HOSPITAL INFECTION AND ANTIBIOTIC CONTROL COMMITTEE

Policies and Procedures on Infection Control Ministry of Health Malaysia 3 5. Evaluate and report on antibiotic usage and resistance patterns and recommend remedial measures when appropriate. 6. Develop and maintain policies for the promotion of good infection control and antibiotic usage guidelines in MOH. 7. Review outbreaks of infection and advice managers on how outbreaks might be managed and prevented. 8. Assist in the planning and development of services and facilities construction and demolition activities in the hospital on issue which are relevant to infection control and antibiotic usage. 9. Monitor and advice on specific areas of hygiene and infection control, catering, CSSD, ventilator and water services, occupational health, pharmacy, operating theatres, endoscopy, etc. 10. Develop programs for the education of staff and students about infection control practices and policies and appropriate antibiotic prescribing. 11. Financial planning and monitoring of budget and expenses of infection control activities.

1.7 Frequency of meetings

1. Meetings must be held at least twice a year. The hospital director or the deputy director should be in attendance. 2. 1 week notification of the date of the meeting and the agenda should be given. 3. The Hospital Director’s Office will provide secretarial help and logistics support to the HIACC in conducting the meetings and activities. All minutes must be endorsed by the chairman and sent in a timely fashion to the Hospital Director. 4. There should be adequate designated space and computerss with internet facilities provided to the Infection Control Team.

1.8 Circulation of minutes

1. Minutes should be kept and verified. 2. Minutes should be sent to all members and to those who attended the meeting. In addition, copies should be sent to: • The Hospital Director • The Dean of the Medical and Allied Health Faculties using the hospital as teaching facilities • Heads of Departments and Units

1.9 Emergency meetings and outbreak control

1. The Chairman may convene an emergency meeting of the Infection Control Committee at any time and all members or their representative will be notified by telephone. Policies and Procedures on Infection Control Ministry of Health Malaysia 4 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 Nurses 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.