Policies and Procedures on Infection Control
Ministry of Health Malaysia
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2. Evaluate implementation of infection control technique.
3. Audit infection control activities
1.13 Ward Link Nurse WLN
The WLN is the Ward Sister of each ward with sufficient nursing experience and who are in authority with staff and doctors in the ward. They are to undertake the WLN role
alongside their other ward duties.
The WLN act as a link between the staff and doctors in the ward and the infection control team, and are accountable to the Nursing Director and the infection control team on
areas related to infection control.
Duties and Responsibilities of WLN Supervision on infection control practices
1. Ensure hand hygiene is being practice in ward
2. Ensure compliance to aseptic technique.
3. Proper cleansing and sterilization according to standard procedures
4. Proper storage of sterile instrument and linen
5. Proper segregation of waste disposal
6. Proper specimen collection and dispatch
7. Isolation of patients as required.
Surveillance
1. Participate in the national point prevalence survey
2. Assist in monitoring of alert organism such as MROMRSAESBL
3. Assist in the prevention and reporting of sharp injuries among staff
4. Collection and reporting of HCAI and outbreaks.
5. Audit activities
Education
1. Immediate reference and advice on matters related to infection control, abiding to
infection control guidelines and standard precaution guidelines. 2.
Disseminate, educate and create awareness on infection control to new health care workers in the wards.
Research
1. Assist in carrying out research, application on evidence based practices and the
conducted of quality improvement activities.
Policies and Procedures on Infection Control
Ministry of Health Malaysia
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2.1 Introduction
Surveillance is one of the most important components of an effective infection control program. It is defined as the systematic collection, analysis, interpretation, and
dissemination of data about the occurrence of HCAIs in a definite patient population.
2.2 Purpose of Surveillance
1. To established and main a database describing endemic rates of HCAIs. Once
endemic rates are known then the occurrence of an epidemic can be detected when infection rates exceed baseline values.
2. To identify trends manifested over a finite period, such as shifts in microbial pathogen
spectrum, infection rates, etc. 3.
To provide continuous observation of HCAIs cases for the purpose of prevention and control.
4. To obtain useful information for establishing priorities for infection control activities.
5. To quantitatively evaluate control measures effectiveness for a definite hospital
population. 6.
To enhance the role and authority of the infection control team in the hospital through participation in ward rounds, consultations and education of healthcare workers.
2.3 Main components of Surveillance system
1. Definition of HCAI
Infections that occur more than hours after admission It must be taken into
account that different infections have different incubation periods, so that each occurrence must be evaluated individually to determine the relationship between its
occurrence and hospitalization.
2. Case Definition
Each case definition must be standardized and consistent. The case definition used nationwide will be that of CDC definitions. Refer to Appendix A for ‘Definitions of
HCAI’ developed by CDC. i. Daily review of all positive culture results
Manually Lab information system Automated disc reader ii. Informed by infection control link nurse when diagnosed by clinician.
iii. Identified during ward rounds antibiotic rounds Infectious disease rounds ICU rounds. iv. Actively looking for cases in targeted surveillance and follow–up these cases.
2. HEALTHCARE ASSOCIATED INFECTION SURVEILLANCE
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Policies and Procedures on Infection Control
Ministry of Health Malaysia
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2.4 Types of Surveillance
1. National surveillance
2. Hospital – wide total surveillance
3. Periodic surveillance
4. Prevalence studies
5. Targeted surveillance
National Surveillance Type of Surveillance
Methods
Targeted organisms : Results collected daily and submitted monthly to Quality
MRSA ESBL in Medical Care section, MOH
refer Appendix B for sample form Point Prevalence
1 day prevalence surveillance, hospital wide. Conducted Study
twice a year on the same day throughout the nation refer appendix C for sample form
Needle stick injury Reported yearly during the National Infection and Antibiotic
Control Committee meeting. Participated by all state hospitals, specialist hospitals, Universities hospitals USM
UKM UM and district hospitals providing microbiology cultures.
Hospital Surveillances
Choice of types of surveillance depends on the requirements of the individual hospital and must be agreed by the Hospital Infection and Antibiotic Control Committee members.
Type of Surveillance Methods
Total Surveillance The most comprehensive surveillance method; it entails
collection of data for all infections in all hospitalized patients. Monthly infection rates are calculated to determine
overall hospital rates and rates by site, care unit, service, pathogen, and surgical procedure.
Advantage: this is useful for establishing baseline and comparative data.
Disadvantage: requires enormous amounts of time and labor.
