INFECTION PREVENTION AND CONTROL

GENERAL POLICIES & PROCEDURES MANUAL

1
 CY 2024
MISAMIS ORIENTAL PROVINCIAL HOSPITAL MANTICAO
POBLACION, MANTICAO
MISAMIS ORIENTAL PROVINCIAL HOSPITAL MANTICAO

Revision by:
Edelbert F. Padilla, RN
Robert B. Flores, RN, MN-NAS

2
TABLE OF CONTENTS
INTRODUCTION.....................................................................................................................................8
PURPOSE................................................................................................................................................8
SCOPE....................................................................................................................................................8
VISION....................................................................................................................................................9
MISSION.................................................................................................................................................9
OBJECTIVES..........................................................................................................................................10
PHILOSOPHY........................................................................................................................................11
INFECTION PREVENTION AND CONTROL ORGANIZATIONAL CHART....................................................12
INFECTION PREVENTION AND CONTROL ROLES AND RESPONSIBILITIES.............................................13
POLICIES AND PROCEDURES ON PATIENT ADMISSION/REFERRAL, ISOLATION AND TIMELY CASE
REPORTING OF HIGHLY TRANSMISSABLE AND NOTIFIABLE INFECTIOUS DISEASES.............................20
POLICIES AND PROCEDURES ON RECYCLING AND REUSE OF MEDICAL EQUIPMENT...........................23
POLICIES AND PROCEDURES ON ANTIMICROBIAL USE BASED ON HOSPITAL ANTIBIOGRAM AND IN
COORDINATION WITH THE PHARMACOLOGIC AND THERAPEUTICS COMMITTEE AND MICROBIOLOGY
LABORATORY........................................................................................................................................25
POLICIES AND PROCEDURES ON ISOLATION OF NOSOCOMIAL INFECTION.........................................27
POLICIES AND PROCEDURES ON CASE CONTAINMENT OF NOSOCOMIAL INFECTION.........................29
POLICIES AND PROCEDURES ON PREVENTION AND CONTROL OF NOSOCOMIAL INFECTION.............31
POLICIES AND PROCEDURES ON INFECTION CONTROL PROCEDURES ON ISOLATION AND UNIVERSAL
PRECAUTION........................................................................................................................................33
POLICIES AND PROCEDURES ON REPORTING OF INFECTION TO PERSONNEL AND PUBLIC HEALTH
AGENCIES.............................................................................................................................................36
POLICIES AND PROCEDURES ON DECONTAMINATION, DISINFECTION AND STERILIZATION FOR
SPECIFIC EQUIPMENT, ITEMS AND AREA.............................................................................................40
POLICIES AND PROCEDURES ON ASEPSIS.............................................................................................43
POLICIES AND PROCEDURES ON PREVENTION AND TREATMENT OF NEEDLE PRICK INJURIES............45

7 MOPH Manticao Patient Ward | General Policies and Procedures Manual

INTRODUCTION

Welcome to the Misamis Oriental Provincial Hospital Manticao's

Infection Prevention and Control (IPC) Policies and Procedures Manual. This
comprehensive guide is designed to provide a clear understanding of the
policies and procedures that govern infection prevention and control
within our hospital. Our primary goal is to minimize the risk of healthcare-
associated infections (HAIs) and ensure the safety and well-being of our
patients, staff, and visitors.

PURPOSE

The primary purpose of this manual is to:

1) Establish consistent guidelines and protocols for preventing and
controlling infections.
2) Promote a culture of safety and hygiene within the hospital
environment.
3) Ensure compliance with national and international infection control
standards and regulations.
4) Protect the health of patients, healthcare workers, and visitors by
minimizing the risk of infection transmission.

SCOPE

This manual applies to all healthcare professionals, administrative

staff, and support personnel working within the Misamis Oriental Provincial
Hospital Manticao. It outlines the responsibilities and expected conduct of
each team member in relation to infection prevention and control,
emphasizing the importance of vigilance, adherence to protocols, and a
commitment to maintaining a clean and safe hospital environment.
1. Infection Prevention and Control Program
The Infection Prevention and Control Program is a critical component
of our hospital's commitment to patient safety and quality care. This
section details the strategies and practices for identifying, monitoring, and
preventing the spread of infections. It includes guidelines for hand
hygiene, use of personal protective equipment (PPE), environmental
cleaning, and waste management.
2. Healthcare-Associated Infections (HAIs) Surveillance

8 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 This section covers the procedures for the surveillance and reporting
of healthcare-associated infections. It includes the roles and
responsibilities of the IPC team, the process for identifying and
investigating outbreaks, and the implementation of corrective actions to
reduce the incidence of HAIs.
3. Infection Control in Specific Clinical Areas
Different clinical areas within the hospital may require specific
infection control measures. This section provides tailored guidelines for
high-risk areas such as the Emergency Room, Operating Room, Intensive
Care Unit (wala ta ani), and Outpatient Department, ensuring that
infection control practices are consistently applied across all departments.
4. Training and Education
Continuous training and education are essential for maintaining high
standards of infection prevention and control. This section outlines the
hospital's commitment to providing ongoing education for all staff
members, including training on the latest infection control protocols,
updates on emerging infectious diseases, and hands-on practice in the
use of PPE and other protective measures.
Commitment to Excellence
Misamis Oriental Provincial Hospital Manticao is committed to
delivering high-quality healthcare services. By adhering to the policies and
procedures outlined in this manual, we strive to uphold our standards of
excellence, ensure patient safety, and foster an environment of
continuous improvement.
We encourage all staff members to familiarize themselves with this
manual and to refer to it regularly to guide their daily responsibilities and
interactions. Together, we can achieve our mission of providing
exceptional healthcare to our community.

VISION

That comprehensive excellent quality to our client patients can

be achieved by a component of caring, compassionate and committed
and value-oriented nursing staff. Promote professional competence by
providing opportunities for in-service education program.

MISSION

The nursing personnel shall provide safe, ethical, prompt,

economical, affordable, effective, promotive, preventive, curative and

9 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
rehabilitative health care services. Practice and implement nursing
process system and holistic approach to patient care.

OBJECTIVES

General Objectives

To ensure the safety and well-being of patients, healthcare workers,

and visitors at Misamis Oriental Provincial Hospital Manticao by
implementing a comprehensive Infection Prevention and Control (IPC)
program that reduces the risk of healthcare-associated infections (HAIs)
and promotes a safe healthcare environment.

Specific Objectives

1. To establish and maintain standards for infection prevention

and control practices. Ensure adherence to safe, ethical, and
evidence-based practices to minimize the risk of infection
transmission within the hospital.

2. To coordinate with relevant departments for the acquisition

of necessary IPC resources. Collaborate with the budget,
supplies, and property sections to procure and utilize appropriate
resources, including personal protective equipment (PPE),
sterilization supplies, and disinfectants, essential for effective IPC
measures.

3. To facilitate ongoing staff development in infection

prevention and control. Provide continuous education and
training opportunities for healthcare workers to enhance their
knowledge and skills in IPC practices, ensuring up-to-date
competency in managing infection risks.

4. To promote professional competency in infection prevention

and control. Encourage and support participation in in-service
education programs, seminars, and workshops related to IPC,
fostering a culture of continuous learning and adherence to best
practices in infection prevention.

10 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 5. To support hospital programs aimed at maintaining a safe
and healthy environment. Promote initiatives that align with IPC
objectives, such as maintaining a mother and baby-friendly hospital
environment by advocating for practices like proper hand hygiene
and safe breastfeeding techniques to prevent infections.

6. To provide student affiliates with learning experiences in

infection prevention and control. Offer nursing students and
other healthcare affiliates hands-on experiences that enhance their
understanding of IPC principles, practices, and the importance of
maintaining a safe healthcare environment.

This structured approach to Infection Prevention and Control at

Misamis Oriental Provincial Hospital Manticao ensures the safety and well-
being of everyone within the hospital, contributing to high-quality patient
care and a safe working environment.

PHILOSOPHY

The Nursing Service Department of Misamis Oriental Provincial Hospital

Manticao strongly believes that:

1. Continuous education of health care practices and nursing care

provides vital skills to the quality of health care services rendered

2. A dynamic and innovative environment enhances the learning

experience of students affiliates and trainees

3. It is the primary responsibility of providing comprehensive,

individualized nursing care to the patients based on their assessed
nursing needs. Nursing care is coordinated and collaborated with
the health team.

4. Its philosophy and objectives are congruent to the mission, vision,

objectives and philosophy of Misamis Oriental Provincial Hospital
Manticao and the Provincial Health Office.

5. The most important asset of an institution is its staff. To provide the

best quality of nursing care, nursing personnel should be adequately
prepared by education, experience and training to assume the
responsibilities of the position. They are to be treated with respect.

11 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 6. Continuing education enhances professional competence. While it is
a personal responsibility of the nursing division to provide
motivation and opportunities for professional growth and
development.

7. Nurses are advocate of patients, as such they should take

appropriate steps to safe guard the patient’s rights and privileges.

8. As a center of wellness, self-care concept through health education

is promoted in partnership with clients, families and significant
others.

INFECTION PREVENTION AND CONTROL

ORGANIZATIONAL CHART

The Infection Control Committee (ICC), also known as the Infection

Prevention and Control Committee, is a committee within healthcare
organizations that focuses on preventing and controlling healthcare-
associated infections (HAIs). The committee typically consists of
healthcare professionals, infection control practitioners, nurses,
administrators, and other relevant stakeholders.
For effectiveness and efficiency in the delivery of services of
Misamis Oriental Provincial Hospital Manticao such committee was
established to monitor, guide and update the hospital for patient centered
health services. Thus, the following personnel are hereby designated to
perform the task as a member of the Infection Control Committee.

Chairperson : Jo-Ann T. Daguman, MD

Infection Control Nurse : Liza Joy D. Culaniban, RN,
MN
Assistant Infection Control Nurse : Jeorafe C. Galaroza,
RN

Members:
1. Willy P. Gunhuran, MD : Chief of Clinics

12 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 2. Robert Flores, RN : Chief Nurse / Nursing
Services
3. Donnah Maureen Lumahang, Rph : Pharmacy Department
4. Celnie Sani Pelias, RMT : Laboratory Department
5. Juresa E. Fabrea : Cleanliness and
Sanitation
6. Mateo Tinoy : Hospital Maintenance
7. Reene Homer Maquilan : Dietary Department
8. Windell Denolan : Pollution Control
Officer/Waste Segregatiuon
9. Edelbert Padilla : Health Education and
Promotion Unit
Mag butang ta same sa org chart sir shin after ani, pls

INFECTION PREVENTION AND CONTROL ROLES AND

RESPONSIBILITIES

UNIT HEAD

REPORTS TO: CHIEF OF HOSPITAL

SUPERVISES: INFECTION CONTROL TEAM AND ACTIVITIES

GEN. DUTIES AND RESPONSIBILITIES

Plans, organizes, directs and control all activities of the
departments.

SPECIFIC DUTIES
1. Take lead role in the effective functioning of the infection
prevention and control team.
2. Assists the hospital in drawing up annual plans, policies
and long-term programs for the prevention of hospital
infection.

13 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 3. Recommends in the preparation of the documents for
support services and advises on infection aspects.
4. Gets involved in setting quality standards with regards to
prevention of healthcare associated infections and in the
audit of infections.

INFECTION PREVENTION AND CONTROL NURSE

REPORTS TO: IPC UNIT HEAD

SUPERVISES: ALL NURSING STAFF, AND HEALTH CARE
WORKERS

GEN. DUTIES AND RESPONSIBILITIES

Coordinates and supervises all activities in the hospital
relevant to infection control.

SPECIFIC DUTIES
1. Acts as coordinator to all hospital staff relevant to
infection control.
2. Identifies healthcare associated infections.
3. Investigates type of infection and infecting organisms.
4. Participates in outbreak investigation.
5. Participates in analyzing trends and risk factors.
6. Conducts surveillance of hospital infections.
7. Participants in training of personnel.
8. Assists in the development of infection control policies
and strategies, reviews and approves patient care
policies relevant to infection control.
9. Ensures compliance with local and national regulations.
10. Serves a liaison with other departments of the
hospital.
11. Provides expert consultative advice to staff health
and other appropriate hospital programs in matters
relating to transmission of infection.
12. Attends professional meetings and conferences on
matters related to infection control.
13. Regularly monitors infection control practices and
compliance to healthcare workers.
14. Monitors staff health in collaboration with the
Employees Health Services Department to prevent
hospital related infection among hospital staff.

14 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 15. Participates in sharp injuries investigation and
prevention activities.
16. Serves as a preceptor studies relevant to infection
control.

MEDICAL TECHNOLOGIST

REPORTS TO: IPC COORDINATOR AND IPC TEAM

SUPERVISES: LABORATORY STAFF

GEN. DUTIES AND RESPONSIBILITIES

Coordinates and implements the safe delivery and handling of
laboratory procedures.

SPECIFIC DUTIES
1. Handles patient and staff specimens to maximize the
likelihood of microbiological diagnosis.
2. Develops guidelines for appropriate collection, transport
and handling of specimens.
3. Ensures laboratory practices meet appropriate standards.
4. Ensures safety laboratory practice to prevent infection
among staff.
5. Performs antimicrobial susceptibility testing following
internationally recognized methods and prevailing
summary reports of prevalence of resistance.
6. Monitors sterilization, disinfection and the environment
where necessary laboratory activities take place.
7. Communicates the results to the infection prevention and
control unit.

CLINICAL DEPARTMENT REPRESENTATIVE

REPORTS TO: IPC UNIT HEAD AND IPC TEAM

SUPERVISES: HOSPITAL STAFF AND PATIENTS

GEN. DUTIES AND RESPONSIBILITIES

15 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 Coordinates with IPCU and directs hospital staff regarding
infection control prevention and control and related issues.

SPECIFIC DUTIES
1. Provides direct patients care using practices which
minimize infection.
2. Supervises and monitors staff implementation and
compliance with infection control practices.
3. Follow appropriate practice of hand hygiene.
4. Works with the IPC Unit.
5. Supports the IPC Unit.
6. Links with staff and with areas of clinical practice.
7. Coordinates with IPC Team/Unit regarding implementation
of policies and guidelines.
8. Helps in surveillance outbreak in investigation.
9. Advises the IPC Unit on recent advances in medical
procedures that have IPC implication.

ADMINISTRATIVE OFFICE REPRESENTATIVE

REPORTS TO: CHIEF OF HOSPITAL

SUPERVISES: ALL EMPLOYEES

GEN. DUTIES AND RESPONSIBILITIES

Acts as liaison between IPC Unit and administration,
implements and executes policies.

SPECIFIC DUTIES
1. Facilitates dissemination and implementation of IPC Unit
recommendations and policies.
2. Ensures financial support for the infection prevention and
control program.
3. Identifies appropriate resources of programs to monitor
infections and apply the most appropriate methods for
preventing infections.
4. Ensures education and training of all staff through
support programs on the prevention and sterilization
techniques, etc.
5. Ensures that the infection prevention control team has
authority to facilitate program functions.

NURSING REPRESENTATIVE

16 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
REPORTS TO: IPC COORDINATOR AND IPC TEAM
SUPERVISES: HIGH RISK AREAS (NURSING STAFF AND NURSING
ATTENDANTS/INSTITUTIONAL WORKERS)

GEN. DUTIES AND RESPONSIBILITIES

Supervises all activities relevant to IPC practices and
procedures.

SPECIFIC DUTIES
1. Supervises staff on implementation and compliance to
IPC practices.
2. Refers cases with IPC implementation.
3. Coordinates with the committee regarding
implementation of policies and guidelines.
4. Helps investigate local outbreaks.
5. Participates in surveillance.
6. Maintains hygiene, consistent with hospital policies and
good nursing practice area.
7. Reports promptly to the attending physician any evidence
of infection in the patients under nurse’s care.
8. Limits patient’s exposure to infections from visitors,
hospital staff, other patients or equipment used in the
diagnosis or treatment.

PHARMACIST

REPORTS TO: IPC UNIT

SUPERVISES: PHARMACISTS

GEN. DUTIES AND RESPONSIBILITIES

Coordinates with the IPC Unit on matters related to IPC.

SPECIFIC DUTIES
1. Obtains stores and distributes pharmaceutical
preparation using practices which limit potential
transmission of infectious agents to patients.
2. Dispenses anti-infectious and maintains relevant records
(potency, incompatibility, conditions of storage and
deterioration).
3. Obtains and stores vaccines making them available as
appropriate.

17 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 4. Provides the AMS Committee and IPC Unit with summary
reports and trends of antimicrobial use.
5. Participates in the development of guidelines for
antiseptics, disinfectants and products used for hand
hygiene.
6. Communicates with IPC Unit and Nursing Services the
Pharmacy Services maintenance and other appropriate
services.
7. Advises staff on appropriate indications for disinfectants,
antiseptics and antibiotics.
8. Keeps record of cost and usage of antibiotics and
disinfectants.
9. Coordinates with IPC Unit on evaluation of disinfectants,
antiseptics and antibiotics and other new products with
IPC implication.

MAINTENANCE

REPORTS TO: IPC UNIT

SUPERVISES: MAINTENANCE STAFF

GEN. DUTIES AND RESPONSIBILITIES

Maintains and controls hospital and IPC related equipment
and facilities.

SPECIFIC DUTIES
1. Tests and maintenance efficiency of equipment within the
IPC requirements.
2. Monitors and maintains the water and electricity supplies.
3. Installs and repairs existing equipment to meet required
IPC standards.
4. Practices standard precautions during performance of
duties.
5. Collaborates with other departments in selecting
equipment and ensuring early identification and prompt
correction of any defect.
6. Performs preventive maintenance of equipment at
prescribed intervals.
7. Inspects all surfaces, walls, floors, ceilings and other
areas in the facilities regularly to ensure they are smooth
and washable.

18 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 8. Ensures regular measurement of air changes per hour of
specific areas in the facility and reports measurement to
IPC Unit/Committee.

HOUSEKEEPING REPRESENTATIVE

REPORTS TO: IPC UNIT

SUPERVISES: INSTITUTIONAL WORKERS

GEN. DUTIES AND RESPONSIBILITIES

Maintains the environment clean and safe.

SPECIFIC DUTIES
1. Maintains and monitors hospital-wide cleanliness and
sanitation.
2. Coordinates with the IPC Team on proper waste disposal
and use of disinfectants.
3. Monitors housekeeping practices with IPC implications.
4. Implements cleaning and disinfection policies in the
workplace.
5. Observes and practice IPC precautions of Institutional
workers during work.
6. Classifies different areas of the hospital based on varying
needs for cleaning.
7. Develops policies on cleaning and disinfection
techniques.
8. Informs the maintenance services on any building
problems requiring repair.
9. Maintains pest control in the hospital.

LAUNDRY AND LINEN REPRESENTATIVE

REPORTS TO: IPC UNIT

SUPERVISES: LAUNDRY AND LINEN STAFF

GEN. DUTIES AND RESPONSIBILITIES

Controls proper handling, storage and processing of soiled
linens.

SPECIFIC DUTIES
1. Implements decontamination/disinfection practices in
delivery and transport of linen.

19 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 2. Coordinates with the IPC Team on the proper disinfectants
to be used.
3. Ensures proper transport, handling, storage and
processing and distribution of line.

DIETITIAN

REPORTS TO: IPC UNIT

SUPERVISES: DIETARY STAFF

GEN. DUTIES AND RESPONSIBILITIES

Implements infection prevention and control precautions
and practices to prevent food-borne disease and other illnesses
related to food preparation and handling.

SPECIFIC DUTIES
1. To ensure proper preparation, storage, delivery and
handling of food.
2. Monitor equipment used for food preparation, serving,
processing and storage are cleaned and sanitized after
use.
3. Monitors compliance of food handlers to IPC practices and
procedures.
4. Issues written policies and instructions for hand hygiene,
clothing, staff responsibilities and daily disinfection
duties.

20 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 POLICIES AND PROCEDURES ON PATIENT
ADMISSION/REFERRAL, ISOLATION AND TIMELY CASE
REPORTING OF HIGHLY TRANSMISSABLE AND
NOTIFIABLE INFECTIOUS DISEASES
Performa Safe Practice and Environment – Infection Docum MOPHM-2024-03-HPP-
nce Area Control ent ID 122-BBC- 6.3.3. b.1
March 8, 2024?
Effective Revision Revision
January 2, 2010 March 8, 2024 001
Date Date No.
existed
Bench
book 6.3.3. b.1 The organization uses a coordinated system-wide approach to reduce the
referenc risks of infection the staff are exposed to in the performance of their duties.
e
Departm
Clinical Department, Ancillary Department and Institutional Workers
ent

IV. Policy Statement

Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
committed to the timely identification, isolation, and reporting of highly
transmissible and notifiable infectious diseases to prevent their spread
within the hospital and the community. This policy establishes guidelines
and procedures for patient admission/referral, isolation, and timely case
reporting of such diseases.
II. Scope
This policy applies to all healthcare personnel involved in patient
care, including physicians, nurses, allied health professionals,
administrative staff, and support personnel, within MOPH Manticao.
III. Procedures

21 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
1. Patient Admission/Referral
1.1. Prompt Assessment. Upon arrival at MOPH Manticao, all
patients undergo a rapid but thorough assessment by trained
healthcare personnel. This assessment includes a review of
symptoms, travel history, and potential exposure to infectious
diseases.
1.2. Risk Stratification. Patients presenting with symptoms
suggestive of highly transmissible or notifiable infectious diseases,
such as fever, cough, respiratory distress, rash, or gastrointestinal
symptoms, are promptly identified and triaged for further
evaluation.
1.3. Referral Protocol. If the patient meets the criteria for
admission and requires specialized care, appropriate referral
procedures are initiated to ensure seamless transfer to the
designated isolation area or referral facility, if necessary.

2. Isolation Procedures
2.1. Identification of Isolation Needs. Suspected or confirmed cases
of highly transmissible or notifiable infectious diseases are isolated
promptly to prevent the spread of infection. Isolation needs are
determined based on the suspected or confirmed mode of
transmission of the infectious agent (e.g., contact, droplet, or
airborne).
2.2. Isolation Precautions. Healthcare personnel implement
appropriate isolation precautions according to the mode of
transmission. This includes wearing appropriate personal protective
equipment (PPE), such as gloves, gowns, masks, and eye
protection, and following specific infection control protocols.
2.3. Isolation Facilities. MOPH Manticao maintains dedicated
isolation facilities to ensure effective isolation and minimize the risk
of transmission to other patients, visitors, and healthcare workers.

3. Timely Case Reporting

3.1. Reporting Requirements. Suspected or confirmed cases of
highly transmissible or notifiable infectious diseases are reported
promptly to the Provincial Health Office of Misamis Oriental and the
Department of Health (Region 10), in accordance with regulations
and guidelines. This includes notifying the Municipal Health Unit
and related communicable disease control unit.
3.2. Documentation. Healthcare personnel document all cases of
suspected or confirmed infectious diseases accurately and

22 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 comprehensively in the patient’s medical record. This
documentation includes relevant clinical information, laboratory
results, and notification to public health authorities to facilitate
contact tracing and disease surveillance efforts.

4. Communication and Coordination

4.1. Interdepartmental Collaboration. Effective communication and
coordination are maintained among healthcare departments
involved in the management of infectious diseases, including
emergency services, inpatient units, laboratory services, and
infection control. Regular interdisciplinary meetings and updates
ensure that all staff members are informed and aligned with the
latest protocols and guidelines.
4.2. Public Health Collaboration. MOPH Manticao collaborates
closely with local public health authorities, including the Provincial
Health Office, Municipal Rural Health Unit, Department of Health
(Region 10) and communicable disease control unit, to facilitate the
investigation, contact tracing, and management of infectious
disease outbreaks within the community. This collaboration includes
sharing relevant clinical and epidemiological information to support
public health efforts.
4.3. The Hospital Epidemiology and Surveillance Unit of MOPH
Manticao shall monitor, investigate and control healthcare-
associated infections (HAIs) within the hospital. This unit will play a
crucial role in ensuring the safety of our patients, visitors, and staff
members by implementing evidence-based infection prevention
and control measures. The committee is also responsible for
collaborating with other departments to develop and implement
policies and procedures related to infection prevention and control

5. Staff Training and Education

5.1. Education on Recognition. Healthcare personnel receive
comprehensive training on recognizing the signs and symptoms of
highly transmissible and notifiable infectious diseases during
orientation and ongoing education sessions. This training
emphasizes the importance of early identification and isolation to
prevent the spread of infection.
5.2. Training on Isolation Protocols. Staff members involved in
patient care receive specialized training on the proper
implementation of isolation precautions and the use of PPE. This
training includes hands-on practice sessions and simulations to
ensure that staff members are proficient in following isolation
protocols and minimizing the risk of transmission.

23 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
IV. Compliance
All healthcare personnel at MOPH Manticao are required to comply
with this Policy on Patient Admission/Referral, Isolation, and Timely Case
Reporting of Highly Transmissible and Notifiable Infectious Diseases. Non-
compliance may result in disciplinary action as per hospital regulations
and applicable laws.

Category I Category II
(Immediate Notifiable within 24 hours) (Weekly Report)
Acute Flaccid Paralysis Acute Bloody Diarrhea
Adverse Event Following Immunization Acute Encephalitis Syndrome
Anthrax Acute Hemorrhagic Fever Syndrome
Human Avian Influenza Acute Viral Hepatitis
Measles Bacterial Meningitis
Meningococcal Disease Cholera
Neonatal Tetanus Dengue Fever
Paralytic Shellfish Poisoning Diphtheria
Rabies Influenza -like Illness
Severe Acute Respiratory Syndrome (SARS) Leptospirosis
Outbreaks Malaria
Non-neonatal Tetanus
Pertussis
Typhoid and Paratyphoid Fever

POLICIES AND PROCEDURES ON RECYCLING AND

REUSE OF MEDICAL EQUIPMENT
Performa Safe Practice and Environment – Infection Docum MOPHM-2024-03-HPP-
nce Area Control ent ID 122-BBC- 6.3.3. b.1

Effective March 8, 2024? Revision Revision

March 8, 2024 001
Date January 2, 2010 Date No.

Bench
book 6.3.3. b.1 The organization uses a coordinated system-wide approach to reduce the
referenc risks of infection the staff are exposed to in the performance of their duties.
e
Departm
All Hospital Department
ent

24 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
committed to promoting sustainability and responsible resource
management through recycling and reuse initiatives, particularly
regarding medical equipment. This policy establishes guidelines and
procedures for the recycling and reuse of medical equipment to reduce
waste, minimize environmental impact, and optimize resource utilization.
II. Scope
This policy applies to all departments and personnel involved in the
procurement, maintenance, and disposal of medical equipment at MOPH
Manticao.
III. Procedures
1. Inventory Assessment
1.1. The hospital shall conduct regular assessments of existing
medical equipment inventory to identify items suitable for recycling
or reuse.
1.2. Equipment in good condition, with functional components, and
meeting safety standards shall be considered for recycling or reuse.
1.3. Equipment used to infectious patients should be properly
identified from those used by non-infectious patients.

2. Evaluation and Testing

2.1. Recyclable or reusable equipment identified during inventory
assessments shall undergo thorough evaluation and testing by
qualified maintenance personnel.
2.2. Testing shall verify the functionality, safety, and compliance of
the equipment with relevant standards and regulations.
2.3. All equipment used by patients should be properly monitored
as to whether patient is potentially infectious or not.

3. Reconditioning and Refurbishment

3.1. Equipment requiring minor repairs or refurbishment to restore
functionality shall be reconditioned by trained personnel.
3.2. Refurbishment may include cleaning, calibration, replacement
of worn parts, and performance testing to ensure optimal
functionality and safety.

4. Recycling Process

25 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 4.1. Equipment deemed unsuitable for reuse or refurbishment shall
be dismantled and segregated into components for recycling.
4.2. Segregated materials, such as metals, plastics, and electronic
components, shall be sent to authorized recycling facilities for
processing and reuse.

5. Reuse and Redistribution

5.1. Recyclable or refurbished equipment in good working
condition shall be reintroduced into the hospital's inventory for
reuse.
5.2. Reusable equipment may be redistributed to departments or
clinics with operational needs, following appropriate inventory
management protocols.
5.3. Potentially highly infectious used equipment should be
immediately washed, cleaned, disinfected with chlorine-based
solutions or other relative chemical solutions for disinfection and
autoclave the equipment prior to reuse.

6. Documentation and Tracking

6.1. All activities related to the recycling and reuse of medical
equipment shall be documented, including inventory assessments,
evaluations, refurbishment processes, and redistribution.
6.2. Documentation shall include equipment specifications,
maintenance records, refurbishment reports, and redistribution logs
to track the life cycle of recycled and reused equipment.
IV. Compliance
All departments and personnel involved in the recycling and reuse
of medical equipment at MOPH Manticao are required to comply with this
Policy. Non-compliance may result in disciplinary action as per hospital
regulations and applicable laws.

26 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 POLICIES AND PROCEDURES ON ANTIMICROBIAL USE
BASED ON HOSPITAL ANTIBIOGRAM AND IN
COORDINATION WITH THE PHARMACOLOGIC AND
THERAPEUTICS COMMITTEE AND MICROBIOLOGY
LABORATORY
Performa Safe Practice and Environment – Docume MOPHM-2024-03-HPP-
nce Area Infection Control nt ID 114-BBC- 6.3.1. x.2
March 8, 2024
Effective Revision
January 2, March 8, 2024 Revision No. 001
Date Date
2010
Bench
6.3.1. x.2 An interdisciplinary infection control program ensures the prevention and
book
control of infection in all services.
reference
Departm
Clinical Department, Pharmacy Department and Laboratory Department
ent

I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao)
recognizes the critical importance of judicious antimicrobial use in
combating antimicrobial resistance and ensuring optimal patient
outcomes. This policy establishes guidelines and procedures for the
appropriate use of antimicrobial agents based on hospital antibiogram
data and in coordination with the Pharmacologic and Therapeutics
Committee (PTC) and Microbiology Laboratory.
II. Scope
This policy applies to all healthcare providers involved in
prescribing, dispensing, administering, and monitoring antimicrobial
therapy within MOPH Manticao, including medical, nursing, and pharmacy
staff.
III. Procedures
1. Antibiogram Utilization
1.1. The Microbiology Laboratory shall maintain and regularly
update an antibiogram, which provides data on the susceptibility
patterns of local microbial isolates to various antimicrobial agents.
1.2. Healthcare providers shall utilize antibiogram data to guide
empiric antimicrobial therapy selection based on the local
prevalence of antimicrobial resistance.

27 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
2. Empiric Therapy Guidelines
2.1. The Pharmacologic and Therapeutic Committee shall develop
and periodically review empiric antimicrobial therapy guidelines for
common infections encountered within the hospital setting.
2.2. Empiric therapy guidelines shall take into account local
antibiogram data, patient demographics, site of infection, and risk
factors for antimicrobial resistance.

3. Antimicrobial Stewardship Principles

3.1. Healthcare providers shall adhere to antimicrobial stewardship
principles, including appropriate antimicrobial selection, dosing,
duration, and route of administration.
3.2. Narrow-spectrum antimicrobial agents shall be preferred over
broad-spectrum agents whenever clinically appropriate to minimize
the risk of antimicrobial resistance and adverse effects.
3.3. The utilization of Antibiotics follows the recommendation of
the Pharmacologic and Therapeutic Committee, Clinical Practical
Guidelines (CPG) and the Philippine National Drug Formulary
(PNDF).

4. Consultation with Infectious Diseases Specialists

4.1. Infectious diseases specialists shall be consulted for complex
cases, severe infections, or instances of antimicrobial therapy
failure.
4.2. Collaborative decision-making between infectious diseases
specialists and primary care teams shall be encouraged to optimize
antimicrobial therapy.

Wala ta ani #4 sir chin - infectious specialist

5. Documentation and Monitoring

5.1. Antimicrobial prescriptions shall be documented in the
patient's medical record, including the indication for therapy, choice
of antimicrobial agent, dosage, frequency, and duration.
5.2. Pharmacists shall review antimicrobial orders for
appropriateness, dosing adjustments, and potential drug
interactions.

6. Education and Training

6.1. Ongoing education and training programs on antimicrobial
stewardship principles and practices shall be provided to healthcare
providers, including physicians, nurses, and pharmacists.
6.2. Educational initiatives shall emphasize the importance of
judicious antimicrobial use, antimicrobial resistance awareness, and
strategies for optimizing patient care.

28 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
IV. Compliance
All healthcare providers at MOPH Manticao are required to comply
with this Policy on Antimicrobial Use based on Hospital Antibiogram and in
coordination with the Pharmacologic and Therapeutics Committee and
Microbiology Laboratory. Non-compliance may result in disciplinary action
as per hospital regulations and applicable laws.

POLICIES AND PROCEDURES ON ANTIMICROBIAL USE BASED ON HOSPITAL ANTIBIOGRAM AND IN

COORDINATION WITH THE PHARMACOLOGIC AND THERAPEUTICS COMMITTEE – recommendation ni
sir chin sa revision ani na policy

Policy Statement:
The Hospital is committed to responsible antibiotic stewardship to combat antibiotic
resistance while considering the financial constraints of patients. It is the policy of the
Hospital to initiate antibiotic therapy with lower-generation antibiotics and reserve higher-
generation antibiotics for cases where the initial therapy proves ineffective. This approach
aligns with best practices for minimizing drug resistance and managing healthcare costs.

Procedures:

1. Initial Antibiotic Therapy:

o Selection: Upon diagnosis of an infection, initiate antibiotic therapy with
lower-generation antibiotics whenever appropriate, based on clinical
guidelines and local antibiograms.
o Assessment: Evaluate the patient’s condition and response to the initial
antibiotic regimen within 48-72 hours of treatment initiation.
2. Monitoring and Evaluation:
o Response Review: Monitor the patient’s clinical response to the antibiotic
therapy, including resolution of symptoms and any adverse reactions.
o Reassessment: After 48-72 hours, reassess the effectiveness of the initial
antibiotic therapy. This includes reviewing laboratory results, patient
symptoms, and any other relevant clinical indicators.
3. Switching to Higher-Generation Antibiotics:
o Criteria for Change: If the patient shows inadequate response to the initial
antibiotic regimen or if cultures and sensitivities indicate resistance or a need
for a broader-spectrum antibiotic, escalate therapy to a higher-generation
antibiotic as necessary.
o Cost Considerations: When prescribing higher-generation antibiotics,
consider the patient’s financial capacity. Provide alternatives or support for
accessing medications where cost is a significant concern.
4. Financial and Access Support:
o Patient Assistance: Collaborate with the hospital’s financial assistance
programs to explore options for patients facing financial challenges in
affording higher-priced branded medications.
o Generic Alternatives: Where available, consider prescribing generic versions
of higher-generation antibiotics to reduce costs while maintaining therapeutic
efficacy.
5. Antibiotic Stewardship:

29 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 oEducation: Ensure that healthcare providers are educated on antibiotic
stewardship principles, including the importance of using lower-generation
antibiotics appropriately and recognizing when escalation is needed.
o Monitoring: Regularly review antibiotic usage patterns and resistance data to
inform and adjust prescribing practices as part of the hospital’s ongoing
antibiotic stewardship program.
6. Documentation and Reporting:
o Records: Maintain accurate documentation of antibiotic prescriptions,
including rationale for initial choices and any changes made based on clinical
response or financial considerations.
o Reporting: Report any significant issues related to antibiotic effectiveness,
resistance patterns, or financial barriers to the hospital’s infection control and
pharmacy committees for further review and action.

POLICIES AND PROCEDURES ON ISOLATION OF

NOSOCOMIAL INFECTION
Performa Safe Practice and Environment – Docume MOPHM-2024-03-HPP-
nce Area Infection Control nt ID 115-BBC- 6.3.2. b.1

Effective Revision
March 8, 2024 March 8, 2024 Revision No. 001
Date Date
Bench
6.3.2. b.1 The organization uses a coordinated system-wide approach to reduce the
book
risks of nosocomial infections.
reference
Departm
Clinical Department, Pharmacy Department and Laboratory Department
ent

I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
committed to preventing the transmission of nosocomial infections within
the hospital setting. This policy establishes guidelines and procedures for
the isolation of patients with suspected or confirmed nosocomial
infections to minimize the risk of transmission to other patients, staff, and
visitors.
II. Scope

30 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 This policy applies to all areas and units within MOPH Manticao
where patients may be admitted, including inpatient wards, intensive care
units, emergency departments, and outpatient clinics.
III. Procedures
1. Identification of Patients Requiring Isolation
1.1. Healthcare providers shall be vigilant in identifying patients
with signs and symptoms suggestive of nosocomial infections,
including healthcare-associated pneumonia, urinary tract infections,
surgical site infections, and bloodstream infections.
1.2. Patients with suspected or confirmed nosocomial infections
shall be promptly evaluated and isolated in accordance with
established protocols.

2. Types of Isolation Precautions

2.1. Standard precautions shall be implemented for all patients to
prevent the transmission of infectious agents.
2.2. Additional transmission-based precautions, including contact
precautions, droplet precautions, and airborne precautions, shall be
implemented based on the suspected or confirmed mode of
transmission of the infectious agent.

3. Isolation Room Placement

3.1. Patients requiring isolation shall be placed in single-patient
rooms whenever possible to minimize the risk of transmission to
other patients.
3.2. If single-patient rooms are unavailable, efforts shall be made
to separate patients with different infectious diseases and to
provide spatial separation between patients to reduce the risk of
transmission.

4. Personal Protective Equipment (PPE)

4.1. Healthcare personnel shall wear appropriate PPE, including
gloves, gowns, masks, and eye protection, when entering the rooms
of patients on isolation precautions.
4.2. PPE shall be donned and doffed according to established
protocols to prevent self-contamination and the spread of infectious
agents.

5. Patient and Visitor Education

5.1. Patients and visitors shall be educated about the importance
of hand hygiene, respiratory hygiene, and other infection
prevention measures.

31 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 5.2. Signs indicating isolation precautions shall be posted outside
the rooms of isolated patients to alert healthcare personnel,
patients, and visitors.

6. Environmental Cleaning and Disinfection

6.1. Environmental cleaning and disinfection procedures shall be
intensified in rooms occupied by patients on isolation precautions.
6.2. High-touch surfaces and patient care items shall be cleaned
and disinfected regularly using hospital-approved disinfectants.
IV. Compliance
All healthcare providers at MOPH Manticao are required to comply
with this Policy on the Isolation of Nosocomial Infections. Non-compliance
may result in disciplinary action as per hospital regulations and applicable
laws.

POLICIES AND PROCEDURES ON CASE CONTAINMENT

OF NOSOCOMIAL INFECTION
Performa Safe Practice and Environment – Docume MOPHM-2024-03-HPP-
nce Area Infection Control nt ID 116-BBC- 6.3.2. b.2

Effective Revision
March 8, 2024 March 8, 2024 Revision No. 001
Date Date
Bench
6.3.2. b.2 The organization uses a coordinated system-wide approach to reduce the
book
risks of nosocomial infections.
reference
Departm
Clinical and Ancillary Department
ent

32 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
committed to preventing the spread of nosocomial infections through
prompt and effective case containment measures. This policy establishes
guidelines and procedures for the containment of nosocomial infections to
minimize the risk of transmission within the hospital setting.
II. Scope
This policy applies to all healthcare personnel involved in the
identification, management, and containment of nosocomial infections at
MOPH Manticao, including medical, nursing, allied health, and support
staff.
III. Procedures
1. Prompt Identification of Cases
1.1. Healthcare providers shall maintain a high index of suspicion
for nosocomial infections and promptly identify patients with signs
and symptoms suggestive of infection.
1.2. Suspected cases shall be evaluated promptly, and appropriate
diagnostic tests shall be performed to confirm the presence of
infection.

2. Isolation and Cohorting

2.1. Patients with confirmed or suspected nosocomial infections
shall be isolated promptly in accordance with established isolation
precautions.
2.2. Cohorting of patients with the same infectious agent may be
considered to facilitate more efficient use of isolation resources and
prevent the spread of infection.

3. Contact Tracing
3.1. Contact tracing shall be initiated for patients who have been
in close contact with individuals diagnosed with nosocomial
infections.
3.2. Close contacts shall be identified, assessed for symptoms, and
monitored for the development of infection as appropriate.

4. Enhanced Surveillance
4.1. Enhanced surveillance measures shall be implemented to
monitor the incidence and prevalence of nosocomial infections
within the hospital setting.
4.2. Surveillance data shall be analyzed regularly to identify
trends, clusters, or outbreaks of nosocomial infections and inform
targeted intervention strategies.

33 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
5. Environmental Decontamination
5.1. Environmental cleaning and disinfection procedures shall be
intensified in areas where nosocomial infections have been
identified.
5.2. High-touch surfaces, medical equipment, and patient care
items shall be cleaned and disinfected regularly using hospital-
approved disinfectants.

6. Education and Training

6.1. Healthcare personnel shall receive education and training on
the recognition, management, and containment of nosocomial
infections.
6.2. Training programs shall emphasize the importance of early
detection, isolation precautions, and adherence to infection
prevention protocols.
IV. Compliance
All healthcare personnel at MOPH Manticao are required to comply
with this Policy on Case Containment of Nosocomial Infections. Non-
compliance may result in disciplinary action as per hospital regulations
and applicable laws.

POLICIES AND PROCEDURES ON PREVENTION AND

CONTROL OF NOSOCOMIAL INFECTION
Performa Safe Practice and Environment – Docume MOPHM-2024-03-HPP-

34 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 nce Area Infection Control nt ID 113-BBC- 6.3.1. x.2
Effective Revision
March 8, 2024 March 8, 2024 Revision No. 001
Date Date
Bench
6.3.1. x.2 An interdisciplinary infection control program ensures the prevention and
book
control of infection in all services.
reference
Departm
Clinical Department
ent

I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
committed to preventing and controlling nosocomial infections to ensure
the safety and well-being of patients, staff, and visitors. This policy
establishes guidelines and procedures for the implementation of infection
prevention and control measures to minimize the transmission of
healthcare-associated infections (HAIs) within the hospital setting.
II. Scope
This policy applies to all areas and activities within MOPH Manticao
where healthcare services are provided, including but not limited to:
1) Inpatient wards
2) Outpatient clinics
3) Operating rooms
4) Intensive care units
5) Emergency departments
6) Laboratories
III. Procedures
1. Hand Hygiene
1.1. Hand hygiene practices, including handwashing and hand
sanitization, shall be promoted and enforced among all healthcare
personnel, patients, and visitors.
1.2. Hand hygiene stations shall be readily accessible throughout
the hospital, with alcohol-based hand rubs available at point-of-care
locations.

2. Standard Precautions
2.1. Standard precautions, including the use of personal protective
equipment (PPE) such as gloves, gowns, masks, and eye protection,
shall be implemented consistently to prevent the transmission of
infectious agents.

35 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 2.2. Healthcare personnel shall adhere to standard precautions
during all patient interactions, regardless of suspected or confirmed
infection status.

3. Transmission-Based Precautions
3.1. Transmission-based precautions, including contact
precautions, droplet precautions, and airborne precautions, shall be
implemented based on the suspected or confirmed infectious agent
and mode of transmission.
3.2. Isolation rooms and designated patient placement strategies
shall be utilized to prevent the spread of multidrug-resistant
organisms (MDROs) and other contagious pathogens.

4. Environmental Cleaning and Disinfection

4.1. Environmental cleaning and disinfection procedures shall be
implemented to maintain cleanliness and reduce the risk of
contamination within patient care areas.
4.2. High-touch surfaces, medical equipment, and patient care
items shall be cleaned and disinfected regularly using approved
disinfectants.

5. Antimicrobial Stewardship
5.1. Antimicrobial stewardship programs shall be established to
promote the appropriate use of antimicrobial agents, reduce
unnecessary antibiotic prescriptions, and prevent the emergence of
antimicrobial resistance.
5.2. Healthcare providers shall adhere to evidence-based
guidelines for antimicrobial prescribing, dosing, and duration of
therapy.

6. Surveillance and Reporting

6.1. Surveillance systems shall be established to monitor the
incidence and prevalence of nosocomial infections within the
hospital.
6.2. Surveillance and reporting shall be conducted by the Infection
Control Committee.
6.3. Healthcare-associated infections (HAIs) shall be promptly
identified, investigated, and reported to relevant authorities in
accordance with regulatory requirements.
IV. Compliance
All healthcare personnel, including medical, nursing, allied health,
and support staff, are required to comply with this Policy on the Prevention
and Control of Nosocomial Infections. Non-compliance may result in
disciplinary action as per hospital regulations and applicable laws.

36 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 POLICIES AND PROCEDURES ON INFECTION CONTROL
PROCEDURES ON ISOLATION AND UNIVERSAL
PRECAUTION
Performa Safe Practice and Environment – Docume MOPHM-2024-03-HPP-
nce Area Infection Control nt ID 120-BBC- 6.3.3. b.1

Effective March 8, 2024 Revision

March 8, 2024 Revision No. 001
Date Jan.2,2024 Date

Bench
6.3.3. b.1 The organization uses a coordinated system-wide approach to reduce the
book
risks of infection the staff are exposed to in the performance of their duties.
reference
Departm
Clinical Department, Ancillary Department and Institutional Workers
ent

I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
committed to implementing effective infection control procedures to
prevent the transmission of infectious agents among patients, healthcare
personnel, and visitors. This policy establishes guidelines and procedures
for the implementation of isolation precautions and universal precautions
within the hospital setting.
II. Scope
This policy applies to all healthcare personnel, including physicians,
nurses, allied health professionals, and support staff, as well as patients
and visitors, within MOPH Manticao.
III. Procedures
1. Isolation Precautions
1.1. Identification and Assessment. Upon admission, all patients
undergo a thorough assessment to identify any infectious
conditions. Suspected or confirmed cases are promptly isolated
based on the type of precautions required.

37 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 1.2. Isolation Protocol: Patients under isolation precautions are
accommodated in designated rooms equipped with appropriate
signage indicating the specific precautions necessary for entry.
1.3. Personal Protective Equipment (PPE) Usage. Healthcare
personnel must wear the prescribed PPE, including gloves, gowns,
masks, and eye protection, before entering the isolation room.
Proper donning and doffing procedures are strictly observed to
prevent cross-contamination.
1.4. Strict Adherence. All staff members and visitors must adhere
strictly to the specified isolation precautions, including hand
hygiene and PPE usage, when interacting with isolated patients.

2. Universal Precautions
2.1. Hand Hygiene. Hand hygiene is emphasized as the
cornerstone of infection control. Healthcare personnel must perform
hand hygiene with soap and water or alcohol-based hand rubs
before and after patient contact, after touching potentially
contaminated surfaces, and upon removal of gloves.
2.2. Personal Protective Equipment (PPE). PPE must be worn as
appropriate for the task or procedure being performed. This
includes gloves for direct contact with blood, body fluids, or
contaminated surfaces, gowns for protecting clothing and
preventing contamination, masks for respiratory protection, and
eye protection to prevent splashes to mucous membranes.
2.3. Safe Injection Practices. Healthcare providers must adhere to
safe injection practices, including using aseptic technique, sterile
needles and syringes for each injection, and proper disposal of
sharps immediately after use.
2.4. Respiratory Hygiene/Cough Etiquette. Patients and visitors are
educated on respiratory hygiene and cough etiquette, including
covering their mouth and nose with a tissue or elbow when
coughing or sneezing, and disposing of tissues properly.

3. Identification of Isolation Status

3.1. Prompt Recognition. Nurses and other healthcare personnel
are trained to recognize signs and symptoms of infectious diseases
and promptly identify patients requiring isolation precautions.
3.2. Communication. Isolation status is communicated effectively
among healthcare team members through electronic medical
records, patient charts, and verbal communication during handover
or shift change.
3.3. Visitor Education. Visitors are informed about the patient's
isolation status upon entry to the hospital or relevant patient care

38 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 area. They are briefed on the precautions to be followed and
provided with necessary PPE if required.

4. Patient Placement and Room Assignments

4.1. Room Allocation. Patients requiring isolation precautions are
assigned to rooms based on the type of precautions needed and
the availability of suitable isolation facilities.
4.2. Priority for Single-Patient Rooms. Priority is given to isolating
patients in single-patient rooms to minimize the risk of transmission
to other patients. However, when single rooms are not available,
efforts are made to ensure appropriate isolation and minimize
cross-contamination.
4.3. Spatial Separation. Patients with different infectious diseases
are spatially separated to prevent the spread of pathogens between
patients with distinct conditions.

5. Environmental Cleaning and Disinfection

5.1. Routine Cleaning. Environmental services staff follow a
rigorous cleaning schedule to ensure all patient care areas,
including isolation rooms, are cleaned and disinfected regularly.
5.2. Terminal Cleaning. Isolation rooms undergo thorough terminal
cleaning using hospital-approved disinfectants after the discharge
of a patient. High-touch surfaces, medical equipment, and patient
care items are given special attention to remove any potential
pathogens.
5.3. Protocols for Medical Equipment. Medical equipment used in
isolation rooms is cleaned and disinfected according to
manufacturer guidelines and hospital protocols to prevent the
transmission of infectious agents.
IV. Compliance
All healthcare personnel, patients, and visitors at MOPH Manticao
are required to comply with this Policy on Infection Control Procedures on
Isolation and Universal Precautions. Non-compliance may result in
disciplinary action as per hospital regulations and applicable laws.

39 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 POLICIES AND PROCEDURES ON REPORTING OF
INFECTION TO PERSONNEL AND PUBLIC HEALTH
AGENCIES
Performa Safe Practice and Environment – Docume MOPHM-2024-03-HPP-
nce Area Infection Control nt ID 126-BBC- 6.3.5. x.1

Effective Revision
March 8, 2024 March 8, 2024 Revision No. 001
Date Date
Bench
6.3.5. x.1 When needed, the organization reports information about infections to
book
personnel and public health agencies.
reference
Departm
Clinical Department
ent

I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
dedicated to promoting prompt and accurate reporting of infections to
both hospital personnel and relevant public health agencies. This policy
aims to ensure timely identification, notification, and response to
infectious diseases within the hospital setting and the broader community.
II. Scope
This policy applies to all healthcare personnel, including physicians,
nurses, infection control practitioners, and administrative staff, involved in

40 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
the identification, reporting, and management of infections at MOPH
Manticao.
III. Procedures
1. Identification of Reportable Infections
1.1. Healthcare personnel shall be trained to recognize signs and
symptoms of reportable infections, including notifiable diseases as
defined by local health authorities.
1.2. Standardized criteria for identifying reportable infections, such
as those meeting surveillance definitions or requiring public health
interventions, shall be established and disseminated to relevant
staff.
1.3. The Department of Health (DOH) in the Philippines classifies
infectious diseases into different categories based on their
characteristics and potential impact on public health. The
categories typically include:
1.3.1. Category A. These are diseases of national and international
concern due to their potential for causing epidemics or
pandemics, high mortality rates, and significant public health
impact. Examples include Ebola virus disease, severe acute
respiratory syndrome (SARS), and Middle East Respiratory
Syndrome (MERS).
1.3.2. Category B. These diseases are considered emerging or re-
emerging pathogens that have the potential to cause public
health emergencies. They may not have the same level of
immediate threat as Category A diseases but still require
monitoring and preparedness efforts. Examples include Zika
virus infection, dengue fever, and influenza.
1.3.3. Category C. This category includes diseases that are endemic
in the Philippines or have the potential to emerge as significant
public health threats. These diseases require ongoing
surveillance and control measures. Examples include
tuberculosis, HIV/AIDS, and malaria.

2. Internal Reporting Process

2.1. Healthcare personnel who suspect or diagnose a reportable
infection in a patient shall immediately notify the designated
infection control officer or supervisor.
2.2. Reporting shall be documented using standardized forms or
electronic reporting systems, including relevant patient information,
symptoms, diagnostic test results, and any known exposures.

3. Notification of Public Health Agencies

3.1. In accordance with regulatory requirements, the infection
control officer or designated staff member shall promptly notify the
appropriate public health agencies of reportable infections.

41 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 3.2. Notification shall be made through established reporting
channels, following local, regional, and national guidelines for
infectious disease reporting.
3.3. Notification to the Provincial Health Office.
3.1.1. The disease surveillance officer in coordination with the
Infection Control Committee shall promptly notify the
Provincial Health Office of reportable infections as per local
regulations.
3.1.2. This notification shall be made using established reporting
channels specified by the Provincial Health Office, adhering to
their guidelines and protocols for infectious disease reporting.

3.4. Notification to the Municipal Health Office.

3.1.3. Additionally, the disease surveillance officer in coordination
with the Infection Control Committee shall promptly notify the
Municipal Health Office of reportable infections.
3.1.4. This notification should follow the established reporting
channels outlined by the Municipal Health Office, in
accordance with their specific guidelines and protocols for
infectious disease reporting.

4. Confidentiality and Privacy

4.1. All reports of infections shall be handled with strict confidentiality,
in compliance with applicable laws and regulations governing
patient privacy.

4.2. Patient identifiers shall be protected, and information disclosed

only to authorized individuals involved in public health response
activities.

5. Collaboration with Public Health Agencies

5.1. MOPH Manticao shall collaborate closely with public health
agencies to facilitate the investigation, control, and prevention of
infectious diseases.
5.2. Coordination with the Department of Health – Center for Health
Development Northern Mindanao (DOH-CHDNM) – Research,
Epidemiology, Surveillance, and Disaster Response Unit (RESDRU).
The case reporting process to the Epidemiological Surveillance Unit
(ESU) typically involves several steps to ensure timely and
accurate data collection, analysis, and response to health-related
events. While specific procedures may vary depending on the
jurisdiction and the nature of the disease or condition being
monitored, the following steps generally outline the process:
5.2.1. Case Identification. Healthcare facilities, including hospitals,
clinics, and laboratories, identify and diagnose cases of

42 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 reportable diseases or conditions based on established
criteria and guidelines. These criteria often include clinical
symptoms, laboratory test results, and epidemiological
factors.
5.2.2. Data Collection. Healthcare providers collect relevant
information about each identified case, including
demographic data (such as age, sex, and residence), clinical
symptoms, laboratory results, and any relevant risk factors or
exposures.
5.2.3. Reporting to ESU. Health facilities or designated reporting
entities submit case reports to the local or national
Epidemiological Surveillance Unit according to established
reporting protocols. This may involve electronic reporting
systems, paper-based forms, or other communication
methods.
5.2.4. Data Entry and Verification. Upon receiving case reports, the
ESU staff enter the data into the surveillance database and
verify the accuracy and completeness of the information. This
may involve cross-referencing with other sources and follow-
up with reporting facilities to resolve any discrepancies.
5.2.5. Data Analysis. ESU staff analyze the collected data to detect
trends, clusters, and potential outbreaks of reportable
diseases or conditions. This analysis may involve statistical
methods, geographic mapping, and other epidemiological
tools to identify patterns and risk factors.
5.2.6. Response and Action. Based on the findings of data analysis,
the ESU may initiate public health interventions, such as
targeted disease control measures, outbreak investigations,
and communication campaigns to raise awareness and
prevent further spread of the disease.
5.2.7. Reporting and Dissemination. The ESU regularly reports
surveillance data to relevant stakeholders, including local
health authorities, national health agencies, and international
organizations. This may include routine surveillance reports,
outbreak alerts, and situational updates to inform decision-
making and response efforts.
5.2.8. Monitoring and Evaluation. The ESU continuously monitors
disease trends and surveillance indicators to assess the
effectiveness of control measures and identify areas for
improvement in the surveillance system. This may involve
ongoing data quality assessments, performance reviews, and
stakeholder feedback mechanisms.
5.3. Information sharing, coordination of response efforts, and
implementation of control measures shall be conducted in
partnership with relevant public health authorities.

43 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
6. Education and Training
6.1. Ongoing education and training on infection reporting procedures
shall be provided to healthcare personnel at all levels, emphasizing
the importance of early detection and reporting.
6.2. Training sessions shall cover topics such as recognition of
reportable infections, documentation requirements, and
communication protocols with public health agencies.
IV. Compliance
All healthcare personnel at MOPH Manticao are required to comply with
this Policy on Reporting of Infection to Personnel and Public Health
Agencies. Non-compliance may result in disciplinary action as per hospital
regulations and applicable laws.

POLICIES AND PROCEDURES ON DECONTAMINATION,

DISINFECTION AND STERILIZATION FOR SPECIFIC
EQUIPMENT, ITEMS AND AREA
Performa Safe Practice and Environment – Docume MOPHM-2024-03-HPP-
nce Area Infection Control 124-BBC- 6.3.4. x.1

44 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 nt ID

Effective March 8, 2024 Revision

March 8, 2024 Revision No. 001
Date Jan. 2, 2010 Date

Bench 6.3.4. x.1 Cleaning, disinfecting, drying, packaging and sterilizing of equipment, and
book maintenance of associated environment, conform to relevant statutory requirements
reference and codes of practice.
Departm
Clinical Department, Maintenance and Repair Department and Institutional Workers
ent

I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
committed to maintaining a safe and hygienic environment by
implementing rigorous decontamination, disinfection, and sterilization
protocols for specific equipment, items, and areas within the hospital. This
policy aims to ensure the effective removal or inactivation of
microorganisms, including pathogens, to prevent healthcare-associated
infections and promote patient safety.
II. Scope
This policy applies to all healthcare personnel responsible for the
decontamination, disinfection, and sterilization of specific equipment,
items, and areas at MOPH Manticao, including but not limited to surgical
instruments, endoscopes, patient care items, and high-touch surfaces.
III. Procedures
1. Decontamination
1.1. Definition: Decontamination involves the physical or chemical
removal of contaminants, including microorganisms, from surfaces,
instruments, or equipment to render them safe for further handling
or use.
1.2. Methods: Decontamination methods may include manual
cleaning, automated cleaning (e.g., washer-disinfectors), or
chemical disinfection depending on the nature of the item or
surface and the level of contamination.

2. Disinfection
2.1. Definition: Decontamination involves the physical or chemical
removal of contaminants, including microorganisms, from surfaces,
instruments, or equipment to render them safe for further handling
or use.
2.2. Methods: Decontamination methods may include manual
cleaning, automated cleaning (e.g., washer-disinfectors), or

45 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 chemical disinfection depending on the nature of the item or
surface and the level of contamination.

3. Sterilization
3.1. Definition: Sterilization is the process of eliminating or
destroying all forms of microbial life, including bacterial spores, to
achieve a level of microbial safety suitable for a specific application.
3.2. Methods: Sterilization methods include steam sterilization
(autoclaving) or other validated sterilization processes.

4. Specific Equipment and Items

4.1. Surgical Instruments: Surgical instruments shall undergo
rigorous cleaning, disinfection, and sterilization processes between
uses to prevent cross-contamination and ensure patient safety.
4.2. Patient Care Items: Items such as bed linens, patient gowns,
and reusable patient care equipment shall be laundered or
disinfected according to hospital protocols to minimize the risk of
transmission of pathogens.
4.3. Cleaning of medical equipment/instruments is required prior
to disinfection, decontamination or sterilization to avoid lessening
the effectiveness of the disinfecting solution.
4.4. Cleaning entails washing or wiping with water with detergent.
4.5. Electrical medical equipment such as patient monitor and
pulse oximeter are wiped with a towel damped with 0.5% chloring
solution or Lysol solution and air dried after use.
4.6. Medical and Surgical equipment such as scissors, clamps and
etc. are soaked in Cidex Solution for at least 10 Minutes prior to
use. Cidex Solution is replaced every 15 days.
4.7. Items regularly used such as thermometers may be
disinfected with 70% alcohol.
4.8.

5. High-Touch Surfaces and Areas

5.1. Definition: High-touch surfaces and areas refer to surfaces or
areas frequently touched by multiple individuals, posing a higher
risk of microbial contamination and transmission.
5.2. Disinfection Frequency: High-touch surfaces and areas,
including door handles, handrails, countertops, and medical
equipment touchscreens, shall be disinfected regularly using
hospital-approved disinfectants.
5.3. Patient beddings and rooms must undergo decontamination
and disinfection after every patient use.
5.4. Specific areas such as Operating Room and Delivery Room
complex must have a monthly general cleaning aside from cleaning
and disinfecting done after every shift and cases. Lysol or 0.55%
chlorine solution is used for these areas for cleaning.

46 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 5.5. Intensive cleaning and disinfection are done in the Isolation
areas and Enclosed patient spaces, fumigation is required after
every use.
IV. Compliance
All healthcare personnel responsible for decontamination, disinfection,
and sterilization procedures at MOPH Manticao must adhere to this Policy.
Non-compliance may result in disciplinary action as per hospital
regulations and applicable laws.

47 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 POLICIES AND PROCEDURES ON ASEPSIS
Performa Safe Practice and Environment – Docume MOPHM-2024-03-HPP-
nce Area Infection Control nt ID 117-BBC- 6.3.2. b.3

Effective Revision
March 8, 2024 March 8, 2024 Revision No. 001
Date Date
Bench
6.3.2. b.3 The organization uses a coordinated system-wide approach to reduce the
book
risks of nosocomial infections.
reference
Departm
Clinical and Ancillary Department
ent

I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
dedicated to maintaining aseptic conditions to prevent healthcare-
associated infections and promote patient safety. This policy establishes
guidelines and procedures for asepsis in all clinical and procedural areas
within the hospital.
II. Scope
This policy applies to all healthcare personnel involved in patient
care, including medical, nursing, allied health, and support staff, as well as
patients and visitors within MOPH Manticao.
III. Procedures
1. Hand Hygiene
1.1. Healthcare personnel shall perform hand hygiene using soap
and water or alcohol-based hand rubs before and after patient
contact, after touching potentially contaminated surfaces, and
before and after performing invasive procedures.
1.2. Hand hygiene compliance shall be monitored and reinforced
through ongoing education and training programs.

2. Sterile Technique
2.1. Sterile technique shall be utilized during invasive procedures,
surgical interventions, and other aseptic procedures to prevent
contamination of sterile fields and surgical sites.
2.2. Sterile equipment, including instruments, drapes, and
dressings, shall be handled with care and only by authorized
personnel.

3. Environmental Asepsis

48 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 3.1. Environmental surfaces in patient care areas shall be cleaned
and disinfected regularly using hospital-approved disinfectants.
3.2. Healthcare personnel shall ensure that medical equipment
and devices are cleaned and sterilized or high-level disinfected
according to manufacturer instructions before use.

4. Personal Protective Equipment (PPE)

4.1. Healthcare personnel shall wear appropriate PPE, including
gloves, gowns, masks, and eye protection, when performing
procedures or tasks that may expose them to blood, body fluids, or
contaminated materials.
4.2. PPE shall be donned and doffed according to established
protocols to prevent self-contamination and the spread of infectious
agents.

5. Aseptic Technique in Invasive Procedures

5.1. Aseptic technique shall be maintained during invasive
procedures, including central line insertions, urinary
catheterizations, and wound care.
5.2. Sterile equipment and supplies shall be used, and strict
adherence to aseptic technique shall be ensured to prevent
healthcare-associated infections.

6. Exposure Prevention
6.1. Healthcare personnel shall follow standard precautions and
utilize appropriate PPE to prevent exposure to infectious agents
during patient care activities.
6.2. In the event of exposure to bloodborne pathogens or other
potentially infectious materials, healthcare personnel shall follow
established post-exposure protocols, including immediate wound
care, reporting, and follow-up testing and counseling.
6.3. Keep the exposure of the susceptible to a minimum level.

7. Patient Education
7.1. Patients and their families shall receive education on the
importance of asepsis in preventing infections, including proper
hand hygiene, wound care, and the use of aseptic techniques at
home.
IV. Compliance
All healthcare personnel, patients, and visitors at MOPH Manticao
are required to comply with this Policy on Asepsis. Non-compliance may
result in disciplinary action as per hospital regulations and applicable
laws.

49 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 POLICIES AND PROCEDURES ON PREVENTION AND
TREATMENT OF NEEDLE PRICK INJURIES
Performa Safe Practice and Environment – Docume MOPHM-2024-03-HPP-
nce Area Infection Control nt ID 118-BBC- 6.3.3. a.1

Effective Revision
March 8, 2024 March 8, 2024 Revision No. 001
Date Date
Bench
6.3.3. a.1 The organization uses a coordinated system-wide approach to reduce the
book
risks of infection the staff are exposed to in the performance of their duties.
reference
Departm
Clinical and Ancillary Department
ent

I. Policy Statement
Misamis Oriental Provincial Hospital Manticao (MOPH Manticao) is
committed to preventing and effectively managing needle prick injuries
among healthcare personnel to ensure their safety and well-being. This
policy establishes guidelines and procedures for the prevention,
immediate response, and treatment of needle prick injuries.
II. Scope
This policy applies to all healthcare personnel involved in clinical
activities, including but not limited to physicians, nurses, medical
technologists, and support staff, within MOPH Manticao.
III. Procedures

1. Prevention of Needle Prick Injuries

1.1. Healthcare personnel shall exercise caution and adhere to safe
needle handling practices to minimize the risk of needle prick
injuries.

50 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 1.2. Safety-engineered devices, such as retractable needles and
needleless systems, shall be utilized whenever feasible to reduce
the likelihood of needle stick injuries.

2. Immediate Response to Needle Prick Injuries

2.1. Bleed it, squeeze the wound to encourage bleeding.
2.2. Wash it with soap under running water.
2.3. Cover it with waterproof dressing.
2.4. Report it immediately to the supervisor and write an incident
report.

3. Risk Assessment and Post-Exposure Prophylaxis (PEP)

3.1. An immediate risk assessment shall be conducted to
determine the potential exposure to bloodborne pathogens,
including HIV, HBV, and HCV. – wala ta ani
3.2. Healthcare personnel deemed at risk for bloodborne pathogen
transmission shall be offered appropriate post-exposure prophylaxis
(PEP) in accordance with established protocols and guidelines.

4. Testing and Follow-Up

4.1. Healthcare personnel who experience needle prick injuries
shall undergo testing for bloodborne pathogens, including HIV, HBV,
and HCV, 6 months after exposure.
4.2. Follow-up testing shall be conducted at intervals specified by
guidelines to monitor for seroconversion and ensure timely
intervention if necessary.

5. Documentation and Reporting

5.1. All needle prick injuries shall be documented promptly in the
hospital's incident reporting system within 24 hours.
5.2. Documentation shall include details of the injury,
circumstances surrounding the incident, post-exposure
management provided, and follow-up plans.

6. Support and Counseling

6.1. Healthcare personnel who experience needle prick injuries
shall be provided with appropriate support, counseling, and
information regarding the potential risks and implications of
bloodborne pathogen exposure.
6.2. Confidentiality shall be maintained throughout the process to
respect the privacy and dignity of affected individuals.
Guidelines for Sharp Container Use in Healthcare Settings
Do’s:

51 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 1. Position sharp containers within easy reach of the point of use, such
as patient rooms or treatment areas, to facilitate safe and prompt
disposal of needles and sharps after use.
2. Clearly label containers with prominent signage and color coding to
ensure easy identification and prevent accidental disposal of non-
sharp items, reducing the risk of needlestick injuries.
3. Ensure availability of sharp containers before administering
injections or other procedures involving sharps, promoting a culture
of safety and compliance with disposal protocols.
4. Install containers at an accessible height for healthcare staff to
easily access and replace them, minimizing the risk of strain or
injury during disposal activities.
5. Indicate the fill line at three quarters (3/4) capacity on containers to
provide visual cues for timely emptying and prevent overfilling,
which could compromise safety and hygiene standards.
Don'ts
1. Utilize makeshift containers, such as empty bottles or bins, for
needle disposal, as they lack the necessary puncture resistance and
leak-proof features, posing a significant risk of exposure to
bloodborne pathogens.
2. Agitate containers to create additional space for disposing of more
items, as this can lead to spills and leaks, increasing the risk of
contamination and injury.
3. Place containers near switches, fans, or thermostat controls where
accidental contact may occur, potentially causing disruptions or
injuries to healthcare staff.
4. Recap needles after use, as this practice has been associated with a
higher risk of needlestick injuries and transmission of infectious
diseases.
5. Administer injections carelessly without securing a proper
environment and equipment setup, including a designated sharp
container for immediate disposal.
6. Leave needles and sharps unattended on surfaces, as this can pose
a hazard to both healthcare staff and patients, increasing the risk of
accidental needlestick injuries.
7. Overfill containers beyond their recommended capacity, as this may
compromise their structural integrity and effectiveness in containing
sharps safely. Containers must be
8. Immediately handle containers without first inspecting for
protruding needles to prevent accidental injuries during handling
and disposal activities.
9. Pick up needles from the floor by hand, as this increases the risk of
accidental punctures and exposure to bloodborne pathogens;
instead, use appropriate tools or procedures for safe retrieval and
disposal.

52 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
IV. Compliance
All healthcare personnel of MOPH-Manticao should submit a written
policy incident report within 24 hours for any risk exposure of
communicable/infectious diseases within the hospital to the Infection
Control Committee.

FLOW CHART FOR MANAGING & REPORTING OF NEEDLESTICK INJURIES/SPLASH EXPOSURES

Splash exposure
Needle Prick

Encourage bleeding (do not Thoroughly wash away body

suck the blood) fluids splash to eyes, nose or
mouth

Wash it with soap under

running water

53 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
Dry and cover with water proof
dressing

Identify possible source

of contamination

Report the incidence to your

supervisor

Consult to OPD for further

evaluation and
management.

Reevaluation and follow up

after 6 months

Complete incident report from needle stick

injury/splash exposure and submit to Infection Control
Committee.

Hand Hygiene Guidelines, Policy, and Procedure

1. Purpose

To establish standards for hand hygiene practices to minimize the transmission of infectious agents in
healthcare settings, ensuring the safety of patients, staff, and visitors.

2. Scope

54 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
This policy applies to all healthcare workers, including physicians, nurses, allied health professionals,
support staff, and visitors within the healthcare facility.

3. Definitions

 Hand Hygiene: The process of cleaning hands using either handwashing with soap and water
or using an alcohol-based hand sanitizer.

 Healthcare-Associated Infections (HAIs): Infections acquired by patients during the course of

receiving treatment for other conditions within a healthcare facility.

4. Guidelines

4.1 When to Perform Hand Hygiene

 Before and after patient contact: To prevent the spread of pathogens between patients.

 Before and after touching patient equipment: To ensure that contaminated equipment does
not transfer pathogens.

 Before and after performing invasive procedures: To reduce the risk of infection at the
procedure site.

 After contact with body fluids: To avoid cross-contamination from bodily fluids.

 After touching surfaces or objects in the patient environment: To prevent the spread of
pathogens from contaminated surfaces.

Note:

 It is protocol that the hospital personnel involved in patient care must remove all
unnecessary jewelry while at work.
 Fingernails must be kept short and clean. Artificial nail and nail polishing with all
kinds of color is not allowed.
 If part of the hand has wound, cuts or break in skin, it must be covered and
additional precaution in handling patient is necessary.

55 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
  Hand sanitizer in pocket size container may be available in each staff for routine hand
hygiene.

4.2 Hand Hygiene Techniques

 Handwashing: Use soap and water for at least 20 seconds, focusing on all areas of the hands
including the back, between fingers, and under nails.

 Hand Sanitizing: Use an alcohol-based hand sanitizer with at least 60% alcohol, covering all
surfaces of the hands and rubbing until dry.

5. Policy

5.1 Compliance

 All healthcare workers must adhere to hand hygiene guidelines.

 Compliance will be monitored regularly through observations and audits.

5.2 Hand Hygiene Facilities

 Handwashing stations must be available at key locations including patient rooms, treatment
areas, and before entering and exiting the facility.

 Alcohol-based hand sanitizers should be accessible throughout the facility, particularly at the
point of care.

5.3 Education and Training

 All staff will receive mandatory training on hand hygiene practices during orientation and at
regular intervals.

 Refresher training will be provided as needed, especially when new hand hygiene protocols
are introduced.

5.4 Accountability and Reporting

 Non-compliance with hand hygiene protocols will be addressed through corrective actions,
which may include retraining or disciplinary measures.

 Staff are encouraged to report any issues related to hand hygiene facilities or practices to
their supervisor or infection control team.

6. Procedures

6.1 Handwashing Procedure

1. Wet Hands: Use clean, running water to wet hands.

2. Apply Soap: Apply a sufficient amount of soap to cover all hand surfaces.

3. Scrub: Rub hands together for at least 20 seconds, ensuring that all areas are cleaned.

4. Rinse: Rinse hands thoroughly under running water.

5. Dry: Dry hands using a clean paper towel or an air dryer.

56 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 6. Turn Off Faucet: Use a paper towel to turn off the faucet to avoid recontamination.

6.2 Hand Sanitizing Procedure

1. Apply Product: Dispense an adequate amount of alcohol-based hand sanitizer onto the
hands.

2. Rub: Rub hands together, covering all surfaces of the hands including between fingers and
under nails.

3. Dry: Continue rubbing until hands are dry.

7. Monitoring and Evaluation

7.1 Compliance Monitoring

 Conduct regular audits and direct observations to ensure adherence to hand hygiene
practices.

 Utilize hand hygiene compliance data to identify areas for improvement.

7.2 Feedback and Improvement

 Provide feedback to staff on hand hygiene performance.

57 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
  Review and update hand hygiene policies and procedures based on feedback and emerging
evidence.

8. Documentation

 Training Records: Maintain records of staff training on hand hygiene.

 Incident Reports: Record and investigate any incidents related to hand hygiene failures.

Personal Protective Equipment (PPE) Guidelines, Policy, and Procedures

1. Purpose and Scope

Objective:
To prevent the transmission of infections within the hospital environment.

Scope:
These guidelines apply to all healthcare workers, patients, visitors, and support staff in the
hospital.

2. PPE Guidelines

Types of PPE:

 Gloves: Protect hands from exposure to blood, body fluids, and contaminated
surfaces.
 Gowns: Protect the body and clothing from contact with infectious agents.
 Masks: Protect the nose and mouth from droplets, airborne particles, and
respiratory secretions.
 Eye Protection: Includes goggles or face shields to protect the eyes from splashes or
sprays of infectious materials.
 Head Covers: Used in specific settings to prevent contamination from hair and scalp.

Selection and Usage:

 Risk Assessment: Determine the required PPE based on the risk of exposure and the
type of procedure.
 PPE Selection: Choose appropriate PPE according to the procedure and level of
contact with infectious agents.
 Training: Ensure all healthcare workers are trained in the proper use, donning, and
doffing of PPE.

58 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
3. PPE Policy

Documentation:

 Maintain comprehensive records of PPE usage, including types and quantities used,
and compliance with procedures.

Monitoring and Evaluation:

 Conduct regular audits to ensure adherence to PPE protocols.

 Provide feedback and retraining as necessary to address non-compliance or issues
identified during audits.

Waste Management:

 Follow established protocols for the safe disposal of used PPE, using designated
waste containers.
 Handle PPE in a way that prevents contamination of surfaces and the environment.

Emergency Procedures:

 Develop and maintain contingency plans for managing PPE shortages or

emergencies, including alternative PPE strategies if necessary.

Staff Support:

 Ensure that adequate PPE supplies are available and accessible to all healthcare
workers.
 Provide ongoing support and resources for staff regarding PPE use and infection
control practices.

Compliance with National Standards:

 Align all PPE practices with the 3rd edition of the DOH’s infection prevention and
control standards.
 Adhere to relevant local regulations and policies specific to a Level 1 hospital setting.

4. PPE Procedures

Donning (Putting On) PPE:

1. Hand Hygiene: Perform hand hygiene before donning PPE.

2. Gown: Put on the gown first, ensuring it covers the arms and torso.
3. Mask or Respirator: Place the mask or respirator over the nose and mouth, securing
it properly.
4. Eye Protection: Position goggles or a face shield over the eyes.

59 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 5. Gloves: Put on gloves last, making sure they cover the wrists of the gown.

Doffing (Removing) PPE:

1. Gloves: Remove gloves first, ensuring not to touch the outside of the gloves with
bare hands.
2. Gown: Remove the gown by pulling it away from the body without touching the
outer surface.
3. Eye Protection: Remove goggles or face shield.
4. Mask or Respirator: Carefully remove the mask or respirator, avoiding contact with
the front.
5. Hand Hygiene: Perform hand hygiene immediately after removing all PPE.

Triage of Infectious Patients: Quick Guidelines

1. Purpose

To quickly and safely manage patients with infectious diseases.

2. Scope

Applies to all staff involved in patient assessment at MOPH-Manticao.

3. Guidelines

3.1 Triage Steps

1. Initial Assessment:

o Action: Check patient’s symptoms and recent exposure to infections.

o Goal: Identify if the patient has signs of a contagious disease.

2. Screening:

o Action: Ask about symptoms like fever or cough and recent contact with sick people.

o Goal: Determine infection risk.

3. Isolation:

o Action: Place patients showing infection signs in an isolation area.

o Goal: Prevent spreading the infection.

4. PPE Use:

o Action: Wear gloves, masks, and gowns when dealing with infectious patients.

o Goal: Protect yourself and others.

60 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
 5. Referral:

o Action: Direct patients to the appropriate care area based on their condition.

o Goal: Ensure they get the right treatment.

4. Policy

4.1 Compliance

 Follow these guidelines at all times.

 Regular checks will ensure everyone follows the procedures.

4.2 Training

 Staff will be trained on these procedures during orientation and periodically.

 Training will cover how to handle infectious patients and use PPE.

4.3 Reporting

 Report any issues or deviations to the infection control team.

 Keep records of triage decisions and patient interactions.

5. Procedures

1. Assess: Quickly evaluate symptoms and exposure.

2. Screen: Use a form to categorize the patient’s risk.

3. Isolate: Place high-risk patients in isolation.

4. Use PPE: Wear appropriate protective gear.

5. Refer: Direct patients to the right care area.

6. Document: Record all triage activities and patient details.

6. Monitoring and Feedback

 Regularly review procedures to ensure they work well.

 Make improvements based on feedback.

Policy and Procedure on Proper Handling and Safe Disposal of Sharps/Needle Sticks

Performance Area: Safe Practice and Environment

Bench Book Code: 6.3.3.a.1

Policy: In alignment with the Department of Health (DOH) guidelines and the Infection
Control Policy, the Hospital implements a process for the proper handling and disposal of
sharps and needle sticks. This involves the segregation of waste at the point of generation,
utilizing appropriate containers, and adhering to stringent safety and hygiene practices to
prevent infection and ensure environmental safety.

61 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
Procedures:

1. Waste Segregation:
o Sharps and needle stick waste must be immediately placed into designated
containers at the point of generation to ensure proper segregation.
o Containers for sharps/needle sticks should be yellow in color and prominently
labeled with a biohazard symbol, in compliance with DOH guidelines.
2. Container Specifications:
o Containers must be puncture-resistant, with a secure, tight-fitting cover to
prevent accidental exposure and spillage.
o Containers should be rigid and impermeable, designed to safely contain both
the sharps and any residual liquids from syringes, in accordance with infection
control standards.
3. Tamper-Proof Measures:
o Containers should be tamper-proof to prevent unauthorized access and
potential abuse.
o Ensure that needles and syringes are rendered unusable before disposal by
using safety devices designed for this purpose, as per DOH recommendations.
4. Alternative Container Options:
o When plastic or metal containers are unavailable or cost-prohibitive, use dense
cardboard containers as a secondary option. These containers should be
reinforced to meet safety standards and prevent leakage or damage.
5. Handling and Storage:
o Use appropriate personal protective equipment (PPE), such as gloves, when
handling sharps/needle stick containers.
o Store filled containers in a secure, well-ventilated area that is inaccessible to
unauthorized personnel or the public. The storage area should be clearly
marked and maintained in accordance with infection control protocols.
6. Disposal:
o Sharps/needle stick waste should be disposed of in a cemented vault or a
designated medical waste disposal facility that complies with DOH guidelines.
Ensure that the vault or disposal facility is properly covered and maintained to
prevent environmental contamination.
7. Training and Compliance:
o Ensure that all staff involved in the handling and disposal of sharps/needle
sticks receive regular training on infection control practices and waste
management procedures.
o Conduct periodic audits and inspections to ensure compliance with both
hospital policies and DOH regulations, and address any identified issues
promptly.
8. Emergency Procedures:
o In the event of a needle stick injury or spillage, follow the hospital’s
established protocol for immediate response. This includes reporting the
incident, seeking medical evaluation, and implementing any necessary follow-
up actions in accordance with infection control procedures.

By adhering to these enhanced procedures, the Hospital ensures compliance with the DOH
guidelines and maintains a safe environment for patients, staff, and visitors, effectively
managing the risks associated with sharps and needle sticks

62 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
Safe Injection Practices: Guidelines, Policy, and Procedures

1. Guidelines

Objective:
To ensure safe injection practices that prevent the transmission of infections and protect both
patients and healthcare workers.

Scope:
These guidelines apply to all healthcare workers involved in administering injections,
including doctors, nurses, and other clinical staff.

Key Principles:

 Use of Sterile Equipment: Always use sterile needles and syringes for each patient.
 Avoid Cross-Contamination: Do not reuse or share needles, syringes, or vials
between patients.
 Proper Injection Sites: Use appropriate sites and techniques for injections to
minimize risk and ensure effectiveness.
 Hand Hygiene: Perform hand hygiene before and after injection procedures.

2. Policy

Documentation:

 Record Keeping: Document each injection administered, including the type of

medication, dosage, injection site, and any observed reactions.

Monitoring and Evaluation:

 Regular Audits: Conduct regular audits to ensure compliance with safe injection
practices.
 Feedback and Retraining: Provide feedback and additional training as needed to
address non-compliance or improve practices.

Waste Management:

 Sharps Disposal: Use designated sharps containers for the disposal of needles,
syringes, and other sharp objects. Ensure containers are properly labeled and disposed
of according to regulations.

63 MOPH Manticao Infection Prevention and Control | General Policies and Procedures Manual
Emergency Procedures:

 Incident Reporting: Report and document any incidents or exposures related to

injection practices immediately.
 Contingency Plans: Develop plans for managing potential exposure incidents and
follow-up care.

Staff Support:

 Training: Provide ongoing training on safe injection practices and infection control
protocols.
 Resources: Ensure staff have access to necessary supplies and equipment to adhere to
safe injection practices.

Compliance with National Standards:

 DOH Guidelines: Align all practices with the 3rd edition of the DOH’s infection
prevention and control standards.
 Local Regulations: Adhere to local regulations and policies regarding safe injection
practices.

3. Procedures

Preparation for Injection:

1. Hand Hygiene: Wash hands thoroughly before preparing any injection.

2. Check Medication: Verify the medication and dosage to be administered.
3. Use of Sterile Equipment:
o Open sterile needles and syringes immediately before use.
o Ensure the vial or ampoule is intact and sterile.
4. Avoid Contamination:
o Do not touch the needle or syringe with unclean hands or surfaces.
o Use a new needle and syringe for each patient and each medication.

Administering the Injection:

1. Choose the Injection Site:

o Select the appropriate site based on the type of injection and patient’s
condition.
2. Clean the Site:
o Use an antiseptic swab to clean the injection site and allow it to dry.
3. Inject:
o Insert the needle at the correct angle for the type of injection.
o Administer the medication slowly and smoothly.
4. Withdraw and Dispose:
o Withdraw the needle and immediately dispose of it in a designated sharps
container.
o Apply a sterile bandage to the injection site if necessary.

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Post-Injection Care:

1. Hand Hygiene: Perform hand hygiene after the injection procedure.

2. Documentation: Record the details of the injection in the patient’s medical record.
3. Monitor for Reactions: Observe the patient for any immediate reactions or adverse
effects following the injection.

Handling and Disposal:

1. Sharps Disposal:
o Place used needles and syringes in a puncture-resistant, leak-proof sharps
container.
o Do not overfill the container and follow local disposal regulations for sharps.
2. Clean-Up:
o Clean any spills or contaminated surfaces with appropriate disinfectants.

Incident Management:

1. Exposure Incidents:
o Report any needle-stick injuries or exposure incidents to the infection control
team immediately.
o Follow established protocols for post-exposure prophylaxis and follow-up

Healthcare Personnel Protection: Occupational Health & Safety Guidelines

1. Purpose and Scope

Objective:
To protect healthcare personnel from occupational hazards, including exposure to infectious
agents, and to establish proper procedures for managing post-exposure incidents and
ensuring appropriate vaccination.

Scope:
These guidelines apply to all healthcare workers at the Level 1 hospital, including physicians,
nurses, support staff, and other personnel.

2. Policy

Documentation:

 Health Records: Maintain current health records for all healthcare workers, including
vaccination status and details of any exposure incidents.
 Incident Reporting: Document and report all exposure incidents and any adverse
effects related to occupational health and safety immediately.

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Monitoring and Evaluation:

 Health Assessments: Conduct regular health assessments and screenings for all
healthcare workers to monitor and manage health risks.
 Compliance Audits: Perform routine audits to ensure adherence to occupational
health and safety protocols.

Emergency Procedures:

 Exposure Management: Develop and implement procedures for managing exposure

incidents, including immediate response and follow-up care.
 Contingency Plans: Create plans to handle outbreaks or other emergencies that
could impact healthcare personnel.

Staff Support:

 Training: Offer continuous training on infection control practices, post-exposure

management, and vaccination requirements.
 Resources: Provide access to necessary protective equipment, health services, and
support resources for staff.

Compliance with National Standards:

 DOH Guidelines: Ensure all practices are in line with the 3rd edition of the DOH’s
infection prevention and control standards.
 Local Regulations: Adhere to local regulations and specific policies related to
occupational health and safety.

3. Guidelines for Healthcare Personnel Protection

Occupational Health & Safety:

 Personal Protective Equipment (PPE):

o Usage: Ensure all healthcare workers use appropriate PPE based on risk
assessment and specific procedures.
o Training: Provide comprehensive training on the proper use, donning, and
removal of PPE.
 Workplace Safety:
o Safe Practices: Follow established safety protocols to reduce the risk of
exposure to infectious agents.
o Environment: Maintain a clean and safe working environment, including
proper waste disposal systems.
 Health Monitoring:
o Health Checks: Conduct regular health checks to monitor for symptoms of
infectious diseases among healthcare personnel.

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 o Health Records: Keep detailed records of health assessments and any
occupational health concerns.

Post-Exposure Protocols:

 Immediate Actions:
o First Aid: Provide immediate first aid following an exposure, such as washing
the affected area with soap and water.
o Report: Report the exposure incident to the infection control team and a
supervisor promptly.
 Medical Evaluation:
o Assessment: Obtain a medical evaluation to assess the risk of infection and
decide if post-exposure prophylaxis is needed.
o Testing: Conduct necessary diagnostic tests to identify potential infections.
 Follow-Up Care:
o Monitoring: Monitor the exposed healthcare worker for signs of infection
and provide appropriate care.
o Counseling: Offer counseling and support related to the exposure and
necessary follow-up care.

Vaccination:

 Vaccination Requirements:
o Immunization: Ensure all healthcare workers are current with required
vaccinations, including hepatitis B, influenza, and other relevant vaccines.
o Documentation: Maintain detailed records of vaccinations and ensure
compliance with recommended vaccination schedules.
 Vaccination for New Hires:
o Pre-Employment Screening: Conduct health screenings for new hires and
verify that they receive necessary vaccinations according to facility protocols.
 Booster Shots:
o Routine Updates: Administer booster shots as required based on vaccination
schedules and the individual's exposure risk.

Health Education:

 Training Programs:
o Education: Provide ongoing education on infection prevention, vaccination,
and post-exposure protocols.
o Updates: Keep staff informed of any updates or changes to guidelines or
protocols.
 Awareness Campaigns:
o Promotion: Promote awareness of occupational health and safety practices
and encourage adherence to established protocols.

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Policies and Procedures for Handling Deceased Bodies
with Dangerous Communicable Diseases
1. Purpose and Scope

Objective:
To establish safe and effective procedures for handling, preparing, and managing deceased
bodies with dangerous communicable diseases until they are picked up by a funeral parlor.

Scope:
These procedures apply to all healthcare staff involved in the management of deceased bodies
with dangerous communicable diseases within the healthcare facility.

2. Policy

Documentation:

 Health Records: Maintain accurate records of the deceased, including the disease
status and handling procedures.
 Incident Reporting: Document and report any issues encountered during handling
and preparation.

Compliance with National Standards:

 DOH Guidelines: Ensure practices comply with the 3rd edition of the DOH’s
infection prevention and control standards.
 Local Regulations: Adhere to local regulations concerning the handling and
preparation of deceased bodies.

3. Procedures

Identification and Preparation:

1. Identification:
o Confirm and document the communicable disease status of the deceased.
o Attach appropriate identification tags and biohazard labels to the body.
2. Body Preparation:
o Personal Protective Equipment (PPE): Wear gloves, masks, gowns, and eye
protection.
o Containment: Place the body in a leak-proof body bag or container with
biohazard labeling.
o Disinfection: Clean and disinfect all surfaces and equipment that came into
contact with the body.

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Handling and Storage:

1. Safe Handling:
o Use proper techniques and equipment for moving the body.
o Ensure the body remains in the biohazard bag or container throughout
handling.
2. Storage:
o Designated Area: Store the body in a designated, secure, and appropriately
refrigerated area.
o Access Control: Restrict access to the storage area to authorized personnel
only.

Preparation for Funeral Parlor Pickup:

1. Notification:
o Inform the funeral parlor about the deceased's condition and any specific
handling requirements.
o Arrange for the pick-up of the body as per the facility's protocol.
2. Transfer to Funeral Parlor:
o Secure Transfer: Ensure the body is transported to the funeral parlor in a
secure, leak-proof container.
o Documentation: Provide the funeral parlor with necessary documentation,
including disease status and handling instructions.

Waste Management:

1. Disposal of Contaminated Materials:

o Dispose of contaminated materials, including PPE and body bags, in
designated biohazard waste containers.
o Follow local regulations for the disposal of biohazardous waste.
2. Cleaning and Disinfection:
o Clean and disinfect all equipment and surfaces used in the handling and
preparation process.

Post-Transfer Procedures:

1. Health Monitoring:
o Monitor staff involved in handling and preparation for any signs of illness and
provide necessary follow-up.
2. Review and Improvement:
o Regularly review and update handling procedures based on feedback and
incident reports.
o Ensure ongoing staff training on procedures and protocols.

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