INFECTION PREVENTION AND CONTROL POLICY , HOSPITAL CANSELOR TUANKU MUHRIZ

Policies and Procedures on Infection Prevention and Control HCTM

Equipment and instruments/ devices
1. Disposable equipment should be used where possible (e.g., tourniquet). Where this is not
possible, use dedicated equipment.
2. Healthcare facilities should ensure that all reusable medical equipment (e.g. Blood glucose
meters and other point-of-care devices, surgical instruments, endoscopes, lifting machines) is
disinfected as per manufacture requirement.
3. If equipment must be shared between patients (e.g., automated blood pressure cuffs), ensure
the equipment has been disinfected before use on another patient.

Transfer to another health care facilities/ community long term care facilities
A. Includes

1. Admission to another hospital (Government Hospital/ private Hospitals).
2. Referral to community clinics for procedures such as wound care/ haemodialysis.
3. Referral to a long-term care facility such as nursing homes/ rehabilitation care.

B. General principles
1. When transferring patients to another health or community care setting it is vital to inform the
receiving care provider using the referral letter/ discharge summary or via phone call if the patient
has a known or suspected infection (e.g. Contact to other patients with CRE infection).
2. The staff who transports and receiving the patient should at all times adhere to Standard Precaution
practice and appropriate PPE should be worn according to the risk of transmission as outlined in
section Fundamental Principles of Infection Prevention; section B. When in contact with the patient
(before, during and after transfer).
3. Patient transport vehicles such as ambulances should be terminally cleaned before admitting
another patient.

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SECTION C: ENVIRONMENTAL HYGIENE AND SAFETY

CHAPTER 1.0 : ENVIRONMENTAL CLEANING

General Consideration
The environment in healthcare facilities should be kept dry, clean, well ventilated, and ideally exposed to
sunlight to prevent microbial multiplication and the spread of MDRO pathogens. Reducing bacterial
contamination in the environment reduces the risk for acquiring HCAI. Thus, environmental cleaning is a
fundamental principle of infection prevention in healthcare settings.

The frequency of cleaning and disinfecting individual items or surfaces in a particular area or department
depends on:

• Whether surfaces are high-touch or soiled area
• The type of activity taking place in the area
• The vulnerability of patients housed in the area; and
• The probability of contamination

Routine cleaning
General Clean: is a measure of cleanliness based on visual appearance that includes dust and dirt removal,
waste disposal and cleaning of windows and surfaces. It is the basic cleaning that takes place in ALL areas
of a health care setting.

Hospital Clean is a measure of cleanliness routinely maintained in care areas of the health care setting.
Hospital Clean is 'Hotel Clean' with the addition of disinfection, increased frequency of cleaning, auditing and
other infection control measures in client/patient/resident care areas.
Education and training of both managers and staff undertaking environmental cleaning should be clearly
defined in written policies and evaluated regularly using checklists during inspection.
Because some microorganisms transmitted by the droplet route survive in the environment, attention should
be paid to high-touch items in the room as well as all items within the immediate vicinity of the
client/patient/resident.

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A. General Cleaning Practices for All Health Care Settings
1. Before Cleaning:
• Follow precautions signs and remove clutter before cleaning.
• Follow the manufacturer's instructions for proper dilution and contact time for cleaning and
disinfecting solutions
• Gather materials required for cleaning before entering the room
• Clean hand before enter the room

2. During Cleaning:
• Progress from the least soiled areas (low-touch) to the most soiled areas (high-touch) and from high

surfaces to low surfaces
• Remove gross soil prior to cleaning and disinfection
• Wet/damp mop prior to dry mop
• Water for mop washing shall be replaced whenever the color of water become darker or cloudy.
• Never shake mops and no ‘double-dipping’ of cloths
• Change cleaning solutions as per manufacturer’s instructions; more frequently in heavily

contaminated areas; when visibly soiled; and immediately after cleaning blood and body fluid spills
• Containers for liquid soap, cleaners/disinfectants are disposable and do not practice ‘topping up’

since it can result in contamination.
• Collect waste, handle plastic bags from the top (do not compress bags with hands)
• Clean hands on leaving the room

3. After Cleaning:
• Tools used for cleaning and disinfecting must be cleaned and dried between uses
• Launder mop heads daily; all washed mop heads must be dried thoroughly before reuse
• Clean housekeeping cart and carts used to transport waste daily

B. Cleaning Methods
When a patient is discharged, the room must be cleaned and disinfected thoroughly before the next patient
comes in. Bathrooms should be cleaned last after completing cleaning of the room.

• Routine cleaning of housekeeping surfaces such (as floor) with detergents is sufficient in most
circumstances. In case of outbreaks, especially when due to resistant microorganisms known to
harbor in the environment, additional cleaning with a disinfection solution may be indicated

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• Non-critical equipment in health care settings should only be cleaned with water and detergent or a
low-level disinfectant. For electronic equipment, manufacturer’s cleaning and maintenance
instructions must be followed.

• Products used for cleaning and disinfecting in NICUs must not be toxic to infants
• In operating rooms, environmental cleaning must be performed with a regular documented cleaning

schedule.
• Each hemodialysis station must be treated as an individual entity. After each hemodialysis, sufficient

time between patients must be allocated for adequate cleaning.

Cleaning and disinfection practices for patients on additional precautions/terminal cleaning
In addition to routine cleaning, additional cleaning practices and/or the use of personal protective equipment
for cleaning may be required in health care settings under special circumstances.

Terminal Cleaning
A terminal clean is defined as “a procedure required to ensure that an area has been cleaned/decontaminated
following discharge/transfer of a patient with an infection (i.e. MDROs or communicable disease) in order to
ensure a safe environment for the next patient.

1. Before entering the room, cleaning equipment should be assembled before applying PPE.
2. PPE must be removed, placed in an appropriate receptacle and hands cleaned before moving to

another room or task.
3. PPE must not be worn or taken outside the patient room or bed space.
4. Protocols for cleaning must include cleaning of portable carts or built- in holders for equipment.
5. The room should be decontaminated from the highest to the lowest point and from the least

contaminated to the most contaminated.
6. Remove curtains and placed in red linen bag with alginate plastic after patient is discharge.
7. Use disinfectants such as sodium hypochlorite. The surface being decontaminated must be free from

organic soil.

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Cleaning Rooms on Contact Precautions
Cleaning patient rooms when an individual is on Contact Precautions requires the addition of PPE, as noted
on the sign outside the room, as well as some extra procedures for patients with VRE, C. difficile or
norvovirus.
All staff entering a room on Contact Precautions must put on a gown and gloves on entering the room, and
must remove them and perform hand hygiene on leaving the room. Sufficient time must be allowed for
cleaning and disinfection of rooms of patients on Contact Precautions, particularly for C. difficile or norovirus.

A. Contact Precautions - Clostridium difficile
1. Strict adherence to hand hygiene that include hand washing.
2. C.difficile spores are only killed by sporicidal agents. The following sporicides have shown activity
against C. difficile spores:
• Sodium hypochlorite (1000 parts per million - ppm)
• Accelerated hydrogen peroxide (4.5%)
• Peracetic acid (1.6%)

B. Contact Precautions – Norovirus
Cleaning regimens for norovirus should include:

1. Prompt cleaning of emesis and faeces, including items in the immediate vicinity, followed by
disinfection with an appropriate virucidal disinfectant;

2. Increased frequency of bathroom and toilet cleaning and disinfection on affected units;
3. Strict adherence to hand hygiene.

Cleaning Rooms on Droplet Precautions
A. Routine Cleaning – refer to Routine cleaning notes
B. Terminal Cleaning – refer to Terminal cleaning notes

Cleaning Rooms on Airborne Precautions
Housekeeping staff entering a room on Airborne Precautions for tuberculosis must wear a fit-tested and seal
checked N95 respirator. The door must be kept closed even if the patient is not in the room.

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A. Routine Cleaning - refer to Routine cleaning notes
B. Terminal Cleaning - refer to Terminal cleaning notes

The following additional measures must be taken:
• After patient transfer or discharge, the door must be kept closed and the Airborne Precautions sign
must remain on the door until sufficient time has elapsed to allow removal of airborne
• If the room is urgently needed before the air has been sufficiently cleared of tubercle bacilli, an N95
respirator must be worn during cleaning
• Remove N95 respirator only after leaving room and door has been closed.

Basins for handwashing
Handwash basin is required in each treatment room. The basin should be close to where clinical procedures
are carried out.
Features:

• Large enough and with curved sides to contain and reduce splashes.
• Taps should enable the user to turn them off without contaminating hands i.e. elbow operated.
• The tap outflow should not point directly into the basin outlet to avoid splashing and avoid overflows.
• Basins should be sealed to the wall and allow effective cleaning.
• Walls behind basin and around taps should be protected with a waterproof material to prevent

damage and allow easy cleaning.
• Hand decontamination agents should be wall mounted at an appropriate height near the sink.
• Liquid dispensers must not be refillable
• Paper towels should be available for hand drying.
• A separate foot operated waste bin must be sited by each basin. Open waste bins are not acceptable.

Terminal cleaning/Decontamination of ambulance
To refer General Cleaning Practices for All Health Care Settings

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CHAPTER 2.0 : OPERATION THEATER COMMISSIONING

Introduction
1. Surgical site infections (SSI) are among the most common healthcare-associated infections and lead to

prolonged hospitalization, increased intensive care treatments and hospital readmissions, and higher
mortality.

2. Environmental monitoring aims to assess the level of contamination in an operating theatre. It helps verify
whether the heating, ventilation, and air conditioning (HVAC) system works properly and ensure that the
healthcare personnel adopt the correct behaviors, and assesses the effectiveness of the sanitation
processes.

3. Most surgical site infections (SSI) are endogenous in origin. Exogenous sources of infections are controlled
with the application of appropriate practices and a controlled ventilation system. Sources of infection include:
• the patient
• the operating room staff, from skin scales, expired air, hair, sweats etc.
• the surgical instruments
• clothing worn by operating room staff
• the room and equipment used in the room
• air supplied to the room

4. Microbiology air sampling of operation theater should also be done either as part of an investigation into
theatre-acquired infection.

Engineering Compliance
1. The commissioning test of a new or recently renovated operating theater should include:

• Air quality - air changes rate, air supply rate, ventilation system, air particle count
• Workmanship - joint sealing, gaps around doors
• System - temperature, humidity, pressure

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Recommended specification for Operating Theatre

2. The direction of air flow between rooms in a theater suite is used to ensure that there is no backflow of air
from dirty rooms or from contaminated areas in the hospital.
• Smoke test - Air flow from sterile to clean to dirty area
3. Air particle count - as per required
• Use Air Particle Counter
• Finding based on ISO Standard as per required

Planning for Infection Control Commissioning/Re-commissioning
1. Send written request to perform commissioning to Infection Control Unit.
2. Air sampling conducted when:

• all new and refurbished work has been completed.
• all engineering commissioning procedures have been completed.
• check the theater to ensure it is visibly clean and free of dust.
• full clean of all surfaces must be completed 3 times using disinfectant with sufficient time for

surface to dry in between each cleaning.
• full clean of equipment surfaces using disinfectant at least once.
• the ventilation system has been running continuously for 24 hours.
• leave the OT empty with the doors closed.
• the OT must not be use during this time and no one allowed to come in during the sampling

processes.

3
Es Establish information on OT conditions from engineering department regarding the particulars below:

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• temperature in the OT and related adjacent rooms.
• humidity in the OT room.
• pressure differentials between the rooms
• air changes within each OT.
• air particle count in the OT.

Air Sampling Procedure

1. Preparation
• Prepare the air sampler before the procedure:
• Fully charged the battery
• Get the sieve cap autoclaved a day before the process
• Order the required number of culture places required for sampling process (TSA/ NA)
• Change into clean OT attire.
• Carry out hand hygiene and clean the air sampling machine as per the manufacturer’s
instructions.

2. Sampling Method
• Place the air sampling machine on a hard surface of the operating table (approximately 1m above
floor level), or on a clean dressing trolley, in the center of the OT or at other locations.
• Only one staff shall set up the air sampler in the OT to minimize dispersion contamination.
• Remove the sampling head cover holding only the external edge – do not touch the perforated
surfaces or inside surfaces.
• Remove the lid of the agar plate and using aseptic technique, place the culture plate into the air
sampler.
• Set the timing or air sampler to 10 minutes to sample optimally a volume of 1,000 liters of air.
The sample volume should not be less than 250 liters of air and not more than 1,000 liters as it
will cause the agar to dry off.
• Exit the OT; the ten minute air sampling cycle will begin once the delayed start countdown has
passed.
• All doors must be closed and keep the OT empty until sampling is completed.
• After the ten minute cycle, re-enter the room to remove the agar plate and seal with its protective
lid.
• Label the agar plate with an indelible marker, on the outer casing of the bottom of the plate, with
the date and theater site.
• Once completed, immediately send all plates in a closed carrier container to the Infection Control
Laboratory.

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3. Results and interpretation
a) Incubate the plates at 370C for 48 hours.
b) Inspect the plates after 48 hours and count the colonies grown on each plate, note on the

worksheet.
c) Aerobic cultures on non-selective media should not exceed 10 cfu/m³ for newly built or upgraded

operation room and 35 cfu/m³ for existing operation room.
d) Fungal cultures may be indicated in some circumstances where fungal contamination was

suspected. They are not done routinely for OT commissioning.

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CHAPTER 3.0 : INFECTION CONTROL DURING RENOVATION AND CONSTRUCTION

General information
The construction activities include new construction projects and major demolition of buildings. These
activities create a lot of dust which may carry fungal spores. Moderate levels of dust may be associated with
activities such as sanding of walls prior to painting, construction of new walls and major cabling activities.
Inspection and noninvasive activities such as removal of ceiling board for visual inspection, painting and
minor plumbing works are low risk activities that generally cause minor generation of dusts.

Preliminary consideration
The three major topics to consider before initiating any construction or repair activity are as follows:

a) Design and function of the new structure or area,
b) Assessment of environmental risks for airborne disease and opportunities for prevention, and
c) Measures to contain dust and moisture during construction or repairs.

Pre-construction and renovation consultation should be carried out in advance between all the stakeholders,
including hospital management, infection control unit, risk management unit, safety and health unit, security
unit and engineers team and the contractor. This will help to identify the scope and nature of work and also
to assess the degree of risks and potential patient groups that may be affected.

Procedures to contain or minimize dispersal of dust are necessary during construction activities. Examples
include physical partitioning, rerouting of human traffic away from work areas, wet mopping and door mat
placement at entrance, prompt debris removal, blocking and sealing of air vents where appropriate.

Infection Control Risk Assessment (ICRA)
An infection-control risk assessment (ICRA) conducted before construction or renovation activities can
identify potential exposures of susceptible patients to dust and moisture and determine the need for dust and
moisture containment measures if required. The risk assessment consists of the following 3 steps;

i. Identify the type of construction project activity.
ii. Identify the patient risk groups.
iii. Match the construction activity type with the patient risk group on the construction Class Matrix to establish
the construction class.

This assessment focuses on the type and extent of the construction or repairs
in the work area. It is recommended that regular inspection be done to ensure that infection prevention and
control measures are in place during construction or renovation.
Environmental sampling
There are currently NO recommendations for routine environmental culturing

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during construction.
Air sampling is ONLY recommended for

• Commissioning of new operating rooms.
• Post renovation of operating rooms.
• Outbreak investigation if the source is likely to originate from operating rooms.
Hand-over and pre-occupation stage
It is the hospital’s responsibility to ensure that the area complies with hospital cleanliness standards for
occupation after construction completed. The hospital should thoroughly clean and decontaminate all
surfaces including walls, ceilings and windows as well as high-risk area ventilation systems, service cavities
and ceiling spaces. All this measure subject to scope of works.
Infection Control Risk Assessment
A. Matrix of precautions for construction & renovation
Step One: Identify the type of construction project activity

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Step Two: Identify the patient risk groups
If more than one risk group will be affected, select the higher risk group:

Step Three: Match the construction activity type with the patient risk group on the
Construction Class Matrix to establish the construction class.
Construction Class Matrix
Construction Project Type

Note: Infection Control approval will be required when the Construction Activity and Risk Level indicate that
Class III or Class IV control procedures are necessary.

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Description of required Infection Control Precautions by Class

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SECTION D : INFECTION CONTROL IN SPECIFIC HEALTH SETTING

CHAPTER 1.0 : GENERAL ICU

General intensive care unit
All healthcare personnel working in the Intensive Care Unit (ICU) shall observe strict infection control
measures to minimise transmission of nosocomial infection between personnel and patients or vice versa.
Information about standard precautions, transmission precautions and hand hygiene were discussed in
detail in another chapter.

Healthcare personnel and visitors

1. All healthcare personnel shall perform hand hygiene either with alcohol-based hand rub or hand
washing upon entering and leaving the unit.

2. During the era of managing aerosolised infectious respiratory disease, all healthcare personnel shall
wear masks while entering ICU. The healthcare personnel designated in ICU are to use protective
eyewear in combination with high filtration respirator, as example N95 mask, due to the risk of handling
unanticipated aerosol generating procedure such as cardiopulmonary resuscitation and emergency
tracheal intubation while on duty.

3. All healthcare personnel shall remove their clinical white coat before entering the unit. The staff nurses
and doctors designated in ICU shall change into ICU attire while working in the unit.

4. Change of footwear or using shoe’s cover upon entering ICU are not necessary.
5. Those who wear a headscarf are advised to change into a cap while on duty. The headscarf, tie or

employee ID card, if worn, shall be neatly tucked underneath either scrub, blouse or shirt. The
healthcare personnel with long hair shall neatly tie their hair with no dangling ornament upon duty.
6. Bangles, bracelets and dangling earrings are not allowed during patient care. Ear studs and flat band
rings are allowed.
7. Wrist watch and flat band ring must be removed when performing hand hygiene.
8. Long sleeves shall roll-up above the elbow when handling patients and equipment.
9. Healthcare personnel with transmittable infection are advised not to work in the unit until completely
treated. Quarantine of personnel involved or related to COVID-19 infection shall revert to the latest
guideline released by the hospital management.
10. The number of healthcare personnel during patient’s review and performing procedures shall be kept
to a minimum to minimise the risk of cross contamination and infection.
11. Visitors shall abide by the policy released by the hospital management during COVID-19 endemic.
12. Visitors shall be limited to not more than two relatives per patient at a time.
13. Visitors shall practice hand hygiene before and after visiting the patient.

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14. Visitors shall not be discouraged from direct contact as for example holding hands but must observe
transmission-based precautions whenever applicable.

Personal Protective Equipment

1. Hand hygiene cannot be replaced by wearing gloves. Comply with 5 moments of hand hygiene which
include hand wash or hand rub before touching a patient, before performing a clean or aseptic
procedure, after body fluid exposure, after touching a patient and their surroundings.

2. Perform hand hygiene before and after removing gloves.
3. Wearing sterile gloves are mandatory when performing procedures involving sterile field or sterile

areas of the body such as arterial cannulation, central venous cannulation, culture sampling, tracheal
suction, bronchoscopy, wound dressing, lumbar puncture, percutaneous tracheostomy and urinary
catheterisation.
4. Wear non-sterile gloves when touching blood, saliva, body fluids or secretions, excretions,
contaminated items or surfaces, mucous membrane and non-intact skin.
5. Change gloves when performing separate procedures, from a contaminated to a clean body site on
the same patient.
6. In patient diagnosed with aerosolised infectious respiratory disease, wear high filtration respirator mask
and protective eye wear or face shield to protect mucous membrane of the eyes, nose and mouth
during procedures as well as during patient-care activities that are likely to generate splashes or sprays
of blood, body fluids, secretions such as tracheal intubation, tracheal suction and tracheostomy.
7. Wear a plastic apron when examining patients. Wear a plastic apron and gloves when examined
patients with suspicion or confirmed multi-drug resistant infection.
8. Wear plastic apron or clean, non-sterile gown (for patients with suspicion or confirmed multi-drug
resistance infection) during procedures or patient-care activities that are likely to generate splashes or
sprays of blood, body fluids, secretions or excretions. Examples are chest physiotherapy, wound
dressing, sponging, tracheal intubation and tracheal suctioning.
9. Remove gloves, soiled gown or plastic apron promptly after patient’s examination or procedure and
perform hand hygiene after removal. Do not use the same gown, apron or gloves on the different
patients.
10. Change mask and protective eye wear if visibly soiled or after sudden direct aerosols exposure to the
face such as breathing tube or ventilator disconnection.
11. Refer table below for common procedure and recommendation for personal protective equipment.

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ICU environment

1. The ward shall be kept neat and tidy at all times.
2. Plants and flowers are not allowed in patient-care areas.
3. The cleaning schedule shall follow with adequate daily cleaning of all work areas. The cleaning duty

shall take place in order, from clean to dirty tasks.
4. Floors shall be cleaned according to the cleaning schedule or as necessary. Brooms shall not be used

in clinical areas. Use dust-retaining mops, which are specially treated or manufactured to attract and
retain dust particles.
5. Standard precaution applies in spills management. Confine and contain the spill by using paper towels
or disposable absorbent material to absorb the bulk of the blood or bodily fluid. Spills shall be cleaned
completely before the area is disinfected. Avoid aerosolisation of spilled material.
6. Clean and disinfect high touch areas including work areas, bed rails, drip stands, bedside nursing
tables, light switches, doorknobs, keyboards and computer surfaces with intermediate disinfectant at
least daily or when visibly dirty and allow air dry. Use washable keyboard covers if feasible or
alternatively cover the keyboard with ‘cling wrap’ and change it on a daily basis.
7. Sinks, hand basins, surrounding floor and wall areas shall be cleaned at least daily or as required.
8. Hand basins ideally shall be equipped with non-touch taps with anti-splash devices. Antiseptic hand
wash in non-refillable dispensers and disposable paper towels shall be readily available.
9. Portable trolley or equipment utilised for patient’s daily care or procedure must either be washed or
wiped with intermediate disinfectant before use it for another patient.
10. Intravenous tubing and feeding tube shall close with intravenous line stopcocks and feeding tube
clamp once the tubes are disconnected. Avoid entanglement or leaking of medication, nutrition or fluid
infusion lines on the patient’s bed.
11. Protect pillows and mattresses with water-proof material.
12. The bed along with its mattress shall be clean and disinfect between patients. The bed can only be
used for the next patient when it is completely dry.
13. Patients who are infected or colonised especially with potential multi-drug resistant microorganism or
aerosols-based infection shall be nursed in isolation rooms if available or cohorted in a designated
area or cubicle.
14. Clean wall, blinds, window and plastic borders in patient-care areas when visibly dusty or soiled and
when patients are discharged.
15. Curtains in patient-care areas shall change weekly and when patients are discharged. Use plastic
curtains that can be contaminated regularly on a daily basis if available and feasible.
16. Terminal disinfection must be performed when the patient is discharged. The bed, all reusable items
and equipment in the room as well as patient-care area including wall or plastic borders shall be
cleaned and then disinfected. If there is a window in the room, open the windows to air the room if
feasible. The room or patient-care area can only be used for the next admission when it is completely
dry.

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Medical instruments and equipments

1. All reusable medical items must be thoroughly decontaminated before disinfection and sterilisation to
ensure the cleaning process is effective.

2. All packaged and wrapped sterile items must be transported and stored without compromising its
integrity, sterility and avoidance of contamination. The items must not be used if the packaging is
breached and there is a possibility of contaminated items.

3. Reusable equipment must not be used for another patient until it is appropriately cleaned and/or
disinfected.

4. Each patient shall have their own bedside equipment such as stethoscope, blood pressure cuff,
thermometer and medical pen torch. If needed on another patient, the equipment shall clean with
disinfectant wipes beforehand.

5. Surfaces of physiologic monitors, ventilators and infusion pumps shall be clean at least once daily with
low to intermediate level instrument grade disinfectant and allowed to air dry. Portable medical
equipment such as ultrasound machines including its display, control knobs and transducer shall be
clean after every use with recommended manufacturer disinfectant wipes.

Respiratory equipment

1. Use only sterile water or solution for respiratory care such as suctioning, filling of humidifiers and
nebulisers.

2. If feasible, use a combination of heat-moisture exchanger with viral filter rather than water-heated
humidifier system in order to prevent risks of aerosolised infection to the healthcare personnel. If a
water-heated humidifier is used, utilise a closed system for filling of sterile water in the humidifier
chamber.

3. Change the heat-moisture exchanger and viral filter according to the manufacturer and/or when it is
visibly blocked or soiled.

4. Closed suction system for tracheal suctioning is recommended to prevent breathing tube
disconnection which poses risk of aerosolised infection to the healthcare personnel during COVID-19
endemic.

5. Change of the closed suction system is either according to the manufacturer recommendation, visibly
contaminated, blocked or when the catheter becomes flimsy and too soft for secretion suctioning.

6. Change the entire length of suction-collection tubing and canisters between use on different patients.
7. Do not routinely change the ventilator breathing circuit based on duration of use. Change the ventilator

breathing circuit when visibly soiled and in-between uses by different patients.
8. Drain and discard periodically any condensate in the circuit. Precautions not to allow the condensate

to drain towards the patient. Use a minimum number and length of tubing connector to avoid water
condensation.

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9. Temporarily increase oxygen supply to maximum and put the ventilator on standby mode during
breathing tube disconnection and drain the condensates quickly, to minimise risk of aerosolisation to
healthcare personnel. The practice of these measures only applied when managing aerosolised
infectious respiratory disease.

10. Change the oxygen delivery system including tubing, nasal prong or mask that malfunction when used
on one patient, when it becomes visibly contaminated or between uses on a different patient.

11. Use mesh nebulisation attached to the breathing tube rather than jet nebulisation to avoid aerosol
generating particles. If jet nebulisers are used, clean, disinfect, rinse with sterile water and dry
nebulisers between treatments on the same patient. Replace jet or mesh nebulisers with items that
have undergone sterilisation or high level disinfection between uses on the different patients.

12. Use only sterile solution for nebulisation and dispense the solution into the nebuliser aseptically.
Whenever possible, do not re-use nebuliser medication of an already open vial.

13. Clean and change the mouthpiece and filter of a peak flow meter as well as spirometer between uses
on the different patients.

Isolation rooms in ICU
1. Isolation facility is to control the airflow in the room so that the number of airborne infectious particles

is reduced to a level that ensures cross-infection to other people within the healthcare facility is
unlikely.
2. The design includes its own room ventilation and exhaust system which is equipped with either higher
or lower air supply and exhaust rates.
3. The provision of an anteroom in an isolation room provides adequate area for donning and doffing of
personal protective equipment. It must be provided with self-closing doors and own room hand wash
equipment.

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CHAPTER 2.0: NEONATAL ICU

Introduction
Healthcare-associated infections (HAIs) are a major cause of mortality and morbidity in the neonatal units.
Strict preventive and control measure as well as stringent surveillance of infections within the neonatal
intensive care unit (NICU) is crucial to minimize outbreaks and sporadic incidents.

Personnel

A. Employee health
I. Healthcare worker (HCW) must understand the risks of transmission of contagious diseases to
newborns and report acute infections to their immediate supervisor.
II. HCW with acute airborne infections should not be working.

III. HCW with exudative hand dermatitis, staphylococcal skin lesions, or herpetic hand lesions should
not perform direct patient care.

Varicella and Hepatitis B vaccination for non-immune staff are strongly recommended. (Refer to Policies
and Procedures on Infection Prevention and Control HCTM ; Section F: Occupational Health & Safety).

IV. HCW new to the NICU are required to test for nasal MRSA carriage.
V. Needle stick/sharps injuries must be reported immediately in accordance with hospital policy.

Education
I. All HCW should be briefed and orientated on the Infection Control Policies specific to the NICU
upon entry to the unit.
II. All HCW should attend regular in-services training on Infection Control practices i.e. hand
hygiene, sharps safety, personal protective equipment, and medical waste training etc.

Personal protective equipment
I. Use of gowns and plastic aprons are required upon entering NICU. Protective clothing should
be worn by all HCW in contact with blood, body fluids, secretions, and excretions (with the
exception of sweat), or during close contact with the patient, materials or equipment which
may lead to contamination of clothing with micro-organisms.
II. Personnel should wear a procedure gown prior to performing aseptic procedures.

III. Gloves:
• Gloves must be worn for invasive procedures, contact with sterile sites, and non-intact
skin, mucous membranes, and all activities that have been assessed as carrying a risk of
exposure to blood, body fluids, secretions and excretions; and when handling sharp or
contaminated instruments.

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• Gloves should be worn by personnel taking care of infants with respiratory viral infections
and other infectious diseases to reduce the risk of transmission.

• Gloves should be worn as single use items.
• Gloves should be changed between caring for different patients, or between different

care/ treatment activities for the same patient.
IV. Mask and eye protection/face shield must be worn to protect the mucous membranes of the

eyes, nose, and mouth during procedures that are likely to generate splashes or sprays of
blood, body fluids, secretions, and excretions. N95 mask is used instead when handling
patients with infectious respiratory diseases.
V. A closed incubator may be used in maintaining barrier precautions, however since the exterior
surfaces and entry ports are readily contaminated by micro-organisms, the exterior surface of
the incubator should always be considered contaminated.

Procedures

1. Full aseptic techniques should be observed whenever invasive techniques are performed on the
patient.

2. Blood and body fluid specimens should not be placed on the writing table where patients’ notes are
placed.

3. Care of IV lines:
• Full aseptic technique should be observed for insertion of central venous lines.
• For VLBW infants and very preterm infants (<32 weeks period of gestation), Chlorhexidine in
spirit 1:200 (0.5%) is used prior to insertion of arterial, central line and other aseptic
procedures. The Chlorhexidine should be removed with sterile water or normal saline after the
procedure to avoid dermatitis or chemical burn.
• For infants >32 weeks period of gestation, Chlorhexidine 2% with alcohol 70% is used prior to
insertion of arterial, central line and other aseptic procedures.
• Dressings are changed whenever there is contamination with blood.
• A 0.2µm in-line intravenous filter should be used for infusion of intravenous fluid and
medications except for those listed in Appendix A
• Always maintain the TPN lines in a closed system with no other Infusions running through
it. 0.2µm in-line intravenous filters should be used for infusion of amino acid/dextrose solution
and 1.2µm in-line intravenous filters used for infusion of lipid emulsion.
• In-line filters and three-way tap ports should always be clear of blood contamination and port
must be spigot if not in use.

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• IV-line tubing which is temporarily disconnected should be protected from contamination.
Injections of drugs should be given through an injection port or via a needleless connector.

• Peripheral and central intravenous lines should be removed when no longer required or if there
are signs of local inflammation.

4. Invasive devices including chest tubes, drains and urinary catheters should be removed as early as
possible to minimise risk of infection.

Hand hygiene

1. Good hand hygiene is mandatory as per standard hand hygiene procedure. (WHO Hand Rub and
Hand Wash Technique)

2. Alcohol based disinfectants are used
3. All healthcare staff will be audited on the hand hygiene practices periodically to ensure compliance

using NICU HCTM Hand Hygiene Adherence Monitoring Tool.
4. All jewelry should be removed before hand hygiene as it interferes with effective hand hygiene. Cuts

and abrasions should be covered with waterproof dressings.
5. Rings, watches, bracelets, and artificial nails should not be worn during patient care.
6. Keep natural nails clean and short, ensuring nail does not pass the end of the fingers.
7. All other HCW such as radiographers, physiotherapists and occupational therapists must perform strict

hand hygiene before and after attending to these neonates.

Newborn isolation

1. Most infections in newborns do not require special isolation precautions. General newborn care
measures will prevent transmission of most infections between newborns.

2. Infants suspected or diagnosed with infections transmitted by contact or droplets or aerosol (i.e.,
Rubella, Mumps, Pertussis, perinatal Varicella, Tuberculosis, RSV and COVID-19) may require special
precautions. These infants should be nursed in the isolation room and all HCW must don full personal
protective equipment (PPE) and adhere to strict infection control policy.

3. All patients with infection, especially multi-resistant organism infections and where airborne precaution
is not necessary, must be clearly identified. Aprons/gowns should be changed between patients.

4. Cohorting of infants may be necessary during nosocomial outbreaks.
5. Infants born outside the hospital should be admitted to the isolation room until deemed non-infectious.

Infected mother

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1. Transmission from mother to newborn usually occurs during delivery. The advisability of maternal-
infant contact will be discussed and decided on an individual basis.

2. If a mother develops a fever or infection while the infant is rooming-in, she will be evaluated by the
Pediatric Doctor and advised to refrain from continuing rooming-in until her symptoms resolves.

3. An infant of a mother with active pulmonary tuberculosis should not be separated from mother and
breastfeeding can be continued. Separation is not necessary as these infants would be commenced
on full anti-TB treatment for active TB or Isoniazid prophylaxis for latent TB. Surgical mask however,
should be provided for mother if she is still infectious.

4. A well infant of a mother who has COVID-19 infection should not be separated from mother and
breastfeeding can be continued in the postnatal ward. Surgical mask however, should be provided for
mother.

5. Postpartum separation of the mother and newborn is considered in an uninfected newborn of mother
with peripartum Varicella until maternal lesions have dried.

Newborn

A. Feeding
1. Infant should be given mother’s own milk or donor breastmilk if mother’s own milk is unavailable.
2. If infant is separated from mother, expression of breast milk is highly encouraged. Breast milk
expression can be performed using either hand expression or manual/electric breast pump.
3. Mothers should be taught appropriate hand expression technique and hygiene.
4. If own breast pump is used, mother should be taught regarding cleaning and sterilizing of
equipment and bottles.
5. In NICU, the breast pump is shared among mothers. The funnel and tubing should be changed
between patients. Used funnel and tubing should be washed in soap and water and soaked in
Germisep solution for at least 1 hour. It is then rinsed thoroughly with Sterile Water for Irrigation
and dried on a clean drying rack.
6. If milk expression is performed in NICU, clean bottles should be provided to the mothers.
7. Breast milk expressed at home should be collected and stored in special storage bags or clean,
closed containers, and kept in the refrigerator for a maximum of 48 hours or frozen for three (3)
months. (Please refer to Breast Feeding Guideline WHO/UNICEF 2009)
8. Expressed breast milk from home should be transported to the NICU in an insulated container to
maintain milk temperature. If milk has thawed upon arrival, it should not be refrozen.
9. Breastmilk shall be processed and/or pasteurized following the NICU HCTM Milk Room Standard
Operating Procedure.
10. Sterile liquid ready to feed (RTF) infant formula should be used if breastmilk is not available.

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11. Specialized infant formula reconstituted from powdered infant formula should only be used if
necessary. The reconstituted formula should be pasteurized and kept in the fridge at 4oC for no
longer than 24 hours.

12. The "hang-time" (i.e., the amount of time a formula is at room temperature in the feeding bag and
accompanying lines during enteral tube feeding) for both RTF and reconstituted powdered infant
formula should not exceed 4 hours.

13. Expressed breast milk for bolus enteral feeding that has been warmed should be discarded after
2 hours, whilst the “hang-time” for continuous infusion of pasteurized expressed breast milk should
not exceed 4 hours.

14. Continuous infusion tube feeding should be set up with the same aseptic precautions used for
intravenous fluids. Syringes of milk and tubing should be changed regularly. Orogastric tube for
enteral feeding should be replaced daily.

15. Infant feeding preparation should be performed on a sterile tray. Surface used for preparation
should be cleaned with hospital approved disinfectant before and after use.

B. Skin care
1. Maternal blood and secretions will be removed with sterile cotton sponges and sterile water once
the newborn’s temperature has stabilized. Gloves will be worn for handling of all infants until this
has been done.
2. Localized cleaning of the diaper area and other soiled areas will be carried out as needed, using
sterile water/baby wipes.
3. Whole body bathing and antiseptic soaps are not necessary for routine care but may be indicated
in outbreaks.

C. Cord care
1. The cord will be cut and tied using aseptic technique.
2. The umbilical cord stump is left to dry or may be cleaned with 70% alcohol daily.

D. Eye care
1. At delivery, the newborn’s eyes should be cleansed with sterile cotton to remove secretions and
debris.
2. Profuse purulent discharge within the first day of life should be Informed immediately to the
pediatric doctor to be treated as Gonococcal conjunctivitis until proven otherwise.

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Infant contact with parents

1. Only parents can visit the neonatal wards.
2. Instructions on appropriate hand hygiene and infection prevention measures must be provided to

all parents before handling of their infant.
3. Infants should be handled by their own parents only after proper hand hygiene.
4. Parents are not allowed to visit during sterile procedures.
5. Parents who are unwell with respiratory or diarrheal illness, will not be allowed to visit.
6. During an outbreak, including the COVID-19 pandemic, parental visit will be at the discretion of

the Neonatologist caring for the infant.

Patient care equipment

1. Disposable items are utilized as much as possible where available.
2. All infant care units are cleaned and disinfected between each use. Equipment will be labelled,

cleaned and stored ready for use.
3. Ventilator breathing circuits and tubing must not be routinely changed. Change the circuit when it

is visibly soiled.
4. Unused respiratory equipment should be allowed to remain at bed-side as stand-by for no longer

than 12 hours.
5. All infants are transferred to a clean bassinet, incubator or radiant warmer every seven days or

whenever necessary.
6. Routine daily cleaning of an occupied incubator is recommended. Use different piece of cloth for

inner and outer incubator surfaces. Clean and disinfect only the outside; only clean (neutral
detergent) on inside.
7. Clean used incubators / infant warmers according to a schedule and additionally as required. All
detachable parts should be removed and scrubbed. Portholes, cuffs and sleeves of the incubator
should be cleaned and disinfected. The incubator’s fan should be cleaned and disinfected
according to the manufacturer’s instructions. Maintain the air intake filter as recommended by the
manufacturer. Replace mattresses when the surface covering is broken.
8. Equipment assigned to a single patient such as resuscitation bags, masks, and other items in
contact with the newborn’s skin or mucous membranes should be replaced and sterilized or
receive high-level disinfection on a regular basis.
9. Sterile supplies and equipment are preferably stored according to policy (refer to storage of
Sterilized equipment and supplies).
10. Examining equipment, such as stethoscope should be reserved for use for each patient.
11. Examining equipment, such as ophthalmoscope, tendon hammer, torchlight and transilluminator,
should be disinfected with 70% alcohol in-between patients.

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Housekeeping

1. The unit should be kept clean and dust free. The ward manager/senior staff nurse is responsible
for supervising the cleaning of their areas.

2. Cleaning methods that minimise dust dispersal should be used. Cleaning and dusting of the
accessory areas (shelves and counters) will be done daily with an approved hospital
disinfectant. Phenolic solutions should not be used.

3. Where a piece of equipment is used for more than one patient, e.g., weighing scale, it must be
cleaned following each use.

4. Floors and other horizontal surfaces are cleaned daily with an approved hospital disinfectant.
5. All blood spills should be attended to immediately using spillage kit.
6. No food or drinks are allowed in patient care area.

General policies

1. Soiled linen will be handled according to hospital policy. Clean linen and gowns will be stored in closed
cabinets.

2. Needles, syringes, and sharps are disposed of (uncapped and uncut) into puncture resistant sharp
containers.

3. Staff will report promptly, all occupational injuries or infectious exposures to the hospital Occupational
Safety and Health Committee for treatment and follow-up.

***Common IV Drugs in NICU HCTM that SHOULD NOT infuse through filter
1. Ibuprofen
2. Human Albumin
3. Human Immunoglobulin (IVIG)
4. Insulin
5. Amphotericin B Lipid Complex (Ampholip) – only use the filter provided in box
6. Amphotericin B deoxycholate (Ampho B)

Note: Please check with Hospital Pharmacist if unsure

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CHAPTER 3.0: OPERATION THEATRE

Operation Theatre
This policy deals principally with Infection Control Practices in operating theatre, HCTM. The objective of
the policy is to provide safer environment for both patients and HCWs in the operating theatre.
Maintaining a safer environment in the surgical procedure area
Clean OT attire is a part of aseptic environmental control in OT. It ensures protective barrier for the patients
undergoing surgery as well as for the personnel during the surgical procedures. The OT attire is to be worn
within the OT only. One should not go outside the OT in the attire.
Specific rooms should be designated for performing surgical/ clinical procedures and for processing
instruments and other items.
It is important to control number of HCWs, traffic and activities in these areas since the number of people
and the amount of activity influence the number of microorganisms that are present and therefore influence
the risk of infection post-surgery.

Location of the operating theatre suites
In HCTM, operating theatres may be located in purpose-built units. It is separated from the main flow of
hospital traffic and from the main corridors. The operating theatre is easily accessible from ICU, surgical
wards, emergency rooms and other supporting departments.
The floor should be covered with antistatic material, and the walls painted with impervious, antistatic paint
(polyurethane paint, epoxy paint) to reduce dust levels and allows for frequent cleaning. The surfaces must
with stand frequent cleaning and decontamination with disinfectant.

Layout of the operating theatre
The operating theatre should be zoned and access to these zones should be under the control of OT
personnel.

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Aseptic and clean areas should be separated from the outer areas. Physical barriers are needed in order
to restrict access and to maintain unidirectional movement of air in converted theatre units.
There are 3 main separates zone in the operating theatre: outer zone, clean or semi restricted zone and
aseptic or restricted zone.
A. Unrestricted zone: This zone should contain main access door, an accessible area for the removal

of waste, sluice, storage for medical and surgical supplies and an entrance to the changing facilities.

B. Semi-restricted zone: This zone contains the sterile supplies store, an anesthetic room, recovery
area, scrub-up area, clean corridor and rest rooms for the staff.

Staff must change into theatre clothes, protective hair cover and shoes before entering this area, but there
is no need for a mask, gloves, or a gown. There should be unidirectional access from the above area to
the aseptic area i.e. the operating theatre, preferably via the scrub-up area. The OT should be restricted
to HCWs involved in the actual operation.
C. Restricted zone: This zone should be restricted to the working team. It includes the operating theatre

and the sterile preparation room (preparation of sterile surgical instruments and equipment).
Staff working in this area should change into theatre clothes, should wear masks and gowns and where
necessary, should wear sterile gloves.

Doors
The doors to the OT should be kept closed except for the necessary passage of the patient, personnel,
supplies and equipment.
Disrupted pressurization mixes the clean air of the OT with the corridor air, which has a higher microbial
count. Cabinet doors should remain closed.

Temperature and humidity
The temperature and humidity 70 to 75°F (18 to 22°C) with 50 to 60% relative humidity provides a
compromise between the requirements of the patients and those of the operators.

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Standard ventilation for conventional (general) operating theatres

Airborne contaminants may enter OT via the following routes through the supply air, shed by operating
staff, through surgical activities and transferred from adjacent spaces

The air flow and microbiological air quality should be assessed on commissioning, after major renovation/
repair, change of HEPA filter or outbreak of an infectious disease in the theatre or elsewhere within the
theatre suite.

For emergency and non-emergency repairs, the Infection Control Team must be notified by the manager in
charge of the theatre, at least a week in advance, so that microbiological air sampling, particle air sampling
and tests for positive pressure ventilation can be performed if deemed necessary by the team. (Refer to
Policies and Procedures on Infection Prevention and Control HCTM ; Section C: Chapter 3 : Infection
Control during Renovation and Construction)
The minimum standard for microbiological air counts for conventional (general) operating theatre is less
than 10 CFU/m3 for the newly built or totally upgraded/ refurbished (including the air conditioning system)
operating theatre. For the existing* operating theatres with space and system constraints, the minimum
microbiological air count shall be less than 35 CFU/m3 for temporary basic until the theatre is upgraded.
The reading shall be taken at about 1.0m above the floor level on top of OT Table. Both CFU/m3 readings
shall be obtained upon completion of proper cleaning carried out in accordance to the infection control
protocol and be applicable for the theatres at rest. (Please refer to Chapter on OT commissioning)

The particle count in new or upgraded OT should follow the standard on OT commissioning. (Policies and
Procedures on Infection Prevention and Control HCTM ; Section C: Chapter 2 : OT Comissioning)

Airflow should be from ceiling to floor and directed under positive pressure (15% of access air); higher in
operating room than in the corridor.

The air within the operating room should be at a positive pressure compared with other theatre suites and
with the external corridors, and should be at a minimum of 20 ACH in the theatre. (Policies and Procedures
on Infection Prevention and Control HCTM ; Section C: Chapter 2 : OT Comissioning)

All maintenance and PPM Planned preventive maintenance shall be performed following as per schedule
with Unit Prasarana.

Ultra Clean Ventilated Operation Theatre

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UCV OT is used in high risk operation such as OTs 8,9,10,11 and other operation deem appropriate. The
recommended standard parameters for ultra clean OT as per Chapter OT commissioning and OT protocol.

Ultra clean air or laminar air flow systems

• Laminar air flow is designed to move free air particle over the aseptic operating field in one direction.
It can be designed to flow vertically or horizontally and is usually combined with high efficiency
particulate air (HEPA) filters. HEPA filters remove particles >0.3 micron in diameter with an efficiency
of 99.97%.

• Ultra clean air can reduce the incidence of infection especially for high risk operations. The air from
ultra clean air or laminar flow systems used for high- risk

• surgery must be tested microbiologically annually or following major modification. Preferably, room
should be equipped with laminar air flow system with a unidirectional ventilation system in which
filtered, bacterial free air is circulated over the patient and return to receiving air inlet (HEPA filter).

The particle counts will be performed:

a) Once a year in conventional OT and ultra clean OT
b) HEPA filters are replaced once a year
c) Increased in reported OT infections
d) If any alterations or construction were done within the OT

Procedure to be followed if OT fails a Particle Count test:

I. Inform hospital administrator and engineering unit
II. Close the affected OT
III. Shut down the AHU and look for source
IV. Restart AHU and do terminal cleaning of OT
V. Suggest to re-test after 24 hours
VI. OT should not be utilised until all the measurements are within the standards recommendation
VII. Any failure in getting the particle count and to repeat the test till acceptable particle count.

Type of Air supplied to the operating theatre

1. Plenum/ Unidirectional Ventilation
This is the most frequently used system in general purpose operating theatre.

2. Laminar Flow Ventilation (Ultra Clean Ventilation)

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This system is unidirectional and delivers air flow over the operating table with and minimum of 25
ACH in the theatre.

Operating Theatre Attire

Effective barriers minimises a patient’s exposure to microorganisms that might be shed from skin, mucus
membranes or hair of surgical team members as well as protects surgical team members from infected
patients.

• The operation theatre should have specific written manual procedure for proper attire to be worn.
• Theatre attire consists of body covers (scrub suit ),hand cover, mask and footwear
• Face mask, gown and gloves are added during doing the procedure and a Scrub team will be

wearing sterile gown and glove.
• All personnel should change to new scrub suite before entering the theatre using freshly laundered

attire. All personal should practice good personal hygiene.
• Head cover is worn to protect gross contamination from hair during procedures.
• Change footwear before entering operation theatre area. Footwear should be comfortable,

supportive, able to minimize fatigue and provide personnel safety.
• A disposable 3-ply surgical mask to be worn in restricted area which is 95% efficient in filtering

microbes from droplet particles in exhalation and also filter inhalation. Fluid resistant mask is an
advantage. Change mask when necessary when wet or after it has been removed for other
purposes.
• The attire should be changed if wet or grossly soiled.

Disclaimer: Certain infectious outbreak condition extra precaution will be need in accordance to the
relevant policy.

Surgical hand scrubbing

• Performing surgical hand scrubbing following the guideline in the theatre Manual Standard
Operating procedure. All personal must be well trained to performed hand scrubbing with correct
steps, technique, and method.

• Hands and arms must be thoroughly dried before donning the sterile gown to prevent sterile
breakthrough. Dried using the correct method. Discard the towel and make sure hand must not go
below wrist level.

Further information needs, please refer to Manual Panduan perawatan Dewan Bedah.

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Gowning

• Donned the sterile gown after surgical scrub and drying of hands. Sterile gown can be reusable or
disposable.

• The gown material provides a barrier between the sterile and unsterile area enabling the personal
to come within the sterile field.

• Gowns should be as lint free as possible, free from tears or holes, fluid resistant or fluid proof.
Quality monitoring should be in place to ensure that only gowns of appropriate quality are being
used.

Further information needs, please refer to Manual Panduan Perawatan Dewan Bedah.

Gloving

• Gloves are donned after gowning. Two method of gloving is using closed method technique and
open method technique.

• The closed gloving method is put the glove without the bare skin touching the gloves and
is preferred for establishing the initial sterile field.

• The open gloving method is used when changing a glove during a surgical procedure or when
donning gloves for procedures not requiring gowns.

Further information needs, please refer to Manual Panduan Perawatan Dewan Bedah.

Draping

• Drapes serve on effective barrier to eliminates or minimises passage of microorganisms between
non -sterile and sterile areas. Draping is covering the patient and surrounding area with a sterile
barrier to create a sterile field.

• The scrub person is responsible for the instrument and equipment used and should be familiar
with the draping procedure. Once a drape is placed, it cannot be moved without contamination to
a sterile field.

• Drapes maybe reusable or disposable. Criteria of drape should be impermeable to moist
and microbial penetration to provide an effective barrier to prevent passage of microorganisms.
The drape must also lint free and anti-static to eliminate risk of spark and flame resistant.

Further information needs, please refer to Manual Panduan Perawatan Dewan Bedah

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Establishing a sterile field

• Only sterile items are used within the sterile field.
• A sterile Personal are gowned and gloved. Gowns is considered sterile from chest to level of the

sterile field in front only and 2 inches above the elbows to the cuff on the sleeves.
• Tables are sterile only at the table level. The Mayo stand must be placed over the sterile field when

covered with sterile drape. Only the top level of drape table is considered sterile.
• A sterile Personal touch only sterile items or areas and unsterile personal touch only unsterile item

and areas.

Further information needs, please refer to Manual Panduan Perawatan Dewan Bedah.

Dispensing of the sterile supplies

• All supplies should be opened as close as possible to the time that the surgical procedure is to
commence.

• The integrity of each package must be checked, and the expiry date is prior to the opening.
• Open the first flap away from yourself, the area touched fall below table level and inside of the

wrapper remains sterile.
• Peel back packages should be carefully opened to ensure proper adhesive separation and do not

slide the inner package over the edge of the peel back packages.
• The scrub nurse should take each item directly from the package held by the circulating nurse.
• Once supplies are opened they should not be left unattended. Do not covered the sterile set for

future used
• Sterile package which are dropped on the floor should be considered nonsterile and should not be

used
• Supplies that opened for a patient only used for the patient. Discard the supplies in the event of

cancellation.
• Large bundles of packages should be opened on a flat surface and not while holding in the hand.
• Solutions must be poured in a slow steady stream to avoid splashing. The scrub nurse places the

solution cups at the edge of the table, so that circulating nurse need not reach over the sterile field
to pour.

Further information needs, please refer to Manual Panduan Perawatan Dewan Bedah.

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Maintaining the sterile field

• Precautions should be taken to prevent any strike through by using water resistant materials.
• The scrub team should remain close to and face the sterile field. Any movement are between the

sterile areas. When changing positions, the scrub personnel will pass front to front or back-to-back.
Talking should be kept to a minimum.
• The unscrubbed team should remain at least one foot from the sterile field. Do not pass between
sterile areas.
• Breaks in aseptic technique should be monitored, documented and corrective action taken as soon
as possible.
• A sterile field is maintained by:

i. Placing only sterile items within the sterile field.
ii. Opening, dispensing, or transferring sterile items without contaminating them.
iii. Items located below the level of the draped are consider nonsterile.
iv. Sterile personal touch only sterile item and do not reach across nonsterile area or vice

versa.
v. Recognising any sterile barrier that has been penetrated (wet, cut or torn) is

considered contaminated.
vi. Being conscious of where your body is always and moving within or around the sterile

field in a way that maintains sterility.

Further information needs, please refer to Manual Panduan Perawatan Dewan Bedah

Management of infectious cases that requires additional precaution (e.g. TB and MDRO)

• Pre-operative management
a. Appropriate personal protective equipment should be worn when performing hazardous
procedures. And it should be disposable.
b. All infectious cases should be listed last, unless in an emergency situation. Patient to be sent
straight from ward to the operation room.
c. All infectious case should be informed to all personal involved so that the personal can be kept
to the minimum.
d. Only specifically required equipment should be kept in the operation room.
e. Additional protective face shield should be worn when receiving patient in OT to protect from
splashes especially when patients carry organisms that are transmissible via droplets (SARS,
Ebola, H5N1, Covid 19).

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f. Terminal cleansing will have to be done after each infectious case.

• Intra operative
a. Sent patient straight to OT. Use disposable items wherever possible.
b. Gentle handling during draping is required to minimise aerosol contamination of the
environment.
c. Additional protective face shield should be worn during the procedure to protect from
splashes.
d. Any operating attire to be changed as soon as possible when soiled during the procedure.
e. All the clinical waste should be thrown into the clinical waste bin and sharps to be disposed
into the sharps bin by the person handling the sharps.

• Post-operative

a. All used surgical instruments are wrapped in biohazard plastic bag and should be sent to
CSSD as soon as possible.

b. All laboratory specimens must be in clean secure containers and placed into the biohazard
specimen plastic bag before being send to pathology.

c. Any contamination to the outside of containers should be cleaned with sodium hypochlorite
1:100. Ensure the containers are tightly sealed to avoid spillage.

d. The room and all equipment should be decontaminated with sodium hypochlorite solution
1:100 and left to dry. The room can be reused once it’s dry.

Waste and linen

• Waste should always be disposed of with minimal handling because there is a risk of blood-borne
pathogen transmission.

• Body fluids should be disposed of in the sluice by staff with appropriate PPE.
• Used linen should be contained in red linen laundry bag at the point of used. Linen that is saturated

with body fluids should be placed in fluid proof bags.
• Other contaminated waste should be handled and disposed of according to the facility’s medical

waste process.

Cleaning of the operation theatre

There should be a simple, clear, cleaning policy that can be adhered to easily. The cleaning equipment for
the operating room must be dedicated and kept separate from clean zone.

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The theatre complex should be absolutely clean at all items. Dust should not accumulate at any region in
the theatre.

Soup solution is recommended for cleaning floors and other surfaces. Operating rooms are clean in
between cases (concurrent cleaning), daily (initial and terminal cleaning) and the entire theatre complex
is cleaned thoroughly once a week.

1. Initial cleaning (at the beginning of the day)
Wipe all equipment, furniture, room lights, OT table, surgical light reflectors, other light fittings, slabs and
all surfaces including wall using approved sporicidal disinfectant as per manufacturer guideline with damp
cloth and mop.

2. Concurrent cleaning (between cases)
Clean operating/procedure table and any other potentially contaminated surfaces in operating theatre
with disinfectant. Immediately clean spills of blood or other body fluids according to spillage protocol and
mop the floor using disinfectant.

3. Terminal cleaning (end of the day)
The cleaning process start from clean area to dirty area, all surfaces including wall are wipe, followed by
the equipment and lastly the operating/procedure tables approved sporicidal with damp cloth. A particular
attention to operating/procedure tables, making sure to clean the sides, base, and legs thoroughly. The
floor is clean with mop soaked in a disinfectant solution. All sharps bin are check and it will be remove and
replace if 2/3 full.

4. Weekly cleaning
All portable equipment will removed from the OR. Damp wipe lights and other fixtures with disinfectant.
Clean doors, hinges, facings, glass inserts and rinse with a cloth moistened with disinfectant. Wipe down
walls with clean cloth mop with detergent. Scrub floor using detergent and water. Stainless stell surfaces
are clean with detergent, rinse and clean with warm water. The wheel castors of replace portable
equipment are clean by rolling across toweling saturated with detergent. Wash (clean) and dry all furnitures
and equipment (OT table, suction holders, foot& sitting stools, Mayo stands, IV poles, basin stands, X-ray
view boxes, hamper stands, all tables in the room, holes to oxygen tank, kick buckets and holder, and wall
cupboards.

The floor is swept and the area is mopped with clean water. The OR will be close and allow it to dry for 1
hour. After 1 hour mop the floor with plain water with a clean mop cloth.

Further information needs, please refer to Manual Panduan Perawatan Dewan Bedah

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CHAPTER 4.0 : DENTAL PRACTICE

Introduction
In dental practice, there is a significant risk of cross infection between patients
and oral healthcare workers (OHCW) if adequate precautions are not taken.
These guidelines set out standard infection control measures that OHCW should
take to protect their patients, other OHCW and themselves.

Personal Protective Equipment (PPE)

PPE such as gloves, masks, protective eyewear, face shields and protective clothing
should be worn by all OHCW in appropriate situations.

Note: (specific for dental settings).

Debris, sprays and splashes generated during procedures may contain pathogens,
which can enter the bloodstream of the OHCW (both the operator and assistant)
through the nasal and oral mucosa and the conjunctiva.

1. Gloves
• Gloves must be worn when examining and treating patients or in any other situation where their hands

may come in contact with blood, body fluids and clinical debris.
• Wearing gloves should never replace hand washing. Hands must be washed both before wearing and

after removing gloves.
• Gloves must be discarded in the event of a visible puncture, and hands must be washed before new

gloves are put on.
• Disposable gloves are single use items and must be discarded after each patient.
• If any item not directly involved in patient care needs to be touched, over-gloves (non-powdered

gloves) may be worn or the treatment gloves removed. The over-gloves are then discarded or new
gloves are put on upon returning to patient care.
• Double gloving should be practised during the treatment of high risk patients and during dental
procedures.
• Gloves in boxes must not be exposed to aerosol contamination and therefore must be kept in a closed
space.
• OHCW with non-intact skin (wounds, skin lesions etc.) on their hands must cover all breaks of the skin
with waterproof dressings before wearing gloves (especially when performing a procedure). Double
gloves should be used if the hands are extensively affected.

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• OHCW should however avoid invasive procedures or procedures involving the use of sharp
instruments when their skin lesions are active, or if there are extensive breaks of the skin.

• Medical grade utility gloves that are puncture and chemical resistant must be worn when cleaning
contaminated instruments and clinical contact surfaces. Used utility gloves must be considered
contaminated and handled appropriately until properly disinfected. Utility gloves must be discarded if
their barrier properties become compromised.

2. Mask
• Surgical masks which cover both the mouth and nose should be worn during all dental procedures, by

both the operator and the assistant. N95 mask should be worn during all AGP procedures (during
respiratory infection outbreak).
• Masks should be changed:

- after a patient, if sprays or splashes have been generated during the procedure; or
- when it becomes wet
• Single and 2-ply masks should not be used by either the operator or the assistant as they provide
almost no protection. Fluid-resistant mask should be used and should not be touched while being
worn.

3. Protective eyewear and face shields
• OHCW and clinical support staff must wear protective eyewear to protect the mucous membranes of

the eyes during procedures where there is the potential for penetrating injury or exposure to aerosols,
splattering or spraying with blood, saliva or body substances.
• A face shield may be used as an alternative to protective eyewear.
• However, this does not protect from inhaled microorganisms and must be worn in conjunction with a
surgical mask.
• Patients must be provided with protective eyewear to minimise the risk of possible injury from materials
or chemicals used during treatment.
• Protective eyewear and face shields must be cleaned with soap and water and disinfected with a low-
level disinfectant after each patient.

Cleaning, disinfection and sterilisation of patient care items

1. Instrument classification
Instruments are classified into 3 categories according to the degree of contamination and the type of post-
treatment processing required.

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a. Critical instruments are surgical and other instruments that penetrate soft tissue or bone or enter
or contact the bloodstream (e.g. forceps, scalpels, bone rongeur, scalers and burs). These
instruments must be steam sterilised.

b. Semi-critical instruments are instruments that do not penetrate soft tissue or bone but contact
oral tissue or non-intact skin (e.g. amalgam condensers, mouth mirrors, dental handpieces and
digital radiography sensors). These instruments should be steam sterilised. If steam sterilisation
is not possible they should be treated with a high-level disinfectant.

c. Non-critical instruments and devices are instruments and devices that come into contact only with
intact skin (e.g. x-ray cone, position indicator device for x-ray cone, and face bow). They should
be processed as follows:
▪ not visibly contaminated - clean and disinfect with a low-level disinfectant; or
▪ visibly contaminated with blood - clean and disinfect with an intermediate level
disinfectant.

2. Sterilisation
(Instruments that are sent to CSSD for sterilization will adhere to protocol set by CSSD unit, meanwhile
dental instruments (dental probe, mouth mirror and tweezer etc) which are sterilized in the dental clinic
should follow this section.)

a. Autoclaves
• All critical and semi-critical autoclavable instruments must be autoclaved.
• If the need is to process packaged items or hollow or porous items, a vacuum autoclave is
required.
• If the need is to process only solid, unpackaged instruments, a simple downward displacement
autoclave is sufficient.

b. Heat sensitive instruments
• Instruments that are sensitive to heat, such as intra-oral cameras, electronic periodontal
probes, occlusal analysers and lasers should be cleaned and disinfected with at least a high-
level disinfectant.

Surgical procedures and aseptic technique
1. The requirements for oral surgical procedures (minor oral surgery, dental implant placement etc.)

include:
- Sterile gloves
- Appropriate sterile drapes
- Sterile instrument

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- Surgical hand washing (using antimicrobial hand washing solution)
2. Long hair must be tied back and covered and beards must be also covered. Head cap is compulsory

to be worn during the procedure.
3. The principles of sterile aseptic technique must be applied to all surgical procedures undertaken in the

dental practice setting.
4. Sterile gloves must be worn for all oral surgical procedures (including dental implant placement, cyst

enucleation, removal of unerupted teeth and endodontic surgery).

Environmental infection control

A. Environmental surfaces
• Environmental controls should be considered when designing or refurbishing dental clinics to
reduce the risk of transmission of infectious agents.
• Environmental surfaces are divided into:
i. Clinical contact surfaces
ii. Housekeeping surfaces

B. Clinical contact surfaces
• Clinical contact surfaces are surfaces that might become contaminated with blood during a
procedure and include the dental chair, light handles, dental chair controls, dental radiographic
equipment, chair side computers etc;
• For disinfection of these surfaces refer to Disinfection Manual.
• OHCW must wear medical grade utility gloves and other PPE during the cleaning process.

Other treatment room equipment

A. Waterlines and water quality
• Dental units should have a separate water reservoir system to supply water
or an in-built filtration system to the handpieces and scalers.
• Water from the domestic water supply should be filtered before entering the rinsing cup and
spittoon.
• Sterile irrigants such as sterile water as a coolant are required for surgical procedures such as
dentoalveolar surgery, endodontic surgery, and dental
implant placement.
• Handpieces and scalers should have anti-retraction valves to prevent retrograde contamination of
the lines by fluids from the oral cavity.
• Waterlines must be flushed for a minimum of two minutes each morning and with handpieces
attached for 20 to 30 seconds between each patient.

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B. Dental handpieces and other detachable devices attached to air and waterlines
• These include high and low-speed handpieces, scaling tips, air abrasion devices, and air and water
syringe tips. Surface disinfection or immersions in disinfectants are not acceptable methods for
processing these devices.
• These devices should be autoclaved.
• For handpieces, cleaning and lubrication are the most critical factors in determining performance
and durability. Manufacturers’ instructions for cleaning, lubrication and sterilisation should be
followed closely.
• Hand piece re-processing:
• Flush handpieces while still attached to air/water lines in hose with bur inserted.
• Clean and dry hand piece.
• Flush with hand piece cleaner and lubricant. It is advisable to use an automated hand piece
cleaning and lubricating system for this purpose.
• Pack and autoclave. Non-autoclavable handpieces should not be used. Flush air/ water lines in
hose before re-attaching a hand piece.
• Open package (lubricate, if necessary with separate post-sterilisation lubricant).
• Attach to hose and expel excess lubricant (with bur inserted).

C. Components permanently attached to dental unit waterlines
• These are likely to become contaminated with blood and body fluids during procedures. Examples
include the handles and tubing of saliva ejectors, high volume evacuators, handpieces, scalers
and air/ water syringes.
• These can be covered with protective barriers that should be changed after each procedure. If not
covered during use, they must be cleaned and disinfected with a low-level disinfectant if not visibly
contaminated. If visibly contaminated with blood, they must be disinfected with an intermediate
level disinfectant before use on the next patient.

D. Other non-autoclavable equipment
• Non-autoclavable equipment in the treatment room that might come in contact with the patient’s
blood and body fluids includes shade guides, the handles and tips of light curing units and pulp
testers.
• These must be cleaned and disinfected with a low-level disinfectant if not visibly contaminated. If
visibly contaminated with blood, they must be disinfected with an intermediate level disinfectant
before use on the next patient.
• An alternative is to, whenever possible, cover such equipment with a protective barrier that is
changed between patients.

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E. Suction units (aspirators), spittoons and secretion filters
• Suction lines attached to the dental chair should be irrigated with disinfectant between patients
and intermittently during long procedures. This prevents blood and saliva accumulating and
coagulating in the lines.
• Collection containers in portable suction apparatus must be cleaned and disinfected between
patients.
• Secretion filters/ amalgam traps must be cleaned daily.
• At the end of each day
1. Suck a non-foaming detergent through the high and low volume aspirators.
2. Flush a non-foaming detergent through the spittoon.

Infection control during oral imaging/ radiographic procedures

A. Intraoral imaging for unidentified or non-specified cases (Standard Precautions)
• Protective, non-powdered gloves should be worn for all imaging procedures and changed after
every patient.
• Other PPE should be used to prevent spread of infection by saliva or blood.
• Use a clean sterile image receptor-holder for each patient. Digital receptors must also be placed
inside appropriate dental barrier envelopes.
• Position the holder in the patient’s mouth. Never insert fingers into the patient’s mouth to position
the holder.
• After the imaging procedure, remove the digital receptor from the barrier envelope and discard the
envelope as clinical waste.
• Subsequently wash and clean the holder. If you have used a film packet (without a barrier
envelope), then it should be washed with the holder under running water.
• Remove the film packet with forceps. Dip the film packet in disinfectant solution and dry the packet
with a paper towel before sending for processing.
• If not autoclavable, the holder should be disinfected before use on the next patient

B. Intraoral imaging for identified high-risk patients
• Apply a plastic cover (cling film) to the yoke, tube-head cone, control panel, headrest and any
hand-held switches.
• The operator should double glove and PPE (disposable items where available) should be used.
• The intra-oral receptor (film packet or sensor) should be inserted into a dental barrier envelope to
guard against contamination.
• The enveloped receptor is inserted into a disposable or autoclavable receptor-holder. A disposable
apron should be placed over the lead apron worn by the patient.
• It is advisable to use a disposable receptor holder.
• Open the dental barrier envelope and allow the receptor to drop onto a paper towel/ cup.

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• The contaminated dental barrier envelope and the outer pair of gloves should then be disposed
off as clinical waste.

• The receptor can now be sent for processing.
• All plastic covers (cling film) should be removed and the dental chair, x-ray tube, lead apron,

exposure switch, door handle and other work surfaces should be disinfected using wipe surface
disinfectant and left to dry for 10-15 minutes.
• The inner pair of gloves should be disposed of as clinical waste. When using daylight-loading
automatic processors ensure that there is no salivary contamination of the soft flexible arm
sleeves. Film packets must only be introduced into the processor using clean hands or non-
powdered gloves (powdered gloves may cause artefacts on the films). Digital sensors, including
photostimulable phosphor (PSP) plates (in addition to placing in dental barrier envelopes) should
be disinfected between patients using the method recommended by the manufacturer.

Handling of laboratory materials and equipment

A. Dental laboratory materials
• Impressions, prostheses and appliances should be rinsed thoroughly to remove all visible blood and

debris, and then disinfected before being sent to the laboratory.
• Gloves and other PPE should be worn during handling and transportation of impression, prosthesis

and appliances.
• Items from the laboratory should be cleaned and disinfected with a high level disinfectant, prior to being

sent to the surgery.
• Materials that are to be used in surgical procedures should be heat sterilised or if this is not possible,

the item must be chemically sterilised.
• Containers should be used for transportation of items into and out of the laboratory.
• Laboratory items that become contaminated (e.g. burs, polishing points, rag wheels, articulators, case

pans and lathes) should be cleaned and sterilised or disinfected according to the manufacturers’
instructions.

B. Equipment for repair
• All clinical and laboratory instruments should be cleaned prior to being sent for repair.

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CHAPTER 5.0 : ENDOSCOPY ROOM

Introduction.

Quality assurance in GI endoscopy mandates the appropriate reprocessing of endoscopes and
accessories. In addition to other procedure-related risks, the risk of infection due to endoscopic procedures
has always to be taken into consideration. Endoscope-associated infections risks are categorized as
follows:

Principles of Infection Control in Endoscopy
A. As the carrier status of patients is often unknown:

▪ All patients should be treated as potentially infectious.
▪ All endoscopes and accessories should be reprocessed following every endoscopic

procedure, using a uniform, standardized reprocessing protocol.

B. Patients undergoing digestive endoscopy should be examined and treated without the risk of
transmission of infection or side effects that may result from inadequate reprocessing of endoscopic
equipment.

C. Regular quality control and the institution’s adherence to validated reprocessing procedures is the
responsibility of both endoscopists and clinical service providers and should be monitored by the
hospital-based infection control department.

D. Infection control in endoscopy includes:
1. Cleaning, disinfection, and sterilization of medical equipment.
2. Correct use of personal protective equipment.
3. Personal hygiene.
4. Engineering controls (ventilation, building design, clean water supply).
5. Cleaning, disinfection of environmental surfaces.
6. Adequate administrative control and support.
7. Training and continuing education.
8. Adequate written standardized operating procedures (SOPs).
9. Documentation.

E. Flexible endoscopes are complex instruments which require thorough reprocessing before use on
patients. Failure to adhere to reprocessing guidelines is a factor that may cause bacterial and viral
transmission.

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F. Dr. Earl Spaulding developed a classification system that divides medical instruments into categories
based on the risk of infection involved in their use. The Spaulding classification is as follows:

• Critical: devices that enter normally sterile tissue or the vascular system and should be
sterilized, such as reusable biopsy forceps, laparoscopes, percutaneous cholangioscopes.

• semi-critical: devices that come into contact with intact mucous membranes and do not
ordinarily penetrate sterile tissue. These devices (e.g., endoscopes) should receive a minimum
of high-level disinfection, defined as the destruction of all vegetative bacteria, viruses and
fungi, immediately before use.

• Non-critical: devices that come into contact with only intact skin and do not ordinarily touch
the patient and should receive low-level disinfection or cleaning.
Examples of non-critical devices are such as, blood pressure cuffs, stethoscopes

G. Endoscopes are considered as semi-critical items and should be reprocessed by at least using a high-
level disinfectant approved by the FDA. Complex endoscope design features may allow organic debris
and microorganisms to accumulate, making manual cleaning essential. Biofilm formation may harbor
microorganisms, making strict and meticulous adherence to reprocessing guidelines imperative in
order to prevent cross-contamination between patients and hospital133 acquired infections. Prompt
efficient cleaning processes are the best defense against biofilm formation.

Health and safety of endoscopy personnel

1. Contamination-related hazards come in two forms:
a) From cross-infection from patients or equipment.
b) From chemicals used in cleaning and disinfection.

2. Micro-organisms may also be transmitted directly from patients to endoscopy personnel. Therefore,
protection from direct contact with contaminated endoscopes, accessories and body fluids is essential.
Protection against chemicals used for reprocessing is of the utmost importance to avoid toxic and
allergic reactions.
a) Personnel assigned to reprocess endoscopes must be well trained in the technique of
endoscope reprocessing. These personnel must adhere to infection control principles.
b) Competency testing of personnel reprocessing endoscopes should be done on a regular basis.
Temporary personnel should not be allowed to reprocess endoscopes until competency has
been established.
c) All personnel who use chemicals should be educated about the biologic and chemical hazards
present while performing procedures that use disinfectants.

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Personal protective equipment.

1. Personal protective equipment such as double gloves, gowns (long-sleeved, moisture-resistant),
eyewear (protective glasses), respiratory protection devices (face masks), and protective full-face
visors should be readily available and should be used, as appropriate, to protect staff from exposure
to chemicals, blood, or other potentially infectious material.

2. Staff known to be disease carriers should avoid duties that could potentially transmit their disease to
patients.

3. Staff known to be disease carriers should avoid duties that could potentially transmit their disease to
patients.

4. Regular health surveillance for staff is recommended.

Reprocessing room.

1. There must be a designated and dedicated area for reprocessing of endoscopes.
2. The reprocessing room should be designed to provide a safe environment for healthcare personnel

and patients. Air exchange equipment e.g., ventilation system with exhaust hoods should be used to
minimize the exposure of all persons to potentially toxic vapors.
3. The reprocessing room must be purpose built consisting of a clean and dirty area. There should be
filtered water for use during the cleaning process.

Reprocessing standards.

1. All healthcare personnel should be trained, understand and adhere to standard reprocessing
guidelines. Always consult the endoscope manufacturer’s instructions related to the unique design of
a particular endoscope, which may require specific reprocessing procedures.

2. Endoscope reprocessing should be performed as soon as possible after use, after removal of the
insertion tube from the patient and prior to disconnecting from the power source.

3. Endoscopic reprocessing comprises the following steps:
a) Pre-cleaning. Immediately after use, macroscopically visible dirt is removed from external
surfaces and the interior of scope channels.
b) Leak testing.
c) Manual cleaning. This consists of the manual cleaning of external surfaces and the interior of
scope channels, including brushing.

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d) Rinsing. This is the removal of residual cleaning process chemicals that may interfere with the
following disinfection stage.

e) Disinfection. All microorganisms are reduced to such a level that they will not harm future
patients. Following manufacturer's recommendation.

f) Rinsing. A further rinse removes the chemical load from the instruments/scopes which have
been disinfected.

g) Drying. Internal and external surfaces are dried to avoid growth of waterborne microorganisms.
Using alcohol 70% for force drying.

h) Storage. Endoscopes are stored in a safe and closed cupboard in vertical position.

(a) Pre-cleaning in the endoscopy room.
1. Immediately after removing the endoscope from the patient, wipe the insertion tube with the wet
gauze soaked in the freshly prepared detergent solution or wipes. Check for bite marks or other
surface irregularities.
2. Place the distal end of the endoscope into the detergent solution. Suction the solution through the
biopsy/suction channel, alternate suctioning detergent solution and air several times until the
solution is visibly clean. Finish by suctioning air.
3. Remove the air-water valve; connect the air-water channel cleaning adapter to the air-water port
for continuing flushing and blowing the air and water channel in accordance with the endoscope
manufacturer's instructions.
4. Detach the endoscope from the light source and suction pump
5. Attach water resistant cap.
6. Transport the endoscope in a closed container to the reprocessing room.

(b) Leak testing in the reprocessing room.
1. Perform leak testing after each use according to the manufacturer’s instructions. Leak testing is
performed before immersion of the endoscope in cleaning solutions in order to minimize damage
to parts of the endoscope not designed for fluid exposure.
2. The leak testing procedure will detect any damage to the endoscope. If there is no leakage,
continue with manual cleaning. If a leak is detected the reprocessing procedure must be
interrupted immediately and repair of the endoscope initiated.
3. important during leak testing procedure;
• Do not turn off the maintenance unit if the endoscope is still in the water especially if
leakage is found.
• Do not attach or remove the leakage tester while under water.

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(c) Manual cleaning in the reprocessing room.
Cleaning is the essential and most important step in endoscope reprocessing. Manual cleaning must
always be performed before manual or automated disinfection.

The purpose of cleaning is to remove all inorganic material from the internal and external surfaces of
flexible endoscopes. Without proper cleaning, protein debris can harden and cause biofilm formation on
the biopsy channel of the endoscope. Protein debris remaining on the endoscope surface prevents
disinfection and sterilization fluids or gases reaching all parts of potentially contaminated surfaces. As a
consequence, transmission of infectious organisms may occur upon reuse of the endoscope.

1. Immerse the endoscope in a sink filled with a freshly-made solution of water and a medical
grade, low-foaming, neutral pH detergent formulated for endoscopes.

2. Dilute and use detergent according to the detergent manufacturer's instructions. Detergent
solutions with antimicrobial activity should be freshly prepared at least on a daily basis.

3. Wash all debris from the exterior of the endoscope by using a piece of gauze.
4. Use a channel opening brush to clean all removable parts, including inside and under the

suction valve, air/water valve, and biopsy port cover and openings.
5. Brush all accessible endoscope channels with a channel cleaning brush at least three times

or until there is no visible debris on the brush.
6. After each passage, rinse the brush in the detergent solution, removing any visible debris

before retracting and reinserting it.
7. Attach the endoscope manufacturer’s cleaning adapters for suction, biopsy, air-water

channels, and specific cleaning adapters for special endoscope channels (e.g., elevator
channel, auxiliary channel and double-channel scopes). Flush all channels with the detergent
solution to remove debris.
8. Flush all lumens to remove organic material. Use a 2 to 5 ml syringe to flush the elevator
channel and auxiliary channel. All auxiliary water channels, wire channels and balloon inflation
channels have to be cleaned according to manufacturer’s instructions.
9. Soak the endoscope and its internal channels for the period of time recommended by the
manufacturer.
10. For ultrasonic cleaning of endoscopic accessories it is recommended that the same detergent
as for manual cleaning be used.

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(d) Rinsing.
1. Rinse the endoscope and valves under running tap water of drinking-water quality.
2. Immerse the endoscope and irrigate all channels.
3. Discard the rinsing water after each use to avoid concentration of the detergent and the risk of reduced

efficacy of the disinfectant solution.
4. Clean and rinse the container before the next procedure.

(e) Disinfection.
1. Disinfection should be carried out immediately after cleaning.
2. Failure to adhere to disinfection guidelines is a major contributing factor in transmission of infections.

3. The disinfection process can eliminate most pathogenic microorganisms except bacterial spores. Its
efficacy is affected by factors which include:
• Prior cleaning of the endoscope.
• Presence of organic and inorganic load.
• Type and level of microbial contamination.
• Concentration of the germicide and disinfection time.
• Presence of biofilms.
• Temperature and pH of the germicide used.

4. The disinfectant solution should be tested at least every day for efficacy using the manufacturer’s test
strip.

(f) Final rinsing.
1. Rinse the endoscope and valves under running filtered water.
2. Immerse the endoscope and irrigate all channels.
3. Discard the rinsing water after each use to avoid concentration of the disinfectant and thus damage to

mucosa.

(g) Drying.
1. The drying process is important to prevent growth of microorganisms during storage.
2. It should be performed after each processing cycle and not just before storage as to prevent bacterial

transmission and nosocomial infection.
3. The final drying step greatly reduces the possibility of recontamination of the endoscope with

waterborne microorganisms.
a. Ensure correct final drying before storage.
b. Flush the channels with 70 % alcohol for force dry.
c. Dry the endoscope

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