TONDO MEDICAL CENTER

ORIENTATION INFECTION CONTROL POLICY

STANDARD PRECAUTION
Ma. Isabelita M.Estrella MD, MHA, FPOGS Hand Hygiene
(Medical Center Chief II) - Most important to prevent the
spread of infection
Cristina V. Acuesta MD. (Chief of Medical - Includes:
Professional Staff II) o Hand rubbing
o Hand washing
Medical Specialist - 5 moments of Hand Hygiene
Edgar G. Samonte MD. (Medical Specialist III 1. Before touching the patient
Laboratory) 2. Before performing aseptic task
Monica Y. Tolentino MD. (Medical Specialist II 3. After body fluid exposure risk
Laboratory) 4. After touching the patient
5. After contact with patient
Laboratory Department surrounding
Corazon G. Alcantara MD. (Medical Officer IV) PPE (Personal Protective Equipment)
Ma. Cecilia B. Asilo (Medical Specialist II F.T.) Gloves
- Ideally worn during extraction
Infection Prevention and Control - Change gloves between:
Committee o Contact with different
Dr. Sheryl Gracilla (Chairman) patients
Larena Hernandez (IC Nurse) o Procedures on the same
patient
Mission - Wash hands before and after use of
Internationally competitive multi-specialty gloves
training hospital, delivering quality health - Donning = wear
care. - Doffing = remove
Mask
Vision - To protect mucus membrane of
A hospital for health service excellence nose and mouth
- Ideal: surgical mask (better than
Quality Policy cotton material or gauze mask)
Tondo Medical Center, a tertiary training and o Designed to resist fluids to
service-oriented hospital, committed to varying degrees
delivery safe, compassionate, efficient, - Masks used according to
affordable, and accessible health services to preference (most preferred to least
enhance patient satisfaction, to. Meet legal preferred):
and statutory requirements, and to 1. Surgical Mask
continually improve the quality management 2. N95
system. o Used in cases of:
Measles
Core Values
TB
Understanding
Chickenpox
Nationalistic
o Do fit test to make sure with
Loving and Compassionate no leak since
Innovative microorganisms might pass
Responsive Service through
Integrity 3. Customized mask (cotton
Commitment and Dedication material)
Excellence Goggles
- Mask with eyeshield or goggles
- Used in the Operating Room
Gowns/Aprons
 - To protect the skin and prevent 3. Dont remove used needles, bend,
soiling of clothing break, or manipulate using the hands
- For splashes of blood and body *In case of NSI: wash with soap and
fluids water, wag paduguin, report
- Preferable: impermeable gowns *Reporting through CPAR: will be asked
Caps, Boots, Shoe Covers when and where it happened, corrective
- Replace slippers with new ones for action, prevention, 3 days returned to be
special areas filled out
- 3x caught not following ICC could
be cause for CPAR (Corrective ENVIRONMENTAL CLEANING
Protection Action Request) - After each use: disinfectant soap
- Blood and body fluid may splash or and water
spill or leak onto hair or shoes - For infectious: 0.05% sodium
hypochlorite
SPECIAL AREAS
*remove current PPEs (smack gown, slippers, HANDWASHING
socks etc) and replace with new ones 1. Get enough soap and water
NICU 2. Remove anything on your hands and
OR fingers
3. Cover all areas of your hands and
ER
fingers in washing
*my own names for the steps
EXTENDED PRECAUTION
- Clap
*still apply Standard Precaution (hand
- On top
hygiene and PPEs)
- In-between
1. Airborne
- Choir hands
- Use N95 mask
- Solo thumb
2. Contact
- Drawing
- Rabies
- Wrists
3. Droplet
4. Tissue used in drying hands will be
- Meningococcemia
used to turn off the faucet
- Put on mask if within 1 meter range
- SARS, avian influenza
- Given prophylaxis TRAINING PROGRAM
**Splashes wear mask and gown - Inadequate quantity of urine
**Direct contant hand hygiene o Age is also a factor to
consider
RESPIRATORY HYGIENE AND COUGH o 2-3 mL of urine from baby
ETIQUETTE could already be centrifuged
- Do the dab - Hematology
- Cover with tissue or handkerchief o Manual count if with
- Throw used tissue in yellow plastic discrepancy on values using
bag automated machine
- Do proper hand hygiene o WBC count
Normal value: 5-10
PREVENTION OF NSI (NEEDLESTICK Variations may exist
INJURY) (10.2, 10.4, etc) but
1. No recapping not exceeding 11
- Do fishing method - Quality Control (machines checked)
- If not possible, use forceps to get o Hematology
the cap o Clinical Chemistry
- As much as possible, no recapping o Serology
so throw sharps directly onto
puncture-resistant container - PPE: from head to foot
2. Never direct or point a needle towards - Confidentiality: treat all lab result
any part of the body as confidential
 - 15 days/section (each with working 1 excused absence : 1 day make up (8 hours)
instructions) Unexcused absences:
- 12 areas 1 unexcused absence : 3 days makeup (or 24
- Hospital card (check the ff) hours duty)
o Name *Up to 20% absences only
o Hospital number
o Birthday DEMERITS
o + name tage if patient is Demerit
Action Demerits
already admitted Points
30 mins out of post
Area Rotation Quota Incomplete uniform 2
Clinical Chemistry 29 days 3,000 Late submission
Hematology 15 days 1,200 Improper logging 3
Clinical Microscopy 25 days 500 Improper endorsing
2
Blood Banking 19 days 50 and receiving
Immunology and Drinking
13 days 400
Serology alcohol/hangover (5
Microbiology 18 days 100 as preliminary)
5
Histopathology 12 days 100 Gambling
Drug Testing 12 days 100 Smoking
Phlebotomy 1,500 Insubordination
ER 500 Cellphone/gadgets
OPD 300 use (1st time)
10
Ward-in 400 Immoral acts
Bleeding donors 300 Vandalism
Lost lab request
Lost specimen
Regular duty: 8 AM 5 PM (8 hours) 5 5
Night duty: 4 PM 8 AM (16 hours) (urine and blood)
15 minutes late = 1 day makeup Concealing error
1 hr overlap endorsement
Rotation is every 3 days
(8 hr 8 hr 16 hr)
Repeat Section
From duty: from night duty Repeat Internship
Rotation
No swapping of night duties
Loss of specimen
- Wear scrubs during night duty Histopath
(CSF)
- Wear complete school uniform
during regular duty Wrong blood Alteration or falsification
o Intern type A uniform typing/extraction of data
o Nameplate Swapping of request
o Nametag Forging of signature
o Black shoes Supsension to
o Lab gown Cellphone/gadgets use
Repeat
Demerit point: deducted from grade (2nd time)
Internship
Day demerit: makeup duty Bringing home
Flag ceremony every Monday at 8 AM Extraction of wrong
supplies, reagents,
10 merits = 1 point to final grade patient
and documents
Incident or narrative report for Access of exam/lab info
documentation Stealing
Dishonesty
5th month scheduled for makeups
24 hrs makeup = 3 days duty

MERITS
Action Merits
Excused absences:
Under manpower 2 - Source: DOH
Extension of duty - Promote blood donation in TMC
2 hours 1
8 hours 5 EXAMINATION RULES
16 hours 10 1. Use blue or black ink only
2. No pencil or eraser
Voluntary blood donation 10
3. Chairs are scattered with bags on the
Hospital
5-10 side
programs/activities
4. No makeup exams except if excused
5. Cheating will be given zero score
Additional task for voluntary blood donation 6. Failure in exam will be given remedials
to get full credit: 7. Failure in remedials will be given an
Pep talk with powerpoint presentation oral report (according to section head)
a. RA 7719
b. Anatomy and Physiology GRADING SYSTEM
i. Heart, blood vessels 70%
ii. Importance of RBC, WBC, etc Quality and Quantity 25%
c. Therapeutic use of blood Skills 25%
i. Potential donors Conduct 20%
ii. Pre-donation Scholastic 20%
iii. During donation
iv. Post-donation 30% Lecture and Examination
- Should be simple and easy to
understand