Hospital infection prevention and control protocol

Hospital Infection Control

KEIT DAY HOSPITAL

Hospital infection prevention and control protocol

Official Manual of Clinical, Care and Organizational Protocols

1. Document Control Information

2. Scope of Application

This protocol applies to the operating theatre, ward, outpatient clinics, waiting rooms, reception and every clinical or support area that comes into contact with patients, healthcare workers, instruments or medical materials.

3. Responsibilities

• Medical Directorate: supervision of the infection prevention and control program.
• Nursing Coordinator: daily implementation of hygiene, sanitization and surveillance procedures.
• Surgeons and anesthesiologists: compliance with sterile procedures and perioperative bundles.
• Technical and Maintenance Service: documented inspection of systems and AHUs.

4. Operating Procedure

• Strictly apply hand hygiene, personal protective equipment use, antisepsis and sterile technique procedures in all care and surgical activities.
• Classify patients and procedures according to infection risk and adopt proportionate measures.
• Verify routine environmental sanitization, sanitization between patients and terminal sanitization at the end of the day.
• Properly manage dirty/clean flows, healthcare waste and potentially contaminated materials.
• Apply antibiotic prophylaxis according to the procedure, clinical indication and appropriate timing.
• Perform periodic environmental microbiological surveillance and implement corrective actions in the event of non-conformity.
• Collect, analyze and discuss any cases of healthcare-associated infection, with audits and corrective measures.

5. KEIT Operational Standards

• The operating theatre and clinical areas are managed according to a structured and verifiable sanitization plan.
• KEIT performs serial environmental swab testing every month in the operating theatre, ward, dressing rooms, outpatient clinics, reception and waiting room to detect any contamination or resistant bacteria.
• The protocol includes continuous sanitizable surfaces and construction criteria designed to maximize environmental cleanability.
• The operating theatre AHU operates with advanced filtration, positive pressure and controlled airflow over the surgical area, in accordance with the system design and internal maintenance plan.

6. Records and Documentation

• Sanitization register.
• AHU and systems maintenance register.
• Environmental microbiology reports.
• Non-conformity and corrective action forms.
• Periodic IPC audits.

7. Review and Updates

Quarterly review of surveillance data and annual update of the protocol.

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