Page 13 - policy and procedure infection control

Policies and Procedures on Infection Control

• The Infection Control Sister or the most senior infection control nurse (ICN)
• The Director /Deputy Director of the hospital
• A consultant virologist
• A consultant physician or surgeon
• A consultant pediatrician

• A consultant anaesthesiologist /intensivist
• A representative each from all major clinical departments (preferably at specialist or
consultant level)
• The Nursing Director.
• A pharmacist

• Senior representative from the hospital support service concessionaire.

If a member is unable to attend, a representative should be sent.

1.5 Invited attendance

The following may be co-opted by the Chairman to attend for specific items as indicated
by the agenda:
• Other clinical consultants
• The Financial Manager

• Nursing sisters of specific clinical areas
• The Hospital Engineer(s)
• The Head of Dietetics
• The Central Sterile Supplies Department (CSSD) Manager
• The Operation Theater Matron/ Sister
• The Senior health inspector in-charge of the public health unit.

In addition, post graduate trainees in medical microbiology or infectious diseases may
be invited to attend as observers as part of their in-service training.

1.6 Agenda of the meetings
At each meeting the committee should:
1. Discuss the agenda prepared by the Chairman.
2. Report on the incidence and prevalence of ‘alert’ organisms and important infectious diseases.
3. Report on the occurrence and nature of any outbreaks of infection, and on incidents
involving microbiological hazards (e.g. needle sharp injuries)
4. Report on on-going targeted surveillance of healthcare associated infections

2 Ministry of Health Malaysia