Page 22 - policy and procedure infection control

Policies and Procedures on Infection Control

5. Reports bi-annually and as required if there is an outbreak or when needed.

2.7 Analysis and interpretation of data

Factors to be considered when using formulas for calculation of infection rates in a selected
patient population:
1. Numerator data: number of patients with specified type of infection or number of
infections.
2. Denominator data: 1) number of admissions or discharges. 2) Number of patients
undergoing a specific procedure. 3) Total patient days. 4) Total invasive device days
( ventilator days /CVC days /Urinary catheter days etc)
3. Provision should be made for adjusting data to account for differences among the
study population.

2.8 Preparation and dissemination of reports

1. Compile and prepare summary reports and communicate the information to individuals
who can authorize changes that improve treatment outcomes.
2. All information should be reported to the HIACC Chairman.
3. The coordinator shall communicate with the key persons from the clinical services
and hospital administration.
4. Every outbreak shall be followed by a complete report.

Ministry of Health Malaysia 11