INFECTION CONTROLMANAGEMENT FRAMEWORK

Dr Zubaidah Abdul WahabJabatan PatologiHospital Sg Buloh

MANAGEMENT FRAMEWORK

Organization of Infection Control= Ministry of Health = State/hospital

Role and Responsibilities= Hospital Infection Control and Antibiotic

Control Committee ( MOH/Hospital )= Infection Control Nurse ( Hospital )= Infection Control Link Nurse

(Ward/Department)

Organization of MOH HIACC

- Chairman DG- Member Director Medical

Development Division & Health Division, Chairman of Hospital (HIACC) , Pharmacy Director,

Infection Control in Ministry of Health

National Infection & Antibiotic Control Committee(NIACC)

Chairman Director General

State Infection & Antibiotic Control CommitteeChairman: Clinician

Hospital Infection & Antibiotic Control CommitteeChairman: Pengarah Hospital

Infection Control Nurse

Link nurses

Function of MOH HIACC

Developing policies and procedures related to infection control and antibiotic usage at national level

Act as a source of expertise on matters relating to infection and antibiotic usage

Advisor to MOH

Members of HIACCHospital Director

Infectious Disease PhysicianMedical Microbiologist

All Head of DepartmentMatron

Infection Control Nurses (Sister/Staff nurse)

CSSDPharmacist

Concessional body

Organization of HIACC

Hospital Director

Chairman of HIACC

Committee member:Director Head of Microbiology Unit -SecretaryAll Head of Clinical Department MatronPharmacistRepresentative from consensional bodyCSSD/OT SisterInfection Control Team

Infection Control Team:Infection Control Doctor( ID Pyhsician/ Cli Micro)Infection Control Sister Infection Control Nurse

Functions of HIACC

1. Advisory Committee: The Committee will act as a source of

expertise on matters relating to infection and antibiotic usage.

The committee advises the Hospital Director of the hospital through the Infection Control Chairman.

Functions

2. Surveillance And Monitoring Of Nosocomial Infections

The HIACC will undertake ongoing systematic collection, analysis and interpretation of health data, essential to the planning, implementation and evaluation of infection control policies.

The objective of the surveillance is to: define endemic rates of nosocomial infections identify increases in infection rates above the endemic levels detect occurrence of ‘alert’ organisms

Functions of HIACC

The following types of surveillance will be used depending on the needs and availability of resources: Laboratory based surveillance Outbreak surveillance Targeted surveillance in specific areas such as in intensive care areas Point prevalence surveillanceClinical based surveillance (SSI, DRI,VAP, Antibiotic usage – specific antibiotic, DDD)

Functions of HIACC

3. Review of Policies The committee will develop hospital wide

infection prevention and control policies and procedures.

The committee will also work collaboratively with all clinical units to develop policies and guidelines for antimicrobial usage.

These policies will be reviewed regularly to maintain accuracy and validity.

Functions of HIACC

4. Review infection rates: The committee will review reports of

current nosocomial infection rates, specific surveillance studies, antibiotic-resistance patterns and the implementation of infection control policies from the Infection control team and recommend or implement actions as appropriate.

Functions of HIACC

5. Isolation Policies The committee will be responsible for policies

and procedures for the management of infectious patients in the hospital.

6. Education and Training The committee will organize education

programme for in-service staff and orientation programmes for new nursing staff and interns.

In addition, the infection control team will organize formal and informal lectures to health care workers, interdepartmental meeting.

Functions of HIACC

7. Health care workers protection The committee will be responsible for

policies and procedures for the protection of health care workers from on-the-job exposures to infection and work restrictions when an employee has an infectious disease.

The committee will work collaboratively with the Occupational Health Unit to develop policies and procedures for immunization programmes, and implementation of appropriate preventive measures against sharps injuries.

Functions of HIACC

8. Review Trends in Antibiotic-Resistance Patterns and antimicrobial usage

The committee will work with Pharmacy Department to collate data on antimicrobial usage and advice the Hospital Director on policies regarding hospital antimicrobial usage.

Functions of HIACC

9. Review policies and procedures pertaining to personnel protective equipment and disinfection/sterilization

The committee will be responsible for policies and procedures pertaining to usage of personnel protective gear and disinfectants.

10. Advisor of the Hospital on safety of certain high risk area such as: Operation Theatre (OT) and Intensive Care Unit (ICU)

Functions of HIACC

List of Policies & Procedures of Hospital

Standard & Expanded Precautions – to include isolation procedures, hand washing, personal protective equipment, patient placement & management of spillage

Surveillance – Laboratory Based, Outbreaks, Targetted (in specific areas/infections, Point prevalence, clinical based)

Antibiotic Resistance Antimicrobial usage surveillance Advising & Monitoring Clinical Waste/Cleaning

Management Protection for health care workers – on the

job exposure to infections

Sterilization & Disinfection Environmental Monitoring – air sampling,

water, Guidelines for specific procedures –

catheter care, ventilator, wound care Reporting of Nosocomial Infections Guidelines for Infection Control in

specific areas/infections - Labour Room, OT, GICU, NICU, Haemodialysis, Dental, Mortuary, CSSD, Burns, Pathology, pandemic flu/TB/chicken pox/HIV

List of Policies & Procedures of Hospital

HIACC meeting(at min 2 times a year)

- Report on the incidence and prevalence of “alert” organisms

- Report on the occurrence and nature of any outbreaks of infection and on incidents involving microbiological hazards (e.g needle injuries)

- Report on going targeted surveillance of nosocomial infection

- Report on antibiotic usage patterns- Develop and maintain policies for the promotion

of good infection control and antibiotic usage guidelines in KKM

- Review outbreaks of infection and advise managers on how outbreaks might prevented

- Assist in the planning and development of services and facilities in the hospital on issues which are relevant to infection control and antibiotic usage.

- Monitor and advice on specific areas of hygiene and infection control, catering, CSSD, ventilation and water services, occupational health ,pharmacy , operating theatres, endoscopy,etc.

HIACC meeting(at min 2 times a year)

- Develop programmers for the education of staff and students about infection control practices and policies and appropriate antibiotic prescribing.

HIACC meeting

Chairman of the Hospital Infection and Antibiotic Control committeewill be an Infectious Diseases Physician, Clinical Microbiologist or Senior Consultant.

In the absence of the Chairman, the meeting will be chaired by the Secretary or another Senior Consultant.

HIACC meeting

Infection Control team is delegated to perform the day-to–day infection control

programmes. The team will be working under the

supervision of Chairman and Secretary of the Infection Control and Antibiotic

Committee. The infection control team will serve as

the secretariat for the HIACC. The secretariat is responsible for the minute taking and for various logistic

arrangements.

Infection Control Sister (ICS):This post will be held by Sister and will be appointed by the Director. She is responsible for training of Infection Control and supervises the working of the Infection Control Nurses (ICN).

Infection Control Nurse (ICN)1 : 110/hospital

Roles & Responsibilities of ICT:

1. As a reference on infection control An advisor on infection control for the

hospital An advisor on post exposure prophylaxis

management; As a liason personnel between department

link nurse and ICT /HIACC Assist in formulation of the hospital policies

and guidelines related to infection control.

2. Surveillance of Hospital Acquired Infection (HAI)i. Lab based:

daily screening of lab results in the Microbiology Laboratory (HAI/ MRSA / ESBL producer / MRO)

verification of HAI detected from the lab results

liaise closely with the Clinical Microbiologist

Roles & Responsibilities

2. Surveillance of Hospital Acquired Infection (HAI)ii. Clinical based:

Ward base notification or ward visit verify the HAI cases reported by the link

nurse; Initiate and monitor management of the HAI

cases; follow up of HAI cases (patients

progress/break of HAI link).

Roles & Responsibilities

iii. Targeted surveillance: assist to formulate and perform

identified targeted surveillance (location/pathogen /type of HAI eg: SSI, device-related infection)

iv. Collecting and analyzing data of surveillance performed in the hospital

v. Preparing reports and dissemination of surveillance data

Roles & Responsibilities

Roles & Responsibilities

vi. Conduct investigation and action according to advice of ICT

vii. Liaise closely with ICD/Clinician/MOH/Clinical Microbiologist of ICT

viii. To assist in point prevalence study as decided by the committee

Roles & Responsibilities

3. Supervision on ward staffs on infection control practice

i. Ensure the implementation of infection control policies and guidelines

ii. Discuss an identified or suspected HAI case with ICT;

iii. Monitor of sterilization and disinfection equipments;

iv. Education on proper usage of Personnel Protective Equipments;

Roles & Responsibilities

3. Supervision on ward staffs on infection control practicev. Formulating and monitoring the

implementation of disinfection and sterilization policies according to standard procedures;

vi. Ensure proper management of linen;

vii. Ensure proper segregation and disposal ofwaste;

viii. Ensure proper specimen collection and dispatch;

Roles & Responsibilities

4. Continuous Educationi. Plan and conduct CME on Infection

Control;ii. Conduct ward rounds and teaching;iii. Conduct patient’s education.

Roles & Responsibilities

5. Outbreak management Monitor the microbiology data on certain

pathogen or type of infection; Detect impending outbreak or outbreak Assess outbreak situation; Discuss on the management of the outbreak

with ICT Conduct and monitor outbreak investigations; Advise on necessary infection control

measures; Write and disseminate full outbreak reports; Evaluation of remedial action taken; Recommendation for improvement and

prevention of further outbreak.

Roles & Responsibilities

6. Data management Data collection from surveillance

performed; Tabulation and analyzing of the

data; Preparation of reports as

scheduled; Dissemination of reports to

relevant authorities.

Roles & Responsibilities

7. Environment sampling: Conduct air sampling as required:

- new OT;- post-construction;- outbreak.

Interpret result under supervision of clinical microbiologist;

Supervise in collecting of water sampling, in-use test and other environmental samples as indicated (during outbreak)

Implement plan of action and propose recommendation

Roles & Responsibilities

8. Quality Assurance (QA) activities & research

National Indicator Assurance (NIA) eg: MRSA and ESBL producer

Point surveillance Hospital Specific Approach (HAS) eg:

targeted surveillance - Surgical Site Infection (SSI), Antibiotic resistance pattern

Roles & Responsibilities

8. Quality Assurance (QA) activities & research Accreditation – MSQH, International Standard Audit

- Hand hygiene practices- Antibiotic usage- Isolation practice- Aseptic procedure

Research- Disinfectant usage- Evaluation of alcohol hand rub - Surveillance – SSI, device related infection

THANK YOU