INFECTION PREVENTION AND CONTROL POLICY , HOSPITAL CANSELOR TUANKU MUHRIZ

Policies and Procedures on Infection Prevention and Control HCTM

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Policies and Procedures on Infection Prevention and Control HCTM

CHAPTER 2.5 LINEN MANAGEMENT

INTRODUCTION

Linen in a Hospital Canselor Tuanku Muhriz (HCTM) may include bed sheets and blankets, towels, patient
apparel, scrub suits, gowns, and drapes for surgical procedures. It is widely accepted that high-quality
laundries produce safe, reusable textiles through rigorous implementation of commercial laundering
formulas, which carefully calibrate time, temperature, chemistry and mechanical action. When linen is
heavily contaminated with potentially infective body substances. Contaminated linen may be a source for
Healthcare Associated Infections (HCAI) and an outbreak.

Hygienic clean linen supply

Thus, Hospital Canselor Tuanku Muhriz (HCTM) should receive hygienic clean linen supply for their use.
This is determined by adhering to good policies and practices of hygienic and clean storage and handling
of the linen at every level. This ensures safety of clients/ patients who are hospitalized or receive day care
procedures.

The employees handling the hygienic clean linen must be well trained. The employees or Healthcare
Workers (HCWs) should follow proper hand hygiene procedures and sanitize prior to handling clean
healthcare linens and after touching potentially contaminated surfaces. They should done appropriate
Personal Protective Equipment (PPE): apron and mask but gloving is not required.

Storage

Adequate storage space is very important to keep the clean linen prior to distribution. It must be kept
separate from any soiled linen area and other possible contaminants.

Requirements for the storage area:

● Clean, not dusty, free of vermin and away from drains and pipes
● Temperature to 20 – 25 degree celcius (in the air-conditioned area)
● Linen cupboard must always be kept closed to reduce dust accumulation
● Cupboard and shelves must not be made of wooden material. The materials must be solid and

easily cleaned
● Shelves in the storage should be 5cm from the walls, 20-25 cm from the floor, 50 cm from the ceiling.

‘First in, first out (FIFO)’ must be adhered to based on date of supply (date must be stated on the
packet)
● Regular cleaning schedules (daily) of the cupboard and shelves must be done and documented
regularly
● Clean linen must never be placed on the floor or contaminated surfaces.
● Linen storage facilities are to be used for the storage of clean linen items only and not used for
storage of any other equipment

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Policies and Procedures on Infection Prevention and Control HCTM

● The linen that does not meet the clean hygienic standards should be rejected and returned
Transportation and distribution

● The hygienically clean linen should be wrapped before transportation from the laundry plant
but need to avoid plastic wrapper in view of local humidity and temperature

● Carts transporting hygienic clean linen from laundry to medical facilities must be clean
● The clean linen must be covered during the transport to the central storage and deliver to

the wards/ units
● Carts used for clean or soiled linen must be separated with physical barriers
● Staff members should avoid pressing/ hugging hygienic clean linen to their uniforms at any

times. This is important to prevent cross contamination via the staff’s uniform:
❖ Unloading from laundry bins or trucks onto racks in a clean linen storage area
❖ Moving clean linen from storage area to carts
❖ Removing clean linen from linen carts to a patient room
❖ When clean linen are being used to make a patient bed

SOILED / DIRTY LINEN
Used linen soiled with blood, body fluids, secretions and excretions should be handled, transported and
processed in a manner that prevents skin and mucus membrane exposure. Contamination of clothing and
transfer of micro-organisms to other patients and the environment should be avoided. Adherence to
standard precautions when handling contaminated linen and minimizing agitation of the contaminated items
are considered sufficient to prevent the dispersal of potentially infections aerosols.

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Policies and Procedures on Infection Prevention and Control HCTM

Types Linen Bag

HEALTHCARE WORKERS (HCWs) RESPONSIBILITIES
In performing this, HCWs must don appropriate Personal Protective Equipment (PPE) (apron, mask and
gloves) and perform hand hygiene beforehand:

● To segregate and remove any foreign items before placing soiled linen in the appropriate colour
coded bags.

● To tie the soiled linen bag when it is 3/4 full and replace with another bag. Red linen bag to be
lined with Alginate Bag.

● To place soiled linen bags neatly on the racks at the Used Soiled Linen Area.
● To place contaminated linen directly into a laundry bag in the isolation room/ area with minimal

manipulation to avoid contamination of air, surfaces and persons.

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Policies and Procedures on Infection Prevention and Control HCTM

Used linen awaiting collection must be stored in a secure area away from public access and in the
appropriately labelled wheelie bin. Do not transport linen in trash on linen carts. Never move soiled and
clean linen on the same carts.

WATERPROOF PILLOW AND BEDCOVER
Waterproof pillows and bed cover must not be sent to the laundry for laundering. All pillows and bedcover
must be marked with the ward or area name in permanent marker pen.

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Policies and Procedures on Infection Prevention and Control HCTM

CHAPTER 2.6 INJECTION SAFETY AND SHARPS MANAGEMENT

According to World Health Organisation (WHO), a safe injection is the one that:

• Does not harm the recipient
• Does not expose the provider to any avoidable risks
• Does not result in waste that is dangerous for the community

This principle is also used in any procedures that involve sharps instruments (needle, glass, cannula, sharp
surgical instrument). Unsafe practices will put healthcare workers and patients at risk of contracting
infections.

In general, the practices below are recommended in all procedures which involve handling sharps
instrument:

● Good hand hygiene
● ‘One needle – one needle – one time’ concept
● Wear gloves
● Other single-use personal protective equipment (PPE)
● Good skin preparation and disinfection technique

Skin Preparation and Disinfection

Prior to intradermal, subcutaneous, intramuscular, and venous access operations, the following antisepsis
is recommended:
• Use a 70% alcohol swab on unsoiled skin.

Practical guidance on skin preparation and disinfection
Use the steps below to disinfect your skin:
1. Use a single-use swab or cotton-wool ball to apply a 70% alcohol-based solution. The skin should be

washed with soap and water if it is visibly stained.
2. Wipe the region from the injection site's center outwards, without going over the same spot twice.
3. Apply the solution for 30 seconds, then let it dry for another 30 seconds to guarantee that the

germs are made inactive.

DO NOT soak cotton wool in a container since it becomes extremely contaminated with bacteria from your
hands and the environment.

When administering immunizations, DO NOT use alcohol skin disinfection.

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Policies and Procedures on Infection Prevention and Control HCTM

DO DON'T DO IT

Hand hygiene should be practiced (soap Do Not forget to clean your hands
and water or alcohol rub) for at least 30
seconds, including the wrists and gaps DO NOT use the same set of gloves
between the fingers (follow WHO's 'My 5 on many patients.
moments for hand hygiene). DO NOT re-use gloves that have
been washed.
One pair of non-sterile gloves should be If you have more than one patient,
used per procedure or patient. don't use the same syringe, needle,
or lancet.
For blood sampling and drawing, utilize a After disinfecting the puncture site,
single-use instrument. DO NOT touch it.
Do Not leave the needle unprotected
Cleanse the skin around the venepuncture outside the sharps bin at all times.
site.
Do Not recap a needle using both
Immediately dispose of the used hands.
equipment (a needle and syringe in one
unit) in a sharps bin. A sharp bin should not be overfilled
or decanted.
When it's impossible to avoid recapping a
needle, employ the one-hand scoop
technique.

Do cover the sharp bin with a heat-
resistant lid.

PEP: post-exposure prophylaxis, WHO: World Health Organization
* World Health Organization (30)

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Policies and Procedures on Infection Prevention and Control HCTM

Devices for Injection

To allow clinicians to utilize a new device for each procedure, healthcare organizations should guarantee
that an appropriate supply of single-use devices is available.

Instructions for using injectable devices:
● Use a new sterile single-use device for each procedure, including the reconstitution of a unit of
medication or vaccine.
● Inspect the device's packaging to ensure that the protective barrier has not been breached.
● Discard the device if the package has been punctured, torn, or damaged by moisture, or if the
expiration date has passed.

Medication

1. Instructions for administering drugs in a practical manner
• Step-by-step instructions for safely giving medications
• DO NOT deliver medication to many patients with a single filled syringe (i.e., ensure one
needle, one syringe, one patient)
• If you want to reuse the syringe, don't change the needle.
• DO NOT reconstitute several vials with the same mixing syringe.
• DO NOT store leftover medications with other medications for future

2. Single-dose vials – To avoid cross-contamination, use a single-dose vial for each patient wherever
possible.

3. Multi-dose vials — If there is no other option, utilize multi dose vials.
4. In each patient-care area, only one bottle of a certain medication should be opened at a time.
5. If possible, maintain one multi-dose vial for each patient in a separate treatment or medicine room,

labeled with the patient's name.
6. DO NOT store multi-dose vials in the open ward, since they may be contaminated by spray or spatter

unintentionally.
7. Discard a multi-dose vial:

If the sterility or content of a multi-dose vial has been compromised, the expiry date or time has passed
(even if the vial contains antimicrobial preservatives), or the vial has not been properly stored after
opening, discard it.

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Policies and Procedures on Infection Prevention and Control HCTM

Injection Preparation

Injections should be made in a dedicated clean area free of blood and bodily fluids.
1. Instructions on how to prepare injections in a practical manner.

When preparing injections, three stages must be followed.
• Keep the injection prep area clear of debris so that all surfaces can be cleaned easily.
• Clean the preparation surfaces with 70% Alcohol before beginning the injection session, and if

there is contamination with blood or body fluids, and leave to air dry.
• Gather all of the injection-related equipment.

2. Septum vials procedure
Before piercing the vial, wipe the access diaphragm (septum) with 70% alcohol with a swab or cotton-
wool ball and allow it to air dry before inserting a device.
• For each insertion into a multi-dose vial, use a sterile syringe and needle; never leave a needle
in a multi-dose vial.
• As soon as the loaded syringe and needle have been removed from the multi-dose vial, deliver
the injection as quickly as feasible.

3. Labelling - Label the finished medication container with the date and time of manufacture after
reconstitution of a multi-dose vial.

4. Injection Administration - All injections should be done in an aseptic manner.

5. Instructions for delivering injections in a practical manner

6. When giving an injection, remember to:
• Look up the medication in the drug chart or prescription, as well as the patient's Name,
MRN, IC/Passport and dosage.
• Keep your hands clean.
• Using a swab or cotton-wool ball, wipe the top of the vial with 70% alcohol (isopropyl
alcohol or ethanol).
• In front of the patient, open the packaging to reassure them that the syringe and needle
have never been used before.
• Remove the drug from the ampoule or vial with a sterile syringe and needle.

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Policies and Procedures on Infection Prevention and Control HCTM

Reconstitution
1. If sterile syringe and needle reconstitution is required, remove the reconstitution solution from the

ampoule or vial, insert the needle into the single or multi dose vial's rubber septum, and inject the
required volume of reconstitution fluid.
2. Thoroughly combine the contents of the vial until all visible particles have dissolved.
3. Remove the needle and syringe from a multi-dose vial after reconstituting the contents and discard
them as a single unit into a sharps receptacle.
A system with no needles
If a needleless system is available, do the following:

• Using an alcohol swab, clean the rubber septum of the multi-dose vial.
• Place the spike in the vial with the multi doses.
• Use an alcohol swab to clean the needleless system's port.
• Take a sterilized syringe out of the package.
• Place the syringe's nozzle into the port.
• Remove the reconstituted medication from the equation.
Administration hold-up
If the dose cannot be given right away for any reason, use a one-handed scoop technique to cover the
needle with the cap.
Sharps injury prevention for healthcare staff
Sharp injuries to health professionals can be avoided by following best practices.

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Policies and Procedures on Infection Prevention and Control HCTM

Diagram 1 below is our SOP for giving injection at HCTM
Sharps Management
All disposable sharps waste including syringe and needle, tube holder, winged butterfly needle, intravenous
cannula and glass vials and ampoules should be disposed of immediately into a yellow sharps bin, which
should be within an arm’s reach of the healthcare worker. This bin should be leak-proof, puncture-proof,
closable and clearly labelled as a sharp bin.
Phlebotomy Procedure
A good phlebotomy procedure must include proper planning of what equipment to be used, a proper location
to do the procedure as well as quality assurance. Quality assurance or control have several components,
mainly as followed:
1. Standard Operating Procedures (SOP)

SOP for venepuncture as well as giving injection and inserting intravenous cannula are available in each
clinical area. They should be displayed clearly and be followed by each HCW performing the procedures.
2. Education and training

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Policies and Procedures on Infection Prevention and Control HCTM

This is necessary for all HCW who are involved with venepuncture (venous blood sampling). It includes
knowing the equipment, following SOPs, understanding the anatomy of the venepuncture site,
awareness of risks of blood exposure and prevention of infection.
Training sessions can be organised by each departmental involved. Few sessions of training are also
organised by Unit Keselamatan & Kesihatan Pekerjaan.
3. Correct identification of patient
Positive identification method should be used, whereby a HCW will ask the patient his/her name and
compare the answer with the patient's sticker label or what is written in the request form.
4. Condition of the Sample
This should be such that the blood sample is in good condition, for example not clotted, and using a
technique that prevents haemolysis of the sample, ensuring satisfactory results.
5. Safe Transportation
Transportation should be safe and in accordance with the recommended guidelines of each sample (eg:
some samples need to be sent with ice).
6. Incident Reporting System
Any incident should be reported to HCTM centralised Incident Reporting System, noting the details of
the incident, possible causes and management of adverse events.
7. Availability of Supplies
A person-in-charge in each clinical area should ensure that equipment and PPE for venepuncture, giving
injection and inserting iv cannula are readily available at all times.

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Diagram 2: SOP Venepuncture
Diagram 2 above is the SOP for venepuncture at HCTM. A butterfly-winged needle must be used for this.
(Disclaimer: A hypodermic needle is only used for arterial blood gas (ABG) and blood culture taking
procedures hypodermic) needle is only used for arterial blood gas (ABG) and blood culture taking
procedures.

• During the procedure, select venepuncture site preferably at the antecubital fossa area (between
the forearm and the arm, on the anterior surface of the elbow).

• Hanging the hand down off the bed may aid the process of finding veins.
• Palpate the area to find the vein. Apply a tourniquet about 4 - 5 finger widths above the selected

site. Ask the patient to form a fist so the veins are more prominent.
• Disinfect the site using 70% isopropyl alcohol or other antiseptic agents and allow to dry completely.

DO NOT touch the site once alcohol or other antiseptic agent has been applied. If the site is
accidentally touched, repeat the disinfection process.
• Introduce the needle into the vein swiftly at a 30-degree angle or less, and continue to introduce the
needle along the vein until you see a backflow of blood coming out.
• Once sufficient blood has been collected, release the tourniquet BEFORE withdrawing the needle.
• Withdraw the needle gently and then give the patient a clean gauze or cotton-wool ball to apply to
the site with gentle pressure.

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• Discard the used winged-butterfly needle and the holder (or needle and syringe in the case of ABG
and blood culture sampling) into a yellow sharps bin. Discard any sharps into this bin too. Other
waste goes into the clinical waste bin.

• Label the blood bottle with a patient’s sticker label or handwrite the label, ensuring that it matches
the details on the request form.

• Discard gloves into the clinical waste bin and perform hand hygiene.

Diagram 3: SOP for intravenous cannula insertion
The process of finding veins is similar as above, however you can use veins on the dorsal part of the hands,
depending on the suitability and the purpose of iv cannula insertion.

• Choose cannula size appropriately to the purpose of the procedure.
• After inserting the cannula, withdraw the intravenous stylet and discard it directly into the yellow

sharps bin.
• The disposal process is similar to venepuncture.
• Date of insertion needs to be written down on the plaster label or patient’s notes.
• It is recommended to change the cannula when indicated to avoid infection.

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CHAPTER 2.7 WASTE MANAGEMENT
Waste generated by health care activities includes a broad range of materials, from used needles and
syringes to soiled dressings, body parts, diagnostic samples, blood, chemicals, pharmaceuticals, medical
devices and radioactive materials. About 85% waste generated by health-care activities is general, non-
hazardous waste comparable to domestic waste. The remaining 15% is considered hazardous material that
may be infectious, chemical or radioactive.
Poor management of health care waste potentially exposes health care workers, waste handlers, patients
and the community at large to infection, toxic effects and injuries, and risks polluting the environment. It is
essential that all medical waste materials are segregated at the point of generation, appropriately treated
and disposed of safely.
Wastes from hospitals and healthcare establishments can be categorized into the following types:

i. Clinical waste
ii. Sharp Waste
iii. Laboratory Waste
iv. Pharmaceutical waste
v. Disposable Medical items
vi. Cytotoxic waste
vii. Radioactive waste
viii. General waste.

Clinical waste shall be defined as:

• Any waste which consists wholly or partly of human or animal tissues, blood or other body fluids,

excretions, used drugs, swabs, dressings, syringes, needles or other instruments, being waste
which unless rendered safe may prove hazardous to any other person coming into contact with
it.

• Any other waste arising from medical, laboratory, nursing, dental, veterinary, investigation,

treatment, care, teaching or research, or the collection of blood for transfusion, being waste which
causes infection to any other person coming into contact with it.

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Cytotoxic Waste:
• All cytotoxic waste generated from preparation, administration or residue must be
segregated from other clinical waste, packaged in double purple bags, clearly labeled as
CYTOTOXIC and disposed of in a manner that shall not cause exposure and contamination
to personnel or environment.
• Cytotoxic waste should never be landfilled or discharged to the sewerage system. All
cytotoxic waste should be incinerated to a temperature of at least 1100 degree celsius.
• Disposable procedures must comply with all applicable acts and regulations by the
Department of Environment, Ministry of Natural Resources & Environment. (Manual For
Sterile Preparation, MOH 2021)

Radioactive Waste:
• The radioactive waste is kept in safe containers at dedicated areas until decay down to
level, which is permitted by the regulatory body to be released or discharged to the
environment. All radioactive waste is disposed of in accordance with the Atomic Energy
Licensing Act 304.

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TYPES DESCRIPTION EXAMPLE WASTE SEGREGATION

Clinical Waste contaminated
Waste with blood and other
Group A bodily fluids (e.g.
soiled gloves,
plasters, swab, cotton
wool, dressing,
bandages etc)

Pathological waste
including all human
tissue, organ, body
parts, placenta, tissue
from laboratories etc.

Clinical Sharp waste E.g.
Waste syringes, needles,
Group B disposable scalpels
and blades and other
sharp instruments that
could cause a cut or
puncture.

Trocar is
recommended to be
discarded into a well
fit trocar container.

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Clinical Waste from laboratory
Waste E.g. used culture
Group C plates, tubes, bottles,
blood culture bottles

Clinical Pharmaceutical waste
Waste E.g. expired, unused
Group D and contaminated
drugs and vaccines

Clinical Disposable medical
Waste items (non sharp)
Group E

Bed pan, stoma bag,
incontinence pad,
urine container

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Cytotoxic Cytotoxic waste Policies and Procedures on Infection Prevention and Control HCTM
waste includes any residual
cytotoxic drug (double packaging and
labeled)
All forms of cytotoxic
drugs returned from
patients,
contaminated stocks,
specimens, and all
disposable items
come in contact with
cytotoxic drugs.

Radioactive Radioactive waste
Waste from Nuclear
Medicine

Example: isotope

Return the spent
radioactive source to
the vendor or supplier
especially for long
half-life radioactive
source.

Send back to the
manufacture (Local Supplier /
vendor) or Malaysia Nuclear
Agency

(WasTeC)

(Standard operating
procedure, Nuclear Medicine
HCTM)

General Waste that does not
waste (non pose any particular
clinical / infectious/ biological,
non- chemical, radioactive
hazardous or physical hazard
waste)

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*The color of the plastic bags are subjected to change due to availability of material, technology and
practices in the near future.
HCWs Responsibilities :

• Clinical waste (Group A and E) shall be discarded into yellow bags for collection.
• Used sharps shall be discarded into a sharp container.
• Do not remove needles from the syringes.
• All syringes without needles are discarded into a clinical waste bin.
• DO NOT disconnect the used Intravenous giving set.It should be tightly secured

and disposed of into the clinical waste bin.
• Sharps containers when filled to the fill line (¾full) shall be sealed to prevent

further filling of sharps.
• Container covers should be tightened and locked before use.

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CHAPTER 2.8 DISINFECTION AND STERILISATION

GENERAL PRINCIPLES

Infection prevention and control require the use of sterile medical equipment for aseptic procedures in hospital.
Reusable medical equipment must be reprocessed before it can be re-used. Reprocessing critical and semi-critical
single-use medical equipment is not encouraged.

Safe reprocessing of medical equipment is very important to ensure sterility to:
• Prevent transmission of microorganisms to personnel and clients/ patients and
• Minimizing damage to medical equipment/ devices from foreign material (e.g., blood, body fluids, saline
and medications) or inappropriate handling.

There must be a centralized area for reprocessing medical equipment or devices. Reprocessing performed
outside the centralized area must be kept to a minimum. In smaller settings, such as clinics or offices in the
community, this refers to any segregated area where reprocessing of equipment/ devices takes place, away from
clients/ patients and clean areas.

DISINFECTION

1. Disinfection describes a process that eliminates many or all pathogenic microorganisms, except
bacterial spores, on inanimate objects. In health-care settings, objects usually are disinfected by liquid
chemicals or wet pasteurization.

2. Disinfectants of medical items or equipments can be classified according to their ability to destroy
different categories of micro-organisms:
• High Level disinfectants : Glutaraldehyde 2%, Ethylene Oxide
• Intermediate Level disinfectant : Alcohols, chlorine compounds, hydrogen Peroxide, chlorhexidine,
• Low level disinfectants : Benzalkonium chloride, some soaps

(To refer to MOH Disinfection Guidelines 2018)

3. Reusable medical equipment/devices must be thoroughly cleaned before disinfection or sterilization to
physically remove contaminants from the items/ equipment. The process for cleaning would include pre-
cleaning (disassembly, sorting, soaking), cleaning, rinsing, drying, physical inspection, lubrication and
wrapping.

4. Gross soiling (faeces, sputum, blood) should be removed immediately at point of use.

5. If cleaning cannot be done immediately, the medical items/ equipment must be submerged in water and
detergent or enzymatic cleaner to prevent organic matter from drying on it.

6. Any brushing if required should be done under water

7. Avoid cleaning the items/equipment under running water to minimize aerosolization or microorganisms.

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8. Steps for Cleaning Process:
a) Soaking
• Do not use saline or corrosive disinfectants as soaking solution
• Avoid prolonged soaking (overnight) of items/equipment
b) Cleaning – can be done manually or using mechanical cleaning machines (e.g. washer
disinfector, ultrasonic washer, washer sterilizer) after gross soil has been removed.
c) Rinsing
• Is necessary after cleaning, as residual detergent may neutralize the disinfectant.
• The final rinse for items/equipment should be with treated water (reverse osmosis/distilled
water). The process involves at least 2 rinses with treated water and the rinse solutions
must be changed after each process.
d) Drying is an important step to prevents dilution of chemical disinfectants which may render them
ineffective and prevents microbial growth. Manufacturer’s instruction for drying of the
items/equipment must be followed and item/equipment may be air-dried or dried by hand with a
clean, lint-free towel.

STERILIZATION
Sterilization describes a process that destroys or eliminates all forms of microbial life and is carried out in
health-care facilities by physical or chemical methods. Steam under pressure, dry heat, EtO gas, hydrogen
peroxide gas plasma, and liquid chemicals are the principal sterilizing agents used in health-care facilities.
(Please refer to Sterilization Policy under the CSSD Policy)

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1. The Central Sterile Service Department (CSSD) / Central Sterile Supply Unit (CSSU)/ Theater Sterile
Services Unit (TSSU) is to provide efficient and effective central sterilization service and supply sterile
items required by the wards, theatre and clinical departments in hospitals so as to efficiently prevent and
control infection.

2. It is responsible for the processing, sterilization and quality control of all sterile supplies and equipment
used in the hospital.

3. Heat sensitive items should be sterilized by low temperature sterilizer
4. All sterilized items shall have the name of item, date of sterilization, code number / name of packer and

load number of sterilizers on the package.
5. Sterility will be determined by inspecting the integrity of the package for signs of damage or contamination,

handling and storage conditions. Sterility is event-related; it is not time-related unless the package contains
unstable components such as drugs or chemicals.
6. Reprocessing of single used devices should be discouraged.
7. Automated cleaning equipment such as washer-disinfectors and ultrasonic cleaners do not require hand
cleaning of instruments and they also do not require pre-cleaning disinfection if disinfectant solutions or
heat disinfection is used in the cleaning process. These methods are therefore safer and more efficient
than manual cleaning. Use recommended solutions and follow manufacturers’ instructions.
8. Sterilizations of all instruments and material shall take place in the CSSD, except

- Pharmaceutical products
- Specimen container and media
- Single-use medical and surgical instruments, equipment or supplies

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Personnel to manage process disinfection and sterilization (Fig 1.1)
9. Staff should be trained in the field of disinfection, sterilization and operating autoclave machines.
10. Staff should change to standard attire, including face mask, cap and foot wear.
11. Staff / personnel should follow the disinfection and sterilization policy and practice and standard precaution

guideline practice.
12. Staff with skin ailments are not encouraged to work in CSSD.
13. Long finger nails, including artificial nails, jewelleries and heavy make-up are not allowed in CSSD.
Instruments
1. Contaminated instrument following manufacturer's guideline.
2. Instruments used on Biohazard cases must be double bagged, labeled biohazard and sent to CSSD as

soon as possible after informing CSSD staff.
3. When the CSSD is closed, decontamination is carried out at users facilities following the ‘Disinfection and

Sterilization Policy and Practice” guidelines. – (To Refer to CSSD policy)

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Packing

All packing methods and wrapping procedures must allow for removal of air and direct contact of the sterilant
with the contents of the package. Sterilization wrapping paper should be used instead of linen as packaging
material.

Storage and preparation rooms

1. Sterile store is used for storage of sterile items only
2. Only authorized personnel shall be allowed to enter the sterile store
3. Bulk store is used for storage raw materials with non-sterile consumables
4. Linen room is used for preparation and storage of linen only.

Sterile storage in the ward

1. Sterility maintenance is directly affected by packaging materials, handling, storage methods and condition.
Sterile storage should only be used to store sterile items.

2. Sterile items/ equipment should be stored and handled in a manner that maintain the
integrity of packs and prevent contamination from any source.

3. The storage area shall be clean and free of dust, insects and vermin.
4. Storage bins, carts and shelves should not be overloaded.
5. All items/ equipment should be stored above floor level by at least 25cm and from ceiling

fixtures by at least 44cm, 5cm from the wall and protected by direct sun light.
6. Temperature within the storage area should range from 22°C - 24°C with relative humidity

from 50% - 60% (should not be near moisture source e.g. sinks).
7. The sterile items should be arranged according to the size (big sets singly, and small set

not more than 3 stacks).
8. ‘First in, first out’ (FIFO) is the principle to follow in the removal and replacement of sterile

items in sterile storage.
9. The shelf life of a packaged sterile item is event-related (no expiry date).

• Physical damage – holes/ tears
• Moisture damage – wet package
10. Routine checking of storage area is necessary on a regular basis and documented.
11. Hand hygiene should be performed before accessing clean/ sterile supplies. Do not use gloves.

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Maintenance
Ensure that all machines/equipment are maintained in good condition and planned preventive maintenance
(PPM) carried out according to the schedule.

1- Safety check for autoclave accordingly (refer to checklist or log for items)
2- Breakdown shall be reported immediately and ensure that action is taken within the time

stipulated.
REPROCESSING ENDOSCOPY EQUIPMENT/DEVICES
(Refer to Policies and Procedures on Infection Prevention and Control HCTM ; Section D: Chapter 5.0 :
Scope Room)

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CHAPTER 2.9 RESPIRATORY HYGIENE AND COUGH ETIQUETTE
Hospital should promote respiratory hygiene/ cough etiquette:

○ Promote the use of respiratory hygiene/ cough etiquette by all HCWs, patients and family
members with acute febrile respiratory illness;

○ Educate HCWs, patients, family members, and visitors on the importance of containing
respiratory aerosols and secretions to help prevent the transmission of respiratory diseases;

○ Consider providing resources for hand hygiene (e.g. dispensers of alcohol- based hand
rubs, hand-washing supplies) and respiratory hygiene (e.g. tissues) in areas of gathering,
such as waiting rooms, should be prioritized.

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CHAPTER 3.0 : TRANSMISSION BASED PRECAUTION

Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition
to Standard Precautions for patients who may be infected or colonized with certain infectious agents for
which additional precautions are needed to prevent infection transmission.
Three types of transmission-based precautions have been developed;

i. Contact Precaution

ii. Droplet Precaution

iii. Airborne Precaution

The core elements of each precaution are outlined below:

Contact
Contact transmission is the most common route of transmission of infectious agents.
It may be any of the following:

a. Direct contact; which occurs through physical contact with blood, body fluids or body lesions e.g. a
person may transmit microorganisms to others by touch.

b. Indirect contact; which occurs when microorganisms are transferred via contaminated objects or
environment e.g. Clostridioides difficile, MRSA

In addition to Standard Precautions, infections that require contact precautions are:
a. Bacteria
• MRSA, ESBL producers, VRE, CRE, MDRO
• Clostridioides difficile
• E.coli 0157:H7
b. Viruses
• Respiratory viruses eg Adenovirus, Influenza, Parainfluenza, RSV, Enteroviruses, Rhinovirus,
some Coronaviruses eg SARS-C0V-2, MERS. Note: Respiratory viruses are mainly transmitted by
the droplet route but can be spread by contact with infectious respiratory secretions.
• Gastrointestinal eg Rotavirus, Astrovirus, Norovirus, Hepatitis A, Hepatitis E virus.
• Others eg HSV, VZV, HPV, Measles, Mumps, Rubella, Parvovirus B19, Ebola
c. Parasites eg scabies
d. Other conditions
· HFMD
· Impetigo
· Non-contained abscesses or decubitus ulcers, especially for Staphylococcus aureus and
Group A Streptococcus.

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*Isolation tray/trolley must contain the following items: non-sterile gloves, non-sterile gowns, surgical masks,
thermometer, BP set, stethoscope, alcohol hand rub.

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Droplet
Droplet transmission occurs by particles >5 m containing infectious agents. These droplets are larger, do
not remain suspended in the air, and do not travel long distances
They are produced when the infected patient talks, coughs, or sneezes, and
during some procedures (e.g. suctioning and bronchoscopy). A susceptible host may become infected if the
infectious droplets land on the mucosal surfaces of the nose, mouth, or eye.
Droplet Precautions are used in addition to Standard Precautions. Droplet Precautions are indicated in
patients with the following infectious agents:

a. Bacteria
• N. meningitidis
• B. pertussis
• H. Influenzae
b. Viruses
Most respiratory viruses:

• Influenza viruses A & B
• Parainfluenza viruses
• Respiratory Syncytial Virus
• Human coronaviruses including SARS-CoV-2
• Enteroviruses
• Rhinoviruses
• Adenoviruses
• Human Metapneumovirus
Others eg Mumps, Rubella, Parvovirus B19 etc

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Core Component In order of preference;
Patient Placement 1. Single room with en-suite bathroom
2. Single room
Personal Protective 3. Cohort – place the patient in a room with a patient(s) who has active
Equipment (PPE) /
Hand Hygiene infection with the same microorganism but with no other infection.
4. In the general ward, but maintain a spatial separation of at least 3 feet
Environmental Control
Patient care between an infected patient and other patients and visitors.
equipment and Linen * Place an isolation trolley / tray at the entrance of the
Patient Transport isolation zone.
* Droplet Precautions signage for the appropriate Personal
Protective Equipment should be displayed before
entering the room / area.
* Need to include the proper instructions of PPE removal.

Basic Requirements:
• Gown
• Gloves
• Mask – A surgical mask is sufficient unless aerosol generating
procedures are performed, an N95 mask should be worn (
nebulizers / intubating / BAL)
• Face Shield or eye protection are recommended for procedures /
activities likely to generate splashes / sprays of blood, body fluids,
secretions and excretions)
− Upon exiting the room: gloves need to be removed first
before gowns.
− 5 moments of Hand hygiene and elements of standard
precaution must be practiced

Patients care items, bedside equipment and frequently touched surfaces
are cleaned daily. Clean the environmental surfaces with hospital-approved
disinfectants.
( as Contact Precaution)

Do not Move patient Unnecessarily
• If can’t be avoided, The patient should wear a surgical mask and
follow Respiratory Hygiene Cough Etiquette in order to minimise
the dispersal of droplet nuclei during transportation.
• Receiving area should be fully aware of patients condition
• Standard Precautions to be practiced always

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Airborne

Airborne Precautions used in addition to Standard Precautions:
• Reduces the risk of airborne transmission of infectious agents (<5 m in size).
• Minute infectious droplets and aerosols may be generated by an infectious person during coughing,
sneezing, talking or performing of procedures (e.g. Intubation).
• These particles remain suspended in air for long periods of time.

Airborne transmission is further classified into obligate or preferential airborne transmission:

• Obligate airborne transmission occurs with pathogens that are transmitted only by deposition of droplet

nuclei under natural conditions (e.g. pulmonary. tuberculosis).

• Airborne transmission occurs with pathogens such as:

a. Bacteria - Mycobacterium tuberculosis
b. Viruses - Measles virus, Varicella Zoster virus, SARS-CoV-2*
c. Fungal - Aspergillus, Histoplasma, Talaromyces marneffei (P. marneffei)

*SARS-CoV-2 for aerosol-generating procedures

Visitors

1. Patient with TB:

• Household contacts who have been exposed do not need to wear an N95 respirator.
• Visitors who are non-household contacts should be discouraged from visiting. They should be

counselled about their risk and taught how to use an N95 respirator appropriately if they do visit.

2. Patient with varicella and measles:

• Household contacts who have been exposed do not need to wear N95 respirator. They should be
assessed for presence of active infections before visiting.

• Visitors who are known to be immune or vaccinated do not need to wear an N95 respirator.
• Visitors who are non-household contacts, not immune or vaccinated and have no history of

varicella and measles should not visit.

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Core Component In order of preference;
Patient Placement 1. Airborne Infection Isolation Room (AIIR)
2. Single room (nursed with door closed) and en-suite bath
Personal Protective 3. Single room
Equipment 4. Cohort (not recommended unless absolutely necessary) or consider
transferring to a centre with AIIR.– consult Physicians /microbiologistss
Environmental
Cleaning The room should meet the following ventilation standards:
Equipment Handling • minimum 12 air changes per hour (ACH)
• inward directional airflow from adjacent spaces to the room with
Transporting patients negative pressure differentials of > - 2.5 Pascal.
• supply of clean air flowing first to the area of the room where staff
or visitors are likely to be present, and then flowing across the bed
area to the exhaust.
• exhaust air directed to outside or HEPA-filtered, if recirculated.
• room monitored on initiation of use and at least daily when in use.
• door kept closed at all times when not required for entry and exit.
• If performing Aerosol generating Procedures : suggested to
perform in a Negative Pressure room

1. N95 mask or Higher level respirator
• Appropriate fit test must be performed
• Avoid touching the mask
• Change if soiled / or failed fit test

2.Practice standard precaution at all times along with 5 moments of hand
hygiene.

3. Appropriate PPE for Contact Precaution if patient has indications.

Patient-care items, bedside equipment and frequently touched surfaces are
cleaned daily. Clean the environmental surfaces with hospital-approved
disinfectants.

1. Dedicate the use of non-critical patient-care equipment to avoid
sharing between clients/patients/residents. E.g. stethoscope,
sphygmomanometer, thermometer or bedside commode

-If unavoidable, then adequately clean and disinfect them before use on
another client/patient/resident
-Do not wear the same gowns and gloves when going from patient-to-
patient within the cohort.

2. Contaminated linen should be handled as little as possible to prevent
gross microbial contamination of the air. Washing /Disinfecting linen
should be handle according to hospital protocol

● Patient movement and transport from the room should be limited
unless for essential purposes.

● If a patient needs to be transported out of the room, inform the
receiving department of the need for airborne precautions.

● Healthcare personnel should wear an N95 mask or respirator
during transportation of patients.

Patients should wear a surgical mask if tolerable and follow Respiratory
Hygiene /Cough Etiquette in order to minimise the dispersal of droplet
nuclei during transportation.

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Translocation

The fourth types of transmission is translocation. However, there is no transmission-based precaution for
this type of transmission.

1. Bacterial translocation is defined as the passage of viable bacteria from the gastrointestinal (GI) tract to
extra-intestinal sites, such as the mesenteric lymph node (MLN) complex, liver, spleen, kidney, and
bloodstream. This may promote the systemic spread of indigenous translocating bacteria to cause lethal
sepsis.

2. Factors that predisposes to translocation
a. intestinal obstruction;
b. jaundice;
c. inflammatory bowel disease;
d. malignancy;
e. pre-operative total parenteral nutrition (TPN);
f. emergency surgery; and
g. gastric colonisation with microorganisms.

3. Measures to reduce bacterial translocation

● Luminal nutrients rather than TPN
● Measures that discourage bacterial overgrowth in the proximal gut.

- Reduce the use of acid suppressing medications
- Consider acidified enteral feeding
- Judicious use of antibiotics (avoid broad spectrum antibiotics)
● Gut-specific nutrients and immune enhancing feeds, such as glutamine and arginine.
● Measures to improve splanchnic blood flow, dopexamine, inotropes and ischaemia-reperfusion injury

(no evidence this improves mortality)

● Measures to control acute abdominal compartment syndrome may lead

to a decrease in translocation

● Intra-operative bowel manipulation has been shown to adversely affect gut barrier function and

increase bacterial translocation in humans

● Decrease the use of opiates in the critically ill when suitable alternatives are available
- Opiate sparing protocols for analgesia are known to reduce nausea and vomiting, enhance transit

times, preserve intestinal migratory motor complexes

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CHAPTER 4.0 : ISOLATION ROOM

Introduction

An isolation facility aims to control the airflow in the room so that the number of airborne infectious particles
is reduced to a level that ensures cross-infection of other people within a healthcare facility is highly unlikely.

This may be achieved by:

● Control of the quantity and quality of intake or exhaust air.
● Maintain different air pressures between adjacent areas.
● Designing airflow patterns for specific clinical procedures.
● Diluting infectious particles with large air volumes.
● Air filtration – HEPA filters, etc.

Patients that’s been diagnosed or suspected with an infectious disease, which either can be transmitted by
contact, droplets or airborne will be required an isolation room to prevent the transmission of microorganism.

The isolation room can be part of a department or a ward, or can be grouped into a dedicated ward or
building.

Classification of Isolation Room

Airborne Infection Isolation Room (AIIR) Protective Environment Room (PE) Contact Isolation Room

Commonly known as Negative Pressure Commonly known as Positive Pressure This type of room is for patients
Room Room infected with MDRO or has
food or water borne diseases.
The air pressure in the patient’s room is The pressure inside the room greater
more negative compared to the corridor, to than the corridor, to promote air flow This room does not require
promote the air flow from the corridor into the from patient’s room to the outside special design measurement
patient’s room. for the ventilation system or for
This is to prevent transmission of air-conditioning.
This is to prevent infectious particles pathogens from the outside
generated by the patient in the isolation environment to enter the isolation room.
room from spreading to other patients, staff
or visitors. These rooms are used to isolate
suspected or infected patients who are
The room required a ventilation system that severely immunocompromised.
shall not share with the other rooms or areas.
Pe is a suite made of a patient's room
AIIR is a suite made of the patient’s room with an ensuite bathroom with an
and a private toilet. However, ensuite anteroom.
bathrooms are not required in certain
specialized areas such as intensive care Examples of cases :
units, neonatal care units, or cardiac care
units. • Bone marrow or organ
transplant recipients
Examples of cases :
• Severe burns
• Tuberculosis • Severe neutropenia
• Chickenpox • Allogeneic Hematopoietic
• Avian Flu
• Measles Stem cell Transplant

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● Proper hand hygiene techniques must be followed before entering and after leaving the room
● To assure safety for the patient and family/visitors, those entering the room shall don the required

PPE according to the type of isolation
● Visitors, including family member presence, should be limited under certain circumstances.
● Children under the age of 12 are not allowed to visit.

AIIR and PE requirements
(A) Anteroom

1. Also known as ‘airlock lobby’
2. Isolation rooms do not necessarily always require the provision of an Anteroom. This should be

determined by the proposed operational policy and be included at an early stage of the design
process. Where an Anteroom is however a requirement, it must be provided with self-closing doors
and be of sufficient area.
3. The Functions of anteroom are:
● A controlled area to transfer of the patients, supplies, or equipment, without contamination on

surrounding health care areas.
● A barrier against the potential loss of pressurisation.
● Controls the entry or exit of contaminated air when the anteroom door is opened.
● A controlled area where personal protective equipment (PPE) can be donned or removed prior

to entering or exit from an isolated contamination area.
● Sinks should be available for hand washing in the anteroom.
● The Anteroom required adequate space for storage of PPE, i.e. gowns, gloves and mask for

the protective isolation.
● Anterooms should not be shared between the isolation rooms.

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(B) Pressure Regulator
1. Each AIIR and PE isolation room should have an individual pressure regulator.
2. Dual function of positive and negative pressure regulators for an isolation room is not recommended.
The faulty or malfunction of the link between both pressures can cause pressure imbalance.
3. When rooms are not properly pressurised, airborne contaminants can escape putting the health of
patients and staff at risk.

* Dual function of pressure regulator (both positive &
negative) for an isolation room which shall not be
permitted

(C) Room pressure monitoring system
The stringent monitoring of room pressurization via appropriate devices or verification mechanism(s) should
be strictly adhered to in order to eliminate any possibilities of pressure scheme changes in the dedicated
isolation room.
All isolation rooms require a permanently installed visual mechanism to constantly monitor the pressure
difference between the isolation room and the adjacent spaces when occupied by a patient.
The nursing care plan when caring for patients in the isolation room will include daily monitoring and
documentation of the room and anteroom.
The maintenance staff shall ensure all related gauges and environmental parameter indicators at the
isolation room are inspected, serviced, and calibrated as per stipulated frequency for optimum operation of
the room.
Records shall be kept for evidence and reference.

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(D) Verifying room pressure

The pressure readings in the isolation room shall be verified on a daily basis by the HCWs to ensure that
the systems are functioning as per designed or standard requirements. Any deviation or inconsistency of
readings shall be immediately reported to the maintenance staff

(E) Smoke test

Smoke test is one of the methods of testing available to verify that the systems are functioning as desired.
For a smoke test, a smoke tube is used to verify the system performance. In Malaysian healthcare facilities,
smoke tube test is acknowledged as a valid passive test for air flow testing.

Smoke tube is a tube that generates white, noncorrosive smoke that is used to create a white trail of the
airflow. This tube is also known as a smoke generator. This smoke tube shall be held parallel to the door,
about 2 inches in front of the gap under the closed door outside the room. Once the tube is squeezed, white
smoke will be generated. The smoke will travel in the direction of airflow. If the room is at a positive pressure,
the smoke will travel away from the door and into the corridor. If the room is at a negative pressure, the
smoke will travel under the door and into the room (from higher to lower pressure).

This test shall be performed while the door is closed. If room air cleaners are being used in the room, they
shall be running. A smoke test is the most reliable method of testing, but is only a qualitative method, which
is a snapshot in time, and is labour intensive. If smoke tubes are not available, an incense stick can be used.

Preparation of the AIIR before patient placement.

1. Always ensure the negative pressure system is functioning

2. Label the sign on the door

3. Remove all non-essential furniture. The remaining furniture should be easy to clean and should not
conceal or retain dirt or moisture within or around it.

4. Place a storage outside the isolation room to stock clean PPE and linen.

5. Stock the sink area with suitable supplies for hand hygiene. Wall-mounted soap and disinfectant
dispensers which are preferable touch free.

6. Ensure there is a two way communication system i.e intercom, and it is functioning well. It is to enable
patients or family members/ visitors to communicate with HCWs to minimize the necessity for HCWs to enter
the room/area.

7. Place appropriate waste bags in the pedal operated bin.

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8. Place a puncture-proof container for sharps disposal inside the isolation room.
9. Keep the patient’s personal belongings to a minimum. Keep water pitchers and cups, tissue wipes, and
all items necessary for attending to personal hygiene within the patient's reach.
10. Each isolation room should be provided with a stethoscope, thermometer, blood pressure cuff, and
sphygmomanometer.
11. Any patient-care equipment that is required for use by other patients should be thoroughly cleaned and
disinfected immediately after use.
12. Place an appropriate container with a lid outside the isolation door for non-disposable equipment that
requires disinfection or sterilization.
13. Ensure daily cleaning of the isolation room/ area.
14. Keep adequate equipment required for cleaning or disinfection inside the isolation room/ area.
15. Educational information on necessary precautions and procedures should be readily available and
accessible for staff, patients, and visitors, while ensuring there Is no breach of medical confidentiality.

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CHAPTER 5.0 : CLINICAL PRACTICES

CHAPTER 5.1 ASEPTIC TECHNIQUE

Adherence to the current national policies and procedures, it is important to maintain aseptic technique to
prevent and minimise spread of infections from multiple sources to a patient . The aim of aseptic technique
is to reduce the incidence of healthcare associated infections by maintaining :

● a microorganisms-free environment in the hospital
● instruments sterility
● sterile field of clinical procedures

Aseptic technique can be maintained by strict adherence to various components as shown in Figure 5.1.

Hand hygiene Non touch technique

Wearing sterile Aseptic technique A sterile field
gloves
Sterility of
Minimizing bacteria instruments/disposa
at entry points
ble items

Figure 5.1 Aseptic technique components

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Non touch technique
1. Non touch technique refers to a method of not touching any surface directly during a procedure.
2. It is important to ensure that the hands do not cause contamination to the sterile equipment or
patient even after doing hand hygiene.

Use forceps to avoid contamination

Use sterile gloves to maintain aseptic technique
3. The sterile instrument or item can be contaminated if it comes into contact with a non-gloved hand

and other non-sterile items.

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Minimising microorganisms on hands by hand hygiene
(Please refer to hand hygiene section)
1. Hand hygiene is a very important practice to prevent HCAI by following the 5 moments of hand
hygiene.

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Wearing sterile gloves to keep the sterility of hands
1. When doing clinical procedures, sterile gloves need to be worn to render the hand sterile.
2. Steps of gloving are shown in the picture as follows.

Please ensure that the first step is done by touching the inner side of the glove.
3. After the gloving process is done, the gloved hand cannot come into contact with non-sterile areas

or items, including the patient's skin.
4. The glove needs to be changed if it is torn, punctured or contaminated.
5. An assistant is recommended to help in doing non-sterile tasks.
6. In case of working alone without an assistant, tasks need to be coordinated before and after

gloving to maintain the sterility.

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Open the outside package of sterile gown and gloves before hand hygiene.

Drop the sterile equipment/items on the sterile field.
7. If one hand needs to perform a non-sterile task once gloved, the sterile hand will be used to

perform the clinical procedures. The examples are shown as in the following pictures.

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Urinary catheterisation
Hold the labia minora with the non-dominant hand and cleanse the urethra

Insert the catheter with the dominant sterile hand

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Inflate the catheter balloon using sterile hand
Connect the indwelling catheter to the urinary bag using sterile technique

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Laryngeal suctioning via tracheostomy
- Hold the non-sterile sucker tubing with the dominant hand and the sterile suction

catheter with the sterile hand.
Minimizing bacteria at entry points

1. Skin preparation is very important before performing sterile procedures to remove common
pathogens on the skin.

2. Although the skin harbors harmless commensals, it may lead to infection if it enters the
bloodstream, especially when the patient is in immunocompromised state.

Pre-procedure skin antisepsis using chlorhexidine

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Creating a sterile field
1. A sterile field is an area created by placing sterile drapes on the patient’s skin around the
procedure site and it will accommodate sterile instruments needed during the procedure.
2. The skin exposed must be as minimum as possible and the sterile field should not come into
contact with non sterile items.
3. HCWs are advisable to wear sterile gown during clinical procedures to avoid contamination of the
sterile field.

Sterile field during surgery
Maintaining sterility of instruments/ disposable items during a procedure
1. The sterility of instruments/items can be maintained by several methods as follows.

a. Non-touch technique
i. Do not touch the inner surface of sterile packages/envelopes upon opening.
ii. Drop the sterile instruments on the sterile field.
iii. Wear sterile gloves to receive the instruments/inside packages without touching the
outside surface.
iv. Use sterile forceps to grasp the instruments during transfer.

b. Place all sterile instruments needed during the procedure in the sterile field, especially when
using long lines or wires e.g. guide wires.

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Preparation for chest drain insertion in a sterile field

2. However, there will be some problems connecting the sterile catheter or tubes to non-sterile
connectors. In some cases, the person performing the procedure should secure the connections
before passing the containers (underwater seal bottles /urine containers) to the assistant for non-
sterile tasks.

Secure the connection of the urinary catheter and bag in a sterile field.
3. Below is the example of central line insertion.

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Preparation of central line equipment on the sterile field.
Central venous catheter insertion

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