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policy and procedure infection control (i-xii) cyan

Quality Medical care Section,Medical Development Division,Ministry of Health MalaysiaPrepared in 2009 Printed in 20102nd editionPoliciesAnd ProceduresOn InfectionControlFORFORFORFORFORWWWWWARDA RDARDARDARDBY THE DIRECTOR-GENERAL OF HEALBY THE DIRECTOR-GENERAL OF HEALBY THE DIRECTOR-GENERAL OF HEALBY THE DIRECTOR-GENERAL OF HEALBY THE DIRECTOR-GENERAL OF HEALTH OF MALATH OF MALATH OF MALATH OF MALATH OF MALAYSIAYSIAYSIAYSIAYSIAA highly effective strategy in reducing healthcare-associated infections in hospitals is throughthe proper implementation and practice of policies and procedures on infection control by healthcareproviders committed to this vital patient safety revised edition of Policies and procedures on infection control Guideline is intended toassist healthcare providers to keep track and adhere to best practices in the control of hospitalinfection in hospitals.

Quality Medical Care Section, Medical Development Division, Ministry of Health Malaysia Prepared in 2009 Printed in 2010 2nd edition Policies And Procedures On Infection

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Transcription of policy and procedure infection control (i-xii) cyan

1 Quality Medical care Section,Medical Development Division,Ministry of Health MalaysiaPrepared in 2009 Printed in 20102nd editionPoliciesAnd ProceduresOn InfectionControlFORFORFORFORFORWWWWWARDA RDARDARDARDBY THE DIRECTOR-GENERAL OF HEALBY THE DIRECTOR-GENERAL OF HEALBY THE DIRECTOR-GENERAL OF HEALBY THE DIRECTOR-GENERAL OF HEALBY THE DIRECTOR-GENERAL OF HEALTH OF MALATH OF MALATH OF MALATH OF MALATH OF MALAYSIAYSIAYSIAYSIAYSIAA highly effective strategy in reducing healthcare-associated infections in hospitals is throughthe proper implementation and practice of policies and procedures on infection control by healthcareproviders committed to this vital patient safety revised edition of Policies and procedures on infection control Guideline is intended toassist healthcare providers to keep track and adhere to best practices in the control of hospitalinfection in hospitals.

2 The availability of this guideline will also ensure uniformity of practice ininfection control in all Ministry of Health (MOH) hospitals in the control policies and procedures , when consistently applied and integrated into allsystems and processes, will yield the desired outcome. reduced infection rates. It is myfervent hope that all relevant parties will adopt the various recommendations set out in thisguideline in their infection control activities for more efficient and effective infection control in ourhospitals, thereby minimising the healthcare-associated infection rates in our , I wish to congratulate the Guideline Committee Members from the National Infectionand Antibiotic control Committee and the Medical Development Division, MOH for their efforts inproducing and revising the Policies and procedures on infection control Guideline 2010.

3 Obviouslymuch time and commitment have been given by them to produce this guideline and I would liketo commend them for a job well done. As the saying goes, There is no elevator to success; youhave to take the stairs .Thank SRI DATO SERI DR. HJ. MOHD. ISMAIL MERICANiMESSAGEMESSAGEMESSAGEMESSAGEMESS AGEFROM THE DEPUTY DIRECTOR-GENERAL OF HEALFROM THE DEPUTY DIRECTOR-GENERAL OF HEALFROM THE DEPUTY DIRECTOR-GENERAL OF HEALFROM THE DEPUTY DIRECTOR-GENERAL OF HEALFROM THE DEPUTY DIRECTOR-GENERAL OF HEALTHTHTHTHTH(MEDICAL)(MEDICAL)(MEDICAL )(MEDICAL)(MEDICAL)This is the 2nd edition on Policies and procedures on infection control Guideline, which was firstpublished in 2001. The Guideline Committee Members from the National infection and AntibioticControl Committee, together with the Quality in Medical care Section, of the Medical DevelopmentDivision have put in much effort to revise and update this new edition, and I would like to commendthem on their at preventing healthcare associated infections in hospitals remain an ongoing and difficultchallenge in the medical care setting.

4 Practising good infection control measures can significantlyreduce patient morbidity and mortality in hospitals and has been proven to be cost-effective need to have one common policy and procedure on infection control guideline, to be adoptedand practised by all hospitals under the auspices of the Ministry of Health (MOH), is of utmostimportance. It will not only ensure standardization of infection control activities in hospitals, butwill also facilitate the future monitoring and audit system on infection ensure successful implementation of the guideline s recommendation, all training on infectioncontrol for our healthcare providers in the MOH will need to utilise the guideline, as it will serveas a valuable technical resource on infection control is my hope that the implementation of this guideline by our healthcare providers, will enhancethe quality of healthcare provided to our patients in MOH hospitals in our noble efforts to ensurepatient-centred DR.

5 NOOR HISHAM BIN ABDULLAH iiiiiMESSAGEMESSAGEMESSAGEMESSAGEMESSAGE FROM THE CHAIRPERSON OF GUIDELINE COMMITTEEFROM THE CHAIRPERSON OF GUIDELINE COMMITTEEFROM THE CHAIRPERSON OF GUIDELINE COMMITTEEFROM THE CHAIRPERSON OF GUIDELINE COMMITTEEFROM THE CHAIRPERSON OF GUIDELINE COMMITTEEThe review of the Policies and procedures on infection control Guideline has been a necessaryendeavor to reflect developments and advancements to the current infection control practices,in order to provide a more up-to-date guide for healthcare first edition of this guideline has been reviewed in its entirety, resulting in a completelyrevised 2nd edition. This Policies and procedures on infection control Guideline has beendeveloped based on evidence from various international policies and procedures in infection changes of notes include updated details on the structure, functions and management inthe chapters on hospital infection and antibiotic control committee, implementation of healthcareassociated infections surveillance as well as hospital outbreak management and edition also includes new chapters on isolation precautions and updates on standardprecautions, hand hygiene, PPE, transmission based and design of isolation room.

6 Variousclinical practices and processes, activities to reduce the common healthcare associated infectionsand infection control in specific healthcare settings are also noteworthy additions to this committee members who contributed to the chapters are well recognized as authoritiesor leaders in the field of infection control . It is my utmost hope that all healthcare providers willbenefit from this Policies and procedures on infection control Guideline. A vote of thanks are inorder for chapter writers and coordinators, the Quality in Medical care Section, MedicalDevelopment Division and all those involved in one way or another, for their support, dedicationand commitment in making this guideline a CHRISTOPHER K. C. LEEADVISORSADVISORSADVISORSADVISORSADVIS ORSY. Bhg. Tan Sri Dato Seri Dr. Hj. Mohd Ismail MericanDirector General of Health MalaysiaY.

7 Bhg. Datuk Dr. Noor Hisham AbdullahDeputy Director General of Health (Medical)Y. Bhg. Dato Dr. Hj. Azmi ShapieDirector Medical Development DivisionDr. Hjh. Kalsom MaskonDeputy Director Quality in Medical care SectionGUIDELINE COMMITTEE MEMBERS LISTGUIDELINE COMMITTEE MEMBERS LISTGUIDELINE COMMITTEE MEMBERS LISTGUIDELINE COMMITTEE MEMBERS LISTGUIDELINE COMMITTEE MEMBERS LISTDr. Christopher Lee Kwong Choong (Chairman)Sg. Buloh Hospital, SelangorDr Tan Kah KeeTuanku Jaafar Hospital, Seremban, Negeri SembilanDato Dr Abdul Jamil AbdullahSultanah Nur Zahirah Hospital, Kuala Terengganu, TerengganuDatin Dr. Ganeswrie a/p RajasekaranSultanah Aminah Hospital, Johor Bharu, JohorDr. Mahiran MustafaRaja Perempuan Zainab II Hospital, Kota Baru, KelantanDr. Timothy WilliamQueen Elizabeth Hospital, Kota Kinabalu, SabahDr. Hjh. Kalsom MaskonDeputy DirectorQuality in Medical care Section, MOHSECRETSECRETSECRETSECRETSECRETARIAARI AARIAARIAARIATTTTTQ uality Medical care Section, Medical Development Division, Ministry of HealthDr.

8 Hjh Kalsom MaskonDr. Rozaini Mohd ZainDr. Juliana Mat SutrisPn. Siti Eisah Hj. NoorPn. Halijah HashimPn. Sa abah RosnanPn. Emira GhazaliDr. Suresh Kumar a/l ChidambaranSg. Buloh Hospital, SelangorDr. Hjh. Zubaidah Abdul WahabSg. Buloh Hospital, SelangorDr. Norhanim AsidinPusat Darah Negara, Kuala LumpurDr. Fong Siew MoyLikas Hospital, SabahDr. Nurahan ManingRaja Perempuan Zainab II Hospital, Kota BaruDr. Kamarul Azhar Mohamad RazaliPediatric Institute, Kuala Lumpur HospitalDr. Rozaini Mohd ZainQuality in Medical care Section, MOHivvHOSPITAL infection AND ANTIBIOTICCONTROL COMMITTEE (HIACC)Dr. Christopher Lee Kwong ChoongHEALTHCARE ASSOCIATED INFECTIONSURVEILLANCEDr. Nurahan ManingISOLATION PRECAUTIONDr. Suresh KumarCLINICAL PRACTICEDato Dr Yasmin AyoubDr. Hjh Rosaida Mohd. SaidDr. Nor Hanim AsidinDr. Ganesanathan a/l ShanmuganathanDr. Norris NaimPn.

9 Norima Mohd NoorPn. Mageswary a/p LapchmananPn. Tan Yoke HwaCik Sameerah Shaikh Abd. RahmanPn. Siti Farrah Zaidah Mohd YazidPn. Rozie AliPREVENTION OF HEALTHCARE ASSOCIATEDINFECTIONSDr. Timothy WilliamDato Dr. Abdul Jamil AbdullahDr. Hj. Azmin Kass RosmanDr. Saiful AzliDr. Ahmad Kashfi Abdul RahmanDr. Mohd Anuar Hau AbdullahDr. Tai Li LingDr. Ng Siew HianINFECTION control IN SPECIFIC HEALTHCARESETTINGDr. Azmin Kass RosmanDr. Nurahan ManingDr. Noraini IsmailDr. Tai Li LingDr. Ng Siew HianDr. Christopher VincentDr. Tan Kah KeeDatin Nooral Zeila JunidDr. Tam Pui YingDr. Salina DinDato Dr. Kuan Geok LanDr. Zaini MansorDr (Ms) Salina IbrahimEn Mohd Tohir IbrahimCONTRIBUTORS LISTCONTRIBUTORS LISTCONTRIBUTORS LISTCONTRIBUTORS LISTCONTRIBUTORS LISTINFECTION control IN SPECIFIC HEALTHCARESETTINGDr Ee Boon LeongDr. Mohd Rashid BaharonDr. Nor Izham Hakim DarailDato Dr.

10 Chang Kian MengPn. Habidah IsaDr. Wong Hin SengPn. Kamariah JusohDr. Rahayu Shahar AdnanPn. Rahijah Abdul RahmanDr. Mohd Shah MahmoodDr. Hjh. Zubaidah Abdul WahabTUBERCULOSISDr. Mat Zuki Mat JaebDatin Dr. Hjh Aziah Ahmad MahayiddinHOSPITAL OUTBREAK MANAGEMENTDr. Mahiran MustafaOCCUPATIONAL HEALTH AND SAFETYDr. Chua Hock HinDatin Dr. Ganeswrie a/p RajasekaranDr. Sirajuddin HashimDr. Kan Foong KeeDr. Andrew GunnENVIRONMENTALDr. Tan Kah KeeDr. Nurahan ManingSTERILIZATIONPuan Habidah IsaPRINCIPLES OF ANTIBIOTIC SURVEILLANCECik Sameerah Shaikh Abd. RahmanCik Shamhanin AdnanPn. Jacqueline LaiSPECIFIC ORGANISM RELATED Zubaidah Abdul WahabDr. Muhammad Nazri AzizDr. Noraini IsmailDr. Ahmad Kashfi Abdul RahmanDr. Anuradha a/p RadhakrishnanDr Suresh KumarDr. Christopher Lee Kwong ChoongDr. Mahiran MustafaDr. Nurahan ManingACKNOWLEDGEMENTACKNOWLEDGEMENTACKN OWLEDGEMENTACKNOWLEDGEMENTACKNOWLEDGEMEN TThe guideline development committee would like to express its heartfelt appreciationand gratitude to Tan Sri Dato Seri Dr.


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