Page 101 - policy and procedure infection control

Policies and Procedures on Infection Control

11. Protect mattresses and pillows with water impermeable material. Clean and disinfect
between patients.
12. Standard precautions apply in spills management. Confine and contain the spill by
using paper towels or disposable absorbent material to absorb the bulk of the
blood or body substances. Spills shall be cleaned up before the area is disinfected.
Avoid aerosolisation of spilled material.
13. Terminal disinfection must be done when a patient is discharged. The bed, all reusable
items and equipments in the room/area are to be cleaned and then disinfected. The
bed can be used for the next patient only when it is completely dry. If possible, open
the windows to air the room. The room can be used for the next admission only when
it is completely dry.

6.2.4 Medical Instruments and Equipment
1. All reusable medical items must be thoroughly decontaminated before disinfection or
sterilisation. If not adequately decontaminated, disinfection or sterilisation is not effective.

2. All packaged and wrapped sterile items must be transported and stored while
maintaining the integrity of packs to prevent contamination. If a sterile item is suspected
of being unsterile (e.g. damaged packaging) the item must not be used.
3. Reusable equipment must not be used for another patient until it has been appropriately
cleaned and/or disinfected.
4. Each patient shall have his/her own set of bedside equipment e.g. stethoscope, BP
cuff, thermometer.
5. Surfaces of computers, keyboards and non-critical medical equipments e.g. physiologic
monitors, ventilators, infusion pumps shall be cleaned at least daily with a low or intermediate
level instrument grade disinfectant and allowed to air dry. Use washable keyboard covers
if feasible. Alternatively cover keyboard with ‘clingwrap’ and change daily.

6.2.5 Respiratory Equipment
1. Use only sterile water/fluid for respiratory care e.g. suctioning, filling of humidifiers
and nebulisers.
2. Use a closed system for filling of sterile water into heated water humidifier.
3. Do not routinely change the ventilator breathing circuit on the basis of duration of
use. Change the ventilator breathing circuit when visibly soiled.
4. Drain and discard periodically any condensate in the circuit. Take precautions not to
allow the condensate to drain towards the patient.
5. Do not routinely change the heat-moisture exchanger more frequently than
recommended by the manufacturer. Change when it malfunctions mechanically or
becomes visibly soiled.
6. Change the oxygen delivery system (tubing, nasal prongs or mask) that is in use on
one patient when it malfunctions or becomes visibly contaminated or between uses
on different patients.

90 Ministry of Health Malaysia