Infection Prevention and Control Policy in the Intensive Care Unit/Critical Care
Unit
1.0
OBJECTIVE
1.1 To standardize the infection control practice and adherence in Intensive
Care Unit / Critical Care Unit (ICU/CCU).
2.0
SCOPE
2.1 This policy shall apply to all ICU/CCU staff members, patients, and
accompanying persons.
3.0
POLICY
3.1 All ICU/CCU staff members shall be oriented on its infection control policy.
3.2 All ICU/CCU shall know how to comply with its infection control policy.
3.3 Level of compliance on infection control shall be assessed and evaluated by
Infection Prevention Control Committee.
4.0 PROCEDURE
4.1 Staff members:
4.1.1 The staff members shall fill out the Health Declaration Monitoring
Form (HDMF) prior going to the scheduled work day.
4.1.2 Symptomatic staff members shall notify the Nurse Supervisor eight
hours prior the scheduled work day.
4.1.3 NO facemask, NO entry shall be strictly implemented. A medical
grade facemask shall be required. Cloth mask or valve mask is
prohibited.
4.1.4 Staff members shall wear the prescribed hospital uniform paired with
a closed shoes. Hair tied up and use hair net, no dangling earrings,
no jewelries except the wedding ring and watch. Nails shall be neatly
trimmed. Artificial nails and nail polish shall be prohibited.
4.1.5 Upon entering the area, change into a clean scrub suit and remove
outside footwear and change into a clean footwear (Memorandum
No. 2022-052)
4.1.6 Practice 5 Moments of Hand Hygiene.
4.1.7 Wear appropriate PPE requirement for healthcare workers and
hospital personnel, refer to Table 1.0 and Table 2.0
4.1.7.1 Gloves shall be worn before handling equipment/items with
chemicals, medication, and/or blood and other body
secretions such as syringes, cotton, etc.
4.1.7.2 Gloves shall be removed and changed after each patient
interaction and when handling the equipment of several
patients.
4.1.7.3 Wear Level 4 PPE in Aerosol Generation Procedures, and
when possible, wear eye protection when blood contact or
splashed procedure is anticipated.
4.1.8 Remove PPE and inside clean footwear and put on smock gown
when leaving the ICU/CCU Area. (Memorandum No. 2022-052)
4.1.8.1 After work, remove work clothes or scrub suit and change into
prescribed hospital uniform.
4.1.8.2 Staff members shall be prohibited from eating and drinking in
the area; eating shall be allowed in the canteen area of the
hospital and in the pantry separated in well-ventilated space
with 1-2 meter radius physical distance for not more than 15
minutes. Consider taking turns during meal breaks. Strictly
NO sharing of food shall be observed.
4.1.8.3 Food and beverages shall not be stored in the area’s
refrigerator or other areas where chemicals, equipment or
other potentially infectious materials are kept.
4.1.8.4 Staff members shall orient patients and accompanying
persons regarding infection prevention and control practice in
the hospital such as hand hygiene, proper segregation of
waste, and certain standard precautions if necessary.
4.1.8.5 Wastes shall be disposed properly:
4.1.8.5.1 Green for biodegradable wastes such as food
4.1.8.5.2 Black for recyclable wastes such as paper plastics
etc.
4.1.8.5.3 Yellow for infectious waste such as PPE, napkins
and/or tissues with secretions, etc.)
4.1.9 Patients and accompanying persons
4.1.9.1 Strictly NO WATCHER and Visitors are allowed in the ICU.
4.1.9.2 If needed, the accompanying person shall be directed to the
QUICK CHECK STATION for initial assessment by the triage
staff at the OPD Area. Temperature shall be checked. Perform
hand hygiene. Alcohol-based hand rub or hand washing area
shall be available in the area.
4.1.9.3 A Health Declaration Form shall be issued to all.
4.1.9.4 Accompanying persons with symptoms and exposure risks
shall be prohibited to accompany the patient. A Rapid Antigen
Swab test shall be required to the unvaccinated accompanying
persons.
11.0.1 Only necessary visits shall be allowed. Relatives shall sanitize
their hands before and after visiting the patient.
4.1.9.5 Clean gowns/Impermeable gown provided by the ICU/CCU
shall be worn when entering the area.
4.1.9.6 Personal outside footwear shall be placed on the shoe rack
provided; and prepared inside clean slippers shall be worn. In
the absence of inside slippers, a shoe cover shall be worn.
4.1.9.7 NO facemask, NO entry shall be strictly implemented. A
medical grade facemask shall be required. Cloth mask or valve
mask is prohibited.
4.1.9.8 Patients
with
confirmed
respiratory
infection
such
as
Tuberculosis, suspect and probable cases for COVID-19 shall
be placed in an Isolation Room.
4.1.9.9 Confirmed cases for COVID-19 shall be placed in the
Bayanihan Isolation Ward.
4.1.9.10 Wastes shall be disposed properly:
4.1.9.10.1 Green for biodegradable wastes such as food
4.1.9.10.2 Black for recyclable wastes such as paper plastics
etc.
4.1.9.10.3 Yellow for infectious waste such as napkins and/or
tissues with secretions, etc.)
4.2 Isolation
4.2.1 Assess the need for isolation. Screen all Intensive Care Unit (ICU)
and Critical Care Unit (CCU) patients for the following:
4.2.1.1
Neutropenia (chemotherapy patients) and immunological
disorder (AIDS, cancer and transplant patients, patients who
are taking certain immunosuppressive drugs)
4.2.1.2
Diarrhea and/or vomiting
4.2.1.3
Undiagnosed rashes and fevers
4.2.1.4
Known communicable disease (tuberculosis, HIV/AIDS, flu,
measles, MRSA, COVID-19, monkeypox)
4.2.1.5
Known
carriers of
an
epidemic strain of
bacterium
(Pseudomonas, Staphylococcus aureus)
4.2.1.6
Suspected or confirmed Group A streptococcal infection (i.e.
necrotizing fasciitis)
4.2.1.7
Bacterial Meningitis
4.2.2 Identify the type of isolation needed.
4.2.2.1
There are two types of isolation in the ICU:
4.2.2.1.1 Protective
isolation-
to
protect
an
immunocompromised patient who is at high risk of
acquiring
micro-organisms
from
either
the
environment or from other patients, staff or visitors.
4.2.2.1.2 Source isolation- to confine the infectious agent and
prevent its spread from one patient to another.
(Source isolation was previously known as ‘barrier
nursing’).
4.2.3 Isolation rooms shall have tight-fitting doors, glass partitions for
observation and both negative-pressure (for source isolation) and
positive-pressure (for protective isolation) ventilations.
4.2.3.1
Negative air pressure - air pressure inside the room is lower
than the air pressure outside the room.
4.2.3.2
Positive air pressure - a pressure within a system that is
greater than the environment that surrounds that system
4.3 Patient at Risk of Nosocomial Infections
4.3.1 Age more than 70 years
4.3.2 Shock
4.3.3 Major trauma
4.3.4 Acute renal failure
4.3.5 Comatose
4.3.6 Prior antibiotics
4.3.7 Mechanical ventilation
4.3.8 Drugs affecting the immune system (steroids, chemotherapy)
4.3.9 Indwelling catheters
4.3.10 Prolonged ICU/CCU stay (>3 days).
4.4 Standard and Transmission Based Isolation Precaution
4.4.1 The attending physician shall determine what type of Isolation
precaution is the case of the patient.
4.4.2 The Nurse shall label what type of isolation precaution the chart and
patients bed.
4.4.3 Standard Precaution
4.4.3.1
Previously called “Universal Precaution”
4.4.3.2
Assumes blood and other body fluid of ANY patient
could be infectious
4.4.3.3
Standard Precaution I
4.4.3.3.1 Gloves - use when touching blood, body fluids,
secretions, excretions and contaminated items
4.4.3.3.2 Gowns - use during procedures and patient care
activities when contact with clothing/ exposed skin
with blood/ body fluids, secretions and excretions
are anticipated
4.4.3.4
Standard precaution II
4.4.3.4.1 Mask and Goggles - use during patient care
activities likely to generate splashes or sprays of
blood, body fluids, secretions and excretions
4.4.4 Transmission Based isolation precaution
4.4.4.1
Contact Precautions - gown and gloves for contact with
patient or environment of care (e.g. presence of stool
incontinence, draining wounds, uncontrolled secretions,
pressure ulcers, draining body fluids)
4.4.4.2
Droplet Precautions - surgical mask and face shield
within 3 feet of patient (e.g. respiratory viruses)
4.4.4.3
Airborne Infection Isolation - particulate respirator is
use (e.g. N95), negative pressure isolation room also required
(e.g. tuberculosis, influenza, measles, H1n1 flu)
4.5 Hand Hygiene
4.5.1 Hand washing - is like a "do-it-yourself" vaccine—it involves five
simple and effective steps (Wet, Lather, Scrub, Rinse, Dry) you can
take to reduce the spread of diarrheal and respiratory illness so you
can stay healthy. Regular hand washing, particularly before and
after certain activities, is one of the best ways to remove germs,
avoid getting sick, and prevent the spread of germs to others. Hand
hygiene must be more frequent in the intensive care unit.
4.5.2 Hand Rubbing - Applying an antiseptic hand rub to reduce or inhibit
the growth of microorganisms without the need for an exogenous
source of water and requiring no rinsing or drying with towels or other
devices.
4.6 5 Moments for Hand Hygiene
4.6.1 Before touching a patient,
4.6.2 Before clean/aseptic procedures,
4.6.3 After body fluid exposure/risk,
4.6.4 After touching a patient, and
4.6.5 After touching patient surroundings.
4.7 Strategies to reduce VAP
Ventilator-associated pneumonia (VAP) is a lung infection that develops in a
person who is on a ventilator. A ventilator is a machine that is used to help a
patient breathe by giving oxygen through a tube placed in a patient’s mouth
or nose, or through a hole in the front of the neck. An infection may occur if
germs enter through the tube and get into the patient’s lungs.
4.7.1 Consider noninvasive ventilation whenever possible
4.7.2 Keep head elevated at 30-45° in the semi-recumbent body position
4.7.3 Daily oral care
4.7.4 Daily sedation vacation if feasible and assessment of readiness to
extubate
4.7.5 Avoid re intubation whenever possible
4.7.6 Routine change of ventilator circuits is not required
4.7.7 Monitor endotracheal tube cuff pressure (keep it >20 cm H 2 O) to
avoid air leaks around the cuff, which can allow entry of bacterial
pathogens into the lower respiratory tract
4.7.8 Prefer endotracheal tubes with a subglottic suction port to prevent
pooling of secretions around the cuff leading to micro aspiration
4.7.9 The heat moisture exchanger may be better than the heated
humidifier
4.7.10 Closed endotracheal suction systems may be better than the open
suction
4.7.11 Periodically drain and discard any condensate that collects in the
tubing of a mechanical ventilator
4.7.12 The Nurse shall continue to implement the VAP bundle of care
checklist.
4.8 Strategies to reduce CLABSI
A central line-associated bloodstream infection (CLABSI) is a serious
infection that occurs when germs (usually bacteria or viruses) enter the
bloodstream through the central line.
4.8.1 Prefer the upper extremity for catheter insertion. Avoid femoral
route for central venous cannulation (CVC) if possible.
4.8.2 Use maximal sterile barrier precautions (cap, mask, sterile gown
and sterile gloves) and a sterile full-body drape while inserting
CVCs,
4.8.3 Clean skin with more than chlorhexidine preparation with alcohol
(usually 2% chlorhexidine with 70% w/v ethanol) before CVC,
arterial catheter insertion, etc., (Hospital order no. 2022-466)
4.8.4 Use chlorhexidine spray when the catheter is expected to remain in
place for more than 5 days and only if the bloodstream infection
rates are high in the unit despite successful implementation of
measures to reduce CLABSI (Hospital order no. 2022-466)
4.8.5 Use either sterile gauze or sterile, transparent, semipermeable
dressing to cover the catheter site. Replace the catheter site
dressing only when the dressing becomes damp, loosened, or
visibly soiled
4.8.6 Evaluate the catheter insertion site daily and check if a transparent
dressing is present and palpate through the dressing for any
tenderness
4.8.7 Insertion date of central line shall be documented
4.8.8 Use chlorhexidine wash daily for skin cleansing to reduce CLABSI
(Hospital order no. 2022-466)
4.8.9 Use needleless intravascular catheter access systems and avoid
stopcocks. If possible, consider using closed catheter access
system than open system.
4.8.10 Clean injection ports with a chlorhexidine spray (Hospital order no.
2022-466) accessing the port only with sterile devices. Dual Cap
stopcocks when not in use
4.8.11 Assess the need for the intravascular catheter daily and remove
when not required
4.8.12 Peripheral lines shall not be replaced more frequently than 72
hours. Routine replacement of CVCs is not required
4.8.13 Replace administration sets, including secondary sets and add-on
devices, every day in patients receiving blood, blood products, or
fat emulsions
4.8.14 If other intravenous fluids are used, change in no less than 96-hour
interval and at least every 7 days
4.8.15 Needleless connectors shall be changed frequently (every 72
hours)
4.8.16 Replace disposable or reusable transducers at 96-hour interval.
4.8.17 The Nurse shall continue to implement the CLABSI bundle of care
checklist.
4.9 Strategies to reduce CAUTI
Catheter Associated Urinary Tract Infection (CAUTI) is an infection of the
urinary tract caused by a tube (urinary catheter) that has been placed to
drain urine from the bladder.
4.9.1 Insert catheters only for appropriate indications
4.9.2 Follow aseptic insertion of the urinary catheter
4.9.3 Maintain a closed drainage system
4.9.4 Maintain unobstructed urine flow. At all times the urinary catheter
shall be placed and taped above the thigh and the urinary bag should
hang below the level of the bladder
4.9.5 The urinary bag shall never have floor contact
4.9.6 Foley catheter shall be changed as prescribed by the doctor.
4.9.7 Remove the catheter when it is no longer needed.
4.9.8 Handwashing shall be done immediately before and after
manipulation of the catheter site or apparatus.
4.9.9 The Nurse shall continue to implement the CAUTI bundle of care
checklist.
4.10 Strategies to reduce SSI
4.10.1 Antiseptic Prophylaxis
4.10.2 Parenteral Antimicrobial Prophylaxis
4.10.3 Glycemic Control
4.10.4 Normothermia
4.10.5 Supplemental oxygenation
4.10.6 Maintain sterile dressing on wound 24-48 hours after surgery. Then
change the dressing every 2-4hours until wound no longer drain or
is clear then change dressing 2 times a day
5.0 Bed Sores and Pressure Sores
5.1 Prevention
5.1.1 Inspect skin daily, keep it clean and dry
5.1.2 Change patient position regularly, at least every 2 hours
5.1.3 Lay patient at 30 degrees
5.1.4 Avoid malnutrition
5.2 Stages of Bedsores
5.2.1 As per National Pressure Ulcer Advisory Panel, bedsores fall
into four different stages, consisting of the following:
5.2.1.1
Stage 1
Stage 1 is the beginning stage of bedsores, and typically is
associated with the following:
5.2.1.1.1 The skin is still intact, but will appear red on people with
a fair complexion.
5.2.1.1.2 The skin area around the bedsore will not blanch
when touched.
5.2.1.1.3 People with dark complexion may not manifest
change in skin color at all, while others may have a
bluish color.
5.2.1.1.4 The affected part is usually painful and warm to the
touch.
5.2.1.2 Stage 2
Stage 2 is when the bedsore becomes an open wound, and consist
of the following:
5.2.1.2.1 The bedsore has a crater-type appearance and the
areas of fat around the infected wound may be
exposed.
5.2.1.2.2 The bedsore appears pinkish in color and looks like a
fluid-filled blister.
5.2.1.3 Stage 3
When bedsores reached the 3rd stage, they are now considered
deep wounds, and consist of the following:
5.2.1.3.1 The pressure sore appears like a crater, with or
without yellow-colored dead tissue attached (known
as slough).
5.2.1.3.2 The damage goes beyond the infected areas and
into healthy skin layers
5.2.1.3.3 The open skin shows fat around the infected area.
5.2.1.4 Stage 4
Stage 4 is the final and most advanced stage of bedsores, consisting
of the following:
5.2.1.4.1 The wound has become so damaged that bones,
tendons, and muscles may be exposed.
5.2.1.4.2 The bottom part of the pressure sore shows slough
and dry, dead tissue.
5.3
Bed Sore Treatment
5.3.1 Stage I
5.3.1.4
A combination of antibiotics and cleaning solution
5.3.1.5
Position patient regularly
5.3.1.6
Supportive aids shall be available such as
specialized mattress, pillows, cushion and air bed
5.3.2 Advanced Stages
5.3.2.4
Debridement in order to successfully remove the
damaged
tissues
5.3.2.5
Wound cleansing, antibiotics, pain medications
6.0 Bed Bath
Giving bed bath cleans the skin of the patient. It helps in making the skin free of
infection and helps the patient feel better and relaxed.
6.0.1 Materials needed:

Disposal gloves

Water basin

Wash clothes

Chlorhexidine soap, powder, lotion, deodorant, comb and mouth
care supplies
6.0.2

Clothing (Gown)

Soft blanket
Before giving a bed bath:
6.0.2.1 Provide privacy
6.0.2.2 Keep the room warm
6.0.2.3 Fill the basin with warm water
6.0.2.4 Put a soft blanket over the top sheet that is covering
the patient. Pull back the top sheet to keep it from
getting wet.
Help remove the patient’s clothes.
Keep the patient warm by covering the body with
the blanket.
6.0.3
Giving the bed bath:
6.0.3.1 Wear disposable gloves.
6.0.3.2 Wet the bath towel without soap. Gently wipe one
eyelid by wiping from the inner corner of the eye to
the outer corner.
Dry the eyelid using a towel.
Rinse the washcloth with water. Wash and dry the
other eyelid.
6.0.3.3 Using soap and water, wash the face, neck, and
ears. Rinse and dry the washed areas. Wash
patient’s hands, arms and underarms. Rinse and
dry them well.
6.0.3.4 Fold down the blanket to wash the chest and
stomach (belly). Wash, rinse, and dry these areas.
Cover the chest and stomach with the blanket.
6.0.3.5 Remove the blanket from one of the legs and put a
towel under the leg. Wash, rinse, and dry the foot
and leg. Do the same with the other leg.
6.0.3.6 Fold down the blanket. Wash the patient’s neck,
back, buttocks (rear end), and thighs (upper legs).
Rinse washcloth in the basin and remove the soap
from the washed areas. Dry the back, buttocks, and
thighs.
6.0.3.7 The perineum shall be the last area to wash. Wear
disposable gloves when washing this area. This
part of the body shall be washed every day to
prevent it from smelling and becoming infected.
6.0.4
Washing a woman’s perineum:
6.0.4.1 Fill the basin with clean warm water. Fold the towel
in half. Ask or help the woman to lift her buttocks.
Put the towel under the buttocks. Ask the woman
to bend her knees and spread her legs. With a
soapy washcloth in one hand, separate the labia
(“lips” of the vagina) with the other hand. Wash the
labia from front to back. Do not touch the anus with
the washcloth. Germs from the anus could get into
the vagina and cause an infection.
6.0.4.2 Rinse the washcloth and remove the soap from the
perineum. It is important to remove all the soap
because it can irritate the skin. Dry the area with a
dry towel.
Do not put powder on the perineum
because it may harden.
6.0.4.3 Wash the anus next. Ask the woman to turn onto
her side so that she is facing away from you. Ask
her to rise up her top leg. This will let you see and
clean the skin around the anus. Slide the towel
under the woman’s buttocks. Use toilet paper or a
paper towel to remove bowel movement that may
be on the skin. You may need to wet the toilet paper
or paper towel if the bowel movement has dried.
Throw the toilet paper or paper towel away in a
trash bag. Wash, rinse, and dry the anal area.
6.0.5
Washing a man’s perineum:
6.0.5.1 Fill the basin with clean warm water. Ask or help
the man to lie on his back. Fold the towel in half
and put it under the man’s buttocks. Ask the man to
bend his knees slightly and spread his legs. Hold
the penis with one hand. With the other hand, wash
the tip of the penis with a soapy washcloth. Rinse
the washcloth and remove the soap from the penis.
6.0.5.2 If the man has a foreskin, gently push it back. Wash
the end of the penis.
Rinse the washcloth and
remove the soap from the end of the penis.
6.0.5.3 Using a soapy washcloth, wash the rest of the penis
and the scrotum. Rinse and dry well.
6.0.5.4 The anus shall be washed next. Ask the man to
turn onto his side with the top leg raised. This will
let you see and clean the anal area easier. Fold the
towel in half and put it under the man’s buttocks.
Use toilet paper or a paper towel to remove bowel
movement that may be on the skin. You may need
to wet the toilet paper or paper towel if the bowel
movement has dried. Throw the toilet paper or
paper towel away in a trash bag. Wash, rinse, and
dry the anal area.
6.0.5.5 Check if the person has skin that is red or sore.
These may be areas where the skin is broken or
getting infected.
6.0.6
After the bath:
6.0.6.1 Rub lotion onto the person’s arms, legs, feet, or
other dry skin areas. Help to dress the person.
Offer to help him with mouth, hair, foot, or nail care.
6.0.6.2 Throw away the dirty water and clean the
washbasin. Put away items used to give the bath.
7.0 Tracheostomy Care
7.1 Materials Needed:
Sterile tracheostomy cleaning kit which includes:
7.1.1 Sterile tray
7.1.2 Sterile field
7.1.3 Sterile brush
7.1.4 Sterile 4x4 gauze pads
7.1.5 Sterile gloves
7.1.6 Sterile dressing pads
7.1.7 Sterile tracheal ties
7.1.8 Clean inner cannula (Fenestrated Cannula)
7.1.9 Hydrogen peroxide
7.1.10 Sterile water (Irrigating Solution)
7.1.11 Sterile suction catheter
7.1.12 Suction machine
7.1.13 Ambu-bag
7.1 Procedure:
7.1.1 Wash your hands
7.1.2 Open the cleaning kit and spread the sterile field out on to the
work area.
7.1.3 Pour the hydrogen peroxide in one tray and sterile water on the
other side
7.1.4 Place the sterile glove on your dominant hand
7.1.5 Remove the items from the kit with the sterile gloved hand and
put them on the sterile field
7.1.6 Suction the patient
7.1.7 Disconnect the patient from the vent with your non-sterile hand.
7.1.8 Unlock and remove the inner cannula with your non-sterile hand
and place it in the tray with the hydrogen peroxide to soak. If using
a non-disposable inner cannula.
7.1.9 Insert a clean inner cannula into the trach tube and reconnect the
patient to the vent.
7.1.10 Use the sterile brush to clean the inner cannula. Rinse the inner
cannula with the sterile water
7.1.11 Use the sterile 4x4 to dry the inner cannula.
7.1.12 Store the clean inner cannula in a covered container
7.1.13 Suction the patient as needed
7.1.14 Remove the soiled trach dressing using the non-sterile hand
7.1.15 Clean the skin with a gauze pad moistened in the sterile water.
Dry the skin with a sterile 4x4.
7.1.16 Apply a clean tracheal dressing and change the tube holder if
needed.
7.1.17 Throw away all of the disposable supplies
7.1.18 Wash your hands
8.0 MEDICAL EQUIPMENT CLEANING AND MAINTENANCE
Medical equipment used in the hospital units need to be cleaned by designated
staff members, when unavailable, shall be delegated with supervision to the
nursing attendants.
8.1 Procedure
The Nurse Supervisor of each nursing unit shall assign a staff member to
perform cleaning and disinfecting on the unit’s medical equipment.
8.1.1 Check user manual of equipment before cleaning for choice of
disinfectant and correct process.
8.1.2 Assemble the equipment to be cleaned in the unit’s dirty utility
room or designated location.
8.1.3 Assemble all cleaning material before starting (disinfectant,
bleach solution, 60-70% alcohol or universal wipes).
8.1.4 Start cleaning the machines in an orderly manner from least
contaminated to the most contaminated for example, from the
top to the bottom.
8.1.5 Put the equipment in a clean area and allow to dry before using
again.
9.0 General
9.1 Clean and disinfect area every 2 hours or as necessary especially
frequently touched objects such as charts, door knobs, computer,
equipment, etc.
9.2 ICU rooms shall be properly cleaned up/disinfected properly prior to
patients’ admissions and after discharge.
9.3 Availability of identified sink for disposal of liquid contaminated wastes in
the medication room and wash area.
9.4 Walls and ceilings shall be kept in good repair, because microorganism
tends to colonize on walls that are moist or sticky. Wall to wall disinfection
shall be once a week regardless of no patient admitted at the ICU room or
as necessary.
9.5 Used of required cleaning detergent and disinfectant are advised. Use ½
cup bleach solution in 1 gallon water as disinfectant.
9.6 Use of brooms in sweeping the floor shall be prohibited. Instead, use
vacuum cleaner or damp mopping per shift or as necessary.
9.7 Frequency of changing contraptions shall be strictly observed as follows:
 IV lines and tubing 72 hours or as necessary
 IFC – 7 days or as necessary
 NGT (PVC – 7 days or as necessary, Silicon – 30 days)
9.8 Disposable items commonly and/or usually used after nursing procedure
9.8.1 Suction catheter for mouth - 1 day or as necessary, for nose – 1 day
or as necessary and for ET – single use
9.8.2 Syringes – single use
9.9
IV container shall not hang for more than 24 hours to avoid microbial
growth.
9.10 Accompanying persons who have been exposed to chicken pox,
tuberculosis, mumps, measles, or any other infectious disease with in
the past 3 weeks shall report to the nurse before visiting. In some cases,
they shall be prohibited to visit as it might pose a risk to their health.
9.11 All staff members and accompanying persons entering patient’s room
with yellow tag shall strictly observe standard precaution.
9.12 Room temperature at 25-270C shall always be maintained.
9.13 The far end of the area shall be assigned as the Isolation Rooms.
9.14 Disposal of liquid contaminated wastes and by products from patients
shall be done only at the identified lavatory located at the ICU
department.
9.15 Each patient shall be entitled to have exclusive items for their personal
use alone. Examples of such items are the following:
9.15.1 The use of individualize cardiac monitor, suction machine, wall
oxygen and cannula.
9.15.2 The use of feeding materials. (asepto syringe, calibrated
glasses, utensils and water). Properly stored in the patients’
cubicle.
9.15.3 The use of individualize cleaning materials for the abovementioned feeding materials.
9.15.4 Identified personal materials used in morning care are the
following:
2 basins
toothbrush and toothpaste
2 hand towels
comb
cotton
1 towel
razor
cotton buds
liquid soap
chlorhexidine wet wipes
Bactidol
shampoo
feminine wash
diaper
underpads
lotion
deodorant
Tongue depressor Gauze pads
tissue
alcohol
Spoon
Straw
mask
chlorhexidine pads – 10 pieces.
Chlorhexidine soap
9.16
Personal care supplies shall not be shared between patients and
shall be cleaned after use.
9.17
Each patient’s personal care supplies shall be identified with his/her
name and kept at his/her bedside in a clean container (e.g. in a washable
cosmetic bag or plastic container). Toothbrush and oral hygiene products
shall be kept in a separate bag.
9.18
Osteorized feeding (OF) shall be stored at the refrigerator at all times
and shall be consumed within 24 hours.
10.0
Waste Management
10.1
Waste should always be disposed according to type.
10.1.1 Green for biodegradable wastes such as food
10.1.2 Black for recyclable wastes such as paper plastics etc.
10.1.3 Yellow for infectious waste such as napkins and/or tissues with
secretions, etc.)
10.2
Waste collection and disposal by the housekeeping staff shall be done after
every shift or as needed.
10.3
Only yellow trash bins shall be seen in comfort rooms, black and green in
working areas, and complete set on central disposal area. And for patient’s
room, complete set of trash bins are seen yellow in comfort rooms and black
and green on allocated room area.
10.4
When the punctured-proof container is already ¾ full, cover shall be gently
closed, place in yellow plastic, close tightly, and attach a label “SHARPS” and
the name of forwarding department by nursing attendant and endorsed to
housekeeping
staff
for
proper
disposal.
11.0
Environmental Care
11.1
Staff members and housekeeping shall ensure that all areas are
maintained in a clean and neat manner at all times.
11.2
Working tables, cabinets, and shelves - Damp dusting shall be
done every two hours or as necessary.
11.3
Floors - Wet dust mopping shall be done every two hours or as
necessary.
11.4 Sinks - Shall be cleaned every two hours or as necessary.
11.5 Comfort room - Shall be cleaned every two hours or as necessary.
11.6 Wall to wall - Shall be done weekly or as necessary.
11.7 Ceiling - ceilings shall be cleaned weekly or as necessary.
11.8 Curtains - shall be changed weekly or as necessary.
11.9 Refrigerator, water dispenser, and electric fan shall be cleaned weekly or
as necessary.
11.10 Filter of air-conditioning unit shall be cleaned monthly or as necessary.
11.11 Blinds shall be cleaned through damp dusting or spraying of disinfectant
after discharge.
11.12 Frequently touched surfaces (e.g. computer keyboards, handrails, door
knobs, bed side tables, tap handles, mirrors) shall be cleaned every two
hours or as necessary.
12.0 Safe Handling of Blood or Body Fluid Spill
12.1
The spillage shall be removed using appropriate PPE.
12.2
Cover the spillage with disposable paper roll or cloth to soak up and
contain the spillage.
12.3
Once contained, the spill and disposable roll shall be placed in a yellow
waste bag.
12.4
If the spillage contains glass and other sharp objects disposable roll
shall be collected using a scoop to avoid handling contaminated sharps.
12.5
Disinfect by wiping the floor using approved disinfectant (bleach
solution or Presept ) by the housekeeping staff.
13.0 Linen Management
13.1 Clean linens shall be kept in a closed area or covered when not in use.
13.2 All linens shall be used only by the patients.
13.3 Used linens shall be changed daily or when visible soiled.
13.4 For patients with communicable diseases, linens shall be changed after
use.
13.5 Soiled linens shall be discarded in a designated hamper.
13.6 All soiled linen shall be considered potentially infectious.
13.7 Soiled linen shall be handled as little as possible and with a minimum of
agitation to prevent gross microbial contamination of the air and of
persons handling the linen.
13.8 Linen shall not be sorted or rinsed in patient care areas.
13.9 All soiled linen shall be bagged at the location where it was used and
segregated as wet and dry. Wet or heavily soaked linens are placed in
a plastic bag first before discarded into a leak proof laundry bags to
prevent spillage. Leak proof laundry bags shall be placed with yellow
plastic and shall be identified by labels as DRY or WET.
13.10 Caution shall be exercised to help prevent laundry bags from being
OVERFILLED.
13.11 Soiled linen shall be collected by linen staff every shift or as needed.
14.0
SAFETY
14.1 Medication and equipment
14.1.1 All ICU patients shall use Safeset instead of macroset.
14.1.2 Triple lumen extension port shall be provided as necessary.
14.1.3 All Intravenous medications shall be given needleless.
14.2 Safe Environment
14.2.1 All patients side rails shall be elevated at all times. Side rails shall
be included during room disinfection.
14.2.2 The use of available beds shall be used by the patient alone.
14.2.3 No pillows are allowed inside the ICU.
14.2.4 Strictly no smoking/vaping inside the ICU.
15.0
Patient Transport
15.1.1 Patients for admission and for transfer to the wards or units shall
be conducted anytime through provided routes. Pathways shall
be cordoned, sanitized, and disinfected after every patient
transport.
15.1.2 Concerned and/or receiving departments shall be notified
immediately about the precautions to be performed upon transfer
of patient.
Table 1.0 CONTENTS OF PPE
PPE LEVEL
PPE LEVEL 4
PPE LEVEL 3
PPE LEVEL 2
CONTENTS

Coveralls or Hazmat Suit

Impermeable Gown

Surgical Cap

Fit Tested N95 Mask

Goggles or Face Shield

2 Layers of Gloves

Dedicated Shoes

Impermeable Shoe Covers

Impermeable Gown

Surgical Cap

Fit Tested N95 Mask

Goggles or Face Shield

2 Layers of Gloves

Impermeable Shoe Covers

Impermeable Gown

Medical Grade Facemask

Goggles or Face Shield

1 Layer of Gloves (if needed)

PPE LEVEL 1
Medical Grade Facemask
Table 2.0 PPE REQUIREMENT FOR HOSPITAL PERSONNEL
UNIT
PATIENT CATEGORY
PPE REQUIRED
OPD Triage Staff
General
PPE Level 2
Security Guards
General
PPE Level 1
Nursing
ICU Patients
PPE Level 2
Attendants
*PPE Level 3-4 for
Isolation Areas
Housekeeping
General
Staff
PPE Level 2
*PPE Level 3-4 for
Isolation Areas
Admitting
Patients for OPD Consult, Patients
PPE Level 1
Section/Concierge and Hospital Services and Ancillary
Procedures
ICU/CCU Nurse
ICU/CCU Patients
Supervisors
ICU/CCU Nurses
PPE Level 3 to PPE
Level 4
ICU/CCU Patients
PPE Level 3 to PPE
Level 4
16.0
REVISION:
Policy will be revised every 2 years or as needed.
17.0
APPROVALS:
Prepared by:
Reviewed by:
Approved by: