dr tamer said infection control specialist, ieip, u.s. naval medical research unit no3(namru-3),...
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Importance of Policies and Guidelines in Infection Control
Dr Tamer SaidInfection Control Specialist, IEIP,
U.S. Naval Medical Research Unit No3(NAMRU-3), Cairo Egypt
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Guidelines, Policies, and Procedures
Guidelines: any document that aims to streamline particular processes
according to a set routine. By definition, following a guideline is never mandatory
Policies plan or course of action, intended to influence and determine
decisions, actions, and other matters
SOPsdetailed, written instructions to achieve uniformity of the
performance of a specific function
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Example : Driving and the traffic
GuidelinesTypes of carsDriving styles
Traffic law and policiesRight and wrong
ProceduresGo left and go right
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International Guidelines
When national guidelines are missing or up-dated
International public health problem e.g. Pandemic
Should be adapted (not translated !!)
International organizations. WHO , CDC, APIC
http://www.cdc.gov/ncidod/dhqp/guidelines.html http://www.apic.org/AM/Template.cfm?Section=Practice http://www.who.int/csr/resources/publications/ICHC_booklet_FINAL.pdf
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National Guidelines
Important core component of national IC program
Form reference for all local policies and procedures at the facility level
National IC organization supported by the governmentDevelop (adapt) national guidelinesOfficial documentations
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Guidelines to develop IC Guidelines
Identify topicForm task force group (local and international experts) to
search scientific resources, assess local data and write 1st draftIC professionals , Microbiologists, ID specialistsClinical staff (Doctors, nurses, Surgeons)
Discuss 1st draft among national IC steering committeeDistribute 2nd draft to select users (pilot)Modify according to feedback and international reviewImplement definitive versionRevaluate (up-date) after 3 years or with any major need
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National Guidelines of Infection Control : Egypt Experience
Review of existing guidelinesGroup of local and international expertsDevelopment of draftReview of the draft (Local and International)Consensus workshopDevelopment of final draftReview at CDCFinal form review and translationDistribution of 1st edition 20042nd Edition 2008
http://www.drguide.mohp.gov.eg/NewSite/E-Learning/InfectionControl/infctrl.asp
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Contributors
Task force group (local and international experts)
MOHP – NICU Egypt (coordination)
Faculties of medicine and nursing, Egyptian medical syndicate
Many international contributorsCDC, APIC, IFIC, CIC
NAMRU – 3
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Basic set of IC guidelines
Standard precautionsHand HygieneInstrument reprocessingPrevention and management of sharp injuries
Early detection of disease and isolation precautionsPatient placement and environmental sanitationUse of PPE
Aseptic techniquesTailored according to national scope of practice
Waste managementInfection Prevention and Control in Health Care Informal Network ,Report of the Second Meeting, June 2008
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Formulation of Policies and Procedures
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What is a policy?
A policy is a broad statement that guides action toward a goal.
Policies define general principles that are to be followed. Many different actions can be taken as long as the principles are respected
It is written to help define what we are trying to accomplish.
Written to be applicable for many unforeseen situations.
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What is a procedure or work instruction?
Specific steps to take that should be followed exactly without deviation
They describe how, who, when the policy is operationally put into action.
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Example : hand washing policy and procedure
Policy: before entering the NICU, staff will do an antiseptic hand wash to remove endogenous and exogenous germs
Procedure: before entering the NICU, at the beginning of the shift, staff will remove jewelry, roll up sleeves and wash hands with soap and water and dry them. Then use 1.5 ml of 62% alcohol antiseptic for hands and rub until dry. ETC
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Example : PPE policy and procedure
POLICY: Staff will use and have access to personal protective equipment that prevents contamination of person and clothing, exposure to harmful chemicals, body fluids, and infectious agents including respiratory pathogens.
PROCEDURE : Janitors will wear protective rubber boots, gloves, hospital uniform. Goggles and aprons are available when washing floors
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Is this a policy or a procedure?
Wear a personal respirator inside a TB patient’s isolation room.
Staff shall wear masks to protect themselves when patients may have infectious respiratory pathogens, and during cough inducing procedures.
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Policies and procedures work together to communicate standards
The procedures are simple steps to take that workers can use for 90% of the circumstances. (Stepping stones)
Policies help guide actions when the exact steps do not apply. (Handrails outlining a path)
A policy says “go East”
The procedure says “turn left, then right then left”
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Why does the hospital need policies and procedures?
To communicate exactly what is expected to all staff
To standardize care to use practices known to be effective
To help answer questions when supervisors are not around
To help orient new staff to facility-specific practices
To avoid degradation of practices from safe to unsafe
To look good!!
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Who formulates policies
IC policies are usually formulated by the IC Team on behalf of management
Clinical staff and specialists are consulted
Verified by the IC Committee
Goes to Top Management for verification
Comes back as an official policy
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Policies and procedures Development Scheme of process
Pick topicBuild a
team
Study − related guidelines− Available local data
Accommodate to− Existing policies− Needs− Available resources
Develop P & PObtain approvals
Disseminate Monitor complianceRevaluate
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How to formulate a policy
Revise reference guidelinesFind out what existsEstablish the aim of the policy Establish the objectivesLook for current resources and how these can be
appliedMay need to carry out surveillance or research into
that particular aspect.
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Pitfalls !!
Adopting a policy from another country which has a different resource base to yours (Budget, culture, training)
Not enough local data or surveillance information to formulate a policy
Policy too complicated
Unclear procedures
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Policies and Procedurescore content
Specific TitleDate written, date revised, date to be reviewedTo whom it appliesReferences, sample formsWhere to go for questions, comments, additional
informationWho is the responsible departmentPolicy statementStandard operating procedures
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Writing policy
Write a draft Consult with the users of the policy
Ask for their inputFind out what is currently happeningDiscuss improvements with them
Rewrite the draftDiscuss with managementFinalise policyCirculate for consultationGet WRITTEN APPROVAL
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Working policySet a date for when the policy will be put into placeCall a meeting and go through the policy with everyoneAsk for commentStart training on the new policyMonitor the outcome of the new policy
Difficulties in implementationProvide support
Revise aspects that do not fit into the work pattern
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Working policy (2)Make sure a copy of the policy is available in each health
working area or unit
Revise the policy after 12- 18 months
Document revisions and circulate.
Monitor policy
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Update Policies and Procedures
Procedures need to be updated for changes in equipment, supplies, new diseases, when past procedures were unclear etc.
Try to answer the most common questions with the procedures. “Safe” “Appropriate” don’t answer questions.
Generally update policies and procedures every two years or when needed.
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Summary
Find out what the policy is needed for?Make sure there is enough evidenceWrite a draftConsult widelyProvide training Send out a written documentMonitor complianceRevise frequently.
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Thank You