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3. Place a bacterial filter on the patient’s endotracheal tube or at the expira-
tory side of the breathing circuit of a ventilator preferably models specified by the manufacturer to filter particles 0.3 ìm in size in both the unloaded
and loaded states.
4. Closed suction system should be used.
7.3.7 Operating theatre
1. General policy and procedures on environmental control must be strictly
adhered. 2.
Procedures should be scheduled for patients with suspected or confirmed TB disease when a minimum number of HCWs and other patients are
present in the surgical suite, and at the end of the day to maximize the time available for removal of airborne contamination.
3. An N95 disposable respirator should be used by HCW when dealing with
infectious or potentially infectious TB patient in OR 4.
Post-operative recovery of a patient with suspected or confirmed TB dis- ease should be in an AII room in any location where the patient is recover-
ing. 5.
If an AII or comparable room is not available for surgery or postoperative recovery, air-cleaning technologies can be used. However, the infection
control committee should be involved in the selection and placement of these supplemental controls.
7.3.8 Bronchoscopy Suite
1. Postpone non-urgent procedures on TB patients until the patient is deter-
mined to be noninfectious. 2.
In urgent cases e.g. massive haemoptysis, bronchoscopist and the as- sistants should wear N95 respirator and face shield for protection.
3. Air cleaning system should be installed in the bronchoscopy suite.
4. Ventilation system must be operated and maintained efficiently.
7.3.9 Laboratories
refer to laboratory section,
1. Personnel who work with mycobacteriology specimens should:
• Be trained in methods that minimize the production of aerosols and
• Undergo periodic competency testing including direct observation of
their work practices. •
Prepare for prompt corrective action following a laboratory accident. •
Follow good laboratory practice at all time and accept responsibility for correct work performance to assure the safety of fellow workers.
• Tuberculosis culture laboratory must have a well-maintained and
properly functioning biological safety cabinet BSC, with HEPA filter andor air supply system.
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2. All specimens suspected of containing M. tuberculosis including speci-
mens processed for other microorganisms should be handled in a Class I or II biological safety cabinet BSC.
3. Standard personal protective equipment should be available and consists
of: •
Laboratory coats - which should be left in the laboratory before going to non-laboratory areas.
• Disposable gloves - Gloves should be disposed of when work is
completed, the gloves are overtly contaminated, or the integrity of the glove is compromised.
• Face protection e.g., goggles, full-face piece respirator, face shield,
or other splatter guard should also be used when manipulating specimens inside or outside a BSC.
• Respiratory protection N95 should be worn when performing
procedures that can result in aerosolization outside a BSC. •
Laboratory workers who use respiratory protection should be trained on respirator use and care, and fit testing.
4. Appropriate ventilation should flow from clean to contaminated areas.
• In peripheral lab, windows should be located in such a way that air
currents do not pass over the area of smear preparation in the direction of the laboratory worker preparing the smears.
• In culture laboratories, air should be continuously extracted to the
outside of the laboratory at a rate of six to twelve air changes per hour. Supply and exhaust air devices should be located on opposite
wall with supply air provided from clean areas and exhaust air taken from less clean areas.
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Note :
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8.1 Introduction
All health care facilities especially major hospitals would have an on going surveillance activities for healthcare associated infection HCAI. The usual level of occurrence or
incidence of an infection within the facility is usually known and this would be considered as the mean control limit. However, an upper control limit of the occurrence of the infection
should be identified in order to serve as an alert line for the Infection Control Team ICT to investigate for a probable outbreak.
DEFINITION OF HEALTHCARE ASSOCIATED INFECTION OUTBREAK EITHER ONE
1. Two or more associated cases occurs at the same time within same locality
department 2.
Greater than expected rate of infection compared with the usual background case for the place and time
3. In certain newly emerging disease e.g. Legionnaires infection or anthrax, will only
require 1 single case.
In HCAI outbreak, clinical findings of reported cases should be reviewed closely. It is important to directly examine the patients, reviewing of the medical records and have a discussion with the
doctor in-charge. A discrepancy between the clinical and laboratory findings may occur if an outbreak is factitious, for example due to laboratory error. An outbreak maybe judged minor or
major after consideration of its complexity, number of person affected, pathogenicity of the organism involved, potential transmission and any unusual features.
8.2 Steps in Outbreak Investigation and Management
NO PROCEDURES
RESPONSIBILITES
A probable diagnosis of an outbreak arises from laboratory based surveillance or clinical report from a unitdepartment
Investigate and gather information on the probable outbreak, both from microbiological data, environmental investigation and patient’s
placement and movement. Carry out mapping of cases.
Suspect a true outbreak if cases appear to be linked in time, space or persons. Produce a preliminary report and hold the discussion.
ICN ICN
ICCT 1.
2.
3.
8. HOSPITAL OUTBREAK MANAGEMENT
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Alert all parties involved of probable outbreak and carry out further investigations such as screening of involved patients, contacts
and an environment microbiological samples to identify source, reservoir and mode of transmission.
Produce report on the outcome of the investigations possible primary source, microorganism, magnitude of an outbreak and
recommendation immediate actions to contain the outbreak and prevent further transmission.
Discussion at the ICCT level only if it is a minor outbreak. HIACC chairman will then inform Hospital Director if it is a major outbreak.
Declare outbreak. Recommend closure of unitward if indicated.
Check if infection control policies and procedures are breached. Administer outbreak control measures according to the known
modes of transmission airborne, droplet or contact of the organisms and appropriate source control. contaminated TPN,
chlorhexidine.
Re-evaluate the outbreak situation and effectiveness of interventions. Take remedial action if the outbreak is still not
contained.
Announce end of outbreak when no more new cases or the number of cases has reduced to usual mean control limit. arbitrarily within
1 month
A final report is produced at the end of the outbreak. Recommend on change of infection control policies or procedures if indicated
Disseminate report to all relevant departments. ICN
ICCT
ICCTHIACC Hospital Director
ICN ICCT
ICCT
HIACC
ICCTHIACC ICCT
4.
5.
6.
7. 8.
9.
10.
11. 12.
For community outbreak involving other healthcare facilities consult ‘SOP for potential infectious disease MOH 2004’Public Health Division
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9.1 Introduction
