OPERATIONAL POLICY AND PROCEDURE

Title: Infection Control Coordination Code: OPP/PCI # 02

Effective Date: 15th April 2018 Replaces: OPP/PCI # 02 April 2015
Applies To: Hospital wide Nature: Multidisciplinary

I. DEFINITIONS:

Coordination of the Infection Control activities throughout Almana General Hospitals involves
medicine, nursing & others as appropriate to the organization.

II. PURPOSES:

Prevention of healthcare associated infections is the responsibility of all individuals & services
providing healthcare. Everyone must work cooperatively to reduce the risk of infection for
patients & staffs. This includes personnel providing direct patient care, management, and
physical plant, provision of materials & products & training of health workers. Infection control
programs are effective, provided they are comprehensive & include surveillance & prevention
activities as well as staff training.

III. POLICY STATEMENTS:

The major preventive effort should be focused in the hospital & associated healthcare facilities.
Risk prevention for patients & staff is a concern of everyone in the facility & must be supported
at the level of senior administration. A yearly work plan to assess & promote good health care,
appropriate isolation, sterilization & other practices, staff training & epidemiological
surveillance should be developed. Hospital must provide sufficient resources to support this
program.

IV. PROCEDURES AND RESPONSIBILITIES:

The administration & / or medical management of the hospital must

provide leadership by supporting the hospital infection control
program.
They are responsible for:
Hospital
1. a. Establishing a multidisciplinary Infection Control Committee.
Management
b. Identifying appropriate resources for a program to monitor
infections & apply the most appropriate methods for
preventing infection.

Title: Infection Control Coordination

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 c. Ensuring education & training of all staff through support of
programmes on the prevention of infection in disinfection &
sterilization techniques.
d. Delegating technical aspects of hospital hygiene to
appropriate staff such as:
¾ Nursing
¾ Housekeeping
¾ Maintenance Hospital
2.
¾ Clinical microbiology laboratory Management
e. Periodically reviewing the status of healthcare associated
infections and effectiveness of interventions to contain them.
f. Reviewing, approving & implementing policies approved by
the Infection Control Committee.
g. Ensuring the infection control team has authority to facilitate
appropriate program function.
h. Participating in outbreak investigation.
The Infection Control Committee provides a forum for
multidisciplinary input & cooperation & information sharing. This
committee should include wide representation from relevant
programs: e.g. management, physicians, other health care workers,
clinical microbiology, pharmacy, central supply, and maintenance,
housekeeping & training services. The committee must have a
reporting relationship directly to either administration or the medical
staff to promote program visibility and effectiveness.
In an emergency (such as an outbreak), this committee must be able
to meet promptly. It has the following tasks:
a. To review & approve a yearly program of activity for
surveillance & prevention.
Infection Control
3. b. To review epidemiological surveillance data & identify areas
Committee
for intervention.
c. To assess & promote improved practice at all levels of the
health facility.
d. To ensure appropriate staff training in infection control &
safety.
Healthcare establishments must have access to specialists in
infection control, epidemiology & infectious disease including
infection control officer and infection control nurses. They
may be administratively part of another unit, (e.g
microbiology laboratory, medical or nursing administration,
public health services). The optimal structure will vary with
the type, needs, and resources of the facility.

Title: Infection Control Coordination

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 The reporting structure must, however, ensure the infection control
team has appropriate authority to manage an effective infection
control program. The infection control team or individual is
responsible for the day-to-day functions of infection control, as well
as preparing the yearly work plan for review by the infection control
committee and administration. Infection Control
4.
These individuals have a scientific and technical support role: e.g. Team
surveillance and research, developing and assessing policies and
practical supervision, evaluation of material and products, control of
sterilization and disinfection, implementation of training
programmes. They should also support and participate in research and
assessment program at the national and international levels.
Clinicians have unique responsibilities for the prevention and control
of hospital infections:
a. By providing direct patient care using practices, which
minimize infection.
b. By following appropriate practice of hygiene (e.g. hand hygiene
, isolation).
c. Serving on the Infection control Committee.
d. Supporting the infection control team.
Specifically, physicians are responsible for:
e. Protecting their own patients from other infected patients and
from hospital staff who may be infected.
f. Complying with the practices approved by the Infection control
Committee.
g. Obtaining appropriate microbiological specimens when an
infection is present or suspected.
5. h. Notifying cases of hospital-acquired infection to the team as Clinicians
well as the admission of infected patients.
i. Complying with the recommendations of the Antimicrobial use
committee regarding the use of antibiotics.
j. Advising patients, visitors and staff on techniques to prevent the
transmission of infection. Instituting appropriate treatment for
any infections they themselves have and taking steps to prevent
such infections being transmitted to other individuals, especially
patients.
The Microbiologist is responsible for:
a. Handling patient and staff specimens to maximize the
likelihood of a microbiological diagnosis.
b. Developing guidelines for appropriate collection, transport
and handling of specimens.
c. Ensuring laboratory practices meet appropriate standards.

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 d. Performing antimicrobial susceptibility testing following
internationally recognized methods and providing summary
reports of prevalence of resistance.
e. Monitoring sterilization, disinfection, and the environment
The Clinical
6. where necessary.
Microbiologist
f. Timely communication of results to the Infection control
Committee or the Infection Control Officer.
g. Epidemiological typing of hospital microorganisms where
necessary.
Implementation of patient care practices for infection control is the
role of the nursing staff. Nurses should be familiar with practices to
prevent the occurrence and spread of infection and maintain
appropriate practices for all patients throughout the duration of their
hospital stay.
The Nursing Director is responsible for:
a. Participating in the Infection control Committee.
b. Promoting the development and improvement of nursing Director of
7. techniques and ongoing review of aseptic nursing policies with Nursing and
approval by the Infection control committee. Nursing Staffs
c. Developing training programmes for members of the nursing
staff.
d. Supervising the implementation of techniques for the
prevention of infections in specialized areas such as the
operating suite, the intensive care unit, the maternity unit and
newborns.
e. Monitoring of nursing adherence to policies.
The Nurse in charge of the ward is responsible for:
a. Maintaining hygiene, consistent with hospital policies and
good nursing practice on the ward. Director of
8. b. Monitoring aseptic techniques, including hand hygiene and Nursing and
use of isolation equipments. Nursing Staffs
c. Reporting promptly to the attending physician any evidence of
infection in patients under the nurse’s care.
d. Initiating patient isolation and ordering culture specimens
from any patient showing signs of a communicable disease,
when the physician is not immediately available.
Director of
e. Limiting patient exposure to infections from visitors, hospital
9. Nursing and
staff, other patients, or equipment used for diagnosis or
Nursing Staffs
treatment.
f. Maintaining a safe and adequate supply of ward equipment,
drugs and patient care supplies.

Title: Infection Control Coordination

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 The Infection Control Nurse is a member of the infection control
team and responsible for:
a. Identifying healthcare associated infections investigation of
the type of infection and infecting organism.
b. Participating in training of personnel.
c. Surveillance of hospital infections.
d. Participating in outbreak investigation.
Infection Control
10. e. Development of infection control policy and review and
Nurse
approval of patient care policies relevant to infection control.
f. Ensuring compliance with local and national regulations.
g. Liaison with public health and with other facilities where
appropriate.
h. Providing expert consultative advice to staff health and other
appropriate hospital programmes in matters relating to
transmission of infections.
A Central Sterilization Department serves all hospital areas,
including the operating suite. An appropriately qualified individual
must be responsible for management of the program. Responsibility
for day-to-day management may be delegated to a nurse or other
individual with appropriate qualifications, experience & knowledge
of medical devices.
The responsibilities of the central sterilization service are to clean,
The Central
decontaminate, test, prepare for use, sterilize & store aseptically all
Sterile Supply
11. sterile hospital equipment. It works in collaboration with the Infection
Department
Control Committee and other hospital programmes to develop and
(CSSD)
monitor policies on cleaning and decontamination of:
a. Reusable equipment
b. Contaminated equipment including
c. Wrapping procedures, according to the type of sterilization
d. Sterilization methods, according to the type of equipment
e. Sterilization conditions (e.g. temperature, duration, pressure,
humidity)
The head of this service must:
a. Oversee the use of different methods – physical, chemical &
bacteriological – to monitor the sterilization process.
b. Ensure technical maintenance of the equipment according to
The Central
national standards & manufacturer’s recommendations.
Sterile Supply
12. c. Report any defect to administration, maintenance, infection
Department
control & other appropriate personnel.
(CSSD)
d. Maintain complete records of each autoclave run and ensure
long-term availability of records.
e. Collect or have collected, at regular intervals, all outdated
sterile units.

Title: Infection Control Coordination

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 The Hospital Pharmacist is responsible for:
a. Obtaining, storing & distributing pharmaceutical preparations
using practices, which limit potential transmission of
infectious agents to patients.
b. Dispensing anti-infectious drugs & maintaining relevant
records (potency, incompatibility, conditions of storage &
deterioration).
c. Obtaining & storing vaccines or sera, & making them
available as appropriate.
d. Maintaining records of antibiotics distributed to the medical
departments.
e. Providing the Drug & Therapeutic Committee & Infection The Hospital
13.
Control Committee with summary reports & trends of Pharmacist
antimicrobial use.
f. Having available the following information on disinfectants,
antiseptics & other anti-infectious agents.
The hospital pharmacist may also participate in the hospital
sterilization & disinfection practices through:
a. Participation in development of guidelines for antiseptics,
disinfectants & products used for washing & disinfecting the
hands.
b. Participation in guideline development for reuse of equipment
& patient materials.
c. Participation in quality control of techniques used to sterilize
equipment in the hospital including selection of sterilization
equipment (type of appliances) & monitoring.

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 The Manager of Food Services must be knowledgeable in food
safety, staff training, storage & preparation of foodstuffs, job
analysis, & use of equipment.
The head of catering services is responsible for:
a. Defining the criteria for the purchase of foodstuffs, equipment
use, & cleaning procedures to maintain high level of food
safety
b. Ensuring that the equipment used & all working & storage
areas are kept clean.
c. Issuing written policies and instructions for hand washing, The Hospital
14. clothing, staff responsibilities and daily disinfection duties. Kitchen Manager
d. Ensuring that the methods used for storing, preparing and
distributing food will avoid contamination by microorganisms
e. Issuing written instructions for the cleaning of dishes after
use, including special considerations for infected or isolated
patients where appropriate
f. Ensuring appropriate handling & disposal of wastes
g. Establishing programs for training staff in food
h. Preparation, cleanliness, and food safety
i. Establishing a Hazard Analysis of Critical Control Points
(HACCP) programme, if required.
The Laundry is responsible for:
a. Selecting fabrics for use in different hospital areas, developing
policies for working clothes in each area & group of staff, &
maintaining appropriate supplies
b. Distribution of working clothes & if necessary, managing
changing rooms
c. Developing policies for the collection & transport of dirty
linen
d. Defining, where necessary, the method for disinfecting
infected linen, either before it is taken to the laundry or in the
laundry itself The Laundry
15.
e. Developing policies for the protection of clean linen from Service
contamination during transport from the laundry to the area of
use
f. Developing criteria for selection of site of laundry services
g. Ensuring appropriate flow of linen, separation of “clean” &
“dirty” areas
h. Recommending washing conditions (e.g. temperature,
duration)
i. Ensuring safety of laundry staff through prevention of
exposure to sharps or laundry contaminated with potential
pathogens.

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 The Housekeeping Service is responsible for the regular & routine
cleaning of all surfaces & maintaining a high level of hygiene in the
facility. It is responsible for:
a. Classifying the different hospital areas by varying need for
cleaning, developing policies for appropriate cleaning
techniques.
b. Procedure, frequency, agents used etc., for each type of room,
from highly contaminated to the most clean & ensuring that
these practices are followed.
c. Developing policies for collection, transport & disposal of
different types of waste (e.g. containers, frequency)
d. Ensuring that liquid soap & paper towel dispensers are
replenished regularly.
e. Informing the maintenance service of any building problems
requiring repair: cracks, defects in the sanitary or electrical
equipment, etc.
16.
f. Caring for flowers & plants in public areas
g. Pest control (insects, rodents)
h. Providing appropriate training for all new staff members &
periodically, for other employees & specific training when a
new technique is introduced
i. Establishing methods for the cleaning & disinfection of
bedding (e.g. mattresses, pillows)
j. Determining the frequency for the washing of curtains,
screening curtains between beds, etc
k. There should be a continuing program for staff training
l. Housekeeping staff must know to contact staff health if they
have a personal infection, especially infections of the skin,
digestive tract & respiratory tract.
m. Stress personal hygiene, the importance of frequent & careful
washing of hands & cleaning methods.

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 Maintenance is responsible for:
a. Collaborating with housekeeping, nursing staff or other
appropriate groups in selecting equipment & ensuring early
identification & prompt correction of any defect.
b. Inspections & regular maintenance of the plumbing, heating &
refrigeration equipment & electrical fittings & air
conditioning; records should be kept of this activity.
c. Developing procedures for emergency repairs in essential
departments ensuring environmental safety outside the
hospital e.g. waste disposal & water sources.
d. Participation in the choice of equipment if maintenance of the
equipment requires technical assistance
e. Inspection, cleaning & regular replacement of the filters of all Maintenance
17.
appliances for ventilation & humidifiers. Department
f. Testing autoclaves (temperature, pressure, vacuum, recording
mechanism) & regular maintenance (cleaning the inner
chamber, emptying the tubes).
g. Monitoring the recording thermometers of refrigerators in
pharmacy stores, laboratories, the blood bank & Kitchens.
h. Regularly inspecting all surfaces – walls, floors, and ceilings –
to ensure they are kept smooth & washable.
i. Repairing any opening or crack in partition walls or window
frames.
j. Maintaining hydrotherapy appliances
k. Notifying infection control of any anticipated interruption of
services such as plumbing or air conditioning.

V. REFERENCES:

1. Schechler WE et al. requirements for infrastructure & essential activities of infection

control & epidemiology in hospitals: a consensus panel report. Society of Healthcare
Epidemiology of America. Infect Control Hosp Epidemiol, 1998, 19:114-124.
2. Gaynes RP. Surveillance of healthcare associated infections. In: Hospital infections,
fourth edition. Bennet & Brachman, eds. Piladelphia, Lippincott-Raven, 1998:65-84.
3. CDC: Centers for Disease Control and Prevention -2017
4. WHO: World Health Organization Guidelines / Programs, 2001-2017
5. Ministry of Health- Core Components & Essential Activities of Regional Directorate-
Infection Control Programs, 1st edition-2017
6. Saudi Central Board for Accreditation of Healthcare Institutions;3rd ed., 2016.
7. Joint Commission International Accreditation for Hospitals; 6th ed., 2017.
8. GCC-CIC Infection Prevention and Control Manual-2013
9. OPP/PCI # 02- Infection Control Coordination,5th edition (Deleted)

Title: Infection Control Coordination

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