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

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

Example : Driving and the traffic

GuidelinesTypes of carsDriving styles

Traffic law and policiesRight and wrong

ProceduresGo left and go right

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

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

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

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

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

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

Formulation of Policies and Procedures

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.

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.

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

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

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.

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”

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!!

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

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

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.

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

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

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

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

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

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.

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.

Thank You