Page 15 - policy and procedure infection control

Policies and Procedures on Infection Control

2. Emergency meetings are arranged for the control of outbreaks of infection and when
the infection Control Team requires additional support and notification of the problem
in accordance with the major outbreak policy.
3. The Chairman will chair all emergency meetings, and is in charge of the technical
aspect of outbreak control measures.

1.10 Administrative arrangements
1. The Infection Control Team, is responsible for the day-to-day infection control activities
of the hospital and reports directly to the Chairman of the HIACC
2. The HIACC draws up policies on all aspects of prevention and control of infections
for the hospital.
3. These policies must receive the support of the hospital’s management.
4. In the absence of separate activity budget code for infection control, the budget for
the costs of infection control is part of the Medical Microbiology budget and for the
unpredictable and ad-hoc activities such as large outbreaks or hospital wide
campaigns, it will be borne by the hospital’s operational budget.

1.11 The Infection Control Nurse (ICN)
1. The Infection Control Nurse(s) is a full-time member of the Hospital’s Infection Control
Team, which is headed by the Infection Control Doctor.
2. The ICN is responsible to the ICD but is professionally accountable to the Director
via the appropriate Nursing Director within the nursing hierarchy.
3. The primary duties of the nurse are to assist the Infection Control Doctor with the
prevention and control of infection in hospital.
4. This is achieved through the implementation of infection control policies and procedure,
and by educating hospital and non-hospital personnel.
5. The number of ICN should conform to the Ministry’s norm of 1 ICN:110 beds.

1.12 Duties and responsibilities of the infection Control Nurse

The Infection Control Nurse must:

Clinical
1. Liaise closely with the hospital medical microbiologist and clinicians.
2. Supervise and advise on isolation technique policies and procedures generally and
in specific clinical situations.
3. Provide clinical advice and support to nurses, midwives, health visitors and other
non-clinical personnel on infection control issues.
4. Analyze and provide feedback on microbiology reports to head of department.

4 Ministry of Health Malaysia