2nd Edition - وزارة الصحة السعودية

1 Copyright 20132nd Edition 2013 National Guard Health Affairs Gulf Cooperation Council Centre for infection Control Riyadh 22490, Kingdom of Saudi Arabia 1 - Infection Control 2 Infection - Prevention 1 Title 1432/9036 no. 1432/9036 ISBN: 978-603-9022-3-0 The National Guard Health Affairs Infection Prevention and Control Department, as host secretariat and directorate for the Gulf Cooperation Council Centre for infection Control (GCC-CIC) has the sole copyright to this publication. Any part or parcel of this manual may not be copied, deleted, reproduced, or cited without prior approval and/or acknowledgment of source from the Director of the GCC-CIC. Language editing was performed by: King Abdullah International Medical Research Center (KAIMRC) National Guard Health Affairs, Riyadh, Kingdom of Saudia Arabia. Bismillah artwork from Comments, reviews, and feedbacks on this manual may be directed and brought to the attention of the Director of the GCC-CIC.

2 Mail Code 2134, Box 22490 Riyadh 11426, Kingdom of Saudi Arabia Phone: 966-1-8043720 Fax: +966-1-2520437 / +966-1-8043733 E-mail: MESSAGE from the CHIEF EXECUTIVE OFFICER is with utmost enthusiasm that I would like to congratulate all members of the GCC Centre for infection Control (CIC) on the release of the second (2nd) Edition of the Infection Prevention & Control Manual. This has been a successful journey for the GCC-CIC Team as they have established a truly helpful, effective, and comprehensive manual touching the core of patient safety. The National Guard Health Affairs King Abdulaziz Medical City in Riyadh continue to host and support the GCC Centre for infection Control and will provide in its full capacity the assistance needed for the countries fruition of their activities and achievements to the utmost for the activities of the Centre. This updated second Edition of the Infection Prevention & Control Manual proves to be a valuable publication as it provides a positive resource for all infection control preventionists and healthcare facilities to significantly improve the quality, well-being, and patient safety of all.

3 We are proud of such an accomplishment borne out of the collaborative efforts among GCC States. I would like to extend my gratitude to each and everyone in the GCC-CIC Advisory Board and their staff for their continuing efforts and contributions in propelling the progress and success of the GCC Centre for infection Control. Bandar Al Knawy, MD, FRCPC Chief Executive Officer, King Abdulaziz Medical City President, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS) National Guard Health Affairs Riyadh, Kingdom of Saudi Arabia It FOREWORD All humility, we acknowledge Your aid, O Allah. Without your guidance, love and cause, this humble contribution would never become a reality. With immense pleasure, we are presenting to the GCC States this second (2nd) Edition of the GCC-Centre for infection Control (CIC) Infection Prevention & Control Manual, duly adopted during the Health Ministers 64th Conference (Riyadh: 5-6/2/2008) and ratified in the 2013 Annual Advisory Board Meeting of the GCC-CIC (Riyadh: 27-30/1/2013).

4 Designed to give up-to-date guidelines for the GCC States, this manual provides evidence-based infection control practices for all healthcare setting. The consistent application of proper infection control principles and practices instilled in all healthcare activities is necessary to achieve patient safety and the best patient outcomes. This updated manual s policies and procedures are highly commendatory as it addresses better ways to manage particular patient populations; properly detect significant microorganisms, or airborne transmission risks which are detrimental to a safe environment; and the correct procedures to conduct Hand Hygiene techniques, aseptic techniques, medical waste management, employee health, and management of patient with multidrug resistant organisms; as well as, many more methodologies that will ensure high standards in healthcare delivery. These policies and procedures when incorporated into the fabric of each healthcare facility functions should yield a healthy and safe environment for patients, staff, and visitors.

5 The GCC Health Minister s Council wishes to encourage its members to continue to strive for excellence in the prevention of healthcare associated infections and improved safety for all who interface with its healthcare facilities through partnership activities. In conclusion, I ask the Almighty Allah to well accept this deed and make it purely for Him. Allah is the Guidance to the Straight Path. Tawfik Khoja, MBBS, DPHC, FRCGP, FFPH, FRCP (UK) Director General of the Executive Board Health Ministers Council for Gulf Cooperation Council (GCC) States In PREFACE GCC Centre for infection Control (CIC) has completed the updates for the 2nd Edition of the Infection Prevention & Control Manual. The field of patient safety, specifically infection prevention and control, has been rapidly expanding and there is a global and urgent need to support infection prevention programs around the world with the utilization of appropriate tools, policies, and procedures to reflect best healthcare practices.

6 In the second Edition of the GCC-CIC Infection Prevention & Control Manual, all of the previous policies were reviewed and edited to reflect updates in infection control (IC) practices. In addition, this manual aims to address other important requirements in improving and maintaining safe and healthy facilities, hence, a new section on Environmental Health was included to expand on the expert information and guidance that is needed to implement infection prevention and control strategies in healthcare institutions in the Gulf Countries. Current trend demands proper management of certain patient populations and early detection of significant microorganisms, or airborne transmission risks. It is highly important that information and guidelines are readily available, hence, additional policies on negative pressure room monitoring, rapid MRSA surveillance, animal research, and hematopoetic stem cell transplantation have been added in the second Edition .

7 A user guide has also been introduced in this manual to facilitate proper utilization by Infection Control Programs in the GCC member States healthcare facilities. Property right remains with the GCC Centre for infection Control (CIC) National Guard Health Affairs, as such, in accordance with international copyright standard, the manual may not be reviewed or translated without the prior approval of the GCC-CIC. Any additions, deletions, and/or revisions must be done in consultation with the Director of the GCC-CIC. Should there be any conflict of these policies with the existing GCC member State s legislation, the specific member State s legislation should take precedence and such issue discussed with the Director of the GCC-CIC. Any omission of procedures related to infection prevention and control from this manual does not imply that they are not recommended by the GCC-CIC and should be brought to the attention of the Director of GCC-CIC.

8 Hanan Balkhy, MD, MMed, FAAP, CIC Director, GCC Centre for infection Control Executive Director, Infection Prevention & Control National Guard Health Affairs Mail Code 2134, Box 22490 Riyadh 11426, Kingdom of Saudi Arabia Tel: +966-1-8043720 Fax: +966-1-2520437 Email: TheIntroduction: User Guide a reference guide for easy use of this manual, the following policy titles were modified from the first Edition to this updated version for better clarity and content relevance as follow: SECTION PAGE NEW TITLE OLD TITLE III-02 37 Isolation (Expanded) Precautions Expanded Precautions III-10 64 Patients and Sitters in Isolation: IC Education and Compliance Patients and Sitters Not Complying with Isolation Precautions V-02 101 Screening and Treatment of Tuberculosis in Healthcare Workers Contract Tracing, Screening, and Treatment of TB in HCWs VII-4 171 Management of Occupational Exposure to HBV, HCV, and HIV Management of Needlestick Injuries /Blood ad Body Fluid Exposure IX-1 247 Sterile Supplies and Equipment Management Cleaning, Disinfection, and Sterilization IX-2 252 Waste Management Infectious Waste Management IX-3 257 Single Use Devices (SUD) Reprocessing/Reuse of Disposable Items As we are forced to address the management of certain patient populations, early detection of significant microorganisms, or airborne transmission risks, it is important that information and guidelines are readily available.

9 The following policies were added in the hopes of meeting some of the abovementioned needs: SECTION PAGE NEW TITLE III-11 37 Negative Pressure Room Monitoring IV-10 64 Rapid MRSA Surveillance VII-6 171 Hematopoeitic Stem Cell Transplantation (HSCT) VIII-11 247 Animal Research Furthermore, Section 10: Environmental Health was added in this revised manual to provide procedures on how to manage other important requirements in order to improve and maintain safe and healthy facilities. This section includes the following policies: SECTION PAGE NEW TITLE ICM - X-01 263 Water Quality Monitoring Program and Requirements ICM - X-02 268 Hemodialysis Water Quality Monitoring ICM X-03 271 Hazardous Chemical Gases and Sampling ICM X-04 273 Microbial Air Sampling in Patients Areas ICM X-05 276 CSSD Health Challenges ICM X-06 278 Food Hygiene ICM X-07 284 Housekeeping ICM X-08 289 Pest Control ICM X-09 297 Infection Prevention and Control Procedures for Hospital and Healthcare Facility Construction / Renovation AsGulf Cooperation Council-Center for infection Control (GCC-CIC) Mission Statement INTRODUCTION The Gulf Cooperation Council (States) Centre for infection Control takes its direction from National Guard Health Affairs, King Abdulaziz Medical City-Riyadh, (KAMC-R).

10 SCOPE OF SERVICES The scope of service of the Infection Control Program supports all the services provided and comprises--hospital infection, environmental health, occupational safety, and field epidemiology and public health--all structured within the Department of Infection Prevention and Control. It functions to support a high quality of care through the prevention and control of infections and infectious diseases using epidemiologic and quality improvement methodologies, evidence-based healthcare, education, research and collaboration. As the Gulf Cooperation Council (States) Centre for infection Control, so appointed at the 58th Meeting of the Ministers of Health for the GCC States, its scope of service is widened beyond the confines of KAMC-R to all healthcare facilities in the Gulf State countries. In an attempt to clarify this role and expanded scope, and to develop a framework, to guide its activities, a proposal was formulated and submitted for review and approval; thus formalizing the GCC (States) Centre for infection Control.