Los Objetivos de Desarrollo del Milenio

Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced.

6.3.1.x.1 core

An interdisciplinary infection control program ensures the prevention and control of infection in all services.

Presence of an Infection Control Committee (ICC) with defined goals, objectives, strategies and priorities or for a primary hospital - a designated doctor and nurse in-charge of infection control CORE __ __ __ __ __ __ __ __ __ __ DOCUMENT REVIEW

1. ICC composition (for a primary hospital - proof of designation of a doctor and nurse in-charge of infection control)

2. ICC functions and activities

3. Minutes of meeting, at least quarterly activities

4. Statistics on nosocomial infections

INTERVIEW

Ask a member of the ICC regarding infection control program of the hospital

6.3.2.a.1 The organization uses a coordinated system-wide approach to reduce the risks of nosocomial infections.

The organization undertakes case finding and identification of nosocomial infections

Presence of program for case finding and identification of nosocomial infections __ __ __ __ __ __ DOCUMENT REVIEW

1. Surveillance forms for nosocomial infection 2. Nosocomial Infection Case Reports

3. Hospital Acquired Infection Reports: semi annual infection rates, antibiotic resistance pattern

6.3.2.b.1 core

The organization uses a coordinated system-wide approach to reduce the risks of nosocomial infections.

The organization takes steps to prevent and control outbreaks of nosocomial infections

Presence of a coordinated system-wide procedure for isolation of nosocomial infections CORE __ __ __ __ DOCUMENT REVIEW

Procedures on isolation of nosocomial infections

INTERVIEW

Ask staff in ER, wards and ICU the procedures on isolation

isolation - physical isolation of a patient with infection

6.3.2.b.2 core

The organization uses a coordinated system-wide approach to reduce the risks of nosocomial infections.

The organization takes steps to prevent and control outbreaks of nosocomial infections

Presence of a coordinated system-wide procedure for case containment of nosocomial infections CORE __ __ __ __ DOCUMENT REVIEW

Procedures on case containment of nosocomial infections

Note : case containment - means prevention of spread of infection examples: reverse isolation, prophylaxis for exposed personnel, vaccination, immunization

INTERVIEW

Validate from staff in ER, wards and ICU the procedures on case containment

6.3.2.b.3 core

The organization uses a coordinated system-wide approach to reduce the risks of nosocomial infections.

The organization takes steps to prevent and control outbreaks of nosocomial infections

Presence of a coordinated system-wide procedure for asepsis CORE __ __ __ __ DOCUMENT REVIEW Procedures on asepsis INTERVIEW

Ask staff from ER, wards, laboratory and ICU about the approaches for asepsis during diagnostic and treatment procedures

6.3.3.a.1 core

The organization uses a coordinated system-wide approach to reduce the risks of infection the staff are exposed to in the performance of their duties.

There are programs for prevention and treatment of needle stick injuries, and policies and procedures for the safe disposal of used needles are documented and monitored

Presence of policies and procedures on the prevention and treatment of needle stick injuries and safe disposal of needles CORE __ __ __ __ __ __ __ __ DOCUMENT REVIEW

1. Policies and procedures for prevention and treatment of needle stick injuries

2. Policies and procedures on proper handling and safe disposal of sharps/needle sticks

INTERVIEW

Interview hospital staff on how they handle and dispose needles

OBSERVATION

6.3.3.b.1 core

The organization uses a coordinated system-wide approach to reduce the risks of infection the staff are exposed to in the performance of their duties.

There are programs for the prevention of transmission of airborne infections, and risks from patients with signs and symptoms suggestive of tuberculosis or other communicable diseases are managed according to established protocols

Presence of program on prevention of transmission of airborne infections and risks from patients with signs and symptoms suggestive of tuberculosis or other communicable diseases CORE __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ DOCUMENT REVIEW

1. Infection control procedures on isolation and universal precaution 2. Program for the protection of healthcare workers e.g. personal protective equipment (PPEs)

3. Policies on all patient admission/referral, isolation and timely case reporting of highly transmissible and notifiable infectious disease e.g. meningococcemia, SARS, avian flu, etc

4. Hand hygiene procedures

5. Environmental care and healthcare waste management 6. Procedures on recycling & reuse of equipment i.e. personal protective equipment

INTERVIEW

Validate hospital policies on infection control such as use of PPEs, isolation precautions and hand washing

OBSERVATION

1. Observe for use of gloves, surgical masks

2. Look for sinks or lavatories or designated areas for hand washing or dispenser for sanitizers

3. Look for separate holding area/room for highly infectious cases 4. Ask a hospital staff to demonstrate hand washing technique

6.3.4.x.1 core

Cleaning, disinfecting, drying, packaging and sterilizing of equipment, and maintenance of associated environment, conform to relevant statutory requirements and codes of practice.

Presence of policies and procedures on cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments and supplies CORE __ __ __ __ __ __ DOCUMENT REVIEW

1. Policies and procedures on cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments and supplies

2. Policies on decontamination, disinfection, sterilization, disinfectants for specific medical equipment/items and area