Republic of the Philippines

Province of Negros Occidental

City of San Carlos
SAN CARLOS CITY HOSPITAL
Hda. Sta. Ana (C2 Road) Barangay Palampas, San Carlos City, Negros Occidental
Trunkline Nos. (034) 312-5661/ 312- 5663 (034) 312-5771/ 312- 5773
E-mail add: scchospital@yahoo.com
______________________________________________________________________________

February 15, 2023

INFECTION PREVENTION AND CONTROL PROGRAM OF THE HOSPITAL

I. PROJECT PROPOSAL : Infection Prevention and Control Program

II. PROJECT LOCATION: San Carlos City Hospital

III. PROJECT COST:

IV. SOURCE OF FUNDS: San Carlos LGU

V. TARGET AND NUMBER OF BENEFICIARIES: Patients, patients accompanying,

hospital staff and visitors

VI. RATIONALE/ BACKGROUND:

A. Policy mandate

The emergence of the COVID-19 pandemic in 2020, amplified the urgency to revise the
National Policy on Infection Prevention and Control to strengthen the IPC across all health
facilities and thus better manage the COVID-19, other emerging infectious diseases, and all
future public health emergencies.

The order aims to strengthen the healthcare service delivery by focusing on sustainable,
manageable and critical interventions that optimize the available resources supported by
evidence and sufficient groundwork for IPC.

This order shall include systems that will drive better execution of the IPC program such
as mechanisms for reporting and feedback. Ultimately, this shall contribute to quality patient-
centered care for all Filipinos, as aligned with the Republic Act (RA) No. 11223 otherwise
known as the Universal Health Care (UHC) Act and the A.O. 2022-0038 or the Health Sector
Strategy for 2023-2028.

B. OBJECTIVES
a. To develop effective and efficient implementation of IPC programs
b. To strengthen the delivery of healthcare services through better execution of the
IPC program through reporting and feedback mechanism
c. To improve patients safety, quality of care, management of emerging infectious
diseases, the AMS program

C. General Guidelines

a. All public and private health facilities shall adopt the National Policy on the
Infection Prevention and Control (IPC).

b. The National Policy on IPC shall be part of the overall initiatives in improving
patient safety, quality of care, management of emerging infectious diseases,
the Antimicrobial Stewardship program and the current facility licensing
standards of the DOH.
c. The National Policy on IPC shall be based on the World Health Organization’s
eight (8) core components of IPC.

d. All public and private health facilities shall establish effective and efficient IPC
programs that involve multidisciplinary and multimodal strategies to prevent
and control the spread of infections. The IPC Committee, in partnership with the
AMS Committee, the Health Care Waste Management Committee, the Patient
Safety Committee and the Pharmacy Therapeutics Committee.

Specific Guidelines

The eight (8) core components shall serve as the framework for the health
facilities IPC Programs.

1. Infection Prevention and Control Program Management Structure

Creation of IPC Management Structure under the Head of Office with

sufficient resources and clear lines of responsibility between the IPCC (Infection
Prevention and Control Committee) and IPCU (Infection Prevention and Control
Unit):

IPCC shall oversee the IPC program implementation, coordinate with

and provide recommendations to the IPCU. A multidisciplinary committee
composed of representatives from the various health facility departments
involved in the IPC activities.

IPCU shall be in-charge of the day to day operations in the

implementation of the IPC program, and shall be composed of the following:

a. Primary Care and Other Health Facilities-

IPC-trained designated health care officer with dedicated time to the
implementation of IPC activities in coordination with the primary care
physician in charge of the facility.

2. Infection Prevention and Control Guidelines, Policies, and Procedures

Written guidelines, policies and procedures on the following:

a. hand hygiene
b. standard transmission-based precautions
c. triage of infectious patients
d. aseptic technique
e. cleaning, disinfection and sterilization of medical devices and
equipment
f. environmental cleaning and disinfection
g. healthcare waste management
h. safe injection practices
i. prevention of highly communicable infections
j. outbreak investigation
k. healthcare workers protection and occupational safety against
infectious diseases, such as COVID-19, blood borne-infections (HIV,
Hepatitis B, Hepatitis C), and other emerging infectious diseases
that include:

 Vaccination (COVID-19 vaccine)

 Post-exposure prohylaxis (Hepatitis B vaccine)
 PPE use and fit testing
 Medical Check Up
 3. Infection Prevention and Control Education and Training

a. Capacity building activities for IPC.

b. Regular infection prevention and control education

programs focusing on relevant topics appropriate for specific clinical settings

c. Periodic evaluation and assessment of education/training programs to measure

its effectiveness to the staff involved in IPC.

4. Healthcare-Associated Infection Surveillance

a. Implementation of the outbreak investigation and over-all surveillance process

for hospital acquired infection or HAI.
b. Use of standard reporting forms which shall be provided to the IPCC from the
data collected.

5. Multimodal Strategies

Multimodal strategies are the five-step approach to IPC that includes

preparation for action, conduct baseline assessment, develop and execute an
action plan evaluate impact and develop an ongoing action plan and review
schedule to sustain the program over the long term.

6. Monitoring, Audit, and Feedback of Infection Prevention and Control

Reporting of hospital infection rates, (SSI, CAUTI, HAI)

7. Workload, Staffing and Bed Occupancy

Surge capacity management plan shall be instituted in cases of increasing bed

occupancy rate (ideal BOR is 80-85%) to ensure Infection Prevention and
Control Standards are maintained to reduce the risks of HAI and spread of AMR.

8. Built Environment, Materials and Equipment for Infection Prevention

and Control

a. Ensure constant access to clean and sufficient quantity of water for the
performance of basic IPC measures ( hand hygiene, environmental cleaning,
decontamination of devices and health care waste management

b. Lay out adequate natural or mechanical ventilation, decontamination of

reusable medical devices, triage, and space for temporary cohorting/
isolation/physical separation

c. availability of sufficient and appropriate IPC supplies and equipment such as

mops, detergent, disinfectant, PPE and sterilization, and reliable
power/energy supply for performing all IPC measures.

VIII. BUDGETARY REQUIREMENTS

Minimum Requirements
1. IPC Budget
Personnel –
Trained Healthcare Officer / Trained IPC link person
 2. IPC Guidelines, Policies and Procedures
Annual medical check up (CBC, X-RAY)
Vaccination of hospital staff ( COVID-19 , Pneumonia and Flu vaccines)
Post exposure prophylaxis to needle stick injured hospital staff

3. Trainings and Education:

Appropriate education and training for clinical and non-clinical staff on IPC guidelines
Invite Speakers, Venue for the Training/Seminars, Snacks/Food

4. HAI Surveillance
Implementation of over-all surveillance process for hospital acquired infections
a. Antibiogram or Antibiotic Resistance Patterns

5. Multimodal strategies
Implement interventions to improve hand hygiene, safe injection practices,
decontamination of medical instruments, devices and environmental cleaning

6. Monitoring, Auditing and Feedback

Hand hygiene monitoring among hospital staff (clinical and non-clinical)

7. Workload Staffing and Bed Occupancy

Spacing of at least one metre between the edges of beds
WHO patient/staff ratio 1:12 nurses , 1:24 attendants
No more than one patient per bed

Alcohol, Disinfectant, Heavy Duty Sprayer/ Misting Machine/

Dichloroisocyanurate for cleaning and misting
8. Built Environment, Materials and Equipment for IPC
A safe and sufficient quantity of water
Functional and improved sanitation facilities
Functional hand hygiene facilities should always be available at the point of care,
toilets and service areas
Sufficient and appropriately labelled bins to allow health care waste segregation and
disposal.
Sufficient and appropriate supplies and equipment and reliable power/energy should be
available for performing IPC practices
Adequate single isolation rooms

IX. IMPLEMENTATION PERIOD :

February 2023

X. STATUS OF THE PROPOSED PROJECT.

Awaiting approval

Prepared by: Alejandro Manuel SJ Cruz

IPC Physician

Noted by: Mary Genevieve G. Montaño, MD

MS II/ OIC Chief of Hospital