National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities 2024 PDF

‫اإلدارة العامة لمكافحة عدوى المنشآت الصحية‬ General Directorate of Infection Prevention and Control of Healthcare Facilities (GDIPC) National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities...

‫اإلدارة العامة لمكافحة عدوى المنشآت الصحية‬ General Directorate of Infection Prevention and Control of Healthcare Facilities (GDIPC) National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities Version 5 2024 In the Name of ALLAH, Most Gracious, Most Merciful 1| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  General Director's Message C ompliance of healthcare facilities in implementing effective infection prevention & control measures is vital for patient, visitor, and staff safety. One tool to assess the proper implementation of infection prevention & control measures in clinical areas is the Infection Control Audit in a standardized methodology. This manual serves as a guide for auditors to assess the facility in infection control. The manual consists of several standards and sub-standards that reflect current guidelines and good practice in infection prevention and control within a healthcare environment. To ensure that IPC measures are met, as well as ensuring that the quality of the infection control practice within institutions are at the best level, Ministry of Health conducts continuous auditing visits by qualified auditors. The audit report and its recommendations help to ensure that practices improve their compliance to infection prevention and control according to current national guidelines and should serve as a useful reference point. Therefore, it is essential that this report and its recommendations is given consideration and that the action plan which outlines how the practice plan to address the issues highlighted is completed and returned appropriately as advised. Dr. Khalid Hamdan AL Enazi Director General, General Directorate of Infection Prevention & Control of Healthcare Facilities Ministry of Health Kingdom of Saudi Arabia 2| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  ICA GUIDELINES TASKFORCE Prepared By Contributors Dr. Ashraf A. Elkelany Dr. Hala M. Roushdy Dr. Faiza Rasheed Dr. Hanan M. Hathout Dr. Foued Romdhane Dr. Mohammed A. Alqahtani Dr. Nasser Alshanbari Dr. Khaled M. Sayed Dr. Sameh E. Tawfik Dr. Muhammad R. Malik Dr. Tabish Humayun Dr. Yousif B Saad Ms. Abrar Mutlaq Mr. Adel alanzi Ms. Aisha Alshehri Ms. Eman Barnawi Ms. Arwa Shesha Mr. Nawaf M. Almatrafi Ms. Ghazail M. Albeshi Mr. Rayed A. Asiri Mr. Moteb Alsadei Ms. Reyouf S. Alazmi Ms. Raniah Alnahdi Ms. Taghreed A. Alsaqer Mr. Riyadh S. Alshehri Mr. Salem A. Aldhubaib Ms. Samirah M. Alkhaldi Ms. Wafa Alshammari Ms. Ahlam Alamri Reviewed by: Ms. Ahlam Alamri Supervisor, IPC Programs, GDIPC Approved by: Dr. Khalid H. Alanazi Director General, GDIPC Dr. Faiza A. Al Fozan Assistant Director General, GDIPC 3| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  Table of contents Title Page # Message from the General Director 2 ICA Guidelines Taskforce 3 ICA Visit Protocols 19 DOMAIN – A # INFECTION PREVENTION & CONTROL ADMINISTRATIVE MEASURES Element # A - 1: Leadership Support Page # 23 Adequate resources are allocated to infection prevention & control (IPC) department (e.g., 23 A-1.1 offices, internet access, IT support...etc.). Adequate infection prevention & control supplies are provided to healthcare workers (HCWs) for A-1.2 24 successful implementation of IPC program (e.g., PPE, disinfectants, etc.). Infection prevention & control team is given a full authority to implement the IPC policies and 26 A-1.3 procedures. Hospital leaders' support IPC team and their supervision role when some functions are outsourced 27 A-1.4 (e.g. laundry or dietary services). Element # A - 2: Infection Prevention & Control Department Page # 28 For hospitals (≥ 150 beds): the director of IPC department is full-time employee qualified in infection 28 A-2.1 control through certification, training, and experience for a minimum of two years. For hospitals (< 150 beds): the director of IPC department is a full-time employee qualified in A-2.2 29 infection control through certification, training, or experience for a minimum of two years. The director of IPC program reports directly to the highest administrative authority (general director A-2.3 29 or medical director of the hospital). The facility has infection prevention & control staffing ratio of not less than 1 full-time practitioner for A-2.4 every 100 beds assigned merely for the IPC program in order to accomplish the tasks in an 30 effective manner. An additional one full-time IPC practitioner is staffed for every 30 beds in critical care units (e.g., A-2.5 ICU, PICU, ER, Burn Unit …etc) assigned merely for the IPC program in order to accomplish the tasks 30 in an effective manner. An additional one full-time IPC practitioner is staffed for every 120 dialysis patients per day assigned 31 A-2.6 merely for the IPC program in order to accomplish the tasks in an effective manner. IPC practitioners are qualified in infection control through certification, training, or experience for a A-2.7 32 minimum of one year. IPC practitioners have updated infection control skills and knowledge through continuous medical A-2.8 33 education program and attendance in IPC scientific activities. Element # A - 3 : Infection Prevention & Control Committee Page # 35 There is written approved terms of reference document for the IPC committee containing structure, 35 A-3.1 rules, duties, and members responsibilities. Meeting minutes are written in a manner of task force tables with time frame for the actions needed 37 A-3.2 and the documented actions must be followed in the next meeting. A-3.3 IPC committee is chaired by the hospital director or medical director. (Updated) 42 Membership of IPC committee includes head of IPC, IPC department members, medical director, A-3.4 head of nursing services, head of laboratory department (microbiology), head of surgical operating room, head of CSSD, head of critical care units (ICUs), head of pharmacy department, head of 4| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  dietary services, head of environmental health department, head of housekeeping department, 39 head of administrative or financial department , head of medical supply department, and other guest members as needed. A-3.5 IPC committee meets on a regular basis (at least quarterly) or when required on urgent demand. 40 Functions of IPC committee include, but not limited to: (revision and evaluation of the IPC yearly A-3.6 plan, review and approval of IPC policies & procedures, review of surveillance data, & discuss 41 respiratory protection program related activities & measures, etc). Element # A - 4 : Infection Prevention & Control Program Page # 43 There is a program to reduce the risk of healthcare associated infections (HAIs) that involves A-4.1 43 patients, staff, trainees, volunteers, families, and visitors. A-4.2 The program is applied to all areas of the hospital according to the scope of service. 47 The IPC program is based on current scientific knowledge, referenced practice guidelines and A-4.3 applicable national laws and regulations. 49 Element # A - 5 : Infection Prevention & Control Annual Plan Page # 52 The annual plan is based on Infection control risk assessment (ICRA) (i.e., addresses processes, A-5.1 procedures, resources, and devices that are identified by the IPC practitioners to be associated 52 with risk of HAIs). The plan includes goals for patient safety (e.g. standard precautions, transmission based isolation A-5.2 56 precautions, healthcare bundles, and patient/family education). The plan includes goals for healthcare workers (HCWs) safety (e.g., immunization, post exposure A-5.3 57 management, and HCWs education). The plan includes metrics of required changes in targets and goals to measure achieved A-5.4 58 proposed activities. Element # A - 6 : Infection Prevention & Control Page # 60 Policies & Procedures Infection prevention & control policies and procedures are developed by IPC department and to A-6.1 be approved by IPC committee (policies and procedures are based on approved MOH 60 guidelines and scientific references (e.g. GCC, CDC, WHO or APIC). IPC policies and procedures are organized in one manual that is well- distributed and available in A-6.2 62 all hospital areas. Infection prevention & control policies and procedures are revised periodically by the IPC A-6.3 63 department every 2-3 years, or when required. Element # A - 7 : Infection Prevention & Control Page # 64 Education & Training Annual infection control training program is based on need assessment and include basic and A-7.1 68 specialized infection prevention & control training sessions. (Updated) IPC department provides continuous education and training (formal & on- job training) for HCWs A-7.2 69 on infection prevention & control with competency assessment. IPC department provides orientation and training on basics of infection prevention & control for A-7.3 70 newly hired HCWs before or maximum within 1 month of joining their work. IPC department provides education on infection prevention & control for patients, families, and A -7.4 70 visitors. Basic Infection Control Skills License (BICSL) Training Program is implemented based on the A -7.5 71 national regulations and guidelines for all HCWs in the Healthcare Facilities. (Updated) All IPC practitioners in the healthcare facility have a valid BICSL trainer certification based on the A-7.6 72 national regulations and guidelines. (New) A-7.7 All HCWs are having valid, printed, and hang BICSL cards. (New) 73 5| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  DOMAIN – B # INFECTION PREVENTION & CONTROL KEY MEASURES Element # B - 1 : Hand Hygiene Page # 74 There is a written infection prevention & control policy and procedure for hand hygiene, including B-1.1 74 types, indications, supplies, techniques, and monitoring tools. Hand washing facilities and supplies (sinks with hot and cold water, plain and antimicrobial soap, B-1.2 and towels) are available and easily accessible (at least one sink for every 2-4 beds in the critical 75 care areas and at least one sink per patient's room). Alcohol - based hand rub dispensers are available in adequate numbers (one dispenser per B-1.3 75 patient's bed, one at every nursing station, and at any service area). Hand hygiene compliance rate is regularly monitored and results are discussed in IPC committee B-1.4 76 meetings for corrective actions. Visual alerts for hand hygiene are available (WHO 5 moments - hand wash techniques - hand rub B-1.5 76 techniques) and HCWs are oriented about it. HCWs (8 - 10) are performing hand hygiene properly (appropriate technique and recommended B-1.6 76 duration). WHO hand hygiene Improvement strategy tools are applied to improve the quality of hand B-1.7 78 hygiene. Reporting of hand hygiene self-assessment (HHSA) is active and ongoing (WHO HHSA framework - B-1.8 80 action plan to improve the quality of hand hygiene). Element # B - 2 : Personal Protective Equipment (PPE) Page # 83 There is a written infection prevention & control policy and procedure for PPE including types, B-2.1 83 indications, donning, doffing, & safe disposal techniques. B-2.2 PPE is available in all patients care areas in adequate amounts and proper qualities. 85 HCWs are properly trained and demonstrate the appropriate use of PPE (i.e., careful selection in B-2.3 86 relation to indications, proper donning and doffing, correct sequence, and proper disposal) Respirator fit testing is conducted for all HCWs based on the national regulations needed' B-2.4 88 frequency or when required. Element # B - 3 : Isolation Precautions Page # 90 There are written policies and procedures for standard and transmission based precautions, B-3.1 90 including types, duration of isolation, patient transport, and visitors control. There is a clinical hand washing facility with hands free operation inside the patient's room or in the B-3.2 90 anteroom (if available). Patient's room is provided with private toilet and shower (for isolation room in ICU,NICU , CCU toilet B-3.3 90 and shower are optional). PPE and alcoholic hand rub are available outside the patient’s room at the corridor or in the B-3.4 91 anteroom (if available). All PPEs are doffed inside the patient’s room except N95 respirator which is removed outside B-3.5 airborne infection isolation room (AIIR) after closure of the door of patient's room or anteroom (if 91 available). Visitors receive proper instructions from assigned HCW before entering into an isolation room, and B-3.6 92 they should comply with recommended isolation required precautions. A log book is available and used for all individuals entering the rooms/cubicles of isolated patient B-3.7 92 with airborne infections (e.g. Pulmonary TB). Non-Critical patient-care equipment are single use or dedicated to one patient or if not available B-3.8 and shared equipment have been used', proper cleaning & disinfection of shared equipments 94 must be strictly followed. The signs used to indicate categories of isolation precautions are clear and visible for HCWs and visitors, in bilingual (Arabic & English), color coded and compatible with diagnosis (e.g; contact: B-3.9 95 green, airborne: blue, and droplet: pink or red) (it is preferable to use the MOH approved isolation signs). The receiving unit or facility is informed about the required isolation precautions and to ensure the B-3.10 95 availability of appropriate PPE. 6| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  The transfer of patient under isolation precautions is restricted to medically necessary purposes, Isolation transportation cards must be used and should be consistent with the patient diagnosis , B-3.11 colour coded , posted in Arabic and English, and indicating the type of precautions required for 96 staff (it is preferable to use the MOH approved isolation transportation cards) and through less crowded traffic route. For transport of patient under contact isolation precaution: Contain and cover all skin lesions and infected or colonized wound if available with clean B-3.12 97 bandage/dressing. Instruct patient to wear a clean gown, and clean linen should be used. For transport of patient under droplet/airborne isolation precaution: B-3.13 Instruct the patient to wear a surgical mask and follow respiratory hygiene and cough etiquette. 97 Cover exposed skin lesions (if any) with clean bandages and/or clean linens. Patients with burns larger than 25% of the total body surface area (TBSA) are kept in a single room B-3.14 100 or physically separated from other patients. B-3.15 Portable chest x-ray is available for usage in isolation room when needed. 101 The required number of airborne infection isolation room (AIIR) should be predicted in each B-3.16 101 hospital based on the facility' risk assessment or based on the national approved standard. Airborne infection isolation rooms specifications' fulfill with MOH required specifications as the following: *Standard isolation rooms. B-3.17 *Windows are sealed and fixed (i.e., could not be opened). 102 *Openings in walls and ceiling are sealed and airtight. *Doors are properly designed and well sealed. Airborne Infection Isolation Rooms (AIIRs) are under negative pressure (minimum -2.5 Pascal) with B-3.18 air totally exhausted to outside (100%) through High-Efficiency Particulate Air (HEPA) filters. The 103 exhaust air ducts including that from bathroom are independent of the building exhaust air system. There is 100% fresh air supply (i.e. return of air is not permitted) from central AC or concealed B-3.19 separate unit. All components of AIIR ventilation unit (supply & exhaust) are connected to 104 emergency power supply to maintain air pressurization in the event of power failure. There is a fixed monitor outside the patient room in the corridor to continuously monitor the pressure B-3.20 difference between the patient room and corridor, with activation of audiovisual alarm when the 105 ventilation system failed. There is evidence of regular monitoring of negative pressure difference of AIIRs: Daily when in use (i.e., a patient isolated inside). B-3.21 105 Weekly when not in use (i.e., no patient isolated). Monthly check by maintenance personals. B-3.22 Air exchange of AIIR is ≥ 12 air changes per hour (≥ 12 ACH) with monthly monitoring. 106 B-3.23 AIIRs are used only for isolation of suspected or confirmed cases with airborne infectious diseases. 106 Element # B - 4 : Aseptic Technique Page # 108 B-4.1 There is a written policy and procedure for clean, and aseptic techniques. 108 Separate clean area is available and maintained for preparation of medications (i.e., away from B-4.2 109 patients’ treatment areas). For invasive procedures, sterile devices and supplies are used after patient’s skin antisepsis (e.g., B-4.3 110 sterile syringes, needles and medications are used after skin antisepsis with approved antiseptics). A peripheral venous catheter is properly fixed, with a clearly written date of insertion, and to reduce risk of infection and phlebitis, it is replaced - if still needed - as follows: B-4.4 111 In adults: it is not replaced more frequently than every 72 to 96 hours. In children: it is replaced only when clinically indicated. B-4.5 Preparation & dilution of medications are only done by ready-made single-dose sterile solutions. 113 Single-dose or single-use vial is used for a single procedure/injection in a single patient and it is not B-4.6 114 stored for future use even for the same patient. Needles and syringes including prefilled syringes, and vacutainer holders are used for a single B-4.7 115 procedure/injection. B-4.8 Cartridge devices such as insulin pens are used for only one patient. 116 7| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  Supplies are brought to patient’s care area only when needed and after patient discharge, all B-4.9 remaining single-use items are discarded while reusable ones are sent to CSSD for reprocessing 117 (even unused items with intact original wrap). Whenever possible, multi-dose vial is used for a single patient, with recorded patient's name and B-4.10 date of the first use (when it has been accessed for the first time), and discarded after 28 days, 118 unless the manufacturer specifies a different shorter or a longer date (i.e., reuse life). If multi-dose vial is used for more than one patient, they should only be kept and accessed in a B-4.11 119 dedicated clean medication preparation area away from immediate patient treatment areas. The self-sealed rubber cap of a medication vial or an IV solution bottle is disinfected with approved B-4.12 121 antiseptic wipes (e.g., alcohol wipes) prior to any access. IV sets (including secondary sets and add-on devices) that are continually used to infuse crystalloid B-4.13 solutions (hypotonic, isotonic, or hypertonic), are replaced at least every 7 days, but not more 122 frequently than 96-hour intervals. IV sets that are used to administer blood, blood products, lipid emulsions, or dextrose/amino acid B-4.14 122 TPN solutions are replaced within 24 hours of initiating the infusion. For a ventilated patient, ventilation circuit is only changed when visibly soiled or mechanically B-4.15 123 malfunctioning. Sterile solutions are used in nebulizers, humidifiers, or any aerosol generating system and changed B-4.16 between patients and every 24 hours for the same patient, unless the manufacturer of ready-made 124 sterile solutions specifies different dates. Hand hygiene practiced before breastmilk expression and sterile container is used for breastmilk B-4.17 125 collection and preservation. B-4.18 HCW wears mask during insertion of a catheter or injection into spinal or epidural space. 125 Element # B - 5: Single Use Items (SUI) Page # 127 The facility has an implemented policy for No Reuse of single use items based on the national 127 B-5.1 regulations. Element # B - 6: Respiratory Protection Program Page # 129 There is a written policy and procedure for RPP with well-defined programs' components & B-6.1 activities and based on current scientific knowledge, approved MOH guideline, reference 129 practice, and regulations. There is a written policy and procedure for dealing with suspected or confirmed respiratory illnesses B-6.2 patients based on updated national guidelines. It contains early detection, management, and 130 transfer of respiratory illness patients. The IPC committee regularly discuss RPP program’s activities, progress, and any issues with B-6.3 132 potential to impede the effective implementation of the program There is a designated respiratory triage facing the entrance of the Emergency and Hemodialysis B-6.4 133 units of the hospital. i.e., First area to be reached by any patients. Written reminders in the emergency department for updated definitions of respiratory illnesses of B-6.5 national alert are available and based on updated national guidelines and staff are quite familiar 135 with these definitions Flowchart is available in Emergency and Hemodialysis Units for early detection& management of B-6.6 136 respiratory illness patients Patients who have acute infectious respiratory symptoms are instructed to wear surgical masks and B-6.7 placed in a dedicated and separated waiting area with at least 1.2 meter distance between 137 them. The facility conducts a tracing for all HCWs who have exposed to a confirmed respiratory illnesses B-6.8 138 (e.g: TB or MERS-CoV) cases as per the latest national guidelines. There is an implemented system for reporting, follow up, and management of exposure to open B-6.9 139 pulmonary TB, MERS-CoV, chicken pox, measles, mumps, and rubella. Aerosol generating procedures (AGPs) (e.g; nasopharyngeal swabs, tracheal aspirate, etc)of B-6.10 suspected infectious respiratory patients are performed by trained HCWs , and there must be 140 schedule for assigned trained HCWs to cover all shifts. HCWs must perform aerosol generating procedures (AGPs) on any suspected or confirmed respiratory illnesses cases in a negative pressure room or single room with a portable high-efficiency B-6.11 140 particulate air (HEPA) filter machine (if the negative pressure room is not available) and by using proper PPE (e.g., N95 fitted mask, eye protection, gloves, and gown). 8| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  There is a proper maintenance of all portable HEPA filter machines and all HEPA filters are changed B-6.12 141 on a regular basis and according to the manufacturer’s recommendations. Element # B - 7 : Employee Health Program Page # 143 There is a written policy and procedure for employees’ health (i.e., pre-employment counseling B-7.1 143 and screening, immunization, post exposure management, and work restriction). There is a special clinic for employees’ health that provides pre-employment counseling and B-7.2 144 screening, immunization, post exposure management and work restriction. B-7.3 All employees have a baseline screening for hepatitis B, hepatitis C, HIV, and tuberculosis (TB). 145 The immune status of newly hired HCWs against hepatitis B, measles, mumps, rubella, COVID-19, and varicella are determined by documented vaccination, serological evidence of immunity, B-7.4 145 documented clinical / laboratory evidence of disease with life long immunity). Appropriate vaccine(s) are administered to those who are susceptible. B-7.5 The influenza vaccine is administered annually to targeted HCWs as per MOH recommendations. 146 Newly hired HCWs are screened for tuberculosis upon contracting with Purified Protein Derivative B-7.6 based Tuberculin Skin Test (PPD-based TST). The test is repeated annually for those who are non- 147 reactive and PPD-based TST conversion rates are monitored and calculated. There is an implemented system for reporting, follow up, and management of sharp or needlestick B-7.7 149 injuries and of blood/body fluid exposures. Reporting is active and ongoing (i.e., reliable reports of sharp or needlestick injuries and B-7.8 blood/body fluid exposures are sent through approved national platform or other approved 149 reporting system in a timely manner). The Employee health clinic team regularly monitors different types of HCWs exposure and B-7.9 recommend corrective actions to prevent recurrence, e.g., devices with safety mechanisms (self- 150 sheathing needles-retractable needles and scalpels... etc.). Updated medical records (or copies) are available for all HCWs of supportive services (i.e., kitchen, B-7.10 151 laundry, housekeeping, waste management …etc.) The screening, immunization, and post exposure management data are kept in HCWs medical B-7.11 151 records. There are regular training activities for employee health program.(an active annual education and B-7.12 152 training plan for the employee health program targeting healthcare worker) Exposed health care workers are isolated when needed (either home isolation in staff B-7.13 153 accommodation or in their home or in identified rooms at the hospital). B-7.14 Approved national/MOH protocol for work restriction is strictly applied. 154 DOMAIN – C # HAIs SURVEILLANCE & OUTBREAK MANAGEMENT Element # C - 1 : Outbreak Management Measures Page # 165 The facility has a written policy and procedure for dealing with Healthcare-associated outbreaks C -1.1 165 based on the approved scientific reference and up-to-date national MOH guidelines. (Updated) There is a screening policy for all MDROs implemented for the admission or transferred patients to C -1.2 168 the health care facility according to the up-to-date national MOH guidelines(New) There is a defined outbreak management team (OMT) chaired by hospital director or medical C -1.3 director with clear roles & responsibilities and include all key members involved in outbreak 169 management. Investigation and control measures of confirmed healthcare-associated outbreaks are led by the C -1.4 170 director of the IPC department in the hospital. (Updated) The outbreak management team members are trained and having experience and skills in C -1.5 management of outbreaks based on the latest national MOH guidelines & regulations. 172 If an outbreak is confirmed, the IPC department alerts the hospital director through approved C -1.6 channel of communication and the OMT will be activated consequently and will be discussed in 173 the nearest committee. (Updated) 9| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  If an outbreak is confirmed, the infection prevention & and control department activates the C -1.7 notification through an approved national platform based on the national MOH guidelines and 173 regulations within 48 Hours. (Updated) If an outbreak is confirmed, the OMT members meet as required, and the meeting-recommended C -1.8 174 actions will be implemented and followed. (Updated) If an outbreak is confirmed, the facility implements outbreak management approaches C -1.9 (investigation forms, line lists, contact tracing, and outbreak management action plan (OMAP) 175 based on the national MOH guidelines and regulations within 72 hours. (Updated) There is a well-designed notification system between the IPC department, laboratory, and all C -1.10 departments in the hospital for any critical values (i.e MDROs, positive cultures..), and all these 176 values' must be monitored regularly. Element # C - 2 : Emergency Preparedness & Response to Page # National Infectious Diseases’ Threats 178 There is a policy and procedure for emerging and re-emerging infectious diseases based on the C -2.1 178 national guidelines and references. (Updated) Active surveillance ( log book) is implemented for monitoring HCWs with signs and symptoms of C -2.2 180 exposure to any emerging and re-emerging infectious disease. (Updated) All HCWs must follow the national recommendations of preventive measures for emerging and re- C -2.3 182 emerging infectious diseases with public threats. (Updated) All HCWs must receive continuous job-specific training on emerging and re-emerging infectious C -2.4 183 diseases. (Updated) Element # C - 3: Antimicrobial Stewardship / Antibiogram Page # 179 There is a written policy and procedure for antimicrobial stewardship program (ASP) and authorized ASP committee formulated & approved by ASP committee members that is chaired by C -3.1 179 clinical pharmacist or infectious disease (ID) consultant with a clear roles and responsibilities and meets on regular basis (at least bi-annually). There is a written restricted antibiotics policy implemented in the facility, and it should be C -3.2 183 developed & followed up by the pharmacy and infectious disease department. There is an Interventional policy implemented to Improve antibiotic usage which is developed & C -3.3 184 approved by the pharmacy department. The ASP committee members include: infectious disease physician, pharmacist, microbiologist, IPC C -3.4 practitioner, head of critical care units, head of operating room, head of surgical department, 185 head of nursing services and other departments as needed. Antibiogram is regularly discussed by antimicrobial stewardship committee with action plan and C -3.5 187 interventions to improve the use of antimicrobials and prevent resistance. Hospital leaders dedicate necessary human, financial, and information technology resources to C -3.6 the ASP committee(support training ASP/MDROs program- participating in the world awareness 187 antimicrobial week celebrations(WAAW) , assign ID consultant, etc) Antibiogram is regularly discussed by antimicrobial stewardship committee with action plan and C -3.7 196 interventions to improve the use of antimicrobials and prevent resistance. (Updated) Education about AMR & optimal antimicrobial prescription are provided regularly to the HCWs at C -3.8 197 least biannually by the ASP team members (each per their role). Page # 198 Element # C - 4 : HAIs Surveillance There are written policies and procedures for surveillance of health care associated infections, C - 4.1 using CDC-NHSN definitions approved by national MOH guidelines (e.g., VAP/VAE, CLABSI, CAUTI, 198 SSI and MDROs according to the hospital's scope of services). There is a written policy and procedure for surveillance of dialysis event, using CDC-NHSN C - 4.2 198 definitions which are approved by national MOH guideline. Adequate number of computers and a reliable internet service are available for effective C - 4.3 199 implementation of surveillance program without any interruption. IPC practitioners are well trained regarding the national approved electronic surveillance platform C - 4.4 199 and familiar with CDC-NHSN definitions approved by national MOH guideline. Surveillance system is carried out in all critical care units (active, prospective, targeted and patient C - 4.5 203 based surveillance). SSI surveillance is applied according to national MOH guideline (i.e. selecting only 1 - 3 types of C - 4.6 204 high risk procedures or most common surgeries during at least 6 months). Hospital has a system for post operative follow up and communication with post surgical patients C - 4.7 regularly after discharge for any signs and symptoms of surgical site infections including patients 205 with implants. 10| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  Surveillance data (targeted patients, numerators, denominators, and device utilization ratio) are C - 4.8 208 validated by IPC practitioners at least once monthly. Surveillance data are regularly collected & reported to MOH through national approved electronic C - 4.9 211 surveillance platform. Results of surveillance are regularly analyzed, interpreted, and communicated to HCWs and C - 4.10 212 concerned departments. Results of surveillance are regularly reviewed by the IPC committee, and the action plan is C - 4.11 213 developed and followed up accordingly (at least once quarterly). Results of surveillance are used to reduce HAIs through well designed quality improvement C - 4.12 214 projects. Element # C - 5 : Patient's Care Bundles For Prevention Of HAIs & Page # 216 MDROs C - 5.1 There is a written policy and procedure concerning patient's care bundle for prevention of CAUTI. Page # 217 Hospital has a competency-based training program for insertion and maintenance of urinary C-5.1a 218 catheters. IPC practitioners regularly conduct auditing rounds to monitor and document HCWs’ adherence to C-5.1b recommended practices for insertion and maintenance of urinary catheters in critical care units 219 (weekly). IPC department provides compliance audit feedback to the critical care unit's HCWs regarding their C-5.1c performance in the insertion and maintenance of urinary catheters regularly and corrective actions 220 are applied accordingly. Urinary catheter insertion is performed under complete aseptic technique including antimicrobial C-5.1d handwashing with sterile items (urinary catheter, urinary bags, gloves, solution and single-use gel). 222 Cleansing the perineal area with skin antiseptic solution and with sterile draping of the patient. Hospital applies urinary catheter maintenance activities including securement of the catheter to the patient's thigh, ensuring low level fixation of urine bag below the level of the bladder at all times, C-5.1e 224 maintain a continuous closed drainage system, antiseptic cleaning in the drain port for urine drainage and, routine meatal hygiene. Nursing staff review daily the ongoing need of indwelling urinary catheter and the possibility of C-5.1f 226 discontinuation with the treating physician. C - 5.2 There is a written policy and procedure concerning patient's care bundles for prevention of CLABSI. Page # 228 Hospital has a competency-based training program for insertion and maintenance of central line C-5.2a 229 catheter. IPC practitioners regularly conducting auditing round to monitor and document adherence to C-5.2b recommended practices for insertion and maintenance of central catheter lines in critical care units 231 (weekly). IPC department provides compliance audit feedback to the critical care unit's HCWs regarding their C-5.2c performance in insertion and maintenance of central catheter lines regularly and corrective actions 235 are applied accordingly. Central line catheter insertion is performed under ultrasound guidance with complete aseptic C-5.2d technique including antimicrobial handwashing, & use of maximum barrier precautions (sterile 236 gloves, mask, sterile gown, and sterile full body drape). preparation of the skin site with an alcoholic chlorhexidine solution, and use of transparent C-5.2e 237 chlorhexidine impregnated dressing. Nursing staff scrub the access port or hub with friction immediately prior to each use with an C-5.2f 239 appropriate approved antiseptic for at least 15 seconds. Nursing staff review daily the ongoing need of central venous catheter and the possibility of C-5.2g 240 discontinuation with the treating physician C - 5.3 There is a written policy and procedure concerning patient's care bundles for prevention of VAEs. Page # 242 C-5.3a Hospital has a competency-based training program for prevention of VAEs. 243 IPC practitioners regularly conducting auditing round to monitor and document adherence to C-5.3b 245 recommended practices for management of ventilated patients in critical care units (weekly). IPC department provides compliance audit feedback to the critical care unit's HCWs regarding their C-5.3c performance for management of ventilated patients regularly and corrective actions are applied 246 accordingly. Hospital applies bundle of care for management of ventilated patients includes elevation of the C-5.3d 248 head of the bed to between 30 and 45 degrees, daily sedative interruption with assessment of 11| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  readiness to extubate, peptic ulcer prophylaxis, deep venous thrombosis prophylaxis, and daily oral care with appropriate antiseptic solution. There is a written policy and procedure concerning patient's care bundles for the prevention of Page # 252 C - 5.4 surgical site infections (SSIs) Hospital has a competency-based training program for surgical care improvement including surgical C-5.4a 253 site infections prevention care bundle (preoperative, Intraoperative & post-operative phases). IPC practitioners regularly conduct auditing round to monitor and document adherence to C-5.4b 255 recommended practices for surgical site infection prevention care bundles (weekly). IPC department provides compliance audit feedback to the surgical HCWs regarding their C-5.4c performance in surgical site infections prevention care bundle regularly and corrective actions are 256 applied accordingly. Hospital applies bundle of care for prevention of surgical site infections including proper antimicrobial prophylaxis, no preoperative hair removal or use of electric hair clippers if hair removal C-5.4d is necessary, controlled 6 AM postoperative serum glucose, maintaining perioperative 257 normothermia, patient full body shower at least the night before surgery with antimicrobial soap, and intraoperative skin preparation with approved antiseptic. There is a written policy and procedure concerning patient's care bundles for the prevention of C - 5.5 Page # 261 MDROs. C-5.5a Hospital has a competency-based training program for prevention of MDROs. 262 IPC practitioners regularly conducting auditing round to monitor and document adherence to C-5.5b 264 recommended practices for management of Patients with MDROs (weekly). IPC department provides compliance audit feedback to the HCWs regarding their performance in C-5.5c 265 implementation of MDRO bundle on regular basis and corrective actions are applied accordingly. Hospital applies bundle of care for prevention of Multidrug Resistant Organisms (MDROs) including C-5.5d judicious Use of Antimicrobial Agents, Patient placement in hospitals, standard Infection Control 266 Precautions to Prevent Transmission of MDROs, environmental measures etc. There is a written policy and procedure concerning patient's care bundles for prevention of dialysis Page # 270 C - 5.6 event (DE). C-5.6a Hospital has a competency-based training program for hemodialysis patients' care bundle. 271 IPC practitioners regularly conducting auditing round to monitor and document adherence to the C-5.6b 273 recommended practices for management of hemodialysis patient to prevent DE (weekly). IPC department provides compliance audit feedback to the hemodialysis HCWs regarding their C-5.6c performance in recommended practices for management of hemodialysis patient to prevent DE 274 regularly and corrective actions are applied accordingly. Hemodialysis HCWs apply bundle of care for prevention of DE including catheter connection, C-5.6d 275 disconnection, and the required access (fistula/graft) care, as per the type of catheter inserted. DOMAIN – D # DEPARTMENTAL INFECTION PREVENTION & CONTROL MEASURES Element # D - 1 : Hemodialysis (HD) Unit Page # 281 D - 1.1 There is a written policy and procedure for infection control in hemodialysis unit. 281 D - 1.2 The distance separating adjacent dialysis chairs or beds is not less than 1.2 m. 282 Special room is available for central venous line insertion, and it is equipped with appropriate hand D - 1.3 282 washing facility and required PPE. Hand washing supplies (sinks, soap, water, paper towels, antimicrobial soap),are available in D - 1.4 283 adequate number (one for every 4 chair/beds) and easily accessible. D - 1.5 Alcohol hand rub dispensers are available (one for every patient's chair/bed) 283 Appropriate PPE are available and used according to standard and/or transmission based D - 1.6 precautions (gloves: clean/sterile - gowns: clean/sterile - face shield or goggles - mask or N95 284 respirators). D - 1.7 Patient and staff members wear masks for all central venous catheter (CVC) access connections. 285 12| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024 D - 1.8 Mobile common medication carts or trays are strictly prohibited. 286 Separate clean area is available and maintained for preparation of medications and not handling D - 1.9 286 or storing contaminated or used supplies, equipment, blood samples, or biohazard containers. Unused supplies or medications within the patient's station are not used on other patients and D - 1.10 287 never returned to the common clean area. Patient care equipment such as blood pressure cuffs, stethoscopes, and thermometers are D - 1.11 allocated to a single patient during the whole session and are disposed (if single use) or cleaned 288 and disinfected (if reusable) at the end of each patient's treatment session. Written rules are strictly followed for the process of internal cleaning and disinfection of dialysis D - 1.12 289 machines in-between patients (as per manufacturer's recommendations). Cleaning and disinfection of hemodialysis patients’ environment is performed after each treatment D - 1.13 session with MOH approved disinfectants using a detailed checklist to ensure disinfection of all 290 environmental surfaces at patient’s zone especially high touched areas. Cleaning and disinfection of the water treatment and distribution system is performed at least once D - 1.14 weekly. Complete dialysis system is considered during the disinfection procedure (water treatment 291 system, distribution system, and dialysis machines). Quantitative microbiological testing for water and dialysate is conducted at least monthly, and if D - 1.15 293 standard is exceeded, testing is done weekly until meeting standard. Quantitative endotoxin testing for water and dialysate is performed at least once per month, and if D - 1.16 293 not up to the standard, testing is repeated weekly until the problem is resolved. D - 1.17 The results of microbiological and endotoxin testing of water documents are available. 295 Patient is tested for HBV markers (HBsAg, anti-HBc, anti-HBs) upon admission & with vaccination D - 1.18 provided to susceptible one. Patient with negative results are periodically re-tested with prompt 295 review of results. Patient is tested for HCV markers upon admission (ALT and anti-HCV – ELISA) & patients with D - 1.19 295 negative results are periodically re-tested with prompt review of results. Previously HCV +ve patient who was treated with direct antiviral agents (DAAs) and achieved D - 1.20 295 sustained virologic response (SVR), is tested for HCV-RNA (PCR) semi-annually to detect relapse. Only patients with risk factors for HIV infection (High-risk behaviors, e.g., repeated blood D - 1.21 295 transfusions, drug abuse …etc) are tested for markers of HIV infection. HVB +ve patients are strictly segregated in a separate room(s), treated by dedicated staff during D - 1.22 dialysis sessions using designated machines, equipment, instruments, supplies, and medications 297 which are used only for them. Training and education of patients (or family members for patients unable to be responsible for D - 1.23 their own care) regarding infection prevention & control practices should be given upon admission 298 to dialysis and at least annually thereafter. Element # D - 2: Compound Sterile Preparation (CSP) In The Page # Pharmacy 301 D - 2.1 There is a written IPC policy and procedure for compound sterile preparation (CSP) area. 301 Compound sterile preparation (CSP) is restricted to competent pharmaceutical HCW except D - 2.2 during emergency situations, it could be covered with HCW familiar with aseptic techniques and 304 proper use of appropriate PPE. Compound sterile preparation (CSP) room/area is a functionally separate facility which is under D - 2.3 305 positive pressure. The doors of the compound sterile preparation (CSP) room/area are equipped with an auto- D - 2.4 305 closure mechanism. Mixing IV medications is performed only in laminar air flow hood or safety cabinet, with air supplied D - 2.5 305 through High-Efficiency Particulate Air (HEPA) filter. Compound sterile preparation (CSP) room/area is cleaned and disinfected with an approved D - 2.6 detergent/disinfectant and by assigned well trained housekeeper in cleaning/disinfection 306 methods. Working surface (under the laminar air flow hood) is regularly disinfected by an approved D - 2.7 307 disinfectant using non-lining wipes. D - 2.8 Maintenance records for hoods and safety cabinets are available. 307 D - 2.9 All supplies and containers used in CSPs preparations are sterile. 308 13| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  Element # D - 3 : Operating Room (OR) Page # 309 There is a written policy and procedure for IPC in OR including a clear policy to handle patients D - 3.1 under air-borne infection isolation precaution inside OR (e.g., TB) & patients with infectious 309 transmissible diseases are scheduled towards the end of the operating list. There is a clear demarcation between unrestricted, semi restricted, and restricted zones of OR with D - 3.2 310 restrictions and special precautions for movement between these zones. Floors, walls, & ceiling are formed of one piece without connections, cracks, or decorative parts, D - 3.3 with minimal openings that are completely sealed, and withstand repeated cleaning and 312 disinfection. D - 3.4 At least one large scrubbing sink is available at entry to each operating theater. 312 Storage areas in the OR are organized and well maintained and distribution of sterile items D - 3.5 313 following the first in -the first out (FIFO) principle. D - 3.6 Only necessary items are kept in the restricted area of the OR. 314 D - 3.7 Doors are kept closed and only necessary HCWs are allowed in the theater. 314 OR environment is maintained clean and there are clear procedures for cleaning and disinfection D - 3.8 314 by allocated housekeeping staff after each surgical procedure and at least daily. Ventilation system operates all the time and never shuts down even in long holidays, and air is D - 3.9 315 introduced from the ceiling and exhausted near the floor. All re-circulated or fresh air is filtered through High-Efficiency Particulate Air (HEPA) filters that are D - 3.10 315 maintained and replaced as per the manufacturer recommendations. D - 3.11 Operating room is maintained at positive pressure (at least +2.5 Pascal) with respect to corridors. 315 D - 3.12 Operating Room is maintained at ≥ 20 air changes per hour (ACH) with 20% fresh air. 315 D - 3.13 Operating room temperature ranges from 21 °C to 24 °C and relative humidity from 20% to 315 Element # D - 4 : Laboratory Department Page # 317 D - 4.1 There is a written policy and procedure for IPC in the laboratory. 317 Access is restricted with a sign incorporating the universal biohazard symbol posted at the D - 4.2 318 entrance. D - 4.3 Eating, drinking, wearing contact lenses, and storing food are not permitted. 318 All manipulations of infectious materials that may generate aerosols are properly contained or D - 4.4 319 conducted in a biological safety cabinet (BSC - class II-B). Biological safety cabinets (BSC - class II-B) dedicated for aerosols generating procedures are well D - 4.5 322 maintained, tested, and certified at least annually. D - 4.6 Whenever possible, plastic tubes are used instead of glass ones to avoid sharp injuries. 323 Each work area contains a dedicated well-equipped sink for washing hands together with easily D - 4.7 323 accessible eyewash facility to be used in emergency in case of exposure to blood and body fluids. Specimen collection and receiving area are equipped with hand washing facilities and proper D - 4.8 324 PPEs. Mycobacteriology laboratory that manipulates cultures of suspected or confirmed Mycobacterium D - 4.9 324 Tuberculosis cases should be in at least Biosafety Level III Laboratory (BSL-3 laboratory). Microbiological cultures should be autoclaved within the laboratory in an autoclave that is placed in appropriate location and fullfils quality control parameters (except cultures for organisms not D - 4.10 325 mentioned in the approved list of highly infectious microorganisms, that could be double packed and send to the contractor for final disposal as infectious medical waste. D - 4.11 Working surfaces and equipment are regularly cleaned and disinfected. 328 D - 4.12 Laboratory HCWs perform hand hygiene and wear appropriate PPE when indicated. 329 14| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  Element # D - 5: Dental Services Page # 330 D - 5.1 There is a written IPC policy and procedure for the dental setting. 330 No reprocessing of instruments is carried inside the dental clinic (all the contaminated items are D - 5.2 331 sent to the central sterilization services department (CSSD)). All reusable dental instruments (critical and semi critical dental items) are sent to CSSD after each 331 D - 5.3 patient. Contaminated dental instruments including dental handpieces are transferred to the central 331 D - 5.4 sterilization services department in a closed, sealed, and puncture resistant containers. If transportation to CSSD is not expected within two hours, instruments inside transferring containers 331 D - 5.5 are sprayed with transportation gel/spray before sending them. Single-use devices (e.g., disposable examination set, anesthesia carpule/cartridge, etc. …) are D - 5.6 332 discarded immediately after each patient. If needles with self-sheathing mechanism and recapping devices are not available, dental care D - 5.7 333 HCW use one-handed recapping (scoop technique) for recapping needles. Clinical contact surfaces (contaminated and frequently touched surfaces in the patient-care D - 5.8 area): light handles, bracket trays, switches on dental units, computer equipment are either barrier 334 protected or cleaned and disinfected after each patient. Housekeeping surfaces (e.g., floors, walls, and sinks) cleaned with water and detergent or D - 5.9 335 approved MOH disinfectant/detergent on a routine basis or when they are visibly dusty or soiled. The products and protocols recommended by dental unit manufacturer to maintain water quality D - 5.10 are followed. (if the manufacture instructions are not available, water lines are disinfected daily 337 /weekly with an approved MOH solution and as per the manufacturer’s instructions In order to ensure that the water used in routine patient treatment meet standards for drinking D - 5.11 water (that is, less than 500 CFU/mL of bacteria), water sampling is taken from all water outlets at all 339 the clinics with a minimum frequency of semiannually and sent to the microbiology lab. During surgical procedures, only sterile solutions are used as a coolant / irrigant using an D - 5.12 340 appropriate delivery device. D - 5.13 Dental care HCWs apply standard precautions while performing dental x-rays. 341 D - 5.14 Dental lab HCWs adhere to standard precautions while performing dental lab procedures. 342 Before handling dental prostheses and prosthodontics materials in the dental lab (e.g., impressions, D - 5.15 bite registrations, and occlusal rims), they are cleaned and disinfected according to 343 manufacturer’s instructions. DOMAIN – E # SUPPORTIVE SERVICES DEPARTMENTS & RELATED MEASURES Element # E - 1: Medical Departmental Stores Page # 346 E - 1.1 There is a written policy and procedure for the medical departmental stores. 346 Medical storage areas are of adequate capacity, regularly cleaned, secured and away from E - 1.2 347 contamination, air vents and direct sunlight. Medical storage areas have controlled ventilation with adjusted temperature and humidity E - 1.3 347 (temperature ranges from 22 °C to 24 °C & relative humidity up to 70%) Storage shelves dimensions are at least, 40 cm from the ceiling, 20 cm from the floor, and 5 cm E - 1.4 348 from the wall. Storage shelves are made of easily cleanable material, e.g., fenestrated stainless steel, aluminum E - 1.5 348 or hard plastic. Sterile and clean items are completely separated from personal items, foods and drinks. No expired E - 1.6 348 items, broken packs or packs with stains are present. E - 1.7 No Items are kept in their original shipping boxes, especially in the clinical areas. 348 \ 15| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  Element # E - 2: Dietary Services Department Page # 350 E - 2.1 There is a written policy and procedure addressing dietary services and kitchen staff hygiene. 350 E - 2.2 Adequate numbers of hand washing facilities and/or hand rub antiseptic devices are available. 352 Kitchen staff practice hand hygiene properly and use suitable PPE while handling food, gloves E - 2.3 353 should be changed while moving between Critical Control Points. Kitchen staff with respiratory infections, gastroenteritis, diarrhea or hand infections or wounds are E - 2.4 354 restricted from handling food. Medical evaluation is performed routinely upon hiring, every 6 months and after returning from long E - 2.5 355 vacation. Results are reviewed by the employee’s health clinic and the IPC team. All kitchen staff receive vaccines against hepatitis-A, typhoid and meningococcal meningitis and E - 2.6 355 influenza vaccine. Kitchen is designed as physically separated areas with specified equipment & supplies (e.g., mixers, juicers, boards, plates, knives … etc.) for different types of food. Boards, plates and knives used to E - 2.7 356 cut meat, poultry, fish or vegetables are identifiably separated (color- coded) and immediately washed after use. Temperature requirements and protection from contamination are considered during receiving, E - 2.8 storage, preparation, display and transportation of food. Freezers & fridges temperatures are 357 continuously monitored and documented on log sheets and relevant actions are taken. Water used for cooking is supplied by commercially approved companies or hospital water that is E - 2.9 tested at least monthly to ensure that its quality meets regulatory national standards for potable 358 water. Food containers are properly labelled with expiry dates that should be checked every time before E - 2.10 359 use, and all food products should be arranged in respect to first in first out (FIFO) principle. E - 2.11 Fruits and vegetables are washed and disinfected. 360 Food containers and cooking utensils are washed immediately after being emptied, and E - 2.12 360 thoroughly dried before storing or used. E - 2.13 There is an Insect and rodent control plan that is strictly implemented. 361 E - 2.14 The kitchen environment is clean (i.e., frequently cleaned, dry and dust free). 362 Storage shelves dimensions are at least, 40 cm from the ceiling, 20 cm from the floor, and 5 cm E - 2.15 364 from the wall. E - 2.16 Food carts in use are dedicated for hot & cold meals. 364 Element # E -3 : Laundry Department Page # 365 There is a written policy and procedure for linen management, (e.g., collection, transportation, E - 3.1 365 sorting, washing, storing, and dispensing). Work flow is unidirectional from a soiled area to clean area with complete physical separation E - 3.2 367 between them. E - 3.3 Hand hygiene facilities and supplies are available & easily accessible. 367 Dirty linen are separated from clean linen during collection & transport and linen carts used for E - 3.4 368 clean and dirty linen are clearly identified. All workers who handle the soiled textiles follow standard precautions (i.e., handled as little as E - 3.5 possible, practicing hand hygiene using appropriate PPE, leak-proof laundry bags and containers 368 for collection). During high temperature washing cycle, water temperature is at a minimum of 71°C (159.8°F) for 25 E - 3.6 378 minutes (heat disinfection), and must be recorded. (Updated) The amount of residual chlorine (bleach) should be between 50 and 150 ppm and must be E - 3.7 378 monitored and controlled. (New) E - 3.8 During low temperature washing cycle water temperature is at 22°C - 25°C (71°F-77°F) (Updated) 378 E - 3.9 Routine inspection for blood or/and body fluid stains conducted after washing. 379 16| National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 5- 2024  Element # E - 4 : Mortuary Department Page # 372 There is a written policy and procedure that address safe handling of dead bodies, including E - 4.1 372 postmortem handling of patients under isolation precautions and bodies with open wounds. E - 4.2 Hand hygiene facilities and supplies are available & easily accessible. 373 There is a schedule of housekeeping activities (cleaning and disinfection) for all environmental E - 4.3 373 surfaces including the inside of refrigerator and deep freezing equipment. Transport cadaver bags that fulfill MOH approved specifications are available in 2 sizes & to be E - 4.4 375 used for dead bodies. E - 4.5 All mortuary HCWs are well trained on hand hygiene, and proper use of PPE. 375 Transportation card that denotes the type (s) of isolation precautions is attached to the dead body E - 4.6 377 of patient under any type of isolation. Mortuary HCWs are fully oriented about handling deceased patients with infectious diseases or E - 4.7 378 died while under isolation precautions according to the relevant approved hospital policy. Element # E - 5: Construction & Renovation Measures in Healthcare Page # 379 Facilities There is a written policy and procedure for IPC considerations during demolition, renovation, and E - 5.1 379 construction projects. IPC team is involved prior to, during, and post any construction, demolition, and renovation project E - 5.2 380 (planning, ICRA, IPC permit, continuous follow - up, and authority to stop the project). Microbiological cultures are conducted after construction for positive pressure isolation rooms and E - 5.3 381 operating theater or when required (e.g, outbreak) based on the IPC recommendations. IPC measures are followed during the construction, demolition, and renovation projects by using E - 5.4 382 infection control risk assessment (ICRA). Element # E – 6 : Housekeeping & Hospital Environment Page # 388 There is a written policy and procedure for environmental cleaning & disinfection including safe E - 6.1 388 management of blood/body fluids spills. E - 6.2 There is a written policy and procedures for pest control (regular schedule & pesticides list). 389 Each unit has an environmental cleaning/ disinfection schedule that records responsible worker, E - 6.3 390 used agents, methods of cleaning, and the environmental surfaces intended to be cleaned. Cleaning agents and disinfectants are consistent with hospital's policy and used in the correct E - 6.4 391 method according to manufacturer's recommendations including dilution and contact time. E - 6.5 There are separate clean and dirty utility rooms in each patient care area. 391 Housekeepers are trained on hand hygiene, use of PPE, methods of cleaning, and proper and safe E - 6.6 392 mixing of chemicals. Only experienced housekeeping staff are allowed in critical care units. E - 6.7 Hospital environment, lockers, and cabinets are regularly cleaned, dry and dust free. 393 E - 6.8 Bedside curtains are clean, free of stains and changed regularly & when visibly contaminated. 393 E - 6.9 Terminal cleaning process is done by using ultraviolet machine or fog machine when indicated. 394 Terminal cleaning process after discontinuation of isolation is supervised by the in-charge nurse, E - 6.10 395 and in case of an outbreak by IPC practitioner. Biological spill kits are available in all areas that have risk of blood and body fluid splashes and E - 6.11 395 HCWs are capable of using them properly. Routine environmental microbiological cultures (for air, water, or environmental surfaces) are not E - 6.12 recommended routinely. Only environmental sampling is conducted when indicated and 396 approved by the IPC team. Endocavitary ultrasound probes are cleaned, and high level disinfected then covered with clean E - 6.13 396 cover till use. There is a specific area for routine scheduled cleaning and disinfection of incubators or when E - 6.14 required and by using approved MOH disinfectant and based on manufacturer's 398 recommendation. Hydrotherapy equipment (for example, hubbard tanks, tubs, whirlpools, whirlp