Patient and Family Rights (PFR)
April 8, 2017
IV Push IVP Medication Administration Guidelines
April 9, 2017
What is the purpose of having an Infection Control Department in your hospital?
It is to reduce the risk of healthcare associated infections (HCAI) among patient’s visitors & healthcare workers (HCWs).
On what basis your infection control program is functioning?
Based on current scientific knowledge / accepted practice guidelines / MOH Rules & Regulations.
Are your Infection Control Team members qualified in Infection Control?
Yes, Infection Control Nurses are qualified through education, training & experience
The Infection Control Doctor is qualified in Clinical Microbiology / Public Health / Fellowship in
Infection Control
Who is the highest hospital authority to supervise the Infection Control Department?
CHIEF EXECUTIVE OFFICER / MEDICAL DIRECTOR
Who are the members of ICC & what are their functions?
Infection Control Doctor / Infection Control Nurses / Medical Director / Nursing Director / QI
Coordinator / Internal Medicine / General Surgery / Obstetrics & Gynecology / Pediatric /
Orthopedic / Employee Health Physician / Pharmacy
Invited Members: Housekeeping / Catering / CSSD / Operating Room Head Nurse
Is there an Infection Control Manual in your unit?
Yes, it is available in the hospital Intranet service.
How frequently Infection Control Manual is revised?
Once in 3 years. Amendments are done as per the needs based on epidemiological risk assessment.
Did you get Infection Control education?
Yes, I got my orientation on Infection Control at the time of joining work & on an annual basis I get Infection Control Refresher courses. In addition CME lectures are provided during the occurrence of epidemiologically significant Infectious Diseases (e.g. MERS-CoV / Ebola) I do get education on a regular basis during Infection Control rounds at patient care locations / other allied health care services during changes in the trends of certain Infectious Diseases including the key performance indicator data viz: HCAI rate, Rate of ventilator associated pneumonia, catheter associated urinary tract infection, central line associated blood stream infection, surgical site infection & the prevalence of multidrug resistant organisms such as Acinetobacter spp & Methicillin resistant Staphylococcus aureus.
How does the Infection Control staff
for HCAIs?
Infection Control surveys are performed by the Infection Control Nurses based on the
Infection Control Policy entitled Surveillance to Determine Rates of Infection.
They review patient charts for clinical Diagnosis / Microbiology reports / other lab parameters / Antimicrobial therapy / Hospital census checking for patient’s re-admission. In addition the treating physicians notify the infection control team on notifiable infectious diseases, other hospital acquired infections including post operative wound infections by utilizing the healthcare associated infection surveillance form.
How does the Infection Control Dept. integrate their analysis with the QI projects?
The Infection Control Dept. performs QI projects to reduce the device associated infections such as prevention of ventilator associated pneumonia (VAP), Central line Associated Blood stream infection (CLABSI) ,reducing the incidence of blood culture contamination (BCC) rate, prevention of Middle Eastern respiratory syndrome Coronavirus (MERS-CoV) infections, Reduce the incidence of Needle stick injuries.
Does the Infection Control Department give you the analyzed data on HAIs on a regular basis?
Yes, the data’s are provided to us on a quarterly basis & are presented as graphs on HAI / NSI / HH / CAUTI within ICUs (HAI/VAP/CLABSI/CAUTI/NSI/HH) are provided.
Are the HAI rates benchmarked?
Yes, they are benchmarked internally among departments.
Is there any performance improvement projects conducted at your hospital?
Prevention of Ventilator Associated Pneumonia / Central line Associated Blood stream infection
(CLABSI), Prevention of Needle Stick Injuries /Blood & Body Fluid Exposure.
How do you protect yourself from Needle Stick Injuries?
The Hospital prevents re-capping of needles If recapping is necessary at certain critical locations, scoop method is employed. Needles / sharps are disposed at the point of use in sharp boxes
How do you safely handle sharp boxes?
The sharp boxes are fixed onto walls at all patient care locations / they are puncture resistant/ closed & sent for disposal when it is 314th full / 2 weeks old. The temporary lids are kept closed when not in use.
How do you protect yourself & other patients from patients with communicable Infectious Diseases?
We implement standard precautions for all patients at all times of patient care. We implement isolation precautions (contact / droplet / airborne) according to the clinical Diagnosis / microbiology evidences / epidemiological evidences).
What is the ratio of Airborne Infection Isolation Room (AIIR) versus hospital beds?
There should be 1 AIIR for every 25-30 beds.
How do check the air pressure within the Airborne Infection Isolation Room (AIIR)?
The Engineering & Maintenance department colleagues visit the AIIR on a daily basis & check the air pressure by smoke test. In addition they check the air flow by using the balometer each month.
What is the minimum required air pressure within Airborne Infection Isolation Room (AIIR)?
It should be negative air pressure of 12 air exchanges / hour
How do you check that your N95 mask is fitted properly?
I will perform the leak proof test by inhaling & exhaling after fitting the N95 mask in the anteroom & if it is fitted adequately no air will leak through the mask edge.
Annual respiratory fit test (qualitative/quantitative) for N-95 mask.
Show the fit test card & sticker.
Are your isolation boards bilingual?
Yes, the isolation boards are written both in the most common languages in the region.
Contact — Green, Airborne — Blue; Droplet – Red
Is your Airborne Infection Isolation Room (AIIR) air designed under negative pressure & air is exhausted outside & does it have its own dedicated rest room & hand washing facilities?
Yes.
What are the disinfection products used in your hospital?
Clorox / Biotek / Precept tablets / 70% Isopropyl Alcohol / 0.05% Chlorhexidine (HCG) / 2% CHG /
10% Povidone iodine/ 50% citric acid / CIDEX OPA (glutaraldehyde)/ 10 – 40% formalin
What kind of air pressure is maintained in the endoscope disinfection room?
Negative air pressure of 12 air exchanges / hour is maintained in the above locations.
Are the sterilization products purchased after discussing with the Infection Control Dept?
Yes
Is your Operating Room fitted with dedicated air ventilation system?
Yes.
How do you respond when a sterilized item sent to you by the CSSD team ask for recall of sterile items.
I will immediately send back all the packs sterilized with similar load numbers because it indicates that sterilization check by the biological indicator test has failed.
What is the air pressure within the sterile storage room within the CSSD?
15 positive air exchange / hour; Temperature maintained between 18-22 degree centigrade
Humidity is maintained <60%
What is the time duration for holding Sterilizations records in the CSSD UNIT?
1 year to allow inspection. Records should include load list/daily function test/spore test result/lot number/operator name.
What infection control precautions would be undertaken while transporting items to & from CSSD?
All used items would be transported in RED color coded closed containers
All sterile items would be transported in BLUE color coded closed containers
Is there any place in the hospital used for disinfection & sterilization other than the CSSD?
Other than Endoscopy (for endoscope disinfection) all other items are sterilized only in the CSSD.
Do you use flash steam sterilizer in the OR.
No
How do you calculate the expiry date for sterilized items?
We have the event related shelf life, which means “Sterility Preserved unless Integrity Broken”.
What are recommendations for sterile items storing shelves within the sterile storage room?
The shelves within the sterile storage room should be kept at a distance of 20cms from the floor / 40 cms from the ceiling / 5cms from the wall so as to avoid any dust / pests from wall contacts would be prevented.
What cleaning & disinfection chemical products used by the housekeeping services?
Clorox (sodium hypochlorite)/ Precept Tablets (Sodium dichloroisocyanurate) / Biotek
What percentage of Clorox dilution is used for cleaning & disinfection of varied patient care locations?
1: 9 (Dilution of Jounce Clorox: 9ounce water) – Clorox is used for disinfecting blood/body fluid spillage
1:40 iDilution Jounce Clorox: 40 ounce water) – Clorox is used for disinfecting floor
1:80 (Dilution Jounce Clorox: 80 ounce water) Clorox is used for disinfecting surfaces & furniture
What procedure is used for protecting visitors & children from contact with housekeeping trolleys?
The Housekeeping trolleys are always kept under lock & as well not left unattended on corridors.
Do any healthcare provider request for microbiological air sampling of any hospital environment?
No, microbiological air sampling is always done only on consultation with the Infection Control Team.
How do you manage blood / body fluid spill in the patient care locations?
We have the policy & procedure for handling blood / body fluid spill & it is implemented by using the blood spill kit available in the unit.
How do you handle infectious waste?
Infectious waste are segregated at source by discarding in yellow infectious waste color coded
bags which are 150 micron in thickness & once it becomes 314th full, it is closed, secured, labeled with pertinent details & handed over to the housekeeping staff to be transported to the infectious waste storage room & by 24hours it is collected by an external contractor for incineration at a site located farther away from residential areas.
How do you handle deceased patients?
Standard precautions are employed while handling all deceased patients. For deceased patients with infectious diseases, appropriate isolation precautions are implemented in addition to standard precautions. The deceased body bags are tagged with the isolation precautions to be followed by the handlers.
What is the recommended temperature for the deceased body freezers?
2 — 8 degree centigrade / 36 — 46 degree Fahrenheit & the temperature is logged on a daily basis.
How frequently the morgue is cleaned & disinfected?
It’s done twice a day both in the morning / evening & after every time a dead body is handled
within the morgue.
What is the program employed in kitchen for providing a safe food for patients & HCWs?
HACCP (Hazard critical control point) program is implemented.
What is the Ministry of health recommendation for the kitchen staff for preventing food contamination?
All staff working in the kitchen are checked for enteric pathogens & nasal colonization for Staphylococcus aureus / Corynebacterium diphtheriae on a quarterly basis in addition to checks at the time of joining for work & when the staff comes back from their vacation.
How do you prevent transmission of infectious diseases when patients are served food?
All patients with infectious diseases are being served in disposal containers.
How does your hospital makes itself free from rodents / pests in kitchen & other patient care locations?
The hospital has its own pest control services & they visit the hospital locations on a regular scheduled time & perform pest control activities. In addition, whenever a pest is identified we could contact the pest control services through our hospital communication system for immediate corrective actions.
How do you handle infected / soiled linen?
Soiled / infected linen are collected in RED ALGINATE water soluble bag which is then double bagged in RED color coded Infected linen labeled bag & stored in hampers which are then collected by the hospital laundry services for washing & disinfecting the same at the centralized laundry services.
What is the ideal space between beds in the haemodialysis unit for preventing transmission of infections?
1.2 to 1.5 meters should be maintained between patients.
Do you have medical equipments dedicated for haemodialysis patients?
Yes, we keep equipments such as stethoscopes/blood pressure cuffs/clamps/scissors for each patient & are disinfected at the end of each patient treatment.
How the Haemodialysis staffs are protected against blood borne viral infections?
All staff are vaccinated against HBV & are checked for seroconversion for HBV/HCV/HIV on an annual basis.
How do you protect your Haemodialysis patients from acquiring blood borne viral infections?
Standard precautions including blood & body fluid protections are implemented for all patients & they are checked for seroconversion on quarterly basis. All the patients are vaccinated against HBV & non responders are provided with series of 2 boosters. Any non responder to booster vaccines is considered susceptible to HBV & so is tested for HbsAg every month.
What is the minimum level of antibody to hepatitis ‘B’ surface antigen considered as protective?
10 mIU/m1 is considered protective against HBV following vaccination.
What precautions are undertaken to protect haemodialysis patients from getting infection through haemodialysis water?
The haemodialysis water is analyzed for microbial growth & Endotoxin detection on a monthly basis & any error is being corrected by disinfection of the water by effective reverse osmosis, chemical & hot process.
What is the recommended air exchange rate within the operating room?
Minimum of 15 positive air exchanges is maintained in the operating rooms & all air entering the OR are filtered via HEPA filters & dirty air is exhausted through the exhaust located near the floor.
How do you triage patients suspected with Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) & Ebola Virus infection?
I will assess the patient for signs & symptoms as per the triage screening checklist & will also enquire on travel history & immediately accommodate him/her in the airborne isolation room for the Physician’s evaluation.
Are you aware about the Infection control guidelines for handling patients with MERS-CoV ?
Yes,
Do you know the contact number for transporting clinical samples for MERS-CoV?
Yes, it is *********
What kind of transport media is used for sample collection to diagnose MERS-CoV?
Viral Transport Media (VTM) from Microbiology lab.
What transport protocol you would follow when transferring patients within & outside the facility?
Inform the receiving unit / facility about the isolation precautions needed to be implemented & their clinical diagnosis.
What precautions you would follow with regard to visitors visiting patients with MERS-CoV?
One visitor is permitted but under the supervision of a nursing staff & the visitor would not be allowed to come into contact with the patient.
When do you discontinue isolation precaution for a patient with MERS-CoV?
48-72 hours after patient becoming asymptomatic, isolation precautions can be discontinued
Are you well versed in donning & doffing the PPE in sequence?
Yes, (Note: get yourself well trained by reviewing the posters placed in front of isolation rooms)
What is the first step in performing hand hygiene with soap & water?
Wet the hands with water.
What is the recommended hand hygiene practice after contact with a patient suspected with
Clostridium difficile associated diarrhea (CDAD)?
Hand hygiene with soap & water.
What precautions are taken when a healthcare provider is suffering from upper respiratory tract infection?
The healthcare provider informs his/her supervisor or manager & visits the staff physician for evaluation & treatment. He/she will be barred from providing patient care during his/her infectious time period.
What precautions would be taken before doffing (removing) the N95 mask after providing care for a patient with open pulmonary tuberculosis?
Hand hygiene.
What is the frequency of curtain change in patient care locations?
Curtains are changed immediately if it is soiled with blood or body fluids. If not soiled or if the patient is not under isolation precautions, curtains are changed once month.
What precautions are undertaken when a patient with open pulmonary tuberculosis is recovered following a surgical procedure in the OR?
Recovery is done within the OR & transferred to the Airborne Infection Isolation Room (AIIR).
Describe a clinical situation where terminal cleaning of a patient care location is done.
Terminal cleaning is done when a patient with MDRO (MRSA, MDR Acinetobacter baumannii), Open Pulmonary TB, Chicken pox & any other communicable diseases are discharged. Terminal cleaning includes thorough cleaning of all room surfaces (walls, floor & roof), all patient care equipments & change of curtains.
How do you make sure that the disinfectant solution used for cleaning the floors are with adequate concentration?
I am aware that the housekeeping personnel have adequate training & have the required measuring containers for dilution of chemicals (Clorox, precept tablets, Biotek) & when time permits, I do supervise the chemical disinfectant dilution process.
What precautions are undertaken during the chemical dilution process?
The housekeeping personnel were educated on wearing the PPE & to perform the dilution in a room where eye wash station is available.
What is the shelf life for diluted Clorox & Biotek?
24 hours for Clorox & 7 days for Biotek.
