INFECTION PREVENTION AND CONTROL POLICY , HOSPITAL CANSELOR TUANKU MUHRIZ

Policies and Procedures on Infection Prevention and Control HCTM

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Policies and Procedures on Infection Prevention and Control HCTM

FOREWARD BY HOSPITAL DIRECTOR
HCTM

It is with utmost pleasure that I pen this foreword
to commemorate this policy of the Infection
Prevention and Control Policies and Procedures
for Hospital Canselor Tuanku Muhriz UKM. This
policy was put together by a multidisciplinary
team comprising of nurses, physicians, surgeons,
microbiologists, pharmacists, nutritionists, engineers, technologists and many more. I would like to thank
and congratulate everyone involved in producing this policy, especially the Infection Control Unit. They
have been charged with many tasks which include reforming and consolidating national policies from
Ministry of Health, Malaysia to ensure that they are feasible for adaptation within our healthcare facilities.
Infection prevention and control should be high on the agenda for healthcare workers, students, patients
and stake holders in reducing healthcare-associated infections. Infection prevention and control will always
be at the centre of all battle against infectious agents in healthcare. Thus, we have to constantly work
towards new ways to win this battle.

This policy is to be used as a reference by healthcare workers, management and operations staff to ensure
policies and procedures are adhered to. When all relevant parties work together to adhere to good infection
prevention and control, we can aim to reduce the risk of healthcare associated infections. This policy is
also as a guide to standardize infection prevention and control activities for quality improvement and future
monitoring on audit system in this hospital. Together, we can master these challenges for a safer healthcare
system in Hospital Canselor Tuanku Muhriz.

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Policies and Procedures on Infection Prevention and Control HCTM

FOREWARD BY HEAD OF INFECTION CONTROL UNIT

The Policies and Procedure on Infection Control Guideline has
been a necessary endeavor to reflect developments and
advancement to the current infection control practices, in order to
provide a more up-to-date guide for healthcare providers.
This Policies and Procedures on Infection Control Guideline has
been developed based on evidence from various international
policies and procedures in infection control.
The structure, functions and management in the chapters on
hospital infection and antibiotics control committee,
implementation of healthcare associated infections surveillance as
well as hospital outbreak management and sterilization.
This edition also includes new chapters on isolation precautions and updates on standard precautions,
hand hygiene, PPE, transmission based and design of isolation room. Various clinical practices and
processes, activities to reduce the common healthcare associated infections and infection control in
specific healthcare settings are also noteworthy additions to this guideline.
Guideline committee members who contributed to the chapters are well recognized as authorities or
leaders in the field of infection control. It is my utmost hope that all healthcare providers will benefit from
this Policies and Procedures on Infection Control Guideline. A vote of thanks are in order for chapter writers
and coordinators, the Quality in Medical Care Section, Medical Development Division and all those involved
in one way or another, for their support, dedication and commitment in making this guideline a reality.

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Policies and Procedures on Infection Prevention and Control HCTM

CONTENTS PAGE
12
I. FOREWARD BY HOSPITAL DIRECTOR HCTM 13
II. FOREWARD BY HEAD OF INFECTION CONTROL UNIT 17
III. LIST OF CONTRIBUTORS 23
IV. ABBREVIATIONS 25
26
SECTION A: INFECTION PREVENTION AND CONTROL GOVERNANCE
NO CHAPTERS PAGE
1. INTRODUCTIONS 30
2. NIACC
3. HIACC 36
4. INFECTION CONTROL UNIT 40
5. INFECTION CONTROL LINK NURSE (ICLN) 47
6. EDUCATION AND TRAINING 48
51
SECTION B: FUNDAMENTAL PRINCIPLE OF INFECTION PREVENTION 55
NO CHAPTERS 64
1. HCAI SURVEILLANCE 70
2. STANDARD PRECAUTION BUNDLES 76
2.1 HAND HYGIENE 77
2.2 PERSONAL PROTECTIVE EQUIPMENT 84
2.3 ENVIRONMENTAL HYGIENE
2.4 MANAGEMENT OF BODY FLUIDS AND SPILLAGE 89
2.5 LINEN MANAGEMENT 101
2.6 INJECTION SAFETY AND SHARPS MANAGEMENT 103
2.7 WASTE MANAGEMNT 105
2.8 DISINFECTION AND STERILISATION 110
2.9 RESPIRATORY HYGIENE AND COUGH ETIQUETTE
3. TRANSMISSION BASED PRECAUTION 114
4. ISOLATION ROOM 117
5. PROCEDURES 122
5.1. ASEPTIC TECHNIQUES 125
5.2. WOUND CARE 136
5.3. BLOOD AND BLOOD COMPONENTS TRANSFUSION 138
5.4. ENTERAL NUTRITION 144
5.5. PARENTERAL NUTRITION 145
6. PREVENTION OF HCAI
6.1. CATHETER ASSOCIATED URINARY TRACT INFECTION
6.2. SURGICAL SITE INFECTION
6.3. HOSPITAL ACQUIRED PNEUMONIA
6.4. INTRAVASCULAR CATHETER RELATED INFECTION
6.5. CENTRAL VENOUS CATHETER RELATED INFECTION
7. OUTBREAK INVESTIGATION AND MANAGEMENT
8. UNKNOWN PATHOGEN OUTBREAK
9. COMMUNICATION AND SHARING

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Policies and Procedures on Infection Prevention and Control HCTM

SECTION C : ENVIRONMENTAL HYGIENE AND SAFETY PAGE
151
NO CHAPTERS 156
1. ENVIRONMENTAL CLEANING 160
2. OPERATION ROOM COMMISSIONING
3. INFECTION CONTROL DURING CONSTRUCTION AND RENOVATION

SECTION D : INFECTION CONTROL IN SPECIFIC HEALTH SETTING PAGE
164
NO CHAPTERS 170
1. GENERAL INTENSIVE CARE UNIT 177
2. NEONATAL INTENSIVE CARE UNIT 187
3. OPERATION THEATRE 194
4. DENTAL PRACTICE 201
5. ENDOSCOPY ROOM 206
6. MORTUARY 212
7. NEPHROLOGY AND HEMODIALYSIS 224
8. LABORATORY 228
9. FOOD SERVICES 236
10. PHARMACY
11. HEMATOLOGY AND ONCOLOGY

SECTION E : SPECIFIC MICROORGANISM IN INFECTION CONTROL PAGE
242
NO CHAPTERS
1. GRAM POSITIVE MDRO – METHICILLIN-RESISTANT STAPHYLOCOCCUS 246

AUREUS (MRSA) 249
2. GRAM POSITIVE MDRO – VANCOMYCIN-RESISTANT ENTEROCOCCI 251
273
(VRE) 277
3. MULTI RESISTANT GRAM NEGATIVE MDRO
4. INFECTION CONTROL POLICY FOR MDROs
5. VIRUSES
6. FUNGAL INFECTION

SECTION F : OCCUPATIONAL SAFETY AND HEALTH FOR HEALTHCARE WORKER PAGE
280
NO CHAPTERS 282
1. DEFINITION 285
2. POST EXPOSURE PROPHYLAXIS FOR BLOOD-BORNE PATHOGEN 290
3. HEALTHCARE WORKER SCREENING FOR TUBERCULOSIS
4. IMMUNIZATION FOR HEALTHCARE WORKER

SECTION G : ANTIMICROBIAL RESISTANCE (AMR) PAGE
293
NO CHAPTERS 297
1. AMR SURVEILLANCE 298
2. ANTIBIOTIC SURVEILLANCE 300
3. POLICY AND GUIDELINES ON AMR 312
4. AMR PROTOCOL
5. SURGICAL ANTIBIOTIC PROPHYLAXIS

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Policies and Procedures on Infection Prevention and Control HCTM

LIST OF CONTRIBUTORS

Section Introductions
Pn. Puteri Fairuz Izyan Binti Zainuddin
Pn. Nur A`Ain Binti Borhan
Cik Siti Khadijah Binti Baharuddin

Section A : HIACC
Dr. Maliha Farah Nurhazirah Binti Yahya

Section B : Fundamental Principle Of Infection Prevention
Pn. Siti Rokiah Binti Yusof
Pn. Puan Zurina Mohd Salleh
Pn. Nor Rina Mahawar
Pn. Farahnaz Binti Ab Rahman
Dr. Nur Ayuni Ahamad Faudzi
Dr. Maliha Farah Nurhazirah Binti Yahya
Pn. Norhaniza Zainal Abidin
Dr. Tang Yee Loong
Pn. Aznida Juhari
Pn. Yushailalizam Jusoh
Dr Birinder Kaur A/P Sadu Singh
Pn. Anum Abd Halim
Pn. Nurhayatie Binti Mohamad Kosnen
Pn. Razila Binti Yacob
Pn. Rafidah Binti Mustafa Albakri
Prof Cheah Saw Kian
Pn. Haslinda Kamis
Prof. Madya Dato' Dr Wan Rahiza Wan Mat
Pn. Norazima Mohd Arsad
Dr. Sharifah Azura Salleh
Pn. Iva Mascinta Ibrahim
Pn. Nora Shasheela Abdullah
Pn. Siti Hapidah A.Hamid
Pn. Shawarulhida Bt Mat Radzi
Dr. Nora 'Aini Ramly
Pn. Mary Julia Savarimuthu
Pn. Farahzilla Anuwar

Section C : Environmental Hygiene And Safety
Pn. Sunita Binti Sulaiman
En. Mohamad Nor Mas'ud
En. Mohamad Aizat Jusli
En. Khairul Hazdi Yusof
Pn. Farahzilla Anuwar

Section D : Infection Control In Specific Health Setting
Prof Aliza Mohamad Yusof
Pn. Norrafidah Md Sapuan
Prof Madya Dr Shareena Ishak
Pn. Siti Fatkhiyah
Prof. Madya Dr Azarinah Izaham
Pn. Sumaiyah Bt Ismail
Dr. Loh Wayen
En. Mohd Zulkifli Mohd Zain

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Policies and Procedures on Infection Prevention and Control HCTM

En. Hairol Azman Bin Mohamad Yusop
Prof. Madya Dr Ruslinda Mustafar
Dr. Lydia Kamaruzaman
Dr. Nur Afifah Binti Suhemi
Pn. Norasyikin Johan
Dr. Birinder Kaur A/P Sadu Singh
Prof Madya Dr. Nor Rafeah Binti Tumian
Pn. Haslinda Bt Kamis

Section E : Specific Microorganism In Infection Control
Prof Madya Dr. Ramliza Ramli
Dr Zalina Ismail
Prof. Madya Dr. Petrick@Ramesh K. Periyasamy
Dr. Najma Kori
Prof Madya Dr Asrul Abdul Wahab
Dr. Muttaqillah Najihan Abdul Samat
Prof Madya Datin Dr Noor Zetti Zainol Rashid
Dr. Siti Norlia Othman
Dr. Umi Kalsom @ Satariah Ali
Prof Madya Dr Tzar Mohd Nizam Khaithir
Prof Madya Dr Ding Chuan Hun
Dr. Ummu Afeera Zainulabid

Section F : Occupational Safety And Health For Healthcare Worker
Dr. Khamsiah Nawawi
Dr. Nurmasitah Mohamad Nazri
Pn. Rosilawati Matsarip
Pn. Farah Waheeda A Azis

Section G : Antimicrobial Resistance
Pn. Lau Chee Lan
Cik Chin Suet Yin
Prof Madya Dr Raha Bt Abdul Rahman
Prof Madya Dr. Ramliza Ramli
Dr. Najma Kori

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AAMI Policies and Procedures on Infection Prevention and Control HCTM
ABHR
ABG ABBREVIATIONS
ACH
AERs Association of the Advancement Medical Instrumentation
A&E Alcohol Based Hand Rub
AFB Arterial Blood Gas
AHU Air Change Per Hour
AIIR Automated endoscope reprocessors
AMR Accident and emergency
AMS Acid Fast Bacilli
AML Air Handling Unit
APR Airborne Infection Isolation Room
ASP Antimicrobial Resistance
AV Antimicrobial Stewardship
BAL Acute Myeloid Leukaemia
BP Air-purifying respirators
BMT Antimicrobial Stewardship Program
BSI Arteriovenous
BSL-3 Bronchoalveolar Lavage
BSC Blood Pressure
BUD Bone Marrow Transplant
CVADs Blood Stream Infection
CAUTI Biosafety Level 3
CCU Biosafety Cabinet
CABSI Beyond Use Date
CBD Central Venous Access Devices
C.DIFF Catheter Associated Urinary Tract Infection
CDC Cardiac Care Unit
CDR Catheter Associated Blood Stream Infection
CHG Calmodulin Binding Domain
CSSD Clostridium deficille
CSSU Centers for Disease Control and Prevention
CFU Cytotoxic Drug Reconstitution
CI Chlorohexidine
CLSI Central Sterile Supplies Department
CLABSI Central Sterile Supply Unit
COVID-19 Colony Forming Unit
CNE Continuous Infusion
CNS Clinical and Laboratory Standards Institute
CPD Central Line Associated Blood Stream Infection
CPE Coronavirus Diseases (2019)
CRBSI Continuous Nursing Education
CRE Central Nervous System
Continuous Professional Development
Carbapenem-Producing Enterobacterales
Catheter Related Blood Stream Infection
Carbapenem-Resistant Enterobacteriaceae

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Policies and Procedures on Infection Prevention and Control HCTM

CSP Compounded sterile preparations

CT Computerized Tomography

CVADs Central Venous Access Devices
CVC Central Venous Catheter
DDD Define daily dosing
DNA Deoxyribonucleic Acid

DIACC District Infection and Antibiotic Control Committee
DIVA Difficult Intravenous Access
EPP Exposure Prone Procedures
ESBL Extended Spectrum Beta-Lactamase
ESBL-E Extended Spectrum Beta-Lactamase-Enterobacteriaceae
EUCAST European Committee on Antimicrobial Susceptibility Testing
EBM Expressed breast milk
EBV Epstein-Barr virus
ED Emergency Department
EJ external jugular
EtO Ethylene Oxide
FDA Food and drug administration
FFR Filtering Facepiece Respirator
FFP fresh frozen plasma
FIFO First In First Out
G-CSF Growth Colony Stimulating Factors
GI Gastrointestinal
GICU General Intensive Care Unit
GIT Gastrointestinal
GMP Good manufacturing practice
GMT Good Microbiological Technique
GN-MDROs Gram negative-Multidrug Resistance Organisms
GP-MDROs Gram positive-Multidrug Resistance Organisms
GPP Good Preparation Practice
HA-BSI Healthcare Associated Blood Stream Infection

HA-COVID Healthcare Associated Covid-19

HAI Healthcare-associated infections

HA-MDRO Healthcare Associated Multidrug Resistance Organism

HAP Hospital Acquired Pneumonia

HACCP Hazard Analysis and Critical Control Point
HBV Hepatitis B Virus

HCP Healthcare Personnel
HCAI Healthcare Associated Infection
HCAP Healthcare Associated Pneumonia
HCTM Hospital Canselor Tuanku Muhriz
HCV Hepatitis C Virus
HCW Healthcare Workers
HDF Hemodiafiltration

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Policies and Procedures on Infection Prevention and Control HCTM

HEP B Hepatitis B
HEP C Hepatitis C
HepBAb Hepatitis Antibody
HepBAg Hepatitis Antigen
HPV Human papillomavirus
HFMD Hand, Foot, and Mouth Disease
HEPA High Efficiency Particulate Air
HH Hand Hygiene
HHSAF Hand Hygiene Self – Assessment Framework
HIACC Hospital Infection and Antibiotic Control Committee
HIV Human Immunodeficiency Virus
HLF Horizontal Laminar Flow
HSCT Hematopoietic Stem Cell Transplant
HSV Herpes Simplex Virus
HVAC system Heating, Ventilation and Air-Conditioning system
ID Identity /identification
IDSA Infectious Diseases Society of America
IC Identity Card
IC Infection Control
ICD Infection Control Doctor
ICLN Infection Control Link Nurse
ICN Infection Control Nurse
ICP infection control and prevention
ICRA Infection Control Risk Assessment
ICU Intensive Care Unit
IMR Institute for Medical Research
IPC Infection Prevention and Control
ISO International Organization for Standardization
IU International Unit
IV Intravenous
IVC Inferior Vena Cava
IVFE Intravenous fat emulsion
IVIg Intravenous Immunoglobulin
JKTU Jawatankuasa Terapeutik Dan Ubat-ubatan
JPMD Jabatan Perkhidmatan Makmal Diagnostik
JPDSM Jabatan Perkhidmatan Dietetik & Sajian Makanan
KPC Klebsiella pneumoniae carbapenemase
LFC Laminar Flow Cabinet
MDR Multidrug Resistant
MDRO Multidrug Resistance Organism
MDR-GNB Multidrug-Resistant Gram-Negative Bacilli
MDR TB Multi-Drug Resistant TB
MEIR Medical Effects of Ionizing Radiation
MERS-CoV Middle East Respiratory Syndrome Coronavirus
MIC. Minimal inhibitory concentration
MLN. Mesenteric Lymph Node

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MLT. Policies and Procedures on Infection Prevention and Control HCTM
MMR
Medical Laboratory Technologist
MOH Measles, Mumps, and Rubella
Ministry of Health
MOHE Ministry of Higher Education
Methicillin Resistant Staphylococcus aureus
MRSA Medical Registration Number
Methicillin Resistant Staphylococcus Aureus Bacteraemia
MRN Medical Adhesive-Related Skin Injury
Not Available
MRSAB Nutrient agar
Not Detected
MARSI New-Delhi Metallo-beta-lactamase
National Infection and Antibiotic Control Committee
NA Neonatal Intensive Care Unit
National Surveillance of Antimicrobial Resistance
NA Obstetrics & Gynaecology
Oral Healthcare Workers
ND Oral and Maxillofacial
NDM Outbreak Management Team
NIACC Occupational Safety and Health Administration
Operation Theatre
NICU Operation Room
NSAR Occupational Safety and Health
O&G Powered Air Purifying Respirator
OHCW Penicillin-Binding Protein 2a
OMF Peritoneal Dialysis
OMT Peripherally Inserted Central Catheter
OSHA peripheral intravenous catheter
OT Pharmacokinetics/Pharmacodynamics
OR Parenteral Nutrition
OSH Protective Environment
PAPR post-exposure prophylaxis
PBP2a Post Mortem Blades
PD Parenteral Nutrition
PICC Personal Protective Equipment
PIVC Plan Preventive Maintenance
PK/PD Point Prevalence Survey
PN Photostimulable Phosphor
PE Pusat Perubatan Universiti Kebangsaan Malaysia
PEP Reverse Osmosis
PM40 Relative Humidity
PN Respiratory Syncytial Virus
PPE Ready to Feed
PPM Surgical antibiotic prophylaxis
PPS Severe Acute Respiratory Syndrome
PSP
PPUKM 11
RO
RH
RSV
RTF
SAP
SARS

Policies and Procedures on Infection Prevention and Control HCTM

SARS-COV-2 Severe Acute Respiratory Syndrome Coronavirus 2
SHEA Society for Healthcare Epidemiology of America
SEMD Safety-Engineered Medical Devices
SIACC State Infection and Antibiotic Control Committee
SOP Standardized Operating Procedures
SSI Surgical Site Infection
TB Tuberculosis
Tdap Tetanus, Diphtheria, and Pertussis
TDM Therapeutic Drug Monitoring
TDS Total dissolved solids
TPN Total Parenteral Nutrition
TSA Trypticase soy agar
TSSU Theatre Sterile Services Unit
UCV Ultra Clean Ventilated
UCV OT Ultra Clean Ventilated Operation theatre
UVGI Ultraviolet Germicidal Irradiation
UKM University Kebangsaan Malaysia
UKMMC University Kebangsaan Malaysia Medical Center
UNICEF United Nations International Children's Emergency Fund
USP United States Pharmacopeia
UTI Urinary Tract Infection
UV Ultraviolet
UV-C Ultraviolet-C
VAD Vascular Access Device
VAP Ventilator Acquired Pneumonia
VIM Verona Int`egron-Mediated Metallo-beta-lactamase
VISA Vancomycin-Intermediate Staphylococcus aureus
VRE Vancomycin-Resistant Enterococci
VRSA Vancomycin-Resistant Staphylococcus aureus
VLBW Very Low Birth Weight
VLF Vertical Laminar Flow
VZV Varicella Zoster Virus
WHO World Health Organization
XDR-TB Extensively drug-resistant Tuberculosis

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Policies and Procedures on Infection Prevention and Control HCTM

SECTION A: INFECTION PREVENTION AND CONTROL GOVERNANCE

1.0 : INTRODUCTION
❖ Infection prevention and control (IPC) practices play important roles in minimising the spread of
healthcare associated infection among patients, healthcare workers, supporting service staff,
students, caregivers and visitors.
❖ A facility-wide programme related to infection prevention and control is required in every healthcare
setting to reduce the risk of infection transmission.
❖ Therefore, infection control governance is crucial to coordinate the safety and quality of services.
❖ According to the current national policies and procedures by Ministry of Health (MOH), infection
prevention and control governance is divided into different levels, consisting of multi-tier
committees which monitor and facilitate the implementation of IPC.
❖ The levels consist of :
■ National Infection and Antibiotic Control Committee (NIACC)
■ State Infection and Antibiotic Control Committee (SIACC)
■ Hospital Infection and Antibiotic Control Committee (HIACC)
■ District Infection and Antibiotic Control Committee (DIACC)
❖ As for Hospital Canselor Tuanku Muhriz (HCTM), HIACC HCTM will be directly under NIACC for
IPC coordination.

Figure 1 : IPC governance level in HCTM
2: NATIONAL INFECTION AND ANTIBIOTIC CONTROL COMMITTEE (NIACC)

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Policies and Procedures on Infection Prevention and Control HCTM

National Infection and Antibiotic Control Committee (NIACC)

Introduction 1. The National Infection and Antibiotic Control Committee (NIACC) is a
governance body essential for coordinating and facilitating national efforts in
IPC implementation as following:
• minimising and preventing healthcare associated infection (HCAI)
• promoting judicious use of antimicrobials to control antimicrobial
resistance (AMR).

2. The NIACC will be participated by Ministry of Health and University Hospitals.

Functions 1. NIACC will develop policies and procedures on infection control, AMR and
antibiotic usage in Ministry of Health, Malaysia.

2. The Committee will provide expertise on matters related to infection control,
AMR and antibiotic usage.

3. The Committee will review issues/problems pertaining to infection control,
AMR and antibiotic use

4. The Committee will advise the Chairman of State Infection and Antibiotic
Control Committee(SIACC) including the Hospital Director and related
Head of Division on any related issues.

5. Raised issues from this meeting will be discussed in the National
Antimicrobial Resistance Committee meeting.

Scope All infection prevention and antibiotic control activities will be addressed by NIACC
involving :

• Healthcare facilities under Ministry of Health
• University Hospitals

Terms of reference

Information The NIACC will act as a platform for information sharing and to coordinate activities
sharing in MOH and University Hospitals.

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Policies and Procedures on Infection Prevention and Control HCTM

Interactions The Committee is well represented by the experts in:

• Health system
• Public health
• Disease-specific programmes

Membership Duration of membership
• The members will be appointed every 2 years.

Composition of National Infection and Antibiotic Control Committee (NIACC)

• Please refer to figure 2.

Roles and Responsibilities

1. Chairman
a. Chair the NIACC meetings.
b. Responsible for facilitating and coordinating activities of national
infection and antibiotic control.

c. Provide a platform for programme planning and implementation.
d. Review and approve NIACC output.
e. The meeting will be chaired by a delegate assigned by the

Chairman in the absence of the Chairman.

2. Members of National Infection and Antibiotic Control Committee (NIACC)
a. Attend each NIACC meeting.
b. Give technical input
c. Provide a report to the committee regarding progress of the
activities, problems, target achievement and actions to be
taken.

3. Secretariat National Infection and Antibiotic Control Committee (NIACC)
a. Pharmacy Practice & Development Division will be the main
secretariat.
b. Propose the meeting schedule and prepare the meeting
agenda.
c. Responsible for preparing the documents, reports and
minutes of meetings.
d. Keep a record of the progress on recommendations.
e. Responsible for NIACC correspondence

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Policies and Procedures on Infection Prevention and Control HCTM

Meeting Format for National Infection and Antibiotic Control Committee
1. Frequency of Meetings
a. At least once a year
b. Notification of the date and agenda of the meeting shall be given
to the committee members at least two weeks before the meeting.
c. Minutes shall be made available and ratified.
2. Agenda of the meetings
a. Infection and antibiotic control reports should be included in the
agenda of the meeting as following :
i. Incidence and prevalence of MDRO organisms and
emerging resistant organisms
ii. National Surveillance of Antibiotic Resistance
iii. Antimicrobial Resistance Containment activities
iv. Healthcare Associated Infection Surveillance
v. Antibiotic Utilisation Surveillance
vi. Tuberculosis Surveillance among Healthcare Workers
vii. Sharp Injuries among Healthcare Workers
b. Quorum
i. The meeting should be attended by at least two thirds of
the members.
ii. A simple majority is needed if a vote is required on any
matter.
c. Meetings on Outbreak Management
i. In case of any outbreaks, the Chairman shall call for an
urgent meeting to discuss the action measures and
control of outbreaks.
ii. Members will be invited accordingly.
iii. Other related personnel may be invited if needed

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Policies and Procedures on Infection Prevention and Control HCTM

Chairman

Secretary
(Deputy Director of Pharmacy

Senior Director of Pharmaceutical Services, Ministry of Health
Principal Director of Oral Health, Ministry of Health

Director of Medical Development Division, Ministry of Health
Director of Diseases Control Division, Ministry of Health
Head of Infectious Disease Service, Ministry of Health
Head of Clinical Microbiology Service, Ministry of Health

Director of Pharmacy Practice & Development Division, Ministry of Health
Director of Engineering Services Division, Ministry of Health
Director of Nursing Division, Ministry of Health

Director of Family Health Development Division, Ministry of Health
Deputy Director of Medical Care Quality Section, Medical Development Division,

Ministry of Health

Figure 2 : Organisation chart of NIACC

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Policies and Procedures on Infection Prevention and Control HCTM

3.0 : HOSPITAL INFECTION AND ANTIBIOTIC CONTROL COMMITTEE (HIACC)
Hospital Infection and Antibiotic Control Committee (HIACC)

Introduction 1. The Hospital Infection and Antibiotic Control Committee (HIACC) acts a
governance body essential to :
● Coordinate IPC activities/programmes at hospital level to reduce and
prevent HCAI
● Promote judicious antimicrobials usage
● Control AMR emergence

2. The HIACC will be participated by multi-disciplinary departments and units.

Functions 1. HIACC will develop policies and procedures on infection control, AMR and
use of antibiotics in HCTM.

2. The Committee will function as the source of expertise on matters pertaining
to infection control and antibiotic usage.

3. HIACC will prepare and submit the report to NIACC
4. Any issues/problems pertaining to infection control and use of antibiotics will

be reviewed by HIACC and advice will be given to healthcare workers
through the Head of Department/Unit.
5. Raised issues from this meeting will be brought up in the NIACC meeting.

Scope All hospital activities related to infection prevention and antibiotic control will be
addressed by HIACC.

Terms of reference

Information The HIACC will act as a platform for information sharing and to facilitate activities in
sharing departments/units in HCTM

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Policies and Procedures on Infection Prevention and Control HCTM

Interactions The Committee is well represented by the experts with clearly defined roles and
responsibilities in:

● Health system
● Public health
● Disease-specific programmes

Membership Duration of membership

● The duration of appointment will be for 2 years and the selected
members should be able to make decisions for respective
departments/units.

Composition of Hospital Infection and Antibiotic Control Committee (HIACC)
• Please refer to figure 3.

Roles and Responsibilities

1. Chairman
a. Chair the HIACC meetings.
b. Responsible for facilitating and coordinating hospital activities
related to infection and antibiotic control.
c. Review and approve HIACC output.
d. Assign a member to chair the meeting in the absence of chairman.

2. Infection Control Doctor (ICD) Coordinator
a. An ICD should possess the following criteria such as:
i. appropriate training and experience pertaining to infection
and antibiotic control.
ii. good communication skills
iii. good leadership qualities.

b. Represent the hospital at NIACC meetings.
c. Assist the Chairman to facilitate and coordinate hospital activities

related to infection prevention and antibiotic control.

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Policies and Procedures on Infection Prevention and Control HCTM

d. Act as a leader in infection prevention and antibiotic control activities
at the hospital level.

e. Prepare the report of infection prevention and antibiotic control.
f. Give advice to the Chairman and Committee on actions to be taken

if the hospital achievements do not meet the national performance
indicators (as set by NIACC).

3. Infection Control Nurse (ICN) Coordinator

a. Acts as a member and secretariat of HIACC that is responsible to :

i. Schedule and prepare the agenda of each HIACC meeting
ii. Prepare draft of minutes of meetings
iii. Maintain a spreadsheet to track progress on

recommendations (documents/reports/minutes of meetings)
iv. Assists in facilitating HIACC correspondence
b. Collaborate with ICD Coordinator to disseminate/ promote the latest
information regarding infection control and AMR in the hospital. (e.g
updated guidelines)
c. Work closely with ICD Coordinator to facilitate and coordinate the
action plan of annual activities related to infection control and AMR
at the hospital level (e.g World Hand Hygiene Day)

d. Collect, analyse and prepare the surveillance reports of infection
control and AMR in the hospital. ICN coordinator is also responsible
to submit the surveillance reports to NIACC secretariat according to
MOH requirements.

e. Assists in presentation of surveillance reports related to infection
control and AMR during HIACC meetings as appropriate.

f. Work together with ICD Coordinator during outbreaks to:

i. Conduct outbreak investigations
ii. Give relevant advices
iii. Monitor the outbreak management in the hospital
iv. Give relevant information/ notification to MOH
g. Provide input/advice regarding service development
projects/activities in terms of financial, specification, design and
commissioning of new buildings, renovation as well as contracts in

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Policies and Procedures on Infection Prevention and Control HCTM

the hospital.

h. Give input/advice regarding purchase of equipment/consumables
related to infection control if necessary.

i. Assists ICD Coordinator in the preparation of annual reports
pertaining to infection control and AMR activities.

4. The Secretariat of Hospital Infection and Antibiotic Control Committee
(HIACC)
a. The Infection Control Unit will be the main secretariat.
b. Propose the meeting schedule and prepare the
meeting agenda.
c. Responsible for preparing the documents, reports and
minutes of meetings.
d. Keep a record of the progress on recommendations.
e. Responsible for HIACC correspondence

5. Members of Hospital Infection and Antibiotic Control Committee (HIACC)
a. Attend each HIACC meeting.
b. Give technical input
c. Representatives from the departments/ units must be selected
among senior personnel and should be represented by a permanent
alternate in the absence of the main representative.

Meeting Format for Hospital Infection and Antibiotic Control Committee

1. Frequency of Meetings
a. At least twice a year
b. Notification of the date and agenda of the meeting shall be given to
the committee members at least two weeks before the meeting.
c. Minutes shall be made available and ratified.

2. Agenda of the meetings
a. Infection and antibiotic control reports should be included in the
agenda of the meeting as following :
i. Incidence and prevalence of MDRO organisms and/ or
emerging resistant organisms
ii. Hospital Surveillance of Antibiotic Resistance
iii. Healthcare Associated Infection Surveillance

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Policies and Procedures on Infection Prevention and Control HCTM

iv. Antibiotic Utilisation Surveillance
v. Infection Prevention and Control Audit
vi. Hand Hygiene Compliance Surveillance
vii. Sharp Injuries among Healthcare Worker
viii. Tuberculosis among Healthcare Worker
ix. Outbreak and action plan.
b. Quorum
i. The meeting should be attended by at least two thirds of the

members.
ii. A simple majority is needed if a vote is required on any

matter.
d. Emergency meetings and outbreak control

i. In case of any outbreaks of infection, the Chairman shall call
for an urgent meeting to discuss the action measures and
control of outbreaks.

ii. Members will be invited accordingly.
iii. Emergency meetings are held to assist the Infection Control

Unit in terms of additional support and problem notification
in accordance with the major outbreak policy.

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Policies and Procedures on Infection Prevention and Control HCTM

Chairman
(Hospital Director)

Infection Control Doctor Secretariat
(ICD) Coordinator (Infection Control Unit)

Infection Control Nurse
(ICN) Coordinator

Hospital Deputy Director
Infectious Disease Physician and/ or Paediatrician
Clinical Microbiologist/ Science officer
Infection Control Nurse (by appointment)
Consultant Physician
Consultant Surgeon
Consultant Orthopaedic surgeon
Consultant Paediatrician
Consultant Anaesthesiologist/ Intensives
Consultant Obstetrician
Consultant Oral Maxillofacial (OMF)/ Dentistry
Pharmacist
Hospital Engineer
Medical officer of Hospital Infection Control Unit (by appointment)
Occupational Safety and Health Officer (Environmental and Occupational Health) / Senior Health
Inspector in-charge of Public Health Unit
Hospital Nursing Matron
Head of Assistant Medical Officer
Hospital Support Services Concessionaire Manager
Nursing Matrons/ Sisters of specific clinical areas (e.g. Critical care areas) when deemed necessary
Head of Dietetics (when deemed necessary)
Central Sterile Supplies Department (CSSD) Manager
Operation Theatre Nursing Matron/ Sister (when deemed necessary)
Financial Manager (when deemed necessary)

Figure 3 : Organisation chart of Hospital Infection and Antibiotic Control Committee

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Policies and Procedures on Infection Prevention and Control HCTM

4.0 : INFECTION CONTROL UNIT/TEAM
1. Infection Control Unit HCTM consists of :
a. Head of Unit
b. Deputy Head of Unit
c. Medical Officer
d. Science Officer
e. Nursing Sister
f. Infection Control Nurse (ICN) / personnel
g. Medical Laboratory Technologist (MLT)

2. The Head of Infection Control Unit HCTM is a clinician/microbiologist appointed by the hospital
director.

3. The numbers of full time ICN should be adequate to cover the hospital beds in the ratio of 1:110
in accordance with MOH norm.

Duties and responsibilities of the Infection Control Team Members
(Head of IC unit/team and Infection Control Nurse/Personnel)

Clinical Duties and Administrative
Surveillance responsibilities of Education
Infection Control Unit

members

Coordination/ organisation of Research and quality
infection control activities improvement activities

4.1 Clinical duties
● Work together with other HIACC and IC members.

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Policies and Procedures on Infection Prevention and Control HCTM

● Monitor and provide advice regarding policies related to infection prevention and control.
● Act as the source of expertise to give clinical advice and support to HCW in accordance with

infection control issues.
● Ascertain the clinical significance of MDROs laboratory results or an outbreak possibility.
● Advise and support HCW and other related external agencies on clinical matters.
● Provide a platform for guidance and support to the infection control link nurse (ICLN).

4.2 Surveillance

● Responsible for facilitating the hospital surveillance activities.
● Gather relevant information pertaining to infection and antibiotic control such as HCAI point

prevalence studies, antibiotics audits, hand hygiene audits etc.

4.3 Coordination/ organisation of infection control activities

● Potential infectious threats need to be recognised and advise the relevant personnel regarding
appropriate remedial actions to be taken.

● Identify, investigate and take immediate action and control measures during outbreaks of infection.
● Work closely with the Infection Control Team and clinicians to monitor critical care units routinely.

4.4 Administrative

● Involve in the development and implementation of policies related to infection control.
● Supervise compliance with infection control policies as well as audit activities.
● Prepare relevant reports on time

4.5 Education

● Participate in education and training programmes for all HCW.
● Read appropriate literature and join relevant courses, seminars, meetings and exhibitions to keep

updated with the latest advances.
● Provide advice to the relevant personnel regarding microbiological hazards in occupational health

safety and related infection control issues.
● Involve and facilitate educational campaigns in accordance with infection control.

4.6 Research and quality improvement activities

● Join research projects in accordance with hospital infection.
● Provide a platform for clinical audit/quality improvement projects related to infection control

activities and its effectiveness needs to be evaluated.

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Policies and Procedures on Infection Prevention and Control HCTM

5.0 : INFECTION CONTROL LINK NURSE (ICLN)
● The ICLN is a well experienced nurse with adequate knowledge preferably in infection control, who
is appointed in each ward.
● The link nurse role is alongside other ward duties.
● The link nurse will be a liaison between the HCWs in the ward and the Infection Control Unit
regarding infection control matters/issues.

Duties and responsibilities of ICLN

Clinical Surveillance

Duties and
responsibilities

of Infection
Control Link
Nurse (ICLN)

Education

5.1 Clinical duties
Monitor the practices in infection control standards as following :
● Ensure hand hygiene compliance in the ward
● Ensure aseptic technique is being followed.
● Ensure PPE compliance in respective wards.

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Policies and Procedures on Infection Prevention and Control HCTM

● Proper cleansing, disinfection and sterilisation in accordance with standard procedures.
● Proper sterile instruments and linen storage.
● Proper specimens collection and dispatch.
● Proper healthcare waste segregation and disposal.
● Isolation of patients according to the relevant transmission-based precautions.
● Provide input on immediate sharp injuries and mucosal exposure management.

5.2 Surveillance

● Involve in national surveillance and audit activities.
● Assist to prevent and report MDRO, HCAI, sharp injuries and mucosal exposures among HCWs.
● Assist in outbreak notification.

5.3 Education

● ICLN will be a resource staff and provide input on infection control matters.
● Disseminate, educate and increase awareness among HCWs in respective wards regarding

infection control.

6.0 : EDUCATION AND TRAINING

1. Specific education and training on infection prevention and control policies and procedures
should be provided for all healthcare workers (HCWs).

2. The purpose of the infection control training is to educate and advise HCWs on :

a. The infectious hazards at work
b. Their role in reducing the transmission of infection to others
c. Hand hygiene

IPC education and training components

Role of hospital Director Education and Role of all HCWs
training
Role of HIACC Training programmes
components to encompass
Role of Infection Control
professionals 27 Infection Control
protocols

Education strategies

Policies and Procedures on Infection Prevention and Control HCTM

6.1 Roles of hospital personnels

Profession Role
Hospital director
● Orientation on the importance of infection control
Hospital Infection and Antibiotic programmes should be given to health administrators.
Control Committee (HIACC)
● As instructed by the Hospital Infection and Antibiotic
Infection control professionals Control Committee (HIACC), health administrators
(Infection Control Nurse, should provide a platform to train HCWs on good
Infection Control practices of infection control, but not limited to requisite
Doctor/Coordinator, Ward Link knowledge.
Nurse)
● Training requirements of all staff need to be evaluated
and relevant training can be done through:
o awareness programmes
o in-service education
o on-the-job training

● Ensure that regular education and training
programmes are available for the staff in accordance
with essential infection control standards that suit their
duties/ job description, but not limited to requisite
knowledge.

● Organize periodic re-training or orientation of staff and
the impact of training should be evaluated.

● Involve in training programmes for all HCW.
● Read appropriate literature and join relevant courses,

seminars, meetings and exhibitions to keep updated
with the latest advances.
● Provide advice to the staff regarding microbiological
hazards in occupational health safety
● Join and facilitate educational campaigns related to
infection control as advised by HIACC
● Disseminate, educate and create awareness among
new HCWs/students in the wards in accordance with
infection control

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Policies and Procedures on Infection Prevention and Control HCTM

● Provide education on infection control to patients and
visitors, especially high risk groups in order to create
awareness.

Health Care Workers ● Well prepared with requisite knowledge and skills on
good practices of infection control.

● Attend training programmes on infection control.

6.2 Training programmes to encompass Infection Control Protocols

1. All hospital staff from clinical and non-clinical settings must be given education, but not limited to
requisite knowledge on infection control protocol such as :
a. Transmission modes of infectious agents
b. Risk identification, assessment and management strategies including transmission-based
precautions
c. Physical work environment orientation, especially its infectious hazards
d. Procedures of safe work
e. Proper standard precautions practices
f. Correct PPE choice and use, with good techniques of donning and doffing as well as
respirators fit test
g. Suitable attire
h. Practices of hand hygiene
i. Requirements of cleaning, disinfection and sterilization in clinical areas and equipment
j. Spills management
k. Safe sharps management
l. Sharp injuries and mucosal exposures reporting
m. Management of waste
n. Policy and practice of antibiotics

2. This knowledge should be kept updated and included in the orientation of staff which is alongside
their duties.

3. Job or task-specific education and training is also important to be provided during orientation and
annual courses before working in hazardous areas, including :
a. PPE usage
b. Test of instrument cleaning and sterilization competency
c. Central and peripheral lines insertion and management
d. MDRO transmission risks and its prevention

4. Competency assessment in infection prevention and control practices should be carried out for
HCWs.

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Policies and Procedures on Infection Prevention and Control HCTM

5. Thus, active participation in education programmes needs to be maintained on a regular basis.
6.3 Education strategies

1. Education strategies refer to effective plannings to encourage HCWs in participating various
educational programmes, such as :
a. Educational meetings
i. Didactic - lecture, presentation, seminar
ii. Interactive - workshop with role play, case discussion, problem based learning
b. Educational materials
i. Printed
ii. Audiovisual
c. Educational outreach, involving a visiting infection prevention and control expert
d. Continuing medical education
e. Multifaceted, tailored interventions
f. Interprofessional education
g. Simulation exercise

2. Education programmes can be included in :
a. Orientation programs of staff
b. Credentialing packages
c. Annual training and competency testing
d. Training of policy and procedures
e. ICLN workshop

3. All staff can contact the Infection Control Team regarding education activities at respective
departments/units

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Policies and Procedures on Infection Prevention and Control HCTM

SECTION B : FUNDAMENTAL PRINCIPLES OF INFECTION PREVENTION

CHAPTER 1.0 : HEALTHCARE ASSOCIATED INFECTION (HCAI) SURVEILLANCE

Introduction

Surveillance is one of the most important components of an effective infection control program. It is defined
as the systematic collection, analysis, interpretation, and dissemination of data of HCAIs in a definite
patient population.

Purpose of Surveillance
1. To establish and maintain a database describing endemic rates of HCAIs. Once endemic rates are

known then the occurrence of an epidemic can be detected when infection rates exceed baseline
values.
2. To identify trends manifested over a period, such as shifts in microbial pathogen spectrum, infection
rates, etc.
3. To provide continuous observation of HCAI cases for the purpose of prevention and control.
4. To obtain useful information for establishing priorities for infection control activities.
5. To quantitatively evaluate control measures’ effectiveness for a definite hospital population.
6. To enhance the role and authority of the infection control team in the hospital through participation in
ward rounds, consultations and education of healthcare worker.

Main Components of Surveillance System
Definition of HCAI
Healthcare associated infections are infections that patients acquire 48 or more hours after admission
during the course of receiving treatment for other conditions within a healthcare setting (CDC).

Case Definition
Each case definition must be standardised and consistent. The case definition used nationwide will be that
of CDC definitions.
(Refer to ‘Definitions of HCAI’ developed by CDC).

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Policies and Procedures on Infection Prevention and Control HCTM

Types of Surveillance
a) Surveillance and reporting (outcome)
• Healthcare Associated Infections (HCAI)
• Healthcare Associated Blood Stream Infection (HA-BSI)
• Healthcare Associated Multi Drug Resistance Organism (HA-MDRO) and Methicillin
Resistant Staphylococcus aureus Bacteraemia (MRSAB)
b) Surveillance and reporting (procedure)
• Hand Hygiene
• Central Venous Catheter Care Bundle Compliance Surveillance
• Urinary Catheter Care Bundle Surveillance
c) Audit
• Infection Prevention And Control Audit
• Hand hygiene self-assessment framework
d) Other surveillances
• Hospital Surveillances
• Targeted / “High risk” patients

Healthcare Associated Infections (HCAI)
The prevalence of hospital infections in Malaysia is being observed through the healthcare associated
infections (HCAI) surveillance program. The HCAI is determined through a one day hospital wide Point
Prevalence Survey (PPS) which is conducted twice a year involving 21 MOH hospitals and 3 university
hospitals.

The common types of infections surveyed in this programme are urinary tract infection (UTI), surgical site
infection (SSI), pneumonia, blood stream infection (BSI) and clinical sepsis.

(Refer to Manual Point Prevalence Survey for Healthcare Associated Infection & Antibiotics, 3rd Edition
2019)

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Policies and Procedures on Infection Prevention and Control HCTM

Primary Healthcare Associated Bloodstream Infection (HABSI)
Primary Healthcare Associated bloodstream infection (HABSI) represents about 15% of all nosocomial
infections and affects approximately 1% of all hospitalised patients, with an incidence rate of 5 per 1,000
central-line days. Approximately 90% of primary BSIs occur in patients with intravascular devices,
especially central lines.

BSI increases the mortality rate, prolongs patient stay in the hospital and generates substantial extra costs.
For these reasons, surveillance and prevention of BSI are high priorities. One month- period prevalence
survey is conducted twice a year nationwide.

(Refer to Manual PPS for HA-BSI 2nd edition (2015) for methodology, case definition and data
management for surveillance)

Healthcare Associated Multi Drug Resistance Organism (HAMDRO) and Methicillin Resistant
Staphylococcus aureus Bactereamia (MRSAB)
Multidrug resistance organism surveillance is the continuous active laboratory based monitoring of the
incidence of specified organisms such as Methicillin Resistant Staphylococcus aureus, ESBL- Escherichia
coli, ESBL Klebsiella pneumoniae, MDR Acinetobacter baumannii , Carbapenem Resistant
Enterobacteriaceae and Vancomycin Resistant Enterococcus . All laboratories shall use a standard
definition for identification and reporting of these organisms. This surveillance program measures both
healthcare associated infection and colonisation attributed to the organism of interest.

(Refer to Manual for MDRO & MRSAB surveillance 2nd edition (2017) for methodology, case definition
and data management for surveillance)

Hand Hygiene (HH)
Hand hygiene is considered to be the primary measures necessary for reducing HCAI. “Save lives clean
your hand” campaign launched by WHO in 2009 focuses on 5 moments for HH to protect HCW, patient
and healthcare environment against the spread of pathogens thus reducing HCAI. Although the action of
HH is simple, the lack of compliance among HCW continues to be a problem. Evaluation of HH practices
is one of the important elements to improve HH compliance. One way of evaluating the practice is by doing
audit. HH compliance audit is performed according to requirement by MOH.

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Policies and Procedures on Infection Prevention and Control HCTM

Central Venous Catheter (CVC) Care Bundle Compliance Surveillance

Central Line Associated Blood Stream Infection (CLABSI) is an important healthcare associated infection
in hospitals which cause high mortality and morbidity rates as well as increased healthcare costs. CVC
care bundle has been proven to be effective in reducing the rate of infections.

Care bundles are described as groups of best practices with respect to a disease process that individually
improves care but when applied together result in substantially greater improvement.

CVC care bundle consists of:
• Hand hygiene
• Maximal barrier precaution upon insertion
• Chlorhexidine skin antisepsis
• Optimal catheter site selection
• Daily review of line

One month- period prevalence survey is conducted according to requirement by MOH.

(Refer to Central Venous Catheter Care Bundle Compliance Surveillance manual (2016) for methodology,
definitions and data management)

Urinary Catheter Care Bundle Surveillance

Urinary tract infection (UTI) is among the common types of HCAI and about 75% are associated with a
urinary catheter. The most important risk factor for developing a catheter associated urinary tract infection
(CAUTI) is prolonged use of the urinary catheter. Thus, catheters should only be used for appropriate
indications and removed as soon as they are no longer needed.

Use of CAUTI bundle has been demonstrated to reduce the rate of UTI. Urinary Catheter Care Bundle
consists of:

• Indication for indwelling catheter
• Sterile technique for catheter insertion
• Maintain a sterile closed drainage system
• Position drainage bag below the level of the bladder at all times, including during transport
• Secure indwelling catheter to prevent movement and urethral traction
• Daily review for indication of continuation

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Policies and Procedures on Infection Prevention and Control HCTM

Hand Hygiene Self-Assessment Framework
This is a tool developed by WHO to analyse hand hygiene promotions and practices within an individual
healthcare facility. It reflects existing resources and achievements thus helps to focus on future plans and
challenges.

The framework consists of 5 components namely system change, training and education, evaluation and
feedback, reminder in workplace and institutional safety climate for hand hygiene. There are 27 indicators
representing key elements for each component. Each indicator is formulated as questions with defined
answers. Each answer is assigned a certain score. Based on the score achieved for 5 components, the
facility is assigned to one of four levels of hand hygiene promotion and practice: inadequate, basic,
intermediate and advanced.

(Refer WHO Hand Hygiene Self-Assessment Framework 2010 for a complete description on how to use
the assessment tool, scoring and interpretation)

Hospital Surveillances
Choice of types of surveillance depends on the requirements of the individual hospital and must be agreed
by the Hospital Infection and Antibiotic Control Committee members.
Example: SSI- surgical site infection by Surgical department

Targeted Patients in Special and Critical Care Area
The focus in this type of epidemiological surveillance is on patients at increased risk of nosocomial
infections (e.g. post-surgical patients, ICU patients, and patients receiving mechanical ventilation). The
denominator of the incidence rate formula should contain only data on patients belonging to the targeted
group. Infection risk indices can and must be used.

This study permits concentration of effort on areas where infection control measures may have the greatest
effect and better use of limited resources; taking into account differences in infection risk for different
patient populations. However, this study may miss clusters or outbreaks of infections not included in the
surveillance program.

Example: BSI, CVC care bundle in critical care (ICU, NICU & hospital dialysis centre)

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Policies and Procedures on Infection Prevention and Control HCTM

HCAI Surveillance List in HCTM

No Surveillance

1 Carbapenem Resistance Enterobacteriacae
(CRE) Surveillance

2 Point Prevalence Survey on Healthcare Associated Infection
( HCAI ) & Antibiotics Surveillance

3 Multidrug Resistance Organism ( MDRO ) dan Methicillin Resistant Staphylococcus
aureus

Bacteremia ( MRSAB ) Surveillance
4 National Hand Hygiene Compliance Surveillance

5 Infection Prevention and Control ( IPC ) Audit
6 Personal Protective Equipment

( PPE ) Doffing Practices Audit
7 Hand Hygiene Self – Assessment Framework

( HHSAF )

8 Healthcare Associated Covid-19 ( HA COVID-19) Infection Surveillance

9 Surgical Site Infection Surveillance
(Surgery )

10 Surgical Site Infection Surveillance
( O&G )

11 Sharp Injuries & Mucosal Exposure Management
( Refer OSHA HCTM )

12 Central Venous Catheter Care Bundle ( CVC ) Surveillance

13 Period Prevalence Survey on Healthcare Associated Blood Stream Infection ( HA-BSI)
Surveillance.

14 Catheter Associated UrInary Tract Infection
( CAUTI ) Surveillance

15 Ventilated Associated Pneumonia
( VAP ) Surveillance

16 Vaccination & Blood Taking Programme for HCTM staff
( Refer OSHA HCTM )

17 TB Contact Tracing Management for HCTM Staff & Student
( Refer OSHA HCTM )

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Policies and Procedures on Infection Prevention and Control HCTM

CHAPTER 2.0 : STANDARD PRECAUTION BUNDLES

CHAPTER 2.1 HAND HYGIENE
Hand Hygiene
Hand Hygiene is a general term used to describe cleaning hands by using soap and water, antiseptic wash
or by using an alcohol-based hand rub (ABHR) solution. Hand Hygiene is considered to be the single most
important way to stop the spread of germs.
Performing Hand Hygiene
Hand hygiene ideally should be carried out at the point of care. The point of care represents the time and
place at which there is the highest likelihood of transmission of infection via healthcare staff, whose hands
act as mediators in the transfer of microorganisms. In the hospital, the environment is usually at the
patient’s bed, but in the other context it could be in a treatment room, cot, chair, ambulance or a patient’s
home.
An alcohol-based hand rub (ABHR) is the preferred method for cleaning the hands when they are not
visibly dirty.
Perform hand washing with plain or antimicrobial soap and water if hands are visibly soiled or dirty. Caring
for a patient with suspected or known gastrointestinal infection or a spore forming organism.
Liquid soap from reusable containers must be cleaned regularly every 24 hours and dried before refilling
with fresh soap to avoid microbial contamination. If the liquid soap reaches a minimum level, it needs to be
changed and cleaned despite less than 24 hours.
Bar soap is not recommended as they can easily become contaminated. Gloves should not be regarded
as a substitute for hand hygiene. An alcoholic rub or hand wash should be performed after removing gloves
and before sterile gloves are worn.
Proper technique for decontamination of hands is probably of greater importance than the agent used.

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Policies and Procedures on Infection Prevention and Control HCTM

Before performing hand hygiene:
● Expose forearms
● Remove all hand/wrist jewellery, watches
● Ensure finger nails are clean, short and artificial nail or nail products are not worn
● Cover all cuts or abrasions with water proof dressing

See figures for the technique of Hand Hygiene.

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Policies and Procedures on Infection Prevention and Control HCTM

*For the procedure involving the wrist (e.g palpation of the abdomen), additional step on rotational rubbing
of right wrist clapsed in left palm and vice versa should be included

Five (5) moments in Hand Hygiene:

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Policies and Procedures on Infection Prevention and Control HCTM

Surgical Scrub
1. Remove rings, wrist-watch, and bracelets before beginning the surgical hand preparation.
2. When performing surgical hand antisepsis using an antimicrobial soap, long scrub times are not

necessary. Recommended duration is 2-3 minutes but not exceeding 6 minutes and should include
wrists and forearms.
3. If hands are visibly soiled, wash hands with plain soap before surgical hand scrub.
Sterile disposable or auto-clavable nailbrushes may be used to clean the fingernails only, but not to scrub
the hands. A brush should only be used for the first scrub of the day. (Refer to Operating Room
Guidelines)

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Policies and Procedures on Infection Prevention and Control HCTM

CHAPTER 2.2 PERSONAL PROTECTIVE EQUIPMENT
Introduction
Personal protective equipment (PPE) refers to protective clothing, head cover, gloves, face shields,
goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or
the spread of infection or illness.

PPE is commonly used in health care settings such as hospitals, doctor's offices and clinical labs. When
used properly, PPE acts as a barrier between infectious materials such as viral and bacterial contaminants
and your skin, mouth, nose, or eyes (mucous membranes). The barrier has the potential to block
transmission of contaminants from blood, body fluids, or respiratory secretions. PPE may also protect
patients who are at high risk for contracting infections through a surgical procedure or who have a medical
condition, such as, an immunodeficiency, from being exposed to substances or potentially infectious
material brought in by visitors and healthcare workers. When used properly and with other infection control
practices such as hand-washing, using alcohol-based hand sanitizers, and covering coughs and sneezes,
it minimizes the spread of infection from one person to another. Effective use of PPE includes properly
removing and disposing of contaminated PPE to prevent exposing both the wearer and other people to
infection.
When selecting PPE, three key things need to be considered:

● Type of anticipated exposure.
This is determined by the type of anticipated exposure, such as touch, splashes or sprays, or large
volumes of blood or body fluids that might penetrate the clothing and by the category of isolation
precautions a patient is on.

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Policies and Procedures on Infection Prevention and Control HCTM

● Durability and appropriateness of the PPE for the task.
Whether a gown or apron is more suitable. If a gown is selected, whether it needs to be fluid
resistant, fluid proof, or neither.

● Fit.
PPE must fit the individual user, and the employer should ensure that all PPE are available in sizes
appropriate for the workforce that must be protected.

All PPE should be:
● Located close to the point of use;
● Stored to prevent contamination in a clean/ dry area until required for use (expiry dates must be
adhered to);
● Single use items unless specified by the manufacturer; and
● Disposed of after use into the correct waste stream i.e. healthcare waste or domestic waste.
● Reusable PPE items, e.g. non-disposable goggles/ face shields/visors must have a
decontamination schedule with responsibility assigned

Gloves
Glove wearing by HCWs is recommended for two main reasons:

1. To prevent microorganisms which may be infecting, commensally carried, or transiently present
on HCWs’ hands from being transmitted to patients and from one patient to another; and

2. To reduce the risk of HCWs acquiring infections from patients.
3. Changed immediately after each patient and/ or following completion of a procedure or task;
4. Changed if a perforation or puncture is suspected; and
5. Appropriate for use, fit for purpose and well-fitting to avoid excessive sweating and interference

with task performance.

Limit opportunities for touch contamination by:
-Do not touch the face area or adjust PPE with contaminated gloves.
-Do not touch environmental surfaces except as necessary during patient care.

Double gloving is recommended during some Exposure Prone Procedures (EPPs) e.g. orthopaedic and
gynaecological operations or when attending major trauma incidents.

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Policies and Procedures on Infection Prevention and Control HCTM

Isolation gowns and aprons
1. Clinical and laboratory coats or jackets worn over personal clothing for comfort and/ or purposes
of identity are not considered PPE.
2. Disposable plastic aprons should be worn when there is a risk that clothing or uniform may become
exposed to blood, body fluids, secretions and excretions, with the exception of sweat.
3. Full body gowns need only be used where there is the possibility of extensive splashing of blood,
body fluids, secretions or excretions and should be fluid repellent.
4. However, when contact precautions are used to prevent transmission of an MDRO, donning of
both gown and gloves prior to room entry, regardless of the anticipated level of contact, may reduce
unanticipated contact with an MDRO in the environment.
5. The practice of routine gowning upon entrance into an intensive care or other high risk area does
not prevent colonization or infection of patients.
6. Removal of isolation gowns before leaving the patient care area is advised to prevent opportunities
for possible contamination outside the patient’s room.

Face protection: masks, goggles, face shields
1. Masks are used for three primary purposes in healthcare settings:

a) To protect health care workers from contact with infectious material from patients e.g.
respiratory secretions and sprays of blood or body fluids as defined in standard and droplet
precautions.

b) Worn by healthcare workers when engaged in procedures requiring sterile technique to
protect patients from exposure to infectious agents carried in a healthcare worker’s mouth or
nose.

c) Placed on coughing patients to limit potential dissemination of infectious respiratory
secretions from the patient to others (i.e. Respiratory Hygiene/ Cough Etiquette).

2. Two types of mask available, the surgical mask and particulate respirator (e.g. N95) used to
prevent inhalation of small particles that may contain infectious agents transmitted via the airborne
route.

3. Personal eyeglasses and contact lenses are NOT considered adequate eye protection.

4. Disposable or non-disposable face shields may be used as an alternative to goggles. As compared
with goggles, a face shield can provide protection to other facial areas in addition to the eyes.

5. Removal of a face shield, goggles and mask can be performed safely after gloves have been
removed, and hand hygiene performed. If the masks are used, then they should:
a) Be worn according to the manufacturer’s instructions.
b) The front of the mask should not be touched by hands while being worn and must be removed
by untying and handling only by the ties and never by the face-covering part which may be

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Policies and Procedures on Infection Prevention and Control HCTM

heavily contaminated with microorganisms.
c) Not be worn loosely around the neck, but be removed and discarded as clinical waste as

soon as practicable after use.

Respiratory protection
Air-purifying respirators (APRs) work by removing gasses, vapors, aerosols (droplets and solid particles),
or a combination of contaminants from the air through the use of filters, cartridges, or canisters.

1. Personal respiratory protection is required when dealing with micro- organisms that spread by
droplet and airborne route. It should be worn during the performance of aerosol-generating
procedures (e.g. intubation, bronchoscopy, suctioning) of patients with, SARS-CoV-2, SARS,
MERS-CoV infection, avian influenza, pandemic influenza and other novel respiratory syndromes.
In these instances, surgical masks are not effective protection.

2. The respirator provides protection against inhalation of very tiny (<5 microns in size) airborne
particles to the HCWs

3. Respiratory protection currently requires the use of a respirator with N95 or higher filtration – see
Table A.

4. N series respirators provide protection against non-oil-based aerosols including Mycobacterium
tuberculosis and the ‘95’ indicates that the mask material is capable of 95 % efficient filtration of
particles 0.3 m in diameter.

5. The appropriate respirator for a particular situation will depend on the environmental
contaminant(s).

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Policies and Procedures on Infection Prevention and Control HCTM

Table A : Type of respirator

Filtering Facepiece Respirator (FFR)

• Disposable
• Covers the nose and mouth
• Filters out particles such as dust, mist, and fumes
• Select from N, R, P series and 95, 99, 100 efficiency level
• Does NOT provide protection against gasses and vapours
• Fit testing required

Powered Air Purifying Respirator (PAPR)

• Can be used to protect against gasses, vapours, or

particles, if equipped with the appropriate cartridge,
canister, or filter

• Battery-powered with blower that pulls air through attached

filters or cartridges

• Provides eye protection
• Low breathing resistance
• Loose-fitting PAPR does NOT require fit testing and can be

used with facial hair

• Tight-fitting PAPR requires fit testing

N95 Filtering Facepiece Respirator Surgical mask

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Policies and Procedures on Infection Prevention and Control HCTM

Close Contact Aerosol- Generating
Procedure
SEASONAL INFLUENZA Surgical mask
N95 Filtering Facepiece
Patient with suspected or confirmed N95 Filtering Respirator (FFR) equivalent
seasonal influenza Facepiece Respirator or higher
(FFR) equivalent or
AIRBORNE PRECAUTIONS higher N95 Filtering Facepiece
Patient with suspected or Respirator (FFR) equivalent
confirmed infectious disease Surgical mask or higher
requiring airborne precautions (e.g. equivalent or higher
measles, tuberculosis) N95 Filtering Facepiece
Respirator (FFR) equivalent
DROPLET PRECAUTIONS or higher

Patient with suspected or confirmed
infectious disease requiring droplet
precautions (e.g Pertussis, Mumps)

Fit Test

1. Fit test is important to assure the expected level of protection is provided by minimizing the total amount
of contaminant leakage into the respirator.

2. It is done to verify that a respirator is both comfortable and that the size correctly fits the user. It can
be done via 2 ways:

a) Qualitative testing kit where it relies on the respirator wearer’s sense of taste and involuntary
cough (irritant smoke) to determine if there is a gap in the seal of the respirator use.

i. Usually uses OSHA accepted qualitative fit testing kit either using one of the below:
• a sweet tasting aerosol mist
• a bitter tasting aerosol mist

ii. Qualitative Fit test kit is strongly recommended to be available for user assessment at

all healthcare facilities.

b) Respiratory user seal – check (fit- check)

i. It is a procedure conducted by the respirator wearer to determine if the respirator is
properly sealed to the face.

ii. Respirator user Seal Check is performed every time the respirator is to be worn by the
user.

iii. The user check is performed as a positive and negative pressure check.
iv. A positive pressure check is when the person wearing the respirator exhales gently

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Policies and Procedures on Infection Prevention and Control HCTM

while blocking the paths for the air to escape around the face piece. A successful test
creates a slight pressure and causes the face piece to fill up but there is no leak of air
to the surrounding.
v. A negative pressure check is when the person wearing the respirator inhales sharply
while blocking the paths for the air to enter around the face piece and the respirator
collapses slightly under negative pressure.
vi. When should it be done
• Qualitative fit testing should be done everytime when there is a change in the

brand, model and size of respirator facepiece and if weight of user fluctuates or
facial/dental alterations occur. Otherwise, fit testing recommended to be
performed at least annually to ensure continued adequate fit.
• Respirator user Seal Check is performed every time the respirator is to be worn
by the user.

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Policies and Procedures on Infection Prevention and Control HCTM

CHAPTER 2.3 ENVIRONMENTAL HYGIENE

1. Policies and procedures for routine cleaning and disinfection of environmental surfaces is part of
infection prevention plan. The implementation of the cleaning and disinfection processes is either by the
HCWs or the appointed maintenance company.

2. Cleaning refers to the removal of visible soil and organic contamination from a device or environmental
surface using the physical action of scrubbing with a surfactant or detergent and water or appropriate
chemical agents.

3. Emphasis for cleaning and disinfection should be placed on surfaces that are most likely to become
contaminated with pathogens, including those in close proximity to the patient (e.g. bedrails) and
frequently touched surfaces in the patient-care environment (e.g. doorknobs).

4. Policies and procedures for cleaning and decontamination of spills of blood or other potentially infectious
materials. (Refer to Policies and Procedures on Infection Prevention and Control HCTM ; Chapter 2.4:
Management on spillage).

5. Environmental services staff should be trained and responsible for routine cleaning and disinfection of
environmental surfaces. Cleaning procedures can be periodically monitored or assessed to ensure that
they are consistently and correctly performed.

6. HCWs should follow the manufacturer’s recommendations for use of products selected for cleaning and
disinfection (e.g. amount, dilution, contact time, safe use and disposal).

7. The area coverage of the cleansing services shall include the following user areas: Medical, specialized,
general and other areas as described in the maintenance contract or agreement.

Colour coding of mop heads used in the cleansing services: The cleaning services should use the
following colour code accordingly:

WHITE OFFICE FLOOR
BLUE WARD FLOOR / CLINICS
GREEN UTILITY / SLUICE ROOM
RED BLOOD / INFECTED ISOLATION ROOM
YELLOW
TOILET

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Policies and Procedures on Infection Prevention and Control HCTM

CHAPTER 2.4 MANAGEMENT OF SPILLAGE
Management of Spillage
Management of spillage in healthcare facilities is very important. The process of spills management differs
based on the setting in which they occur and the volume of the spills.

● In patient-care areas, healthcare workers can manage small spills by cleaning with detergent
solution.

● For spills containing large amounts of blood or other body substances, workers should contain and
confine the spill by:
- removing visible organic matter with absorbent material (e.g. disposable paper towels)
- removing any broken glass or sharp material with forceps

If spillage has occurred on soft furnishings, a detergent solution can be used to clean the area thoroughly.
Do not clean soft furnishings with a disinfectant such as sodium hypochlorite. Soft furnishings can also be
wet vacuumed. Following cleaning of soft furnishings, every effort must be made to air the room to allow
drying of the furnishing before reuse.
Small spills
Remove with absorbent material, wipe with Sodium hypochlorite 1:10 or other suitable disinfectant solutions.

Large spills
Cover spillage with absorbent material, pour Sodium hypochlorite 1:10 and leave for 5-10 min. Wipe up with
absorbent material and place in a yellow bin.

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Policies and Procedures on Infection Prevention and Control HCTM

See figures for Spillage Management and Disinfectant Tablets for Spillage.

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