents, radiological materials, physical, mechanical, or other workplace hazards. Personal protective equipment may
include items such as gloves, gowns or coverall, face masks & respirators, goggles & rubber boots etc When used properly, PPE acts as a barrier
between infectious materials such as viral and bacterial contaminants and skin, mouth, nose, or eyes (mucous membranes). The barrier has the
potential to block transmission of contaminants from blood, body fluids, or respiratory secretions. Effective use of PPE includes properly removing
and disposing of contaminated PPE to prevent exposing both the wearer and other people to infection.

Sub standards Explanation

IC Team must follow up to ensure availability of required PPE items within the units. Unit
staff must follow the supply chain rules to ensure sufficient stock is available at all times
Substandard # 6:1 in coordination with infection control department.

Sufficient and appropriate PPE During routine monitoring rounds, observe the availability of PPE
are available in adequate PPE must be available at the point of use
amount, types & sizes with
proper qualities and readily Check Availability of various types of PPE in all patient care areas:
accessible to HCP.
- Different sizes & types of gloves including heavy duty gloves
- Surgical masks
- Gowns / Aprons
- Protective eye/face wear (Goggles , face shields)

Assess the quality of PPE:

- Yellow gowns: Check if fluid resistant and of thick material

- Gloves: Check if good quality or loose at wrists etc
-
Any deficiency of PPE items or poor quality of PPE such as gown / gloves must be
immediately escalated to administration in order to protect the staff from acquiring infections.

1358 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 As part of IPCCC implementation process, conduct targeted training for all categories of
staff in each quarter in order to achieve 100% coverage at the end of each year.
Train and evaluate the same staff on PPE practice as described in the manual.

Staff MUST use following PPE:

Substandard # 6:2
- Protective yellow overall
Infectious waste worker uses - Heavy-duty gloves
personal protective equipment - Protective shoes
appropriately during handling - Regular mask
medical waste (protective - Googles
yellow overall / heavy-duty
gloves / protective shoes / 1: Appropriate PPE use:
regular mask / googles)
Sequence of donning PPEs:

Perform hand hygiene

https://youtu.be/H4jQUBAlBrI Don gown. Gown should cover the body from neck to knees and should be secured at
Watch Video How to safely put neck and waist.
on PPE Don surgical facemask. Place surgical mask over nose, mouth and chin then fit flexible
nosepiece over nose bridge and secure head with ties or elastic.
Don goggles/face shield.
Don gloves. Extend gloves over yellow gown cuffs.

Sequence of doffing PPEs:

Remove gloves.
Remove gown. Unfasten ties, peel gown away from neck and shoulder, turn inside out,
fold into a bundle and discard.
Perform hand hygiene.
Remove goggles/face shield
Perform hand hygiene.
Remove surgical mask.
Perform hand hygiene.

1359 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Hand Hygiene
Hand hygiene is the cornerstone of infection prevention & control activities. Practicing hand hygiene is a simple yet effective way to prevent
infections. Cleaning hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult to
treat. On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 31 hospital
patients has at least one healthcare-associated infection.

Sub standards Explanation

Availability of hand hygiene supply (Alcohol based hand sanitizers, antiseptic soaps, paper towels etc.)
Substandard # 7:1 in all patient care areas, nursing stations and other appropriate places is crucial for effective
implementation of hand hygiene program.
Hand washing
facilities and Hand Washing Facilities:
supplies (sinks with
hot & cold water / Infection Preventionists must ensure during daily/ weekly rounds that hand washing facilities are
plain liquid soap / available that meet the needs of the unit and are clean and in good repair.
paper towels, Observe availability of water supply (hot and cold) for hand washing (Place hands under the water
Alcohol - based tap if hands free operation or open the tap to check for hot & cold water supply)
hand rub dispenser) Observe the availability of following supplies: 1: Plain (non-antimicrobial) soap Paper Towels for
is available in waste drying
room.
Hand Rub Dispensers:

- Check the availability of hand rub dispensers as per requirements:

One dispenser at appropriate location..

❖ The dispensers should not be installed over or directly adjacent to electrical outlets and switches.
❖ Randomly open dispenser to check if hand sanitizer is available & not expired.

1360 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 7:2 Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand antisepsis
Hand washing – washing hands with plain or antimicrobial soap and water.
Infectious waste Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
worker without the need for an exogenous source of water and requiring no rinsing or drying with towels or
demonstrates other devices.
appropriate
techniques for hand IC Team must ensure training on hand hygiene practices during IPCCC training phase:
washing and hand
rubbing - Each healthcare personnel must be well trained on how and when to perform hand hygiene with
appropriate technique and recommended duration.
- During routine monitoring rounds, observe the practice of staff, whether they are compliant with
hand hygiene or not. Assess if they are following the recommended duration, steps and technique
of hand rubbing & hand washing.
- Assess the competency during IPCCC audit phase by asking staff to demonstrate hand hygiene.

2: Hand rub technique:

Hand rubbing / cleansing with an alcohol-based hand rub is accomplished by applying alcohol-based
hand rub into palm and briskly rubbing over all surfaces and under nails until dry.

- Apply a 3-5ml of the product in a cupped hand and cover all surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa
- Palm to palm with fingers interlaced
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
- Duration of the entire procedure: 20-30 seconds once dry, your hands are safe.

3: Hand washing technique:

Hand washing with plain or antimicrobial soap includes following steps:

- Wet hands with water

- Apply enough soap to cover all surfaces
- Rub hands together vigorously for at least 15 seconds, generating friction on all surfaces of the hands
and fingers
- Rub hands palm to palm
- Right palm over left dorsum with interlaced finger and vice versa
- Palm to palm with finger interlaced
- Backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm and vice versa
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa, (to remove debris from under the fingernails
- Rinse hands with water
- Dry thoroughly with a single-use towel
- Use towel to turn off faucet/tap
- Duration of the entire procedure: 40-60 seconds and your hands are safe

1361 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must provide and ensure availability of visual alerts at appropriate places; besides each
Substandard # 7:3 hand rub dispenser, hand washing sink etc would serve as quick reminders for staff hence
incorporating the culture of best practices.
Visual alerts are
available: ❖ Observe availability of visual education tools / Visual alerts for staff reminders at workplaces are
how to do hand rub, posted at appropriate places.
how to do hand
wash. - How to hand wash poster beside ach hand washing sink
- How to handrub poster beside each hand hygiene dispenser

1362 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard - 8 MEDICAL WASTE STORE SPECIFICATIONS

The medical waste store must fulfil the MOH specification. is consistent with the approved national specifications (adequate in
space, away from traffic, secured, well ventilated with temperature <18 °C., provided with water source & adequate drainage,
and its walls & floors are easily cleanable

Sub standards Explanation

Substandard # 8.1
Medical Waste room must fulfil the following national specifications:
Located away from traffic &
other hospital services with Location & Security:
clearly visible biohazard Medical waste room must be located away from patients & visitors traffic & other hospital
symbol / signage. services.
Biohazard signage posted which is clear and visible to alert the traffic.
Substandard # 8.2 Secured and locked i.e Door is closed all the time and only authorized persons are allowed
to enter
Fit the size of the expected
waste production of the
facility based on the Infrastructure:
maximum allowed duration Must have adequate space to fit the size of the expected waste production of the facility
of waste storage of 24 based on that the maximum duration of waste storage in 24 hours.
hours. Walls and floors are smooth and of easily cleanable material. No cracks, openings etc
Angles and places of convergence of the ceiling, walls, and the floor are curved for easy
Substandard # 8.3 cleaning and disinfection.
The room must have a smooth floor (easy cleanable) and door well-sealed to protect it
Door is closed all the time
and only authorized persons from water leakage, rain, and spread of odour, rodents, insects, birds and stray animals.
are allowed to enter. Have source for clean water and discharge slot for the purposes of cleaning and
disinfection.
Substandard # 8.4 Sewage hole must be well sealed.
Only relevant items and required supply are kept inside the store. It must never be used to
Never used to store other store other unrelated items e.g. personal belongings or food items etc
unrelated items.

1363 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 8.5 Ventilation Parameters:

Floors, walls and ceilings Well ventilated with temperature monitor (displaying temperature <18 °C).
are one piece without cracks Records must be available in the area for purpose of verification.
and coated with materials
tolerant to repeated cleaning
Cleaning:
and disinfection.
Medical waste room must be clean and well maintained.
Substandard # 8.6
Equipped with hygiene washing sink with required supplies like soap paper tissues
Angles and places of
convergence of the ceiling, a) During routine rounds IC team must ensure that all infection control measures are
walls , and the floor are followed.
curved for easy cleaning b) Observe the amount of waste bags stored and randomly check the labels for dates if
and disinfection. following the protocols of waste transportation outside the facility for final disposal.
c) Supervisor must keep records for daily collection & final treatment of waste by the
Substandard # 8.7
company.
Have source for clean water d) Observe how the waste bags are arranged. They must never be kept directly over the
and discharge slot for the floor or piled up on top each other.
purposes of cleaning and e) Evaluate the store if all specifications are met during IPCCC audit phase. Communicate
disinfection all findings and deficiencies to the supervisor in the form of formal feedback for
necessary corrective actions.
Substandard # 8.8
Train & evaluate performance of infectious waste workers.\
Well-equipped hand hygiene
Assess competency to ENSURE they have met all training requirements for
sink is available.
implementation of appropriate infection control measures.
Substandard # 8.9

Ventilation temperature
should not exceed 18˚C.

1364 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Housekeeping & Unit Environment
Environmental cleaning and disinfection is of significant importance in healthcare facilities. Cleaning and disinfection of the patient care
environment is an important aspect of preventing transmission of microbes that can lead to patient and staff harm. Failure to comply with
environmental cleaning protocols would result in infection transmission within the healthcare settings. The determination of environmental
cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen
transmission. Environmental cleaning principles includes following:
1. Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough environmental cleaning than
moderately & lightly or non-contaminated surfaces and items.
2.Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g., immunosuppressed) require
more frequent and rigorous environmental cleaning than surface and item areas with less vulnerable patients.
3.Potential for exposure to pathogens: High-touch surfaces (e.g.,tap handles door knobs etc.) require more frequent and rigorous
environmental cleaning than low-touch surfaces (e.g., walls).
Appropriate cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of
healthcare-associated infections.
Cleaning is the physical removal of foreign and organic materials on objects or surfaces with the use water, soap or detergents, and
mechanical friction (scrubbing action).
Disinfection is the process that kills and prevents microbial growth on surfaces and equipment using appropriate disinfectants.

Sub standards Explanation

Availability of approved disinfectants is important for effective implementation of
environmental surfaces disinfection standards.
Substandard # 9.1
Review the availability of disinfectants in daily/weekly rounds. Ask the head nurse to
provide checklist to ensure availability and adequacy of different variety of disinfectants.
Adequate MOH approved
disinfectants are available in Ensure disinfectant is MOH approved & appropriate for the area / surface to be
the department. disinfected.
(Provide units with list of approved disinfectants with dilutions and contact time and suitability
for intended area / surface based on manufacturer’s recommendations)

All work locations where employees may come into contact with blood or other potentially
infectious material must have blood spill kits available to safely and effectively clean up any
Substandard # 9.2 spills.

There is at least one spill kit The spill kit must include the following:
available in the department.
- Personal protective equipment (PPE) such as gown, gloves, eyewear, mask.
- Supplies such as forceps, plastic scoop and scraper, absorbent granules or
absorbent pads,
- hospital-approved disinfectant,
- yellow plastic bag and sharp container.
IC Team must ensure that each unit have at least one biological spill kit to manage any
accidental spill of blood or body fluids (e.g. Vomitus) in order to avoid risk of
contamination & infection transmission.
Check the availability of the biological spill kits in the area and review if the contents are
complete and not expired.

1365 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 During the training phase of IPCCC implementation process, provide training to the
housekeeping staff / nursing staff on the appropriate use of spill kit. Explain its
importance and hazards if not done according to recommendations. Video demonstration
would be more beneficial.
Nursing staff must supervise the entire process in order to ensure spill is managed
appropriately in hospitals where housekeeping staff are responsible for biological spill
clean-up as per policy.
During audit phase of IPCCC, ask the same Nursing / housekeeping staff to demonstrate
Substandard # 9.3 management of blood spill who had received prior training.
Provide feedback on performance and correct the mistakes. (If any)
HCW knows how to use spill
kit properly. STEPS INVOLVED when cleaning and decontaminating spills of blood or other potentially
infectious materials:

Control access to area:

Prevent people from walking through affected area and spreading the blood or other potentially
infectious material to other areas.
Use the signage for wet floor sign

Contain spill:
Use other absorbent granules or absorbent pads to contain the spill.
Put on appropriate PPEs.
Use plastic scoop or other mechanical means to remove any broken glass or other sharp objects
from the spill area, and dispose into the sharp container.
Sprinkle absorbent granules over the spill and leave for two minutes or as per the manufacturer’s
recommended contact time. Allow the spill to solidify before removing.
If there is no available absorbent granules contain the spill by placing absorbent pads (i.e. paper
towel) on top of the spill and apply the appropriate disinfectant. To avoid creating aerosols, never
spray disinfectant directly onto the spilled material. Instead, gently pour disinfectant on top of paper
towels covering the spill or gently flood the affected area, first around the perimeter of the spill,
then working slowly toward the spilled material. If sodium hypochlorite solution (5.25% household
chlorine bleach) is used, prepare a fresh solution on a daily basis. Leave for the recommended
contact time.

Substandard # 9.4 Scheduling of cleaning and disinfection activities and subsequent documentation in cleaning
logs /checklists is extremely important to ensure effective implementation & to have the
Cleaning is done properly documented evidence of regular cleaning process. Head nurse must ensure cleaning process
using checklist that include is done & documented appropriately as per schedule.
cleaning frequency,
responsible worker, Each unit must have the schedule for cleaning and disinfection activities.
housekeeping surfaces (e.g.,
floors and walls), used Schedule must include the frequency, the used disinfectant and the responsible staff.
agents, methods & Roles must be specified with clear instructions.
environmental surfaces
intended to be cleaned.

Infection control practitioners must ensure that infectious waste workers follow
Substandard # 9.5 instructions for regular cleaning & disinfection of medical waste containers and collection
trolleys
Cleaning and disinfection of Following must be ensured:
medical waste containers
and collection trolleys are - Infectious waste staff must regularly clean and disinfect medical waste containers &
done with approved MOH waste collection containers with MOH approved disinfectants.
disinfectants . - Staff must be knowledgeable about the appropriate dilution & contact time of dinfectants.

1366 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must conduct training of housekeeping staff in coordination with environmental
services supervisor followed by monitoring & auditing the staff practices.
All housekeeping staff shall be made aware of and adhere to Isolation Precautions, Standard
Precautions and Safety data sheet (SDS) instructions in patient care areas and must be
educated on the cleaning agents, disinfectants, proper dilution and contact time.
Training must include following key parameters:
Substandard # 9.6
Housekeeping staff must adhere to Standard Precautions and if required Expanded
Precautions when performing routine practices of cleaning and following infection control
Housekeepers are well
measures. Routine practices related to environmental cleaning include:
trained on hand hygiene,
proper use of PPE, methods
HAND HYGIENE:
of cleaning & proper & safe
mixing of chemicals. Hand hygiene as the most important and effective measure to prevent the spread of
healthcare associated infections. Hand hygiene must be practiced:
Before initial patient environment contact (e.g., before coming into the patient’s room
or bed space).
After potential body fluid exposure (e.g., after cleaning bathroom, handling soiled
linen, equipment or waste).
After patient environment contact (e.g., after cleaning client/patient/resident room;
after cleaning equipment such as stretchers; after changing mop heads).
After using the toilet.
It is necessary to clean hands after removing gloves. The use of gloves does not replace the
need for hand hygiene.

PERSONAL PROTECTIVE EQUIPMENT (PPE):

Cleaning staff should wear and use Personal Protective Equipment (PPEs):

Gloves - when there is risk of hand contact with contaminated items with blood and
body fluids.
Gown - if contamination of uniform or clothing is anticipated (e.g., cleaning bed of
incontinent patient).
Mask and eye protection or face shield - where appropriate to protect the mucous
membrane of the eyes, nose and mouth during activities where sprays of secretion
are likely
Provide training on appropriate technique & Steps of PPE donning & doffing.
Train regarding type of PPE items to be worn during different cleaning activities
according to location / area.

METHODS OF CLEANING:

Provide training on proper use of dusting methods for all patient care areas
especially immunosuppressed patient’s areas.
Horizontal surfaces should be wiped at least daily or in between patients’ all high
touch horizontal surfaces (e.g., in procedure rooms) and when visibly soiled with a
clean cloth impregnated with a hospital-approved disinfectant
Mop from cleaner to dirtier areas.
Mop in a systematic manner, proceeding from area farthest from the exit and
working towards the exit (Figure).
Use of wet floor or caution signs to prevent injuries.
Never shake mop heads and cleaning cloths—it disperses dust or droplets that could
contain microorganisms.
Never leave soiled mop heads and cleaning cloths soaking in buckets.
Prepare cleaning solution daily, or as needed and replace with fresh solution as needed.

1367 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Emphasize during training and monitoring phase on appropriate cleaning practices.
Substandard # 9.7 Evaluate the cleanliness of environmental surfaces during IPCCC rounds /
Observe presence of any blood stains on floors etc.
Environmental surfaces are In order to ensure if appropriate cleaning was done. wipe a surface that you suspect it’s
clean and free from soil and not clean or surfaces hard to reach Open lockers or cabinets and check for its cleanliness
dust. from inside. In stock rooms check for dust inside containers which are placed close to
wall.

Infection control team must ensure strict adherence of housekeeping staff to cleaning
Substandard # 9.8 protocols.
Housekeeping equipment’s including mops, bucket must be kept clean and dry after use.
Housekeeping equipment is Housekeeping staff MUST NEVER leave soiled mop heads and cleaning cloths soaking in
kept clean and dry after use. buckets.
Mop heads must be sent to laundry unit after use.

The presence of cockroaches, flies, maggots, ants, mosquitoes, mice, rats, and other pests
indicate an unhealthy environment in a healthcare facility. The key to minimizing pests is to
Substandard # 9.9 eliminate food sources, eradicate areas for nests and burrows, install screens on windows
and doors, seal off penetrations to the outside, and apply pesticides as a last resort.
There is a regular schedule
for pest control including the Infection control must develop a schedule for pest control in different units.
frequency, date, time & Schedule must include frequency of pesticide spraying, date & time of spraying.
approved pesticides being Pesticides used MUST be approved & not included in the list of banned pesticides: Refer
used. to GCC manual for list of banned pesticides. (ICM - X- 08 Pest Control Pg 377)
Regular follow up must be done with environmental services staff to ensure if pesticidal
spraying was done and only approved postcodes were used.

1368 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Infection Control Precautions in Special Situations (e.g COVID - 19
Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.
Substandard # 10.1 Following must be ensured:

Daily logbook is - All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
activated in the unit book.
for HCWs to record - This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
presence or absence symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
of fever, respiratory & - Head nurse holds the key responsibility to ensure that log book is complete and signed by all
GI symptoms etc. HCWs on daily basis.
before starting work - Head nurse must review to assess the need for any staff to be evaluated by occupational health
shift. clinic or need work restriction.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.
Use attached template.

1369 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
Substandard # 10.2
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.
All HCWs must abide
by the policy of In health care settings, First and foremost, a mask is a core component of the personal protective
universal masking i.e equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
wearing surgical face in conjunction with gown, gloves, and eye protection.
mask at all times while
in their respective All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
clinical setting. expected to wear surgical face masks, at all times, while in their respective clinical care settings.

This universal mask approach will serve to:

Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a
mask achieves source control and decreases the risk of spreading infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have
mild COVID-19 infection that have not yet been recognized .

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt accordingly.

Universal Masking Guidance

A single mask can be worn across different cases and between cares of different patients.
When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
Masks must be changed if they become wet or contaminated during a case.
Surgical mask is not allowed to be worn outside the clinical care areas.
Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette and
frequent hand hygiene.

Process to Use and Discard Surgical Mask:

A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
Masks will be available at each entrance to the unit, and will be used throughout the shift.
In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
Medical waste containers will be placed at each exit for the used masks to be discarded.

1370 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.

Social distancing / physical distancing is a mean for keeping a safe space between oneself and other
people. To practice social / physical distancing, there MUST be distance of at least 6 feet (about 2
arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 10.3 prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers, mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
visitors & Patients droplets can also be inhaled into the lungs.
strictly adhere to the
principles of social Recent studies indicate that people who are infected but do not have symptoms likely also play a
distancing, cough role in the spread of COVID-19. Since people can spread the virus before they know they are
etiquette and frequent sick, it is important to stay at least 6 feet away from others when possible, even if they do not
hand hygiene during have any symptoms.
duty hours / visiting Cough Etiquette:
hospital.
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross ‐
transmission of these organisms to others occurs when we fail to wash hands effectively.
Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1371 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
Substandard # 10.4 must provide full support to IC department to ensure stringent implementation of infection control
measure to prevent transmission within the healthcare facilities from patient to HCW, patient to
Interdepartmental another patient, HCWs to patients & in between HCWs.
mobility of healthcare
workers is strictly Following must be ensured:
prohibited unless
related to work Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
(Medical Waste clinical staff) to avoid the unnecessary mobility in between the units.
Collection etc) Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary, Medical Waste Collection etc

1372 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1373 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1374 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 COVID – 19 DAILY MONITORING LOG SHEET FOR HEALTHCARE
WORKERS
UNIT -------------------------- DATE ------------------------ TIME /SHIFT ------------------------

All HCWs MUST check in before starting work shift. Symptomatic staff must be excluded from work and notified to infection control department

Name: Name: Name: Name: Name:

ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______
Name: Name: Name: Name: Name:
ID: ID: ID: ID: ID:
Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig: Job Title : Sig:
□ No symptoms □ No symptoms □ No symptoms □ No symptoms □ No symptoms
□ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C □ Fever_____ °C
□ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath □ Shortness of breath
□ Sore throat □ Sore throat □ Sore throat □ Sore throat □ Sore throat
□ Cough □ Cough □ Cough □ Cough □ Cough
□ Runny nose □ Runny nose □ Runny nose □ Runny nose □ Runny nose
□ Headache □ Headache □ Headache □ Headache □ Headache
□ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain □ Muscle/joint pain
□ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day □ Diarrhea __ times/day
□ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea □ Vomiting/nausea
□ Others________ □ Others________ □ Others_________ □ Others_________ □ Others_______

1375 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 OThers

# NAME OF UNIT PAGE #

01 INFECTION CONTROL DEPARTMENT 1377

1376 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 INFECTION CONTROL
DEPARTMENT

Infection Control is the discipline / process by which

health care facilities develop and implement specific policies and procedures to
prevent the spread of infections among health care staff and patients.

Infection Preventionists play a significant role in providing high quality patient care by
continuous monitoring and surveillance activities to reduce the risk of healthcare
associated infections.

Professional development is essential to keeping the Infection Preventionists up to

date with latest knowledge, skills & strategies for preventing infections.

1377 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
IPCCC - STANDARDS IN Infection
control department

HOSPIATAL LEADERSHIP SUPPORT

HUMAN RESOURCES
INFECTION CONTROL DEPARTMENT

INFECTION CONTROL PROGRAM

INFECTION CONTROL ANNUAL PLAN

INFECTION CONTROL COMMITTEE

INFECTION CONTROL POLICY & PROCEDURE

INFECTION CONTROL EDUCATION & TRAINING

CONSTRUCTION & RENOVATION

HAND HYGIENE PROGRAM

SURVEILANCE OF HAIs & DEVICE ASSOCIATED HAIs

PATIENT's CARE BUNDLES FOR PREVENTION OF HAIs & MDROs

ANTIMICROBIAL STEWARDSHIP PROGRAM (ASP)

ANTIBIOGRAM

OUTBREAK MANAGEMENT

OCCUPATIONAL HEALTH

IC PRECAUTIONS IN SPECIAL SITAUTIONS (e.g COVID -19)

1378 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 INFECTION CONTROL DEPARTMENT

Standard – 1 HOSPITAL LEADERSHIP SUPPORT

Leadership support is critical & key driving force for effective implementation & functioning of infection prevention & control programs. The
consistent application of proper infection control principles and practices in all healthcare activities is necessary to achieve the goals of optimum
patient safety and ensure best outcomes. Without leadership support & commitment, it would be difficult to yield a healthy and safe environment
for patients, staff, and visitors.

Sub standards Explanation

Availability of adequate resources is crucial to ensure timely completion of all IC tasks. IC team must
review the current resources and seek for administrative support for provision of all required items:
Substandard # 1.1
Following must be available:
Adequate
resources are Infection control office / department with provision of all required resources. (Computers, printers,
allocated to photocopiers & reliable internet service etc.)
infection control
Department (e.g., The number of computers provided for the IC department must match with the number of Infection
offices, internet control preventionists working in the unit. (Ideally each ICP should have a separate computer with
access, IT support internet connection. But if separate computer not provided for each ICP, would be acceptable if it’s
...etc.) not interfering with continuity of work if there is careful division of daily tasks)

IPC team must have a backup plan to ensure the continuity of work if the internet service is
interrupted.
IC practitioners should be able to access HESN & other online reporting system to regional
directorates & GDIPC with out any hindrance as majority of data reporting is via electronic
mechanism.
There must be efficient IT support to ensure all IT functions are resumed without any significant
delay.
IC team must have direct access to patients & lab data to carry out daily surveillance activities.

1379 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC department must have a plan for continuous supply of PPE that must be implemented in all units.
Provision of PPE checklist for monitoring consumption in all units.
Develop electronic database / Excel spreadsheets as a mechanism of monitoring consumption of IC
supply & to ensure adequacy. This will help in tacking consumption and need assessment for each
Substandard # 1.2 unit.
Keep a documented supply chain / flowchart describing mechanism of supply request from units to the
Adequate infection supply store & role of infection control.
control supplies Prepare a contingency / emergency plan to address the shortage in outbreak situations & other
are provided to unforeseen situations e.g COVID – 19 Pandemic in order to ensure continuous supply of PPE,
HCWs for disinfectants & other IC supply (e.g. Direct purchase, contract with neighbouring hospitals,
successful IC emergency stock not used in routine etc
program (e.g.,
PPE, disinfectants Rationale: In outbreak situations there is increased consumption of IC supply including PPE, hand
...etc.) sanitizers, disinfectants etc so there should be a clear plan to address increased demand in such
unforeseen situations).

IC Team must observe and ensure the following during routine daily / weekly rounds:

Observe the availability of infection control resources and supplies including PPEs (Gowns - clean,
sterile) gloves, (clean, sterile) face shields / eye goggles, Surgical masks, different sizes of N-95
masks, disinfectants, Hand rub dispensers, waste receptacles, sharp containers etc in all units.

Visit the stock room for verification & check the PPE trolleys to ensure enough supply is available.

Randomly open the hand rub dispenser to check for availability of hand sanitizers & if date is valid or
expired

Ask the nurses in charge about the current stock situation including the quality & address the urgent
need items on priority basis that pose significant risk for patients & staff (e.g shortage of N -95 masks,
poor quality gowns & gloves, suction catheters, shortage of sterile kits etc. Investigate the shortage
with the person in charge, when it is clearly observed & issue raised to administration via official
request.

1380 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ICPs must ensure availability of following in the unit as evidence of IC authority to implement all
Substandard # 1.3 Infection Control (IC) policies & procedures in the hospital.

Infection control Statement of authority approved by the hospital director / hospital infection control committee.
team is given full Statement of authority is reviewed and authenticated by the administration of the institution at least
authority to every three years or sooner, as per policy.
implement the The Director of the Infection Prevention and Control Program with his team has the key responsibility
Infection Control and authority to establish policies and procedures for the instruction of healthcare personnel and for
(IC) policies & the overall supervision of infection prevention and control activities in the hospital.
procedures. IC team must keep authority statement and MEMO circulated by top administration office to all units
stating authorization of IC team with regard to infection control practices as the documented evidence
to be presented to the external audit teams.(MOH – CBAHI etc)

IC team must observe and ensure the following:

IC Team members have been given the appropriate attention & respect by the heads & staff of other
departments during daily rounds, training & education activities etc.
IC team can exercise full authority to make decisions and to influence field implementation of all
infection control measures.
Any breach of practice that could compromise the patient safety must be noted and communicated to
relevant heads and hospital director immediately.
All comments, remarks, recommendations and commands related to patient care must be well taken
and followed by the all HCWs.
Heads of the departments must continuously work on IPC improvements & corrective actions if any
breach of IC practice was communicated to them based on internal & external audit findings.

1381 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hospital leadership must provide all necessary support to the IC team if some IC functions are
outsourced to external company.
Substandard # 1.4
Following documents must be kept as documented evidence:
Hospital leaders
support IC 1: Contract of outsourced service: (Laundry / kitchen etc)
personnel
supervision when Contract must be validity with clear description of policies related to out sourced service. (Most
some functions are common outsourced functions are laundry, dietary service and CSSD in some hospitals etc
outsourced (e.g. For instance if Laundry service is outsourced, contract must incorporate details of the collection &
laundry or dietary transportation of the soiled and clean linen including transportation carts, frequency of linen collection,
services) processing of linen with temperature specifications & disinfectants to be used & agreement on
frequency of inspection visits by hospital IC team etc

2: Inspection visit checklists / tools :

Develop the checklist incorporating all details of IC measures in the relevant outsourced service
(Laundry, kitchen etc) based on the referenced guidelines (MOH, CDC etc)
Laundry checklist should contain important items like policies & procedures, direction of workflow,
availability of hand hygiene facilities, washing cycles: high temperature wash (heat disinfection) -
water temperature is at a minimum of 71°C for 25 minutes : low temperature wash cycle (Chemical
disinfection) (22°C C-50°C), sodium hypochlorite is added as a disinfectant during bleach wash
cycle. etc

3: Inspection visit report & action plan:

Keep the records of inspection visits conducted for all outsourced functions.
Report must be sent to the outsourced service team & they must be instructed to submit corrective
action plan based on the findings of visit report.
Inspection / Audit visit should be conducted to outsourced laundry unit at least once in each quarter
by IC Team in collaboration with environmental health team.

4: Leadership Support:

Leadership must consider change of outsourced service if any major breaches has been observed in
repeated visits and no corrections actions had been taken by the outsourced service
For example, if the quality of processed linen is not meeting the expectation of end user or food
quality is not safe to be served to the patients. (Hospitals where both kitchen and laundry services
are outsourced)

1382 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 2 Human Resources
The role of infection preventionists has expanded as a result of the emergence of new diseases, changes in the healthcare delivery system,
social and political factors, such as the shortage of nurses; mandatory reporting of healthcare-associated infections; the need for emergency
preparedness plans and an increased focus on patient safety. The functions of an infection preventionist includes but not limited to surveillance
and epidemiological investigation, identification of infectious diseases, prevention and control of disease transmission and program
management, communication, training and education etc. Infection preventionists also use their skills & experience to monitor and prevent non-
infectious adverse outcomes related to the patient safety. Despite the increased roles of infection preventionists, staffing ratios have been
declining, therefore it’s a dire need to ensure adequate number of IC personnel for smooth functioning of Infection Prevention & control
programs for patients, staff & visitors safety.
Sub standards Explanation

Infection Control Director must fulfil criteria as per substandard to be eligible for the post of infection
control director. All updated relevant documents / certificates must be present in personal files.
Substandard # 2.1
Assignment Letter / Job Description:
For hospitals ≥ 150
beds: the director of
Infection control Director must be working as full time in the department as per assignment letter
IC department is full
from HR/administration & a clearly stated job description with roles and responsibilities of IC
time personnel
director as full time.
qualified in infection
control through
CV, certificates & training evidence:
certification, training
AND experience for
The personal file of the IC director must have evidence reflecting educational background .
two years at least.
(Physician, nurse, microbiologist, public health Specialist etc)
All relevant degrees / certifications in infection Control (Masters in Infection Control, CIC, Diploma
in infection Control etc) must be present in Personal files.
Substandard # 2.2
Attendance in training activities (local, national, international conferences, workshops, seminars
& symposiums etc)
For hospitals < 150
There must be evidence of at least 02 years of experience in infection control.
beds: the director of
It’s not mandatory for Infection Control Director to be a physician / doctor. As long he / she is
IC department is a
qualified based on abovementioned credentials and working full time this substandard would be
full time personnel
fully met.
qualified in infection
control through nce
- IC Director must have knowledge and skills about infection control to lead the department.
for two years
- Must show full involvement in development / review of policies and procedures.
certification, training
- Clear role in surveillance activities and implementation of other IC measures.
and experience at
- There must be division of time for data management, policy & procedure development,
least. (SI)
education, employee health, quality improvement, program development, consulting &
managing potential outbreaks etc
-
Infection Control Director will be considered working as FULL TIME in the infection control department
only if the below mentioned criteria is fulfilled:

- Available and accessible at all time and dedicate 100% of working hours to infection control
departmental activities.
- IC Directors DO NOT hold any additional administrative tasks (e.g. Medical Director, etc.)
- Exception for ID consultants and clinicians who will be considered FULL TIME only if they
spend 3 out of 5 working days OR dedicate 70% of working hours to the Infection control
departmental activities with no additional tasks.

1383 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 2.3 IC department must have a clear organization chart for the reporting authority of the IC program
director.
Director of IC
program reports Organogram should clearly delineate that IC director is directly reporting directly to top
directly to the management and not to assistants / assigned designees, quality director or any other
highest administrative personnel.
administrative
authority (General Infection Control Director MUST report directly to the hospital or medical director both in verbal and
director or Medical written communications.
director of the
hospital). Organizational chart must be available / posted in the department.

1384 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Staffing requirement for the IPC department is based on the bed capacity of the hospital, critical
care units.
- For ICP requirement in the dialysis unit its related the number of patients dialyzed each day.
Substandard # 2.4 IPC team must ensure availability of following documents in the to be presented to external inspection
At least one full time teams/ auditors.
IC practitioner is a) IC departmental organizational chart.
assigned for every b) Document stating bed capacity of hospital including emergency beds, dental chairs,
100 regular beds inpatient location beds & others etc
including medical c) Document showing bed capacity of each critical care unit. (ER, PICU, NICU etc) where
departments, ventilation and hemodynamic monitoring are routinely performed.
surgical d) Document showing number of dialysis beds / chairs in Haemodialysis unit.
departments, dental e) Number of dialysis sessions done per day.
units …etc.
Required number of ICPs in relation to total bed capacity:
Substandard # 2.5
- 001 – 100 beds : 1 ICP is needed
- 101 – 200 beds : 2 ICPs are needed
An additional one IC - 201 – 300 beds : 3 ICPs are needed
practitioner for each - 301 – 400 beds : 4 ICPs are needed
30 beds in critical - 401 – 500 beds : 5 ICPs are needed & so on
care units (e.g. ICU,
PICU, ER, burn unit ICP s must have clear work schedule of ICPs for allocation of tasks as per requirement in all areas
…etc) (at least of hospital according to the scope of services.
one). ICPs must be clear about work distribution & responsibilities in the IC department to avoid
confusion, duplication or missing of tasks. (e.g. Hand hygiene observations, surveillance
activities, monitoring & evaluation, education & training etc)
Substandard # 2.6
Required number of ICPs for Critical Care Units:

An additional one IC - < 30 beds : No additional ICP is needed

practitioner for each - 30 – 59 beds : 1 additional ICP is needed
120 dialysis patients - 60 – 89 beds : 2 additional ICPs are needed
per day (at least - 90 – 119 beds : 3 additional ICPs are needed & so on
one).
Required number of ICPs for Dialysis Units:

- < 120 dialysis patients per day (1- 119 sessions) : No additional ICP is needed
- 120 dialysis patients per day (120 & above) : An additional ICP is needed

1385 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control Practitioners must fulfil criteria as per substandard to be eligible for the job of
infection control practitioner . All updated relevant documents / certificates must be present in
personal files.

CV, Certificates & Training evidence:

- Keep updated personal file with educational background (Physician, nurse, microbiologist,
medical technologist, public health Specialist etc)
- Evidence of degrees / certifications in infection Control (Masters in infection Control, CIC,
Diploma in infection Control etc)
Substandard # 2.7
- Attendance in training activities (local, national international conferences, workshops,
seminars & symposiums etc)
a: IC practitioners
- There must be evidence of at least 01 years of experience in infection control.
are qualified in
- Departmental continuous educational activities conducted inside the hospital. Check for
infection control
schedule of CME activities, content delivered and attendance sheets to ensure 100% of
through
Infection Control staff has attended with competency assessment.
certification, training
or have experience
The infection control Director & Infection Control Practitioners must have the knowledge and
of at least one year.
expertise in microbiology, epidemiology, sterilization and disinfection, infectious diseases,
antiseptic usage, clinical practices and statistics. The Infection Preventions functions in pivotal
b: ICPs should have
roles as educator, investigator, researcher, patient advocate, agent of change, consultant,
updated infection
statistician, sanitarian, role model & a coordinator.
control skills and
knowledge through
Professional development is essential to keeping infection preventionists up-to-date with the latest
continuous medical
knowledge, skills & strategies for preventing infections.
education program
and attendance of IC
Competence has been defined as essential knowledge, behaviours & skills that an individual
scientific activities.
possess and demonstrate in a specific discipline. It implies an expert level of knowledge and skill
that is transferrable to the practice of Infection Prevention & Control. (Simply stated , It’s the ability
to put knowledge into action)

Infection Preventionists must acquire skills & knowledge to critically review and understand the
scientific evidence regarding infection prevention interventions & engage and educate a diverse
group of stakeholders (e.g. Physicians, nurses, lab & radiology technicians, respiratory therapists,
environmental services staff & administrators etc

In order to keep up with updated skills and knowledge following must be considered:

1) Develop a culture of mandatory daily / biweekly / weekly departmental training activity of 30-40
minutes’ duration) led by IC director.
2) Prepare the annual education plan of IC departmental training activities.
3) Topics and contents to be divided among IC director & ICPs according to speciality and
assigned areas. This will keep the IC team updated and develop communication skills.
4) ICPs can present and discuss relevant substandard as per assigned units / departments for
IPCCC activities. (Use the attached template)
5) Ensure to review & refresh all IC substandard and infection control concepts at least once per
year.

1386 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 3 Infection Control Program

Infection Control is the discipline / process by which health care facilities develop and implement specific policies and
procedures to prevent the spread of infections among health care staff and patients.
An Infection Prevention and Control (IPC) programme is the most important component of safe, high-quality health service
delivery. IC program implemented in the hospital is critical not only to prevent HAIs but also to prepare for and respond to
communicable diseases crises like COVID – 19 pandemic etc.
IPC programme with a dedicated, trained team should be in place in each acute health care facility for the purpose of preventing
HAI and combating AMR through IPC good practices. Purpose of IC program is to eliminate the risk of HAIs and work related
infections within the healthcare facility through the implementation of established guidelines and policies.
IC Teams need to incorporate a set of essential core components to help plan, organize and implement an IPC programme.
Core components, together with their constituent elements, should be implemented in line with the priorities of the IPC
programme and the resources.

Sub standards Explanation

IC team must develop a comprehensive infection prevention & control program incorporating
following core elements included but not limited to:
Substandard # 3.1
- Introduction
There is a program to
reduce the risk of - Goals , Mission & Vision of IC Program : Goals of the infection control program need to be
(HAIs) which involves incorporated into the mission statement of the facility. A mission statement should tell who you
patients, staff, are, what you do, and should communicate a clear view of purpose and set a strategy for
trainees, volunteers, accomplishing the goals e.g. “Our mission is to promote a healthy and safe environment by
families and visitors. preventing transmission of infectious agents among patients, staff and visitors”

- Organizational structure of the IPC program (IPC staffing & responsibilities)

- Infection Control Committee
- Scope of service : Activities performed by the Prevention and Control of Infection Department
members fall within the current Prevention & Control of Infection standards and these include the
following:
- Surveillance of Healthcare associated infections & Antimicrobial Resistance (AMR).
- IPC activities related to patients, visitors and health care workers’ safety and the prevention of
AMR transmission. (Hand hygiene program, respiratory protection program. Employee health
Program etc
- Development or adaptation of guidelines and standardization of effective preventive practices
(standard operating procedures) and their implementation.
- Ensuring implementation of at least: - standard precautions - transmission-based precautions -
appropriate selection and use of IPC supplies (for example, personal protective equipment,
hand hygiene products, antiseptics, etc.) –
- Assurance that patient care activities are undertaken in a clean and hygienic environment and
supported by adequate infrastructures.
- Maintaining effective aseptic techniques for health care practices.
- Reduce risks associated with procedures, medication preparation and invasive devices
- Outbreak prevention and response, including triage, screening, and risk assessment especially
during community outbreaks of communicable diseases & communicable disease reporting.
- Health care worker education and practical training.
- Education of patients, visitors and families about prevention and control of infection
procedures.

1387 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 - Assessment and feedback of compliance with IPC practices.
- Assurance of continuous procurement of adequate supplies & equipments relevant for IPC
practices.
- Environmental monitoring (waste management, food service, water and air monitoring)
- Monitoring and evaluation of IPC programme (Process & Outcome indicators)
- Additional Program Components / services:

o Housekeeping services , CSSD services , laundry services, pharmacy services & FMS
etc
o Infection Control Risk Assessment & development of annual IC Plan
o Performance improvement projects

Aim of Infection prevention & control program is to ensure the safety of patients, staff, trainees, volunteers, families
and visitors by their involvement.

Patients:

Patients are integrated within the infection control program through education. They are aware of their rights, concerns of their
safety and standard precautions to be followed. Some examples of how patients can contribute in reducing HAIs.

- Patient must observe doctor or nurse whether they cleaned their hands? If not, ask them to wash their hands with soap
and water or an alcohol-based hand rub (hand sanitizer) before they start working with you.
- Ask visitors to clean their hands every time they enter room. And ask them to follow any special instructions from your
doctors and nurses.
- Clean their own hands often with soap and water or hand sanitizer, especially after using the bathroom.
- If they cough or sneeze, cover mouth and nose with a tissue and discard the tissue right away. Then clean your hands.
- If your treatment involves a medical device like a urinary catheter, ask the doctors and nurses why it’s needed and when
it will be removed. Report any symptoms you have to your doctors or nurses.
-
Staff & Trainees:

- Hand hygiene, compliance with work practices, appropriate use of personal protective equipment, compliance with all
infection control policies and procedure, reporting exposure to communicable illness & needle stick injury etc

Visitors & Families:

All visitors’ areas are under infection control supervision.

- Visitors are educated on precautions to be taken while being in the surrounding of a patient, the importance of hand
hygiene and the isolation precautions required in case of isolated patients.
- Visitors are also educated on the importance of not visiting patients while having a contagious / communicable disease.
- Infection control department is communicating with the follow up department to assure compliance with the correct
visiting time in accordance with the hospital security plan.

1388 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Scope of hospital services is a structural measure that reflects whether a hospital has the
resources—facilities, staff, and equipment—to treat and provide care for the medical conditions
Substandard # 3.2 affecting potential patients.

The program is Services directly related to patients: includes emergency services, outpatient services, inpatient
applied to all areas of services, services in Intensive care units & operative rooms (OR) etc.
the hospital according
to the scope of Supportive / auxiliary services: CSSD, dietary services, pharmacy services, laundry, laboratory
services. services, radiology services & housekeeping etc

Each patient care & support service department must have relevant infection control programs with
detailed referenced policies & procedures fully applicable according to the services provided by the
unit.

IC team must ensure availability of the following:

IPC policy and procedure for each individual program / department in an electronic system,
manual or any written and printed documents.
Each unit must have specific / relevant IC programs implemented according to the scope of
services

For example, at least following policies & procedures related to specific program must be available
in Intensive Care Unit:

- Standard & expanded infection control program (Isolation precautions etc)

- Aseptic Technique
- Hand Hygiene program
- Respiratory Protection Program
- HAI surveillance Program including the prevention bundles.(Central line, Urinary Cather,
Ventilator & MDROs bundles)
- Outbreak Management Program
- AMR Program
- Employee Health Program (Post exposure Management & follow up etc)
- Waste Management Program
- Environmental Services Program
- Training & Education Program etc

Observe during routine daily / weekly rounds:

Practices of HCWs if are in alignment with the IPC standards and measures related to their scope
and mandate of their departments. e.g.

- Practicing 5’ moments of Hand Hygiene

- Selecting & using appropriate PPE according to type of isolation precautions
- Donning, fit tested - seal checked N95 with appropriate technique.
- Aseptic technique during medication preparation
- Not recapping needles & safe sharp disposal
- Following appropriate signage / reminders posted in appropriate languages (Hand hygiene &
PPE donning / doffing posters, etc)
- Aware and oriented about IPC education materials (e.g. case definition & education about
MERS – CoV, Cough etiquettes / Respiratory hygiene etc)
- Cleaning & disinfection practices

1389 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 a) Train the staff on infection control best practices during IPCCC training phase.
b) Evaluate the staff & unit performance during IPCCC audit phase.

Ask staff if they could easily answer and respond to your questions regarding how to apply IPC
services, practices and measures while they are dealing the patients.

Give them specific tasks to demonstrate according to the unit /area.

How to prepare & transport medication to the patients?? (Assess hand hygiene, aseptic
technique etc)
Ask about protocols of patient transportation under airborne isolation precautions ??
Ask about elements of any care bundles (SSI, VAP, Central line etc & their implementation. How
will you perform oral care for ventilated patients??
Preoperative measures for prevention of surgical site infections ??
Ask about steps of post exposure follow up & management of needle stick injuries etc (Assess
implementation of employee health program)

An ongoing program of theory and practice for continuing education is a major requirement and mandate. Therefore, education, reminders, and
instructions on infection prevention and control practices and the principles of Standard Precautions are available for all categories of staff,
patients, families and sitters through the IPC Department.

1390 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must develop IC Program based on below mentioned criteria:

a) IC program should be based on valid scientific references.

b) Each hospital / organization supports a comprehensive infection prevention and control program within
the recommendations of the World Health Organization (WHO) and Centers for Disease Control and
Prevention (CDC), standards of the JCIA, and the guidelines of the Ministry of Health (MOH) & IC
standards of local accrediting body.
c) All relevant references must be kept in Infection control office and used as reference for updating,
answering and facing any scientific debates.
d) References would include APIC, CDC, WHO, IHI, FDA, OSHA, GCC, MOH etc

1: Association for Professionals in infection Control and Epidemiology (APIC):

a) The Association for Professionals in Infection Control and Epidemiology (APIC) is the leading
professional association for infection preventionists (IPs) with more than 15,000 members.
b) It was established in 1972 to provide education & science based information to strengthen & improve
practice of infection Control by developing professional and practice standards, education & training
programs, scientific journal etc
c) It established Certification Board of Infection control & epidemiology (CBIC) in 1982 to administer an
infection Prevention & control certification Program (CIC)
d) APIC is a major proponent of zero tolerant perspective for HAIs . This idea requires culture change for
Healthcare workers where no infection is perceived as acceptable by any member of healthcare team.

2: Centers for Disease Control & Prevention (CDC): 2

Substandard # 3.3 a) The Centers for Disease Control and Prevention (CDC) is the leading national public health institute of
the United States formed on July 1, 1946.
b) It especially focuses its attention on infectious disease, food borne pathogens, environmental
The IC program is health, occupational safety and health, health promotion, injury prevention and educational activities
based on current designed to improve the health of citizens.
scientific knowledge, c) In the 1960s, the Centers for Disease Control and Prevention (CDC) began recommending that
referenced practices hospitals conduct surveillance for the occurrence of nosocomial infections.
guidelines and
applicable national 3: Food & Drug Administration (FDA):
laws and regulations.
a) FDA is responsible for implementing, monitoring & enforcing standards for the safety, efficacy &
labeling of all drugs and biologicals for human use.
b) Activities related to IC teams food, blood, & medical devices (especially single use devices) and
antimicrobial products and chemical germicides used with medical devices.

4: Institute for healthcare improvement (IHI):

a) Independent not - for - profit organization helping to lead the improvement of healthcare throughout
the world.
b) IHI works to accelerate improvement by building the will for change, cultivating concepts for improving
patient care, and helping healthcare systems put those ideas in) action (e.g. Healthcare bundles etc)

5: Joint Commission (JCIA):

a) Joint commission started publishing minimum infection prevention & control standards in 1953.
b) JCIA standards are used by many institutions including hospitals, long term care facilities in order of
establish a framework for an infection prevention program.

6: National Institute for occupational safety & health (NIOSH):

a) Established in 1970 & became part of CDC in 1973.

b) Responsible to conduct laboratory and epidemiological research on occupational hazards.
c) Decisions regarding type of devices used for employees protection (Respirators, sharp containers ) are
part of NIOSH mandate.

1391 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 7: Occupational Safety & Health Administration (OSHA): 2

a) Began infection prevention & control activities in 1973 with publication of blood borne pathogens rules.
b) OSHA standards focus on determining employee’s health risks as a result of exposure to
communicable diseases.

8: World Health Organization (‘’WHO”):

a) World Health Organization (WHO) is a specialized agency of the United Nations that is concerned with
international public health. It was established on 7 April 1948, and is headquartered in Geneva,
Switzerland.
b) Aim is to ensure health promotion via elimination & eradication of communicable diseases,
Antimicrobial resistance, training of health workforce, & improve monitoring data & information. Etc

9: Gulf Cooperation Council Center for Infection Control (GCC - CIC):

a) GCC manual was designed to give up-to-date guidelines for the GCC States that provides evidence-
based infection control practices for all healthcare settings.
b) The consistent application of proper infection control principles and practices in all healthcare activities
is necessary to achieve the goals of optimum patient safety and ensure best outcomes.(1)

10: National References: (Ministry of health (MOH)

a) Reference of national guidelines / MEMO pertaining to specific programs (National outbreak

guidelines, national MERS –CoV guidelines, National guidelines for Haemodialysis & dental units
etc)

1392 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 4 Infection Control Annual Plan
Annual IC Plan is a written, risk based document with goals and measurable objectives, strategies and evaluation methods.
Risk Assessment: Risk assessment is a term used to describe the overall process or method to identify & evaluate risk factors that have the
potential to cause harm to the patients, staff & visitors.
Annual Risk Assessment helps focus IC activities on essential tasks to reducing critical infection control risks. It Improves patient safety, staff
safety, improves efficacy (desired results), Identifies training issues, help understanding of disease transmission and prevention, for implementing
new interventions etc

Sub standards Explanation

IC Team must conduct infection control risk assessment using the standardized tool before formula time
the annual plan for next year. IC team must have the following to be presented to the external audit
teams for evaluation of annual plan.
Infection Control Risk assessment (ICRA)
Infection Control Annual Plan

Steps Involved in risk Assessment:

Substandard # 4.1 Step: 1 Annual Infection Control Program Review:
(Analyse & review data which is the basis of the annual risk assessment)
There is an annual - Data aggregation and analysis
plan that is based - Healthcare-acquired infection trends (Identified infections with the highest probability
on Infection Control and potential for harm (known risk, potential risk, contamination, exposures)
Risk Assessment- - Compliance with infection control standards
ICRA (i.e. addresses - Communicable diseases (prevalence rates, incidence rates)
the - Identified environmental issues / concerns
epidemiologically - Identified organizational areas of weakness etc
important infections, Step 2: Risk Assessment Grid / Tool:
processes,
procedures and - Rank risks by score to determine organizational priorities
devices associated - Assist in determining where to focus with available resources
HAIs. - Provides basis for developing the Infection Control Plan
- Identify gaps in infection prevention measures / processes
- Provide leadership and patient care providers with known and potential risks which
Substandard # 4.2 can directly affect patients & Health care providers.

The plan includes Risk Assessment Scoring: A Numeric scoring system based upon probability of event occurring.
goals for patient
safety (e.g. - Multiply the ratings for each risk in the area of probability, impact and organization
standard, preparedness = Risk Score
transmission based - Ranking risks by total score to help identify priorities
isolation - Sort in order of risk
precautions, - Priorities are used in the development of the Infection Control Plan
healthcare bundles,
patients and family Annual Plan must include the following:
education). Goals for Patient Safety:
Standard precautions, transmission based isolation precautions, Healthcare bundles, and patient /
family education and alike MUST be mentioned clearly in the plan in a detailed fashion, in which the
objectives and activities are written along with the KPIs relevant to them.
There must be risk assessment for the patient safety data e.g. health care bundles are well – related
to the HAIs rates.

1393 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Example: Isolation Activities:

Potential Risk: Lack of Airborne Precautions / AIIRs in the facility

Goals / Measurable Objectives: Provide adequate isolation facilities / AIIRs according to bed capacity 1 AIIR / 25
beds etc
Strategies / Methods: 1: Send request / Follow up previous requests for provision of Negative pressure isolation
rooms, HEPA filters & fixed monitors for continuous monitoring of negative pressure differentials & Air changes per
hour etc 2: Make clear guidelines on management of patients with airborne infections till availability of Airborne
Infection Isolation Rooms (AIIRs)

Responsible Person (s): Higher Administration, Infection control Team for follow up , Directorate / Ministry (MOH
hospitals only)
Timeframe: January 1, 2021 - December 31, 2021 with specified timeframe for each activity

Monitoring / Evaluation: Assessment of the need for more airborne isolation rooms depending on the volume of
patients in need for airborne isolation admitted to the hospital.

Goals for Patient Safety:

❖ Staff immunization, post exposure management, and staff education are MUST be clearly
identified in the plan in a detailed fashion, in which the objectives and activities are written along
with the KPIs relevant to them.

❖ There must be risk assessment for the staff safety data e.g. post exposure management are well –
related to the incidents reports of contracting infections. Number of Needle stick injuries reported
in 2020 etc

Example: Staff Safety

Substandard # 4.3
Potential Risk: Declining influenza vaccination coverage among Health Care Workers
The plan includes
Goals / Measurable Objectives: 100% influenza vaccination coverage among targeted heal care
goals for staff safety
workers.
(e.g. Immunization,
Strategies / Methods: 1: Staff Education & awareness regarding importance of influenza vaccination. 2:
Post-exposure
Availability of adequate vaccines & relevant IC supply. 3: Explore & address reasons for declining rate.
management and
4: Disciplinary procedures for HCWs who are noncompliant with the vaccination policy.
staff education).
Responsible Person (s): Employee Health Team, Infection control Team
Timeframe: Annually January 1, 2020 - December 31, 2020 with specified timeframe for each activity
Monitoring / Evaluation: Vaccination census & coverage rates in each quarter

IC Team must be well prepared to respond to auditor’s Interview:

a) Rationale behind the existing annual plan.

b) Enumerate goals for patient & staff safety.
c) How plan was formulated - steps of the appropriate plan format , logical framework including
the elements like risk priority, objectives, situation analysis, activities linked with time, place,
persons and others.
d) How to monitor and evaluate the progress regarding Key Performance Indicators (KPIs) of
patient safety. Example: Quarterly Central line Bundle Compliance rate (KPI); if high CLABSI
rate was the identified risk for patient safety

1394 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must monitor the achievements of annual plan goals at periodic intervals.
There must be a system or monitoring tool to gauge the achievements for each goal.

Quantitative assessment for comparing, and tracking performance of required changes in

targets and goals to reduce hospital acquired infections e.g. Bundle compliance rates etc.
Add KPIs column in the logical framework of the plan.
Prepare any document to convince that mechanism of follow up and monitoring is established
and functioning.
Substandard # 4.4
Monitoring and evaluation processes / dashboards of relevant KPIs are present in any form eg
electronic or manual.
There is a system or
a tool to monitor
Purpose of Monitoring:
achievements of the
annual plan's goals.
IPC programmes should be periodically evaluated to assess:

– The extent to which the objectives are met & the goals are accomplished.
– Whether the activities are being performed according to requirements.
– To identify aspects that may need improvement identified via standardized audits.

Regular monitoring / evaluation of goals and timely feedback of health care practices according to
IPC standards should be performed to prevent and control HAI and AMR at the health care facility
level. Feedback should be provided to all audited persons and relevant staff.

IC team must be well prepared for interview during external audit visit.

1. Knowledge regarding mechanism of monitoring and evaluation in terms of setting KPIs specific for
each goal.
2. Responding effectively and efficiently to any declining /decreasing rates and failure to achieve the
previously – set goals.

1395 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 INFECTION CONTROL ANNUAL PLAN

Potential Risks / Strategies / Responsible Method of Evaluation /

Goals /Objectives Timeframe
Problems Interventions persons KPIs

Procedure related risk: To ensure Patient Strict implementation Surgical staff, Annual SSI preventive Checklist
Safety of surgical bundle Surgeons, January 1, monitoring (Daily/weekly
1: Surgical Site
Anaesthesiologist 2021- rounds
Infection - Risk Score
Provision of resources s December 31, SSI Rate (Monthly /
= 48
Overall SSI rate ≤ to implement bundle 2021 Quarterly)
0.50% Central Sterile SSI Bundle Compliance
Rationale: variables (prophylactic
Processing Staff Daily/ Monthly rate (Monthly/Quarterly)
Surgical site infections antibiotics ,clippers /Quarterly
are the most common etc) follow up SSI rates per 100
Infection Control
healthcare associated C-sec = Reduce by operative procedures are
Team
infection, accounting 50% Number of SSI / Continuous Training & calculated by dividing the
for 31% of all HAIs Expected SSI Education of OR staff number of SSIs with the
Patient Educators
among hospitalized number of specific
patients. SSIs are a Fx = reduce by 50% operative procedures and
Improve patients TQM staff
substantial cause of Number of SSI / multiplying the results by
morbidity, prolonged education on pre-
Expected SSI 100. SSI rate calculations
hospitalization, and operative showering are performed separately
death. post discharge wound for different types of
Procedures involving 100% compliance car etc, operative procedures and
contact with a medical with elements of stratified by the basic risk
device or surgical Surgical BundIe Distribution of updated index
instrument with a antibiotic policy .
patient’s sterile tissue 100% percent
or mucous membranes compliance with Meticulous sterilization
poses a major risk of defined process for practices.
introducing pathogens cleaning, disinfecting
which can lead to and sterilization of
infection. critical and semi-
Failure to properly critical devices and
clean, disinfect or instruments
sterilize equipment may
lead to SSIs.

1396 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 5 Infection Control Committee
Infection control committee is a multidisciplinary body vested with the responsibility to coordinate, evaluate, and support the activities of the
Infection Prevention and Control Program and to communicate with all departments of the healthcare facility to ensure the engagement and full
support to the program by all stakeholders. The ICC advocates for the program shall ensure all resources needed are available.
The Infection control committee (ICC) coordinates an objective and systematic review process to evaluate the quality and appropriateness of
patient care as it relates to infection prevention and control.
Sub standards Explanation

IC Team must develop terms of reference (TOR) of Infection Control Committee meeting which must
fulfil the following criteria:

TOR must be valid and updated

Substandard # 5.1 Approved by top administration

Structure (Composition of IC committee with inclusion of membership from all relevant

There is written units)
approved terms of
references for the The committee consists of multidisciplinary team members.
infection control
committee containing Chairman : Hospital Director or Medical Director
structure, rules, duties Deputy Chairman : Nominated by chairman
and members Committee coordinator
responsibilities. Committee secretary

Substandard # 5.2 Permanent Members : included but not limited to:

There is IC committee a) Head of Infection Control Department
that is chaired by the b) Head of Nursing Department
hospital administrator c) Head of Quality Management & Patient safety
or one his senior d) Head of Critical Care Departments (ICU, NICU, PICU, CCU etc)
medical designees and e) Head of Obstetrics / Gynaecology Department
includes f) Head of Surgery Department
representatives from g) Head of Operating Room (OR)
medical staff, nursing h) Head of Laboratory (Microbiology)
staff, IC team director i) Head of Renal Dialysis unit / Nephrology
and supportive service j) Head of Pharmacy Department
to share and supervise k) Head of Emergency Medicine (ER)
IC activities, l) Representative from Employee Health Clinic
microbiology, OR, m) Head of Central Sterile Supply Department (CSSD)
CSSD, pharmacy, n) Head of Dietary services Department
dietary services, o) Head of Environmental health Department
housekeeping, and p) Head of Administrative & Financial department
other departments as q) Infection Control Department Members
needed.

Guest Members:

Chairman & deputy can invite any hospital employee from different departments on an official basis
when matters pertaining to their services e.g. Family & community Medicine, dental, supply &
logistics etc

1397 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Purpose of multidisciplinary committee :

To provide oversight of the infection prevention and control program.

To coordinate, evaluate, and support the activities of the Infection Prevention and
Control Program and to communicate with all departments of the healthcare facility to
ensure the engagement and full support to the program by all stakeholders.
The ICC advocates for the program shall ensure all resources needed are available.

Rules of operations including:

Frequency of meetings : (Quarterly or as scheduled in hospital, special meetings will be

called by chair when circumstances dictate etc))
Agenda : (All matters to be addressed by the committee should be brought to the
attention of the chairperson, Infection Preventionists (IP), and/or the appropriate
committee members.
Committee coordinator will prepare the agenda & chairman will sign agenda before
distribution to all members)
Attendance & Quorum : Appointed members are expected to attend and participate in
committee activities. 50 - 60% of committee members plus committee chairman/deputy
chairman shall constitute quorum of regular & additional meetings.
Minutes taking : Proceedings of the meetings shall be recorded & prepared by the
secretary / IC coordinator of committee and circulated to all members in a timely
manner before next proceeding.

Duties / Functions of IC Committee :

General functions of committee includes but not necessarily restricted to the following:

1. To ensure that hospital IC practices meets the requirement of accrediting bodies CBAHI etc
2. Pursue opportunities to improve patient care and clinical performance.
3. Recommend practices to resolve identified infection control problems in care and performance.
4. Recommend corrective actions to governing bodies when necessary.
5. Establishes, reviews and approves the hospital infection prevention and control (IP&C) policies
and procedures at least every three years.
6. Approve the type and scope of surveillance activities including stratified infection risk, focused
infection studies, and prevalence and incidence studies.
7. Determine the amount of time required to conduct infection surveillance, prevention and control
activities
8. Evaluates and revises on a continuous basis the procedures and mechanisms developed by the
(IP&C) team to serve established standards and goals.
9. Brings to the attention of the (IP&C) any infection control related issues arising in different
departments of the hospital and suggests solutions.

Responsibilities of members & attendees:

1. Attend at least 75% of meetings having read all agenda & papers beforehand.
2. Act as champions disseminating information and good practice as appropriate.
3. Identify agenda items to be considered by chair of committee ahead of time.
4. If unable to attend send apology to chair and secretary and send designee to attend on their
behalf.
5. Contribute to discussion and maintain confidences.

1398 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must organize infection control committee meeting at least once in each quarter with
attendance from all relevant units.

Following must be available for verification process by audit teams:

1. Meeting minutes with attendance records of last 03 committee meetings for purpose of
verification.
2. ICC team composition with multidisciplinary involvement matching with composition /
Substandard # 5.3 structure of IC committee members as described in Terms of Reference.
3. Evidence that each IC committee is chaired by hospital director or his assigned designee.
The IC committee 4. Special meetings can be called by the Chair when circumstances dictate.
meets regularly (at
least once quarterly). 5. Issues discussed in IPC committee meetings are assigned to concerned representatives and
should be traceable and timely closed.

ICC meeting must be conducted if 50% or above Quorum is present as mentioned in the
TOR.
50% of Committee members + Committee chairman / deputy chairman constitute a quorum
of regular & additional meetings.
If the Quorum is not met (i.e. attendance falls below 50% level of any meeting) the
meeting will be rescheduled upon discretion of chairman.

Functions of IC committee:

a) To review of the hospital infection prevention and control policies and procedures. (Hospital
infection prevention and control policies and procedures manual MUST be approved and
signed by the committee members who had discussed and revised thoroughly the manual.)
Substandard # 5.4
b) To review of the reports of healthcare associated infections surveillance submitted regularly by
The function of IC
the infection prevention and control team and suggestion of appropriate actions. (Rate of HAI
committee include but
should be tracked and followed meticulously in the committee, AND the members are always
not limited to (revision
suggesting and agreeing – upon the appropriate actions.)
and evaluation of IC
annual plan, review
and approval of IC
c) Revision of the yearly plan submitted by infection prevention and control team and suggestion of
policies and
additions/changes if necessary. (Upon presentation of annual plan by IPC department, the
procedures, review of
members would recommend and advice if any additions, modifications and amendments are
surveillance
necessary and required.
data...etc).
d) Evaluates and revises on a continuous basis the procedures & the mechanisms developed by the
infection prevention & control team to serve established standards and goals.

e) Each member of the committee acts as an advocate of infection prevention & control in his
department, trying to promote its principles, and ensures application of its rules.

1399 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Example:

High CLABSI rate in NICU was discussed as urgent an issue in last infection control
committee meetings by IC department. Causes and corrective actions were discussed with
approval of CLABSI improvement project for NICU. Head / Representative from NICU & other
team members in NICU should be well aware of PIP as implementations would be executed
through them as per suggested solution in IC committee meeting.

Infection control committee representatives must be aware about HAIs (CLABSI,CAUTI, VAP/
VAE, SSI, MDROs) & Hand hygiene trends projected in last committee meetings concerning their
units and actions taken to reduce them. (VAP/VAE rate in ICUs & implementation of care
bundles, SSI rates and SSI bundle compliance, Hand hygiene compliance rates etc )

In the event of any new issue related to infection control in their unit /area; it must be
communicated to chairperson or designee & brought to the attention of the infection prevention
& control team with suggested solutions.

IC Team must follow standard format for documenting the Meeting Minutes:

a) Meeting minutes of IC committee should incorporate Meeting number, Date, time, venue, Title,
List of Attendees, absentees & apologies etc

b) It should include Agenda / Items, Discussion & Findings, Actions / Recommendations,

Responsible Person/s, Time frame & status. (Open / Closed)

c) Agenda would include call to order, Review of previous meeting minutes.

Substandard # 5.5 d) Infection control reports (Healthcare-Associated Infection Rates, Multi-Drug Resistant Organisms
MRSA rates, any outbreaks, Hand hygiene compliance rate etc)
Meeting minutes
written in a manner of
e) Departmental Infection control Issues & solutions e.g. delayed release of culture results from
task force tables with
microbiology lab etc, Discussion of antibiogram,
time limit for the
f) Employee health issues (e.g. Not all hospital employees attending the employee health clinic for
actions needed and
annual medical check-up /Influenza vaccination refusals etc), inadequate IC supply, Issues related
actions must be
to isolation rooms, construction & renovation, outbreaks etc,
followed in the next
g) Adjournment and Closing remarks,
meeting.
h) Status of last committee meetings recommendations to be reviewed. (Closed issues to be
considered as accomplishments. These accomplishments shall / can be submitted to the
management as part of the committee’s performance.
i) Issues that are not yet addressed / accomplished to be considered as pending issues. These
pending issues shall be added as agenda in the old business to find solutions to close the
issues. If not, it should be closed as ‘abandoned’, a new alternate solution need to be in place.
j) Is still not resolved need to be escalated to executive committee.
k) Issues discussed in IPC committee meetings are assigned to concerned representatives and
should be traceable, timely followed, monitored and evaluated.
l) Discussions, conclusions, recommendations, assignments, actions, and approvals are
documented in the minutes of the committee meetings.
m) Minutes are distributed to each Committee member and are forwarded to other appropriate staff.

1400 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Example:

Agenda / Items to be discussed: Infection Control Surveillance statistics

Discussion: CLABSI rates in 3rd Quarter had retained high with average rate of 10.06
CAUTI rate for 3rd Quarter was 6.24
Recommendations /Actions: Strict implementation of infection control measures during
insertion / maintenance and daily necessity review to be intensely implemented and applied
by the clinicians to able to reduce occurrence of HAI associated with CLABSI and CAUTI as
the committee concluded.
Responsibilities: Clinicians, nurses, ICPs
Time frame: Jan - March 2021
Status: Closed

❖ The minutes shall be distributed after to all committee members and forwarded to all relevant staff.
❖ Minutes of each committee meeting shall be maintained in a permanent separate file.
Committee annual report on yearly performance to be developed and distributed.

Procedure:
- Committee members will identify agenda items for consideration by the chairman, coordinator
/ secretary at least 12 days before the meeting.
- All matters to be addressed by the committee should be brought to the attention of the
- chairperson, Infection Preventionists (IP), and / or the appropriate committee members.
- The committee chairman shall instruct to include these issues / recommendations in the
next agenda for discussion.
- Committee coordinator will prepare the agenda.
- Chairman will sign the agenda before distributing to all member’s prior the time of the meeting.
- Chairman requests from members to discuss the new agenda, to update committee on previous
agenda / matters and present report to the committee.
- Committee meets quarterly or as scheduled in the hospital.
- Discussions, conclusions, recommendations, assignments, actions, and approvals
are documented in the minutes of the Committee meetings by IC coordinator / secretary.
- The minutes shall be approved & signed by chairperson of the Committee. i.e. Hospital Director,
Medical Director.

1401 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 6 Infection Control Policy & Procedures
.
Evidence-based Policies & Procedures / guidelines should be developed and implemented for the purpose of reducing HAI and AMR. The
education and training of relevant health care workers on the guidelines and the monitoring of adherence with guideline recommendations
should be undertaken to achieve successful implementation.
Appropriate IPC expertise is necessary to write or adapt and adopt policies & procedures which should be evidence-based and reference
international or national standards. Every facility should have an infection prevention manual compiling evidence-based practices for patient
care. This manual should be developed and updated in a timely manner by the infection control team. It is to be reviewed and approved by
infection control committee.
Sub standards Explanation
IC Team must develop policies and procedures considering the criteria specified in the
substandard:
Substandard # 6.1
Validity : All policies and procedures should be valid (updated within 2 - 3 years and when
indicated)
Infection control
policies & procedures
Title of Policy:
are developed by IC
department to be
approved by IC
Old Title Suggested improved Title
committee (P&P are
based on scientific
Management of Infectious Diseases
references approved by Outbreaks
Outbreak
MOH ( GCC, CDC, WHO
Infection Control Measures in Dental
& APIC)). Dental Unit
Settings
Management of Infectious Medical
Waste Management
Waste
Blood Spill Management of Blood & body fluid spills

Content of policy:

Comprehensive: Covers all aspects of infection control relevant to particular unit, program
etc.
Fully applicable: All elements of the policy can be applied and comply with the hospital’s
scope of services.

References:

All policies and procedures must be based on scientific references approved by MOH (
GCC, CDC, WHO & APIC)

Signatories:

Signed from authorized personnel (i.e., owner of the policy / hospital director or medical
director / concerned department head) – Infection Control & Quality Head etc

Approvals:

Each policy & procedure should be discussed and approved by IC Committee (Check for
specific policy approval in the documented Infection control committee meeting minutes)

• Approval by IC committee is required for the infection control manual as a whole before
distribution and also for individual policy after major changes.

1402 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control Team must prepare and distribute IC Manual & ensure:

- IC Manual is updated as per hospital policy.

Substandard # 6.2
- Nicely designed & appropriately indexed with table of contents (Policy number, Title of Policy &
Page numbers.)
IC policies and - Divided into appropriate sections for ease of accessibility (Administrative policies,
procedures are Departmental policies & procedures, Isolation Procedures, Environmental health , support
collected and organized services etc)
in one manual that is - IC Manual must be available in the infection control department (Electronic + Printed version)
well-distributed and - The manual must be available in each department. (Electronic or hard version)
available in all hospital - Importance of written documents is considered least not to encounter shut down of the
areas. electricity / system failure

Conduct training & orientation session for staff in all units regarding Infection control
policies and procedures specific for their units during IPCCC training phase.
Observe staff during daily / weekly rounds & evaluate performance during IPCCC audit
phase.

- Provide and ensure each staff is able to access infection control policy and procedure applicable
to their area of work.
- Healthcare workers must be well familiarized with IC policies and procedures and know how to
access the system whenever needed.

For example staff working in ICU must be oriented about following infection control policies and
procedures but not limited to:

- Policies and Procedures for standard precautions including hand hygiene, PPE use etc
- Policies and Procedures for Transmission based precautions (Contact, droplet, Airborne)
- Policies and Procedures for Aseptic technique
- Policies and Procedures for Patient's Care Bundles for Prevention of HAIs & MDROs
- Policies and Procedures for Cleaning & disinfection of Medical Equipment
- Policies and Procedures for Environmental Services
- Policies and Procedures for Management of infectious Waste

IC team must ensure the following for revision of IC policies and procedures:

- Availability of Main policy stating the periodic revision of each policies and procedures. (2
OR 3 years)
- Any relevant document stating Policies and Procedures will undergo revisions every 2 OR 3
Substandard # 6.3
years & when required.
- If new guidelines from ministry or new updates are available.
IC policies and
- Revision dates mentioned on the policies MUST match revision policy for purpose of
procedures are revised
verification.
periodically by the IC
department every 2-3
Key Points:
years, or when
required.
- Policies and procedures exceeding the revision dates will be considered (Not met)
- Each hospital should start revision process ahead of time in order to avoid delay.
- Any new guidelines / updates released from Ministry of Health need to be incorporated in
the policies within 2 months maximum.

1403 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 7 Infection Control Education and Training
Training & education is the most important domain of infection control program to ensure and sustain the competencies of
healthcare workers (HCWs) in infection control practices by limiting the chances of infectious disease transmission among HCWs,
patients, sitters, and visitors. This can be achieved by ensuring all HCWs are properly informed, trained and provided with the
required knowledge and skills on infection control best practices. Further, by engaging leadership support to provide the
necessary resources for implementing trainings on infection control best practices & establishing auditing tools on performance
measurements to ensure the accountability of leadership and HCWs.
Learning is a way to transform knowledge, insights, and skills into behaviour.
Competency is proven ability to use knowledge and skills on personal, social, and/ or methodological capabilities in work and
study situations, especially in professional practices and professional development.
Accountability is being responsible for one’s own actions and disclosing the results in a transparent manner.
Sub standards Explanation
Infection Prevention & control department MUST provide education and training on infection control
best practices to all health care workers through available teaching modalities using adult education
principles. The learning environment in healthcare settings is unique Successful educational
Substandard # 7.1 activities in healthcare should be informed by educational needs of the healthcare personnel as
learning needs would vary because of the diversity of the healthcare personnel.

IC department to ensure the following:

There is an effective
Annual infection control training plan that is not routinely including the same programs and
system which is based
topics but updated annually based on need assessment and staff interests and include lectures
on need assessment
and practical training.
and provides IC
Annual plan can be updated as per necessity that could significantly pose risk to the patient
education and training
safety e.g. increased VAP rate in ICUs necessitates urgent training program including all
to all health care
personnel involved in ventilator insertion and care.
workers especially
when new policies and Educational program also should incorporate basic program for all staff, plus specialized
procedures are program for different staff categories as specialized program for staff working in OR and
developed. surgery department, ICUs, AKU, etc….
Educational program courses and training workshops shall cover all health care personnel
belonging to different specialties and categories (trainee, volunteers, new employees, lab, OR,
CSSD, etc…).

1404 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Prevention & control department MUST provide continuous education & training to all
health care personnel on infection control best practices. 100% of staff training coverage must be
ensured for staff working in the patient care areas, support services departments, environmental
services etc. These skilled & trained HCP would have a positive impact on patient safety and prevent
adverse patient outcomes.

Following must be ensured by infection control department:

Training files (Hard / soft version) that includes valid and accurate documentation of previously
conducted training activities including schedule of training, list of attendees & competency
testing.
Training files can be organized according to unit/department or professional category with the
Substandard # 7.2 aim to ensure 100% training coverage for all HCWs at least once per year.
Training must include basic infection control skills training & on job training relevant to their
Infection Control
area of work.
department provides
IC Team must organize and complete all training data to be presented to external auditors.
continuous education
When auditors randomly select personal files of healthcare workers to review the evidence of
and training (formal
training in the form of certificates of pre-employment basic training, job specific training and
and on-job training)
competency assessment.
for HCWs on infection
Evidence of attendance of any scientific conferences, symposiums, workshops, webinars etc
control with
conducted by MOH, CBAHI or any other training body. e.g CSSD staff , dialysis staff, OR Staff or
competency
ICU staff if attended any IC training course specific for their speciality.
assessment.
Aim of such training activities and courses is to have significant impact on employees’
knowledge, attitude & practices that must be reflected in his /her routine tasks and activities.

Competency assessment:
Training & education activities must be followed by assessing the competency of each
healthcare personnel.
IP&C Department must train and validate the competence of trained HCWs every year and a
certificate must be provided which should be kept in staff personal files.
If the HCW does not meet the criteria for competencies, his / her learning needs will be
identified and a repeat educational plan must be developed.

1405 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must ensure implementation of policy for orientation & education of newly hired HCWs
on basics of infection control skills before they can commence work in their respective clinical
areas.

IC department must provide training on basics of infection control skills followed by competency
Substandard # 7.3 assessment:

Infection Control - Complete the educational module and pass the post-test with a minimum of 80% passing rate.
department provides Training should be completed within the first month of employment in the hospital for those
orientation and newly-hired clinical staff.
training on basics of - Demonstrate competency on hand hygiene by undertaking a practical test under the
infection control skills supervision of a trained observer.
for newly hired HCWs - Demonstrate competency on donning and doffing of personal protective equipment (PPEs) by
maximum within 1 undertaking a practical test under the supervision of a trained observer.
months of joining the - Pass the N95 mask fit test or if the HCW fails the N95 fit testing, undergo Powered Air
work. (BICSL) Purifying Respirator (PAPR) testing . N95 and/or PAPR fit tests should be mandated by the
designated department and made as a hospital policy that would be valid for 1-2 years or as per
hospital policy.
- Complete mandatory vaccination (Meningococcal & influenza vaccination)
- On completion of training and orientation BICSL card must be issued for a period of 02 years.
- For renewal of employment, BICSL status must be valid.

Infection Control department provides MUST provide health education on infection control for
patients, families and visitors.

IC team must ensure the availability of the following:

Bilingual infection control health education & awareness material must be designed / formulated
to help in the education of the patients and visitors, e.g. Posters, Brochures, pamphlets,
booklets, leaflets etc. containing information easy to understand with help of pictorial display.
The educational material must be posted and available in all patient care areas, waiting areas,
Substandard # 7.4 entrances at the place easily seen and readable by patients, families and visitors. e,g hand
hygiene, cough etiquette, COVID 19 & MERS educational material, etc.
Infection Control
In the patient care areas/units, education provided to patients and visitors must be structured
department provides
and documented in patient’s files.
education on infection
control for patients, For example, haemodialysis patients must receive education about personal hygiene,
families and visitors. importance of frequent hand hygiene, care of central venous catheter at home, how to take
shower with intact CVC etc
Visitors are educated on precautions to be taken while being in the surrounding of a patient, the
importance of hand hygiene and the isolation precautions required in case of isolated patients etc
education must be provided on how to don / doff PPE and perform hand hygiene before entering
isolation room.
Education must also include importance of not visiting patients under isolation precautions for
their safety. etc

1406 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 8 Construction and Renovation
Planning of construction and renovation in the healthcare setting MUST incorporate defined steps and precautionary measures
to ensure that environmental health risk assessments, interventions, and infection control practices are being followed. There
must be an established multidisciplinary team composed of IP&C, Safety and Engineering staff, with the involved clinical areas
to ensure patient safety given that clear lines of communication among all concerned departments are in place & followed.
Sub standards Explanation
Infection Prevention and Control Department must develop and distribute policies and procedures
for infection control precautions during demolition, renovation & construction projects:

Following items must be incorporated in Policies and procedures:

Comprehensive and Descriptive:

Establishment of multidisciplinary team which is composed of Infection Control, General
Substandard # 8.1 Services, Risk Management and Housekeeping personnel.
The team is responsible for planning and implementing proactive preventive measures for the
There is a written whole duration of the construction project and in establishing clear lines of communication
policy and procedures among all concerned to ensure patient safety.
for IC considerations
IC team must be authorized to be informed before starting any construction activity in the
during demolition,
hospital. IC Authority should be directed to all departments and construction team to be pre-
renovation, and
informed before starting any construction & renovation activities or projects (i.e., maintenance
construction projects.
personnel should obtain an Infection Control Construction Permit) MUST be clearly stated in
policy.
Infection Control Risk Assessment Matrix of Precautions for Construction & Renovation (ICRA):
infection control precautions during construction & renovation and upon completion of project
(i.e., Class I, II, III, and IV), after identifying: a) Type of Construction Project Activity (i.e., type A,
B, C and D). b) PATIENT RISK GROUP that will be affected during construction & renovation
activities (i.e. LOW RISK, MEDIUM RISK, HIGH RISK AND HIGHEST RISK)

1407 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Role of infection control personnel in providing education to workers and staff involved in the
project to ensure through periodic follow up that preventive measures are outlined,
implemented and maintained during all phases of any construction and renovation projects
Authority of infection control department to stop construction projects if breaches in preventive
measures arise that may expose patients and HCWs to infections or environmental hazards
Fully applicable: all elements of the policy can be applied and comply with the hospital’s scope
of services
This policy applies to all construction/renovation works within healthcare facilities by ensuring
preventive maintenance are done (i.e., heating, ventilation and air conditioning (HVAC) system,
ventilator cleaning, filter replacement, etc.) that may compromise and/or contaminate air and
water supply.
Based on scientific references approved by MOH ( GCC, CDC, WHO & APIC) ❖ Signed from
authorized personnel (i.e., owner of the policy / hospital director or medical director / concerned
department,
Approved by IC committee*
Valid (updated within 2 - 3 years and when indicated)

Infection Prevention and Control Department MUST ensure availability of all required documents
related to construction & renovation activities in the hospital:

Multidisciplinary team meetings that indicate involvement of infection control team in planning
and executing any construction & renovation projects (Meeting minutes or any relevant
evidence must be kept to be presented to external audit teams.
Substandard # 8.2
Infection Control Construction Permit: infection control department’s permission must be taken
before starting any construction & renovation activities. Keep copy of IC permits in the unit.
The Infection
Prevention and Control
Infection Control Risk Assessment Matrix (ICRA): posted at the construction & renovation site
Department should be
with all precautions (proactive preventive measures) are outlined and very well explained to the
involved (in Planning,
construction staff (or at least the supervisor of each shift) to be strictly implemented and
ICRA, IC permit,
maintained during all phases of the project.
continuous follow - up
and authority to stop Periodic follow up of IC Practices and other preventive measures during all phases of the
the project) and pre- construction & renovation project. This is depending on the PATIENT RISK GROUP (e.g.,
informed officially construction projects involving HIGH RISK patient care areas as surgical units require frequent
about all current and visits as compared to construction activities in LOW RISK areas as general administrative area)
future construction
activities at the Authority statement / Circular issued from administration for Infection control department to
Healthcare facilities. stop the construction project if there are significant breaches in IC practices that may expose
patients and HCWs to infections or environmental hazards.

– All required documents must be available in the unit to be presented to external audit team
from MOH / CBAHI for purpose of verification.
– IC team must be well familiarized with all steps of construction & renovation activates to
respond to questions from external audit teams.

1408 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must be well oriented and knowledgeable about IC role during construction &
renovation activities:

– IC team members must be fully aware about any ongoing construction & renovation activity
in the hospital of & involvement of IC department in planning and executing any
construction & renovation projects (e.g., prior to execution of construction & renovation
activities that involve critical units, there should be some arrangements to shift patients to
other safe areas, isolation of construction & renovation site, creation of dust barriers,
isolation of HVAC system … etc.) and understanding of importance of ICRA, permission,
follow up and stopping the construction project when required

IC Team must provide training & education to other stakeholders of construction & renovation
projects (e.g. site manager or project’s supervisor of the ongoing shift):

– Construction & renovation project team must be well familiarized with importance of IC
measures & involving IC department in every step of the project starting from planning to
execution to completion.
– IC members must ensure that construction & renovation project team fully understand &
strictly implements IC precautions / preventive measures during all phases of such activities.

Healthcare associated infections are caused by pathogens like Mycobacterium species, Aspergillus
species, Legionella species present in the dust and debris generated by construction activities
considered as major hazards. Therefore IP&C personnel must be active team members in all
phases of any construction/renovation projects where they will play a major role in providing
education to workers and staff involved in the project to ensure that preventive measures are
outlined, implemented, and maintained.

IC Department must ensure availability o following documents:

Substandard # 8.3
A. Pre-Construction Preventive Measures:
IPC measures are Infection Control Risk Assessment Permit Form - Construction Permit:
followed before,
during and after An Infection Control Risk Assessment Form: Construction Permit will be completed and
construction, submitted by the proponent contractors and/or maintenance staff to the IPC office prior to the
demolition and commencement of any project.
renovation projects by
using Infection Control This construction permit MUST be posted on the door of the work site by the project
Risk Assessment management department and a copy given to Facility Management & Safety or the department
(ICRA). head hosting the construction work. (Considering the education level of construction workers
translation of IC measures in local language will help in better understanding and subsequent
implementation)

Infection Control Risk Assessment Matrix (ICRA), which should be formulated with accurate
Identification of type of construction project activity (i.e., type A, B, C and D) & patient risk
group that will be affected during construction & renovation activities (i.e. LOW RISK, MEDIUM
RISK, HIGH RISK and HIGHEST RISK) - Entail all required IC precautions (i.e., proactive
preventive measures: Class I, II, III, and IV), that must to be strictly implemented, maintained
and periodically observed through follow up visits during different phases of the project –

1409 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control Risk Assessment Permit Form - Construction Permit must be signed by all
involved stakeholders.

B. Preventive Measures during Construction and Renovation

The concerned hospital ward / department is responsible for addressing the needs of
immunocompromised patients. They should be moved to an area away from the construction
zone if the air quality cannot be assured during construction. Immunocompromised patients
should wear a mask if it is necessary to transport them through or near the construction
areas/zones.
Facility Management must ensure that:

– All windows, doors, air intake and exhaust vents are sealed in areas of the hospital adjacent
to buildings that are going to be demolished including areas confining susceptible patients,
to prevent air and dust leaks into patient care areas.
– A dust barrier is created from the floor to the ceiling with the edges sealed. Plastic (for
short-term projects) or sheetrock (for long-term projects) are examples of materials that
can be used to seal the construction area.
Refer to GCC Manual for details & required forms ; CONSTRUCTION AND RENOVATION MEASURES IN THE HEALTHCARE
FACILITY (ICM - X- 10) pg 381 -391

C. Post-Construction Preventive Measures

Facility Management will be responsible for ensuring that the following procedures have been
complied with:
– Thoroughly clean construction zone, including all horizontal surfaces, before the barrier is
removed, and again after the barrier is removed and before patients are readmitted to the
area. Allow time for all dust to settle before doing terminal cleaning.
– Ensure that the multidisciplinary team or designee conducts a final walk-through to ensure
ventilation system is functioning properly in the constructed area and adjacent areas.
– Ensure to flush water lines prior to use if these were disrupted.
– Consider hyper chlorinating stagnant potable water or superheating and flushing all distal
sites before restoring or repressurizing the water system if there are concerns about
Legionella and Aspergillus etc

Trained personnel from IP&C will inspect the finished area before barriers are removed and
patients are re-admitted. An air sampling will be conducted if required.

All relevant records and documents must be kept in the IC department to be presented during
verification process by external inspection teams.

Refer to GCC Manual for details & required forms; CONSTRUCTION AND RENOVATION MEASURES IN THE HEALTHCARE
FACILITY (ICM - X- 10) pg 381 -391

1410 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 9 Hand Hygiene Program
Hand hygiene (HH) is the single most effective measure for preventing disease transmission in the healthcare setting; and, to
describe indications and techniques for hand hygiene.
Hands may easily become contaminated with infectious microorganisms, which can enter the body through a break in the skin
or be transmitted to a susceptible host and cause infection. All personnel, physicians, nurses, technicians and others who are
responsible for complying with the hand hygiene policy should lead by example considering infection control to be everyone’s
responsibility. Artificial nails and chipped nail polish may be associated with an increase in the number of bacteria on finger nails
and should not be used.
Resident flora (resident bacteria) refers to the microorganisms residing under the superficial cells of the stratum corneum and
also found on the surface of the skin.
Transient flora (transient bacteria) refers to the microorganisms that colonize the superficial layers of the skin and are easily
removed by routine hand hygiene.

Sub standards Explanation

Hand hygiene is a critical component of patient & staff safety. Effective patient safety and infection
prevention programs require that healthcare personnel must be familiar with hand hygiene
recommendations and consistently adhere to them

IC Team must ensure availability of Policies & Procedures for Hand Hygiene which should be
comprehensive incorporating all aspects of hand hygiene program as follows:

Types of hand hygiene:

Hand hygiene is a general term referring to hand washing, antiseptic hand rub, or surgical hand
antisepsis.
Substandard # 9.1
Hand washing – washing hands with plain or antimicrobial soap and water.
There are written Hand rubbing – Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms
infection prevention without the need for an exogenous source of water and requiring no rinsing or drying with towels or
policies and other devices.
procedures for hand Surgical hand antisepsis – An antiseptic hand wash or antiseptic hand rub performed
hygiene, including
preoperatively by surgical personnel to eliminate transient and reduce resident flora.
types, indications,
supplies, techniques Indications:
and monitoring.
Five moments of hand hygiene: before touching a patient, before clean/aseptic procedures, after
body fluid exposure risk, after touching a patient, after touching patient’s surroundings.
Hand wash with water and soap: When hands are visibly soiled, potential exposure to spore
forming organism (Clostridium difficile, Bacillus anthracis), before eating and after using a
restroom etc
❖ Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene
in healthcare settings, unless hands are visibly soiled.
❖ Use only soap and water when dealing with spore forming bacteria (e.g., Clostridium difficile)
and /or when hands are visibly soiled.
1: Plain (Non-Antimicrobial) Soap:
- These soaps are detergent-based and will remove lipids, adhering dirt, and organic matter
- They have no antimicrobial activity. Such soaps can remove transient flora from the skin

1411 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 2: Antimicrobial Soap:

❖ These soaps are detergent-based and will remove lipids, adhering dirt, and organic matter. They
have antimicrobial activity.
❖ They can remove transient and resident flora from the skin. ( Examples: Alcohol, chlorhexidine,
chlorine, Quaternary ammonium compounds etc)
3: Alcohols:

Alcohol-based hand rub is a solution that contains 60% to 95% alcohol and is designed to be applied
to hands to reduce the number of viable microorganism on the hands. Although ethyl alcohol and
isopropyl alcohol are both effective against bacteria, fungi, and viruses, isopropyl alcohol has slightly
greater activity against bacteria & ethyl alcohol has greater activity against viruses. 1

Techniques:
Technique should be well described in the policy apart from visual illustrations:
o Hand washing with soap and water:
o Hand rubbing with alcohol
o Surgical Hand Antisepsis

Monitoring for Adherence:

Hospitals should incorporate details of Hand hygiene monitoring protocols in the policy:

CDC & WHO guidelines require monitoring of health care providers adherence to recommended
hand hygiene practices with feedback about performance

– Direct observation of sample of hand hygiene opportunities and calculate the rate of adherence
(Number of hand hygiene episodes performed / Number of hand hygiene opportunities) by
ward or service.
– Assess the quality of hand hygiene adherence (time spent per hand hygiene episode, whether
soap was used during hand washing, etc.)
– Monitor the volume of specific hand hygiene products.
– Could be automated systems that have potential to monitor all patient care episodes & provide
“just in time” reminders to staff who has forgotten to perform hand hygiene.

Other domains of Policies & procedures:

P/P for Hand Hygiene should be :

❖ Fully applicable: all elements of the policy can be applied and comply with the hospital’s scope
of services
❖ Based on scientific references approved by MOH ( GCC, CDC, WHO & APIC)
❖ Signed from authorized personnel (i.e., owner of the policy / hospital director or Medical director
/ concerned department)
❖ Approved by IC committee
❖ Valid (updated within 2 - 3 years and when indicated.

The WHO and CDC guidelines recommend that healthcare workers be provided with a readily
available alcohol-based hand rub product. Data suggest that this recommendation will increase the
frequency of healthcare worker hand hygiene and result in decreased incidence of dermatitis
caused by the drying effects of soap and water and abrasive towels.

1412 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Monitoring hand hygiene adherence and providing performance feedback to health care workers is a
critical component of multimodal hand hygiene promotion programs.
IC team must establish a hand hygiene team composed of linked staff working in different units.
These infection control link staff must be identified and trained on protocols of hand hygiene. It’s the
Substandard # 9.2 responsibility of IC to conduct training and ensure linked staff functions as advocate of infection
control in their area of work / jurisdiction. Trained staff must acquire enough IC skills to observe the 5
There is hand hygiene moments of hand hygiene in various departments/units.
team in the hospital to
monitor hand hygiene Observation is a sophisticated activity requiring training, skill and experience.
compliance rate. The Observers have to be trained according to the principles of “My five moments for hand hygiene”
team has appropriate Direct observation is the most accurate methodology.
training to observe 5 The observer must familiarize him / herself with the methods and tools used and must be trained
moments of hand (and validated) to identify and distinguish the indications for hand hygiene occurring during
hygiene in hospital’s health care practices at the point-of-care.
departments. The observer must conduct observations openly, without interfering with the ongoing work, and
keep the identity of the health-care workers confidential
Compliance should be detected according to the "My 5 Moments for Hand Hygiene" approach
recommended by WHO.
Crucial concepts for observing hand hygiene Indication and opportunity:
Health care activity:
- Succession of tasks during which health-care workers' hands touch different types of surfaces:
the patient, his/her body fluids, objects or surfaces located in the patient surroundings and within
the care environment
- Each contact is a potential source of contamination for health-care workers' hands
Indication:
- The reason why hand hygiene is necessary at a given moment.
- It is justified by risk of germ transmission from one surface to another.
Opportunity:
- Moment when hand hygiene is necessary during health care activities to interrupt germ
transmission by hands.
- A hand hygiene action must correspond to each opportunity.
- Multiple indications may come together to create a single opportunity.

1413 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1414 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 9.3
IC Team must ensure timely reporting of hand hygiene compliance rate to the regional coordinator &
Reporting of hand central body of hand hygiene program.
hygiene compliance
rate is active and Monthly hand hygiene reports submitted to regional hand hygiene coordinator via electronic system. (Review
last 3 months to ensure quality and frequency of submission hand hygiene data.
ongoing (i.e. reliable
data is passed through
NB: As per quality requirements hand hygiene compliance rate above 80% is not acceptable by central body of
regional coordinator to national hand hygiene program. (Cut off limit is 80%)
the central body of
national hand hygiene
program in timely
manner).

Substandard # 9.4 IC department must ensure availability of the following documents regarding hand hygiene
compliance and evidence of discussion in IC committee meetings for corrective actions.
The collected data IC team members must be fully ready for external audit visits and present any documented
about hand hygiene evidence to justify the items in the substandard.
compliance are
analysed and Hand Hygiene Compliance reports:
interpreted properly. - Trended data overtime that compares the hand hygiene compliance rate over the months and
Results are discussed compare different staff categories & units.
in IC Committee
meetings for Infection Control Committee Meeting Minutes:
corrective actions.
- Review the last 3 committee meeting minutes & verify if hand hygiene trends are presented &
discussed.
- Check for suggestive correction actions if hand hygiene compliance is low.

Substandard # 9.5 Corrective Actions would include:

Hand hygiene - Continuous education & training of HCWs

improvement - Continuous monitoring & observation
intervention is applied - Performance feedback on compliance
depending on when - Ensuring availability of supplies for hand hygiene in adequate amount and appropriate
the results showed a places. Convenient and acceptable hand hygiene products & dispensers.1
low compliance rates - Disciplinary action for any breach in practices
result. - Administrative support
- Performance Improvement Project (PIP) for hand hygiene
- Motivational & incentive programs etc

Hand Hygiene remains a foundation of patient safety and infection prevention, yet achieving and
maintaining adherence remains a challenge.
Education alone seldom leads to adequate adherence to hand hygiene in healthcare.
Multimodal multidisciplinary strategies are more like to lead to change and improve hand hygiene
practices.
Complex dynamic of behavioural change requires a combination of education, motivation &
system change.

1415 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Feedback is an important domain of infection control programs implemented in the hospital for
performance improvement.
IC department must train, monitor & evaluate different categories of healthcare workers followed by
Substandard # 9.6 dissemination of formal & and informal feedback to the relevant frontline healthcare workers & units.

Feedback about the Following MUST be shared:

hand hygiene
compliance rate - Send hand hygiene compliance rates for each unit including projected trends according to
should to be sent to professional category.
the frontline HCWs in - Hand hygiene graphs must be displayed on the IC bulletin board of each unit to be readily seen
the relevant by all healthcare workers and external audit teams.
department. - Low hand hygiene compliance MUST alert the unit staff for improvement strategies including
strict adherence to 5 moments of hand hygiene.
- Unit with high compliance could get the “BEST UNIT PERFORMANCE ON HAND HYGIENE’’
certificate OR a “HAND HYGIENE CHAMPION” could be identified and acknowledged.

Successful and sustained hand hygiene improvement is achieved by implementing multiple

actions to tackle different obstacles and behavioural barriers. Based on the evidence and
recommendations from the WHO Guidelines on Hand Hygiene in Health Care, a number of
components make up an effective multimodal strategy for hand hygiene.
The WHO multimodal hand hygiene improvement strategy has been proposed to translate into
practice the WHO recommendations on hand hygiene and is accompanied by a wide range of
practical tools (implementation toolkit) ready to use for implementation.

The key components of the “WHO” Multimodal Hand Hygiene Improvement strategy are:

System change:

Ensuring that the necessary infrastructure is in place to allow health-care workers to practice
hand hygiene. This includes two essential elements:
Substandard # 9.7
• Access to a safe, continuous water supply as well as to soap and towels
WHO Hand Hygiene • Readily accessible alcohol-based hand rub at the point of care
Improvement Strategy Training / Education:
tools are applied to
improve the quality of Providing regular training on the importance of hand hygiene, based on the “My 5 Moments
hand hygiene. for Hand Hygiene” approach, and the correct procedures for hand rubbing and hand
washing, to all health-care workers.

Evaluation and feedback:

Monitoring hand hygiene practices and infrastructure, along with related perceptions and
knowledge among health-care workers, while providing performance and results feedback to
staff.

Reminders in the workplace:

Prompting and reminding health-care workers about the importance of hand hygiene and
about the appropriate indications and procedures for performing it.

Institutional safety climate:

Creating an environment and the perceptions that facilitate awareness-raising about patient
safety issues while guaranteeing consideration of hand hygiene improvement as a high
priority at all level.

1416 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must ensure availability & implementation of following Hand hygiene improvement strategy
tools in the infection control department:

Tools for System Change (Ward Infrastructure Survey, Alcohol-based Hand rub Planning and
Costing Tool, etc)
Tools for Training / Education (Slides for the Hand Hygiene Co-coordinator, Slides for Education
Sessions for Trainers, Observers and Health-Care Workers, Hand Hygiene Training Videos,
Observation Form etc)

Tools for Evaluation and Feedback (Hand Hygiene Technical Reference Manual, Observation
Tools: Observation Form and Compliance Calculation Form etc

Tools for Reminders in the Workplace Your 5 Moments for Hand Hygiene Poster, How to Hand
wash Poster, How to Hand rub Poster

Tools for Institutional Safety Climate. Template Letter to Advocate Hand Hygiene to Managers,
Template Letter to Communicate Hand Hygiene Initiatives to Managers

IC Team must ensure implementation In different patient care areas:

“WHO” Education tools as reminders at workplace :

▪ Your 5 Moments for Hand Hygiene Poster

▪ Hand Hygiene: When and How Leaflet
▪ SAVE LIVES: Clean Your Hands Screensaver
▪ How to Hand rub Poster
▪ How to Hand wash Poster
▪ Glove Use Information Leaflet
▪ Hand hygiene information leaflets etc

IC team must be well oriented about the WHO Hand Hygiene Improvement Strategy tools on how to
practically apply them.

❖ Infection control team member about the “WHO” multimodal hand hygiene improvement
strategy tools.
❖ Ask how they are using and implementing the various tools used for improving hand
hygiene.
❖ Randomly ask how they are implementing WHO tools for hand hygiene observations. (ER,
HDU, Wards, ICU, NICU etc) using “WHO” observation forms.

1417 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Hand hygiene self-assessment framework is a systematic tool with which is used to obtain a
situation analysis of hand hygiene promotion. Health-care facilities can track their progress in
Substandard # 9.8 hand hygiene resources, promotion, and activities, plan their actions and aim for improvement
and sustainability through the use of the WHO Hand Hygiene Self-Assessment Framework.
Reporting of Hand
Hygiene Self- The Hand Hygiene Self-Assessment Framework is divided into five components and 27
Assessment is active indicators. The five components reflect the five elements of the WHO Multimodal Hand Hygiene
and ongoing (WHO Improvement Strategy and the indicators have been selected to represent the key elements of
HHSA Framework - each component.
Action plan to improve
the quality of hand IC Team must ensure availability of the following documents:
hygiene).
- Hand hygiene self-assessment report submitted to “World Health Organization” and
“GDIPC”.
- Ensure completeness of self-assessment document incorporating all five components.
- For GDIPC, reporting is via electronic online system once per year.
- For World Health Organization “WHO” reporting is once per year.

IC Team must be well familiarized with components of hand hygiene self-assessment framework
and able t explain the process when interviewed by external auditors.

- Have knowledge about the components and major indicators of each components.
- Know how the tool works and how is the interpretation done.
- Frequency of submitting Hand Hygiene Self-Assessment Framework to GDIPC & “WHO”

Components & Indicators of HHSA framework :

1) System Change:
Indicators:

- How easily available is alcohol-based hand rub in your health-care facility?

- What is the sink: bed ratio? etc

2) Training and Education:

Indicators:
- How frequently do health-care workers receive training regarding hand hygiene in your
facility?
- Is a process in place to confirm that all health-care workers complete this training?
- Is a system in place for training and validation of hand hygiene compliance observers? etc

3) Evaluation and Feedback:

Indicators:

- Are regular (at least annual) ward-based audits undertaken to assess the availability of hand
rub, soap, single use towels and other hand hygiene resources?
- Direct & Indirect Monitoring of Hand Hygiene Compliance
- Is immediate feedback given to health-care workers at the end of each hand hygiene
compliance observation session?
- Systematic feedback is regular (at least 6 monthly).
- Feedback of data related to hand hygiene indicators with demonstration of trends over time.

1418 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 4) Reminders in the Workplace:
Indicators:

- Are the Hand hygiene posters displayed?

- How frequently does a systematic audit of all posters for evidence of damage occur, with
replacement as required?

5) Institutional Safety Climate for Hand Hygiene:

Indicators:

- Hand hygiene team is dedicated to the promotion and implementation of optimal hand
hygiene practice in the facility
- Facility leadership made a clear commitment to support hand hygiene improvement (e.g. a
written or verbal commitment to hand hygiene promotion received by the majority of health-
care workers )etc

1419 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 10 Surveillance of HAIs
Surveillance is an essential component of an effective infection prevention and control (IPC) program. Surveillance is a systematic method of
ongoing collecting, consolidating, and analysing data concerning the distribution and determinates of a given disease or event, followed by the
dissemination of that information to those who can improve the outcome.
Surveillance is a critically important component of any MDRO control program, allowing detection of newly emerging pathogens, monitoring
epidemiologic trends, and measuring the effectiveness of interventions. Multiple MDRO surveillance strategies have been employed, ranging
from surveillance of clinical microbiology laboratory results obtained as part of routine clinical care, to use of active surveillance cultures (ASC)
to detect asymptomatic colonization.

Health Care Associated Infections ( HAIs) are defined as a localized or systemic condition resulting from an adverse reaction to the presence
of an infectious agent(s) or its toxin(s).
- There must be no evidence that the infection was present or incubating at the time of admission to the care setting. ·
- Clinical evidence may be derived from direct observation of the infection site or review of information in the patient chart or other
clinical records. ·
- An infection is considered HAI if the date of event of the NHSN site-specific infection criterion occurs on or after the 3rd calendar day
of admission to an inpatient location where day of admission is calendar day 1

Surveillance can be used for the following purposes:

• To measure the incidence of healthcare associated infections (HAI) and organisms

• To establish an endemic rates of HAI
• To detect, investigate and control hospital clusters or outbreaks of HAI
• To monitor, evaluate, and implement the necessary preventive measures
• To work on reducing HAI using standard bundles
• To monitor antimicrobial susceptibilities etc

Sub standards Explanation

Substandard # 10.1
There are written policies and procedures for Surveillance of health care associated infections (SSI, CAUTI, CLABSI,
VAP/VAE, MDROs and DE Surveillance ) using CDC-NHSN definitions according to the hospital's scope of services..

• Policies & procedures for HAI surveillance could be a separate policy for each type of device associated HAIs or it
could be a combined policy for all 03 device associated HAIs (CLABSI , CAUTI, & VAE/ VAP)
• Preferably a separate policy for procedure associated HAI (SSI)
• Preferably a Separate policy for Surveillance of MDROs.
ICP team must develop policies & procedures for HAI Surveillance which should be :

Comprehensive: It covers all aspects of Surveillance which define the types of surveillance to be carried out with regard to
healthcare-associated infections. Policy should include but not limited to:

Written standardized definitions /Criteria : for identification of each type of HAIs (device associated HAIs
(VAE/VAP, CLABSI, CAUTI ), procedure associated HAIs (SSIs) & MDROs.

Related Criteria of HAI identification MUST be mentioned:

- Infection Window Period for HAI

- Date of HAI event
- Present on admission (POA)
- Repeat Infection Timeframe (RIT)
- Secondary BSI Attribution Period
- Device removal and reinsertion
- Transfer Rule
- Multiple Transfer

1420 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Window Period for HAI:

It is the 7-days during which all site-specific infection criteria must be met. o It includes the day the first positive diagnostic test
that is an element of the site-specific infection criterion, was obtained, the 3 calendar days before and the 3 calendar days after.

Date of HAI event:

It is the date the first element used to meet an NHSN site-specific infection criterion occurs for the first time within the seven-
day infection window period

Present on admission (POA):

An infection is considered Present on Admission (POA) if the date of event of the NHSN site-specific infection criterion occurs
during the POA time period, which is defined as the day of admission to an inpatient location (calendar day 1), the 2 days before
admission, and the calendar day after admission.

Repeat Infection Timeframe (RIT):

It is a 14-day timeframe during which no new infections of the same type are reported.

Secondary BSI Attribution Period:

It is the period in which a positive blood culture must be collected to be considered as a secondary bloodstream infection to a
primary site infection o This period includes the Infection Window Period combined with RIT

For Device Associated HAI Surveillance:

- Policies and procedures should define the detailed methodology of how the numerator & denominator data will be
collected.

o Numerator: (Number of events of VAP / VAE, CAUTI, CLABSI etc)

o Denominator : (Patient days, device days etc )

- How data will be analysed, interpreted & presented. (VAP rate, CLABSI rate, Device utilization ratios etc).Usually
displayed as graphs / trends in comparison with CDC / NHSN benchmark*.
- How data will be disseminated to all stakeholders. (Feedback to all units about HAI trends) for further action. (email or
written document etc)

NOTE: Hospitals reporting through HESN system should clearly describe all steps related to HESN system (Data entry &
creating encounters, frequency of bundle review, encounter UDFs to be filled in case of device and non-device associated
events etc.).

2: For Procedure associated HAI Surveillance:

- Policies and procedures for SSI Surveillance should define methodology of SSI surveillance using CDC definitions.

▪ Superficial incisional SSI

▪ Deep incisional SSI
▪ Organ /space SSIs
- Policy should describe the steps of data collection for specific surgical procedure (Patient information, procedure
information, wound class, ASA score etc.).
- Criteria for selection of surgical procedures.
- Post discharge surveillance protocols and frequency of follow up (30/90 days)

1421 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
- How data will be analysed, interpreted & presented. (SSI Rate .Usually displayed as graphs / trends in comparison with
CDC /NHSN benchmark*.
- How data will be disseminated to all stakeholders. (Feedback to all units about HAI trends) for further action. (email or
written document etc)

NOTE: (Hospitals reporting through HESN should describe all steps for SSI surveillance based on HESN - SSI flowchart
including encounters, SSI bundle review , encounters for SSI event & post discharge follow up methodology)

2: MDROs Surveillance:

MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents.
Although the names of certain MDROs describe resistance to only one agent (e.g MRSA, VRE), these pathogens are frequently
resistant to most available antimicrobial agents.

MDRO surveillance policy must clearly state the methodology of MDRO surveillance.

MDRO policy should have clear & specific definitions of Gram positive MDROs (include MRSA and VRE etc ) & Gram
negative MDROs. (Ceph R-Klebsiella Cabapenum resistant Enterobacteriaceae (CRE): MDR Acinetobacter MDR
Klebsiella or Pseudomonas, ESBLs etc

b) Methodology of MDRO Surveillance:

• Policy should describe which MDROs are being monitored for purpose of surveillance.

• (Facilities may choose to monitor one or more of the following MDROs: MRSA, VRE, Ceph R- Klebsiella, CRE, and/or
multidrug-resistant Acinetobacter spp.

• Specify Type of locations for MDRO surveillance: Facility wide or Selected locations within the facility (1 or more)

• Data collection protocols for MDRO surveillance (patient information, MDRO types, Specimen sites (Blood, rectal,
stool, urine, axilla etc, MDRO presentation (colonization Vs. Clinical infection etc & source: Hospital acquired Vs.
Community acquired) (Standardized forms to be used for data collection (GCC/CDC

• MDROs surveillance policy should specify that MDROs will be monitored for all Specimen types or for Blood
Specimens Only.(e.g. MRSA Bacteraemia)

DE Surveillance:

Policies and procedures for DE Surveillance must fulfil following criteria:

Comprehensive:

It covers all aspects of dialysis event Surveillance, which define the setting, targeted populations, and case definitions using
CDC-NHSN case definitions, data collections methods, data analysis and reporting instructions.

Setting:

- Surveillance occurs in outpatient’s haemodialysis centers.

- inpatients or peritoneal dialysis patient’s are excluded from the DE surveillance.

1422 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Populations:

- Regular / Maintenance hemodialysis outpatients.

- Transient Patient: patients transferred from another facility and received in-center hemodialysis at our location on the
first two working days of the month.

Data collections:

Policies and procedures should define the detailed methodology of how the numerator & denominator data will be collected.
Numerator: (Number of dialysis events)
Denominator: (patient’s months)

Haemodialysis outpatients with each vascular access type for the first 2 working days each month are used on the
denominators for dialysis event surveillance.
If the patients have multiple vascular access, only the vascular access with highest risk of infections is reported.

Other domains of Policies & procedures:

Fully applicable: all elements of the policy can be applied and comply with the hospital’s scope of services
Based on scientific references approved by MOH ( GCC, CDC)
Signed from authorized personnel (i.e., owner of the policy / hospital director or Medical director / concerned
department)
Approved by IC committee
Valid (updated within 2 - 3 years and when indicated.

NOTE:

❖ Small hospitals who do not have capacity to provide intensive care service to the patient or the patient will not stay more
than 1 day & patients will be referred to the nearby tertiary care hospital must have clear policy and procedures for HAI
Surveillance matching with scope of service.
❖ Policies and procedures for HAI surveillance must be tailored according to hospital situation and scope of service.

1423 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training & Education:

IC team must be well trained about all steps and protocols of data reporting via HESN
Substandard # 10.2 electronic system.
Train the newly joined staff about all protocols and they must enter data under direct
IC practitioners are well supervision in the initial phase in order to ensure accuracy of data entry.
trained regarding
electronic IC-HESN Following must be available and refreshed on frequent basis:
surveillance system and
familiar with CDC-NHSN - CDC – NHSN definitions & surveillance protocols according to HESN.
definitions approved by - Surveillance data collection sheets, CDC / HESN manual paper forms.
GDIPC-MOH. - ICPs must have good understanding of identification of HAI events based on CDC Criteria.
- Must be well trained and skilled regarding methodology of client registration in HESN
system and creating different type of encounters e.g. (Encounter for Central line insertions,
Substandard # 10.3
Encounter for CLABSI event, Encounter for end of surveillance etc.) and how to fill the
Surveillance data are electronic forms.
reported to IC regional - ICPs should be well oriented to register all patients admitted in critical care units as clients
directorate and GDIPC- with or without devices.
MOH through IC-HESN - IPC team to assess knowledge on how data is entered, analysed using HESN system.
electronic surveillance - How to make corrections in HESN based on errors identified in data quality dashboards.
-
system.
Computers & internet service:

Substandard # 10.4 - The number of computers provided for the IC department must match with the number of
Infection control practitioners working in the unit.
Adequate number of - Ideally each ICP has a separate computer with internet connection. But if separate computer
computers and a not provided for each ICP, would be considered fully compliant if it’s not interfering with
reliable internet service continuity of work.
are is available for - The staff should have access to a reliability internet service and backup plan to ensure the
electronic surveillance continuity of work if there is no availability of internet service.
to be carried out - IT support should be available with less troubleshooting time.
continuously without
any interruption. Timely Data Reporting:

- ICPs must enter complete Surveillance data for targeted units, devices & procedures to IC
regional directorate and GDIPC-MOH through IC-HESN electronic surveillance system
without delay.

1424 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10.5 IC department must have the surveillance methodology for each type (Device, non-device &
procedure associated HAIs ) and surveillance data collection sheets to make sure its implemented
IC-HESN surveillance in all critical care units (ICU, CCU, NICU, PICU, Burn Units etc. based on availability of critical care
system is carried out in units in each hospital.
all critical care units
(active, prospective, Following surveillance protocols must be adopted:
targeted and patient
based surveillance). 1: Active Vs Passive:

a: Active Surveillance:

- Infection Preventionists (ICPs) vigorously look for HAIs by applying the CDC criteria during a
patient’s stay.
- Information accumulated by using a variety of data sources within and beyond the nursing ward
such as laboratory, admission/discharge/transfer, radiology/imaging, , as well as patient charts,
nurses /physicians notes, temperature charts, etc.

b: Passive Surveillance:

- Persons who do not have a primary surveillance role, such as ward nurses or respiratory
therapists, identify and report HAI

2: Patient Based Vs Laboratory Based:

Patient-based:

- Count HAI, assess risk factors, and monitor patient care procedures and practices for adherence
to infection control principles.
- Requires ward rounds and discussion with caregivers.

Laboratory-based :

- Detection is based solely on the findings of laboratory studies of clinical specimens.

3: Targeted Vs. Comprehensive:

Targeted / Priority-directed:

1: Focus is on specific events, processes, organisms, and/or patient populations.

2: Targeted Units (Critical Care Units only) (ICU, CCU, NICU, PICU, Burn Units etc.)
3: Targeted devices associated HAIs (Ventilator, Central Line, Urinary catheter associated )
4: Targeted Non device associated events (Pneumonia, BSIs, UTIs etc)
5: Targeted procedures for SSI (High risk – high volume) Select Procedures which are done
more frequently and associated with increased infection risk .

Comprehensive

- Continuous monitoring of all patients for all events and/or processes

- Highly personnel resource intensive if done manually

1425 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 4: Prospective Vs Retrospective:

Prospective Surveillance:

- Monitor patients during their hospitalization : Prospective surveillance of events (CLABSI, CAUTI
,VAP, SSI etc and their corresponding denominator data (Patient days, Device days, number of
selected surgical procedures etc) by a trained Infection Preventionist (IP).
- For SSIs, also monitor during the post-discharge period. (30 / 90 Days depending on
surveillance period and the type of surgery accordingly) ** (Refer to attached reference)
- Process of Post discharge surveillance follow up for SSI:

1. Post discharge follow up form to be available in Surgical OPDs & Wards, ER etc for
patients coming for follow up after surgery.
2. Follow up via Phone call etc.

Retrospective Surveillance:

Identify infections via chart reviews after patient discharge or death. Also required during
outbreaks.

Substandard # 10.6 IC team must ensure the following for SSI surveillance:

SSI surveillance is SSI Surveillance policies & Procedures including post discharge surveillance protocols
applied according to SSI Surveillance data collection sheet
GDIPC guidelines (i.e. Charts & graphs to assess SSI Surveillance statistics for targeted high risk, high volume surgical
selecting only 1 - 3 procedures.
types of High risk SSI surveillance report for past 6 months to confirm if the same surgeries were followed.
procedures or most Review the document for total number of surgical procedures done in last few months to
common surgeries for confirm if it’s a high volume procedure. (Selected Surgical Procedures) (HESN + Non HESN
at least 6 months). hospitals)
Review the list of surgeries with number performed in last year to assess the logical selection
for SSI Surveillance. (High risk & high volume) etc

IPC team MUST be well aware of all protocols to satisfy external auditors:

SSI surveillance definitions , process including post discharge surveillance etc

Type & number of surgical procedures followed with duration of each.
Aware about most common surgeries done in the hospital to match their selection.

1426 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 10.11 Example 2: Increased SSI rate in Year- 2020

Results of surveillance If SSI rate is on higher side for the last few quarters, IC team members should develop a corrective
are used to reduce HAIs action plan to find out the causes of increased SSI rate over past few months.
through well designed
quality improvement Causes could be: decreased compliance to SSI bundle, non-availability of prophylactic antibiotic,
projects. use of razors instead of hair clippers etc., poor aseptic technique during the procedure etc.

Interventions would include increased adherence to SSI bundle elements, strict implementation of
aseptic technique in OR, continuous education & training activities etc.

IC Team must ensure the following:

Performance Improvement project related to Surveillance based on results of HAI statistics.

Select specific indicators after reviewing results of surveillance and consideration of their
attributable morbidity, cost, preventability and transmission risks. They reflect the current priority
areas according to infection control program and policy development.
Example: If surveillance trends show the projected rate for specific HAI e.g. Increased CLABSI rate in
NICU. IC department should design a CLABSI improvement project for NICU considering the significant
risk in this population if strict adherence to IC measures were not followed by NICU staff.
A Performance Improvement Project (PIP) is a quality tool with concentrated effort on a particular
problem in one or more areas of the facility. It involves gathering information systematically to
clarify issues or problems, and intervening for improvements. The Steps Defined by FOCUS PDCA.
The FOCUS PDCA acronym describes the basic components of the improvement process.

- F - FIND A PROCESS / OPPORTUNITY FOR IMPROVEMENT

- O- ORGANIZE A TEAM
- C - CLARIFY THE CURRENT UNDERSTANDING OF THE PROCESS
- U - UNDERSTAND VARIATION IN THE PROCESS
- S - SELECT A STRATEGY FOR IMPROVEMENT
- P – PLAN
- D – DO
- C – CHECK
- A - ACT

IPC team must be aware about the details and steps of improvement project & relevant units must
be well communicated about the interventions related to specific Performance Improvement
Project (PIP).

Head of the department ,Nursing staff, doctors, RTs & other relevant medical staff in critical care
units must be well oriented regarding any ongoing Performance Improvement Project (PIP)

1427 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 11 Patient's Care Bundles for Prevention of HAIs and MDROs
- Patients’ care bundles are the series of evidence based practices / interventions related to devices or process of care that, when
implemented together, will achieve significantly better outcomes than when implemented individually.
- Bundle is an implementation tool aiming to improve the care process and patient outcomes in a structured manner. It comprises a small,
straightforward set of evidence-based practices (generally 3 to 5) that have been proven to improve patient outcomes when performed
collectively and reliably.

Sub standards Explanation

Substandard # 11.1

There are written policies and procedures concerning patient's care bundles for prevention of VAP/VAE, SSI, CAUTI, CLABSI, and
MDROs

Substandard # 11.2

There are written policies and procedures concerning patient's care bundles for prevention of DE (catheter, fistula and graft
care bundle)

Review:
Policies & Procedures for prevention of CLABSI, CAUTI, VAP, SSI & MDROs incorporating care bundles which should be
with clear Title & comprehensive as follows:

❖ Title :

- Prevention of Central Line Associated Blood Stream Infections / Central Line Care Bundles
- Prevention of Ventilator Associated Pneumonia - VAE / Ventilator Care Bundles
- Prevention of Catheter Associated Urinary tract Infection / Urinary Catheter Care Bundles
- Prevention of Surgical Site Infections / Surgical Care Bundles
- Prevention of Multidrug resistant Organisms (MDROs) / MDROs Prevention Bundle

❖ Purpose: (Clearly stated purpose of each)

e.g. Strict adherence to infection control measures during insertion & maintenance phase of CVCs in order to prevent device -
related blood stream infection.

❖ Procedure:

- Policies should clearly describe procedures with rationale of each bundle element.
- P/P should clearly describe applicability of all acre bundles according to location (critical care unit (ICU, NICU, PICU),
surgical wards, Medical Wards etc
- The policies and procedures should define how data on care bundles will be collected, analyzed, interpreted, disseminated
with necessary correction actions when needed. (Find details under specific substandard etc)

1428 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
- P/P should define Roles and responsibilities of concerned unit in implementation of health care bundles.
• Daily review is the responsibility of assigned staff of critical care units for all devices.
• Role of Infection control Practitioners is to ensure implementation of all elements of care bundles in daily rounds.
• SSI bundle implementation is the shared responsibility of surgical / maternity wards team, OR team & infection control
Team to follow for implementation. etc
• For MOH hospitals reporting via HESN, policies should be tailored accordingly.
Other domains of Policies & procedures:
P/P for Care Bundles should be :
❖ Fully applicable: all elements of the policy can be applied and comply with the hospital’s scope of services
❖ Based on scientific references (IHI and GCC & CDC Surveillance guidelines).
❖ Signed from authorized personnel (i.e., owner of the policy / hospital director or Medical director / concerned department)
❖ Approved by IC committee
❖ Valid (updated within 2 - 3 years and when indicated.

Substandard # 11.3

Hospital adopts and implements patient's care bundle for prevention of VAP / VAE – CLABSI – CAUTI according to GDIPC
guidelines and data are regularly collected, analysed evaluated and corrective interventions are considered (or taken)
accordingly.

❖ Compliance with the any bundle is defined as the percentage of intensive care patients on the elements of the Bundle are
documented on daily goals sheets and/or elsewhere in the medical record.
❖ NOTE: This is an "ALL-OR-NONE " INDICATOR. If any of the elements are not documented, the patient is not counted in the
numerator. If a bundle element is contraindicated for a particular patient and this is documented appropriately in the
medical record, then the patient is considered compliant with regard to that measure. (Ref: IHI)

1429 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Infection Control Team MUST ensure the availability of following data for care bundles:

- Bundle forms for the prevention of Ventilator Associated Pneumonia VAP / VAE – CLABSI – CAUTI
- Bundle forms should be standardized adopted from Institute of Healthcare Improvement (IHI) & GDIPC
- Devices bundle compliance rates i.e Ventilator Bundle Compliance Rates, Central Line Bundle Compliance Rates ,Urinary
Catheter Bundle Compliance Rates (Trend Analysis over months)
- Document for corrective actions

Elements of Ventilator Bundle:

1) Elevate the head of the bed to 30-45degrees
2) Provide a daily sedation vacation and assess the readiness to extubate
3) Provide peptic ulcer disease prophylaxis
4) Provide deep vein thrombosis prophylaxis (unless contraindicated
5) Provide oral care using chlorhexidine

Elements of Central Line Bundle:

1) Hand hygiene
2) Maximal barrier Precautions
3) Chlorhexidine Skin Antisepsis
4) Optimal Site Selection
5) Daily review of line necessity

Elements of Urinary Catheter Bundle:

1) Avoid unnecessary urinary catheters
2) Insert using aseptic technique
3) Maintain catheters based on recommended guidelines (daily care)
4) Review catheter necessity daily and remove promptly

1430 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Data Collection:

❖ Bundle review for devices need to be documented daily by the assigned nurse in the critical care units while
patient is on devices (ventilator - Central Line, Urinary Catheter)
❖ Manual or Electronic forms adopted from (IHI – GDIPC) need to be utilized.
❖ ICPs would collect data once or twice per week as per hospital’s bundle data collection Plan.

Note: If a bundle element is contraindicated for a particular patient and this is documented appropriately, the bundle is
considered compliant with regard to that element. (e.g. no bed elevation for patients with cervical injury etc)

Sampling strategy: Compliance can be measured by selecting all patients in the unit(s) on a randomly selected day each
week. Sample should include all patients on devices.

Data Analysis: (Devices Bundle Compliance):

FORMULA
Number of patients on devices who have
received all elements of the specific care bundle
(ventilator - Central Line, Urinary Catheter)
Devices Overall Bundle Compliance = -------------------------------------------------------------------- x 100
Total number of patients on Devices reviewed
for bundle compliance

(Bundle compliance for individual element would guide towards targeted corrective interventions in case of low compliance.

Data Evaluation:

- Evaluation of bundle compliance rates must be done at intervals as per hospital plan. (Monthly, Quarterly etc)
- Evaluate the bundle compliance monthly / quarterly and assess over time if decreasing which should prompt immediate
corrective interventions.
- Calculate and compare Bundle Compliance for past quarters (Trended Analysis)
- Evaluate goals set in annual plan for bundle compliance for specific device.

o Goal: Reduction of VAP – CLABSI – CAUTI by 50% in one year in a certain ICU unit
o Goal: 100% of all patients on DEVICES in the intensive care unit(s) must receive all elements of care
bundle.

Corrective Interventions:

❖ Results of low devices bundle compliance to be linked with corrective interventions & improvement projects.

1431 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11.4

Hospital adopts and implements patient's care bundle for prevention of SSI according to GDIPC guidelines and data are regularly
collected, analysed evaluated and corrective interventions are considered (or taken) accordingly.

The surgical bundle is a group of evidence-based interventions for patients undergoing surgery that, when implemented
together, result in better outcomes (reduce SSI) than when implemented individually.
The science supporting each bundle component is sufficiently established to be considered the standard of care.
Review: (in Infection Control department)
❖ Care bundles for prevention of surgical site infections consistent with recognized professional practices. IHI - GDIPC.
❖ SSI Bundle Compliance Rates (Trended Analysis over months)
❖ Document for corrective actions
Components of Surgical Bundle:

1) Prophylactic Antibiotics

- Appropriate Selection of prophylactic antibiotics;

- Timely antibiotic administration
- Timely antibiotic discontinuation
2) Appropriate Hair removal
3) Postoperative glucose control
4) Postoperative normothermia (36.1-37.1 C˚):

Data Collection:

SSI bundle data collection form need to be documented in each patient’s file undergoing surgical procedures.
Data need to be filled by the concerned units as per protocols provided by IC department. (Surgical wards, OR etc Data
need to be filled by the concerned units as per protocols provided by IC department. (Surgical wards, OR etc
2: Data Analysis:

FORMULA
Number of Surgical Patients who have received
all 06 elements of the SSI Bundle
SSI Bundle Compliance = ------------------------------------------------------- x100
Total number of surgical patients reviewed
for bundle compliance

Sampling Strategy:

Hospitals may decide to collect data using all patients with specific surgery during a certain time or sampling if there is
a sufficient volume of cases.

Data Evaluation:

❖ Evaluation of bundle compliance rates must be done at regular intervals as per hospital plan.
❖ Evaluate the bundle compliance monthly / quarterly and assess over time if decreasing which should prompt immediate
corrective interventions.
❖ Review the trended data for SSI Bundle Compliance for past quarters.

Corrective Interventions:

❖ Results of low SSI bundle compliance to be linked with corrective interventions & improvement projects.

1432 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11.5

Hospital adopts and implements patient's care bundle for prevention of MDROs according to GDIPC guidelines and data are
regularly collected, analysed, evaluated and corrective interventions are considered (or taken) accordingly.

Multidrug Resistant Organisms (MDROs) develops resistance to one or more commonly used antibiotics. These includes
MRSA: Methicillin-Resistant Staphylococcus aureus VRE: Vancomycin-resistant Enterococcus, MDR Pseudomonas
aeruginosa, Klebseilla pneumoniae, and Acinetobacter baumannii , MDR-ESBLs etc
Factors contributing to MDROs in healthcare setting:

- Inappropriate and uncontrolled use of antimicrobial agents in healthcare setting

- Inadequate adherence to infection control measures
- Availability of vulnerable host (Sever underlying disease Compromised host defences, Recent surgery, Indwelling
medical devices, ICU patients etc)
- Selective pressure exerted by exposure to antimicrobial in the community

❖ Strict adherence to infection control measures including proper cleaning & disinfecting is essential to reduce
transmissions / infections !!!

❖ To prevent and control the transmission of MDROs, staff must be fully educated about the elements of adopted care
bundle. The hospital should regularly collect and analyse the data and assess bundle compliance rate for performance
improvement.
Infection Control Department MUST have following documents related to care bundles:

- Bundle forms for the prevention of Multidrug Resistant Organisms (MDROs)

- MDRO Bundle forms could be adopted from CDC (prevention of Multidrug-resistant organisms (MDROs , as no ready to
use MDRO bundle form is available yet)
- MDRO Bundle Compliance Rates (Trended Analysis over months)
- Document for corrective actions/ improvement projects (if any)
- Review how hospital defines the data collection methods and sources (e.g., hospital information system, verbal and
written communication, medical record review, direct observation).

Elements / Components of MDRO Bundle:

1) Administrative Measures / Structure & system administrative support

2) Prevention MDRO transmission / Infection Control Measures
3) Judicious use of antimicrobials
4) MDRO surveillance
5) Education and Training of Healthcare Personnel
Data Collection:

- MDRO bundle review need to be documented daily by the assigned nurse in the critical care units / other inpatient
locations while patient is under isolation.
- Manual or Electronic forms need to be utilized.
- ICPS would collect data once or twice per week as per hospital’s bundle data collection Plan
Sampling strategy: Compliance can be measured by selecting all patients in the unit(s) on a randomly selected day / days
each week. Sample should include all patients with MDROs on the date of review.

1433 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Data Analysis: (MDROs Bundle Compliance):

Number of patients with MDROs who have

received all elements of the MDRO Bundle
MDRO Bundle Compliance = ------------------------------------------------------- x 100
Total number of patients with MDROs
on day of week of sample

(Calculating Bundle compliance for individual element would guide towards targeted corrective interventions in case of low
compliance.

Data Evaluation:

1) Evaluation of bundle compliance rates must be done at regular intervals as per hospital plan.
2) For instance evaluate the bundle compliance monthly / quarterly and assess over time : if decreasing it should
prompt immediate corrective interventions.
3) Review the MDROs Bundle Compliance for past quarters. (Trend analysis)

Corrective Interventions: Results of low MDRO compliance to be linked with corrective interventions & improvement
projects.

Substandard # 11.6

Hospital adopts and implements patient's care bundles for DE Surveillance (catheter, fistula and graft bundle) according to
GDIPC guidelines and data are regularly collected, analysed evaluated and corrective interventions are considered (or
taken) accordingly.

Infection Control Team must ensure availability of following documents related to patient care bundles for the prevention of
Dialysis events.
Catheter, fistula and graft Bundle forms for the prevention of dialysis events.
Bundle forms should be standardized adopted from Institute of Healthcare Improvement (IHI) & GDIPC)
Dialysis events Bundle Compliance Rates (Trended Analysis over months).
Document for corrective actions & Improvement projects (If any)

Elements / Components of Catheter, fistula and graft Bundle:

For the Catheter:
o Haemodialysis catheter connections
o Haemodialysis catheter disconnections
o Haemodialysis catheter exit site care
o Dialysis station routine disinfections
o Haemodialysis injectable medications preparations
o Haemodialysis injectable medications administrations.

For the fistula and graft:

o Arteriovenous fistula and graft cannulations
o Arteriovenous fistula and graft decannulations
o Dialysis stations routine dis infections
o Haemodialysis injectable medications preparations
o Haemodialysis injectable medications administrations.

1434 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 11.7
IC team must analyse and interpret the data for bundle compliance for each type of devices, Surgical
bundle, MDROs & dialysis bundles.
Data are analysed and Results of bundle compliance must be communicated to the concerned units in the form of formal
interpreted. Feedback feedback.
about results and Without timely feedback to all stakeholders; corrective interventions cannot be implemented.
compliance rates are
provided to the relevant
departments.

Substandard # 11.8
IC Team must ensure the care bundles are implemented in all critical care units & other
relevant patient care areas.
Data of patient's care
Ensure regular data collection from all concerned units.
bundles are regularly
Bundle data for all 03 devices & surgical bundle must be entered in HESN electronic system
reported to IC regional
as per GDIPC guidelines.
directorate and GDIPC-
MOH through IC-HESN
electronic system

1435 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training & Data Validation:
IC Team must conducted refresher training & education session with staff working in all critical
care units, OR, surgical wards & other inpatient locations where care bundles can be
implemented.

Following must be incorporated:

Bundle forms for devices (Ventilator, Central Line, Urinary Catheter) must be available in files
of patients with devices in critical care units (Manual/ electronic)

Nursing staff must ensure that patients with devices have received all elements of bundle
care and appropriately documented in patient files. In case of contraindication of certain
bundle variable, valid reason must be mentioned in nurses / Doctors notes.
Substandard # 11.9

Patient's care bundles are Randomly review the patient files to check for daily review of bundles done for targeted
followed daily by nursing
staff of Critical care units. patients in critical care units (ICU, NICU, & PICU etc)
IC practitioners check the Daily review of patient care bundles is the responsibility of nursing staff of critical care
compliance and validate
the data (at least once units.
weekly). ICPs during routine rounds must ensure validation of data collected from Critical Care units.
Patient must actually receive all care bundles rather mere documentation. Randomly observe
patients to match information available in patient’s files and that provided by nursing staff of
concerned unit.
Substandard # 11.10 For hospitals reporting HAI Surveillance data through HESN electronic system, additional

Competency of HCW is validation of manual bundle compliance with bundle compliance in HESN must be done.
conducted regularly in
critical units. Competency Assessment:

Provide training to the nursing staff & evaluate the performance / assess competency during
IPCCC audit phase.

Ask staff about the different type of care bundles and its clinical significance.
Ask about the rationale of different elements of care bundles e.g significance of oral care for
ventilated patients, early removal of devices without necessity, etc
Ask about the procedure for daily bundle review and importance of documentation.
To assess the skills, give a specific task and evaluate performance e.g steps for changing
central line dressing , providing oral care for ventilated patients.
Provide verbal and formal feedback on performance and consider for retraining of needed,

1436 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 12 Antimicrobial Stewardship Program (ASP)
Antimicrobial Stewardship Program (ASP) refers to a systematic approach to optimizing antimicrobial therapy through a variety of structures
and interventions. ASP is a key component of a multifaceted approach to preventing emergency of antimicrobial resistance.
ASP promotes not only limiting inappropriate use but also optimizing antimicrobial selection, dosing, route, and duration of therapy to maximize
clinical cure or prevention of infection.
ASP limits the unintended consequences, such as the emergence of resistance, adverse drug events, and unnecessary costs.
Antimicrobial Stewardship with efficient Infection control program can limit the emergence & transmission of antimicrobial – resistant bacteria.
It must be the priority for each hospital to establish an Antimicrobial Stewardship Program (ASP) in order to improve the use of antimicrobial
agents, which resides within the hospital’s highest quality improvement and patient safety governance structure, as well as the hospital’s
quality and safety strategic plan.
Optimizing the use of antibiotics is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and
combat antibiotic resistance. Antibiotic stewardship programs can help clinicians improve clinical outcomes and minimize harms by improving
antibiotic prescribing. Strategic multidisciplinary and facility specific efforts to optimize antimicrobial prescribing, Right drug, Right dose, Right
duration & recognize when not needed.

Sub standards Explanation

Infection Control Team must develop the policies and procedures for antimicrobial stewardship
program applicable to the healthcare facility.

Policies & Procedures for Antimicrobial Stewardship Program (ASP) which should be
comprehensive incorporating all core elements of ASP as follows:

Key Terminologies:

Substandard # 12.1 Antimicrobial Stewardship Program (ASP), Antibiogram, Antimicrobial Stewardship Committee
(ASC), Antimicrobial Stewardship Team (AST) , Clinical Pathway / Guidelines etc
There is an applicable
Antimicrobial Purpose :
Stewardship policy
including the role and - To standardize the processes of antimicrobial use in the hospital in an effective and efficient
responsibilities and way.
program KPIs for each
department such as - To deliver high-quality care consistently using evidence-based practices and functions in
pharmacy , microbiology accordance with the national guidelines. etc
& infection control). Applicability:

- For all clinicians, health administrators, and personnel involved with the proper utilization of
antimicrobials in hospitals and affiliated facilities.
Clear policies and procedures need to be adopted from core component of ASP (CDC – WHO)
according to hospitals scope of services:

1: Hospital Leadership Commitment:

❖ Hospital leadership commitment is of utmost importance to emphasize the necessity of

antimicrobial stewardship programs for dedication of necessary human, financial and
information technology resources.

1437 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 2: Accountability & Responsibility:

❖ A leader or co-leaders , such as a physician and pharmacist, to be appointed who will be

responsible for program management and outcomes.(Multidisciplinary AMS leadership
committee in place with clear terms of reference)
❖ Multidisciplinary Antimicrobial Stewardship Team (AST)
❖ Other health professionals identified and involved in ASP activities
For small facilities ASP champion could be appointed.**
Larger facilities have achieved success by hiring full-time staff to develop and manage
stewardship programs while smaller facilities report other arrangements, including use of part-
time or even off-site expertise, sometimes referred to as tele stewardship (.1)

3: Pharmacy Expertise:

A clinical pharmacist to be appointed ideally as the co-leader of the stewardship program, to lead
implementation efforts to improve antibiotic use & to reflect the importance of pharmacy
engagement for leading implementation efforts to improve antibiotic use

4: AMS Actions:

Priority Interventions to Improve Antibiotic Use:

Prospective audit and feedback (sometimes called post-prescription review):

- This is an external review of antibiotic therapy by an expert in antibiotic use, accompanied by

suggestions to optimize use, at some point after the agent has been prescribed

Pre-authorization System for Restricted Antimicrobials:

- Each hospital has to have restricted antimicrobial policy where specific antimicrobials would
be restricted by specific physicians in each hospital.

- Preauthorization requires prescribers to gain approval prior to the use of certain antibiotics.
This can help optimize initial empiric therapy because it allows for expert input on antibiotic
selection and dosing, which can be lifesaving in serious infections, like sepsis. It can also
prevent unnecessary initiation of antibiotics.

Facility-specific treatment guidelines / Antibiotic guidelines and the associated clinical

pathways/protocols:

- Greatly enhance the effectiveness of both prospective audit and feedback and preauthorization
by establishing clear recommendations for optimal antibiotic use at the hospital.
- Guidelines are means to standardize clinical practice and avoid misuse and overuse of
antimicrobial therapy. They serve as tool guiding prescribers who lack competencies for
antimicrobial prescription.
- Use of antimicrobial order forms with optimal timing and duration can assist pharmacist to
automatic discontinuation when the predefined duration is completed.

Prescribing Physicians:

- During continuation of treatment, the prescribing physician should l monitor antimicrobial drug
levels as required by the hospital policy and ensure daily consideration of de-escalation,
intravenous - oral switch or stopping antimicrobials (based on clinical picture and laboratory
results).

1438 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 ASP Point-of-care (POC) interventions:

AST will provide direct feedback to the prescriber and an opportunity to educate clinicians on
appropriate prescribing. This includes but not limited to:

- Reviewing appropriateness of choice of antimicrobial and eliminating dual therapy.

- Directed therapy based on microbiological studies.
- Dose optimization
- Parenteral-to-oral conversion
- Therapeutic drug monitoring
- Automatic stop orders
- Appropriateness of time of initiation of antibiotic therapy with respect to time of
surgery for prophylactic use and with respect to time of cultures for therapeutic use.
etc

5: Tracking / Monitoring & Surveillance:

- Monitoring appropriateness of antibiotic use at the unit and/or facility-wide level through audits
or PPS (Point Prevalence Studies)
- Tracking the types and acceptance of recommendations from prospective audit and feedback
interventions, which can identify areas where more education or additional focused
interventions might be useful.
- Monitoring of preauthorization interventions by tracking agents that are being requested for
certain conditions and ensuring that preauthorization is not creating delays in therapy.
- Monitoring adherence to facility-specific treatment guidelines. If feasible, consider tracking
adherence by each prescriber. Etc
- Measurement is critical to identify opportunities for improvement and assess the impact of
improvement efforts
o Evaluation of process (Are policies and guidelines being followed as expected?)
o Evaluation of outcome (Have interventions improved antibiotic use and patient
outcomes?)

6: Reporting & Feedback:

- Antibiotic stewardship programs should provide regular updates to prescribers,

pharmacists, nurses, and leadership on process and outcome measures that address both
national and local issues, including antibiotic resistance.
- Regular evaluation and sharing of health-care facility data on antibiotic use with
prescribers
- Regular evaluation and sharing of health-care facility resistance rates with prescribers etc

7: Education

- Basic training in optimal antibiotic use for health-care professionals

- Continued training in optimal antibiotic use for health-care professionals etc

Education is a key component of comprehensive efforts to improve hospital antibiotic use;

however, education alone is not an effective stewardship intervention. Education is most
effective when paired with interventions and measurement of outcomes. Case-based education
can be especially powerful, so prospective audit with feedback and preauthorization are both
good methods to provide education on antibiotic use.

1439 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 8: Supplemental Antimicrobial Stewardship Strategies:

- Combination empirical therapy and de-escalation strategy

- Antimicrobial dose optimization
- Antimicrobial Order Form ( AOF)
- Conversion from IV to PO therapy
- Surveillance of antimicrobial resistance
- Health-care facility access to IT services to support AMS activities
- Computer Surveillance and Decision Support

Antimicrobial Stewardship program KPIs :

❖ ASP infection control KPIS: Antibiogram, surgical prophylaxis, C. diff infection

❖ ASP Laboratories KPI (TAT, TDM)
❖ PHARMACY: Numbers of Interventions

1440 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Antimicrobial Stewardship Committee (ASC) is a standing committee responsible for reviewing all
Substandard # 12.2 Drug Formulary management requests related to antimicrobial agents; wherein the composition
includes physicians and pharmacists specialized in the field of infectious diseases. Antimicrobial
There is an Antimicrobial Stewardship Committee (ASC) can be either stand-alone or embedded in another existing
stewardship committee committee structure (e.g. drug and therapeutics committee, pharmacy committee etc).
that meets on regular Antimicrobial Stewardship Committee (ASC) is explicitly in charge of setting and coordinating the
basis (at least AMS programme / strategy according to its terms of reference.
biannually) The Antimicrobial Stewardship Team (AST) is a hospital-based team of experts in the field of
infectious diseases responsible in monitoring the appropriateness of antimicrobial usage.

Infection Control Team must develop Terms of reference of Antimicrobial Stewardship

Committee (ASC) and verify the following:

- TOR must be valid and updated

- Approved from hospital director
- Structure of Antimicrobial Stewardship Committee (ASC) would include but not limited to:

A dedicated Antimicrobial Stewardship (AMS) leader / co leaders identified for the health-care
facility.

▪ Consultant, Infectious Diseases

Substandard # 12.3
▪ Clinical Pharmacists
Antimicrobial
stewardship committee
Multidisciplinary Antimicrobial Stewardship Team (AST) with roles and responsibilities of each
is chaired by physician
member:
and pharmacist. The
members include
- Infection Control Preventionist / Coordinator
physician, pharmacist,
- Representative from the Microbiology Department
microbiologist, IC
- Representative from nursing department
practitioner, infectious
- Representative from critical care units
disease department,
- Members from infectious diseases department
Critical care units, OR,
- Representative from OR
Surgical department,
- Representative from surgical department
Nursing department and
- Clinicians & other members as needed
other department as
needed.
Rules of operations of ASC meetings:

a) Frequency of ASC meetings:

• TOR should specify frequency of Antimicrobial Stewardship Committee (ASC)
meetings.
• A Antimicrobial stewardship Committee (ASC) shall meet on a regular
basis (at least biannually or as scheduled in the hospital.

b) Agenda of ASC meetings

c) Attendance & Quorum
d) Minutes taking etc

1441 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Duties / Functions of Antimicrobial Stewardship Committee (ASC):

Consultant, Infectious Diseases will serve as Team Leader/ co leader and perform the following:
e.g

- Provide expert advice, educate prescribers, and play a major role in the development
- and implementation of antimicrobial policy and prescription guidelines.
- Use antimicrobial stewardship as clinical outcome measures and quality improvement

Clinical Pharmacist will perform the following:

- Review antimicrobial orders in accordance with the Antimicrobial Guidelines and provide
timely feedback (where applicable) to the prescriber.
- Work with and educate ward pharmacists to identify potential patients for stewardship
interventions (e.g. de-escalation, IV to oral switch etc.).
- Ensure dose optimization is carried out especially for complex antimicrobials and complex
clinical scenarios
- Attends rounds with the AST etc

Infection Control Preventionists / Coordinator will perform the following:

- Prepares surveillance and audit reports

- Obtain and timely provision of data as required by the Program
- Ensures complete filling of the forms (whenever applicable)
- Provide help in organizing the administrative and educational activities etc

Clinical Microbiologist will perform the following:

- Provision of timely and accurate reporting of culture and antimicrobial susceptibility data
- Prepare antibiogram on bi-annual basis (every 6 months)
- Work closely with the attending clinician, infectious diseases specialist and antimicrobial
pharmacist in the management of patients with infections. etc

AMR Hospital Team < 150 beds:

– Head of the hospital / medical directors

– Head of infection control /Team
– Head of the departments
– Microbiology doctor / Supervisor
– Head nurse • Head of the pharmacy
– ID consultant if available
– Regional AMR coordinator if available

1442 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Support from the senior leadership of the hospital is critical to the success of antibiotic
stewardship programs in order to get the resources needed to accomplish its. goals

Antimicrobial Stewardship Team (AST) MUST be supported by hospital leaders to improve

Substandard # 12.4 Antimicrobial Stewardship Program (ASP):

Hospital leaders dedicate Human Resource Support:

necessary human,
financial and information - Employing experienced staff for AMR program (e.g., clinical pharmacist, microbiologist,
technology resources to infectious diseases consultant, clinicians, nursing staff and others as needed for ASP..)
the committee.
- There must be time allocation for stewardship program leader (s) to manage the
program and conduct daily stewardship interventions & ensuring that staff from key
support departments have sufficient time to contribute to stewardship activities.

- Outlining stewardship-related duties in job descriptions and annual performance reviews

for program leads and key support staff.

Financial support:

- Allocating funds to support training and education for program leaders and hospital staff.
(e.g. attendance in stewardship training courses and meetings) etc

- Making formal statements of support for efforts to improve and monitor antibiotic use.

- Direct purchase of supply needed for Antimicrobial Stewardship Program (ASP).

(Necessary Antibiotics etc)

- Dedicated, sustainable and budgeted financial support for AMS activities in the action plan
(e.g. support for salary, training and information technology (IT) support).

IT Support:

- Building up & implementing special IT system for improving antibiotics dispensing

according to specific responsibilities and strict rules, approved by Antimicrobial
Stewardship Committee (ASC).

- As required by the Antimicrobial Stewardship Team (AST), IT to provide access to the

Hospital Information System (HIS) ,electronic medical record (EMR), software and
hardware support, as well as, support in maintaining electronic files, records, etc.

1443 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Measurement is critical to identify opportunities for improvement and to assess the impact of
interventions.
Measurement of antibiotic stewardship interventions may involve evaluation of both processes
Substandard # 12.5 and outcomes. For example, a program will need to evaluate if policies and guidelines are
being followed as expected (processes) and if interventions have improved patient outcomes
Antimicrobial and antibiotic use (outcomes).
Stewardship committee Both process measure (did the intervention result in the desired change in antimicrobial use?)
monitor adherence to a and outcomes measure (did the process implemented reduce the resistance or unintended
documentation guideline consequences of antimicrobial use?)
(name, dose, duration,
route of administration There MUST be an effective tracking & monitoring system:
and indication).
Monitoring appropriateness of antibiotic use at the unit and/or facility-wide level through audits
(There is an effective or PPS (Point Prevalence Survey)
and efficient system
implemented for - The Antimicrobial Stewardship Team (AST) undertakes audits or PPSs, at the unit and/or
monitoring and tracking health-care facility level, to assess the appropriateness of infection management and antibiotic
of antibiotic prescription prescription (e.g. indication, agent, dose and duration of antibiotic therapy in specific
and resistance patterns.) infectious conditions such as pneumonia or surgical prophylaxis) according to
policy/guidance.

Substandard # 12.6 Monitoring compliance of antibiotic stewardship interventions by the Antimicrobial Stewardship
Committee (ASC).
Antimicrobial
Stewardship committee - The Antimicrobial Stewardship Committee (ASC) monitors compliance with one or more of the
monitor antibiotic use specific interventions put in place by the AMS team (e.g. indication captured in the medical
(consumption) at the record for all patients on antibiotics).
unit and/or facility
(defined daily dose DDD Monitoring of antibiotic susceptibility and resistance rates for a range of key indicator bacteria:
, Days of therapy DOT)
- The Antimicrobial Stewardship Team (AST) monitors antibiotic susceptibility and resistance
rates for a range of key indicator bacteria.
- Monitoring resistance at the patient level (i.e. what percent of patients develop resistant super-
infections). etc

Monitoring quantity and types of antimicrobial consumption at the unit and/or facility-wide
level. (Defined daily dose DDD , days of therapy DOT )

- Documents that evaluate trends for antibiotics prescription which should be based on updated
antibiotics resistance pattern of the facility specific antibiogram. (Appropriateness of
antimicrobial start (choice, dose, duration, route etc

Antimicrobial consumption is an aggregated rate of antimicrobial used for benchmarking

purposes.
Defined Daily Dose (DDD) is the assumed average maintenance dose per day for a drug used for
its main indication in adults.
Days of Therapy (DOT) are simply the number of days that a patient is on an antibiotic,
regardless of dose. Any dose of an antibiotic that that is received during a 24 hours period
represent 1 DOT

1444 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Antibiotic stewardship Committee should provide regular updates to prescribers, pharmacists,
nurses, and leadership on process and outcome measures.
ASC should provide feedback to prescribers and HCWs on improving antibiotic use and
resistance including (e.g. facility-specific reports on antibiotic use, how they can improve their
Substandard # 12.7 antibiotic prescribing, current antibiogram).
Antibiotic resistance information should be prepared in collaboration with the hospital’s
microbiology lab and infection control and healthcare epidemiology department.
Antimicrobial
Antibiotic stewardship Team (AST) MUST ensure the following:
Stewardship committee
provides feedback to
- Report containing analysis and interpretation of antibiotic use and resistance patterns to all
prescribers and HCWs
concerned stakeholders (doctors, nurses and other relevant staff etc) - (Manual / Electronic)
on improving antibiotic
use and resistance
- AST provide direct feedback to the prescriber and an opportunity to educate clinicians on
including (e.g. facility-
appropriate prescribing.
specific reports on
antibiotic use, how they
Report should include:
can improve their
antibiotic prescribing,
- Regular evaluation and sharing of health-care facility data on antibiotic use with
current antibiogram).
prescribers.(Health-care-facility reports on the quantity of antibiotics
purchased/prescribed/dispensed which are reviewed and analyzed, and key findings are shared
with prescribers along with specific action points.)

- Regular evaluation and sharing of health-care facility resistance rates with prescribers
The facility reports on antibiotic susceptibility rates are reviewed, and analyses and key findings
are shared with prescribers along with specific action points.

- Evaluation of appropriateness of data on antibiotic use is shared with prescribers

Findings from audits/reviews of the quality/appropriateness of antibiotic use are communicated
directly to prescribers along with specific action points.

- Health-care facility antibiogram for key antibiotics informed by data on antibiotic use and
resistance
The health-care facility aggregate antibiogram is developed and regularly updated based on a
review and analysis of facility antibiotic use and antibiotic-resistant bacteria. The antibiogram
may help to inform updates of clinical guidelines.

Substandard # 12.8 The Antimicrobial Stewardship Team (AST) must ensure the following:

There is a hospital- Hospital specific treatment recommendations to assist with appropriate selection of
specific treatment antibiotics for common clinical conditions.
recommendation to These treatment recommendations must be in accordance with national antimicrobial
assist with antibiotic guidelines & local susceptibility patterns.
selection for common Knowledge of local susceptibility is essential to guide physicians toward appropriate
clinical conditions, based antimicrobial choices.
on MOH guidelines and
local susceptibility.

1445 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 There must be optimal use of antibiotics to treat common infection which includes:

1. Community-Acquired pneumonia
2. Urinary tract infection
Substandard # 12.9
3. Skin and soft tissue infections
4. Surgical prophylaxis for prevention of surgical site infections
Each facility has specific
To ensure optimal use of antibiotic for treating these common infections, each facility must
interventions (real
have specific interventions in place:
implementation) in place
to ensure optimal use of
The intervention including (but not limited):
antibiotics to treat the
common infections.
– Pre-authorization system for restricted antimicrobials (group A & B ONLY)
Community-acquired
pneumonia 2. Urinary
o Preauthorization requires prescribers to gain approval prior to the use of
tract infection 3. Skin
certain antibiotics.
and soft tissue infections
o Enforce the approval system of restricted antimicrobials.
4. Surgical prophylaxis
o Each hospital has to have restricted antimicrobial policy where specific
The intervention
antimicrobials would be restricted by specific physicians in each hospital.
including(but not limited)
o If a physician is not privilege to prescribe an antibiotic, he has to go over
: 1- Approval of
required steps to obtain authorization.
restricted antibiotics
o At initiation of treatment, the prescribing physician will provide a clinical
(group A&B ONLY) 2-
rationale for antimicrobial initiation. Etc
Optimization of the
therapy 3- de-escalation
– Optimization of the therapy to ensure appropriate and rationale prescribing
4- Stop the antibiotics 5-
– De-escalation (Antimicrobial de-escalation (ADE) is defined as the discontinuation of one
Change from IV to oral
or more components of combination empirical therapy, and/or the change from a broad-
6- Change the antibiotics
spectrum to a narrower spectrum antimicrobial.)
according to preferred
– Automatic stop orders for specified antibiotic prescriptions, especially antibiotics
regimen in protocol
administered for surgical prophylaxis
– Parenteral-to-oral conversion (IV to oral switch)
– Change the antibiotics according to preferred regimen in protocol
– Appropriateness of time of initiation of antibiotic therapy with respect to time of surgery
for prophylactic use and with respect to time of cultures for therapeutic use.

1446 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Infection Control team in collaboration with ASP team members must ensure the following
activities related to training & education:
Educational plan about antimicrobial resistance and optimal prescription of antimicrobials.

Availability of scientific education material related to antimicrobial stewardship is available and

well distributed (Booklets, leaflets, brochures, ASP toolkits etc)

Attendance sheets of lectures or workshops related to the antibiotics guidelines and AMR
Substandard # 12.10 stewardship program.

Documents for target groups and calculation of coverage rates for different Units / groups
Education about AMR &
optimal antimicrobial - Education is a key component of comprehensive efforts to improve hospital antibiotic use & is
prescription are provided most effective when paired with interventions and measurement of outcomes.
regularly.
- Education need to be provided to prescribers, pharmacists, nurses, and patients about adverse
reactions from antibiotics, antibiotic resistance, and optimal prescribing.

Education could be provided by adopting multiple strategies:

- Passive • Printed educational materials • Clinical practice guidelines • Formal lectures •

Seminars, conferences • Educational courses • Reminders • e-learning
- Active • Discussion groups, journal clubs • Educational outreach visits and academic
discussions • Prospective Audit and feedback • case scenarios, interactive educational
workshops etc

1447 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 13 ANTIBIOGRAM

Antibiogram summarizes the cumulative proportions of pathogenic organisms that are susceptible to particular antimicrobials. This
provides a profile of the susceptibilities of specific pathogenic bacteria to antimicrobial agents as tested in routine clinical
microbiology practice. An antibiogram is a useful tool for the infection preventionists to determine the status of strategies in place
to reduce multidrug resistant organisms and monitor trends emerging in the drug resistance.
Data should be analysed when at least 30 isolates are tested for a given pathogen, and only the first isolate should be included
from patients with multiple positive cultures, regardless of the body fluid tested or the antimicrobial susceptibility pattern.
Sub standards Explanation

Substandard # 13.1
IC Team must ensure the following with regard to antibiogram.
Antibiogram report is
prepared by the Hospital must prepare the antibiogram at least once per year.
hospital at least Reported to GDIPC and regional directorate as per MOH regulations (Hospital >150 beds).
annually and reported
to GDIPC and regional
directorate as per IC team must ensure availability of following documents in the unit for purpose of verification & to
MOH regulations be presented to external audit teams (MOH – CBAHI etc)
(Hospital >150 beds).

Minutes of last 3 Antimicrobial Stewardship Committee (ASC) meetings to review antibiogram

Substandard # 13.2 reports and discussion of members about its consequences.

Antibiogram is Documents that show corrective interventions and action plan to improve the antibiotic use
regularly discussed by
Antimicrobial ▪ Modification of antibiotics prescription based on updated antibiotics
Stewardship resistance pattern of the antibiogram
Committee and action ▪ Restriction policy and restricted antibiotics
plan and interventions ▪ Direct purchase of necessary antibiotics … etc.
to improve the use of
antimicrobials are
developed (Hospital >
150 beds).

1448 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must develop a training program in collaboration with lab personnel and relevant clinical
staff to address the following:

– Inappropriate negative or indeterminate culture

– No culture obtained
– Culture after antibiotics and no growth
– Contamination during sample collection & transportation
Substandard # 13.3
Key points to consider for training:
There is a training
Specimen collection guidelines include:
program to control the
challenge of
– Use standard precautions for collecting and handling all clinical specimens.
inappropriate negative
– Utilize appropriate collection device(s)
or indeterminate
– Use sterile equipment and aseptic technique to collect specimens.
culture (e.g. no culture
– Collect specimens during the acute phase of illness (or within 2 to 3 days for viral
obtained, culture after
infections)
antibiotics and no
– Collect specimens before administration of antibiotics wherever possible.
growth or
– Avoid contamination with indigenous flora from surrounding tissues, organs, or secretions.
contamination).
– Optimize the capture of anaerobic bacteria from specimens by using proper procedures.
– Collect a sufficient volume of specimen to ensure that all tests requested may be
performed.
– Inadequate amounts of specimen may yield false-negative results.
– Label specimens properly with patient’s name and identification number, source, specific
site, date, time of collection, and initials of collector.
– Provide clear and specific instructions on proper collection techniques to patients when
they must collect their own specimens.

1449 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 13.4 IC team adhere to antibiogram General Data Specifications in collaboration with all concerned units.

Antibiogram General Antibiogram data specifications includes the following:

Data Specifications. 1.
Analyze & present – Antibiogram is analysed & presented, at least annually.
antibiogram, at least – Include only final, verified test results.
annually. 2. Include – Include only species with testing data for 30 or more isolates.
only final, verified test – Include only diagnostic isolates, not surveillance (Active surveillance cultures are excluded)
results. 3. Include only – Eliminate duplicates by including only the first isolate of a species per patient, irrespective
species with testing of body site or antimicrobial profile.
data for 30 or more – Include only antimicrobial agents routinely tested.
isolates. 4. Include – Report percentage sensitive (%S) and do not include percentage with intermediate
only diagnostic susceptibility (%I).
isolates (not
surveillance). 5. Antimicrobial susceptibility testing (AST): Laboratory testing performed on microbes to find out if
Eliminate duplicates by they are susceptible or resistant to one or more drugs. Results of antimicrobial susceptibility testing
including only the first show if bacteria are susceptible (can be treated with the drug), intermediate (may be treatable
isolate of a species with the drug, but may require adjusted dosage), or resistant (cannot be treated with drug).
per patient,
irrespective of body Susceptible (s): A bacterial strain is said to be susceptible to a given antibiotic when it is inhibited in
site or antimicrobial vitro by a concentration of this drug that is associated with a high likelihood of therapeutic success.
profile. 6. Include only
Intermediate (i): The sensitivity of a bacterial strain to a given antibiotic is said to be intermediate
antimicrobial agents
when it is inhibited in vitro by a concentration of this drug that is associated with an uncertain
routinely tested. 7.
therapeutic effect.
Report percentage
sensitive (%S) and do Resistant (r): A bacterial strain is said to be resistant to a given antibiotic when it is inhibited in vitro
not include percentage by a concentration of this drug that is associated with a high likelihood of therapeutic failure.
with intermediate
susceptibility (%I).

1450 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 14 Outbreak Management
Disease outbreak is generally defined as "the occurrence of cases of disease in excess of what would normally be expected in a
defined community, geographical area or season". ln hospital settings, outbreak should be suspected when Healthcare Associated
infections (HAl's) occur above the background rate or when unusual microbe or adverse event is recognized.
Outbreak in healthcare facilities are often multifactorial including breaches in infection control or clinical practices, contaminated
devices, infected or colonized patient and /or healthcare worker.
The aim of an outbreak investigation is to identify possible contributing factors, prevent further disease transmission, identify
populations at risk of a disease, and prevent similar occurrences in the future and to evaluate the effectiveness of infection control
measures (Refer to MOH guidelines for more details)
Each hospital should have clear policies and procedures for managing infectious diseases outbreaks in the hospital, including early
identification, initiation of appropriate control/containment measures to prevent the spread, and assignment of roles and
responsibilities etc.

Sub standards Explanation

IC Team must develop Policies & Procedures for management of health care associated infection
(HAI) outbreaks based on updated GDIPC outbreak management guidelines.

Policies & Procedures should be comprehensive incorporating all aspects of Outbreak Management
program as follows:

Outbreak determination / detection / Identification /Recognition:

Substandard # 14.1
Outbreak management in healthcare facilities begin with the timely identification of an outbreak.3
There are written Different sources could be utilized to identify an existence of an outbreak: Notifications and
policies & procedures routine surveillance. Laboratory services notification. informal reports from hospital clinicians, the
for management of regional epidemiology unit.3
health care associated Surveillance for HAIs & adverse events can be a great aid in recognition of outbreaks in
infection (HAI) healthcare settings because it provides both baseline and ongoing monitoring.
outbreaks based on
updated GDIPC
outbreak management Outbreak Investigations:
guidelines.
Generally, Primary components / steps of outbreak investigation includes the following:

– Confirming existence of an outbreak

– Alerting key partners about investigation
– Performing a literature review
– Establishing a preliminary case definition
– Developing a methodology for case finding
– Preparing an initial line list and epidemic curve
– Form a tentative hypothesis
– Evaluate hypothesis
– Institute initial control measures
– Monitor, Evaluate and Refine the control measures
– Prepare and disseminate a final report

1451 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Control of HAIs Outbreak :

The primary goal is control of the outbreak and prevention of additional cases. ln general,
control measures are usually directed against one or more segments in the chain of
transmission (agent, source, mode of transmission, portal of entry, or host) that are
susceptible to intervention.
For some diseases, the most appropriate intervention may be directed at controlling or
eliminating the agent at its source.
Control measures include, but not limited to:

- Strict hand hygiene compliance

- Isolation / Cohorting when needed
- Staff training and education
- Thorough environmental cleaning etc

Each healthcare facility is required to establish an outbreak management team with clear roles and
responsibilities of each member during any unforeseen situation based on MOH guidelines.

IC department must establish an outbreak management with representation from all relaxant
departments with clear roles and responsibilities:
Substandard # 14.2
– There must be a document enlisting the members of outbreak management team.(OMT)
There is a defined
approved by Hospital director / CEO.
outbreak management
– Distributed to all concerned departments & stakeholders.
team
– Members of outbreak management team includes but not limited to the following:

– Medical Director
Substandard # 14.3
– Infection Control head
– Clinical Microbiologist
The outbreak
– Infection Control Practitioner
management team is
– Infectious Disease consultant
qualified, trained, have
– Occupational Health Physician.
experience and skills
– Head of the nursing department
to detect and deal with
– Head of concerned department
outbreak..
– Environmental health officer (ln the case of suspected food poisoning)
– Supportive services and supplies
– Hospital Epidemiologist

**Additional members to be added according to the nature of the outbreak.

1452 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 II - Attributes & skills of outbreak management team:

– Qualified, trained, have experience and skills to detect and deal with outbreak..
– Following must be available in personal file as evidence of OMT qualifications, training &
skills. etc
–
o Basic qualification of outbreak management team.
o Evidence of training / certifications etc related to outbreak management (outbreak
specific training activities. - Workshops, symposiums, conferences, webinars etc
– local / National / International.
o Check relevant certificates / evidence of attendance in personal file.

IC team must provide periodic formal and on site training to the OMT during routine rounds etc
Evaluate the performance during IPCCC audit phase.
Assess the skills using different outbreak scenarios / situation and how they will respond:

Example: Unit Head NICU etc

There were increased number of MDR - Acinetobacter baumannii cases reported from Neonatal
ICU of your hospital. An outbreak was declared in the unit. IC team has already started Outbreak
investigation. As part of outbreak management team, what role you will play to contain / control
further transmission in your unit??

Answer:

Monitoring / observation of adherence to infection control practices in order to prevent further

transmission. (strict adherence to hand hygiene, use of dedicated equipments, rigorous
environmental cleaning, contact isolation/cohorting., dedicated staff assignments, early detection
& reporting of new cases in liaison with lab judicious antimicrobial use etc

Acinetobacter Baumannii is a Gram-negative bacillus that can cause infections in the blood, urinary tract, and lungs (pneumonia),
or in wounds in other parts of the body. It can also “colonize” or live in a patient without causing infections or symptoms, especially
in respiratory secretions (sputum) or open wounds.
Acinetobacter can live for long periods of time on environmental surfaces and shared equipment if they are not properly cleaned.
The germs can spread from one person to another through contact with these contaminated surfaces or equipment or though
person to person spread, often via contaminated hands.

Infection Control Director hold the key responsibility to investigate & initiate the control measures
for control of HAIs outbreaks in any unit of hospital.
Substandard # 14.4
Following parameters must be considered:
Investigation and
control measures of – Outbreak investigation must be systematic, following stepwise approach as per guidelines.
HAIs outbreak in the necessary steps of outbreak investigation.
affected hospital are – Control measures must be initiated as soon as possible which are applicable to the type of
led by director of IPC outbreak.
department. – IC director shall be responsible to lead all meeting for ongoing outbreak/s, analyse the
situation, modify /add interventions & follow up implementation process in the concerned
unit with his/her team.

1453 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team must follow the specified criteria and guidelines for active surveillance screening;
Substandard # 14.5
Definitions of MDROS
Active surveillance Screening policy for patients and health care workers according to the type of HAIs outbreak
through the screening microorganisms.
programs and policies, Screening policy for HAIs outbreak contact patients based on the Outbreak Management of
are based on a Healthcare Associated Infections MOH Guideline, 2020, GCC MANULA MDROS section 4, page
selected criteria (68-96) and CDC guideline of MDROS.
chosen according to There should be screening policy for gram positive bacteria (MRSA and VRE).
the nature and Screening policy for gram positive bacteria (Acinetobacter, Klebsiella, ESBLS, etc..). screening
characteristic of the policy or C. auris.
targeted HAIs immediate notification from hospital laboratory to Infection Perfectionists regarding critical
outbreak. results of microorganism as MRSA, VRE, ESBLS, CRE, C Auris, C. Diff, pseudomonas through a
Phone call, email, notification form or etc.).

Substandard # 14.6 IC Team must ensure the following in case of HAI outbreak in any unit/s:
In case of an outbreak,
infection control Notification of HAIs Outbreak:
department actively
notifies IC regional Responsibility of infection control department to actively notify IC regional directorate and
directorate and GDIPC GDIPC simultaneously through the official notification form within 2-6 hours.
simultaneously
through the official
notification form
within 2-6 hours

1454 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 14.7
Activate investigation forms;
In case of an outbreak,
activate investigation
In case of an outbreak, activate investigation forms (line list and contact tracing) within 24-48
forms (line list and
hours.
contact tracing) within
Line list – Listing of all cases including their demographic data and other required information
24-48 hours.
as per outbreak notification form.
Contact Tracing - Contact List of exposed patients & list of exposed healthcare workers
Substandard # 14.8

In cases of an Outbreak Management Action Plan (OMAP):

outbreak, IPC
personnel and HCWs In cases of an outbreak, IPC personnel and HCWs in the defined area and location of the
in the defined area outbreak should immediately activate the Outbreak Management Action Plan (OMAP)
and location of the Action plan includes details including all actions which have been taken to control the outbreak
outbreak should (planning, organizing, coordination and controlling)
immediately activate Action plan should specify goals/objectives, strategies / actions taken / responsible person and
the Outbreak time frame.
Management Action IC Team must ensure adherence to all infection control measures as per Outbreak Management
Plan (OMAP) Action Plan
Any breach of practice must be communicated to relevant unit head and medical director if
needed.
Substandard # 14.9

In case of outbreak IC Committee meeting:

the IPC department In case of outbreak the IPC department should alert the hospital IPC Committee in the nearest
should alert the meeting.
hospital IPC An urgent ICC meeting can be called upon based on the extent of outbreak (if needed).
Committee in the
nearest meeting.

Substandard # 14.10 IC Department must ensure availability of the following:

Evidence of critical / panic results received from the laboratory (Manual / electronic)
Infection control
prevention and
A log book / electronic file in the infection Control Department showing the critical lab values /
practitioners
panic results received form hospital laboratory. (All type of MDROs : (Pseudomonas,
department receive
Acinetobacter, E coli, klebsiella etc ), Clostridium difficile, blood borne pathogens ; Hepatitis
immediate notification
B,C & HIV etc
from the hospital
laboratory regarding
IC Team must be oriented about the process of receiving critical results from lab to respond to different
critical values (i.e. questions from the external audit teams (MOH- CBAHI)
MDROs results,
positive cultures..), Infection Preventionists MUST be well aware about the mechanism regarding immediate
and updated log book notification from hospital laboratory. (Phone call, email, notification form etc)
for these critical How they are interpreting and notifying any critical lab value related to specific department.
values is available in What is their role and immediate action when they receive the result.
IPC department.

1455 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC Team must incorporate basic outbreak training in the annual training & education plan for all
staff to orient them about the protocols and step of outbreak management.
Substandard # 14.11
Outbreak training must cover the following key aspects:
The IPC department
– Definition & type of outbreaks
must have an annual
– Steps of outbreak investigation
training plan of basic
– Roles & responsibilities at different level (Unit staff – unit head – lab etc)
outbreak training.
– Standard Infection control measures & their importance
– Line list and contact tracing procedures etc

Upon declaring the closure of outbreak, infection control director must develop a detailed report
on outbreak investigation & control measures.
IC director must submit the report to the Regional Directorate and GDIPC simultaneously.
Substandard # 14.12
Report must also be shared with hospital administration, concerned units & other member of
outbreak management team.
IPC director at the end
of the outbreak must
Outbreak report must include but not limited to the following key domains:
submit a final detailed
report and submit to
– Introduction
Regional Directorate
– Brief summary of outbreak
and GDIPC
– Details about the index cases and other positive cases (HCWs + exposed patients)
simultaneously.
– Causes of outbreak – Modes of Transmission
– Steps of outbreak investigation
– IC interventions / Control measures
– Environmental Sampling & results etc

1456 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 15 Occupational Health

All healthcare workers (HCWs) are at risk of exposure to an environment in which the potential of an unknown infection hazard always exists.
Occupational health Program assist in the prevention and control of occupationally acquired infections and hazards, particularly those related
to hospital work. Occupation health clinic Identify any infection risk related to employment and institute appropriate preventive measures.
Occupational Health clinic assist in the provision of a safe working environment for the staff.

Sub standards Explanation

Establishing and occupational health clinic is the necessity of all health care facilities.
Each healthcare facility includes occupational health clinic that provides the following
Substandard # 15.1 services:

The healthcare facility - Pre-employment counselling & baseline screening

includes occupational - Establish and maintain accurate and confidential medical records of employees
health clinic that - Assess and determine the immune status and immunization requirements of employees for
provides pre- vaccine-preventable diseases and institute the appropriate measures.
employment - Provide treatment and medical advice to individual employees and act as a resource for
counselling and employees to obtain care.
screening, - Monitor and investigate infectious diseases, potentially harmful infectious exposures and
immunization, post outbreaks of infections among HCWs.
exposure management - Monitor and investigate the needles stick and sharp injuries among HCWs.
and work restriction. - Work restrictions.
- Employee health related education & training programs
- BICSL license & N95 fit testing
- The clinic has a definite time and assigned staff (either full-time or part-time)

IC team must develop and update detailed polices and procedure for occupational health
program that fulfils the following criteria:
Substandard # 15.2
– Comprehensive: it covers all aspects of infection control regarding employee’s health program,
including (but not limited to):
There are approved
written policies and
Pre-employment counselling & baseline screening - The pre-employment history and
procedures for
assessment provides the basis of pre-employment evaluation for all Health Facilities
employee's health
employees.
related issues (e.g.
Determining of immune status & administering appropriate vaccines
pre-employment
Reporting, follow up and management of needle stick or sharp injuries and blood or body
counselling and
fluid exposures.
screening,
Reporting, follow up and management of exposure to open pulmonary TB, MERS-CoV,
immunization, post-
chicken pox, measles, mumps, and rubella
exposure management
Work restrictions.
and work restriction)
Employee health related education & training programs
BICSL license & N95 fit testing

– Fully applicable: all elements of the policy can be applied and comply with the hospital’s scope
of services
– Based on scientific references approved by MOH ( GCC, CDC, WHO & APIC)
– Signed from authorized personnel (i.e., owner of the policy / hospital director or medical
. director / concerned department)
– Approved by IC committee
– Valid (updated within 2 - 3 years and when indicated)

1457 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
Substandard # 15.3 IC Department must have clear plan written protocol for screening any newly hired employee
for hepatitis B, hepatitis C, HIV and tuberculosis (TB).
All employees have a
baseline screening for - Screening data of all HCWs must be kept in staff files. (Electronic / Manual)
hepatitis B, hepatitis C, - Electronic / Manual records must be updated & well organized.
HIV and tuberculosis
(TB). IC Department determines Immune status of newly hired staff against HBV, Measles, mumps,
rubella and varicella:

Optimal vaccination of HCWs can prevent the transmission of certain diseases, and prevention is
more cost effective than case management and outbreak control.

- Occupational Health Clinic must have a clear plan & written protocols for identifying
susceptible staff based on documented vaccination, serological evidence of immunity, or
documented clinical / laboratory evidence of the disease.
- Vaccination programs for susceptible HCWs i.e Administration of appropriate vaccine(s) to
susceptible HCWs
- Vaccination activities / Lists of target groups for different vaccines & coverage rates.
Substandard # 15.4 - Occupational health clinic must have a vaccination tracking system / dashboards to track
the susceptible staff on vaccination schedule to ensure all doses are received at the
The immune status of recommended time frame.
newly hired staff Level of immunity is defined as:
against HBV, Measles, – Hepatitis B virus: evidence of immunity by level of HBsAb > 10 m IU/ ml
mumps, rubella and – Measles: Presumptive evidence of immunity is written documentation of vaccination with two doses of
varicella are MMR vaccine administered at least 28 days apart, laboratory evidence of immunity, laboratory
determined by confirmation of disease.
documented – Mumps: presumptive evidence of immunity if they have written documentation of vaccination with two
vaccination, serology, doses of MMR vaccine administered at least 28 days apart, laboratory evidence of immunity, laboratory
evidence of immunity, confirmation of disease.
documented clinical/ – Rubella: Personnel should have documentation of one dose of live rubella vaccine on or after their first
birthdays or laboratory evidence of immunity to rubella.
laboratory evidence of
– Varicella HCP are considered to have immunity if they have laboratory evidence of immunity, an evidence
disease with life long of clinical diagnosis or verified varicella or zoster, or documentation of age appropriate vaccination.
immunity).
Occupational health clinic must ensure all screening records of newly hired staff are complete
Substandard # 15.5 and updated with vaccination of those who are susceptible based on the serology results.
Administration of Completeness of staff health records is extremely important to ensure HCWs are screened as
appropriate vaccine(s) per requirements and received appropriate vaccines when applicable.
to susceptible HCWs. Following must be ensured for validation of screening and vaccination records by external audit
visits by either MOH or CBAHI etc

Randomly selected files are reviewed usually and complete data is expected:
Examples of random selection could be according to area or job category:
– Medical records / file of medical director, head of ICU department, ER nurse, surgeon, lab.
Technician, respiratory therapist, laundry staff … etc.
– There must be updated data of evidence of baseline screening for hepatitis B, hepatitis C, HIV
and tuberculosis (TB)
– Evidence of immunity regarding hepatitis B, measles, mumps, rubella and varicella
(Documented vaccination -Serological evidence of immunity - Documented clinical / laboratory
evidence of the disease)
– Evidence of administration of appropriate vaccine(s) to those who are susceptible

1458 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Occupational health clinic MUST ensure that all targeted HCWs have received influenza vaccination
as per recommendations of ministry of health.

Following must be ensured:

Substandard # 15.6

The influenza vaccine – Lists of target groups for annual influenza vaccination
is administered – Annual report of the employee health clinic that includes overall coverage rate of annual
annually to targeted influenza vaccination
HCWs as per MOH – Staff health files must be complete and influenza vaccination coverage rate must be calculated
recommendation. for each year.
– Valid annual influenza vaccination records
– Additional evidence would be Basic Infection Control Skills Licence (BICSL card) with evidence
of annual influenza vaccinations.
– Staff refusals must be documented and escalated to administration (If any)

Occupational health clinic MUST conduct N-95 respiratory fit testing in collaboration with infection
Substandard # 15.7
control department.
N95 respiratory fit
Following must be ensured:
testing is conducted
for all HCWs every 2
– Valid organized records of N-95 Fit test of all targeted HCWs
years or when
– N – 95 Fit test must be repeated every 02 years unless required earlier.
required.
– A valid fit test ID must be issued from occupational health Clinic / infection control department.

Occupational health clinic MUST ensure following must be completed to rule out evidence of
tuberculosis:

Following documents MUST be available:

– Overall coverage rate for baseline PPD-based Tuberculin Skin Testing of hospital’s staff.
– Lists of target groups (non-reactive HCWs) for annual PPD-based TST
– Annual report of the employee health clinic that includes coverage rate of annual PPD-based
TST & conversion rate.
Substandard # 15.8 – All records must be available and updated.

Newly hired staff are Further Reading:

screened for TB upon A Purified Protein Derivative based Tuberculin Skin Test (PPD-based TST) should be
hiring, with PPD test administered, read, and interpreted by trained personnel.
done for newly hired
staff and annually for Intradermal method (Mantoux) is used to administer the PPD-based TST .
non-reactive HCWs. Baseline screening should be conducted at the time of hire. Those individuals who have a
PPD conversion rates history of having received the BCG vaccination should be included unless they have
are monitored and documentation of a previous positive reaction
calculated. A two-step TST should be performed when the initial TST is negative and there is no
documented negative TST during the preceding 12 months . • Interpretation of the TST depends
on measured TST induration in millimetres, the person's risk for being infected with M.
tuberculosis, and risk for progression to active TB if infected.
If personnel have a positive TST, a chest radiograph should be done promptly to check for
active disease. A history of exposure should be obtained to determine if infection is
occupational or community-associated.
The person should be instructed to report symptoms that are suggestive of TB as chest
radiographs do not need to be repeated unless the person is symptomatic.

1459 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 A recent converter should be referred to a healthcare provider for consideration of preventive
therapy .

PPD-based TST conversion: a 10-mm or greater increase in the size of the TST induration
during a 2-year period in a person with a documented negative <10mm baseline 02 step TST
result.
Conversion rate: Percentage of persons whose test result has converted within a specified
period. (i.e., to calculate a conversion rate, divide the number of conversions among HCWs in
the setting in a specified period (numerator) by the number of personnel who received tests in
the setting over the same period and multiply by 100).

Role of Occupational health clinic is to ensure safety of healthcare worker by implementing a system
Substandard # 15.9 for reporting, follow up and management of needle stick injuries & blood and body fluid exposure

Reporting through Following records must available in the clinic:

electronic system is
active and ongoing EPINeT forms (or other equivalent forms) during the last 3 - 6 months for HCWs who had
(i.e., reliable reports of experienced sharps / needle stick injuries & blood / body fluid exposure.
sharp or needlestick Evidence of regular reliable reporting (i.e., ongoing & active reporting in timely manner e.g
injuries and incident reports.
blood/body fluid Annual report of the employee health clinic that includes sharp & needlestick injuries &
exposures are sent to blood/body fluid exposures rates
GDIPC through EPINet, There must be medical records / documents of all those HCWs who had exposure to
HESN or other sharp/needle stick injuries or blood/body fluid for:
approved reporting – Evidence of POST EXPOSURE follow up and management
system in a timely – Post Exposure Prophylaxis (PEP)
manner). – Vaccination against Hepatitis B virus - Hepatitis B immune globulin (HBIG) to
susceptible HCWs
– Follow up serological testing
– Counselling & treating diseased HCWs, … etc..

- Occupational Health Team must have enough knowledge and expertise on post exposure
follow up management protocols.
Substandard # 15.10 - HCWs working in all patient care areas, laundry staff and waste collecting staff etc must be well
oriented and trained regarding the system of reporting, follow up and management of exposure
There is an to needle stick injury and body fluid exposure.
implemented system - They must have enough knowledge of when , how, & where to report an incident of sharp
for reporting, follow ,needlestick & blood /body fluid exposure.
up and management - Staff must be well trained on FIRST AID measure after sudden exposure or injury.
of exposure to needle
stick injury and body - Occupational Health Nurse / doctor must know and perform the following: (Refer to National
fluid exposure. occupational health guidelines for details and stepwise management.
How to evaluate both the exposed employee and the source patient?
How to properly apply post-exposure follow up & management plan for HBV, HCV or HIV.
How to report, manage and follow up a nurse who had exposed to sharp injury from
unknown source
How to report, manage and follow up a lab. technician who had exposed to needlestick
injury from a patient +ve for HBV & HIV.
Must receive training regarding EPINet, HESN or other approved reporting system
Knows how to report a case of sharp/needlestick injury or blood/body fluid exposure to
GDIPC through EPINet, HESN or other approved reporting system
How do you properly interpret changes in sharp/needlestick injuries & blood/body fluid
exposure rates? • Instead of direct questions, indirect ones or scenarios are advisable.

1460 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Occupational health clinic is to ensures effective implementation of a system for reporting, follow up
and management of exposure to open pulmonary TB, MERS-CoV, COVID-19, chicken pox, measles,
mumps and rubella.

Following records must available in the clinic:

Documented evidence of exposure (lists of HCWs who had exposed to MERS-CoV, open
pulmonary TB, chicken pox, measles, mumps or rubella, with classification into low or high risk
/ protected or non-protected exposure etc)
Isolation room’s logs that record HCWs who had exposed to the above mentioned diseases
Substandard # 15.11 Evidence of reliable reporting of exposures to regional directorates / GDIPC when indicated
(e.g., exposure to MERS - CoV confirmed cases, exposures during chicken pox or measles
There is an outbreaks, … etc..).
implemented system
for reporting, follow Annual report of the employee health clinic that includes exposure incidents to MERS-CoV,
up and management open pulmonary TB, chicken pox, measles, mumps and rubella Document
of exposure to open
pulmonary TB, MERS- Occupational Health Team must have enough knowledge and expertise on post exposure
CoV, COVID-19, follow up management protocols.
chicken pox, measles, - Occupational Health Nurse / doctor must know and perform the following: (Refer to National
mumps and rubella. occupational health guidelines for details and stepwise management.

Application of post-exposure reporting, follow up & management plan for MERS-CoV, open
pulmonary TB, chicken pox, measles, mumps and rubella
Know how to report, manage and follow up a physician who had unprotected exposure to a
patient confirmed for MERS-CoV.
How to report, manage and follow up a respiratory therapist who had exposed to a case of open
pulmonary TB
How to report, manage and follow up exposures during chicken pox outbreak
How to report, manage and follow up a nurse who had exposed to a patient +ve for measles.

Occupational health clinic team must prepare and maintain the following records to ensure
Substandard # 15.12 continuous monitoring and follow up of various staff exposures followed by corrective actions to
prevent recurrences:
Annual report of the employee health clinic that includes rates of different exposures (or
The Employee health changes in exposure rates with or without corrective interventions)
clinic team regularly [[

Documented evidence of corrective intervention: -

monitors different
types of staff exposure Change in specific policy to replace a risky procedure with a less risky procedure
and take Replacing a risky device or equipment with a device or equipment that has more advanced
recommended safety features
corrective actions to Comparing exposure rates before & after corrective actions or prevention strategies.
prevent recurrence IC committee meeting minutes that discuss and interpret rates of different exposures (or
(e.g. engineering changes in exposure rates) classified by department, occupational category, device-based …
controls as self- etc.
sheathing needles or Occupational health Clinic ensures continuous communication & provide formal feedback to the
safety scalpels). HCWs involved in corrective interventions or prevention strategies. All records are maintained in
the staff health files.

1461 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Screening, immunization and post-exposure management medical records (or copies) MUST be
available for all personnel and supportive services staff (i.e. kitchen, laundry, housekeeping, waste
management ... etc.) in the occupation health clinic. Records must be duly updated (Electronic or
Substandard # 15.13
printed version)
Updated medical Documented including all employees with professional / job categories including personnel in
records (or copies) supportive services (i.e., kitchen, laundry, housekeeping, waste management …etc.)
are available for all
personnel and For each staff following records must be available, complete & up-to-date
supportive services - Evidence of baseline screening
(i.e. kitchen, laundry, - Evidence of immunity or administration of appropriate vaccine (s) to those who are
housekeeping, waste susceptible
management ... etc.) - Evidence of post exposure follow up and management
including screening, - Records of work restrictions after potential exposures following the MOH work
immunization and restriction policy.
post-exposure -
management. All records and staff medical files are well organized & updated by occupation health clinic staff
to be able to present required sampling documents to the external audit teams without
significant time delay. (MOH – CBAHI)

Occupation health clinic MUST ENSURE that appropriate work restrictions policy is implemented and
followed for staff based on MOH approved policies and procedures & updated guidelines.
Substandard # 15.14
Work restrictions for healthcare personnel after potential work-related or community exposures
Applied work or infected with infectious diseases of importance in healthcare settings is of utmost
restrictions for HCWs importance for decreasing the transmission of infections from healthcare personnel to patients.
are consistent with
MOH approved Occupation health clinic ENSURES that healthcare personnel strictly adhere to work restrictions
policies. policy e.g exposures to COVID -19, MERS- CoV, measles, mumps, varicella, tuberculosis etc

1462 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Training and education is the key to successful implementation of any program within the hospital
setting. Therefore, continuous training and education activities must be planned and conducted for
all staff in the hospital.

Following must be available to have a documented evidence of training activates for occupational
health program:

- Evidence of training activities for occupational health program:

- Annual report of the employee health clinic that includes yearly educational and training
- Lists of target groups for training
Substandard # 15.15 - Trainees’ Attendance sheets
- Records of educational and training activities with calculation of Training coverage rates.
There are regular (Electronic records are preferable to track the staff training activities.)
training activities for
employee health Components or elements of the educational activities and training program includes but not
program. limited to:
- Hand hygiene. b. Modes of disease transmission.
- PPE - Respiratory protection & N95 fit testing
- Sharp & needle stick injuries (risks & prevention)
- Post exposure management & follow up
- Recommended / mandatory vaccination
- Work restriction
- The importance of presenting themselves to employee health when they suspect an
infectious disease may be present (e.g., rash, fever).
- The importance of cooperating with the Infection Prevention and Control Department,
complying with standard precautions & importance of screening and immunization.

Occupation health clinic in collaboration with infection Control department must ensure the
following:
Substandard # 15.16
Availability of allocated room(s) in staff accommodation for home isolation.
Exposed health care Room(s) should be:
workers are isolated - Adequately ventilated with separate air conditioning system
when needed (either - With separate Facilities (e.g., private bathroom(s)
home isolation in staff - If home isolation in staff accommodation is not attainable, specified rooms that are
accommodation or identified in the hospital for home isolation of HCWs when required must be available e.g
identified rooms in the during COVID - 19 pandemic or any other situation.
hospital for HCWs - Staff must be well oriented and trained regarding rules of home isolation and following
isolation). recommended IC measures to protect others form acquiring infection,

1463 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Standard – 16 Infection Control Precautions in Special Situations (e.g COVID - 19 Pandemic)

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The new strain of coronavirus
was identified in December 2019 in Wuhan city, Hubei province of China.
Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without requiring
special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic
respiratory disease, and cancer are more likely to develop serious illness. Hence strict implementation of infection control
measures when managing suspected and confirmed COVID-19 cases & following special protocols during COVID – 19 pandemic
reduces the risk of acquiring infections within the health care settings.
Sub standards Explanation

IC department must ensure provision of daily monitoring logbook in all units/departments for health
workers to record presence or absence of COVID – 19 symptoms before starting their duty shift.

Following must be ensured:

Substandard # 16.1
- All HCWs are instructed to record the COVID – 19 symptoms (if any) in the daily monitoring log
Daily logbook is
book.
activated in the unit
- This documentation is mandatory for all HCWs to rule out presence or absence of COVID 19
for HCWs to record
symptoms such as fever, cough. Shortness of breath, GI symptoms etc.
presence or absence
- Head nurse hold the key responsibility to ensure that log book is complete and signed by all
of fever, respiratory &
HCWs on daily basis.
GI symptoms etc.
- Head nurse must review to assess the need for any staff to be evaluated by occupational health
before starting work
clinic or need work restriction.
shift.
- Infection control practitioners must ensure that daily monitoring rules are followed and validate
the information by randomly selecting any staff.

Use attached template (Appendix 009)

1464 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Universal Masking in Hospitals in the Covid-19 Era:

According to MOH guidelines, during COVID – 19 era, preventive measures for protecting patients
and health care workers from the virus MUST be intensified. These should include universal use of
masks by all health care workers.

In health care settings, First and foremost, a mask is a core component of the personal protective
equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections,
in conjunction with gown, gloves, and eye protection.
Substandard # 16.2
All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be
All HCWs must abide
expected to wear surgical face masks, at all times, while in their respective clinical care settings.
by the policy of
universal masking i.e
This universal mask approach will serve to:
wearing surgical face
mask at all times while
Protect patients and HCWs from exposure to infection from asymptomatic COVID-19
in their respective
infected HCW (a mask achieves source control and decreases the risk of spreading
clinical setting.
infection)
Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients
or patients have mild COVID-19 infection that have not yet been recognized.

- IC Team must ensure implementation & strict adherence to universal masking policy by
all HCWs working in patient care areas.
- MEMO/Circular must be sent to all units to follow universal masking policy through
administration.
- Any breach of practice must be noted and dealt appropriately.

Universal Masking Guidance

- A single mask can be worn across different cases and between cares of different patients.
- When providing care to a patient with known or suspected COVID-19 the mask should be
removed and wear new one after hand hygiene.
- Masks must be changed if they become wet or contaminated during a case.
- Surgical mask is not allowed to be worn outside the clinical care areas.
- Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
Personnel working in nonclinical areas, where persons are reliably separated by more than 1.5
meter should not wear masks BUT when walking through common clinical areas where care is
delivered, the mask policy applies.
- Stop at an entry point prior to entering the clinical area to use surgical masks.
- These employees should practice principles of social distancing, respiratory etiquette
and frequent hand hygiene.

Process to Use and Discard Surgical Mask:

- A surgical face mask will be used at the start of each shift, for those individuals working in
clinical care units.
- Masks will be available at each entrance to the unit, and will be used throughout the shift.
- In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
- At the end of shift, HCWs will be asked to doff their face masks as they exit the unit.
- Medical waste containers will be placed at each exit for the used masks to be discarded.

1465 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 1: Social distancing is a set of interventions or measures intended to prevent the spread of
a contagious disease by maintaining a physical distance between people and reducing the number of
times people come into close contact with each other. It usually involves keeping a certain distance
from others and avoiding gathering together in large groups.
Social distancing, also called “physical distancing,” means keeping a safe space between yourself
and other people. To practice social or physical distancing, there MUST be distance of at least 6
feet (about 2 arms’ length) from other healthcare workers during the duty hours.

Why Practice Social Distancing?

COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a
Substandard # 16.3 prolonged period.
Spread happens when an infected person coughs, sneezes, or talks, and droplets from their
Health Care workers mouth or nose are launched into the air and land in the mouths or noses of people nearby. The
strictly adhere to droplets can also be inhaled into the lungs.
principles of social Recent studies indicate that people who are infected but do not have symptoms likely also play a
distancing, cough role in the spread of COVID-19. Since people can spread the virus before they know they are
etiquette and frequent sick, it is important to stay at least 6 feet away from others when possible, even if they do not
hand hygiene during have any symptoms.
duty hours.
Cough Etiquette:
The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when
an infected person coughs or sneezes, so it’s important that respiratory etiquettes are practiced
(for example, by coughing into a flexed elbow when paper tissue is not available).

Hand Hygiene:
Promoting good hand hygiene is one of the most basic yet powerful tools to reduce the spread of
COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or
handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in
healthcare settings.
Hands are a critical vector for transmitting microorganisms with in the healthcare facilities. Cross‐
transmission of these organisms to others occurs when we fail to wash hands effectively.

Hand hygiene with Alcohol Based Hand Rub (ABHR) for at least 20 – 30 sec effectively
reduces the number of pathogens that may be present on the hands of healthcare providers
after brief interactions with patients or the care environment.
CDC recommends using ABHR with 60-95% alcohol in healthcare settings. Unless hands are
visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical
situations due to evidence of better compliance compared to soap and water. Hand rubs are
generally less irritating to hands and are effective in the absence of a sink.

Hands should be washed with soap and water for at least 40-60 seconds when visibly soiled,

- IC department during routine rounds MUST ensure increase adherence to hand hygiene,
respiratory hygiene & social distancing during work hours in health care facilities, thus
protecting health care workers and patient from COVID-19 and other pathogens.
- Appropriate & clear visible signage must be posted to alert staff to follow recommended
precautions during COVID – 19 pandemic.

1466 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 IC team members must ensure that there is no overcrowding within the hospital units. Leadership
must provide full support to IC department to ensure stringent implementation of infection control
Substandard # 16.4 measure to prevent spread of transmission with in the healthcare facilities from patient to HCW.
patient to another patient, HCWs to patients & in between HCWs.
Interdepartmental
mobility of ICPs is Following must be ensured:
strictly prohibited
unless necessary for Circular/ MEMO from hospital director addressed to all health care providers (Clinical & non
Infection Prevention & clinical staff) to avoid the unnecessary mobility in between the units.
control activities. Moving in between departments and eating together in pantries is strictly prohibited.
HCWs must limit the movement unless absolutely necessary for medical reasons e.g mandatory
inspection rounds, daily surveillance activities etc

1467 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1468 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
1469 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
SECTION - IV

TOOLS & RESOURCES

1470 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Certificate of Appreciation

This certificate is awarded to

-----------------------------------------------------------------------

for the
“BEST UNIT PERFORMANCE”
in the implementation of the
“Infection Prevention & Control Core Components” (IPCCC)
in Quarter -------- Year ----------

We truly appreciate your efforts & hope for sustainable performance.

Hospital Director : -----------------------------

Infection Control Director : ------------------

1471 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Certificate of Appreciation

This certificate is awarded to

-----------------------------------------------------------------------

for the
“BEST HOSPITAL PERFORMANCE”
in the implementation of the
“Infection Prevention & Control Core Components” (IPCCC)
in Quarter -------- Year ----------

We truly appreciate your efforts & hope for sustainable performance.

Regional Infection Control Director ----------------------------

1472 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 Certificate of Appreciation
This certificate is awarded to

-----------------------------------------------------------------------

for the
“BEST REGIONAL PERFORMANCE”
in the implementation of the
“Infection Prevention & Control Core Components”
(IPCCC)
in Quarter -------- Year ----------

We truly appreciate your efforts & hope for sustainable performance.

General Directorate of Infection Prevention & Control Administration

(GDIPC)

1473 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
SECTION - V

REFERENCES

1474 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
REFERENCES:

1. Improving Infection Prevention & Control at the 16. Centres for Disease Control and Prevention. Core
health Facility; Interim practical manual supporting Elements of Hospital Antibiotic Stewardship Program.
implementation of the WHO Guidelines on Core 17. http://www.cdc.gov/getsmart/healthcare/implementation/co
Components of Infection Prevention and Control re- elements.html
Programmes. 18. A WHO Practical Toolkit for Antimicrobial Stewardship
2. World Health Organization (2016). Guidelines on Programmes in Health-Care Facilities in low – and Middle
Core Components of Infection Prevention and –Income countries
Control Programmes at the National and Acute https://apps.who.int/iris/bitstream/handle/10665/329404/97
Health Care Facility Level. Geneva, Switzerland. 89241515481-eng.pdf 3 19 – 27)
3. GCC Infection Prevention & Control Manual 3rd 19. Antimicrobial Resistance Committee, National
Edition 2018 Antimicrobial Guidelines for Community and Hospital
4. Association for Professionals in Infection Control Acquired Infections in Adults; Ministry of Health- General
(APIC) and Epidemiology, Inc. (2014). (4th ed.) Administration of Pharmaceutical Care Revised 2018.
5. Center for Disease Control and Prevention (CDC). 20. World Health Organization. Antimicrobial Resistance
https://www.cdc.gov/ Factsheet. Sept 2016.
6. WHO Guidelines on Hand Hygiene in Healthcare http://www.who.int/mediacentre/factsheets/fs194/en/#
2009 (World Alliance for Patient Safety). World Health Organization. Global Action Plan on
7. Middle East Respiratory Syndrome Coronavirus ; Antimicrobial Resistance. WHO. Geneva (CH): 2015.
Guidelines for Healthcare Professionals :Version Available from:
5.1 May 21, 2018 : Ministry of health Guidelines http://www.who.int/drugresistance/global_action_plan/en/
8. “WHO” Middle East Respiratory Syndrome 21. Guidelines for the Prevention of Intravascular Catheter-
Coronavirus (MERS-CoV) : Monthly summary Related Infections, 2011
https://www.who.int/emergencies/mers-cov/en/ https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.h
9. “CDC ” Middle East Respiratory Syndrome tml
Coronavirus (MERS-CoV) 22. Health Care Associated Infections Surveillance Manual
https://www.cdc.gov/coronavirus/mers/index.htmIn GCC - 2018 (3rd Edition)
terim Infection Prevention and Control 23. HESN – HAI Surveillance Manual (GDIPC)
10. Centers for Disease Control and prevention https://hesn.moh.gov.sa/webportal/infection-
(CDC).. Available at: contro
http://www.cdc.gov/coronavirus/mers/guidelines- 24. GCC - NHGA HAI course content – 2019 5) guidelines for
clinical-specimens.htm the Prevention of Intravascular Catheter-Related
11. IP Competency Task Force. APIC Competency Infections, 2011 https://www.cdc.gov/hai/pdfs/bsi-
model for the Infection Preventionists: A guidelines-2011.pdf
conceptual approach to guide current and future 25. https://www.cdc.gov/infectioncontrol/guidelines/bsi/recom
practice . mendations.html#rec18
12. Ministry of health MOH guidelines on the 26. MDRO Prevention and Control
Management of Outbreaks in Healthcare Facilities, https://www.cdc.gov/infectioncontrol/guidelines/mdro/prev
13. https://www.cdc.gov/hai/outbreaks/index.html ention-control.html.
14. Principles of Epidemiology in Public Health 27. https://www.cdc.gov/hai/prevent/prevention_tools.html
Practice, 3'd edition, Centers for Disease Control Prevention Toolkits
and Prevention (CDC), 2016. 28. Ministry of Health : Coronavirus Disease COVID-19
15. Outbreak Investigation in Healthcare Settings Guidelines, V 2.0
http://ndhealth.gov/disease/hai/Docs/WebEx/Outbre 29. Universal Masking in Hospitals in the Covid-19 Era April-
akWebinar.pdf 2020

1475 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities
 General Directorate of Infection Prevention and Control Ministry of Health
Ministry of Health, Kingdom of Saudi Arabia Preventive Health General Department
Email: [email protected] Prince Sultan Ibn Salman Ibn Abdul Aziz,
Visit us at : www.gdipc.org Ar Rahmaniyyah, Riyadh

1476 | Guidelines on Infection Prevention & Control Core Components for practical implementation in healthcare facilities