Hospital Infection Control
KEIT DAY HOSPITAL
Environmental sanitization and microbiological surveillance protocol
Official Manual of Clinical, Care and Organizational Protocols
| Document Code | KEIT-SOP-07 | Version | 2.0 |
|---|---|---|---|
| Revision | 02 | Status | Official |
| Issue Date | 28/03/2026 | Next Review | 28/03/2027 |
| Prepared by | Medical Directorate / Quality | Approved by | |
| Signature and Date | Distribution | Controlled - Internal Use |
Purpose of the document. To officially define the scope, responsibilities, operating procedure, KEIT standards, records and protocol review criteria.
1. Document Control Information
| Application | All clinical, nursing, technical and organizational personnel involved in the described process. |
|---|---|
| Archiving | KEIT internal document management system and controlled copy in the relevant areas. |
| Review | At least annually or earlier in the event of regulatory, organizational or technological updates. |
2. Scope of Application
Applicable to the ward, operating theatres, outpatient clinics, reception, waiting room, dressing rooms and support areas.
3. Responsibilities
- Nursing Coordinator: planning and supervision of the sanitization program.
- Cleaning personnel and healthcare professionals: implementation of procedures according to the specified frequency and product.
- Reference laboratory/microbiology service: analysis of environmental swabs.
4. Operating Procedure
- Define the frequency, method, product and sanitization contact time for each area.
- Perform cleaning and disinfection between patients in procedural areas and terminal sanitization at the end of the day.
- Separate pathways and materials for clean and contaminated areas.
- Perform periodic environmental sampling at critical points and on high-touch surfaces.
- Analyze microbiological results and classify any non-conformities.
- Immediately implement corrective actions: extraordinary sanitization, process review, training or technical maintenance.
5. KEIT Operational Standards
- KEIT performs serial environmental swab testing every month in multiple areas of the facility, including the operating theatre, ward, dressing room, reception and waiting room.
- Surfaces and coverings are selected to facilitate cleaning, disinfection and surface continuity.
- Microbiological trends are monitored over time to identify abnormalities at an early stage.
6. Records and Documentation
- Sanitization plan.
- Signed implementation records.
- Environmental swab reports.
- Non-conformity and corrective action register.
7. Review and Updates
Review of microbiological data and the sanitization plan at least every six months.
Implementation Note
This document is an internal operational draft. Before final adoption, review by the Medical Directorate, Clinical Directorate, Legal Advisor and the relevant department managers is recommended.
This document is an internal operational draft. Before final adoption, review by the Medical Directorate, Clinical Directorate, Legal Advisor and the relevant department managers is recommended.
8. Related Attachments and Forms
- Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol.
- Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.
9. Final Approval
| Position | Name and Signature | Date |
|---|---|---|
| Medical Directorate |
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